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Electrical Injuries in the Emergency Department: An Evidence-Based Review (Trauma CME)

 Electrical Injuries - Electric Shock - Burns - Lightening - Cover

Electrical Injuries in the Emergency Department: An Evidence-Based Review - Trauma CME

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  About This Issue

A patient presenting to the ED after an electric shock is a potential multisystem trauma patient. All body systems can be affected by electrical injury: musculoskeletal, cardiac, vascular, respiratory, and neurologic. History and physical examination will be the best indicators of the extent of injury.

•  What are the cutaneous markers for deep tissue injury?
•  How should you prioritize traumatic injury over burn injury?
•  What do the entrance/exit points tell you about which body system may be injured?
•  What are the chances for DVT following deep vascular burn?
•  What are the chances for neurologic injury, including deafness, paresthesia, and delayed depression?
•  All patients will need an ECG, but who requires cardiac monitoring? Who can be discharged?
•  Should you use the Parkland formula for fluids?
•  Should you give prophylactic antibiotics?
•  How should patients with Taser injuries be managed?

  Issue Information

Author: Joshua Gentges, DO; Christoph Schieche, MD

Peer Reviewers: Kelly P. O’Keefe, MD, FACEP; Mark Silverberg, MD, FACEP

Publication Date: November 1, 2018

CME Expiration Date: November 1, 2021

CME Credits: 4 AMA PRA Category 1 CreditsTM, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2A or 2B CreditsIncluded as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits.

PubMed ID: 30358379

  Issue Features
  Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
    1. Varied Tissue Resistance to Electricity
    2. Relating Voltage and Current to Tissue Injury
  6. Differential Diagnosis
    1. Cutaneous Injury
    2. Musculoskeletal Injury
    3. Cardiovascular Injury
    4. Respiratory Injury
    5. Vascular Injury
    6. Neurological Injury
    7. Other Injuries
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
  9. Diagnostic Studies
    1. Electrocardiogram
    2. Laboratory Testing
    3. Diagnostic Imaging
  10. Treatment
    1. Minor Injuries
    2. Major Electrical Injuries
  11. Special Populations
    1. Pediatric Patients
    2. Pregnant Patients
    3. Patients With Taser (Electrical Control Device) Injuries
    4. Lightning Strikes
  12. Controversies
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls for Electrical Injuries in the Emergency Department
  16. Time- and Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway for Emergency Department Management of Electrical Injuries
  19. Tables and Figures
    1. Table 1. Physical Effects at Selected Currents
    2. Table 2. Effects of Low-Voltage Versus High-Voltage Electrical Shock
    3. Table 3. Indications for Cardiac Monitoring After Electrical Injury
    4. Figure 1. Flash Burns in a High-Voltage Injury
    5. Figure 2. High-Voltage Burn
    6. Figure 3. An Electrical Control Device Used by Law Enforcement
    7. Figure 4. Lichtenberg Figures
  20. References

 

Abstract

Electrical injuries can be caused by exposure to current from low-voltage and high-voltage sources as well as lightning strikes, and the circumstances of the exposure will dictate management strategies. Human tissues have varying resistance characteristics and susceptibility to damage, so injuries may be thermal, electrical, and/or mechanical, potentially causing burns, thrombosis, tetany, falls, and blast injury. This issue reviews the types of trauma seen with electrical injury and how body systems can be affected by occult or delayed effects, and the optimal evidence-based resuscitation and management strategies associated with each.

 

Case Presentations

You arrive to work at the regional burn center’s ED, and a nurse pulls you into resuscitation bay 1. Paramedics have presented with a thirtysomething man in cardiac arrest. He had been helping his daughter build a curious device called a Jacob’s ladder—a homemade machine that creates an electrical arc. His presenting rhythm was asystole but by the time of his arrival in the ED, he is in ventricular fibrillation. You wonder if his cardiac arrest is related to the device, and what your next best step is...

As you start work, you wonder where your end-of-shift colleague is. The question is answered when the curtain for bay 2 is pulled back and you see her intubating a young man. She tells you he arrived by ambulance for “burn care.” He fell 12 feet to the ground after his mop pole touched a power line above the semi-trailer he was cleaning. There are minor burns to his hands and chest wall, but more worrisome is the pink fluid draining from his ears and nose. As you assess the patient, you wonder how best to prioritize the patient's workup...

Just as you sit down, a nurse tells you that he has put another electrical injury patient in bay 3; the patient is a 24-year-old man who accidently touched an electrical socket and was thrown backwards to the floor. He didn't hit his head, but he complains of feeling “tingly” all over and slightly nauseated. His vital signs are: blood pressure, 130/ 86 mm Hg; respiratory rate, 16 breaths/min; heart rate, 68 beats/min; and oxygen saturation, 100% on room air. He has no past medical history and a normal physical exam. The nurse asks if he should get an ECG and send a troponin; you wonder...what is best practice?

 

Introduction

Patients with electrical injury pose unique diagnostic and therapeutic challenges that emergency clinicians must not miss. Each year, approximately 10,000 patients present to United States emergency departments (EDs) with electrical burns or electric shock,1 with fatalities declining from around 1000 per year in the early 2000s to 565 in 2015,2 likely because of improved occupational protections.3 An estimated 4% of burn center admissions are due to electrical burns.4 Most electrical injuries are due to household or occupational exposures.1,2 There is a trimodal distribution of patients with electrical injuries; young children are affected most often by household current, adolescent males by high-risk behavior (eg, playing near high-voltage current sources), and adult males by occupational exposure.5-8 Lightning strikes are a subset of electrical injuries with unique features. In the United States, between 25 and 50 people die each year from lightning strikes.2

Electrical injuries can affect every organ system and can cause thermal, electrophysiological, traumatic, and metabolic derangement. Patients may resemble ordinary cardiac, trauma, or burn victims, making recognition challenging, and history is sometimes difficult to obtain. Management of these cases has evolved over time, especially in recommendations for cardiac monitoring and ear, nose, and throat (ENT) care for pediatric oral electrical burns. This issue of Emergency Medicine Practice reviews the current evidence for diagnosis and management of electrical injuries, focusing on recognition of life-threatening and occult injury.

 

Critical Appraisal of the Literature

A literature search was performed using Ovid and MEDLINE® for the period between 1966 to 2018, with the terms emergency, electrical injury, electrocution, and lightning. This provided a list of 477 articles that was narrowed to 88 after initial review. Some resources were identified from article reference lists, and some articles with redundant or outdated information were excluded. The experimental evidence pertaining to electrical injuries is limited, and most clinical practice is based on expert opinion and observational studies. The most recent statistical information was obtained directly from United States governmental survey and statistical data or from occupational and advocacy organizations. Practice guidelines are limited and based on expert opinion, case studies, and observational studies.

 

Risk Management Pitfalls for Electrical Injuries in the Emergency Department

1. “I sent the patient with a low-voltage minor electrical burn home and told her she was fine (she was!). She came back to the ED 2 weeks later and is angry because she developed dizziness and paresthesia in her fingers.”

Electrical injuries have a high incidence of delayed neurological sequelae,41 with studies noting between 25% and 80% of patients reporting neurological complaints after electric shock.39,40 It is important to give specific, detailed discharge instructions, including return precautions for numbness, dizziness, weakness, and mental status changes.

6. “The 2-year-old had a small burn on his face after playing with an electrical cord. There was no airway involvement, and I sent him home to follow up with a burn specialist. Then 24 hours later, he came back bleeding profusely from the mouth…that airway was touch-and-go.”

Oral burns in children who chewed on an electrical cord have up to 24% incidence of bleeding from the labial artery. Proper initial management is controversial, but ENT consultation should be obtained, and if the patient goes home, you must give strict discharge instructions and set patient/family expectations for the possibility of bleeding.48,49

10. “This high-voltage injury patient came to the ED with 10% total body surface area burns. I followed the Parkland formula for fluids, but she stayed hypotensive and, during her hospital course, developed acute renal failure. I thought that formula was solid for taking care of a burn patient.”

Electrical burns on the skin do not necessarily give a clear picture as to how much tissue was actually damaged by thermal and electrical energy. Isotonic IV fluids sufficient to maintain urine output at 1.0 to 1.5 cc/kg/ hr must be given to these patients. Continue fluid resuscitation until you reach that urine output and urine myoglobin has cleared. Fluid requirements may be much higher than specified by the Parkland formula. CK levels and myoglobinuria should be monitored.

 

Tables and Figures

Electrical Injuries - Electric Shock - Burns - Lightening - Physical Effects at Selected Currents

 

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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  2. The Fire Protection Research Foundation. Multiple cause of death, 1999-2015 results form. Available at: https://wonder.cdc.gov/controller/datarequest/D77. Accessed October 10, 2018. (Government database)
  3. National Fire Protection Association. Occupational Injuries from Electrical Shock and Arc Flash. 2018. Available at: https://www.nfpa.org/News-and-Research/Fire-statistics-and-reports/Research-reports/Electrical-safety/Occupational-Injuries-from-Electrical-Shock-and-Arc-Flash-Events. Accessed October 10, 2018. (Research foundation report)
  4. American Burn Association. Burn incidence fact sheet. 2016; http://ameriburn.org/who-we-are/media/burn-incidence-fact-sheet/. Accessed October 10, 2018. (Data from National Burn Repository)
  5. Electrical Safety Foundation International. ESFI Occupational Injury and Fatality Statistics. 2017; http://www.esfi.org/workplace-injury-and-fatality-statistics. Accessed October 10, 2018. (Industry data)
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  CME Information

Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.

Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.

Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Gentges, Dr. Schieche, Dr. O'Keefe, Dr. Silverberg, Dr. Mishler, Dr. Toscano, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Dr. Jagoda made the following disclosures: Consultant, Daiichi Sankyo Inc; Consultant, Pfizer Inc; Consultant, Banyan Biomarkers Inc; Consulting fees, EB Medicine.

Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.

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AAP AAP
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AEMAA AEMAA
HONcode HONcode
STM STM

 

Last Modified: 11/16/2018
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