EMERGENCY CARE TECHNIQUES FOR ELECTROCUTION PATIENT MANAGEMENT

Electrocution, the passage of electrical current through the body, can result in a diverse and potentially devastating spectrum of injuries, ranging from superficial burns to life-threatening cardiac arrhythmias, neurological damage, and multi-organ failure. The severity of injury is influenced by several factors, including the type of current (alternating current (AC) is generally more dangerous than direct current (DC) at the same voltage due to tetanic muscle contractions and a higher likelihood of ventricular fibrillation), voltage, amperage, duration of contact, current pathway through the body, skin resistance, and environmental factors. Effective management necessitates a systematic, step-by-step approach, beginning at the scene and continuing through specialized critical care and rehabilitation.

Pre-hospital Management: Scene Safety and Initial Assessment

The initial response to an electrocution incident prioritizes rescuer safety above all else. A compromised scene poses a significant risk of further casualties.

1. Scene Safety:
   • Power Disconnection: The absolute first step is to ensure the power source is de-energized and confirmed safe before approaching the victim. This often requires the expertise of utility company personnel or trained electricians. If the power cannot be immediately disconnected, non-conductive materials (e.g., a dry wooden stick) may be used to separate the victim from the source, but this carries significant risk and should only be attempted by trained individuals in specific circumstances.
   • Personal Protective Equipment (PPE): Rescuers must wear appropriate PPE, including non-conductive gloves, to prevent accidental electrocution from residual current or conductive materials.
   • Environmental Hazards: Assess for secondary hazards such as falls, fires caused by arcing, explosions, or structural collapse.
2. Initial Patient Assessment (Primary Survey – ABCDE): Once the scene is safe, a rapid primary survey is performed, similar to any trauma patient, while maintaining cervical spine immobilization due to the high risk of associated falls or tetanic muscle contraction-induced fractures.
   • Airway (A): Assess for patency. Look, listen, and feel for signs of obstruction. Be prepared to clear the airway of foreign bodies or secretions.
   • Breathing (B): Evaluate respiratory effort, rate, and depth. Administer high-flow supplemental oxygen via a non-rebreather mask, regardless of oxygen saturation, due to the potential for occult tissue hypoxia. Assist ventilation with a bag-valve-mask if respiration is inadequate or absent.
   • Circulation (C): Check for pulses. Initiate cardiopulmonary resuscitation (CPR) immediately if the patient is pulseless and apneic. Attach an automated external defibrillator (AED) and follow its prompts; ventricular fibrillation (VF) is a common initial arrhythmia. Control any obvious external bleeding.
   • Disability (D): Perform a quick neurological assessment (e.g., AVPU scale: Alert, Verbal, Pain, Unresponsive).
   • Exposure (E): Carefully expose the patient to assess for obvious entrance and exit wounds and other injuries, while maintaining body temperature.
3. Rapid Transport: After stabilizing life-threatening conditions, the patient should be rapidly transported to the nearest appropriate emergency department, preferably one with burn unit capabilities or tertiary trauma care. Pre-notification to the receiving facility is crucial to allow for preparation.

Emergency Department Management: Resuscitation and Primary Survey

Upon arrival at the emergency department, a structured approach is essential for comprehensive and timely management.

1. Primary Survey (Re-assessment and Resuscitation):
   • Airway (A): Re-evaluate airway patency. In patients with significant facial/neck burns, stridor, or altered mental status (GCS < 8), early endotracheal intubation is often indicated to protect the airway and facilitate ventilation, even if not immediately critical, due to the risk of progressive upper airway edema.
   • Breathing (B): Ensure adequate ventilation. Assess for signs of smoke inhalation (if fire was involved), such as carbonaceous sputum or wheezing. A chest X-ray may be indicated.
   • Circulation (C):
     • Cardiac Monitoring: Immediate and continuous 12-lead ECG monitoring is paramount. Electrocution can cause a wide range of arrhythmias, from transient sinus tachycardia to life-threatening ventricular fibrillation, asystole, or complex heart blocks. Serial ECGs are necessary to monitor for delayed cardiac sequelae, such as myocardial ischemia or injury.
     • IV Access: Establish at least two large-bore intravenous (IV) lines.
     • Fluid Resuscitation: Aggressive fluid resuscitation is a cornerstone of management, even in the absence of obvious large external burns. Electrocution often causes significant internal tissue damage, leading to massive fluid shifts into interstitial spaces and potential rhabdomyolysis. Use crystalloids (e.g., Ringer’s Lactate). The goal is to maintain adequate tissue perfusion and prevent acute kidney injury (AKI) from myoglobinuria.
     • Arrhythmia Management: Treat life-threatening arrhythmias according to Advanced Cardiac Life Support (ACLS) protocols. Defibrillation for VF/pulseless VT, atropine for symptomatic bradycardia, etc.
   • Disability (D): Perform a more detailed neurological assessment (GCS, pupil response, motor/sensory function). Be vigilant for seizures, spinal cord injury, or signs of increased intracranial pressure.
   • Exposure (E): Fully expose the patient, meticulously assessing all skin surfaces for entrance and exit wounds, thermal burns, and other injuries. Remove all jewelry and constrictive clothing. Cover the patient with warm blankets to prevent hypothermia, as large burn surface areas or prolonged exposure can lead to significant heat loss.

Secondary Survey and Ongoing Management

Once life-threatening conditions are addressed, a thorough head-to-toe secondary survey is performed, focusing on the unique injury patterns associated with electrocution.

1. Detailed History: Obtain crucial details: type of current (AC vs. DC), estimated voltage, duration of contact, exact current pathway through the body (e.g., hand-to-hand, hand-to-foot), associated fall or trauma, loss of consciousness, and pre-existing medical conditions.
2. System-Specific Examination and Management:
   • Skin and Burns: Meticulously examine for entrance and exit wounds. Electrical burns can appear deceptively small externally while extensive deep tissue damage lies beneath. Distinguish between true electrical burns (where current passes through tissue) and flash burns (from an arc, often superficial) or flame burns (from ignited clothing). Assess the depth and extent of all burns, calculating the total body surface area (TBSA) for thermal burns. Early escharotomy or fasciotomy may be necessary for circumferential burns compromise circulation. Administer tetanus prophylaxis.
   • Cardiovascular System: Beyond initial arrhythmias, monitor for delayed arrhythmias, myocardial dysfunction (cardiomyopathy), or coronary artery spasm. Obtain serial cardiac enzymes (troponin I/T, CK-MB) if myocardial injury is suspected.
   • Neurological System:
     • Central Nervous System (CNS): Acute manifestations include altered mental status, seizures, coma, spinal cord injury (especially with high-voltage currents), and cerebral edema. Long-term effects can include headaches, memory deficits, personality changes, and chronic pain syndromes. Perform hourly neurological checks.
     • Peripheral Nervous System (PNS): Peripheral neuropathies, often delayed, can manifest as weakness, numbness, or paresthesias.
   • Musculoskeletal System: High-voltage currents can cause intense tetanic muscle contractions, leading to fractures (vertebral, long bone, scapular dislocation) or dislocations. Falls associated with electrocution also contribute to fractures.
     • Rhabdomyolysis: Deep muscle necrosis is common due to direct electrical damage and prolonged tetanic contractions. This releases myoglobin, creatine kinase (CK), and potassium into the bloodstream. Myoglobin precipitates in the renal tubules, leading to AKI.
       • Management: Vigorously continue IV fluid resuscitation to achieve a urine output aggressively targeted at 1-1.5 mL/kg/hour (or approximately 100-150 mL/hour in adults). If urine is dark or tests positive for myoglobin, administer sodium bicarbonate (e.g., 100-150 mEq in 1 liter D5W) to alkalinize the urine (target pH > 6.5) and prevent myoglobin cast formation in the kidneys. Mannitol may also be considered to promote diuresis and scavenge free radicals, but use with caution in hypovolemic patients. Monitor CK levels and urine myoglobin serially.
     • Compartment Syndrome: Swelling of damaged muscles within fascial compartments can lead to compartment syndrome, compromising blood supply and causing nerve damage. Monitor for the “5 Ps”—pain out of proportion, pallor, pulselessness, paresthesias, and paralysis. Early fasciotomy is critical if compartment syndrome is suspected or confirmed by compartment pressure measurements.
   • Renal System: Acute kidney injury is a major complication, primarily due to myoglobinuria from rhabdomyolysis and hypovolemia. Monitor urine output, serum creatinine, and BUN.
   • Gastrointestinal System: Although less common, electrical current can cause bowel perforation, gastric or duodenal ulceration, or pancreatitis, especially with abdominal current pathways.
   • Ophthalmological System: Cataract formation can occur months to years after electrocution, particularly with head or facial involvement. Perform a baseline ophthalmologic exam.
   • Auditory System: Hearing loss, tympanic membrane perforation, or vestibular dysfunction can occur if current passes through the head.
3. Diagnostic Investigations:
   • Laboratory Tests: Complete blood count (CBC), serum electrolytes (especially potassium due to rhabdomyolysis), BUN, creatinine, glucose, calcium, phosphate, magnesium, arterial blood gas (ABG), urinalysis (for myoglobinuria), serial CK levels, cardiac enzymes (troponin I/T), coagulation profile.
   • Imaging:
     • X-rays: Cervical spine, chest, and any areas suspected of fracture.
     • CT Scans: Head CT for altered mental status or focal neurological deficits. Abdominal CT if visceral injury is suspected. Spinal CT/MRI if spinal cord injury is suspected.
     • Ultrasound: Focused Assessment with Sonography for Trauma (FAST) for internal bleeding.
   • ECG: Serial 12-lead ECGs are essential.
4. Pain Management: Electrical injuries are often exquisitely painful; aggressive pain control with intravenous opioids is necessary.
5. Wound Care: Clean all visible wounds, apply topical antimicrobials (e.g., silver sulfadiazine cream for burns), and sterile dressings. Initial wound debridement may be required.
6. Specialist Consultations: Early consultation with relevant specialists is crucial:
   • Burn Surgeon/Plastic Surgeon: For management of extensive or deep burns.
   • Orthopedic Surgeon: For fractures, dislocations, and compartment syndrome.
   • Neurologist: For significant neurological deficits, seizures, or spinal cord injury.
   • Nephrologist: For significant rhabdomyolysis or acute kidney injury refractory to fluid management.
   • Cardiologist: For persistent arrhythmias or myocardial dysfunction.
   • Ophthalmologist/ENT: For specific eye or ear injuries.

Long-Term Management and Rehabilitation

Electrocution patients often face a protracted recovery period with potential for long-term physical, neurological, and psychological sequelae.

1. Rehabilitation: Physical therapy, occupational therapy, and speech therapy are often required to address functional deficits (e.g., limb weakness, contractures, neurological impairments).
2. Psychological Support: Patients may experience post-traumatic stress disorder (PTSD), depression, anxiety, body image issues due to disfigurement, and chronic pain. Psychological counseling and support groups are invaluable.
3. Monitoring for Delayed Complications: Regular follow-up is necessary to monitor for delayed ophthalmological issues (cataracts), progressive neuropathies, chronic pain syndromes, and other late manifestations.

Conclusion

The management of an electrocution patient is a complex and dynamic process demanding a systematic, multidisciplinary approach. From ensuring scene safety and performing immediate life-saving interventions in the pre-hospital setting, to meticulous primary and secondary surveys in the emergency department, aggressive fluid resuscitation, prevention of rhabdomyolysis-induced kidney injury, and comprehensive wound and fracture management, every step is critical. Given the potential for devastating immediate and delayed complications across multiple organ systems, a high index of suspicion and continuous reassessment are paramount to optimize outcomes for these severely injured patients.

References:

1. Tintinalli, J. E., et Ma, O. J. (2020). Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (9th ed.). McGraw-Hill Education. (Chapters on Electrical Injuries, Burns).
2. Marx, J. A., Hockberger, R. S., Walls, R. M., & Zlupko, T. (2014). Rosen’s Emergency Medicine: Concepts and Clinical Practice (8th ed.). Elsevier Saunders. (Chapters on Electrical Injuries, Burns).
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