- This document contains information on various electrical injury cases presented to the emergency department, including details on mechanisms of injury, clinical presentations, investigations, and management strategies. Key points include treating electrical injury patients as trauma patients, avoiding premature withdrawal of resuscitation due to the unreliable signs of death, monitoring for cardiac dysrhythmias, rhabdomyolysis, and neurovascular compromise of injured extremities. High voltage or lightning injuries can cause severe internal injuries despite minor external burns and require prolonged cardiac monitoring and aggressive IV fluid resuscitation.

1. QUIZ
• Answers
1. C
2. B
3. A
4. D
5. D
6. B
7. C
8. B
9. A
10. D, but no cases of this being an issue.
11. C
12. B

2. CASES

3. THE ELECTRICIAN
• Found unconscious near a generator. Now awake but amnesic and confused
• Burns to chest and arms
• VWNL
• Ax?
• High voltage injury likely
• Transthoracic
• Mx?
• Resuscitate
• Survey injuries, esp burns and head
• Cx spine precautions and CT
• ECG
• UA
• CK/myoglobin
• IVH, targeting UO >1mL/kg/hr
• NVO – compromised RUL
• TF to FSH burns. Subsequent fasciotomy RUL

4. THE BLOW-DRYER BABE
• Using hairdryer whilst standing on a wet floor
• Felt “a shock”
• R palmar erythema only
• Mx?
• ECG normal
• Silver dressing, ADT, burns clinic FU

5. THE HAPPY CAMPERS
• 3 campers
• Tent struck by lightning
• Cardiac arrest w 10min CPR
• Bleeding ears and unable to hear
• Pale, mottled, numb LLs
• CPR continued and ROSC achieved despite fixed dilated pupils. In ICU, pupils returned to
normal – pt did not have severe hypoxic brain injury
• Ruptured TM
• Keraunoparalysis

6. HOUSE, MD
• Sticks knife into a power socket to see if there is an afterlife
• Suffers cardiac arrest, after which he is apparently fine
• Is this realistic?
• Consider the path of a current – where was the “grounding”?

7. TOUCHED BY GOD
• Professional storm chaser
• Pulseless blue legs amongst other injuries
• Started on heparin infusion on presumption of arterial thrombosis
• ICH results
• Keraunoparalysis
• Does not require treatment and spontaneously resolves

8. HUNGRY HILLARY
• Tried to get toast from toaster w knife 3mo ago. Seen in ED and
essentially unhurt apart from minor R hand burn.
• Now c/o entire R forearm diffuse pain, swelling, and coolness
• CRPS

9. TEETHING THOMAS
• Chewed electrical cord
• Minor oral burns
• Other considerations?
• Then develops airway oedema
• Eventually TF to burns unit
• Represents 2 weeks later with severe labial bleeding
• Eschar separation and labial artery bleeding
• Should have counselled parents on haemorrhage control

10. ELECTRICAL INJURY

11. EPIDEMIOLOGY
• ~25 deaths/year in Australia
• Majority young men in industrial setting

12. FACTORS INFLUENCING DEGREE OF INJURY
• Current, a flow of charge, measured in Amperes
• Voltage, the electrical potential difference driving the flow, the energy per unit of charge
• Resistance, the impedance to flow of charge
• Ohm’s law: I = V/R
• Current α voltage
• Voltage is used to classify injuries because it is the only variable that can be reliably measured.
• Current α 1/resistance
• Low resistance tissues: nerve, muscle, vessels, membranes.
• High resistance tissues: bone, fat, tendon
• Water on skin reduces resistance 40x!
• Power = VI = I2R = V2/R
• Heat = Pt = I2Rt = V2t/R
• Type of current
• DC causes muscle spasm and throwing
• AC can cause repeated spasm and grasping, depending on the frequency, leading to higher exposure time and possible dislocation
• Path of current through pt. Usually to the ground.
• Example: Household = 230V AC

14. MECHANISMS OF INJURY
• Current itself
• Thermal burns
• Mechanical trauma e.g. from throwing or convulsing

15. SOURCES
• >1000V
• Minimum of 24hr cardiac monitoring due to dysrhythmia risk
• BP monitoring due to autonomic dysfunction risk
• Serial neurovascular obs
• Admit cardiology or obs unless otherwise indicated by injuries
• <1000V
• And asymptomatic and examining normally – DC after ECG
• And mild Sx with normal ECG/UA – DC after few hours’ observation
• And ECG changes, LOC, injury – admit

16. LIGHTNING
• Likely admission, potentially ICU or burns unit
• Brief, ultra-high voltage, DC
• Tends to flash over the pt and into orifices e.g. mouth and ears, rather than go through the pt
• 32% mortality. Almost all from initial cardiac arrest or from resp arrest.
• In event of multiple casualty, triage priority altered. First treat those who appear dead. Often respond well to CPR/defibrillation.
• Morbidity is predominantly from neurologic issues.
• Immediate and transient: LOC, seizure, confusion, anterograde amnesia, weakness, paraesthesia, inattention, HA, irritability
• Lightning paralysis “keraunoparalysis”: LL vascular compromise and paralysis lasting a few hr only due to vasospasm and dysautonomia
• Immediate and persistent: hypoxaemic or haemorrhagic injuries
• Delayed: motorneurone disease-like effects
• Fewer burns. More CVS, resp, neuro complications including asystolic arrest. Shockwave effect like a blast.
• Otologic and ophthalmic injury common. TM rupture may be only sign of lightning in pt w collapse outdoors.
• Pt can be approached immediately.

17. TASER
• High voltage, low current electricity through the target
• <15sec and clinically well = NOT dangerous and pts do not
require observation
• All of the few deaths previously associated with taser have
involved dysrhythmia-inducing drugs also

18. CHEWED ELECTRICAL CORD
• Oral arc burns
• Plastics/max-facs for debridement/recon/oral splinting
• Risk of severe labial artery bleeding after delayed eschar separation – pts
need education pre-discharge
• Thinner skin in children = likely more severe injury
• Risk of airway obstruction

19. SYNDROMES

20. CARDIAC
• Dysrhythmia is the most common
• VF at low exposures, asystole at high exposures including lightning
• 4-17% of electrocutions
• Esp hand-to-hand electrocution
• Rarely delayed. Most cases of delayed dysrhythmia also had dysrhythmia initially. Get early ECG.
• Energy levels for cardioversion are unchanged
• Often respond well to defibrillation and resuscitation
• Myocardial injury uncommon
• Mx
• Prolonged resus as pts are young and outcomes are good even if in asystole and signs of brain death may be unreliable in this
group
• Cardiac monitor if dysrhythmia, LOC, or >1000V
• Troponin levels not well studied

21. RESPIRATORY
• Respiratory failure from respiratory muscle tetany or
respiratory centre injury or cardiac arrest
• Mx: secure the airway

22. BURNS
• Vary with voltage. Small, superficial, well demarcated for low voltage. Necrotic punctate ulceration for high voltage.
• Special lightning burns: linear along fluid lines, punctate, feathering (nonserious), thermal.
• Entry and exit. Often under-predict internal damage. Check head/hands/feet.
• Mouth in children.
• Skin flexture “kissing” burns often associated with underlying tissue damage.
• Consider airway burns from coexistent smoke inhalation
• Mx:
• May need more IVH than formulae suggest due to concomitant rhabdomyolysis
• Silver dressings
• ADT
• Elevate
• Burns specialist

23. NEUROLOGIC
• 50% incidence in high-voltage injury, likely because nerve tissue has lowest
resistance.
• Central: LOC, memory disturbance, weakness, spinal cord injury – ALS/TM-
like, seizure, confusion, coma, aphasia
• Autonomic dysfunction: dilated pupils, hypotension, hypertension, arrest,
syncope, vasoconstriction, thermodysregulation, tachycardia,
• Peripheral: motor and sensory, CRPS – may be delayed
• Need CT to differentiate between electric and traumatic effects
• Persistent: inattention, poor memory, impaired learning

24. MUSCULAR
• Commonly rhabdomyolysis, coagulation necrosis, compartment
syndrome from oedema
• Check for myalgia
• NV exam
• Mx: IVH aggressively, check electrolytes <4hourly esp watching
K+, UO >1mL/kg/hr, fasciotomy for compartment syndrome or
ongoing myonecrosis

25. VASCULAR
• Usually tunica media injury leading to aneurysm or rupture.
Intimal injury leads to thrombosis.
• Commonly in small arteries to muscle. Results in myonecrosis.

26. ORTHOPAEDIC
• Highest resistance. Generates high heat when current passes.
• Osteonecrosis, periosteal burns, matrix breakdown
• Trauma from throwing, convulsions, shockwaves. Posterior
shoulder dislocation common.
• Mx: as trauma patient

27. OCULAR AND OTOLOGIC
• Ophthalmologic
• Corneal commonest. Erosion, keratitis, scarring
• Cataract – may be delayed and pts w high voltage injury ought to be
warned, hyphaema, vitreous haemorrhage, optic neuropathy
• Hearing impairment
• Conductive from TM rupture, esp in lightning strike due to shockwave
• Sensorineural from cochlea electrocution

28. GASTROINTESTINAL
• Rare
• Curling’s ulcers in pt w >30% BSA burns. Mx: PPI.
• Ileus
• Vascular insufficiency

29. PREGNANCY
• Burns = uteroplacento blood flow changes and dysfunction can
occur, abruption, abortion, oligohydramnios, growth
retardation,
• CTG/FHR/USS
• Obstetric consultation
• Most have good outcome if low voltage and not transuterine
shock

30. CLINICAL APPROACH

31. HISTORY
• Source and voltage and type of current. Specificity is key as capacitors and
transformers in household appliances can alter the voltage substantially
compared to housing mains voltage.
• Other risk factors in pts w low-voltage exposure
• Duration of contact
• Water involvement
• Spasmic injury
• Transthoracic
• PMHx: cardiac
• Tetanus immunity

32. EXAMINATION
• Entry and exit burns
• High voltage pts
• Ophthalmic including fundoscopy for haemorrhage and optic neuropathy
• Otoscopy for TM rupture
• Neurovascular of extremities

33. INVESTIGATIONS
• Only ECG needed if asymptomatic and low voltage injury
• ECG
• FBC, UEC,
• Coag, G+H if trauma
• CK. Need serial if elevated as this predicts mortality, LOS, risk of amputation.
• Trop – unclear utility and should DW cardiology
• Imaging as for trauma pt
• UA for Hb/myoglobin. If positive, send urine for microscopy ?RBC vs myoglobin.

34. MANAGEMENT
• Resuscitation
• Triage arrested casualties first
• Prolonged CPR indicated – young pts w good outcomes
• Secure airway against burns and in event of resp arrest
• Neurologic death difficult to determine
• Treat as trauma
• Cx spine needs to be cleared
• Image if any neuro issue to distinguish electric and trauma effects
• Eyes and ears are particularly vulnerable
• Burns management including DTPa
• Cardiac monitor if LOC, ECG change, and transthoracic or >1000V exposure
• NV monitoring
• IVH for rhabomyolysis and burns
• Titrate to UO rather than using a formula

35. KEY POINTS
• Avoid being electrocuted on scene
• Do not withdraw resuscitation too early
• Signs of death are unreliable in this patient group
• Treat as trauma
• High voltage DC and lightning injury pts are often thrown violently
• High voltage AC pts may have violent muscle spasm
• Internal injury may be severe despite only minor burns in pts with high voltage exposure
• ECG for all patients
• Cardiac monitor pts w LOC, ECG change, and transthoracic or >1000V exposure
• Frequently need aggressive IVH due to burns and rhabdomyolysis
• UO target 1-1.5mL/kg/hr rather than burns formulae
• Monitor neurovascular status of involved extremities regularly due to high risk of compartment
syndrome, vasospasm, and neurologic effects.
• Counsel pts about delayed effects
• CRPS, inattention, STML, weakness, paraesthesia, depression, cataract

36. REFERENCES
• Environmental and weapon-related electrical injuries - UpToDate
• Electrical Injuries: A Review For The Emergency Clinician - Emergency
medicine practice 2009
• Lightning and Electrical Injuries . Christopher B. Colwell. Emergency
medicine. 2nd ed. 2013.
• Chapter 218: Electrical and Lightning Injuries. Caitlin Bailey.
Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e.
• https://lifeinthefastlane.com/ccc/electrical-injury/

37. MISCELLANY
• Man electrocuted arm to arm
• Intact NV obs initially. Later develops compartment syndrome.
• LITFL info
• Tintinalli info starting from prehosp care section