Special Situations

Electrical Burns
There are 3 types of electrical burns. Minor electrical burns
usually occur as a result of biting on an extension cord. These
injuries produce localized burns to the mouth, which usually
involve the portions of the upper and lower lips that come in
contact with the extension cord. The injury may involve or spare
the corners of the mouth. Because these are nonconductive
injuries (do not extend beyond the site of injury), hospital
admission is not necessary and care is focused on the area of the
injury visible in the mouth. Treatment with topical antibiotic
creams is sufficient until the patient is seen in a burn unit
outpatient department or by a plastic surgeon.
A more serious category of electrical burn is the high-tension
electrical wire burn, for which children must be admitted for
observation, regardless of the extent of the surface area burn.
Deep muscle injury is typical and cannot be readily assessed
initially. These injuries result from high voltage (>1,000 V) and
occur particularly at high-voltage installations, such as electric
power stations or railroads; children climb an electric pole and
touch an electric box out of curiosity or accidentally touch a
high-tension electric wire. Such injuries have a mortality rate of
3-15% for children who arrive at the hospital for treatment.
Survivors have a high rate of morbidity, including major limb
amputations. Points of entry of current through the skin and the
exit site show characteristic features consistent with current
density and heat. The majority of entrance wounds involve the
upper extremity, with small exit wounds in the lower extremity.
The electrical path, from entrance to exit, takes the shortest
distance between the 2 points and may produce injury in any
organ or tissue in the path of the current. Multiple exit wounds
in some patients attest to the possibility of several electrical
pathways in the body, placing virtually any structure in the body
at risk (Table 68-8). Damage to the abdominal viscera, thoracic
structures, and the nervous system in areas remote from obvious
extremity injury occurs and must be sought, particularly in
injuries with multiple current pathways or those in which the
victim falls from a high pole. Sometimes arcing occurs and
results in concurrent flame burn and clothing fire. Cardiac
abnormalities, manifested as ventricular fibrillation or cardiac
arrest, are common; patients with high-tension electrical injury
need cardiac monitoring until they are stable and have been fully
assessed. Higher-risk patients have abnormal
electrocardiographic findings and a history of loss of
consciousness. Renal damage from deep muscle necrosis and
subsequent myoglobinuria is another complication; such patients
need forced alkaline diuresis to minimize renal damage.
Aggressive removal of all dead and devitalized tissue, even with
the risk of functional loss, remains the key to effective
management of the electrically damaged extremity. Early
debridement facilitates early closure of the wound. Damaged
major vessels must be isolated and buried in a viable muscle to
prevent exposure. Survival depends on immediate intensive
care, whereas a functional result depends on long-term care and
delayed reconstructive surgery.

Table 68-8 -- ELECTRICAL INJURY: CLINICAL

CONSIDERATIONS
 CLINICAL
MANAGEMENT
MANIFESTATIONS
Extricate the patient;
perform ABCs of
resuscitation;
immobilize the spine
History: voltage, type
General — of current
Complete blood count
with platelets,
electrolytes, blood
urea nitrogen (BUN),
creatinine, glucose
Dysrhythmias: asystole, Treat dysrhythmias
ventricular fibrillation, Cardiac monitor,
sinus tachycardia, sinus electrocardiogram,
bradycardia, premature and radiographs
atrial contractions with suspected
Cardiac (PACs), premature thoracic injury
ventricular contractions Creatinine
(PVCs), conduction phosphokinase with
defects, atrial isoenzyme
fibrillation, ST-T wave measurements if
changes indicated
Protect and maintain
Respiratory arrest, the airway
acute respiratory
Pulmonary Mechanical ventilation
distress, aspiration
syndrome if indicated, chest
radiograph, arterial
 CLINICAL
MANAGEMENT
MANIFESTATIONS
blood gas levels
Provide aggressive
fluid management
unless a central
nervous system injury
is present
Maintain adequate
urine output,
Acute renal failure, >1 mL/kg/hr
Renal
myoglobinuria Consider central
venous or pulmonary
artery pressure
monitoring
Measure urine
myoglobin; perform
urinalysis; measure
BUN, creatinine
Immediate: loss of
consciousness, motor Treat seizures
paralysis, visual Provide fluid
disturbances, amnesia, restriction if
agitation; intracranial indicated
Neurologic hematoma
Secondary: pain,
Consider spine
paraplegia, brachial
radiographs, especially
plexus injury, syndrome
cervical
of inappropriate
 CLINICAL
MANAGEMENT
MANIFESTATIONS
antidiuretic hormone
secretion (SIADH),
autonomic
disturbances, cerebral
edema
Delayed: paralysis,
CT scan of the brain if
seizures, headache,
indicated
peripheral neuropathy
Search for the
entrance/exit
Oral commissure burns, wound
tongue and dental
Treat cutaneous
injuries; skin burns
burns; determine
Cutaneous/oral resulting from ignition
the tetanus status
of clothes, entrance and
exit burns, and arc Obtain a plastic
burns surgery of ear, nose,
and throat consultation
if needed
Place a nasogastric
tube if the patient has
Viscus perforation and airway compromise or
solid organ damage; ileus
Abdominal ileus; abdominal injury Obtain SGOT (serum
rare without visible glutamate oxaloacetate
abdominal burns transaminase or
aspartate
aminotransferase),
 CLINICAL
MANAGEMENT
MANIFESTATIONS
SGPT (serum
glutamate pyruvate
transaminase, alanine
aminotransferase),
amylase, BUN, and
creatinine
measurements and, CT
scans as indicated
Compartment syndrome
Monitor the patient for
from subcutaneous
possible compartment
necrosis limb edema
syndrome
and deep burns
Musculoskeletal
Obtain radiographs
Long bone fractures, and orthopedic/general
spine injuries surgery consultations
as indicated
Visual changes, optic Obtain an
neuritis, cataracts, ophthalmology
Ocular
extraocular muscle consultation as
paresis indicated
Modified from Hall ML, Sills RM: Electrical and lightning
injuries. In Barkin RM, editor: Pediatric emergency medicine, St
Louis, 1997, Mosby, p 484.

Lightning burns occur when a high-voltage current directly

strikes a person (most dangerous) or when the current strikes the
ground or an adjacent (in-contact) object. A step voltage burn is
observed when lightning strikes the ground and travels up one
leg and down the other (the path of least resistance). Lightning
burns depend on the current path, the type of clothing worn, the
presence of metal, and cutaneous moisture. Entry, exit, and path
lesions are possible; the prognosis is poorest for lesions of the
head or legs. Internal organ injury along the path is common and
does not relate to the severity of the cutaneous burn. Linear
burns, usually 1st- or 2nd-degree, are in the locations where
sweat is present. Feathering or an arborescent pattern is
characteristic of lightning injury. Lightning may ignite clothing
or produce serious cutaneous burns from heated metal in the
clothing. Internal complications of lightning burns include
cardiac arrest caused by asystole, transient hypertension,
premature ventricular contractions, ventricular fibrillation, and
myocardial ischemia. Most severe cardiac complications resolve
if the patient is supported with cardiopulmonary resuscitation
(Chapter 62). CNS complications include cerebral edema,
hemorrhage, seizures, mood changes, depression, and paralysis
of the lower extremities. Rhabdomyolysis and myoglobinuria
(with possible renal failure) also occur.