treatment for pt with electric shock
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Here is a comprehensive, evidence-based guide to the treatment of electric shock injuries:
Treatment of Electrical Injury (Electric Shock)
1. Scene Safety & Prehospital Care
- Stay ≥10 m (32 ft) from downed power lines
- Turn off the electrical source before approaching the victim
- For voltages >600 V, dry wood is NOT safe to use to move the victim
- Anyone still in contact with the source may transmit current to rescuers
- Initiate CPR/rescue breathing as soon as safe contact is confirmed
- Maintain spinal immobilization — tetanic contractions and falls can cause vertebral fractures
— Tintinalli's Emergency Medicine, p. 1441
2. Immediate Resuscitation (ED)
Cardiopulmonary Arrest
- Resuscitate all patients regardless of cardiac rhythm, including those in asystole — favorable outcomes have been documented even in asystole
- Dysrhythmias are treated per ACLS guidelines
- Low-voltage AC → may cause ventricular fibrillation by direct cardiac stimulation
- High-voltage AC/DC → more likely to cause transient ventricular asystole, which may spontaneously revert
Airway, Breathing, Circulation
- Standard ABC/major trauma evaluation
- Maintain spinal immobilization until imaging is complete
- Cardiac monitoring is mandatory for:
- All high-voltage injuries
- Any symptomatic patient (chest pain, LOC, palpitations, arrhythmia, ECG changes)
- Asymptomatic patients with normal ECG after low-voltage exposure do not require admission for cardiac monitoring — risk of subsequent malignant rhythm is very low
3. Fluid Resuscitation
- Use the Parkland formula (4 mL/kg × % TBSA burned over 24 h) only as a starting point
- Extensive deep tissue destruction from high-voltage injury often exceeds what the external burn suggests — fluid requirements are frequently greater than predicted
- Target urine output: >100 mL/hr in adults, 1.5–2 mL/kg/hr in children
- Fluid management resembles crush injury protocols
— Tintinalli's Emergency Medicine, p. 1441; Rosen's Emergency Medicine, p. 2799
4. Myoglobinuria & Rhabdomyolysis
- High suspicion in high-voltage injuries and symptomatic patients
- Aggressive IV crystalloid to maintain UO of 1–2 mL/kg/hr
- Monitor serial serum myoglobin, CK (target <5× ULN), and renal function
- Monitor serum potassium closely (risk of hyperkalemia with acute renal injury)
- Continue high urine output until urine myoglobin normalizes
5. Organ-Specific Assessment & Treatment
| System | Key Actions |
|---|---|
| Cardiac | ECG, continuous monitoring; treat arrhythmias per ACLS |
| Renal | IV fluids; monitor for AKI from myoglobinuria |
| Musculoskeletal | Assess spine, pelvis, long bones; assess for compartment syndrome |
| Vascular | Assess for delayed thrombosis/aneurysm; DC can cause transient vasospasm — watch before intervening surgically |
| CNS/Spine | Head CT if altered mental status; document neuro exam before intubation |
| Skin/Burns | Assess and treat cutaneous burns per burn protocols |
| Eyes | Full ophthalmic exam; delayed cataract formation can occur weeks to years later |
| Ears | Assess for blast injury; middle/inner ear disorders possible |
| GI | Intra-abdominal injury from current or blast |
| Coagulation | Replace factors if bleeding; early surgical debridement |
| Lungs | Assess for inhalation injury, CO poisoning, alveolar blast injury |
6. Compartment Syndrome / Fasciotomy
Fasciotomy within 24 hours is indicated if any one of the following is present:
- Myoglobinuria
- Burns >20% TBSA
- Full-thickness burns >12% TBSA
— Tintinalli's Emergency Medicine, p. 1441
7. Low-Voltage vs. High-Voltage Summary
| Feature | Low Voltage (<1000 V) | High Voltage (≥1000 V) |
|---|---|---|
| Surface damage | Less obvious | Partial to full-thickness burns |
| Cardiac risk | VF possible (esp. if wet) | Asystole or VF |
| Fluid needs | Minimal (if asymptomatic) | Often large |
| Monitoring | Not needed if asymptomatic + normal ECG | Mandatory |
| Associated trauma | Less common | Fractures, spinal cord injury, blunt head trauma |
8. Lightning Strike (Special Case)
- Approach as for high-voltage injury if symptomatic or altered mentation
- Fixed, dilated pupils do not necessarily indicate irreversible brain injury — do not prematurely terminate resuscitation
- Catecholamine surge may cause transient hypertension/tachycardia → treat with β-blockers + hydralazine or clonidine (alpha-2 agonist)
— Rosen's Emergency Medicine, p. 2799
Key principle: Any patient with loss of consciousness, cardiac symptoms, ECG changes, high-voltage exposure, or myoglobinuria requires hospital admission and monitoring. Asymptomatic patients with normal ECG after isolated low-voltage exposure can be safely discharged with wound care and reassurance.
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