Electrical Injury

ELECTRICAL INJURY MAIN TOPIC Description • Electrical injury produces variable types of adverse effects to organs and vital neurovascular structures, often without outward physical signs of injury • Potential to cause burns and deep hidden damage - Coagulation of arteries proximal to the exit wound - Injury may be much more severe than at first thought - See ELECTRICAL BURNS * Delay excision and grafting until the burn area has fully declared itself • Children vulnerable to full thickness orofacial burns - Pale, painless center of lesion - Extends after a few hours - Damage to facial and carotid arteries • Lightning produces a massive voltage of extremely short duration - See LIGHTNING INJURY * Deep thermal injury is unusual Clinical presentation • Cardiac effects - Syncope in 33% of pediatric electrical injury - Asystole most likely due to direct current or lightning injury * 2% of pediatric electrical shock - Ventricular dysrhythmia * 4% of pediatric electrical shock * Case series of 8 patients suffering cardiac arrests due electronic control device use included 3 teenagers22 Formatted: Superscript - Other dysrhythmia - Conduction defects (heart block) common, generally resolve without treatment - Cardiac contusion far more common than infarction • Respiratory effects - Respiratory paralysis due to injury to medullary respiratory center - May persist longer than asystole such that a return to sinus rhythm may degenerate into ventricular fibrillation • CNS effects - Altered level of consciousness: confusion, cognitive or memory defects - Seizures - Neurogenic shock - Brain stem injury with flaccid paralysis - Spinal, sympathetic, and peripheral nerve damage - Sensory and motor deficits may not match - Keraunoparalysis (transient weakness in limb) with autonomic dysfunction after lightning strike * Reversible transient paralysis * Fixed and dilated pupils: not a reason to stop resuscitation • Vascular effects - More common with electrical rather than lightning injury - Spasm: Maximal decrease in blood flow at 36 hours - Delayed thrombosis: due to prolonged decreased endothelial and smooth Deleted: , 15 muscle function Deleted: d - Aneurysm Formatted: Superscript 17 - Arterial rupture: high voltage Deleted: , - Subdural, epidural, or intraventricular hemorrhage Deleted: a - Shock may occur due to vasomotor instability Formatted: Superscript • Skin Deleted: Maximal decrease in blood flow at 36 - Burns are common: more frequently requiring grafting than chemical burns hours 20 in children Formatted: Superscript - Small exit, entry wounds may mask extensive damage to blood vessels, muscles, nerves - Deep burns are uncommon with lightning - Oral burns occur in children chewing on cords, potentially leading to delayed labial artery bleeding • Musculoskeletal - Rhabdomyolysis and myoglobinuria can produce renal failure - Fractures or dislocations due to muscle spasm are rare • Eye effects - Cataracts, corneal lesions, intraocular hemorrhages, retinal detachment, optic nerve injury • Ear effects18 Formatted: Superscript - Tympanic membrane perforation: lightning - Transient vertigo: electrical - Sensorineural hearing loss: electrical • Gastrointestinal effects - Rare - Ulcers or evisceration, stomach and intestinal perforation, esophageal stricture - Electrocoagulation of liver and spleen • Blunt trauma common from secondary fall after injury

BASIC SCIENCE Factors that determine the severity of electrical injury • Voltage - Measurement of the "electrical pressure" in a system - High voltage * > 1000 volts * Usually more damaging than low voltage with tendency to "throw" victim (which may help limit contact) * High voltage takes a direct course to ground * Electronic control devices (i.e. TASER) fall in this category - Low voltage * < 1000 volts * Follows path of least resistance • Current (amperage) - Current more critical than voltage - Measure of the rate of flow of electrons - As little as 1 milliamp may produce ventricular fibrillation - 1 milliamp perceived as a tingling sensation - AC (alternating current) * Induces tetanic muscle spasm which can prolong contact by interfering with voluntary release * Most common cause of electrocution * Frequency of the AC may precipitate ventricular fibrillation * More dangerous than direct current (DC) - DC (direct current) * Used for defibrillation etc. • Duration of the contact • Pathway taken by the current • Resistance - Measurement of the difficulty of electron flow - Increases from nerve, blood, muscle, skin, tendon, fat, and bone - Dry skin = 40,000 ohms versus wet skin < 1000 ohms - Thin infant skin and oral mucosa = low resistance • See TYPES OF ELECTRICAL INJURY

EPIDEMIOLOGY • Approximately 1500 deaths per year • Four times more nonfatal injuries • Bimodal pediatric distribution - Exploring toddlers (12 to 24 months) most commonly exposed at home, chewing on extension cords - Adolescents climbing utility poles or trespassing into transformer substations

DIAGNOSTIC STUDIES • Case-by-case based on severity of injuries • CBC • CPK • Cardiac markers • Electrolytes including calcium, BUN, creatinine, glucose • ECG • Urinalysis for myoglobin • Imaging - Chest x-ray if current may have passed through thorax - Cervical spine if AMS - Relevant long bones for specific injury after high voltage or lightning strike - Head CT may be indicated for head injury with loss of consciousness

DIFFERENTIAL DIAGNOSIS • See CAUSES OF ALOC - Hypoglycemia - Intoxication - Drug overdose - Cardiovascular disease - CVA

TREATMENT • Ensure safety of first responders • Separate victim from source of current • Reverse triage if multiple victims especially with lightning strike - Focus on those appearing dead first due to high survival • Advanced life support and trauma protocols • CPR if necessary - Prolonged efforts may be indicated at discretion of treating physician as most victims are young and good outcomes reported even with asystole - See BASIC CPR - See RESUS: ASYSTOLE • Oxygenation and ventilation • Treat dysrhythmia - ECG and enzymes poor predictors of cardiac injury - See RESUS: VENTRICULAR FIBRILLATION - See DYSRHYTHMIAS • Treat seizure - See RESUS: STATUS EPILEPTICUS • Maintain circulation - Fasciotomy or amputation if necessary • Assess for multiple trauma • Volume expansion for thermal burns - Titrate to urine output - May require more fluid that predicted by burn formulas • Fluid restriction if CNS injury - Watch for and treat cerebral edema • Maintain urine output to treat myoglobinuria if present - Lasix or mannitol - Alkalinize the urine - See RHABDOMYOLYSIS AND MYOGLOBINURIA • Comprehensive physical examination - Pay particular attention to the head and neck - Careful exam of the skin and pulses - Cranial, cerebellar, and peripheral nerve exam • Clean and dress burns - Early referral to plastic surgeons but delay excision and grafting until the area declares itself - See BURNS • Address obvious injuries • Tetanus prophylaxis and antibiotics • High voltage or lightning strike - Admit for observation and cardiac monitoring - Repeat examination over days

COMPLICATIONS • Considerable muscle damage may produce myoglobinuria • Long term sequela from electrical and lightning injuries include Deleted: lightning - Paralysis Deleted: s - Dysesthesia - Peripheral mono- or polyneuropathies - Disturbances in mood, affect, and memory * up to 78% develop Diagnostic and Statistical Manual of Mental Disorders psychiatric diagnoses19 Formatted: Superscript

DISPOSITION • All children with oral injuries require plastic surgery or dental consults • Neurosurgical, ophthalmological, and ENT consultations may be needed • Transfer to a burn center may be needed • Admission not required for any nontransthoracic low voltage injuries in an asymptomatic child without ECG abnormalities16 Formatted: Superscript • Admit all high voltage injuries for 12 to 24 hours • Admit all lightning injuries except those with a normal exam, normal lab tests, normal ECG plus adequate home supervision and close follow up care • Admit those presenting with syncope for cardiac monitoring

EDUCATION/PREVENTION • Regulations requiring safety switches on power and lighting circuits • Keep extension cords in good repair • Cover unused outlets with dummy plugs • Keep electrical appliances away from sinks and bathtubs • Supervise electrically operated toys

TIPS • Amount of skin injury is not a reliable predictor of overall severity of injury • Beware of other injuries particularly fractures caused by immense muscle spasm • All victims of electrical burns must be evaluated

LIGHTNING INJURY Description • Lightning produces a massive voltage of extremely short duration - Deep thermal injury is unusual Clinical presentation • Usually obvious clinical presentation due to patient or witnesses reporting a lightning strike - See ELECTRICAL BURNS • Consider lightning strike in unwitnessed falls, cardiac arrests, or unexplained coma in the outdoor setting • Feathering (Lichtenberg figures) - Pathognomonic of lightning injury - Cutaneous imprints form electron showers that track over the skin - Resolve within 24 hours Types of lightning injuries • Direct strike - Most serious form of injury and occurs when carrying or wearing metal objects • Contact injury when lightning strikes object victim is touching • Side flash or splash when victim near an object that is struck • Ground current - Lightning strikes ground close to victim, travels through body from one foot to the other • Thermal flash - Short duration burns • Blast injury: assess for concomitant shrapnel injuries21 Formatted: Superscript - Shock wave from lightning channel can cause tympanic membrane perforation or blunt trauma from the victim being thrown • Upward streamer - Weak streamer that does not become completed lightning channel Complications • High incidence of death or morbidity - 30 percent mortality - 75 percent of survivors have permanent sequela - See TYPES OF ELECTRICAL INJURY

TYPES OF ELECTRICAL INJURY

TYPE Lightning High Voltage Low voltage

DURATION 1/1000 sec Brief Prolonged ENERGY 100,000,000 volts > 1,000 volts < 1,000 volts TYPE DC DC or AC Mostly AC SHOCK WAVE Present Absent Absent CARDIAC Asystole V Fibrillation Atrial or Ventricular Fibrillation14 BURNS Superficial & minor Deep & severe Superficial RHABDOMYOLYSIS Rare Very common Common FASCIOTOMY Rare Extensive Rare MORTALITY Very high Moderate Low

REFERENCES Topic supported by DynaMed Systematic Literature Surveillance • Cooper M, Andrew C. Lightning Injuries. In: Auerbach P, ed. Wilderness Medicine: Management of Wilderness and Environmental Emergencies 3rd Ed. 1995: 261-290 • Fish RM. Electric injury, part III: cardiac monitoring indications, the pregnant patient, and lightning. J Emerg Med. 2000 Feb;18(2):181-7 • Glatstein MM, Ayalon I, Miller E, et al. Pediatric Electrical Burn Injuries: Experience of a Large Tertiary Care Hospital and a Review of Electrical Injury. Peds Emerg Care. 2013:29:737-740 • Haim A, Zucker N, Levitas A et al. Cardiac manifestations following electrocution in children. Cardiol Young. 2008; 18(5); 458-60 • Koumbourlis A. Electrical Injuries. Crit Care Med. 2002 Nov;30(11 Suppl):S424-30 • Martinez J, Nguyen T. Electrical injuries. South Med J. 2000 Dec;93(12):1165-8 • Nield L, Kamat D.Related Articles, Links Long-term Sequelae of Lightning Strike in a Child: A Case Report and Review. Clin Pediatr (Phila). 2004 Jul- Aug;43(6):563-7 • Nguyen BH, MacKay M, Bailey B, et al. Epidemiology of electrical and lightning related deaths and injuries among Canadian children and youth. Inj Prev. 2004;10:122-124 • Ritenour AE, Morton MJ, McManus JG et al. Lightning injury: a review. Burns. 2008 Aug;34(5):585-94 • Schaider J, Hayden S, Wolfe R, et al. eds: Electrical Injury. In: Rosen and Barkins 5 Minute Emergency Medicine Consult 2003: 358-359 • Schaider J, Hayden S, Wolfe R, et al. eds: Lightning Injury. In: Rosen and Barkins 5 Minute Emergency Medicine Consult 2003: 642-643 • Strange G, Ahrens W, Lelyveld S, Schafermeyer R, eds: Electrical and Lightning Injuries. In Pediatric Emergency Medicine: A Comprehensive Study Guide 1996: 593-598 • Whitcomb D, Martinez J, Daberkow D. Lightning Injuries. South Med J. 2002 Nov;95(1 1):1331-4 14. Zanoni S, Siefert J, Darracq M. Atrial Fibrillation with Rapid Ventricular Response Resulting from Low Voltage Electrical Injury. J Emerg Med. 2013 May;45(5):e149-e151. 15. Park K, Park W, Kim M, Kim H, Kim S, Cho G, Choi Y. Alterations in Arterial Function after High-voltage Electrical Injury. Critical Care 2012 Feb;16:R25 16. Searle J, Slagman A, Maab W, Mockel M. Cardiac Monitoring in Patient with Electrical Injuries. Dtsch Arzebl Int 2013 June;110(50):847-853. 17. Toy J, Ball B, Tredget E. Carotid Rupture Following Electrical Injury: a Report of 2 Cases. J Burn Care Res. 2012;33:e161-e166. 18. Modayil P, Lloyd G, Mallik A, Bowdler D. Inner Ear Damage Following Electrical Current and Lightning Injury: a Literature Review. Eur Arch Otorhinolaryngol. 2014;271:855-861. 19. Wesner M, Hickie J. Long-term Sequelae of Electrical Injury. Can Fam Physician. 2013 Sept;59:935-939. 20. Alemayehu H, Tarkowski A, Dehmer J, Kays D, St. Peter S, Islam S. Management of Electrical and Chemical Burns in Children. J Surg Res. 2014 Jul;190(1):210-213. 21. van Waes O, van de Woestinje P, Halm J. “Thunderstruck”: Penetrating Thoracic Injury from Lightning Strike. Ann Emerg Med. 2014 Apr;63(4):457- 459. 22. Zipes D. Sudden Cardiac Arrest and Death Following Application of Shocks from TASER Electronic Control Device. Circulation. 2012;125:2417- 2422.

SEE ALSO • See CENTRAL VASCULAR ACCESS • See ELECTRICAL BURNS • See HAND INJURIES • See PERIPHERAL VASCULAR ACCESS • See RESUS: ASYSTOLE • See RESUSCITATION DRUGS • See RHABDOMYOLYSIS