What is the appropriate acute management for an electrical burn injury?

Acute Management of Electrical Burns

Electrical burns require immediate specialized burn center care with aggressive fluid resuscitation targeting higher urine output (100 mL/hour) than thermal burns, early cardiac monitoring, and urgent assessment for deep tissue injury and compartment syndrome, as surface damage grossly underestimates the extent of internal destruction. 1

Immediate Scene Safety and Resuscitation

• Ensure the power source is turned off before approaching the victim to prevent rescuer injury 1
• Assess for cardiac arrest immediately, as ventricular fibrillation and asystole are the primary causes of death from electrical injury 2, 1
• Initiate CPR and defibrillation if cardiac arrest is present, using standard ACLS protocols without modification 2
• Establish continuous cardiac monitoring for all electrical burn patients due to ongoing arrhythmia risk from both low and high-voltage exposure 1

Airway Management

• Perform early intubation for patients with burns involving the face, mouth, or anterior neck, as extensive soft-tissue swelling develops rapidly and can compromise the airway even after spontaneous breathing resumes 2, 1
• The only urgent indication for immediate escharotomy is compromised airway movement or ventilation 2, 3

Fluid Resuscitation Protocol

Critical distinction: Electrical burns require MORE aggressive fluid resuscitation than thermal burns due to extensive hidden deep tissue destruction.

• Administer 20 mL/kg of balanced crystalloid solution (Ringer's Lactate preferred over normal saline) within the first hour 1
• Target urine output of 100 mL/hour (not the standard 0.5-1 mL/kg/hour used for thermal burns) to facilitate excretion of myoglobin, potassium, and other byproducts of massive tissue destruction 2, 1
• Use Ringer's Lactate as first-line fluid because normal saline increases risk of hyperchloremic metabolic acidosis and acute kidney injury 4, 1
• Rapid IV fluid administration is essential to counteract distributive/hypovolemic shock and ongoing third-spacing losses 2

Burn Assessment

• Use the Lund-Browder chart for TBSA measurement, not the Rule of Nines, as accurate assessment is critical but surface injury does NOT correlate with deep tissue damage in electrical burns 4, 1
• All electrical burns are classified as severe burns requiring immediate burn center referral regardless of visible surface area 1
• Contact a burn specialist immediately, as direct admission to a burn center (avoiding intermediate transfers) improves survival and reduces complications 2, 1

Compartment Syndrome Monitoring and Escharotomy

• Monitor continuously for compartment syndrome by assessing for blue, purple, or pale extremities indicating poor perfusion 3, 1
• Circumferential third-degree burns can cause acute limb ischemia with neurological deficits, downstream necrosis, or thoracic/abdominal compartment syndrome 2
• Perform escharotomy within 48 hours if circulatory impairment or intra-abdominal hypertension develops 2, 1
• Escharotomy should ideally be performed at a burn center by experienced providers due to risks of hemorrhage, infection, and increased morbidity from poorly performed procedures 2, 1

Pain Management

• Administer titrated intravenous opioids or ketamine for severe burn pain 2, 3
• Ketamine is particularly effective for electrical burn pain and can limit morphine consumption 2, 1
• Consider multimodal analgesia combining ketamine with other analgesics, all titrated using validated pain assessment scales 2

Critical Pitfalls to Avoid

The most dangerous error is underestimating injury severity based on visible skin damage alone. Electrical burns cause extensive deep tissue destruction—including muscle, nerve, and vascular damage—that is NOT apparent on surface examination 1, 5, 6

• Do not use standard thermal burn fluid resuscitation targets; electrical burns require higher urine output goals (100 mL/hour) 2, 1
• Do not delay cardiac monitoring, as missed arrhythmias are a significant cause of preventable mortality 1
• Do not perform escharotomy outside a burn center unless absolutely unavoidable; obtain specialist advice first if transfer is impossible 2
• Do not delay fluid resuscitation, as early administration (within 2 hours) significantly reduces morbidity and mortality 3, 1

Ongoing Management Considerations

• Serial surgical debridement using tissue-sparing techniques is required, as the full extent of tissue necrosis evolves over days 7
• Monitor for rhabdomyolysis, acute kidney injury, and myoglobin-induced renal failure through urine output and laboratory values 2
• Early multidisciplinary intervention including physical and occupational therapy prevents contractures and optimizes functional recovery 7