← Diagnosis and Management Guides
Electrical Injury
Key considerations: Cardiac arrhythmia (can be delayed), Rhabdomyolysis, Internal burns greater than external appearance
Cannot miss
- Cardiac arrhythmia (can be delayed)
- Rhabdomyolysis
- Internal burns greater than external appearance
- Spinal injury from fall/tetany
Likely diagnoses
- Low-voltage household injury
- High-voltage occupational injury
- Lightning strike
- Arc flash burn
Red flags
- High voltage (>1000V)
- Lightning strike
- Prolonged contact
- Loss of consciousness
- Entry/exit wounds
- Tea-colored urine
Workup
- history: Voltage source, duration of contact, loss of consciousness, falls, tetanic spasm; exam: Entry and exit wound identification, full trauma survey, cardiac exam, neurologic exam, compartment assessment; labs: ECG (all patients), CK and urine myoglobin, BMP (AKI from rhabdo), UA (myoglobinuria), CBC, coags, lactate; imaging: Trauma imaging if fall suspected, CT as indicated; bedside: Continuous cardiac monitoring, point-of-care glucose
Management
- immediate: Aggressive IV fluids targeting UO 1-2 mL/kg/hr until myoglobinuria clears; Cardiac monitoring minimum 6 hours (24 hours if high voltage or arrhythmia); general: Wound care, tetanus prophylaxis; Sodium bicarbonate for urine alkalinization if significant rhabdomyolysis; Ophthalmology if eye exposure (cataracts); Audiology if lightning strike; Fasciotomy if compartment syndrome
Disposition
- admit: All high-voltage injuries, all with arrhythmia, all with loss of consciousness, all with myoglobinuria; discharge: Low-voltage with normal ECG, normal labs, no symptoms after 6-hour observation; consults: Surgery/burn center, ophthalmology, audiology as indicated
Clinical pearls
- Skin entry and exit wounds dramatically underestimate internal tissue destruction — treat aggressively
- Cardiac arrhythmias can be delayed up to 24 hours after high-voltage injury — monitor
- Lightning strike: 30% mortality, most common cause of death is cardiac arrest — initiate CPR immediately
Source and review
- ABA Electrical Injury Guidelines 2023. Last reviewed: 2024-11-01