7ddekdY_d]0 <DGI8:K@:< >L@;<C@E<JLG;8K< M`j`k nnn%\Yd\[`Z`e\%e\k&^l`[\c`e\j kf[Xp]fipfli ]i\\jlYjZi`gk`fe Electrical Injuries: A Review October 2009 Volume 11, Number 10 For The Emergency Clinician Authors Amanda Dumler Czuczman, MD As usual, the emergency department is hopping. Two minutes before change Harvard Medical School, The Massachusetts General and Brigham and Women’s Hospitals, Boston, MA of shift, a trauma patient rolls in—an electrician in his mid-30s brought in by his coworkers. The patient, who was found unconscious near the genera- Richard D. Zane, MD tor he was repairing, is awake and alert but amnesic, with burns over his Vice Chair, Department of Emergency Medicine, Harvard Medical School chest and both arms. His vital signs are within normal limits. A number of Peer Reviewers management questions enter your mind, including the need for a cardiac Mary Ann Cooper, MD evaluation and hospital admission. As you begin formulating a plan, the Emerita Professor, University of Illinois at Chicago, Chicago, IL nurse tells you that a young woman has arrived after “getting shocked” by her hair dryer, which she was using while standing on a wet bathroom floor. Brian J. Daley, MD, MBA, FACS Professor of Surgery, Department of Surgery, University of She has no obvious injuries or complaints other than very mild erythema Tennessee Medical Center at Knoxville, Knoxville, TN of her right palm. The nurse asks if you want to order an ECG or send any CME Objectives blood tests. Upon completion of this article, you should be able to: It is unusual to have 2 electrical injuries in a single night. No sooner 1. Identify the most serious conditions associated with electrical has this thought crossed your mind than the nurse announces that EMS injury. 2. Recognize which patients require transfer and/or admission. has brought in 3 campers whose tent was struck by lightning. One camper 3. Develop an approach to treating lightning strike victims. is in cardiac arrest with ongoing resuscitation for more than 10 minutes, 4. Discuss the controversies and need for more research with another has blood coming from his ears and complains of difficulty hearing, regard to cardiac monitoring following electrical injuries. and the third has pale, mottled, and numb lower extremities. While cursing Date of original release: October 1, 2009 Date of most recent review: May 20, 2009 yourself for having taken a position with single physician coverage, you Termination date: October 1, 2012 quickly begin triaging these patients. Medium: Print and online Method of participation: Print or online answer form and evaluation lectrical injury is not a common presentation in the emergency Prior to beginning this activity, see “Physician CME Information” on the back page. Edepartment (ED). Nonetheless, every emergency clinician will encounter at least one case during his or her career. Electrical in- This article is eligible juries cause 5000 patients to seek emergency treatment each year for trauma CME credits. and are responsible for approximately 1000 deaths annually in the Editor-in-Chief Francis M. Fesmire, MD, FACEP University, Washington, DC; Director Thomas Jefferson University, Research Editors Andy Jagoda, MD, FACEP Director, Heart-Stroke Center, of Academic Affairs, Best Practices, Philadelphia, PA Erlanger Medical Center; Assistant Inc, Inova Fairfax Hospital, Falls Lisa Jacobson, MD Professor and Chair, Department Scott Silvers, MD, FACEP Professor, UT College of Medicine, Chief Resident, Mount Sinai School of Emergency Medicine, Mount Church, VA Medical Director, Department of Chattanooga, TN of Medicine, Emergency Medicine Sinai School of Medicine; Medical Keith A. Marill, MD Emergency Medicine, Mayo Clinic, Residency, New York, NY Director, Mount Sinai Hospital, New Assistant Professor, Department of Jacksonville, FL Nicholas Genes, MD, PhD International Editors York, NY Instructor, Department of Emergency Medicine, Massachusetts Corey M. Slovis, MD, FACP, FACEP Editorial Board Emergency Medicine, Mount Sinai General Hospital, Harvard Medical Peter Cameron, MD School, Boston, MA Professor and Chair, Department William J. Brady, MD School of Medicine, New York, NY of Emergency Medicine, Vanderbilt Chair, Emergency Medicine, Professor of Emergency Medicine Michael A. Gibbs, MD, FACEP Charles V. Pollack, Jr., MA, MD, University Medical Center, Monash University; Alfred Hospital, and Medicine Vice Chair of Chief, Department of Emergency FACEP Nashville, TN Melbourne, Australia Emergency Medicine, University Medicine, Maine Medical Center, Chairman, Department of Amin Antoine Kazzi, MD, FAAEM of Virginia School of Medicine, Emergency Medicine, Pennsylvania Jenny Walker, MD, MPH, MSW Portland, ME Assistant Professor; Division Chief, Associate Professor and Vice Charlottesville, VA Hospital, University of Pennsylvania Chair, Department of Emergency Steven A. Godwin, MD, FACEP Health System, Philadelphia, PA Family Medicine, Department Peter DeBlieux, MD Associate Professor, Associate of Community and Preventive Medicine, University of California, Professor of Clinical Medicine, Chair and Chief of Service, Michael S. Radeos, MD, MPH Medicine, Mount Sinai Medical Irvine; American University, Beirut, LSU Health Science Center; Department of Emergency Medicine, Assistant Professor of Emergency Center, New York, NY Lebanon Director of Emergency Medicine Assistant Dean, Simulation Medicine, Weill Medical College of Hugo Peralta, MD Services, University Hospital, New Cornell University, New York, NY. Ron M. Walls, MD Education, University of Florida Professor and Chair, Department Chair of Emergency Services, Orleans, LA COM-Jacksonville, Jacksonville, FL Robert L. Rogers, MD, FACEP, of Emergency Medicine, Brigham Hospital Italiano, Buenos Aires, Wyatt W. Decker, MD Gregory L. Henry, MD, FACEP FAAEM, FACP and Women’s Hospital, Harvard Argentina Associate Professor of Emergency CEO, Medical Practice Risk Assistant Professor of Emergency Medical School, Boston, MA Maarten Simons, MD, PhD Medicine, Mayo Clinic College of Medicine, The University of Assessment, Inc.; Clinical Professor Scott Weingart, MD Emergency Medicine Residency Medicine, Rochester, MN Maryland School of Medicine, of Emergency Medicine, University Assistant Professor of Emergency Director, OLVG Hospital, Baltimore, MD of Michigan, Ann Arbor, MI Medicine, Elmhurst Hospital Amsterdam, The Netherlands John M. Howell, MD, FACEP Alfred Sacchetti, MD, FACEP Center, Mount Sinai School of Clinical Professor of Emergency Assistant Clinical Professor, Medicine, New York, NY Medicine, George Washington Department of Emergency Medicine, Accreditation: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the sponsorship of EB Medicine. EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Czuczman, Dr. Zane, Dr. Cooper, Dr. Daley, and their related parties report no signifcant fnancial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support. United States. They also represent 2% to 7% of all 2006 use Class II and Class III evidence and are most admissions to burn units.1-4 Patients with electrical helpful for determining when cardiac monitoring is injuries represent a special challenge because they required. Table 1 summarizes these guidelines. encompass a wide spectrum of presentations— from thermal burns to arrhythmias to spinal cord Etiology And Pathophysiology injuries—that the emergency clinician, by definition, must know how to assess and treat. Electricity is the flow of electrons. It can be ex- Half of electrical injuries occur in the work- pressed as voltage (V) and as current (I), which is 2,5 place and many result in litigation for negligence, measured in amperes (A). The obstruction to flow is 6-7 product liability, or workers’ compensation. High- the resistance (R). According to Ohm’s law, I = V / voltage injuries have the highest potential for legal R, current is directly proportional to voltage and in- consequences as they usually involve young men at versely proportional to resistance. A plumbing anal- 1,2,4 the height of their earning capability. ogy is often used: amperage is the volume of water flowing through a pipe; resistance is the diameter of Critical Appraisal Of The Literature the pipe; and voltage is the difference between the entrance and exit pressures of the pipe. The damage Few prospective randomized controlled trials have incurred during an electrical injury depends upon been conducted on electrical injuries, so clinical the voltage, the resistance of tissues, the amperage practice is based on retrospective reviews and the (or current strength), the type of circuit (direct or general burn literature. This issue of Emergency alternating current), the current pathway, and the Medicine Practice focuses on the challenges of evalu- duration of contact.3,9 ating and managing electrical injuries using the best The safe range of human exposure to electric available evidence from the literature. PubMed® currents is narrow because of the small difference (limits: English human trial, clinical trial, meta- between the threshold of perception of current analysis, practice guidelines, randomized controlled (about 0.2 to 0.4 mA) and the