01Approach to the Critical Patient/attcp57

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

02History/hx53

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

03Physical Exam/exam44

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

04Differential Diagnosis/ddx26

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

05Laboratory Tests/lt29

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

06Diagnostic Tests/dt33

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

07Disposition/dispo24

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

08Treatment/t79

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

09Special Populations/sp24

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

10Background/b28

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

11Patient Discharge Instructions/pdi22

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

12References/r11

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

Evidence & Review

Evidence & Review