What are the admission criteria for a patient with an electrical burn, including voltage >1000 V, loss of consciousness, cardiac arrhythmia or electrocardiogram changes, persistent tachycardia or hypotension, severe disproportionate pain, burns crossing joint lines or involving face, neck, hands, feet, or genitals, entry or exit wounds >2 cm, total body surface area >5 % in children or >10 % in adults, compartment syndrome, associated traumatic injuries, significant comorbidities, need for intravenous fluid resuscitation, continuous cardiac monitoring, or specialist wound care?

Electrical Burn Admission Criteria

All electrical burns should be immediately referred to a specialized burn center, as the American Burn Association classifies all electrical injuries as severe burns requiring specialized care. 1

Mandatory Admission Criteria

High-Voltage Injuries (>1000 V)

• Any high-voltage electrical burn (>1000 V) requires immediate burn center admission regardless of visible skin damage, as these injuries cause extensive deep tissue destruction that often does not correlate with surface appearance. 1, 2
• High-voltage injuries have considerably higher morbidity and mortality, requiring more extensive burn surgery and complex intensive care than low-voltage injuries. 2

Low-Voltage Injuries (<1000 V) with Additional Risk Factors

Low-voltage electrical burns require admission when combined with any of the following:

Cardiac Indications:

• Loss of consciousness at the scene 1
• Any cardiac arrhythmia or ECG abnormalities on initial presentation (ventricular fibrillation, ventricular tachycardia, atrial fibrillation, conduction abnormalities, ST-T wave changes) 1, 3
• Persistent tachycardia or hypotension requiring fluid resuscitation 1

Burn Characteristics:

• Total body surface area (TBSA) >10% in adults or >5% in children 4, 5
• Deep burns 3-5% TBSA 1, 5
• Burns involving function-sensitive areas: face, hands, feet, neck, or genitals 1, 4, 5
• Entry or exit wounds of any size (these indicate current passage through the body with potential deep tissue injury) 1, 6
• Circumferential burns requiring monitoring for compartment syndrome 4

Systemic Complications:

• Compartment syndrome (blue, purple, or pale extremities; severe disproportionate pain; distal neurovascular compromise) requiring emergency escharotomy 4, 5
• Rhabdomyolysis markers: elevated creatinine kinase (CK) or myoglobin levels correlate with injury severity and predict complex clinical course 2
• Associated traumatic injuries from falls or being thrown by the current 3
• Need for intravenous fluid resuscitation to maintain urine output of 100 ml/hour to prevent renal tubular damage from myoglobin 6

Special Populations:

• All electrical burns in children are automatically classified as severe and require burn center admission 5
• Adults >75 years with any electrical burn 5
• Significant comorbidities (diabetes mellitus, cardiac disease) 4

Cardiac Monitoring Duration

Patients with normal initial ECG, no loss of consciousness, and no symptoms can be discharged without continuous monitoring. 3 However, patients meeting admission criteria require:

• 24-hour continuous cardiac monitoring for those with abnormal initial ECG, loss of consciousness, or symptoms 1, 3
• All malignant arrhythmias occur immediately after injury—delayed life-threatening arrhythmias beyond 24 hours have not been observed in modern studies 3
• Routine cardiac monitoring beyond 24 hours post-injury is not necessary in stable patients 2

Critical Assessment Points

Initial Laboratory Evaluation:

• Measure serum CK and myoglobin levels—peak myoglobin occurs at post-injury day 1, peak CK at post-injury day 2 2
• Check electrolytes, particularly potassium and calcium, as ion imbalances significantly correlate with arrhythmias 3
• Cardiac troponins (cTnI or hs-cTnT) are elevated in only 5.7% of cases and do not appear helpful for risk stratification 3

Accurate TBSA Assessment:

• Use the Lund-Browder chart for accurate TBSA measurement, as the rule of nines overestimates by 70-94% and leads to excessive fluid resuscitation 4, 5

Common Pitfalls to Avoid

• Never underestimate injury severity based on visible skin damage alone—electrical burns cause progressive deep tissue destruction through small vessel occlusion and high-temperature resistance injury 1, 6
• Do not delay specialist referral for any partial-thickness or full-thickness electrical burn, as undertriage increases morbidity and mortality 4
• Do not wait for pulse loss in suspected compartment syndrome—irreversible damage occurs within 6-8 hours 5
• Ensure scene safety by turning off the power source before approaching the victim 1

Transfer Considerations

Direct admission to a burn center is preferred over sequential transfers, as this reduces time to excision, duration of mechanical ventilation, and improves survival. 1, 4 Use telemedicine consultation when immediate specialist access is unavailable to guide initial management and determine transfer urgency. 4, 5