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Approach to the Critical Patient
Immediate priorities
Electrical injury stabilization
Scene safety
Power source confirmed off
Secondary electrical exposure risk for staff
Airway and breathing threats
Facial or inhalation burn concern
Respiratory muscle paralysis
Circulation threats
Shock
Cardiac arrest rhythm per ACLS Class I
Spine precautions
Fall or blast mechanism
Altered mental status
Time zero monitoring
Continuous ECG monitoring
Continuous pulse oximetry
Key decision points
Risk stratification
Voltage category
Low voltage less than 1000 V
High voltage 1000 V or higher
Current characteristics
Alternating current tetany risk
Direct current single contraction and throw risk
Current pathway
Transthoracic pathway concern
Hand to hand
Hand to foot
Lightning exposure
Direct strike
Side flash
Ground current
Contact injury
High risk features for adverse outcome
Loss of consciousness
Abnormal ECG
Chest pain
Dyspnea
Significant burns
Rhabdomyolysis concern
Compartment syndrome concern
Initial diagnostics and consult triggers
Early actions
12 lead ECG on arrival
ST segment changes
Conduction block
QT prolongation
Burn and trauma team activation triggers
High voltage exposure
Lightning strike
Full thickness burn
Circumferential extremity burn
Suspected deep tissue injury with minimal skin findings
Early specialty consult triggers
Cardiology for dysrhythmia or ischemia concern
Burn center for electrical burns meeting referral criteria
Surgery for compartment syndrome concern
Ophthalmology for ocular symptoms after lightning
Neurology for persistent focal deficits
History
Exposure details
Electrical exposure history
Source type
Household outlet
Industrial equipment
Power line
Lightning
Estimated voltage and environment
Wet skin exposure
Prolonged contact
Current pathway clues
Entry site
Exit site
Hand involvement
Chest involvement
Duration of contact
Unable to release
Brief shock
Symptoms at time of event
Syncope
Seizure
Palpitations
Chest pain
Dyspnea
Weakness
Paresthesia
Confusion
Injury patterns and complications
Associated injury history
Fall height and impact
Head strike
Spine pain
Long bone pain
Burns
Pain severity
Progressive swelling
Muscle injury symptoms
Severe limb pain out of proportion
Dark urine
Weakness
Eye and ear symptoms after lightning
Visual changes
Hearing loss
Tinnitus
Risk modifiers
Patient risk factors
Cardiac history
Coronary artery disease
Cardiomyopathy
Prior dysrhythmia
Implanted cardiac device
Pregnancy status
Gestational age
Pediatric oral exposure
Chewed cord
Mouth burn
Physical Exam
Primary survey focused exam
Immediate exam targets
Airway and breathing
Soot in oropharynx
Hoarseness
Stridor
Work of breathing
Circulation
Perfusion
Capillary refill
Peripheral pulses
Neurologic status
GCS
Focal deficits
Seizure activity
Skin and extremity exam
Cutaneous and deep injury exam
Entry and exit wounds
Small punctate burns
Charring
Burn depth estimate
Superficial
Partial thickness
Full thickness
Circumferential involvement
Limb
Chest
Compartment syndrome findings
Pain with passive stretch
Tense compartments
Paresthesia
Progressive motor weakness
Vascular compromise
Cool limb
Diminished pulses
Delayed capillary refill
Trauma and multisystem exam
Secondary survey focus
Spine tenderness
Long bone deformity
Shoulder dislocation
Tympanic membrane injury
Eye exam for lightning
Visual acuity
Pupils
Corneal injury concern
Cataract concern
Differential Diagnosis
Life threats and mimics
Critical differentials
Cardiac dysrhythmia from electrical injury
Ventricular fibrillation ICD-10 I49.01
Ventricular tachycardia ICD-10 I47.2
Complete heart block ICD-10 I44.2
Acute coronary syndrome triggered by shock
Myocardial infarction ICD-10 I21.9
Respiratory failure
Airway edema from inhalation injury ICD-10 T27.3
Neuromuscular respiratory weakness
Rhabdomyolysis
Rhabdomyolysis ICD-10 M62.82
Acute kidney injury ICD-10 N17.9
Hyperkalemia ICD-10 E87.5
Compartment syndrome
Traumatic compartment syndrome ICD-10 T79.A
Major trauma from fall
Intracranial hemorrhage ICD-10 I62.9
Cervical spine fracture ICD-10 S12.9
Lightning specific syndromes
Keraunoparalysis transient limb weakness
Tympanic membrane rupture ICD-10 S09.2
Coding and terminology
Electrical and lightning injury codes
Electrical shock ICD-10 T75.4
Lightning injury ICD-10 T75.0
Electrical burn ICD-10 T31 to T32 with TBSA qualifiers
Laboratory Tests
Core labs for risk features
Baseline evaluation labs
Electrolytes and renal function
Sodium mmol/L
Potassium mmol/L
Creatinine
Bicarbonate mmol/L
Creatine kinase for muscle injury concern
Trending every 6 to 8 hours if rising
Severe risk if markedly elevated and rising
Venous blood gas if shock or respiratory failure
pH
Lactate mmol/L
Complete blood count for trauma or burn severity context
Hemoglobin
White count
Cardiac injury labs
Cardiac evaluation labs
High sensitivity troponin for chest pain or ECG ischemia
Serial testing if initial abnormal or symptoms ongoing
BNP only if heart failure concern
Rhabdomyolysis and hemolysis evaluation
Muscle breakdown and renal protection labs
Urinalysis for pigment
Heme positive with few RBCs
Myoglobinuria surrogate
Serum calcium and phosphate for severe rhabdomyolysis
Hypocalcemia early possible
Hyperphosphatemia possible
Coagulation tests if extensive injury or operative planning
INR
Fibrinogen if major burn and resuscitation
Diagnostic Tests
Scoring Systems
Structured assessment tools
Burn size estimation
Rule of Nines
Lund and Browder chart for pediatrics
Burn resuscitation frameworks
Modified Parkland or Brooke as starting point
Electrical burns often require higher volumes than thermal burns
Rhabdomyolysis risk stratification
McMahon score for AKI risk
Higher score associated with dialysis risk
MRI
MRI indications
Persistent neurologic deficit with negative CT
Spine cord injury concern
Brain injury concern
Suspected peripheral nerve injury with persistent deficits
Avoid delays in unstable patients
CT
CT use in electrical injury
Trauma imaging per mechanism
CT head for altered mental status or head trauma
CT cervical spine for high risk fall or neuro deficit
CT angiography for vascular injury concern
Pulseless limb
Expanding hematoma
Hard signs of arterial injury
Ultrasound (or US)
Ultrasound applications
POCUS cardiac assessment
Pericardial effusion
Global contractility
FAST exam for blunt trauma
Free fluid
Doppler for limb perfusion concern
Arterial flow
Venous thrombosis concern
Disposition
Observation and admission criteria
Disposition framework
Admit or transfer to burn center
High voltage exposure 1000 V or higher
Lightning strike
Abnormal ECG
Dysrhythmia
Chest pain with troponin or ECG concern
Loss of consciousness
Significant burns or circumferential burns
Rhabdomyolysis or rising CK
Compartment syndrome concern
Major trauma from fall
Pregnancy with abdominal or transthoracic exposure
ED observation with monitoring
Low voltage exposure with symptoms but normal initial evaluation
Monitor period commonly 6 hours for low voltage with normal ECG and exam per local pathways
Discharge criteria
Low voltage exposure
No syncope
No chest pain
Normal ECG
Normal neuro exam
No significant burn
Reliable follow up and return precautions
Treatment
Resuscitation and monitoring
Immediate management bundle
Continuous monitoring and access
Cardiac monitor
Defibrillator available at bedside for high risk cases
Two large bore IV lines
Airway support escalation
If impending airway edema then early intubation
If hypoventilation then assisted ventilation
Analgesia and sedation
Fentanyl IV 25 to 50 micrograms
Repeat every 5 to 10 minutes as needed
Typical max guided by ventilation and hemodynamics
Morphine IV 2 to 4 mg
Repeat every 10 to 15 minutes as needed
Ketamine IV 0.2 to 0.3 mg per kg for analgesia
Repeat 0.1 to 0.2 mg per kg every 10 to 15 minutes as needed
Dysrhythmias and cardiac arrest
Cardiac complications management
VF or pulseless VT per AHA ACLS Class I
Defibrillation per device protocol
Epinephrine IV 1 mg
Repeat every 3 to 5 minutes
Amiodarone IV 300 mg bolus
Additional dose 150 mg if refractory
Symptomatic bradycardia per ACLS Class I
Atropine IV 1 mg
Repeat every 3 to 5 minutes
Maximum 3 mg
If ineffective then transcutaneous pacing
If ineffective then epinephrine infusion 2 to 10 micrograms per minute
Torsades de pointes
Magnesium sulfate IV 2 g
Infuse over 10 to 20 minutes if pulse present
Push in cardiac arrest
Burns and wound care
Burn management
Active cooling avoided for extensive burns
Cover with clean dry dressings
Tetanus prophylaxis
Tdap if not up to date
Tetanus immune globulin if unimmunized with dirty wound
Burn center referral triggers per American Burn Association guidance
Electrical burns including lightning
Full thickness burns
Circumferential limb burns
Significant functional area burns hands feet face genitalia major joints
Fluid resuscitation and rhabdomyolysis
Rhabdomyolysis prevention and treatment
Crystalloid resuscitation
Isotonic fluid choice
Normal saline
Balanced crystalloid acceptable if no contraindication
Initial bolus for suspected high voltage or rhabdomyolysis
10 to 20 mL per kg IV
Urine output targets per burn protocols for electrical injury
Adults 75 to 100 mL per hour or 1 mL per kg per hour
Titrate fluids to target
Pediatrics 1 to 2 mL per kg per hour until urine no longer pigmented
Then 1 mL per kg per hour
Urine alkalinization
Consider if severe rhabdomyolysis and adequate ventilation
Sodium bicarbonate infusion only with close electrolyte monitoring
Hyperkalemia treatment if present
Calcium gluconate IV 1 g
Repeat if ECG changes persist
Regular insulin IV 10 units with dextrose
Dextrose 25 g IV
Salbutamol nebulized 10 to 20 mg
Dialysis consult if refractory or oliguric AKI
Compartment syndrome and limb ischemia
Limb threat management
Compartment syndrome escalation
Immediate surgical consult
Fasciotomy for confirmed compartment syndrome
Circumferential full thickness burn with vascular compromise
Escharotomy consult
Vascular injury concern
CTA and vascular surgery consult
Infection and antibiotics
Antimicrobials
No routine systemic antibiotics for uncomplicated burns
Use only for clear infection or open fracture or operative indications
Topical antimicrobial per burn protocol if transferred or admitted
Silver based dressings per local formulary
Special Populations
Pregnancy
Pregnancy considerations
Maternal priorities
Maternal resuscitation first
Left lateral tilt if late pregnancy and hypotension
Fetal assessment
Continuous fetal monitoring if viable gestation and significant exposure
Obstetrics consult
Lower threshold for admission
Transthoracic current pathway
Abdominal entry or exit wounds
Geriatric
Older adult considerations
Higher baseline cardiac risk
Lower threshold for troponin testing
Lower threshold for monitoring
Fluid resuscitation caution
Heart failure risk
Frequent lung exam and ultrasound reassessment
Pediatrics
Pediatric considerations
Oral commissure burns from cords
Delayed labial artery bleeding risk
Early burn or plastics consult
Weight based fluids
Urine output targets 1 to 2 mL per kg per hour initially for high voltage concern
Discharge only if reliable caregiver and clear return precautions
Background
Epidemiology
Population and setting
Electrical injuries common in workplace and household settings
Occupational high voltage risk
Household low voltage common exposure
Lightning injuries seasonal and outdoor associated
Thunderstorm exposure risk
Pathophysiology
Mechanisms of injury
Direct electrical effects
Membrane electroporation
Cardiac conduction disruption
Thermal injury
Joule heating tissue damage
Deep muscle necrosis with minimal skin findings
Mechanical trauma
Tetanic contraction fractures and dislocations
Throw and fall injuries
Vascular injury
Intimal injury
Thrombosis
Vasospasm
Therapeutic Considerations
Treatment rationale
Early ECG to detect immediate conduction abnormalities
Normal ECG and low risk features associated with low likelihood of clinically significant delayed dysrhythmia
High voltage management emphasis on occult deep injury
Serial exams for evolving compartment syndrome
Early aggressive fluids to reduce pigment nephropathy risk
Urine output guided resuscitation in electrical burns per burn center protocols
Higher urine output targets than thermal burns often used
Patient Discharge Instructions
Copy discharge instructions
Discharge guidance for low risk electrical exposure
Wound care
Keep burn clean and dry
Dressing changes per instructions
Hydration
Drink extra fluids for 24 to 48 hours unless restricted
Pain control
Acetaminophen as directed on label
Ibuprofen as directed on label if safe for you
Return to ED immediately for red flags
Chest pain
Palpitations
Fainting
Trouble breathing
New weakness
New numbness
Worsening burn pain or swelling
Dark urine or very low urine output
Fever or spreading redness around burn
Follow up
Primary care in 24 to 72 hours if symptoms persist
Burn clinic follow up if any open burn
References
Guidelines and key sources
Evidence base
American Burn Association burn referral guidance includes electrical burns and lightning as burn center referral indications
Burn center evaluation recommended for electrical burns due to occult deep injury risk
American Burn Association protocols for high voltage electrical injury resuscitation use urine output targets 75 to 100 mL per hour or 1 mL per kg per hour in adults
Pediatric initial urine output target 1 to 2 mL per kg per hour until urine no longer pigmented
AHA Guidelines for CPR and ECC 2025 adult advanced life support includes VF and pulseless VT defibrillation and epinephrine and amiodarone as standard care
ACLS interventions Class I recommendations for shockable rhythms
Observational evidence suggests asymptomatic patients with normal initial ECG after electrical injury have low risk of late malignant dysrhythmia
Higher risk groups include voltage 1000 V or higher and loss of consciousness
Emergency Care BC pathway suggests low voltage electrical injuries may be discharged after 6 hours of monitoring if no ECG changes and normal exam
Local protocol variability acknowledged
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.