Electrical injuries are one of the most dangerous and unpredictable trauma. There is no way to clearly measure the extent of the injury and internal damage caused by electrical injuries. Read about the management and treatment of cases involving electrical injury.

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An essential element to keep in mind with any burn or electrical injury patient is that they are a trauma patient first. Follow standard primary and secondary trauma assessment procedures, and then care for burns and electrical injuries. There is no way to precisely quantify the magnitude of electrical injuries and interior damage. This is an "iceberg injury" in which what is seen may not reflect the full extent of the damage. You can find yourself "battling an unseen foe." Pay close attention and be sceptical of any physical findings that don't fully match the clinical picture.

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Identifying and classifying the danger of electrical injuries

Among the variables that assist predict the severity of an injury are the following :

• Voltage
• AC or DC
• Duration of exposure and
• Environmental moisture/humidity level

Exposures to low voltage (600V), such as those in the home or workplace, have a decreased risk of injury. High voltage (>600V) industrial settings, subway tracks, and power lines provide a greater danger of injury.

In comparison to direct current, alternating current (AC) prolongs the time of contact and increases tissue damage by causing muscles to contract and relax for longer periods of time (DC).

The remarkably high survival rates of 70–90% of lightning strikes (up to 1 billion V) are DC with extremely little contact (milliseconds), yet up to 80% of survivors have long-term morbidity. Patients with frozen and dilated pupils (autonomic dysfunction) and chilly, mottled extremities due to vasospasm may first look dead. Asystole is caused by direct depolarisation of the myocardium, although spontaneous ROSC generally occurs. The respiratory arrest caused by medullary paralysis may need more time to cure, and patients may have a subsequent hypoxic arrest.

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Electrical injuries: Immediate consequences and adverse outcomes

Cardiac issues brought on by electrical damage

Electrical damage is seldom associated with serious heart problems. The frequency of cardiac complications ranges from 4 to 17%, although the majority of dysrhythmias are benign. They often arise during the first few hours after an accident. The most frequent ECG abnormalities are bundle branch blocks, AV blocks, QT prolongation, ST alterations, and atrial fibrillation. Generally, these arrhythmias resolve without therapy.

Among deadly arrhythmias, ventricular fibrillation is the most prevalent. Typically, it occurs quickly after electrical exposure. VF occurs more often with AC exposures. Asystole is more prevalent after DC Exposures.

Reasons to check troponins

Rare incidences of ST-elevation myocardial infarction linked with normal coronary arteries have been recorded in the medical literature (likely due to vasospasm). Direct electrical and thermal harm, as well as perhaps thrombogenic consequences of electrical injury, are believed to contribute to coronary ischemia. Due to the arc of lightning travelling through the heart, electrical burns to both hands increase the risk of cardiac problems is a fallacy. Troponins should not be prescribed blindly; rather, the choice to order them should be based on the clinical presentation and any existing risk factors.

Electrical damage resulting in compartment syndrome

The risk of compartment syndrome is considerably increased by both direct and indirect muscle damage caused by electrical exposure. Examine the limbs on a regular basis for considerable discomfort upon passive muscular extension, hard compartments upon palpation, and evidence of poor perfusion. The bar for consulting a surgeon and thinking about a fasciotomy ought to be low.

Electrical injuries often result in rhabdomyolysis and acute kidney injury

CK elevation corresponds with the severity of muscle damage but is unrelated to the likelihood of developing AKI. If the CK level is in the thousands, rhabdomyolysis should be assumed. Urine myoglobin has a low sensitivity and may be negative in up to fifty per cent of individuals with rhabdomyolysis, leading to misdiagnosis. Within hours of presentation, the urine of the majority of patients with rhabdomyolysis caused by electrical damage will be tea-coloured, making the diagnosis evident. In the situation of rhabdomyolysis and AKI, the principles of treatment and activities to be taken based on professional judgment are outlined :

1. Volume depletion must be corrected until the plasma CK level is steady and not rising.
2. To prevent the production of intratubular casts, use sodium bicarbonate (150mEq/L) to raise urine pH above 6.5.
3. In the presence of apparent myoglobinuria after appropriate fluid resuscitation, mannitol or furosemide may be taken into consideration, especially if urine has not cleared of pigment/myoglobin in a timely way (for example, over 3 hours) with fluid administration to guarantee high urine output in the prevention of acute tubular necrosis and renal failure brought on by myoglobinuria.

Remain cautious! If administered too soon, diuretics may potentially directly harm the kidneys and exacerbate renal damage. The patient must first be sufficiently resuscitated with fluids. Consultation with a burn centre is recommended before administering either mannitol or furosemide.

Injuries caused by biting power cord

Bear in mind! Children often get injuries to the corner of the mouth from chewing on electrical cords, such as smartphone cables. It may produce burns to the tongue and mouth, as well as severe, delayed bleeding from the labial artery, which may restrict the airway. When the eschar splits after 5 to 14 days, delayed bleeding may occur.

Rehydrating with fluids after electrical damage

There are some basic suggestions for fluid resuscitation in electrical injuries, such as the following:

1. Patients with electrical burns often need more fluid, as indicated by the modified Brooke/Parkland formula for patients with thermal burn injuries. Unfortunately, there aren't any specific evidence-based recommendations.
2. A constant infusion of IV fluids is favoured over boluses for minimising tissue oedema, which may exacerbate tissue damage in electrically injured patients.
3. Start with Ringer's Lactate at 300-500 mL/hr and titrate to a urine output of more than 100 cc and other indicators of appropriate organ perfusion.

After electrical accidents, keeping an eye on the heart is essential

In the absence of chest discomfort or syncope, the evidence does not support the necessity for cardiac monitoring in individuals with low voltage exposure. ECG monitoring may not be necessary for high-voltage injuries with a normal ECG, according to some data. Some medical specialists suggest cardiac monitoring for high-voltage injuries for 6 to 8 hours.

Resolution for cases involving electrical injury

1. Asymptomatic individuals wounded by low voltage (600V) may be safely released home after a normal ECG; no monitoring time is required.
2. The literature recommends monitoring the patient for 12 hours (including 6–8 hours of cardiac monitoring) even if they are asymptomatic for high voltage injury.
3. High-voltage injuries should always be sent to a burn centre.

There are delayed problems from electrical injuries, thus the discharge instructions are crucial even for patients with seemingly minor injuries. Psychological/neurological symptoms (difficulty with focus, event sequencing, and memory difficulties) and limb ischemia are among the delayed symptoms addressed. For electrical cord bite injuries, inform the parents that if their kid has delayed labial bleeding, they should use their thumb and index finger to grasp the child's lips on both sides with gauze or a towel, then apply pressure on the labial artery, and then return promptly to the ED.

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Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.