ELECTRIC SHOCK; Injuries beyond what the eyes see.​

Authors: Dr. Nour Saleh and Dr. Kilalo Mjema

Case presentation

A 53-years-old male, sustained burn wounds on both hands 40 minutes prior presentation to the ED

Primary survey

Airway: patent and protected.
Breathing: bilateral equal air entry
Circulation: warm extremities, capillary refill time is 1 second
- Vitals on presentation
  - BP: 177/114mmHg
  - HR: 115
  - RR: 16
  - SPO2: 96% in room air
  - T: 36.4
Disability: alert and oriented, pupils 5mm bilateral equal light reaction, glucose: 7.3mmol
Exposure: holding his hands up in pain with some black discoloration

SAMPLE History

Sign and symptoms: pain, see pictures
Allergy: no known allergies
Medications: not on any medication
Past medical history: no known comorbid or any significant medical history
Last meal: he ate about 2.5 hours prior presentation
Event: pain on both hands after sustaining burn injury forty minutes prior presentation to the ED while trying to connect two circuits that sparked causing burn wounds on his hands and felt a jolt of electricity.

No history of heartbeat awareness or any loss of consciousness

Interventions and key steps in management

Make sure ABCD is checked and there is no critical intervention needed
IV access and fluid resuscitation may be considered depending on the case
Analgesics: depends on the severity of pain. Fentanyl 50mcg IV stat can be necessary for many patients.
Informed consent for procedural sedation for the dressing of the wounds.
Sedation: during the dressing of wounds
Point-of-care investigations: ECG, Urine dipstick
Blood samples for some labs should be taken; Creatinine, CK, Myoglobin, Electrolytes, Calcium, and Troponin
Imaging: X-ray if there is a worry for associated fracture
Monitor: input of fluids and output of urine to watch for acute kidney injury, compartment syndrome and rhabdomyolysis
Do not forget tetanus immunization

Associated injuries

Cardiac arrhythmias

Ventricular fibrillation is the most common. It occurs in 60% of patients with electrical current traveling from one hand to the other.
Renal - Rhabdomyolysis

Massive tissue necrosis may result in acute kidney injury. Labs to check includes; Creatinine, Blood Urea Nitrogen, Total CK, myoglobin.
Neurological

Damage to both central and peripheral nervous systems can occur. The presentation may include weakness or paralysis, respiratory depression, autonomic dysfunction, memory disturbances, loss of consciousness.
Skin

Degree of injury cannot determine the extent of internal damage especially with low voltage injuries. Minor surface burns may co-exist with massive muscle coagulation and necrosis.
Musculoskeletal

Bones have the highest resistance of any body tissues resulting in the greatest amount of heat when exposed to an electrical current. Results in surrounding tissue damage and potentially may lead to periosteal burns, destruction of bone matrix and osteonecrosis.
Vascular / Coagulation system

Due to electrical coagulation of small blood vessels or acute compartment syndrome.
Internal organs

The internal organ injury is not common but when it happens may result serious problems such as bowel perforations leading to polymicrobial infection, sepsis, and death.

Disposition

Admission and discharge decisions of burn patients depend on the patient’s current situation, burn percentage according to body surface area, location of the burn, and complications of burn. Low voltage electrocutions, if they are asymptomatic with normal physical examinations, can be discharged. Discharge precautions regarding burn care and complications should be clearly explained to the patient and relatives.