Electrical injury

reatment overview
vigorous resuscitation(4)

o aggressive and prolonged cardiopulmonary resuscitation (CPR) (presence

of fixed and dilated pupils should not prompt discontinuation of
resuscitation efforts)
o automatic external defibrillator (AED) to identify and treat ventricular
tachycardia or fibrillation
o secure airway and provide ventilation and oxygen - early intubation
indicated if evidence of extensive burns (soft tissue swelling may
develop rapidly)
o maintain spinal stabilization if possibility of head or neck trauma

o remove smoldering clothing, shoes, belts to prevent further damage

o rapid IV fluid administration if hypovolemic shock or significant tissue

destruction
patients struck by lightning typically do not need as aggressive fluid resuscitation
as patients with other electric shock(1)
management of burns(1, 2, 3)

o in high voltage injuries do not use estimation of surface burns to guide

therapy since there may be massive necrosis of deeper tissue
o in lightning-strike injuries, burns often superficial requiring expectant
management
o consider surgical decompression or other procedures in selected cases

o refer to specialized burn center

see also

o Cardiac arrest in adults

o Cardiac arrest in children

o Mechanical ventilation

Fluid and electrolytes

initiate rapid IV fluid resuscitation in patients with significant tissue destruction
who have regained pulse(4)
o counteract distributive/hypovolemic shock

o correct ongoing fluid losses due to third spacing

 o ensure adequate fluids to maintain diuresis and facilitate excretion of
myoglobin, potassium, and other products of tissue destruction
(especially in patients with electrical injury)
patients struck by lightning typically do not need fluid resuscitation as aggressive
as patients with other electrical shock(1)
Medications
consider

o mannitol if myoglobulinuria with pigment failing to clear(3)

o pain control with fentanyl and/or morphine (EMS Mag 2010

Feb;39(2):46)
o tetanus immunization

o silver sulfadiazine

see also

o Major burns

o Full-thickness burn

Surgery and procedures

emergent fasciotomy, debridement, and wound exploration for deeper and more
extensive burns(1)
indications for surgical decompression in patients with upper extremity electrical
burn(2)
o progressive neurologic dysfunction

o vascular compromise

o increased compartment pressure (pressure > 30 mm Hg or tissue pressure

reaching within 10-20 mm Hg of diastolic pressure may be evidence of
increased compartment pressure and potential deep tissue injury)
o systemic clinical deterioration from suspected ongoing myonecrosis

surgical decompression of upper extremity electrical burn includes (2)

o forearm fasciotomy

o assessment of muscle compartments

o carpal tunnel release (if warranted)

autologous skin grafting may be necessary(1)

Consultation and referral

specialized burn center(2)
 survivors of lightning strike should be referred for prompt ophthalmology
consult(3)
Other management
aggressive and prolonged cardiopulmonary resuscitation (CPR) indicated in
electrically-shocked patients(1, 3, 4)
o cardiac arrhythmias and respiratory arrest may be only clinical problem,
especially if lightning strike
o patients commonly young without comorbid conditions and may survive
prolonged CPR
o keraunoparalysis with autonomic dysfunction after lightning strike
should not be confused with irreversible neurologic injury (presence of
fixed and dilated pupils should not prompt discontinuation of
resuscitation efforts)
o if 1 person found at scene of injury (especially in lightning strikes),
standard triage should be reversed and first responders should initially
focus on patients appearing dead before patients with signs of life
(survival common in lightning-struck patients without cardiac or
respiratory arrest)
early intubation indicated if evidence of extensive burns (regardless of
spontaneous breathing)(4)
o establishing airway may be difficult if electric burns of face, mouth, or
anterior neck
o extensive soft tissue swelling may develop rapidly

ventilatory support should be continued for reasonable time until cerebral

function can be assessed(1)
morning glucose target < 130 mg/dL (7.2 mmol/L) associated with improved
postburn morbidity and decreased mortality in children with severe burns
over 30% of total body surface (level 2 [mid-level] evidence)
o based on retrospective cohort study

o 287 children with severe burns over 30% of total body surface were
evaluated
o mean morning glucose levels calculated by statistical models and patients
analyzed according to good glucose control (< 130 mg/dL [7.2 mmol/L]
at 6 AM for > 75% of length of stay) vs. poor glucose control (> 130
mg/dL [7.2 mmol/L] at 6 AM for < 75% of length of stay)
o comparing good glucose control vs. poor glucose control

minor infection in mean 3.6 children vs. 7.4 children (p < 0.05)

sepsis in 10% vs. 24% (p < 0.05, NNT 8)

 multiorgan failure in 13.3% vs. 26% (p < 0.05, NNT 8)

mortality 0% vs. 12% (p < 0.05, NNT 9)

o daily mean glucose levels of 140 mg/dL (7.8 mmol/L) for 70% of length
of stay associated with improved morbidity and mortality postburn
o Reference - Ann Surg 2010 Sep;252(3):521, commentary can be found
in Ann Surg 2011 Oct;254(4):671