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ACEP Now: Vol 43 – No 03 – March 2024

FIGURE 4: Computed tomography of abdomen and pelvis with edematous bowel. (Click to enlarge.)

The Unstable, Electrical Injury Patient

In evaluating a patient with electrical injuries, an approach to the stability of the patient should always take precedence. An unstable patient who is altered or with tenuous vital signs should consider trauma and cardiac causes. 10 percent of high-voltage electrical injuries will have an associated, significant traumatic injury.^4,5 High voltage injuries can throw a victim from the electrical source, lead to falls, and cause forceful tetany with spinal hyperextension injuries or joint dislocations. Thus, unstable patients should be stabilized based on a physician’s trauma expertise; whether through Advanced Trauma Life Support, Trauma Combat Casualty Care, or one’s own trauma assessment. In addition, electrical injuries can affect cardiac conduction, leading to dysrhythmias with anything from atrial fibrillation to ventricular fibrillation.^1,4-5 Thus, an electrocardiogram (ECG) and cardiac monitoring should be performed for unstable, electrical injury patients.

Three Injury Patterns: Trauma, Burns, and Electroporation Injuries

Either after stabilization or in a stable electrical injury patient, it may be helpful to categorize and assess for three different injury patterns of trauma, burns, and electroporation injuries.

Burns in electrical injuries can vary from superficial to full thickness based on skin resistance. For high voltage electrical injuries, a high clinical suspicion and thorough evaluation should be performed for any internal burns, even without significant skin findings. Bone has high resistance, leading to periosteal and surrounding myonecrosis. Cardiac muscle can be burned, leading to significant rises in troponin. However, this is not likely due to occlusive myocardial infarction requiring catheterization, but rather direct cardiac muscle damage or vasospasm.^4,6 Internal viscera, such as bowel, can be burned, but is less likely given its high relative electrolyte and fluid content. Lastly, vessels can be damaged by internal burns, which may lead to poor perfusion and delayed complications as thrombosis or third spacing. Treatment for burns should focus on fluid resuscitation as appropriate based on your institution’s burn protocol per Brooke, Parkland, Rule of 10s etc. In addition, subacute injuries as compartment syndrome and rhabdomyolysis should be considered with creatine kinase, urinalysis, electrolyte panel, and monitoring urine output.

Electroporation injuries are caused by inappropriate membrane depolarization to electrically sensitive tissues such as the cardiac electrical conduction system or the nervous system. Dysrhythmias can present as syncope and/or chest pain, and albeit rare, have presented up to 12 hours after injury in low voltage injuries.⁷ Thus, an ECG is recommended for all electrical injuries. Syncope can also occur due to disruption of central nervous tissue. Other electrically sensitive nervous tissue can be damaged, presenting with paresthesias, weakness, and cognitive dysfunction or mood alterations. These can be delayed, up to weeks later, so it’s important to educate patients on the importance of follow-up with burn care well-versed with electrical injuries or neurology if they have or develop these symptoms.^8,9