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Electrical Injuries
Treatment & Management
Updated: May 26, 2021 | Author: Brian J Daley, MD, MBA, FACS,
FCCP, CNSC; Chief Editor: John Geibel, MD, MSc, DSc, AGAF
more...

16

Medical Therapy
Patients with electrical injury should be initially
evaluated as a trauma patient. [22, 23] Airway,
breathing, circulation, and inline immobilization of the
spine should be performed as a part of primary survey.
Maintain a high index of suspicion and evaluate for
hidden injuries. Intravenous access, cardiac monitoring,
and measurement of oxygen saturation should be
started during the primary survey. Fluid replacement is
the most important aspect of the initial resuscitation.
[24] As with conventional thermal injury, electrical
injuries cause massive fluid shifts with extensive tissue
damage and acidosis; therefore, monitoring a patient's
hemodynamics is important. A Foley catheter is helpful
in monitoring urine output and, therefore, tissue
perfusion.

Initial fluid resuscitation should aim for urine output of

greater than 0.5 cc/kg/h if no signs of myoglobinuria
are present and preferably greater than 1 cc/kg/h if
myoglobinuria is present. Since lightning burns are
usually superficial, using a standard formula, such as
the Parkland formula, may be helpful.

The extent or volume of tissue damage involved with

an electrical injury is difficult to assess. The
unpredictable nature of electrical injuries makes
estimating fluid deficits much more difficult. Many
authors increase fluid replacement after an electrical
injury.

Based on the Parkland formula, increase fluid

replacement by 2-3 times, depending on the total
surface area potentially involved. For example,
increase it by 3 if the surface area is 20% and increase
it by 2 (or less) according to an increased percentage
of burned skin. These formulas estimate necessary
initial resuscitation volume over the first 24 hours
(started at the time of the burn).

Use an isotonic balanced saline solution (eg, Ringer's

lactate solution) for fluid resuscitation. Closely follow
urinary output as an indicator of hemodynamic status
and kidney function. Make constant adjustments based
on hourly urine output. Decrease or increase fluid rates
to maintain urine output of 0.5-1 cc/kg/h.

Installing an indwelling urinary catheter is mandatory.

Hematuria or dark urine prompts the need for more
aggressive therapy to prevent myoglobin-induced
tubular necrosis. This is treated with fluids (initiating
diuresis) and bicarbonate.

Administer bicarbonate at 1-2 mEq/kg. With very

extensive injuries, expect acidosis and myoglobinuria,
and initiate bicarbonate with the initial fluid bolus.

Administer mannitol at 1 gram per kilogram body

weight to promote an osmotic diuresis. The target
urine output is up to 2-3 mL/kg/h, with a urine pH
greater than 6.5. Bicarbonate treats the underlying
acidosis and alkalinizes the urine, making myoglobin
more soluble.

Additional diuretics may be administered.

Acetazolamide is the recognized drug of choice
because it also alkalinizes the urine. However, exercise
this diuresis with extreme caution to avoid
hyperosmotic hypoalbuminemia.

Surgical Therapy
Functional outcome of an electrical burn wound is
inversely proportional to the time lapsed before the
start of the reconstructive procedure(s). [22, 23]

As part of the nature of the electrical trauma, tissue

damage leads to vascular thrombosis and skin and
muscle necrosis. This leads to gross limitation on
manipulation of local tissues for reconstruction. The
optimal management of these wounds has evolved to
initial debridement, decompression (fasciotomy), and
aggressive planned debridement and early skin
coverage with the goal of preserving vital structures.
[22, 23]

Fasciotomy serves a dual role as both a therapeutic

tool and a diagnostic tool in the treatment of electrical
injuries. The fact that a burn with a relatively small
surface area may hide massive tissue destruction
beneath cannot be overemphasized. Therefore,
aggressively evaluate any swelling or signs of impaired
circulation.

Impaired circulation to extremities after thermal skin

injury may be the result of constrictive eschar, which
usually is circumferential and of full thickness. Impaired
circulation also may be the result of compartment
syndrome, which is caused by edematous muscles.

Volume is limited as a result of the naturally needed

fascial compartments. When edema occurs in the same
volume compartment, pressures within that
compartment rise. Sufficient pressure to occlude
venous obstruction easily leads to muscle ischemia,
increased edema, and further myonecrosis.

Compartment pressures need not exceed arterial

pressures to cause necrosis. Any questionable
extremity must be examined in the operating room by
removing solid eschar initially, followed by fasciotomy
as indicated. A low threshold for fasciotomy is
indicated because an early fasciotomy may prevent
ischemia and prevent (or at least limit) amputation.

Fasciotomy also serves a diagnostic role. It can be very

important in helping determine the extent of muscular
necrosis. Frankly debride the necrotic tissue to explore
the affected limbs. Repeat assessment, either during
the operation or at dressing changes, can help prevent
secondary infection. Assess muscle viability with serial
technetium scans. If, at second look, additional necrotic
tissue is present, further debride the affected extremity.
In severe cases, early amputation remains the only safe
choice.

Locoregional flaps have served as good alternatives

for coverage of electric burn wounds. Alternatives
include myocutaneous, fasciocutaneous, and muscle
flaps, with a split thickness skin graft serving as an
intermediate biological cover or as a definitive
procedure.

Operative Details and Follow-up

Preoperative details
Bring patients to the operating room after aggressive
resuscitation has reversed shock, assured oxygen
delivery, restored circulating volume, and reestablished
end-organ perfusion. The patient may need tetanus
prophylaxis. Bedside fasciotomy can be performed if
the patient is too unstable to go to the operating room.

Intraoperative details
Follow the principles of good surgical technique.
Perform fasciotomies following prescribed techniques,
and ensure that any at-risk compartment is released.
Make every effort to protect marginal tissue.

Postoperative details
Continue aggressive postoperative assessment for
myoglobinuria. Local wound care is the surgeon's
choice; the authors prefer wet-to-dry gauze dressings
changed at twice-daily whirlpool sessions. Consider
delayed closure of the fasciotomy site or secondary
coverage when appropriate.

Follow-up
Discharge patients with open wounds if adequate
wound-care arrangements are available. Follow-up
care depends on the nature and extent of the injury.
Secondary coverage may be needed, and consulting a
plastic or reconstructive surgeon may be helpful.

For patient education resources, see

the Environmental Exposures and Injuries
Center and Burns Center, as well as Lightning
Strike and Electric Shock.

SECTIONS
Electrical Injuries

Overview

Workup

Treatment

Medical Therapy

• Surgical Therapy

Operative Details and Follow-up

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