Electrical Injuries: Electrical and Lightning Injuries: Merck Manual Pr...

1 of 5

http://www.merckmanuals.com/professional/injuries_poisoning/electri...

SEARCH

> SEE ALL MERCK MANUALS

Merck Manual > Health Care Professionals > Injuries; Poisoning >
Electrical and Lightning Injuries

Electrical Injuries
Electrical injury is damage caused by generated electrical current passing through the body.
Symptoms range from skin burns, damage to internal organs and other soft tissues to
cardiac arrhythmias and respiratory arrest. Diagnosis is based on history, clinical criteria,
and selective laboratory testing. Treatment is supportive, with aggressive care for severe
injuries.
Although accidental electrical injuries encountered in the home (eg, touching an electrical
outlet or getting shocked by a small appliance) rarely result in significant injury or sequelae,
accidental exposure to high voltage results in about 400 deaths annually in the US. There
are > 30,000 nonfatal shock incidents/yr in the US and electrical burns account for about 5%
of admissions to burn units in the US.

Pathophysiology
Traditional teaching is that the severity of electrical injury depends on Kouwenhoven's
factors:
Type of current (direct [DC] or alternating [AC])
Voltage and amperage (measures of current strength)
Duration of exposure (longer exposure increases injury severity)
Body resistance
Pathway of current (which determines the specific tissue damaged)

However, electrical field strength, a newer concept, seems to predict injury severity more
accurately.
Kouwenhoven's factors: AC changes direction frequently; it is the current usually supplied
by household electrical outlets in the US and Europe. DC flows in the same direction
constantly; it is the current supplied by batteries. Defibrillators and cardioverters usually
deliver DC current. How AC affects the body depends largely on frequency. Low-frequency
(50- to 60-Hz) AC is used in US (60 Hz) and European (50 Hz) households. Because
low-frequency AC causes extended muscle contraction (tetany), which may freeze the hand
to the current's source and prolong exposure, it can be more dangerous than high-frequency
AC and is 3 to 5 times more dangerous than DC of the same voltage and amperage. DC
exposure is likely to cause a single convulsive contraction, which often throws the person
away from the current's source.
For both AC and DC, the higher the voltage (V) and amperage, the greater the ensuing
electrical injury (for the same duration of exposure). Household current in the US is 110 V
(standard electrical outlet) to 220 V (used for large appliances, eg, refrigerator, dryer).
High-voltage (> 500 V) currents tend to cause deep burns, and low-voltage (110 to 220 V)
currents tend to cause muscle tetany and freezing contact to the current's source. The
maximum amperage that can cause flexors of the arm to contract but that allows release of
the hand from the current's source is called the let-go current. Let-go current varies with

17/01/2015 23:07

Electrical Injuries: Electrical and Lightning Injuries: Merck Manual Pr...

2 of 5

http://www.merckmanuals.com/professional/injuries_poisoning/electri...

weight and muscle mass. For an average 70-kg man, let-go current is about 75 mA for DC
and about 15 mA for AC.
Low-voltage 60-Hz AC traveling through the chest for even a fraction of a second can cause
ventricular fibrillation at amperage as low as 60 to 100 mA; for DC, about 300 to 500 mA are
required. If current has a direct pathway to the heart (eg, via a cardiac catheter or
pacemaker electrodes), < 1 mA (AC or DC) can cause ventricular fibrillation.
Tissue damage due to electrical exposure is caused primarily by the conversion of electric
energy to heat, resulting in thermal injury. Amount of dissipated heat energy equals
2

amperage resistance time; thus, for any given current and duration, tissue with the
highest resistance tends to suffer the most damage. Body resistance (measured in
2

ohms/cm ) is provided primarily by the skin, because all internal tissue (except bone) has
negligible resistance. Skin thickness and dryness increase resistance; dry, well-keratinized,
2

intact skin averages 20,000 to 30,000 ohms/cm . For a thickly calloused palm or sole,
2

resistance may be 2 to 3 million ohms/cm ; in contrast, moist, thin skin has a resistance of
2

about 500 ohms/cm . Resistance for punctured skin (eg, cut, abrasion, needle puncture) or
moist mucous membranes (eg, mouth, rectum, vagina) may be as low as 200 to 300
2

ohms/cm . If skin resistance is high, more electrical energy may be dissipated at the skin,
resulting in large skin burns but less internal damage. If skin resistance is low, skin burns are
less extensive or absent, and more electrical energy is transmitted to internal structures.
Thus, the absence of external burns does not predict the absence of electrical injury, and the
severity of external burns does not predict the severity of electrical injury.
Damage to internal tissues depends on their resistance
as well as on current density (current per unit area; Pearls & Pitfalls
energy is concentrated when the same current flows
The absence of external burns does not predict the absence
of electrical injury, and the severity of external burns does not
predict the severity of electrical injury.
through a smaller area). For example, as electrical
energy flows in an arm (primarily through lowerresistance tissues, eg, muscle, vessels, nerves), current density increases at joints because
a significant proportion of the joint's cross-sectional area consists of higher-resistance
tissues (eg, bone, tendon), which decreases the area of lower-resistance tissue; thus,
damage to the lower-resistance tissues tends to be most severe at joints.
The current's pathway through the body determines which structures are injured. Because
AC current continually reverses direction, the commonly used terms entry and exit are
inappropriate; source and ground are more precise. The hand is the most common
source point, followed by the head. The foot is the most common ground point. Current
traveling between arm and arm or between arm and foot is likely to traverse the heart,
possibly causing arrhythmia. This current tends to be more dangerous than current traveling
from one foot to the other. Current to the head may damage the CNS.
Electrical field strength: In addition to Kouwenhoven's factors, electrical field strength also
determines the degree of tissue injury. For instance, 20,000 volts (20 kV) distributed across
the body of a man who is about 2 m (6 ft) tall result in a field strength of about 10 kV/m.
Similarly, 110 volts, if applied only to 1 cm (eg, across a young child's lip), result in a similar
field strength of 11 kV/m; this relationship is why such a low-voltage injury can cause the
same severity of tissue injury as some high-voltage injuries applied to a larger area.
Conversely, when considering voltage rather than electrical field strength, minor or trivial
electrical injuries technically could be classified as high voltage. For example, the shock
received from shuffling across a carpet in the winter involves thousands of volts but causes
inconsequential injury.
The electrical field effect can cause cell membrane damage (electroporation) even when the
energy is insufficient to cause any thermal damage.

17/01/2015 23:07

Electrical Injuries: Electrical and Lightning Injuries: Merck Manual Pr...

3 of 5

http://www.merckmanuals.com/professional/injuries_poisoning/electri...

Pathology: Application of low electrical field strength causes an immediate, unpleasant

feeling (being shocked) but seldom results in serious or permanent injury. Application of
high electrical field strength causes thermal or electrochemical damage to internal tissues.
Damage may include hemolysis, protein coagulation, coagulation necrosis of muscle and
other tissues, thrombosis, dehydration, and muscle and tendon avulsion. High electrical field
strength injuries may result in massive edema, which, as blood in veins coagulates and
muscles swell, results in compartment syndromes. Massive edema may also cause
hypovolemia and hypotension. Muscle destruction can result in rhabdomyolysis and
myoglobinuria, and electrolyte disturbances. Myoglobinuria, hypovolemia, and hypotension
increase risk of acute kidney injury. The consequences of organ dysfunction do not always
correlate with the amount of tissue destroyed (eg, ventricular fibrillation may occur with
relatively little tissue destruction).

Symptoms and Signs

Burns may be sharply demarcated on the skin even when current penetrates irregularly into
deeper tissues. Severe involuntary muscular contractions, seizures, ventricular fibrillation, or
respiratory arrest due to CNS damage or muscle paralysis may occur. Brain, spinal cord,
and peripheral nerve damage may result in various neurologic deficits. Cardiac arrest may
occur in the absence of burns as in bathtub accidents (when a wet [grounded] person
contacts a 110-V circuiteg, from a hair dryer or radio).
Young children who bite or suck on extension cords can burn their mouth and lips. Such
burns may cause cosmetic deformities and impair growth of the teeth, mandible, and
maxilla. Labial artery hemorrhage, which results when the eschar separates 5 to 10 days
after injury, occurs in up to 10% of these young children.
An electrical shock can cause powerful muscle contractions or falls (eg, from a ladder or
roof), resulting in dislocations (electrical shock is one of the few causes of posterior shoulder
dislocation), vertebral or other fractures, injuries to internal organs, and other blunt force
injuries.
Subtle or vaguely defined neurologic, psychologic, and physical sequelae can develop 1 to 5
yr after the injury and result in significant morbidity.

Diagnosis
Head to toe examination
Sometimes ECG, cardiac enzyme measurement, and urinalysis

The patient, once away from current, is assessed for cardiac arrest (see Diagnosis) and
respiratory arrest (see also Diagnosis). Necessary resuscitation is done. After initial
resuscitation, patients are examined from head to toe for traumatic injuries, particularly if the
patient fell or was thrown.
Asymptomatic patients who are not pregnant, have no known heart disorders, and who have
had only brief exposure to household current usually have no significant acute internal or
external injuries and do not require testing or monitoring. For other patients, ECG, CBC,
measurement of cardiac enzymes, and urinalysis (to check for myoglobin) should be
considered. Patients with impaired consciousness may require CT or MRI.

Treatment
Shutting off current
Resuscitation
Analgesia
Sometimes cardiac monitoring for 6 to 12 h

17/01/2015 23:07

Electrical Injuries: Electrical and Lightning Injuries: Merck Manual Pr...

4 of 5

http://www.merckmanuals.com/professional/injuries_poisoning/electri...

Wound care

Prehospital care: The first priority is to break contact between the patient and the current
source by shutting off the current (eg, by throwing a circuit breaker or switch, by
disconnecting the device from its electrical outlet). High- and low-voltage power lines are not
always easily differentiated, particularly outdoors. CAUTION: If power lines could be high
voltage, no attempts to disengage the patient should be made until the power is shut off.
Resuscitation: Patients are resuscitated while being assessed. Shock, which may result
from trauma or massive burns, is treated (see Prognosis and Treatment). Standard burn fluid
resuscitation formulas, which are based on the extent of skin burns, may underestimate the
fluid requirement in electrical burns; thus, such formulas are not used. Instead, fluids are
titrated to maintain adequate urine output (about 100 mL/h in adults and 1.5 mL/kg/h in
children). For myoglobinuria, maintaining adequate urine output is particularly important,
while alkalinizing the urine may help decrease the risk of renal failure. Surgical debridement
of large amounts of muscle tissue may also help to decrease myoglobinuric renal failure.
Severe pain due to an electrical burn is treated by the judicious titration of IV opioids.
Other measures: Asymptomatic patients who are not pregnant, have no known heart
disorders, and who have had only brief exposure to household current usually have no
significant acute internal or external injuries that would necessitate admission and can be
discharged.
Cardiac monitoring for 6 to 12 h is indicated for patients with the following conditions:
Arrhythmias
Chest pain
Any suggestion of cardiac damage
Pregnancy (possibly)
Known heart disorders (possibly)

Appropriate tetanus prophylaxis (see Prevention) and topical burn wound care (see Initial
wound care) are required. Pain is treated with NSAIDs or other analgesics.
All patients with significant electrical burns should be referred to a specialized burn unit.
Young children with lip burns should be referred to a pediatric orthodontist or oral surgeon
familiar with such injuries.

Prevention
Electrical devices that touch or may be touched by the body should be properly insulated,
grounded, and incorporated into circuits containing protective circuit-breaking equipment.
Ground-fault circuit breakers, which trip when as little as 5 mA of current leaks to ground,
are effective and readily available. Outlet guards reduce risk in homes with infants or young
children.

Key Points
In addition to burn injuries, AC can freeze the patient's hand to the current source, while DC
can throw the patient, causing injury.
Although skin burn severity does not predict the degree of internal damage, internal damage is
more severe if the skin has low resistance.
Examine patients completely, including for traumatic injuries.
Consider ECG, CBC, cardiac enzymes, urinalysis, and monitoring unless patients are
asymptomatic, are not pregnant, have no known heart disorders, and have had only brief
exposure to household current.
Refer patients with significant electrical burns to a specialized burn unit and, if significant
internal damage is suspected, begin fluid resuscitation.

17/01/2015 23:07

Electrical Injuries: Electrical and Lightning Injuries: Merck Manual Pr...

5 of 5

http://www.merckmanuals.com/professional/injuries_poisoning/electri...

Last full review/revision March 2014 by Daniel P. Runde, MD

Content last modified March 2014

Audio
Copyright
Permissions

Figures

Photographs

Sidebars

Tables

Videos

2009-2015 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Whitehouse Station, N.J., U.S.A.

Privacy

Terms of Use

17/01/2015 23:07