What is the appropriate initial assessment and management of a child who has sustained an electrical injury?

Initial Assessment and Management of Pediatric Electrical Injury

Ensure scene safety by turning off the power source before approaching the child; if impossible, use a non-conducting object to separate the victim from the electrical source, then immediately assess for cardiac or respiratory arrest and initiate CPR with the C-A-B sequence if needed. 1, 2

Immediate Scene Safety and Primary Survey

Scene Safety (Critical First Step)

• Never approach or touch the victim while power remains on 1, 2
• Turn off power at the source (typically near the fuse box in homes) 1
• Use a non-conducting object to separate the victim from the electrical source only if power cannot be immediately shut off 1, 2

Initial Assessment

• Assess responsiveness by talking to the child and gently shaking their shoulders 1
• Check for cardiac arrest: if unresponsive and not breathing, begin standard CPR with C-A-B sequence immediately 1, 2
• Attach an AED as soon as possible, as ventricular fibrillation is a common consequence of electrical injury 2
• For respiratory arrest with maintained cardiac function, provide rescue breathing immediately 1, 2

Critical Pitfall: In multiple-victim scenarios (such as lightning strikes), prioritize patients in respiratory or cardiac arrest first—this reverses typical triage principles 1, 2

Cardiac Management

Immediate Cardiac Assessment

• Attach cardiac monitor/defibrillator to identify rhythm 3
• Obtain 12-lead ECG within 10 minutes to assess for arrhythmias and cardiac injury 1
• Continue cardiac monitoring for at least 24 hours due to risk of delayed arrhythmias 1, 4

Arrhythmia Management

• Follow standard ACLS protocols without modification for electrical injury victims 1
• For unstable monomorphic ventricular tachycardia with pulses: synchronized cardioversion starting at 100 J 1
• For pulseless ventricular tachycardia or ventricular fibrillation: unsynchronized high-energy shocks 1
• Use intravenous amiodarone to facilitate defibrillation and prevent VT/VF recurrences 1

Special Consideration: Lightning strike victims may experience spontaneous return of cardiac activity but continued respiratory arrest, requiring ventilatory support to prevent secondary hypoxic cardiac arrest 1, 2

Airway and Breathing Management

Airway Assessment

• Maintain patent airway and assist breathing as necessary 3
• Administer supplemental oxygen to address hypoxemia 3
• Consider early intubation for extensive burns involving face, mouth, or anterior neck due to potential soft-tissue swelling 1, 2

Spinal Precautions

• Maintain spinal motion restriction by manually stabilizing the head if trauma is suspected 1
• If vomiting occurs, logroll the victim if spinal cord injury is suspected 1, 2

Circulation and Fluid Resuscitation

Vascular Access and Monitoring

• Establish IV or IO access as soon as possible 3
• Monitor blood pressure and pulse oximetry continuously 3

Fluid Administration

• Initiate crystalloid isotonic fluids (0.9% saline) as first-line treatment for shock 2
• Administer fluid boluses of 250-1000 ml with reevaluation after each bolus 2
• Rapid IV fluid administration is critical for victims with significant tissue destruction to facilitate excretion of myoglobin, potassium, and other byproducts 1, 2
• Monitor for signs of fluid overload such as pulmonary edema 2

Laboratory and Diagnostic Evaluation

Essential Laboratory Tests

• Check blood glucose concentration during resuscitation and treat hypoglycemia promptly with 0.5 g/kg glucose as 10% or 25% solution 5
• Obtain complete blood count, electrolytes, renal function, coagulation studies 1
• Monitor creatine kinase and myoglobin levels, especially in high-voltage injuries 6
• Perform regular blood gas analysis 1
• Use pulse oximetry for non-invasive oxygen saturation assessment 1

Critical Pitfall: Never delay resuscitation to obtain blood samples or perform non-essential assessments 1

Specific Medication Considerations

Medications to Avoid

• Do not routinely administer calcium in the absence of documented hypocalcemia, calcium channel blocker overdose, hypermagnesemia, or hyperkalemia 5
• Do not routinely administer sodium bicarbonate in cardiac arrest 5

Seizure Management

• Control seizures with anticonvulsants such as diazepam, phenytoin, or barbiturates 1

Burn and Wound Care

Burn Assessment

• Document total body surface area (TBSA) affected using the Lund-Browder method 2
• Avoid direct application of ice to burns, as it can produce tissue ischemia 1

Common Pitfalls to Avoid

• Underestimating injury severity: Visible skin damage does not correlate with internal injury severity; electrical current travels through tissues of least resistance, causing deep tissue damage not apparent on initial examination 2, 7
• Failure to monitor cardiac function: Arrhythmias are a significant cause of mortality and can occur hours after injury 2, 4
• Inadequate fluid resuscitation: Significant tissue destruction requires aggressive fluid management to prevent renal failure from myoglobin release 1, 2
• Delayed airway management: Soft tissue swelling can progress rapidly in facial burns 1, 2