Table of Contents

 

1. Abstract
2. Case Presentation
3. Introduction
4. Critical Appraisal Of The Literature
5. Etiology And Pathophysiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Airway, Breathing, And Circulation
      2. Cervical Spine And Neurologic System
      3. Cardiovascular System
      4. Skin
      5. Renal System
      6. Eyes And Ears
      7. Musculoskeletal
9. Diagnostic Studies
   1. Laboratory Testing
   2. Imaging
   3. Electrocardiogram
10. Treatment
    1. Airway, Breathing, And Circulation
    2. Cervical Spine And Neurologic System
    3. Cardiovascular System
    4. Skin
    5. Renal System
    6. Eyes And Ears
    7. Musculoskeletal System
11. Special Circumstances
    1. Burns Of The Oral Commissure
    2. Electrical Weapons
12. Cutting Edge
13. Disposition
14. Summary
15. Risk Management Pitfalls For Electrical Injuries
16. Time- And Cost-Effective Strategies
17. Case Conclusion
18. Clinical Pathway For Management Of Electrical Injury In Children
19. Tables and Figures
    1. Table 1. Characteristics Of Electricity And Injury By Electrical Exposure
    2. Table 2. Injuries Due To Lightning
    3. Figure 1. Lichtenberg Figure Secondary To A Lightning Strike
    4. Figure 2. Lund-Browder Chart For Calculating The Percentage Of A Childs Total Body Surface Area Burned
    5. Figure 3. Oral Commissure Burn
20. References

Abstract

Electrical injuries, while uncommon, can be associated with significant morbidity and mortality. In children, the injuries tend to occur in the household; in adolescents, they are most often associated with misguided youthful exploration outside the home. Injuries in adults are primarily occupational and due to workplace accidents. Electrical injuries are categorized by their electrical source and can result from low-voltage, high-voltage, lightning strike, or electrical arc exposure. The injury can range from minor to life threatening, and they can cause multisystem complications. High-voltage electrical exposures usually cause severe burns, whereas victims of lightning strikes may have no obvious physical injury but may present in cardiopulmonary arrest. Strategies to prevent electrical injuries have been developed and should be discussed with families and healthcare providers to reduce the incidence of these injuries in children. This review highlights the current literature related to the evaluation and management of children with electrical injuries presenting to the emergency department.

Key words: pediatric electrical injuries, electrical burns, high-voltage burns, low-voltage burns, lightning injuries, arc injury, cardiac complications, electrocution, Taser, oral burns, rhabdomyolysis

Case Presentation

A 17-year-old male with electrical burns is brought by EMS to your ED. The EMS provider reports that the patient was climbing up a utility pole when he lost his balance. Reportedly, while he was still in contact with the pole, he grabbed onto a live power line and was thrown about 20 feet to the ground. He experienced a loss of consciousness of unknown duration at the scene. Upon your physical exam, the teenager is alert, oriented, and has bilateral third-degree burns to his hands and wrists. What type of electrical exposure is this? What complications are you concerned about this patient developing? What diagnostic studies should you order? Does he require admission to the hospital?

EMS transports a 2-year-old previously healthy boy to your ED after his mother found him chewing on an electrical cord. The physical exam is remarkable for an alert, active, crying child in no acute distress. He has a 2-cm grayish-white lesion with an erythematous border at the right corner of his mouth, and he is drooling. What type of electrical injury is this? What should you do next? Does this child require admission to the hospital? What are the risks associated with this injury, and what are the available treatments?

A 16-year-old female presents to your ED after being struck by lightning while playing soccer during a thunderstorm. She was thrown 10 feet and fell to the ground. Her friend immediately called 911, and when EMS arrived, the patient was noted to be in cardiac arrest in asystole. Paramedics began CPR, without immediate return of spontaneous circulation. She was transported to the nearest hospital, with ongoing compressions and assisted ventilation. In the ED, you intubate her, continue CPR, and administer epinephrine. The patient regains a pulse and converts to normal sinus rhythm. When you examine her, you note a burn on her chest with a feathering pattern. What should you do next in assessing this patient? What complications are associated with lightning injuries? Should this patient be admitted to the hospital?

Introduction

While lightning-related injuries have been described for thousands of years, reports of nonlightning-related electrical injuries date back approximately 300 years.¹ The first reported death from artificial electricity occurred in 1879 and was due to contact with a high-voltage generator.¹ As societies have become more industrialized and more reliant on electricity to power machines, injuries from electricity have become more prevalent.

Pediatric electrical injuries are, primarily, unintentional and preventable. Due to their exploratory nature, young children are most often injured from contact with low-voltage household electrical cords, outlets, and appliances. Teenagers, who often engage in risk-taking behavior or who may encounter electricity in their employment, may have injuries resulting from contact with high-voltage power lines and utility poles.^2-4

There is a wide spectrum of electrical injuries, ranging from minor burns to cardiopulmonary arrest and death.^3,5 Electrical injuries can be classified as low voltage ( < 1000 V), high voltage (> 1000 V), lightning strike, and electrical arc injuries.^5-7 Most household exposures are low voltage. High-voltage and lightning injuries are both secondary to exposure to > 1000 V; however, the primary difference is the duration of contact and pattern of injuries.^3,6,8 (See Table 1.)

Electrical arc injuries occur when a patient is in close proximity to an electrical source and the current jumps from the source to the patient in its attempt to follow the path of least resistance. The current does not pass through the patient; rather, the current arc comes into direct contact with the victim’s skin.⁷ An arc forms between the electrical source and an object (eg, umbrella, metal rod), and it can generate temperatures up to 4000°C. Patients who receive electrical arc injuries can suffer extensive flash-type burns. While arc injuries may be high or low voltage, the majority come from household current and, therefore, are low voltage.⁷

Because of the associated morbidity and mortality in children who suffer electrical injures, prompt, evidence-based care for these patients is essential. This month’s issue of Pediatric Emergency Medicine Practice will address the management of electrical injuries in the pediatric patient.

Critical Appraisal Of The Literature

An online literature search was performed using the PubMed and Ovid MEDLINE® databases. Multiple search terms were used, including: pediatric electrical injuries, electrical injuries, burns, electrical burns, environmental injuries, lightning injuries, cardiac complications, electrocution, Taser®, oral burns, oral commissure stents, amputation after electrical injury, and rhabdomyolysis. All relevant articles were identified and reviewed, and 64 references are included in this article. Treatment guidelines for electrical burn injuries set forth by the Work Loss Data Institute9 were found on the National Guideline Clearing House website (www.guideline.gov), and guidelines from the American Burn Association were also reviewed.^10,11 However, these guidelines only focused on adult patients. To date, there are no published guidelines or randomized controlled trials for the management of electrical burns in children, and the available published clinical evidence on pediatric electrical injuries is lacking.

Risk Management Pitfalls For Electrical Injuries

1. “I know the child was struck by lightning, but he has no external burns, so I thought he could be discharged.” The electrical current can penetrate deeply and cause deep tissue destruction even in the absence of extensive surface-area burns. As noted by a study by Tarim and Ezer, the cross-sectional area of the burn is inversely related to the depth/ extent of tissue injury.³⁹ This is especially true in patients with lightning and high-voltage injuries. You should consider admitting the patient because there may be deep tissue destruction that is not externally visible.
2. “The child suffered full-thickness burns to his chest after contact with a high-voltage power line. I decided to administer prophylactic antibiotics to decrease the risk of infection.” The American Burn Association does not support the administration of prophylactic antibiotics to every patient with a burn; the use of antibiotics should be reserved for those who develop infected wounds.
3. “The child had an electrical burn at the oral commissure. She did not require follow-up with any medical provider, because these types of burns heal without any complications.” Patients with minimal burns to the oral commissure usually do not require extensive diagnostic evaluation or admission to the hospital; however, patients with moderate to severe burns of the oral commissure should be promptly referred to an oral or plastic surgeon because the burn may extend deeper than the superficial layer. The surgeon may place a stent to minimize future scarring. Patients with burns at the oral commissure secondary to chewing on an electrical cord are at a high risk of delayed bleeding from the labial artery 2 to 21 days after the initial incident. Inform the parents of this potential complication prior to discharge.
4. “Even though the patient was electrocuted after touching the third rail, his initial ECG was normal, so I sent him home.” The third rail is the high-voltage electrified rail that provides power to a railway track. All patients with high-voltage injuries should be admitted for cardiac monitoring. Although late dysrhythmias are rare (especially if the initial ECG is normal), high-voltage electrical exposure is an important risk factor for developing a cardiac abnormality.
5. “I think this 6-year-old child with 12% burns can be admitted to my community hospital.” According to the American Burn Association, any patient with > 10% surface-area burn should be transferred to a burn facility for consultation by a burn specialist and further monitoring.
6. “The adolescent who was struck by lightning was observed in the hospital for 2 days and had a normal examination, so I arranged follow-up only with the primary care doctor.” Cataracts are a known complication secondary to lightning strikes. There may be a delay in the development of these cataracts. All lightning-strike victims should be referred for ophthalmologic evaluation. These patients are also at high risk for tympanic membrane rupture and should have a formal evaluation by an otolaryngologist during or immediately after their inpatient stay.
7. “As an EMS provider, I encountered 2 adolescents who had been struck by lightning. One was injured with severe burns to his legs, and the other was unresponsive and pulseless. I attended to the burn victim and pronounced the other victim dead at the scene without any further intervention.” The traditional rules of mass triage do not apply to victims of lightning strike. Even patients who are in cardiac arrest at the scene have a high chance of survival with immediate and prolonged resuscitation; therefore, they should be attended to first.
8. “A teenage boy was found near some downed wires. On physical examination, he was well hydrated, so I did not start intravenous fluids, although the urine appeared brown. I wanted to wait for the test results.” Victims of high-voltage electrical injuries are at high risk for developing rhabdomyolysis. The literature shows that these patients have better outcomes if intravenous fluids are initiated early in the course of treatment.
9. “The girl who was struck by lightning had a normal mental status and neurological examination on initial presentation to the ED, so I discharged her home to follow up with her primary care provider in a few days.” All victims of lightning strike should have repeat neurologic examinations while inpatients, since they are at risk for developing cerebral edema several hours after the insult. Upon discharge, the patient should be referred to a learning specialist for periodic testing to ensure cognitive clarity.
10. “Although the adolescent appeared well after being “tased” by police, I wanted to admit him because it was a high-voltage exposure.” Electrical exposure by electrical weapons causes minimal physical harm, since the exposure is typically brief and a low amperage. Asymptomatic patients do not require extensive diagnostic testing, ED observation, or admission.

Tables and Figures

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 will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

1. Price TG, Cooper MA. Electrical and lightning injuries. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine, Concepts and Clinical Practice. Philadelphia, PA: Mosby Elsevier; 2006:67-78. (Textbook)
2. Toon MH, Maybauer DM, Arcebeaux LL, et al. Children with burn injuries--assessment of trauma, neglect, violence and abuse. J Inj Violence Res. 2011;3(2):98-110. (Review article)
3. Ludwig S, Fleisher GR, Henretig FM, et al. Textbook of Pediatric Emergency Medicine. 6th ed. Baltimore: Williams & Wilkins; 2010:799-803. (Textbook)
4. Lee RC, Zhang D, Hannig J. Biophysical injury mechanisms in electrical shock trauma. Annu Rev Biomed Eng. 2000;2:477- 509. (Review article)
5. * Arnoldo BD, Purdue GF, Kowalske K, et al. Electrical injuries: a 20 year review. J Burn Care Rehabil. 2004;25(6):479-484. (Retrospective review; 700 patients)
6. O’Keefe Gatewood M, Zane RD. Lightning injuries. Emerg Med Clin North Am. 2004; 22(2):369-403. (Review article)
7. Maghsoudi H, Adyani Y, Ahmadian N. Electrical and lightning injuries. J Burn Care Res. 2007;28(2):255-261. (Retrospective review; 202 patients)
8. Koumbourlis AC. Electrical injuries. Crit Care Med. 2002;30(11):S425-S430. (Review)
9. Work Loss Data Institute. Burns. Available at: http://www. guideline.gov/content.aspx?id=25691&search=burns. Accessed April 10, 2013. (Practice guidelines)
10. Saffle JR. Practice guidelines for burn care. J Burn Care Rehabil. 2001;22(4):S1-S69. (Practice guidelines)
11. Arnoldo B, Klein M, Gibran NS. Practice guidelines for the management of electrical injuries. J Burn Care Res. 2006;27(4):439-447. (Practice guidelines)
12. D’Souza AL, Nelson NG, McKenzie LB. Pediatric burn injuries treated in US emergency departments between 1990-2006. Pediatrics. 2009;124(5);1424-1430. (Retrospective review; 62,196 patients)
13. Ciorciari AJ. Environmental emergencies. In: Crain EF, Gershel J, eds. Clinical Manual of Emergency Pediatrics. 5th ed. New York: Cambridge University Press; 2010:200-218. (Textbook chapter)
14. Cooper MA, Andrews CJ, Holle RL. Lightning injuries. In: Auerbach PS, ed. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby Elsevier; 2007:67-108. (Textbook chapter)
15. Akkaş M, Hocagil H, Ay D, et al. Cardiac monitoring in patients with electrocution injury. Ulus Travma Acil Cerrahi Derg. 2012;18(4):301-305. (Retrospective review; 102 patients)
16. Duclos PJ, Sanderson LM. An epidemiological description of lightning-related deaths in the United States. Int J Epidemiol. 1990;19(3):673-679. (Retrospective review; 1916 patients)
17. Centers for Disease Control and Prevention. Lightning-associated deaths--United States, 1980-1995. MMWR Morb Mortal Wkly Rep. 1998;47(19):391-394. (Government publication)
18. * Celik A, Ergün O, Ozok G. Pediatric electrical injuries: a review of 38 consecutive patients. J Pediatr Surg. 2004;39(8):1233- 1237. (Retrospective review; 38 patients)
19. * Gokdemir MT, Kaya H, Söğüt O, et al. Factors affecting the clinical outcome of low-voltage electrical injuries in children. Pediatr Emerg Care. 2013:29(3):357-359. (Cross-sectional study; 36 patients)
20. Garcia CT, Smith GA, Cohen DM, et al. Electrical injuries in a pediatric emergency department. Ann Emerg Med. 1995;26(5):604-608. (Retrospective review; 78 patients)
21. Rabban JT, Blair JA, Rosen CL, et al. Mechanisms of pediatric electrical injury. New implications for product safety and injury prevention. Arch Pediatr Adolesc Med. 1997;151(7):696- 700. (Case series; 144 patients)
22. Cherington M. Spectrum of neurologic complications of lightning injuries. Neuro Rehabilitation. 2005;20(1):3-8. (Review)
23. Ritenour AE, Morton MJ, McManus JG, et al. Lightning injury: a review. Burns. 2008;34(5):585-594. (Review article)
24. Bartholome CW, Jacoby WD, Ramchand SC. Cutaneous manifestations of lightning injury. Arch Dermatol. 1975;111(11):1466-1468. (Case report)
25. Arnoldo BD, Purdue GF. The diagnosis and management of electrical injuries. Hand Clin. 2009;25(4):469-479. (Review article)
26. Singh S, Sankar J, Dubey N. Non-cardiogenic pulmonary oedema following accidental electrocution in a toddler. BMJ Case Rep. 2011 Apr 19;2011. (Case report; 1 patient)
27. Ko SH, Chun W, Kim HC. Delayed spinal cord injury following electrical burns: a 7-year experience. Burns. 2004;30(7):691-695. (Retrospective review; 13 patients)
28. Levine NS, Atkins A, McKeel DW Jr, et al. Spinal cord injury following electrical accidents: case reports. J Trauma. 1975;15(5):459-463. (Case report; 2 patients)
29. Cooper MA. Lightning injuries: prognostic signs for death. Ann Emerg Med. 1980;9(3):134-138. (Retrospective review; 205 patients)
30. ten Duis HJ, Klasen HJ, Reenalda PE. Keraunoparalysis, a “specific” lightning injury. Burns Incl Therm Inj. 1985;12(1):54-57. (Case series; 2 patients)
31. Arrowsmith J, Usgaocar RP, Dickson WA. Electrical injury and the frequency of cardiac complications. Burns. 1997;23(7- 8):576-578. (Retrospective review; 145 patients)
32. Wright RK, Davis JH. The investigation of electrical deaths: a report of 220 fatalities. J Forensic Sci. 1980;25(3):514-521. (Retrospective review; 220 patients)
33. Rai J, Jeschke, MG, Barrow RE, et al. Electrical injuries: a 30-year review. J Trauma. 1999;46(5):933-936. (Retrospective review; 185 patients)
34. Rosen CL, Adler JN, Rabban JT, et al. Early predictors of myoglobinuria and acute renal failure following electrical injury. J Emerg Med. 1999;17(5):783-789. (Retrospective multivariate analysis; 211 patients)
35. Saffle JR, Crandall A, Warden GD. Cataracts: a long-term complication of electrical injury. J Trauma. 1985;25(1):17-21. (Retrospective review; 113 patients)
36. Gluncić I, Roje Z, Gluncić V, et al. Ear injuries caused by lightning: report of 18 cases. J Laryngol Otol. 2001;115(1):4-8. (Retrospective review; 18 patients)
37. Wetli CV. Keraunopathology. An analysis of 45 fatalities. Am J Forensic Med Pathol. 1996;17(2):89-98. (Retrospective review; 45 patients)
38. Pannucci CJ, Osborne NH, Jaber RM, et al. Early fasciotomy in electrically injured patients as a marker for injury severity and deep venous thrombosis risk: an analysis of the National Burn Repository. J Burn Care Res. 2010;31(6):882-887. (Retrospective review; 1469 patients)
39. Tarim A, Ezer A. Electrical burn is still a major risk factor for amputations. Burns. 2013;39(2):354-357. (Retrospective review; 1144 patients)
40. Bailey DM, Bärtsch P, Cooper MA. Electron paramagnetic resonance spectroscopic evidence of increased free radical generation and selective damage to skeletal muscle following lightning injury. High Alt Med Biol. 2003;4(3):281-289. (Case report)
41. Kim SH, Cho GY, Kim MK et al. Alterations in left ventricular function assessed by two-dimensional speckle tracking echocardiography and the clinical utility of cardiac troponin I in survivors of high-voltage electrical injury. Crit Care Med. 2009;37(4):1282-1287. (Prospective clinical study; 20 patients)
42. Milano M. Oral electrical and thermal burns in children: review and report of case. ASDC J Dent Child. 1999;66(2):116- 119. (Case report)
43. Nagel TR, Schunk JE. Using the hand to estimate the surface area of a burn in children. Pediatr Emerg Care. 1997;13(4):254- 255. (Prospective convenience sample; 91 patients)
44. Yeroshalmi F, Sidoti EJ Jr, Adamo AK, et al. Oral electrical burns in children--a model of multidisciplinary care. J Burn Care Res. 2011;32(2):25-30. (Case report; 1 patient)
45. American Burn Association/American College of Surgeons. Guidelines for the operation of burn centers. J Burn Care Res. 2007;28(1):134-141. (Clinical guideline)
46. Hettiaratchy S, Papini R. Initial management of a major burn: II—assessment and resuscitation. BMJ. 2004;329(7457):101-103. (Review)
47. Scharman EJ, Troutman WG. Prevention of kidney injury following rhabdomyolysis: a systematic review. Ann Pharmacother. 2013;47(1):90-105. (Systematic review; 27 studies)
48. Mannix R, Tan ML, Wright R, et al. Acute pediatric rhabdomyolysis: causes and rates of renal failure. Pediatrics. 2006;118(5):2119-2125. (Retrospective review; 210 patients)
49. Parshley P, Kilgore J, Pulito JF, et al. Aggressive approach to the extremity damaged by electric current. Am J Surg. 1985;150(1):78-82. (Retrospective review; 75 patients)
50. Luce E, Gottlieb SE. “True” high-tension electrical injuries. Ann Plast Surg. 1984;12(4):321-326. (Retrospective review; 48 patients)
51. Achauer B, Applebaum R, Vander Kam VM. Electrical burn injury to the upper extremity. Br J Plast Surg. 1994;47(5):331- 340. (Case report)
52. Haberal M. Electrical burns: a five-year experience--1985 Evans lecture. J Trauma. 1986;26(2):103-109. (Retrospective review; 94 patients)
53. Thomas SS. Electrical burns of the mouth: still searching for an answer. Burns. 1996;22(2):137-140. (Review article)
54. Bleetman A, Steyn R, Lee C. Introduction of the Taser® into British policing. Implications for UK emergency departments: an overview of electronic weaponry. Emerg Med J. 2004;21(2):136-140. (Review article)
55. Vilke GM, Bozeman WP, Chan TC. Emergency department evaluation after conducted energy weapon use: review of the literature for the clinician. J Emerg Med. 2011;40(5):598-604. (Systematic review)
56. Bozeman WP, Hauda WE 2nd, Heck JJ, et al. Safety and injury profile of conducted electrical weapons used by law enforcement officers against criminal suspects. Ann Emerg Med. 2009;53(4):480-489. (Prospective multicenter observational study; 1201 patients)
57. Bozeman WP, Teacher E, Winslow JE. Transcardiac conducted electrical weapon (Taser®) probe deployments: incidence and outcomes. J Emerg Med. 2012;43(6):970-975. (Retrospective review; 1201 patients)
58. Gardner AR, Hauda WE II, Bozeman WP. Conducted electrical weapon (Taser®) use against minors: a shocking analysis. Ped Emerg Care. 2012;28(9):873-877. (Retrospective review; 2026 subjects)
59. Garner A. Documentation and tagging of casualties in multiple casualty incidents. Ann Emerg Med (Fremantle). 2003;15(5-6):475-479. (Review article)
60. Shrivastava P, Goel A. Prehospital care in burn injury. Indian J Plast Surg. 2010;43(Suppl): S15-S22. (Review)
61. Tomkins KL, Holland JA. Electrical burn injuries in children. J Paediatr Child Health. 2008;44(12):727-730. (Retrospective review; 22 patients)
62. Bailey B, Gaudreault P, Thivierge RL. Cardiac monitoring of high-risk patients after an electrical injury: a prospective multicentre study. Emerg Med J. 2007;24(5):348-352. (Multicenter prospective observational study; 134 patients)
63. Purdue GF, Hunt JL. Electrocardiographic monitoring after electrical injury: necessity or luxury. J Trauma. 1986;26(2):166- 167. (Retrospective review; 48 patients)
64. Cunningham PA. The need for cardiac monitoring after electrical injury. Med J Aust. 1991;154(11):765-766. (Retrospective review; 70 patients)

Table of Contents: