Electrical Burn Injury - Left Upper Limb (ER Management)

Understanding the Mechanism

• AC household current (220-240V in most countries, 110V in North America) oscillates at 60 Hz
• AC causes tetanic muscle contraction - the "let-go" phenomenon - meaning the patient may have gripped the source involuntarily, prolonging contact
• Ventricular fibrillation occurs at 50-100 mA; asystole at >2A
• It is the amperage, not the voltage, that kills
• Water contact greatly reduces skin resistance (from ~100,000 ohms dry to ~1,000 ohms wet), dramatically increasing current through the body

Immediate ER Assessment - Primary Survey First

Airway, Breathing, Circulation (ABC)

• Airway: Secure if any facial/airway burns, altered consciousness, or stridor - anticipate early intubation before edema occludes airway
• Breathing: SpO2 continuous monitoring; supplemental O2
• Circulation: IV access (2 large-bore IVs), continuous cardiac monitoring (ECG) - this is mandatory. Ventricular fibrillation is the most common cause of death in electrical injury
• Check for pulse in the affected limb - note entry/exit points if visible

Disability (Neuro exam)

• GCS, level of consciousness
• Full spine assessment within 24 hours (electrical injury can cause vertebral fractures from tetanic contractions)

Critical Investigations to Order

Fluid Resuscitation

• 0.5 mL/kg/hr if low rhabdomyolysis risk
• 1.0-1.5 mL/kg/hr if myoglobinuria is present (to flush pigment and prevent acute tubular necrosis)

"Initiate fluid resuscitation with warmed, isotonic crystalloid IV fluids to a target urine output of 0.5 cc/kg/hour if low risk for rhabdomyolysis (greater than 1.0 cc/kg/hour if high risk for rhabdomyolysis). Monitor for the development of hyperkalemia and hyperchloremia."

• Current Surgical Therapy 14e

Wound Assessment - Left Upper Limb

Entry/Exit Points

• AC current creates contact points (not true entry/exit wounds like DC)
• Look for contact burns on the hand (where she held/touched the source) and potentially the feet (ground point)

Burn Depth Assessment

• Superficial skin appearance but severe deep tissue destruction (muscle, nerve, vascular)
• The true extent of injury may not be apparent for 24-72 hours as deep tissues demarcate

Compartment Syndrome - HIGH PRIORITY

• Massive edema from fluid resuscitation and direct tissue injury
• Deep muscle destruction
• Circumferential burns

Cardiac Monitoring Protocol

• Low-voltage injuries (<1000V) with normal ECG on arrival and no arrhythmia: minimum 6-12 hours of monitoring
• Any abnormality on ECG, loss of consciousness, or continued symptoms: admit for 24-hour continuous cardiac monitoring
• Common arrhythmias: sinus tachycardia (most common), VF (most deadly), atrial fibrillation, BBB

Wound Care (Initial ER)

1. Remove all jewelry and clothing from the affected limb immediately - these retain heat and may act as conductors
2. Cover burns with clean, dry sterile dressings (not wet - avoid hypothermia)
3. Do NOT apply ice
4. Topical antimicrobials (silver sulfadiazine or bacitracin) after assessment
5. Do NOT debride in the ER - extent of injury evolves over days

System-by-System Complications to Watch

Burn Center Transfer Criteria

• Electrical burns (any voltage) qualify for burn center transfer
• Upper extremity involvement with possible deep tissue injury
• Need for multidisciplinary care (plastic surgery, hand surgery, vascular surgery)

"The American Burn Association referral criteria recommend that patients with high-voltage electrical trauma to the upper extremity should be referred to specialized burn centers experienced with these injuries."

• Current Surgical Therapy 14e

Summary Management Checklist

• Remove from source / confirm safe scene
• ABC + spine immobilization
• Cardiac monitor + 12-lead ECG
• 2 large-bore IV access + urinary catheter
• Labs: CK, BMP, CBC, troponin, coag, urine myoglobin
• IV fluid resuscitation (LR) - target UO 0.5-1.5 mL/kg/hr
• Remove jewelry/clothing from limb
• Wound assessment - document entry/exit contact points
• Neurovascular exam of limb - hourly (compartment syndrome vigilance)
• Pain management (IV opioids)
• Tetanus prophylaxis
• Consider early fasciotomy if compartment syndrome develops
• Refer to burn center

Sources: Current Surgical Therapy 14e, Rosen's Emergency Medicine, Campbell's Operative Orthopaedics 15e (2026), Miller's Anesthesia 10e