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
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?
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.
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.
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.
Suzanne Roberts, DO, MPH; James A. Meltzer, MD
September 1, 2013