SCGH ED CME 23/7/15

Leesa Equid
Overview
• Statistics
• Recommendations: at home
• Basic physics
• Power source
• Lightning
• Resuscitation of an electrocuted patient
• Specific organ effects – immediate and delayed
• Recommendations: in ED
Statistics
• Australia – 20-30 deaths per year
• Mostly young men at work and small children
• Young children: electrical cords and outlets (low-voltage)
• Older children: power lines (high-voltage) from climbing trees and power poles

• Deaths – low voltage 3-7x high voltage

• Burns unit admissions – 3-5%
• Approximately 1/3 are intentional
Electrical sources
• Tasers/stun guns – high voltage, low amps
• If <15 seconds exposure – no evidence of dangerous lab abnormalities, physiological
changes or immediate/delayed cardiac ischaemia/arrhythmia. Evidence suggests deaths
related to concurrent drug-use / comorbidities

• Australian power points

• Active – brown
• Neutral – blue
• Earth – green/yellow
Lightning
• Up to 30% struck by lightning die – 2/3 within 1 hr, normally from arrhythmia or
respiratory failure
• 74% of survivors may have permanent disability
• Instantaneous, unidirectional current
• Injuries from lightning differ from other electrical injuries, so should be
managed differently
Recommendations: at home
• Don’t clean the house during a storm
• Stay off landlines
• Try to stay indoors (e.g. inside the car)
• Safety of children:
• Residual current device (RCD)
• Electrical outlet covers
Basic physics
Basic physics

Andre-Marie Ampere Alessandro Volta Georg Ohm

1775-1836 1745-1827 1789-1854
Basic physics
𝑉
Ohm’s Law: 𝐼=
𝑅
I – current (Amps)
Andre-Marie Ampere Alessandro Volta Georg Ohm
1775-1836 1745-1827 1789-1854
V – voltage (Volts)
R – resistance (Ohms)

Current = volume (or number) of electrons flowing between 2 points per second
Voltage = the force that drives the electrons across the potential difference
Resistance = the hindrance to flow
Alternating current (AC) – the direction of flow of electrons changes on a cyclical
basis, in standard households.
Direct current (DC) – the direction of flow remains constant. In batteries, railway
tracks, car electrical systems, lightning
Extent of injury determined by:
• Current – amount and type (AC or DC)
• Voltage
• Resistance  wet versus dry skin
• Current pathway
• Duration of contact
 Where did ACDC get there name?

Alternating current (AC) – the direction of flow of electrons changes on a cyclical

basis, in standard households.
Direct current (DC) – the direction of flow remains constant. In batteries, railway
tracks, car electrical systems, lightning
Extent of injury determined by:
• Current – amount and type (AC or DC)
• Voltage
• Resistance  wet versus dry skin
• Current pathway
• Duration of contact
So what?
Effects of different intensities of electrical current:

Current intensity Effect

1mA Tingling sensation; almost not perceptible
3-5mA “Let-go” current for an average child
6-9mA “Let-go” current for an average adult
16mA Maximum current a person can grasp and “let go”
16-20mA Tetany of skeletal muscles
20-50mA Paralysis of respiratory muscles; respiratory arrest
50-100mA Threshold for ventricular fibrillation
>2A Asystole
15-30A Common household circuit breakers
240A Max intensity of household currents in USA
More physics…
• Mechanism of injury
1. Direct effect of electrical current on body tissues
2. Conversion of electrical energy to thermal energy, resulting in deep and superficial
burns
3. Blunt mechanical injury from lightning strike, muscle contraction, or as a
complication of a fall after electrocution
More physics…
• Mechanism of injury
1. Direct effect of electrical current on body tissues
2. Conversion of electrical energy to thermal energy, resulting in deep and superficial
burns
3. Blunt mechanical injury from lightning strike, muscle contraction, or as a
complication of a fall after electrocution

• Joule’s law: Heat = current x voltage x time

Heat = I2 x R x t
More physics…
• Mechanism of injury
1. Direct effect of electrical current on body tissues
2. Conversion of electrical energy to thermal energy, resulting in deep and superficial
burns
3. Blunt mechanical injury from lightning strike, muscle contraction, or as a
complication of a fall after electrocution

• Joule’s law: Heat = current x voltage x time

Heat = I2 x R x t
• 4 classes of electrical injury
1. Entry / exit wounds: skin findings underestimate degree of internal thermal injury
2. Flash (arc) burns occur when current arc strikes skin but doesn’t enter body
3. Flame injuries from clothes catching fire
4. Lightning injury caused by DC current with high voltage. Peak temp is 5x hotter
than the sun, generating a shock wave that transmits through the body
High vs Low voltage
High voltage injury
• >1000 V
• Severe skin burns

Low voltage injury

• Cutaneous burns often minimal unless long duration of contact
• Electrical burns absent in many low voltage deaths (death from VF)
Specific organ effects
• Cardiac
• Renal
• Vascular
• CNS / Peripheral Nervous System
• Spinal cord and Musculoskeletal
• ENT
• Cutaneous burns
Cardiac injuries
Main cause of death from electrocution
• Arrhythmia – 15%, most benign and within first few hours
• Acute cardiac injury can cause asystole and death (with DC / lightning) or
ventricular fibrillation (AC current)  VF main cause of death  60% of
patients with current from hand to hand
• Also: AF, 1st / 2nd AV block, BBBs, ST and T wave changes (generally
resolve spontaneously)
• Coronary spasm
• Myocardial rupture from coagulation necrosis
• Need vigorous resuscitation – patients are often young, not possible to
predict outcome based on rhythm, often revert
Renal and Vascular
RENAL
• Rhabdomyolysis from massive tissue necrosis
• Hypovolaemia due to extravascular extravasation  ATN

VASCULAR
• Secondary to compartment syndrome or coagulation of blood vessels
• Delayed arterial thrombosis
• Aneurysm formation / rupture – as main injury to media of vessels
CNS and Peripheral Nerve injuries
• 50% have impairment (with high-voltage)
• Transient loss of consciousness
• Quadriplegia, hemiplegia, paraesthesia
• Respiratory depression
• Autonomic dysfunction
• Memory disturbances / agitation / confusion
• Coma
• Seizures

• Common – sensory / motor findings from peripheral nerve damage 

often “patchy”, can get complex regional pain syndrome (CRPS)
• Findings commonly delayed from days to months post-injury (high
voltage)
• Keraunoparalysis – temporary paralysis from lightning with blue, mottled,
pulseless extremity from vascular spasm, normally resolves
spontaneously in few hours (lower limb > upper limb) in 2/3
Spinal cord and Musculoskeletal injuries
• Vertebral fractures, joint dislocations from falls
• Direct thermal energy causing coagulation necrosis main cause of muscle
injury  rhabdomyolysis /compartment syndrome
• Osteonecrosis
• Delayed spinal injuries
• Spinal cord damage – most common delayed consequence, resembles:
• Lower motor neuron disease
• Amyotrophic lateral sclerosis
• Transverse myelitis
• Imaging not consistent with outcomes
ENT injuries
EYE INJURIES
• Cataracts – develop months/years later
• Hyphaema, vitreous haemorrhage, optic nerve injury
• LIGHTNING – pupils may be fixed and dilated or asymmetrical – be
aware, not a reason to stop resuscitation

EAR INJURIES
• Tympanic membrane rupture – common
• Hearing loss – immediate/delayed
• Tinnitus, vertigo, facial nerve injury
ENT injuries
MOUTH INJURIES
• Children
• Can injury commissure of the lip, tongue, floor of mouth
• Swelling  airway obstruction
• Often need consultation with surgical/maxfacs for oral splinting
• Delayed vascular injury to labial artery
• Severe bleeding – 5-10%
• Occurs 5 -14 days post injury when eschar separates
• Parents need to be advised regarding first aid management and to represent if
bleeding occurs
Cutaneous injuries
• Entry and exit wounds
• Degree of external injury cannot determine extent of internal injury
• Kissing burn – at flexor creases, associated with extensive underlying
tissue damage
• Observe for neurovascular compromise and compartment syndrome,
often require surgical debridement early, vascular involvement and skin
grafting  conservative approach advised unless clinical deterioration
• Feathering (Lichtenburg) burns – not true burns, cause by electron
showers from lightning, transient, pathognomonic for lightning, need no
treatment
• Limbs should be splinted with wrist at 35-45 degree extension and MCPJs
at 80-90 degree flexion, elevate to reduce oedema
Cutaneous injuries
• Entry and exit wounds
Cutaneous injuries
• Kissing burn – at flexor creases, associated with extensive underlying
tissue damage
Cutaneous injuries
• Feathering (Lichtenburg) burns – not true burns, cause by electron
showers from lightning, transient, pathognomonic for lightning, need no
treatment
Summary of multi-system
presentations of electrical injuries

System Presentation
Skin Cutaneous burns
Cardiac Arrhythmias, cardiac arrest
Respiratory Respiratory arrest due to muscle tetany or central nervous
system causes
Vascular Aneurysm formation, tissue ischaemia
Neurologic Loss of consciousness, transient paralysis or paraesthesia,
peripheral neuropathy, spinal cord injury
Musculoskeletal Fractures or dislocations secondary to muscle spasm or
falls, muscle necrosis, compartment syndrome
Renal Myoglobinuria leading to renal failure
Other Cataracts, neuropsychological effects
Table from: Electrical injuries: A review for the Emergency Clinician: Emergency Medicine Practice,
Oct 2009
ED Treatment
Reverse triage – highest priority to those in cardiac or respiratory arrest
Resuscitation as per trauma guidelines, systematic physical examination
• ABCs, Spinal immobilisation
• Prolonged cardiac resuscitation following electrical injury
• CVS function – assess rhythm, check pulses  everyone gets an ECG
• Skin – inspect for burns, blisters, charred skin – specifically skin creases, areas
around joints and the mouth
• Neurological function – mental status, pupillary reaction, motor function, sensation
• Eyes – visual acuity, anterior chamber, fundoscopy *Lightning – pupils do not reflect
neurological status
• Ear, nose, throat – inspect tympanic membranes, assess hearing, look for signs of
smoke inhalation
• Musculoskeletal – inspect and palpate for injuries (fractures / compartment
syndrome)
• ?ADT status
• NOTE: hypotension unexpected finding with lightning, investigate other causes
ED Treatment
Investigation Indication
ECG All patients
FBC All patients with more than minor burns
UEC All patients with more than minor burns
Urinalysis To evaluate for myoglobinuria
Serum myoglobin If urinalysis positive for myoglobinuria
LFTs/lipase/amylase If intra-abdominal injury suspected
Coagulation profile If intra-abdominal injury suspected or pre-op
Group and hold Pre-op
Imaging Xrays / CTs pending examination findings as per trauma
guidelines
ED Treatment
Fluid resuscitation – often require aggressive IV fluid replacement
Do NOT use Parkland formula (1/2 fluid calculated over 8hrs, the rest over
following 16hrs calculated on 4mL/kg for each % of TBSA burned) as surface
burns underestimate extent of injury
Treatment more aligned to major crush injury fluid resuscitation
Titrate to urine output after initial fluid resuscitation – aim to prevent
rhabdomyolysis
Avoid over-resuscitation
Disposition
ADMIT
• High voltage (>1000V) needs 12-24hrs cardiac monitoring
• Low voltage with mild persistent symptoms and cutaneous burns with
normal ECG and U/A – observe for few hours, then discharge
• Obstetric consultation for pregnant patients (can have placental
abruption)
DISCHARGE
• If asymptomatic after low-voltage exposure with normal physical
examination, no loss of consciousness and normal ECG
• Give information for follow-up and symptoms that may develop requiring
prompt representation (chest pain, palpitations, LOC, wound infection,
cold/mottled/painful extremities, neuropsychological effects)
Disposition - children
DISCHARGE
• If only hand wounds with no CVS/CNS involvement – discharge with
wound care
ECG
• Tetany
• Decreased skin resistance by water/burns
• Unwitnessed
ADMIT for cardiac monitoring 24hrs
• Cardiac history
• LOC
• Voltage >240V
• Abnormal ECG
Disposition: diagram
Case 1 - Triage
3 patients during an match at your local footy club – you are the team First
Aid Officer:
Patient 1 - Deformed left shoulder, shallow breathing, mottled lower limb
Patient 2 - GCS 3, full arrest, evidence of Lichtenburg burn
Patient 3 - Paralysis to legs, cutaneous burns to legs

How do you triage these patients?

Case 2
20yo male, BIBA after suicide attempt via electrocution – put electric razor
and hairdryer in sink of water, inserted both hands into water
History?
Examination?
Investigations?
Disposition?
Case 2
20yo male, BIBA after suicide attempt via electrocution – put electric razor
and hairdryer in sink of water, inserted both hands into water
History?
Multiple attempts at putting both hands into water, kept being thrown to
ground
No loss of consciousness throughout attempts
Pain to both hands – thinks they are burnt
Found by mother who called SJA
Case 2
20yo male, BIBA after suicide attempt via electrocution – put electric razor
and hairdryer in sink of water, inserted both hands into water
Examination?
ABCs – NAD
Small cutaneous entry/exit marks on hands, with normal sensation and
function
Case 2
20yo male, BIBA after suicide attempt via electrocution – put electric razor
and hairdryer in sink of water, inserted both hands into water
Investigations?
ECG – normal sinus rhythm
Urinalysis – NAD
FBC / UEC - NAD
Case 2
20yo male, BIBA after suicide attempt via electrocution – put electric razor
and hairdryer in sink of water, inserted both hands into water
Disposition?
Burns on hands dressed
Psychiatry admission
Summary
Safety first when approaching your patient – do not become a 2 nd patient!
Triage lightning injuries in reverse-triage order
Treat electrical injuries as per trauma guidelines
Care with calculating fluid resuscitation, manage as per crush injuries rather
than cutaneous burns
Be aware of delayed clinical features and inform patients re: follow-up
Who to admit for observation?
Who can be safely discharged home?
Questions?
References
1. Dumler Czuczman A, Zane R. Electrical Injuries: A Review for the Emergency
Clinician. Emergency Medicine Practice Oct 2009
2. Jain S, Bandi V. Electrical and lightning injuries. Crit Care Clin 1999; 151:696
3. Ritenour AE, Morton MJ, McManus JG, et al. Lightning injury: a review. Burns
2008; 34:585
4. Vilke GM, Bozeman WP, Chan TC. Emergency department evaluation after
conducted energy weapon use: review of the literature for the clinician. J Emerg
Med 2001; 40:598
5. Cherington M. Neurological manifestations of lightning strikes. Neurology 2003;
60:182
6. Celebi A, Gulel O, Cicekcioglu H, et al. Myocardial infarction after an electric
shock: a rare complication. Cardiol J 2009; 16:362