Approach
People may present immediately after the injury or late with cardiac or neurologic complications.
People with electrical injury should be evaluated as a multiple trauma patient. Airway, breathing, and circulation assessment, and spine immobilization, should be performed as part of a primary survey. Prior to determining the person’s cardiorespiratory status, the rescuer must first ensure that the danger of further shock has been removed to allow for a safe environment for assessment.[20]
History
In the case of an immediate injury, the history surrounding the event is critical. It is important to determine if the patient lost consciousness at any time.
If the patient is alert, a complete description of the event should be obtained. This should include:
The nature of electrical contact
High or low voltage, or lightning
Length of contact
Time since injury.
If the patient is unconscious, this information is obtained from emergency medical service (EMS) personnel or witnesses. The possibility of associated injury should be determined by asking where the patient was found or if they were working off the ground.
Examination
In some cases the physical exam might be entirely normal. Hypothermia should be suspected when the exact time of injury is unknown, or if the person might have been immobile on the ground for more than a few minutes. In these cases, measurement of core temperature is important.
The physical examination should include a primary survey for life threatening injuries, followed by a head-to-toe secondary survey. An injured extremity may have minimal or no external signs of electrical injury. The percentage of superficial burns may bear no relation to the underlying tissue damage and the rule of nine should be used with caution. Deep tissue injury in the extremities can lead to swelling and subsequent compartment syndrome. This should be suspected and treated accordingly without delay. The colon and the small intestine are the most frequently injured visceral organs. The development of abdominal compartment syndrome secondary to an electrical injury can be catastrophic.[21]
Patients may present with an altered mental state. This could be due to a direct effect of electricity on the brain, a result of anoxia from a cardiac arrhythmia, or as a result of secondary trauma.
Keraunoparalysis (lightning paralysis) is a reversible, transient paralysis that is associated with sensory disturbances and peripheral vasoconstriction in lightning victims.[19][22]
Investigation
In the US and other countries, modern EMSs systems and availability of automated external defibrillators may allow for evaluation and treatment of cardiac dysrhythmias in the prehospital setting.
On arrival at the hospital, immediate cardiac monitoring is imperative for rhythm analysis and monitoring.
A 12-lead ECG should be performed immediately. Nonspecific ST-T changes are common. Atrial fibrillation is the most common arrhythmia.[23]
Complete blood count, serum electrolytes, liver function tests, blood urea nitrogen, creatinine, creatine kinase, and urinalysis for myoglobin should be performed. In the presence of hemodynamic instability, and where internal injuries are suspected, cross-matching and coagulation studies should be requested. Troponin should be preferred as the most specific cardiac injury marker.
If compartment syndrome is suspected, compartment pressures can be measured in the emergency department. This can be particularly useful for the unconscious person.
A urine toxicology screen for illicit drugs and blood alcohol measurements may be indicated, because concurrent substance use may have contributed to the accident.[24]
Imaging studies
A chest x-ray for evaluation for flash pulmonary edema secondary to cardiac dysfunction may be useful. Other imaging may be necessary depending on secondary injuries. A computed tomography (CT) head scan should be performed if a head injury is suspected. A magnetic resonance imaging brain scan is recommended after initial evaluation with CT head for a more complete evaluation of head injury and for a prognostic role in anoxia coma.[25]
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