What are the immediate management steps for a patient admitted with an electrical injury?

Immediate Management of Electrical Injury Admission

Ensure scene safety by confirming power disconnection before patient contact, immediately assess for cardiopulmonary arrest and initiate ACLS protocols, obtain 12-lead ECG within 10 minutes, establish aggressive IV crystalloid resuscitation, and admit all high-voltage (>1000V) exposures, abnormal ECGs, or significant burns for continuous cardiac monitoring. 1, 2, 3

Scene Safety and Initial Assessment

Critical first step: Never approach the victim while power remains on. 1, 2

• Turn off the power source at the main switch (typically near the fuse box) before approaching 1
• If power cannot be immediately disconnected, use a non-conducting object (such as a wooden broom handle) to separate the victim from the electrical source 4, 1
• Verify power disconnection is confirmed before patient transport to prevent injury to responders 3

Immediate Resuscitation

Cardiopulmonary arrest is the primary cause of immediate death from electrocution. 1, 5

• Assess responsiveness by talking to the patient and gently shaking shoulders (avoid violent shaking that could cause cervical spine injury) 4, 1
• If unresponsive and not breathing, begin standard CPR with C-A-B sequence immediately 1, 2, 3
• Attach AED/defibrillator as soon as possible, as ventricular fibrillation is common in electrical injuries 2, 3
• For isolated respiratory arrest with maintained cardiac function, provide rescue breathing immediately 1, 2
• Special consideration for lightning strikes: Prioritize patients in respiratory or cardiac arrest, as they may have spontaneous cardiac recovery but persistent respiratory failure requiring ventilatory support to prevent secondary hypoxic arrest 1, 2, 3

Cardiac Management

Follow standard ACLS protocols without modification for electrical injury victims. 1

• Use synchronized cardioversion starting at 100 J for unstable monomorphic ventricular tachycardia with pulses 1
• Use unsynchronized high-energy shocks (maximum output for in-hospital arrests) for pulseless ventricular tachycardia or ventricular fibrillation 1
• Obtain 12-lead ECG within 10 minutes of first medical contact to assess for arrhythmias and cardiac injury 3
• Continue telemetry monitoring for at least 24 hours or until alternative diagnosis is made 1, 3

Important caveat: Recent research suggests routine cardiac monitoring beyond 24 hours post-injury may not be necessary, as delayed arrhythmias are rare 6, 7. However, guidelines still recommend 24-hour monitoring for high-risk patients 1, 3.

Airway Management

Consider early intubation for patients with extensive burns, particularly involving face, mouth, or anterior neck, due to risk of rapid soft-tissue swelling. 1, 2, 3

• Use caution with airway manipulation due to potential cervical spine injury and progressive edema 3
• Maintain spinal motion restriction by manually stabilizing the head if mechanism suggests trauma or loss of consciousness occurred 1, 3
• If vomiting occurs, turn the victim to the side (logroll if spinal injury suspected) and remove vomitus 1, 2

Fluid Resuscitation

Initiate aggressive IV crystalloid resuscitation immediately with 0.9% normal saline as first-line therapy. 2, 3

• Administer fluid boluses of 250-1000 mL with reassessment after each bolus 2, 3
• Rapid IV fluid administration is particularly important for victims with significant tissue destruction to counteract shock and facilitate excretion of myoglobin, potassium, and other tissue breakdown products 1, 2, 3
• Target lactate reduction of 20% in first hour as marker of adequate tissue perfusion 3
• Monitor for signs of fluid overload such as pulmonary edema 2

Laboratory Assessment

Obtain comprehensive laboratory panel immediately. 3

• Complete blood count, comprehensive metabolic panel with electrolytes, renal function, coagulation studies, and capillary glucose 1, 3
• Serum creatinine kinase (CK) and myoglobin levels correlate significantly with injury severity and predict complications 7
• Highest serum levels typically observed at post-injury day 1 (myoglobin) and day 2 (CK) 7
• Regular blood gas analysis and pulse oximetry for oxygen saturation monitoring 1

Burn Assessment

Document total body surface area (TBSA) using Lund-Browder method, which is more accurate than other assessment methods. 2, 3

• Critical pitfall: External skin appearance grossly underestimates internal tissue damage in electrical injuries; extensive deep tissue necrosis may exist beneath minimal skin changes 3
• Avoid direct application of ice to burns, as it can produce tissue ischemia 1

Admission Criteria

Admit all patients meeting any of the following criteria: 3

• High-voltage exposure (>1000V) 3, 8
• Abnormal initial ECG 3
• Cardiac arrest requiring resuscitation 3
• Burns >10% TBSA 3
• Deep tissue injury 3
• Concomitant traumatic injuries 3
• Loss of consciousness 8

High-voltage injuries carry significantly higher morbidity and mortality, with increased likelihood of loss of consciousness (69.1% vs. 23.6% in low-voltage), cardiac arrest (20% vs. 3.6%), and need for amputation (23.6% vs. 5.5%) 8.

Surgical Consultation

Obtain immediate surgical consultation for: 3

• Significant burns requiring escharotomy or debridement 3
• Suspected compartment syndrome 3
• Deep tissue injury requiring exploration 3
• Potential need for amputation 3

Additional Monitoring Parameters

Continuous monitoring should include: 3

• Cardiac rhythm (telemetry) 3
• Urine output 3
• Vital signs including blood pressure and respiratory rate 3
• Neurological status (16.7% of patients develop neurological deficits, though 48.2% recover) 8
• Peripheral perfusion and compartment assessment 3

Pain Management

Consider multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during surgical management to prevent prolonged pain 2

Common Pitfalls to Avoid

• Never delay resuscitation to obtain blood samples or perform non-essential assessments 1
• Underestimating injury severity based on visible skin damage can lead to delayed recognition of serious complications 2
• Failure to monitor cardiac function can result in missed arrhythmias 2
• Neglecting pressure ulcer prevention measures in patients with spinal cord injuries, including early mobilization (once spine stabilized), regular repositioning, and appropriate support surfaces 2