What is the management for a patient with an electrical injury without burn but with numbness?

Management of Electrical Injury Without Burn but With Numbness

For electrical injury presenting with numbness but no visible burns, immediate cardiac monitoring with 12-lead ECG, aggressive IV crystalloid resuscitation, comprehensive neurological assessment, and hospital admission for at least 24 hours of telemetry monitoring are essential, as external appearance grossly underestimates internal tissue damage and neurologic complications can be delayed. 1

Immediate Safety and Assessment

• Ensure the power source is completely disconnected before approaching or transporting the patient to prevent injury to responders and further harm to the victim 2, 3
• Assess for cardiopulmonary arrest immediately and initiate ACLS protocols with standard C-A-B sequence if needed, as cardiac arrest is a primary cause of death in electrical injuries 3, 1
• Perform a comprehensive neurological examination on admission, documenting all findings including the numbness distribution, motor strength, sensory deficits, and any other neurologic symptoms 4, 5

Critical Cardiac Evaluation

• Obtain a 12-lead ECG within 10 minutes of first medical contact to assess for arrhythmias and evidence of cardiac injury, as ventricular fibrillation, asystole, and ventricular tachycardia are common complications 3, 1
• Continue continuous telemetry monitoring for at least 24 hours or until alternative diagnosis is made, as cardiac arrhythmias can develop in both low and high-voltage injuries 3, 1, 4

Aggressive Fluid Resuscitation

• Initiate aggressive IV crystalloid resuscitation immediately with 0.9% normal saline to counteract shock and facilitate excretion of myoglobin, potassium, and other tissue breakdown products, even without visible burns 6, 1
• Administer fluid boluses of 250-1000 mL with reassessment after each bolus, targeting lactate reduction of 20% in first hour as a marker of adequate tissue perfusion 1
• Monitor for heme pigments (myoglobin) in urine, as muscle damage may be extensive despite minimal external signs, putting the patient at risk for acute renal failure 4

Comprehensive Laboratory Assessment

• Obtain immediate comprehensive laboratory panel including complete blood count, comprehensive metabolic panel with electrolytes, renal function tests, coagulation studies, and capillary glucose 3, 1
• Check urine for myoglobin/heme pigments to assess for rhabdomyolysis, which requires aggressive volume resuscitation and possibly alkalinization of urine or IV mannitol 4

Neurological Management and Monitoring

• Recognize that numbness indicates nerve injury that may be immediate or represent early signs of delayed neurological complications that can manifest up to 2 years post-injury 4, 7, 5
• The severity of electrical injury is NOT proportional to source voltage, visible burns, or loss of consciousness—even low-voltage injuries can cause significant delayed bilateral nerve damage 7, 8
• Perform serial neurological examinations to detect any progression or new deficits, as delayed cerebellar infarction, peripheral nerve injury, and spinal cord damage can occur days to weeks after seemingly minor electrical contact 7, 5
• Consider brain and spinal imaging (CT/MRI) if neurological symptoms progress or new deficits develop, as delayed infarctions and other complications may not be immediately apparent 7

Critical Pitfall: External Appearance is Deceptive

• External skin appearance grossly underestimates internal tissue damage in electrical injuries—extensive deep tissue necrosis, nerve damage, and muscle injury may exist beneath minimal or absent skin changes 1, 4
• The absence of visible burns does NOT exclude significant internal injury, as electrical current travels through tissues of least resistance (nerves, blood vessels, muscles) causing damage along neurovascular bundles 8
• Low-voltage injuries can produce delayed bilateral nerve damage indirectly via spasm and thermal coagulation of the vasa nervorum (blood vessels supplying nerves) 8

Admission Criteria and Disposition

• Admit all patients with electrical injury presenting with numbness for at least 24 hours of cardiac monitoring and serial neurological assessments, regardless of voltage exposure or absence of burns 1, 5
• Admission is mandatory for: abnormal initial ECG, any neurological symptoms (including numbness), loss of consciousness, suspected deep tissue injury, and any concern for delayed complications 1
• Arrange neurology consultation for persistent or progressive neurological deficits, as approximately 16.7% of electrical injury patients develop neurological deficits, with variable recovery patterns 5

Long-term Considerations

• Counsel patients that neurologic complications may present immediately or be delayed (up to 2 years after injury), including chronic pain syndromes, peripheral nerve damage, and diffuse neuropsychologic symptoms 4, 9
• Schedule follow-up neurological assessments, as 48.2% of patients with initial neurological deficits recover, but 33.3% have persistent deficits 5
• The prognosis for electricity-related neurologic injuries is generally better than other traumatic causes, suggesting a conservative approach with serial examinations 4

Additional Monitoring Parameters

• Assess for compartment syndrome in affected extremities, as damaged muscle with swelling within investing fascia may require fasciotomy despite absent external burns 4
• Monitor for traumatic injuries from falls or being thrown, as approximately 15% of electrical burn victims sustain concomitant trauma from tetanic muscle contractions 4
• Consider early intubation if any facial, mouth, or anterior neck involvement exists due to risk of rapid soft-tissue swelling, even without visible burns 3, 1