|About This Issue|
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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.
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?
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.
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.
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.
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.
Points and Pearls Excerpt
Most Important References
Joshua Gentges, DO; Christoph Schieche, MD
Kelly P. O'Keefe, MD, FACEP; Mark Silverberg, MD, FACEP
November 1, 2018
November 30, 2021
Physician CME Information
Date of Original Release: November 1, 2018. Date of most recent review: October 15, 2018. Termination date: November 1, 2021.
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.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of approval begins 07/01/2017. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Approved for 4 AAFP Prescribed credits.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
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.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
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