Electrical Injuries

Robert Primavesi, MDCM, CCFP(EM)

Montreal General Hospital
McGill University Health Centre
 Electrical Injuries
Goals
To identify the important complications of
electrical injuries.
To expose the pitfalls in diagnosis.
To explore the controversies in management.
 Electrical Injuries
Objectives
Define the population at risk.
Determine the factors predicting the severity of
injury.
Differentiate between high-voltage and low-
voltage injuries.
Recognize which patients require admission or
referral.
Decide which patients need cardiac monitoring.
Top 10 Myths of Electrical Injury

*
Top 10 Myths of Electrical Injury
Myth #1

Electrical Injuries Are Uncommon

 Electrical Injuries
Epidemiology
124 deaths in Quebec 1987-
1992
5X additional patients
requiring emergency treatment
3-5% of all burn centre
admissions
Bimodal distribution
Toddlers
Workforce
Top 10 Myths of Electrical Injury
Myth #2

Voltage Is the Most Important

Determinant of Injury
 Electrical Injuries
Factors Determining Severity

OHMS LAW: i = V / R

1. V = voltage
2. i = current
3. R = resistance
 Electrical Injuries
Factors Determining Severity

JOULES LAW:

Power (watts) = Energy (Joules)

time
=Vxi
2
=i xR
 Electrical Injuries
Factors Determining Severity
Skin Resistivity - Ohms/cm2
Mucous membranes 100
Vascular areas 300 - 10 000
volar arm, inner thigh
Wet skin
Sweat 1 200 - 1 500
Bathtub 2 500
Other skin 10 000 - 40 000
Sole of foot 100 000 - 200 000
Heavily calloused palm 1 000 000 - 2 000 000
Top 10 Myths of Electrical Injury
Myth #3

High Voltage Is More Likely to Kill Than

Low Voltage
 Electrical Injury
Factors Determining Severity
A momentary dose of
high voltage electricity is
not necessarily fatal.
Low voltage is just as
likely to kill as high
voltage.

RK Wright, JH Davis. The investigation of electrical deaths: a report of 220 fatalities.

J. Forensic Sci. 1980; 25:514-521.
Cunningham PA. The need for cardiac monitoring after electrical injury. Medical Journa
of Australia. 154(11): 765-6, June 1991.
Top 10 Myths of Electrical Injury
Myth #4

The Extent of the

Surface Burn
Determines the
Severity of Injury
 Electrical Injuries
Patterns of Injury
Direct contact
Direct tissue heating
Contact burns (entry and
exit)
Thermal burns
Top 10 Myths of Electrical Injury
Myth #5

The Pathway the Electrical Current Takes

Through the Victim Predicts the Pattern of
Injuries
 Electrical Injuries
Patterns of Injury
Skin Resistivity
Least Nerves
Blood
Mucous membranes
Muscle
Intermediate Dry skin
Tendon
Fat
Most Bone
 Electrical Injuries
Effects of 60 Hz Current
1 mAmp Threshold of perception
5 mA Maximum harmless current
6 mA Ground fault interrupter opens
10 mA Let-go current
20 mA Possible tetany of resp muscles
100 mA VF threshold
6A Defibrillation
20 A Household circuit breaker opens
Top 10 Myths of Electrical Injury
Myth #6

Electricity Kills by Causing Myocardial

Damage
CK and/or Troponin Are Good Markers
for Myocardial Damage in Electrical
Injury
 Electrical Injuries
Patterns of Injury
James T., Riddick L., Embry J. Cardiac abnormalities
demonstrated post-mortem in four cases of accidental
electrocution and their potential significance relative to
non-fatal electrical injuries of the heart. American
Heart Journal. 120: 143-57, 1990
Robinson N., Chamberlain D. Electrical injury to the
heart may cause long-term damage to conducting
tissue: a hypothesis and review of the literature. Int J
Cardiol. 53: 273-7, 1996
Top 10 Myths of Electrical Injury
Myth #7

All Patients With Electrical Injury Require

24 Hours of Cardiac Monitoring
 Electrical Injuries
Cardiac Monitoring

Alexander L. Electrical injuries of the nervous system. J

Nerv Ment Dis 1941; 94: 622-632
Jensen PJ, et. al. Electrical injury causing ventricular
arrhythmias. Br heart J 1987; 57: 279-283
Norquist C., Rosen CL., Adler JN., Rabban JT.,
Sheridan R. The risk of delayed dysrhythmias after
electrical injuries. Acad Emerg Med. 6: 393, 1999
 Electrical Injuries
Cardiac Monitoring
Study Voltage No. of Initial ECG Initial ECG Late
patients = Normal = Abnormal Arrhythmias

Purdue and 1000 48 40 8 0

Hunt
Wrobel < 1000 35 31 4 0

Moran and 110 850 42 40 2 0

Munster
Kirschmair 220 900 19 15 4 0
and Denstl
Fatovitch and 240 20 18 2 0
Lee
Cunningham 240 70 59 11 0

Kreinke and > 220 31 29 2 0

Kienst
Bailey, et. al. 120 and 240 120 119 1 0

Arrowsmith > 220 73 69 4 0

 Electrical Injuries
Cardiac Monitoring

Cardiac monitoring is not justified in

ASYMPTOMATIC patients,
Or, in patients with only CUTANEOUS burns,
Who had a normal ECG after a 120 v or 240 v
injury.
Top 10 Myths of Electrical Injury
Myth #8

ALL Patients Who Are Asymptomatic and

Who Have a Normal ECG After a 120V or
240V Injury Can Be Safely Discharged
From the ED
 Electrical Injuries
Patterns of Injury
Pregnancy
Fetal monitoring is
mandatory for pregnant
patients
Oral commisure burns
Cataracts
Delayed neuro-
psychological sequelae
Top 10 Myths of Electrical Injury
Myth #9

The HYDRO QUEBEC GUIDELINES

Provide the Standard of Care for Electrical
Injuries
 Electrical Injuries
Summary - The Challenges
Electrical injuries involve multiple body systems.
Entry and exit wounds fail to reflect the true
extent of underlying tissue damage.
Electrical current may cause injuries distant from
its apparent pathway through the victim.
Controversies exist regarding indications for
admission and cardiac monitoring following low
voltage injuries.
 Electrical Injuries
The Future
Surveillance electrographique des patients ayant subi
une lectrisation: tude prospective multicentrique.
Investigateur principal: Benoit Bailey, MD MSc
FRCPC
21 sites across Quebec including RVH, MGH, MCH
Primary objectives:
1. determine the prevalence of cardiac arrhythmias in patients
on initial ECG
2. determine the prevalence of late arrhythmias in patients
who undergo cardiac monitoring
 Secondary objectives:
evaluate the importance of electrical injury in Quebecs EDs
given a normal initial ECG, evaluate if late arrhythmias
develop in patients with tetany, current across the heart, or
with >1000V
given a normal initial ECG, evaluate if late arrhythmias
develop in patients with PMHx of cardiac disease, or
decreased skin resistance
evaluate the incidence of cardiac problems in the year
following electrical injury
 Secondary objectives, contd:

accumulate prospectively an experience with applying the

Hydro Quebec protocol
determine the utility of measuring CK, CK-MB in predicting
ECG abnormalities and the development of late arrhythmias
determine the utility of measuring Troponin in predicting
ECG abnormalities and the development of late arrhythmias
Top 10 Myths of Electrical Injury
Myth #10

er is an Accurate
Reflection of Life in the ER
 Electric Shock:
What Should You Do?
The victim:
Felt the current The current
Yes Yes
pass through passed through
his/her body the heart

No No

Was held by the

Yes
source of the
electric current
1 second Yes
No
or more

No

Lost Yes Cardiac Monitoring

consciousness 24 hours

No

Touched a voltage
source of more
than 1 000 volts
 Electric Shock:
What Should You Do?
Page 2.

Touched a voltage
Yes Cardiac Monitoring
source of more
24 hours
than 1 000 volts

No
Yes

Has burn marks The current Evaluate and treat burns

Yes No
on his/her passed through (surgical evaluation,
skin the heart look for myogolbinuria, etc.)

No

Was thrown from Yes

Evaluate trauma
the source

No

Yes Evaluate fetal

Is pregnant
activity

No
BENIGN SHOCK Direction Services de Sante
Reassure and discharge Hydro Quebec, 1995