30 year old male fell unconsocious after touching high tension wire. H

30 year old male fell unconsocious after touching high tension wire. He regained consciousness after ten minutes. He is conscious, coherent and obeying commands. He is complaining of back pain

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"electrical injury"[MeSH Terms] AND "clinical management"

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High-Voltage Electrical Injury - Clinical Assessment & Management

Situation Overview

This is a high-voltage electrical injury (power lines typically carry >11,000 V, far above the 1000 V threshold). The patient has:

Lost consciousness (LOC) for 10 minutes - now alert, coherent, obeying commands
Back pain - a red flag symptom in this context

This patient must be treated as a multi-system trauma case until proven otherwise.

Why Back Pain is a Red Flag Here

High-voltage AC current causes tetanic muscular contractions. The powerful paraspinal and truncal muscle contractions can cause:

Compression fractures of the vertebral bodies (especially thoracic)
Spinal cord injury from the tetanic contraction or from a fall
Direct electrical injury to the spinal cord

"Increased risk of compression spine fractures or spinal cord injury due to tetany" - Harriet Lane Handbook

High-voltage DC exposure can also throw the victim, causing blunt traumatic spinal injury from the fall.

Immediate spinal immobilization is mandatory until imaging rules out a fracture.

Immediate Priorities (ABC + C-spine)

Priority	Action
Airway	Assess, secure early if any concern - edema can progress
C/T/L/S Spine	Immediate immobilization - do NOT move without imaging
Breathing	SpO2, supplemental O2, target SaO2 >92%
Circulation	IV access x2, continuous cardiac monitoring, 12-lead ECG
Exposure	Full skin exam for entry/exit wounds, burns

Cardiac Concerns

Ventricular fibrillation is the most common fatal arrhythmia in horizontal-pathway currents (up to 60% of cases)
Any dysrhythmia is possible; new-onset atrial fibrillation is the most common arrhythmia seen in survivors
Overall arrhythmia rate post-electrical injury: up to 15%; most are benign and occur within the first few hours
The patient had LOC for 10 minutes - this mandates full cardiac evaluation

Action: 12-lead ECG now. Continuous telemetry monitoring for 24 hours minimum (up to 48 hours per Current Surgical Therapy). Treat dysrhythmias per ACLS guidelines.

Investigations to Order

Test	Rationale
12-lead ECG	Dysrhythmia, ischemia, cardiac injury pattern
Serum troponin	Myocardial damage; if elevated, echocardiogram + prolonged monitoring
Serum myoglobin	Rhabdomyolysis from muscle destruction
Urinalysis + urine myoglobin	Myoglobinuria -> risk of acute kidney injury
CBC, BMP (electrolytes, BUN, creatinine)	Baseline renal function, K+ (rises with rhabdo)
LFTs + lipase	If abdominal symptoms or suspected intra-abdominal current path
Coagulation studies	If significant injury suspected
MRI/CT spine	HIGH PRIORITY given back pain - rule out fracture and cord injury
CT head	If any focal neuro signs or concern for traumatic brain injury
X-rays of injured extremities	If pain, deformity, or bony tenderness

Fluid Management

High-voltage injuries cause deep tissue destruction and rhabdomyolysis. Fluid requirements are similar to crush injuries and exceed standard burn protocols:

IV crystalloid to maintain urine output >100 mL/hr in adults
If myoglobinuria: aggressive IV fluids to flush myoglobin from renal tubules and prevent acute tubular necrosis
Monitor serum potassium closely - rises with rhabdomyolysis and can trigger fatal arrhythmias

Neurological Assessment

The 10-minute LOC is significant. Perform:

GCS (currently appears 15 - conscious, coherent, obeying commands)
Full cranial nerve exam
Motor and sensory examination of all four limbs
Assess for evidence of spinal cord injury: weakness, paresthesias, bladder/bowel dysfunction

Note: Patients can develop delayed neuropsychiatric sequelae - arrange neurology follow-up at discharge if admitted.

Wounds

Identify and document entry and exit wounds (typically entry on the hand/point of contact; exit where grounding occurred)
High-voltage injuries produce deep tissue destruction that is far more extensive than surface appearance suggests - "iceberg effect"
Assess extremities for compartment syndrome (pressure monitoring if clinical suspicion)
Monitor for delayed vascular thrombosis

Disposition

Given this patient has:

High-voltage exposure (power line)
Loss of consciousness
Back pain (possible spinal injury)

Admission is mandatory. Minimum 24-hour telemetry monitoring. Urgent MRI spine. Consider transfer to a burn center if significant burns are found.

Do NOT discharge this patient from the ED without spinal imaging and a period of monitored observation.

Summary of Key Points

High-voltage injuries are deceptively severe - surface findings underestimate deep injury
Back pain after electrical LOC = spinal fracture/cord injury until proven otherwise - immobilize now
10-minute LOC mandates full cardiac, neurological, and renal workup
The injury path through the body (entry-to-exit) determines which organs are at risk - assess accordingly
Rhabdomyolysis, acute kidney injury, and delayed arrhythmias are the main life-threatening complications in survivors

Sources: Rosen's Emergency Medicine, 9th Ed.; Current Surgical Therapy, 14th Ed.; Harriet Lane Handbook, 23rd Ed.; Current Surgical Therapy Table 5 (Critical Care Management of Electric Injury Patient)

X ray spine show wedge compression fracture

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Wedge Compression Fracture - Management in High-Voltage Electrical Injury

This finding confirms what was clinically suspected. The tetanic muscle contractions from high-voltage AC current caused a hyperflexion force on the spine, producing the wedge compression fracture. The back pain was the clinical clue.

Step 1 - Maintain Spinal Immobilization

Do NOT move this patient without full spinal precautions.

Hard collar + spine board / log-roll precautions
Thoracolumbosacral orthosis (TLSO) if thoracolumbar level
All transfers with full spinal precautions until fracture stability and neurological status are clearly defined

Step 2 - Urgent Neurological Assessment (ASIA Score)

This is the most important clinical step right now. The patient is conscious and coherent - a full ASIA (American Spinal Injury Association) classification must be done immediately.

ASIA Standard Neurological Classification - Schwartz's Principles of Surgery, 11th Ed.

Examine systematically:

Component	What to Test
Motor	Key muscles at each level (C5-T1, L2-S1); score each 0-5
Sensory - Light Touch	Test each dermatome bilaterally
Sensory - Pin Prick	Test each dermatome bilaterally
Sacral function	Voluntary anal contraction (S4-5); perianal sensation
Complete vs Incomplete	ANY preserved motor/sensory at S4-S5 = incomplete injury

ASIA Impairment Scale:

A - Complete: no motor or sensory function below lesion including S4-5
B - Sensory incomplete: sensation preserved but no motor below lesion
C - Motor incomplete: motor preserved below, majority of key muscles <grade 3
D - Motor incomplete: motor preserved below, majority of key muscles ≥grade 3
E - Normal motor and sensory function

This patient obeying commands suggests upper limb function is intact. The key question is: are lower limbs affected? Check for weakness in hip flexors (L2), knee extensors (L3), ankle dorsiflexors (L4), toe extensors (L5), ankle plantarflexors (S1).

Step 3 - Imaging

X-ray has confirmed the fracture. Now you need:

MRI Spine (Priority)

Defines cord compression - is there canal compromise?
Identifies cord signal change (contusion, edema, hemorrhage)
Assesses posterior ligamentous complex (PLC) integrity - determines stability
Rules out multi-level involvement (electrical injury can cause multiple levels)

CT Spine

Better bony detail than X-ray
Quantifies degree of vertebral body height loss and retropulsion
Determines kyphotic angle (Cobb angle)
Helps classify fracture stability

Key radiological questions to answer:

What level is the fracture? (Most electrical compression fractures occur in the mid-thoracic or thoracolumbar junction T12-L1)
What is the degree of anterior wedging? (>50% height loss = unstable)
Is there retropulsion into the spinal canal?
Is the posterior ligamentous complex intact?
Are there multiple levels involved?

Step 4 - Fracture Classification and Stability

Using the Denis Three-Column Model:

Column	Components	Wedge Compression
Anterior	Anterior longitudinal ligament + anterior 2/3 vertebral body	Disrupted (compressed)
Middle	Posterior 1/3 vertebral body + posterior longitudinal ligament	Usually intact in simple wedge
Posterior	Posterior bony arch + posterior ligamentous complex	Usually intact

A simple wedge compression fracture (anterior column only, <50% height loss, no retropulsion, intact middle and posterior columns) is generally stable. However, in this electrical injury context - where tetanic forces are enormous and the mechanism is violent - do not assume stability without CT/MRI confirmation.

Unstable fracture features requiring surgical consideration:

50% loss of vertebral body height
30 degrees kyphotic angulation
Retropulsion into spinal canal
Posterior ligamentous disruption
Neurological deficit

Step 5 - Management Plan

If NEUROLOGICALLY INTACT + Stable Fracture (Most Likely in This Patient)

The patient is conscious and obeying commands, suggesting preserved motor function:

Conservative management: TLSO brace immobilization
Bed rest initially, then gradual mobilization with brace
Analgesia: IV morphine or fentanyl acutely; avoid NSAIDs in the short term given risk of renal impairment from myoglobinuria
Physiotherapy - early mobilization once stability confirmed
Neurosurgical / orthopaedic spine consult for definitive management plan

If NEUROLOGICAL DEFICIT PRESENT or Unstable Fracture

Neurosurgical emergency - urgent spine surgery consultation
Timing: Surgery within 24 hours is associated with better neurological outcomes (higher odds of 2-point improvement in ASIA grade at 6 months) - Schwartz's Principles of Surgery
Goals of surgery: Decompression of spinal cord/nerve roots + stabilization
Maintain MAP >85 mmHg for 7 days post-injury to optimise spinal cord perfusion

Steroids (Methylprednisolone) - Controversial

High-dose methylprednisolone (30 mg/kg bolus then 5.4 mg/kg/hr infusion) has been studied in acute SCI:

NASCIS II/III showed modest benefit if given within 8 hours of injury
Benefits were only in post-hoc analyses; associated with increased rates of pneumonia, sepsis, poor wound healing
A recent Cochrane review showed trend towards complications
Current consensus: NOT routinely recommended; may be considered in selected incomplete injuries after shared decision-making with neurosurgery

Step 6 - Continue All Electrical Injury Monitoring in Parallel

The spinal fracture does not replace the systemic electrical injury workup - both must run simultaneously:

System	Action
Cardiac	Continuous telemetry x24h, serial troponins
Renal	Hourly urine output, urine myoglobin, serial creatinine
IV fluids	Maintain UO >100 mL/hr (rhabdomyolysis protection)
Electrolytes	K+ monitoring (rhabdomyolysis raises K+)
Burns	Reassess entry/exit wounds, compartment syndrome monitoring
Analgesia	Adequate pain control (aids breathing, prevents splinting and atelectasis)

Disposition

This patient requires:

ICU or high-dependency admission (electrical + spinal injury)
Neurosurgical consultation (urgent if any neurological deficit)
Orthopedic spine consultation
Full multidisciplinary team: Emergency medicine, Neurosurgery, Orthopedics, Burns surgery (if burns), Nephrology (if AKI develops)
Transfer to spinal cord injury center once medically stabilized if significant neurological deficit is found

Summary of Priorities

Full ASIA neurological examination now - defines urgency of surgery
MRI spine urgently - cord compression? PLC intact? Canal compromise?
CT spine - bony detail, Cobb angle, retropulsion
Spinal immobilization until stability confirmed
Neurosurgical/spine consult - surgery within 24h if neuro deficit
Continue systemic electrical injury workup - cardiac monitoring, rhabdomyolysis management
Adequate analgesia without compromising neurological monitoring

Sources: Schwartz's Principles of Surgery, 11th Ed.; Rosen's Emergency Medicine, 9th Ed.; Harriet Lane Handbook, 23rd Ed.; Current Surgical Therapy, 14th Ed.

Serum myoglobin or creatinine kinase

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That's the definitive answer from the Tietz Textbook of Laboratory Medicine. Here is the complete response:

Serum Myoglobin vs Creatine Kinase (CK) - Which to Use?

Short Answer: Serum CK is superior

"Evidence that rhabdomyolysis has occurred is better provided by an increase in serum creatine kinase activity not attributable to a cardiac source. There is no strong evidence demonstrating that urinary myoglobin measurement provides useful prognostic information in this setting."

Tietz Textbook of Laboratory Medicine, 7th Ed.

"Serum creatine kinase (CK) is cleared much more slowly, so measurement of serum CK levels is a more sensitive test."

Rosen's Emergency Medicine, 9th Ed.

Why CK is Better Than Myoglobin

Property	Serum Myoglobin	Serum CK
Molecular weight	Small (17.8 kDa)	Larger
Clearance	Rapidly cleared from serum (half-life ~1-3 hrs)	Slowly cleared (half-life ~36-48 hrs)
Sensitivity	Lower - may already be undetectable at presentation	Higher - remains elevated for days
Specificity for muscle	Present in cardiac + skeletal muscle	CK-MM isoform is skeletal-muscle specific
Prognostic value	No strong evidence for prognostic use	Correlates with degree of muscle destruction
Urine dipstick	False negatives and positives common	Not applicable
Timing of peak	6-12 hours, then falls rapidly	24-72 hours, sustained elevation

The Problem with Myoglobin

Myoglobin is a small protein. After rhabdomyolysis:

It floods the plasma
Saturates renal tubular reabsorption
Gets filtered and excreted into urine
Is directly nephrotoxic - precipitates in renal tubules causing acute tubular necrosis
But it is cleared from serum so rapidly that by the time the patient reaches hospital, serum levels may already be falling or undetectable - even if significant muscle destruction occurred

Urine dipstick for blood will be positive (myoglobin cross-reacts with the hemoglobin reagent) but this gives up to 50% false negative rate in rhabdomyolysis because myoglobin may already have been cleared from the urine.

What to Order in This Patient

Order BOTH, but rely on CK as the primary marker:

Serum CK (total + isoforms)
- The primary marker for diagnosis and monitoring
- CK-MM elevated = skeletal muscle (rhabdomyolysis)
- CK-MB elevated = cardiac muscle injury (also relevant here given electrical injury)
- Serial measurements every 6-12 hours
- CK >5000 U/L = significant rhabdomyolysis; >10,000 U/L = high risk for AKI
Serum myoglobin - Order on arrival; if already low it does NOT rule out rhabdomyolysis
Urine myoglobin / urine dipstick - Brown/red urine with positive dipstick for blood but no RBCs on microscopy = myoglobinuria; this is a clinical bedside clue
Serum creatinine + BUN - Monitor for developing AKI
Urine output - The most important monitoring parameter; maintain >100 mL/hr with IV fluids

Practical Takeaway

In this patient who touched a high-tension wire and has confirmed muscle injury (electrical + possibly from spinal fracture immobility) - serum CK is the test to follow serially. It will tell you:

How much muscle has been destroyed
Whether the rhabdomyolysis is improving or worsening
When it is safe to reduce IV fluid rate

Myoglobin is gone from the serum too fast to be a reliable monitor. CK stays elevated and guides your fluid management.

Sources: Tietz Textbook of Laboratory Medicine, 7th Ed.; Rosen's Emergency Medicine, 9th Ed.

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