A 44 year-old male with unknown past medical history came by emergency medical services (EMS) to the emergency department (ED) for an electrical injury and fall from a high voltage electrical pole. Per EMS, the patient was found at the bottom of a high voltage line with diffuse burns and amputation of his left forearm. The patient was Glasgow Coma Scale (GCS) 15 on scene and complaining of back pain. He was intubated by EMS due to the extent of his injuries. His vitals were stable and endotracheal tube confirmed with end capnography and chest radiography.

FIGURE 1: Electrical burns of the patient’s bilateral feet. (Click to enlarge.)

The patient had a small left pneumo-thorax. A left thoracostomy, foley, nasogastric tube, and central venous catheter were placed prior to computed tomography (CT) imaging. The patient’s initial troponin was 17.78 ng/mL, creatine kinase greater than 60,000 U/L, glucose of 53 mmol/L, creatinine of 1.88 mg/dL and potassium of 5.7 mEq/L. He had estimated 45 percent total body surface area burns and received lactated Ringer’s infusion per Burns Rule of TENS (estimating to the nearest 10 percent TBSA and multiplying by 10 for the initial mL/hr; 40-80 kg adults) cefazolin, D50, warming, calcium gluconate, and tetanus.

FIGURE 2: Traumatic amputation and electrical burn of the patient’s left arm. (Click to enlarge.)

Electrical injuries—excluding lightning injuries—account for roughly 10,000 nonfatal shock incidents a year and 500 deaths a year. While uncommon, electrical injuries disproportionately account for five percent of burn admissions in the U.S. and five percent workplace-related deaths.^1-3 It’s important to understand the nuances of electrical injuries in order to identify hidden injuries and appropriately treat them.

Quick Review of the Physics

FIGURE 3: Electrical

burns of the patient’s leg with proximal tibia intraosseous line. (Click to enlarge.)

A brief review of the physics of electricity can help with clinical understanding. Electricity, in the form of electrons, travel down a gradient from high to low potential. The difference of the potential is the voltage (V). The “amount” of electrons in a timeframe down this gradient is the current. Resistance is the impedance of these electrons by the material and dissipates energy as heat. Our bodies have varying amounts of resistance—the higher the fluid and electrolyte content, the less resistance there is. Our skin is the barrier to prevent electricity from traveling into deeper tissues but varies in its resistance. Wet, thin skin of a child who just got out of a pool will allow electricity to pass into deeper tissues, which can lead to unseen internal burns. Thick, dry, and calloused skin of a construction worker can have as much as 100 times more resistance than the previous example.⁴ This may lead to more heat dissipated at the skin with impressive burns to skin, but less transmission of electricity to deeper tissues. Current can be alternating current (AC) or direct current (DC) with AC typically more dangerous as it is more likely to cause tetanic contractions and increase contact time with the electrical source. “High voltage” is defined by texts as 600 V and 1,000 V.^2,3,5 Except for laundry or electrical car outlets (240 V AC), all U.S. household outlets are rated at 120 V AC. This means most household injuries are low voltage, with high voltage injuries happening in industrial settings or associated with power lines.