Electrical injuries, although relatively uncommon, are inevitably encountered by most emergency

physicians. Adult electrical injuries usually occur in occupational settings, whereas children are
primarily injured in the household setting. The spectrum of electrical injury is broad, ranging from
minimal injury to severe multiorgan involvement to death.
Electrical injuries are shown in the images below.
Grounded sites of low-voltage injury on the feet.
Electrical burns to the hand.
Approximately !!! deaths per year are due to electrical injuries in the "nited #tates, with a
mortality rate of $-%&.
'(
)lassifications of electrical injuries generally focus on the power source
*lightning or electrical+, voltage *high or low voltage+, and type of current *alternating or direct+,
each of which is associated with certain injury patterns.
This article reviews the pathophysiology, diagnosis, and treatment of electrical injuries caused by
manufactured electricity, for further information on lightning injuries, please see -ightning .njuries.
Pathophysiology
Electricity is generated by the flow of electrons across a potential gradient from high to low
concentration through a conductive material. The voltage */+ represents the magnitude of this
potential difference and is usually determined by the electrical source. The type and extent of an
electrical injury is determined by voltage, current strength, resistance to flow, the duration of
contact with the source, the pathway of flow, and the type of current *ie, direct or alternating+.
Voltage
Electrical injuries are typically divided into high-voltage and low-voltage injuries, using %!!/ or
!!!/ as the cutoff. 0igh morbidity and mortality has been described in 1!!/ direct current injury
associated with railroad 2third rail2 contact.
'3(
.n the "nited #tates and )anada, typical household
electricity provides !/ for general use and 34!/ for high-powered appliances, while industrial
electrical and high-tension power lines can have more than !!,!!!/.
'$(
/oltage is directly
proportional to current and indirectly proportional to resistance, as expressed by 5hm6s -aw7
/ 8 . 9 :, where . 8 current, / 8 voltage, : 8 resistance.
Current
The volume of electrons flowing across the potential gradient is the current, which is measured in
amperes *.+. .t is a measure of the amount of energy that flows through a body. Energy is
perceptible to the touch at a current as low as mA. A narrow range exists between perceptible
current and the 2let go2 current7 the maximum current at which a person can grasp and then
release the current before muscle tetany ma;es it impossible to let go. The 2let go2 current for the
average child is $-% mA, this is well below the %-$! A of common household circuit brea;ers. <or
adults, the 2let go2 current is 1-= mA, slightly higher for men than for women. #;eletal muscle
tetany occurs at 1-3! mA. /entricular fibrillation can occur at currents of %!-!! mA.
'4(
Resistance
The impedance to flow of electrons across a gradient is the resistance *:+ and varies depending
on the electrolyte and water content of the body tissue through which electricity is being
conducted. >lood vessels, muscles, and nerves have high electrolyte and water content, and thus
low resistance, and are good conductors of electricity?better than bone, fat, and s;in.
'%(
0eavily
calloused areas of s;in are excellent resistors, whereas a moderate amount of water or sweat on
the s;in surface can decrease its resistance significantly.
Type of circuit
Electrical current can flow in of 3 types of circuits7 direct current *@)+ or alternating current
*A)+, in which the flow of electrons changes direction in rhythmic fashion. A) is the most
common type of electricity in homes and offices, standardiAed to a freBuency of 1! cyclesCsec
*0A+.
0igh-voltage @) often causes a large single muscle contraction that throws the victim away from
the source, resulting in a brief duration of contact with the source flow. .n contrast, A) of the
same voltage is considered to be approximately $ times more dangerous than @), because the
cyclic flow of electrons causes muscle tetany that prolongs victims6 exposure to the source.
Duscle tetanyoccurs when fibers are stimulated at 4!-! 0A, the standard 1! 0A of household
current is within that range. .f the source contact point is the hand, when tetanic muscle
contraction occurs the extremity flexors contract, causing the victim to grasp the current and
resulting in prolonged contact with the source.
Table . Ehysiologic Effects of @ifferent Electrical )urrents *5pen Table in a new window+
Effect Current (milliamps)
Tingling sensation/perception 1-4
Let-go current Children 3-4
Let-go current - Women 6-8
Let-go current Men 7-
!"eletal muscle tetan# 16-$%
&espirator# muscle paral#sis $%-'%
(entricular )i*rillation '%-1$%
Types of electrical burns
@epending on the voltage, current, pathway, duration of contact, and type of circuit, electrical
burns can cause a variety of injuries through several different mechanisms.
A histologic picture of an electrical burn is shown below.
A histologic picture of an electrical burn showing elongated py;notic
;eratinocyte nuclei with vertical streaming and homogeniAation of the dermal collagen *4!9+. )ourtesy of EliAabeth
#atter, D@.
@irect contact7 )urrent passing directly through the body will heat the tissue causing
electrothermal burns, both to the surface of the s;in as well as deeper tissues, depending on
their resistance. .t will typically cause damage at the source contact point and the ground
contact point. )ontact burns are shown in the image below.
)ontact electrical burns, 3!-/ alternating current nominal. The right ;nee was the energiAed side, and the left
was ground. These are contact burns and are difficult to distinguish from thermal burns. Fote entrance and exit
are not viable concepts in alternating current.
Electrical arcs7 )urrent spar;s are formed between objects of different electric potential
that are not in direct contact with each other, most often a highly charged source and a ground.
The temperature of an electrical arc can reach 3%!!-%!!!
o
), resulting in deep thermal burns
where it contacts the s;in. These are high-voltage injuries that may cause both thermal and
flame burns in addition to injury from direct current along the arc pathway.
<lame7 .gnition of clothing causes direct burns from flames. >oth electrothermal and
arcing currents can ignite clothing.
<lash7 Ghen heat from a nearby electrical arc causes thermal burns but current does not
actually enter the body, the result is a flash burn. <lash burns may cover a large surface area of
the body but are usually only partial thic;ness.
Epidemiology
Frequency
United States
Electrical injuries are estimated to cause approximately %!!-!!! deaths per year in the "nited
#tates.
'$, 4(
They are responsible for $-%& of all burn unit admissions and cause 3-$& of
emergency department burn visits in the pediatric population.
#ome evidence exists that the incidence of low-voltage injuries among children is declining,
perhaps because of widespread use of ground fault circuit interrupters *G<).s+, but rates of high-
voltage injuries, usually involving power lines or rail sources, has remained steady.
'1(
@ue to the
nature of occupational haAards with electricity, electrical injuries represent the fourth leading
cause of wor;-related traumatic death *%-1& of all wor;ers6 deaths+.
'H(
MortalityMorbidity
Dorbidity and mortality are largely affected by the particular type of electrical contact involved in
each exposure. 5verall mortality is estimated to be $-%&.
', I(
<lash burns have a better prognosis
than arc or conductive burns.
'%(
Eersons who experience low-voltage injuries without immediate cardiac or respiratory arrest have
low mortality, but there may be significant morbidity from oral trauma in children who bite
electrical cords
'=(
or adults who suffer burns to the hand.
Eersons who experience low-voltage injuries with cardiac or respiratory arrest may recover
completely with immediate )E: on scene, however, prolonged )E: and transport time may
result in permanent brain damage.
0igh-voltage injuries often produce severe burns and blunt trauma. Eatients are at high ris; of
myoglobinuria and renal failure. >urns are often ultimately much worse than they initially appear
in the E@.
Race
Fo racial susceptibility to electrical burns exists. 5ccupational trends show more )aucasian
tradespeople in high-ris; occupations, and therefore )aucasians are more li;ely than other races
in the "nited #tates to experience occupation-related electrical injuries.
Se!
:ates of childhood electrical injury are higher among boys than girls
'1(
, rates of adult injury are
significantly higher in men than in women, li;ely because of occupational predisposition. Dost
series show more than I!& of electrical injuries occur in men.
'I, !, , 3(
"ge
A bimodal distribution of electrical injuries exists among the very young *children J 1 y+ and
among young and wor;ing-aged adults.
'$(
Eatterns of electrical injury vary by age *eg, low-voltage
household exposures among toddlers and high-voltage exposures among ris;-ta;ing adolescents
and via occupational exposure+.
'4, $(
#istory
Electrical injuries can present with a variety of problems, including cardiac or respiratory arrest,
coma, blunt trauma, and severe burns of several types. .t is important to establish the type of
exposure *high or low voltage+, duration of contact, and concurrent trauma.
$o%&'oltage "C in(ury %ithout loss of consciousness andor arrest
These injuries are J !!!/ exposures usually in the home or office setting. Typically, children
with electrical injuries present after biting or chewing on an electrical cord and suffer oral burns.
Adults wor;ing on home appliances or electrical circuits can also experience these electrical
injuries. -ow-voltage A) may result in significant injury if there is prolonged, tetanic muscle
contraction.
$o%&'oltage "C in(ury %ith loss of consciousness andor arrest
.n respiratory arrest or ventricular fibrillation that is not witnessed, an electrical exposure may be
difficult to diagnose. All unwitnessed arrests should include this possibility in the differential
diagnosis. Kuery ED# personnel, family, and cowor;ers about this possibility. .nBuire if a scream
was heard before the patientLs collapse, this may be due to involuntary contraction of chest wall
muscles from electrical current.
#igh&'oltage "C in(ury %ithout loss of consciousness andor arrest
"sually high-voltage injuries do not cause loss of consciousness but instead cause devastating
thermal burns. .n occupational exposures, details of voltage can be obtained from the local power
company.
#igh&'oltage "C in(ury %ith loss of consciousness andor arrest
This is an unusual presentation of high-voltage A) injuries, which do not often cause loss of
consciousness. 0istory may need to come from bystanders or ED# personnel.
)irect current *)C+ in(ury
These injuries typically cause a single muscle contraction that throws the victim away from the
source. They are rarely associated with loss of consciousness unless there is severe head
trauma, and victims can often provide their own history.
Conducted electrical de'ices
)onducted electrical weapons *)EGs+ such as tasers are weapons used by law enforcement that
deliver high-voltage current that is neither true A) or @) but is most li;e a series of low-amplitude
@) shoc;s.
'%(
They can deliver %!,!!! / in a %-second pulse, with an average current of 3. mA.
'1(
Though they have been temporally associated with deaths in the law enforcement setting,
conducted electrical devices *)E@s+ in healthy volunteers have been shown to be safe without
evidence of delayed arrhythmia or cardiac damage as measured by troponin ..
'H, 1(
5ne study of their use in 3! law enforcement incidents showed mostly superficial puncture
wounds from the device probes, and significant injuries only from trauma subseBuent to shoc;,
not from the device itself. 5f 3 deaths in custody, neither was related to )EG exposure.
'I(
5verall significant injuries from )EG exposure are rare, and usually occur due to trauma or in
conjunction with intoxication.
'=, 3!(
Physical
Electrical injuries can cause multiorgan dysfunction and a variety of burns and traumatic injuries.
A thorough physical examination is reBuired to assess the full extent of injuries. 5ccupational
injuries have a high li;elihood of future litigation, and physical examination findings should be
documented with photographs if possible, with the proper releases, and filed in the patient6s
medical record.
5verall, low-voltage exposure tends to cause less overall morbidity than high-voltage, but it is
important to ensure by accurate history that a seemingly low-voltage burn was not in fact from a
high-voltage source *li;e a microwave, computer, or T/ monitorMany device that 2steps-up2
voltage via a transformer+. -ow-voltage burns can still cause cardiac arrhythmias, seiAures, and
long-term complications if contact is near the chest or head.
Cardio'ascular
Eatients may present in asystole or ventricular fibrillation */<+ in addition to other arrhythmias.
#udden death due to /< is more common with low-voltage A), whereas asystole is more often
associated with high-voltage A) or @). /entricular fibrillation can be caused at voltages as low
as %!-3! mA, which is lower than the typical household current. 5ne series showed cardiac
arrhythmias following 4& of low-voltage injuries.
'3(
Electricity can also cause conduction abnormalities and direct trauma to cardiac muscle fibers.
#urvivors of electrical shoc; can experience subseBuent arrhythmias, usually sinus tachycardia
and premature ventricular contractions *E/)s+. 5ne study identified $ cases of delayed
ventricular arrhythmias up to 3 hours after the incident.
'3(
5ther studies have shown no ris; of
delayed arrhythmias in patients with initially normal E)Gs, both in low-voltage household
exposures and after )EG exposure.
'33, =, 3$, I(
-ong-term cardiac complications from electrical injury
are rare.
Respiratory
)hest wall muscle paralysis from tetanic contraction may cause respiratory arrest if the current
pathway is over the thorax. .njury to the respiratory control center of the brain can also cause
respiratory arrest. The lungs are a poor conductor of electricity and generally are not as
susceptible to direct injury from current as tissues with lower resistance.
S,in
A variety of burns and thermal injuries from electricity affect the s;in and soft tissues. These are
often the most severe seBuelae of electrical burns after cardiac arrhythmias and may initially
appear minor despite significant deep tissue injury subseBuently reBuiring fasciotomy or
amputation. >urns are often most severe at the source and ground contact points, the source is
usually the hands or the head while the ground is often in the feet. The strength and duration of
contact with the source largely influence the severity and extent of tissue damage. All burns
should be carefully documented and, if possible, photographed.
High-voltage electrothermal burns
Typically, these show a contact point where the person touched the circuit and a ground point.
These may produce significant damage to underlying tissue while largely sparing the surface of
the s;in. These burns may appear as painless, depressed areas with central necrosis and
minimal bleeding. The presence of surface burns does not accurately predict the extent of
possible internal injuries, as s;in with high resistance will transmit energy to deeper tissues with
lower resistance. A high-voltage burn is shown below.
0igh-voltage electrical burns to the chest.
Arc burns
Ghen an arc of current passes from an object of high to low resistance, it creates a high
temperature pathway that causes s;in lesions at the site of contact with the source and at the
ground contact point *not always the feet+. These areas typically have a dry parchment center
and a rim of congestion around them. There will be clues to the internal pathway ta;en by the arc
based on the location of these surface wounds. Arcs can also cause electrothermal, flash, and
flame burns, so multiple burns of varying appearance may be observed. Arcs do not occur in low-
voltage injuries. An arc burn is shown below.
Arcing electrical burns through the shoe around the rubber sole. 0igh-voltage
*H1!! /+ alternating current nominal. Fote cratering.
Flash burns
<lash burns are caused by heat from a nearby electrical arc that can reach upwards of %!!!
o
).
These can pass over the surface of the body or through, depending on the path of the arc
causing the flash. They may 2splash2 over the surface of the body, resulting in diffuse but
relatively superficial partial-thic;ness burns. There is no internal electrical component. A flash
burn is shown below.
#uperficial electrical burns to the ;nees *flashCferning+.
Flame burns
<lame burns are caused by ignition of clothing or nearby objects. These cause thermal burns
similar to other flame burns.
Low-voltage burns
These behave li;e ordinary thermal burns and range from local erythema to full-thic;ness burns.
These reBuire several seconds of contact to cause s;in burns, sometimes reaching current levels
high enough to cause /< before causing any significant s;in damage.
'4(
@irect contact burns may
occur only if the circuit through the person was prolonged for more than a few seconds. -ow-
voltage burns are shown below.
EnergiAed site of low-voltage electrical burn in a %!-year-old electrician.
Grounded sites of a low-voltage injury in a $$-year-old male suicide
patient.
Contact burns
)ontact burns usually have a pattern from the contacted item *branding+ and may appear similar
to flash burns. A contact burn is shown below.
)ontact electrical burn. This was the ground of a 3!-/ alternating current
nominal circuit. Fote vesicle with surrounding erythema. Fote thermal and contact electrical burns cannot be
distinguished easily.
Pediatric oral burns
These are most commonly encountered in children younger than 1 years who bite or suc; on a
household electrical cord. A local arc of current crosses from one side of the mouth to the other.
The orbicularis oris muscle may be involved, and cosmetic deformity of the lips may occur if the
burn crosses the commissure. #ignificant edema may be noted and within 3-$ days eschar
formation. -ife-threatening bleeding can occur at 3-$ wee;s post injury if the labial artery is
exposed when the eschar falls off. .nitial presentations may underestimate the extent of the
ultimate injury, patients reBuire aggressive airway management.
'=(
These patients should be
referred for early follow-up to a burn specialist, plastic surgeon, and an oral surgeon.
-eurologic
Dost acute )F# or spinal deficits resulting from electrical injuries are due to secondary blunt
trauma or burns. 5ften, the patient has transient confusion, amnesia, and impaired recall of
events if not fran; loss of consciousness. @irect effects of electrical current are most severe if the
respiratory control center of the brainstem is affected resulting in respiratory arrest. )urrent may
also cause seiAure or direct spinal cord injury if there is hand-to-hand flow. #pinal cord injury can
also result from direct current effects or blunt trauma. "nless a patient is completely lucid with full
recollection of the events, initial )-spine immobiliAation is indicated.
)urrents cause acute muscle tetany at relatively low currents and freBuencies, li;e those found in
most households. Duscle tetany causes victims to grasp the source, prolonging contact time, and
can also paralyAe respiratory muscles resulting in asphyxiation.
-ong-term neurologic complications include seiAures, peripheral nerve damage, delayed spinal
cord syndromes, and psychiatric problems from depression to aggressive behavior.
Musculos,eletal
Acute injuries include fractures from blunt trauma and compartment syndrome from burns. The
chest and extremities should be examined for circumferential burns. Ealpate the extremity and
perform distal neurologic, vascular, and motor examination to determine if there is suspicion of
a compartment syndrome. .f this is the case, compartment pressure can be measured and early
fasciotomy may help prevent subseBuent amputation.
'(
.f available, early surgical consultation
should be obtained for a patient with concerns for compartment syndrome. Dassive muscle
damage can cause severe rhabdomyolysis and subseBuent renal failure.
E-Thead
The head is a common point of entry for high-voltage injuries. Eatients may have perforated
tympanic membranes, facial burns, and cervical spine injury. Approximately 1& of victims
develop cataracts, usually months after the initial injury, with increasing freBuency the closer
contact is to the head.
'34, !(
Causes
Electrical injury occurs when a person becomes part of an electrical circuit or is affected by the
thermal effects of a nearby electrical arc. .njuries are caused by high-voltage A), low-voltage A),
or @).
#igh&'oltage "C
0igh-voltage injuries most commonly occur from a conductive object touching an overhead high-
voltage power line. .n the "nited #tates, most electric power is distributed and transmitted by
bare aluminum or copper conductors, which are insulated by air. .f the air is breached by a
conductor, *eg, an aluminum pole, antenna, sailboat mast, crane+, any person touching the
conductor can be injured. 5ccupational injuries may include direct contact with electrical
switching eBuipment and energiAed components.
$o%&'oltage "C
Generally, 3 types of low-voltage injury occur7 children biting into electrical cords producing lip,
face, and tongue injuries, or the adult who becomes grounded while touching an appliance or
other object that is energiAed. The latter type of injury is decreasing with the increasing use of
ground fault circuit interrupters *G<).s+ in circuits where people might easily become grounded.
G<).s stop current flow in the event of a lea;age current *ground fault+ if the ground fault is
greater than !.!!% amps *!.1 G at 3! /+.
)irect current *)C+
@) injuries are generally encountered when the third energiAed rail of an electrical train system is
contacted while the person is grounded. This sets up a circuit of electric current through the
victim, causing severe electrothermal burns and myonecrosis.
'3(
$aboratory Studies
.n all patients with more than a trivial electrical injury andCor exposure, the following tests should
be considered7
)>) ? 0emoglobin, hematocrit, white blood cell count
Electrolytes ? #odium, potassium, chloride, carbon dioxide, blood urea nitrogen, glucose
)reatinine ? 0igh ris; of rhabdomyolysisCmyoglobinuria in electrical injuries *Dortality in
one study was %=& for patients with acute renal failure.
'3%(
+
"rinalysis ? #pecific gravity, p0, hematuria, and urine myoglobin if urinalysis is positive
for hemoglobin
#erum myoglobin ? .f urine is positive for myoglobin, a serum level should be obtained.
Arterial blood gas ? To be obtained for patients needing ventilatory support, or those with
severe rhabdomyolysis who reBuire urine al;aliniAation therapy
)reatine ;inase *)N+ levels
o This level may be extremely elevated in patients with massive muscle damage
from high-voltage injuries. Formal )N values published by the laboratory may be low for
typical construction and electrical wor;ers whose vocation involves heavy exercise. #ome
evidence suggests that initial )N levels may help predict which patients could benefit from
early fasciotomy to prevent subseBuent amputations.
'(
o )N-D> subfractions are also often elevated in electrical injuries, but their
significance in the setting of electrical injuries is not ;nown.
'$(
)N-D> fractions and troponin
should be chec;ed if the current pathway involved the chestCthorax, if the patient has any
signs of ischemia or arrhythmia on E)G, or if the patient has specific complaints of chest pain.
o 5ne retrospective review created a decision rule for clinical identification of
patients li;ely to have rhabdomyolysis.
'31(
Dultivariate modeling revealed that high-voltage
exposure, prehospital cardiac arrest, full-thic;ness burns, and compartment syndrome were
associated with myoglobinuria. @efining 2positive2 as O3 of these findings has a sensitivity of
=1& and negative predictive value of ==&.
.maging Studies
)hoice of imaging studies is dictated by the presence of blunt trauma, altered mental status,
cardiac or respiratory arrest, and type of electrical exposure. #tudies to be considered are as
follows7
)hest radiography - Any patient with cardiac or respiratory arrest, shortness of breath,
chest pain, hypoxia, )E: at the scene, or fallCblunt trauma
0ead computed tomography - Any patient with altered mental status, significant traumatic
mechanism, seiAure, loss of consciousness, or focal neurologic deficits
)ervicalCspine imaging - Eatients with loss of consciousness or significant trauma should
be cervical spine immobiliAed and imaged accordingly. Formal mental status without significant
injuries may be clinically cleared, whereas others may reBuire plain radiography. Eatients with
focal neurologic deficits or evidence of spinal cord injury should undergo full spinal imaging.
)TCultrasonography - @epending on the amount of trauma sustained and the pathway of
the current exposure, patients may reBuire further imaging to evaluate for internal injuries.
.maging modality varies depending on suspected injury and availability.
/ther Tests
EC0cardiac monitoring
All adult patients should have an initial E)G and cardiac monitoring in the E@. The duration of
monitoring depends on the circumstances of the exposure, any patients with chest pain,
arrhythmia, abnormal initial E)G, cardiac arrest, loss of consciousness, transthoracic conduction,
or history of cardiac disease should undergo monitoring. Fo definitive guideline is available on
duration of monitoring for adults, but patients are unli;ely to develop significant arrhythmias after
34-4I hours if they have no other significant injuries. #everal large reviews have not identified ris;
of delayed arrhythmia among patients with low-voltage exposure and no arrhythmia upon initial
presentation. 5ne such review of =1 exposures concludes that admission for cardiac monitoring
is not indicated among such patients.
'3H(
#everal studies have shown that low-voltage *household+ exposures in patients with no cardiac
complaints and a normal initial E)G can be safely discharged.
'3I(
.t is unclear how this applies to
patients with preexisting heart disease. .n the pediatric population, healthy children with
household current exposures *3! to 4!/, no water contact+ can be safely discharged if they are
asymptomatic, without a /< or cardiac arrest in the field, and have no other injuries reBuiring
admission.
'3=, 3$(
Procedures
5btain intravenous access in all adult patients with electrical injuries. )onsider central access in
any patient with significant trauma, large burns, cardiac or respiratory arrest, or loss of
consciousness.
<asciotomy of a burned extremity may be reBuired in high-voltage injuries or prolonged low-
voltage injuries. 5btain early surgical consultation, preferably with experience in burn
management, early in the treatment of any patient with a high-voltage burn, since appropriate
early fasciotomies may prevent subseBuent amputations. .f emergently indicated, fasciotomy
should not be delayed.
Prehospital Care
<irst, rescuers should practice awareness of scene safety and be sure there is no imminent threat
to bystanders or responders in attempting to remove the victim from the electrical source. <or
high-voltage incidents, the source voltage should be turned off before rescue wor;ers enter the
scene.
After ensuring scene safety, rescuers should approach victims of electrical injuries as both
trauma and cardiac patients. Eatients may need basic or advanced cardiac life support. They
should be )-spine and spine immobiliAed as indicated by the mechanism of injury.
Given that injuries may be limited to a ventricular arrhythmia or respiratory muscle paralysis,
aggressive and prolonged )E: should be initiated in the field for all electrical injury victims, as
they are li;ely to be younger with fewer comorbid conditions and have better chances of survival
after prolonged )E:.
Emergency )epartment Care
#tabiliAe patients and provide airway and circulatory support as indicated by A)-#CAT-#
protocols. 5btain airway protection and provide oxygen for any patient with severe hypoxia,
facialCoral burns, loss of consciousnessCinability to protect airway, or respiratory distress. )ervical
spine immobiliAation PC- spinal immobiliAation is needed based on the mechanism of
injuryCneurologic examination. Erimary survey should assess for traumatic injuries such
aspneumothorax, peritonitis, or pelvic fractures.
After primary assessment, begin fluid resuscitation and titrate to urine output of !.%- m-C;gCh in
any patient with significant burns or myoglobinuria. )onsider furosemide or mannitol for further
diuresis of myoglobin. "rine al;aliniAation increases the rate of myoglobin clearance and can be
achieved using sodium bicarbonate titrated to a serum p0 of H.%. 5btain adeBuate intravenous
access for fluid resuscitation, whether peripheral or central. .nitiate cardiac monitoring for all
patients with anything more than trivial low-voltage exposures.
>urn care should include tetanus immuniAation as indicated, wound care, measurement of
compartment pressures as indicated, and it may include early fasciotomy. Extremities with severe
burns should be splinted in a functional position after careful documentation of full neurovascular
examination.
The ris;s of electrical injury to the fetus in a pregnant patient are un;nown. Eregnant women who
are involved in electrical injuries should have a careful examination for traumatic injuries and
obstetrical consultation. Gomen in the second half of pregnancy should be admitted for fetal
monitoring in any cases of severe electrical injuries, high-voltage exposures, or minor electrical
injuries with significant trauma.
Consultations
Eatients with high-voltage electrical injuries reBuire the ongoing care of a burn specialist, which
should be instituted as early as possible, as aggressive early intervention via fasciotomy can
prevent subseBuent limb amputation.
)onsider additional consultations with traumaCcritical care, orthopedics, plastic surgery, and
general surgery, depending on the type and severity of traumatic injuries.
Medication Summary
0ydration is the ;ey to reducing the morbidity of severe burns. .f there is significant muscle
damage with myoglobinuria, an osmotic diuretic andCor al;aliniAing agent is indicated.
Fluids
Class Summary
Extravascular pooling of fluids through damaged endothelium leads to vascular hypovolemia and
hypotension. Eatients reBuire fluid resuscitation with normal saline or lactated ringer.
$actated Ringer

Essentially isotonic and has volume restorative properties.
/smotic diuretics
Class Summary
5smotic diuretics assist the ;idneys in excreting myoglobin if present. They can help avoid acute
renal failure in patients with significant myoglobinuria.
/iew full drug information
Mannitol */smitrol+

5smotic diuretic that is not metaboliAed significantly and that passes through glomerulus without
being reabsorbed by the ;idney.
$oop diuretics
Class Summary
These agents decrease plasma volume and edema by causing diuresis.
/iew full drug information
Furosemide *$asi!+

Eroposed mechanisms for furosemide in lowering intracranial pressure include *+ lowering
cerebral sodium upta;e, *3+ affecting water transport into astroglial cells by inhibiting cellular
membrane cation-chloride pump, and *$+ decreasing )#< production by inhibiting carbonic
anhydrase.
@ose must be individualiAed to patient.
Further .npatient Care
.npatient care is reBuired for patients with anything other than minor low-voltage injuries. >urn
and trauma care, preferably at a specialiAed center, should be instituted early. Any patients with
cardiac arrest, loss of consciousness, abnormal E)G, hypoxia, chest pain, dysrhythmias, and
significant burns or traumatic injuries must be admitted.
Further /utpatient Care
Eatients exposed to low-voltage electrical sources who are otherwise completely asymptomatic
with a normal physical examination can often be discharged from the emergency department.
Eatients with minor burns or mild symptoms can be observed for several hours and discharged if
their symptoms resolve and they do not have elevated )ENCmyoglobinuria. Eatients should be
made aware of possible long-term neurologic or ocular effects of electrical injuries, and have
follow-up available as needed. Any patient with significant hand burns should be referred to a
hand specialist for close follow-up.
Transfer
All patients with a history of exposure to high-voltage electricity and patients with significant burns
should be transferred to a specialiAed burn center for further inpatient treatment and
rehabilitation.
Eediatric patients with significant oral burns should be transferred to a pediatric burn center.
Eatients with minor oral burns and close follow-up can be discharged.
)eterrencePre'ention
Erevention of high-voltage electrical injuries reBuires ongoing public education about potential
haAards, and targeted education to individuals in construction trades, those using cranes and lifts,
or those exposed to the extreme danger of overhead power lines. 5ne study found particularly
high rates of electrical injuries in cable splicers, electricians, line wor;ers, and substation
operators.
'$!(
Erevention strategies and occupational safety changes should be targeted to these
high-ris; occupations.
Erevention of household exposures reBuires public education about child protection, outlet
covers, and appliance safety. Appliances that produce a shoc; should not be used until
professionally repaired. Encourage use of G<).s on all outlets but especially bathrooms,
;itchens, and exterior outlets.
Complications
$o%&'oltage
.f no significant burns are present and if consciousness returns before arriving to or in the E@, full
recovery is expected. :are persistent arrhythmias have been reported.
Eersistence of unconsciousness carries a worse prognosis, and full recovery is not expected after
34 hours of unconsciousness.
Gith proper treatment, the disfigurement of low-voltage mouth injuries can be minimiAed. #carring
is almost always present.
#igh&'oltage
#urvival with massive burns is now the rule rather than the exception. 0owever, there are still
very high rates of amputation and significant morbidity from traumatic injuries and burns.
Prognosis
<or those without prolonged unconsciousness or cardiac arrest, the prognosis for recovery is
excellent.
>urns and traumatic injuries continue to cause the majority of the morbidity and mortality from
electrical injuries.
Patient Education
<or excellent patient education resources, see eDedicine0ealth6s patient education article
Thermal *0eat or <ire+ >urns.