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

Table of Contents

 

About This Issue

Electrical exposure can cause a range of injuries depending on the voltage, source, and event history. Secondary injuries can also occur, depending on the mechanism (eg, blunt trauma from being thrown from a source or falling, or delayed hemorrhage from an oral commissure burn). Multiorgan injury can occur, and the emergency clinician should be prepared to identify and stabilize potential multiorgan system injuries. This issue discusses low-voltage, high-voltage, and lightning strike injuries and provides evidence-based recommendations for management in the emergency department (ED). You will learn:

How injury severity depends on various aspects of the exposure including: (1) the resistance of the victim’s skin, mucosa, and internal structures; (2) the type of current flow; (3) the frequency of the current; (4) the intensity; (5) the duration of contact; and (6) the current’s pathway through the body

Unique characteristics of low-voltage, high-voltage, and lightning injuries

How different body systems are affected by electrical injuries

Key aspects of prehospital care of pediatric patients with electrical injuries, and how this may differ from normal procedures

Various presentations of electrical injuries

When diagnostic studies such as an electrocardiogram (ECG), laboratory testing, and imaging studies are warranted

Recommendations for trauma assessment, fluid administration, muscle and compartment assessment, and analgesia administration

Special considerations for managing patients with lightning injuries, including the timing, duration, and urgency of various complications

Management recommendations for patients with oral commissure burns, including which patients need urgent evaluation by an oral or plastic surgeon, which patients need follow-up, and key anticipatory instructions that should be provided to families/guardians

Recommendations for management of pregnant patients with electrical exposures

Which patients with conducted electrical weapon (CEW) exposure do not need routine ECG, laboratory evaluation, prolonged ED evaluation, or admission for cardiac monitoring

Evidence-based recommendations for disposition of patients with electrical burns, including criteria for hospital admission and burn center referral

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Systems Affected by Electrical Injuries
      1. Central and Peripheral Nervous System
      2. Vascular
      3. Cardiopulmonary
      4. Cutaneous
      5. Musculoskeletal
      6. Renal
      7. Eyes and Ears
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
10. Diagnostic Studies
    1. Electrocardiogram
    2. Laboratory Studies
    3. Imaging Studies
11. Treatment
    1. Minor Injuries
    2. Major Injuries
       1. Fluid Administration
       2. Muscle and Compartment Assessment
       3. Analgesia
       4. Managing Infection
12. Special Considerations
    1. Lightning Injuries
    2. Oral Commissure Burns
    3. Cardiac Electronic Devices
    4. Pregnancy
    5. Conducted Electrical Weapons
13. Controversies and Cutting Edge
    1. Electrocardiogram and Cardiac Monitoring
    2. Prophylactic Antibiotics
    3. Neuropsychological Symptoms
14. Prevention
15. Disposition
    1. Referral to a Burn Center
    2. Patients With Cardiac History
    3. Patients With Oral Commissure Burns
16. Summary
17. Time- and Cost-Effective Strategies
18. Risk Management Pitfalls in Pediatric Patients With Electrical Injuries
19. Case Conclusions
20. Clinical Pathway for Emergency Department Management of Electrical Injuries in Children
21. Tables and Figures
    1. Table 1. Pathophysiologic Effects at Varying Currents
    2. Table 2. Comparison of Low-Voltage, High-Voltage, and Lightning Injuries
    3. Table 3. Presentations of Electrical Injuries
    4. Table 4. Mechanisms of Lightning Injury
    5. Table 5. Complications of Lightning Injuries
    6. Table 6. Admission Criteria
    7. Table 7. Burn Center Referral Criteria
    8. Figure 1. Mechanisms Involved in Electrical Myocardial Injuries
    9. Figure 2. Entry and Exit Point Burns
    10. Figure 3. Modified Lund-Browder Chart
    11. Figure 4. Lichtenberg Figure
    12. Figure 5. Oral Commissure Burn
22. References

Abstract

Electrical injuries in pediatric patients are uncommon but can be life-threatening and require efficient and effective identification and management. Injury severity is based on the characteristics of the electricity, the duration of contact with the electrical source, and the current’s pathway through the body. This issue discusses the specific threats posed by high-voltage, low-voltage, and lightning injuries. The various presentations are described, including burns, arrhythmias, respiratory arrest, cardiac arrest, blunt trauma from falls or blast events, rhabdomyolysis, tympanic membrane rupture, and altered mental status, among others. The most current literature is reviewed, and an evidence-based approach is provided for the diagnosis and management of electrical injuries in pediatric patients presenting to the emergency department.

Case Presentations

A 13-year-old girl who was struck by lightning while playing soccer is brought in by EMS…

• The girl was playing soccer in an open field when a thunderstorm started. While trying to take shelter, lightning struck a tree approximately 2 feet away, and she was thrown several feet. An adult observed that she was unresponsive, so he called 911 and initiated CPR. When EMS arrived, an AED was placed and a shock was delivered, with subsequent return of spontaneous circulation. The patient was prepped for transport with a C-collar in place. During transport, her cardiac rhythm was sinus tachycardia, with a palpable pulse, and bag-valve mask ventilation was initiated for no spontaneous respirations.
• Upon arrival to the ED, the girl is unresponsive. She has an intact airway but no spontaneous respirations. She has symmetric, clear breath sounds with bag-valve mask ventilation. Cardiac rhythm is sinus tachycardia with a palpable pulse, and her blood pressure is 130/90 mm Hg. She has a GCS score of 3. Her pupils are 4- to 5-mm and nonreactive. She has a Lichtenberg figure across her rib cage, an erythematous irregular patch on the dorsum of her right foot, and there is bloody drainage from her left ear.
• How should you evaluate and manage this patient in the ED?

An 18-month-old boy is brought in by his parents after he was found chewing on an electric cord...

• The boy is well appearing, with age-appropriate vital signs. He is noted to have grayish-white tissue on the right oral commissure, without bleeding. His dentition and tongue are intact, he has no trouble handling his secretions, and he is able to drink without problem.
• What complication of this injury should you consider? What is the appropriate disposition for this patient? How should you advise the parents?

A 3-year-old girl is brought into the ED by her father after she was found crying and sitting by a kitchen electrical outlet with a fork next to her…

• The girl is well appearing, with age-appropriate vital signs. She is playing quietly with her father.
• On examination, no external injuries are noted.
• What workup and monitoring are required in the ED? What should this patient’s disposition be? What education should you give her father?

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Clinical Pathway for Emergency Department Management of Electrical Injuries in Children

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. Consumer Product Safety Commission. National Electronic Injury Surveillance System (NEISS) Estimates Query Builder. Accessed November 15, 2021. (Government database)

4. American Burn Association. Burn incidence fact sheet: burn incidence and treatment in the United States: 2016. Accessed November 15, 2021. (Data from National Burn Repository)

9. * Böhrer M, Stewart SA, Hurley KF. Epidemiology of electrical and lightning-related injuries among Canadian children and youth, 1997-2010: a Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) study. CJEM. 2018;20(4):586-591. (Retrospective review; 1183 injuries) DOI: 10.1017/cem.2017.49

20. * Allorto N, Atieh B, Bolgiani A, et al. ISBI practice guidelines for burn care, part 2. Burns. 2018;44(7):1617-1706. (Practice guidelines) DOI: 10.1016/j.burns.2018.09.012

24. * 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) DOI: 10.1097/01.bcr.0000144536.22284.5c

35. * Chen EH, Sareen A. Do children require ECG evaluation and inpatient telemetry after household electrical exposures? Ann Emerg Med. 2007;49(1):64-67. (Systematic review; 7 articles from 1966-2007) DOI: 10.1016/j.annemergmed.2006.05.004

38. * Hansen SM, Riahi S, Hjortshøj S, et al. Mortality and risk of cardiac complications among immediate survivors of accidental electric shock: a Danish nationwide cohort study. BMJ Open. 2017;7(8):e015967. (Retrospective study; 11,462 patients) DOI: 10.1136/bmjopen-2017-015967

39. * Searle J, Slagman A, Maaß W, et al. Cardiac monitoring in patients with electrical injuries. An analysis of 268 patients at the Charité Hospital. Dtsch Arztebl Int. 2013;110(50):847-853. (Retrospective; 268 patients) DOI: 10.3238/arztebl.2013.0847

40. * McLeod JS, Maringo AE, Doyle PJ, et al. Analysis of electrocardiograms associated with pediatric electrical burns. J Burn Care Res. 2018;39(1):65-72. (Retrospective review; 86 patients) DOI: 10.1097/bcr.0000000000000591

58. Pinto DS, Clardy PF. Environmental and weapon-related electrical injuries. Accessed November 15, 2021. (Review article)

59. * Bailey B, Gaudreault P, Thivierge RL, et al. Cardiac monitoring of children with household electrical injuries. Ann Emerg Med. 1995;25(5):612-617. (Retrospective review; 141 patients) DOI: 10.1016/s0196-0644(95)70173-7

63. Joffe MD. Moderate and severe thermal burns in children: emergency management. Accessed January 15, 2021. (Review article)

90. * Barajas-Nava LA, López-Alcalde J, Roqué i Figuls M, et al. Antibiotic prophylaxis for preventing burn wound infection. Cochrane Database Syst Rev. 2013(6):CD008738. (Cochrane review; 36 randomized controlled trials, 2117 participants) DOI: 10.1002/14651858.CD008738.pub2

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Keywords: electrical injuries, pediatric electrical injuries, electrical burns, high-voltage, low-voltage, lightning, lightning strike, lightning injuries, TASER, conducted electrical weapons, CEW, oral commissure burns, labial artery hemorrhage, Lichtenberg figure, EKC, ECG, electrocardiogram, burns, total body surface area, TBSA, Lund-Browder Chart, prevention, burn center referral criteria