What are the acute complications and first‑line management of a person who receives an electric shock?

Acute Complications and Management of Electric Shock

Electric shock victims require immediate scene safety assessment, followed by aggressive cardiopulmonary resuscitation if needed, as cardiac arrest from ventricular fibrillation is the primary cause of immediate death. 1, 2

Immediate Scene Safety (Critical First Step)

Never approach or touch the victim while power remains on – this is the most critical safety measure. 1, 2

• Turn off the power at its source (typically near the fuse box in homes). 1
• If power cannot be immediately shut off, use a non-conducting object to separate the victim from the electrical source. 1, 2
• Only after the scene is safe should you approach and assess the victim. 1

Acute Complications

Cardiac Complications (Most Life-Threatening)

• Cardiopulmonary arrest is the primary cause of immediate death from electrocution. 1, 3
• Ventricular fibrillation is the most common fatal arrhythmia, particularly with alternating current (AC) exposure. 1, 4, 5
• Other arrhythmias include ventricular asystole and ventricular tachycardia, which can occur with both low and high-voltage current. 1, 3
• AC is more dangerous than direct current (DC) because it causes tetanic muscle contractions that "lock" victims to the electrical source, prolonging exposure and increasing the likelihood of ventricular fibrillation during the cardiac vulnerable period. 1

Respiratory Complications

• Respiratory arrest may result from injury to the brain's respiratory center or from tetanic contractions/paralysis of respiratory muscles. 1
• Lightning strike victims may experience spontaneous return of cardiac activity but continued respiratory arrest, requiring immediate ventilatory support to prevent secondary hypoxic cardiac arrest. 1, 2

Other Multisystem Injuries

• Thermal burns (both external and internal along the current pathway). 1, 2
• Neurologic complications. 4
• Associated blunt trauma from falls or tetanic muscle contractions. 4
• Rhabdomyolysis with risk of acute kidney injury. 6

First-Line Management

Immediate Resuscitation

Begin standard CPR with C-A-B sequence immediately if the victim is unresponsive and not breathing. 1, 2

• Attach an AED as soon as possible, as defibrillation is often required. 1, 2
• For victims with respiratory arrest but maintained cardiac function, provide rescue breathing immediately. 1, 2
• Prolonged CPR is warranted – victims are often young without underlying cardiac disease, making successful resuscitation more likely even after extended efforts (documented survival after 65 minutes of CPR). 4, 7

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, 2
• Use unsynchronized high-energy shocks for pulseless ventricular tachycardia or ventricular fibrillation. 1, 2
• Obtain a 12-lead ECG within 10 minutes of first medical contact to assess for arrhythmias and cardiac injury. 1
• Continue cardiac monitoring for at least 24 hours to detect delayed arrhythmias. 1, 8

Airway Management

• Consider early intubation for patients with extensive burns involving the face, mouth, or anterior neck due to risk of airway swelling. 1, 2, 3
• Maintain spinal motion restriction by manually stabilizing the head, as associated trauma is common. 1, 4
• If vomiting occurs, turn the victim to the side (logroll if spinal injury suspected) and remove vomitus. 1, 2

Fluid Resuscitation

Initiate rapid IV fluid administration with crystalloid isotonic fluids (0.9% saline) for victims with significant tissue destruction. 1, 2, 3

• Administer fluids using a fluid challenge technique with boluses of 250-1000 ml, reevaluating after each bolus. 2, 3
• This counteracts shock and facilitates excretion of myoglobin, potassium, and other byproducts of tissue destruction. 1, 2
• Monitor for signs of fluid overload such as pulmonary edema. 2, 3

Laboratory Assessment

• Obtain complete blood count, electrolytes, renal function, coagulation studies, and capillary glucose level. 1
• Measure blood glucose during resuscitation and treat hypoglycemia promptly with approximately 0.5 g/kg glucose solution. 1
• Regular blood gas analysis and pulse oximetry for oxygen saturation monitoring. 1

Burn Management

• Avoid direct application of ice to burns, as it can produce tissue ischemia. 1
• Document total body surface area (TBSA) affected using the Lund-Browder method, which is the most accurate. 2, 3
• All electrical burns are classified as severe and require immediate referral to a specialized burn center. 3

Special Considerations for Multiple Victims

When multiple victims are struck simultaneously by lightning, give highest priority to patients in respiratory or cardiac arrest – this reverses normal triage priorities. 1, 2, 4

Critical Pitfalls to Avoid

• Underestimating injury severity based on visible skin damage – internal injuries may be extensive despite minimal external burns. 2, 3
• Failure to monitor cardiac function adequately – delayed arrhythmias are a significant cause of mortality. 2, 3
• Approaching the victim while power is still on. 1, 2
• Terminating resuscitation efforts prematurely – electrical shock victims have better prognosis than typical cardiac arrest patients due to younger age and absence of underlying cardiac disease. 4, 7
• Routine calcium or sodium bicarbonate administration is not recommended unless specifically indicated. 1