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

Compartment Pressure Measurement

Equipment (Stryker Intracompartmental Pressure Monitor)

• A saline-filled syringe
• A digital manometer
• A needle with a side port (18G needle typically)

Step-by-Step Technique

1. Setup

• Assemble: connect the manometer between the syringe and the needle
• Prime the system with saline - ensure no air bubbles

2. Position the limb

• Keep the limb at the level of the heart (not elevated, not dependent) - elevation falsely lowers readings

3. Needle insertion

• Clean the skin with antiseptic
• Insert the needle perpendicularly into the compartment to be measured
• Inject a few drops of saline to:
  • Confirm the needle is not in a tendon
  • Ensure no air pockets
  • Open the tip against the compartment wall

4. Read the pressure

• The digital gauge gives the reading in mmHg
• Wait for the reading to stabilize
• Take 2 readings per compartment
• Also check adjacent compartments (pressure can spread)

5. Measurement site

• Obtain measurements within 5 cm of the injury/fracture site - this is where pressures are highest

Forearm Compartments (Relevant for This Patient)

Forearm flexor compartment measurement

Forearm extensor compartment measurement

Mobile wad compartment measurement

Interpreting the Readings

Delta P Rule (more reliable, especially in hypotensive patients)

Delta P = Diastolic BP - Compartment Pressure

• Delta P > 30-40 mmHg → can manage conservatively
• Delta P < 30 mmHg → perfusion is inadequate → fasciotomy

Important Notes

• Hands and feet have too many small compartments to measure reliably - if compartment syndrome is suspected there, many specialists proceed directly to surgical decompression without pressure measurement
• If no Stryker device is available, an arterial line setup or needle-manometer system can be improvised
• For obtunded or unresponsive patients (who cannot report pain), continuous intracompartmental monitoring has ~94% sensitivity and ~98% specificity
• If compartment syndrome is clinically obvious (tense limb, pain with passive stretch, absent pulses) - do not delay fasciotomy waiting for pressure readings

Time Window

Functional impairment is unlikely if compartment syndrome is diagnosed and treated within 6 hours of onset.

Source: Tintinalli's Emergency Medicine - A Comprehensive Study Guide