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Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e

Chapter 218: Electrical and Lightning Injuries Caitlin Bailey

INTRODUCTION

Electrical injuries are divided into high-voltage injuries (≥1000 V), low-voltage injuries (<1000 V), and electricarc flash burns, which by definition do not result in passage of current through the tissues. Lightning injury isan extreme and unique form of electrical injury. This chapter also discusses injuries caused by electroniccontrol devices, such as the Taser®. Burns from electrical accidents can result from heating due to electriccurrent flow through tissues, explosions, and burning of flammable liquids, clothes, and other objects. Burnsare discussed in the chapter 216, "Thermal Burns."

EPIDEMIOLOGY

Approximately 6500 electrical injuries occur per year in the United States, accounting for 4% of total burns. Ofthese, the majority are work related (61%), mostly industrial injuries. The overall complication rate is 10.6%,

with the fewest complications among children age 1 to 5 years (2%).1 The most common high-voltageinjuries in the United States are also work related and include arc burns in electricians and high-voltage

injuries in power line workers.2 The Electrical Safety Foundation International estimates that contact with

electric current caused nearly 1800 workplace fatalities between 2003 and 2010.3 High-voltage power lineinjuries are particularly disabling because they oen lead to deep-muscle necrosis and the need for

fasciotomy and amputation.2

BASICS OF CURRENT FLOW

Electric current is the movement of electrical charges. Table 218-1 lists a few key terms related to electricity.

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TABLE 218-1

Electrical Terms and Units of Measure

Term Unit of Measure

Electric current

Movement of electrical charges

Amperes

Current flow

Driven by voltage or electrical potential dierence

Volts

Resistance

Hindrance to flow of current

Ohms

Ohm's law (current = voltage/resistance)

The current is proportional to voltage.

The current is inversely proportional to resistance.

—

Current flow is measured in amperes. Current flow is driven by an electrical potential dierence, which ismeasured in volts. Intervening material between two or more contact points resists electric current flow; thisresistance is measured in ohms. Ohm's law describes the relationship between current (I), voltage (V), andresistance (R) and states that the current through a conductor between two points is directly proportional tothe potential dierence or voltage drop across the two points and inversely proportional to the resistancebetween them. For example, a person who grasps a grounded pipe in one hand and a metal cable connectedto a 120-V source in the other hand will experience a current flow through the body, the magnitude of whichvaries inversely with the resistance of the circuit. If the total resistance from the power source, through theperson, and to ground is estimated to be 1000 Ω, the current would be I = (120 V)/(1000 Ω) = 0.120 A = 120mA.

Conductors are materials that allow electric current to flow easily. Insulators are materials that do not allowelectric current flow. Most biologic materials conduct electricity to some extent. Tissues with high fluid andelectrolyte content conduct electricity better than tissues with less fluid and electrolyte content. Bone is thebiologic tissue with the greatest resistance to electric current, whereas nerves and vascular structures havelow resistance. Dry skin has high resistance, but sweaty or wet skin has much less resistance.

Many of the physiologic eects of electric shock are related to the amount, duration, and type of current(alternating current [AC] or direct current [DC]) and the path of current flow (Table 218-2). DC current flows ina constant direction, whereas AC current alternates direction in a cyclical fashion. Standard householdelectricity is AC. Electricity in batteries and lightning is DC. Low-frequency (50- to 60-Hz) AC can be moredangerous than similar levels of DC because the alternating current fluctuations can result in ventricular

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*Ranges are approximate and depend on various factors.

fibrillation. The identification of electric shock as due to AC or DC is also important to reconstruct themechanism of injury. AC current can produce muscular tetany, during which the victim cannot let go of theelectrical source. Both AC and DC current can hurl the victim away from the current source, which results insevere blunt force injury.

TABLE 218-2

Eects of Current

Eect Current PathMinimum Current:

60 Hz AC (mA)*

Tingling sensation, minimal perception Through intact skin 0.5–2.0

Pain threshold Through intact skin 1–4

Inability to let go: tetanic contractions of hand and

forearm tighten grasp, decreasing skin resistance

From hand through

forearm muscles into

trunk

6–22

Respiratory arrest: can be fatal if prolonged Through chest 18–30

Ventricular fibrillation Through chest 70–4000

Ventricular standstill (asystole): similar to defibrillation; if

current stops, sinus rhythm may resume

Through chest >2000

For current to flow through an individual, a complete circuit must be created from one terminal of a voltagesource to a contact area on the body, through the subject, and then from another contact on the person tothe other terminal of the voltage source (or to a ground that is connected to the voltage source). Currentflows through a person from one contact area to another along multiple, somewhat parallel paths. Forexample, electrical power source contacts just on the le hand and le leg would result in current flowthrough those limbs and the trunk, including the heart, muscles of respiration, and other tissues in the trunk.Current would not flow through the other limbs or head, because they are not in an electrically conductivepath between the two power source contacts. The pattern of current flow through the body, if known, can beused to raise or lower suspicion of injury to certain body parts; for instance, hand-to-hand flow involvescrossing the thorax and heart, raising the suspicion for cardiac involvement.

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An exception to the requirement that a circuit be present occurs with electrostatic discharge. Electrostaticdischarge is the transfer of excess charge to or from a person or object to another object and results whenobjects at dierent potentials come into direct contact with each other. An example is static electricity, whichcan cause pain and reflex movements.

MECHANISMS OF ELECTRICAL INJURY

HIGH- AND LOW-VOLTAGE INJURIES

The risk for serious and fatal electrical injury increases with voltage, especially >600 V (Table 218-2). Highvoltage is usually defined as >1000 V. Power lines in U.S. residential areas typically carry 7620 V AC. This isstepped down by transformers to 240 V AC before entering most residential and nonindustrial buildings. Inthe United States, home outlets are 120 V, and in Europe and Australia, they are 240 V. Urban subwayelectrical third rails may be 600 V or more AC or DC. High-voltage injuries are more oen associated withsevere musculoskeletal, visceral, and nervous system injury than are low-voltage injuries.

Electricity-induced injuries can occur via several mechanisms: (1) direct tissue damage from the electricalenergy, (2) tissue damage from thermal energy, and (3) mechanical injury from trauma induced by a fall ormuscle contraction.

ELECTRICAL BURNS

Electrical burns are severe when high voltages are involved, because only a fraction of a second of current

flow is necessary for severe damage to occur.4 Burns are less common with low-voltage injuries, because

low-voltage contact produces little heat energy in the skin and other tissues.5

ELECTRIC ARC INJURIES

Electricity arcing from one conductor to another may radiate enough heat to burn and even kill persons 10 ormore feet from the arc. There can also be a blast force that throws the person. Arcs that do contact a persondirectly will have heating due to current flow through the body, in addition to the flash burn and mechanical

blast forces. Serious burns oen result.6 The voltages that create an electric arc are usually in the thousandsof volts. Temperatures as high as 20,000°C (35,000°F) are created. Serious, and sometimes fatal, burns mayresult from heat radiated by the arc and clothing ignited by the arc.

TETANIC CONTRACTIONS

Electric current can induce sustained muscular contraction, or tetany. The overall eect varies according to

type (AC or DC), frequency, voltage, and extent of contact.4,7 For example, AC current flowing through theforearm can cause flexor tetany of the fingers and forearm that overpowers actions of the extensor muscles.

Forceful muscle contractions can cause fractures and joint dislocations, especially around the shoulders.8 Ifthe hand and fingers are properly positioned, the hand will grasp the conductor tightly, leading to prolonged,

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low-resistance contact with the power source because the person cannot let go. This allows current to flowfor many seconds or minutes.

The increased duration of contact and the decreased contact resistance caused by a tight sustained graspgreatly increase the heat-related damage to deep tissues. Heating due to electric current builds over time.Because heating is directly proportional to the duration of current flow and proportional to the square of thecurrent amplitude (until burning and other tissue changes occur), a person who is unable to let go of aconductor for 30 seconds receives about 90 times as much tissue heating as a person who recoils from thevoltage source in one third of a second. To make injury still more severe, a tight grasp on a conductordecreases contact resistance, which leads to an increase in current flow. Thus, heat-related injury to deeptissues is oen more than a hundred times worse when there is a history of the patient's being unable to letgo of the conductor.

Current flow through the trunk and legs may cause brief, but strong, opisthotonic (arching) posturing and legmovements. The person appears to be thrust from the voltage source due to these muscle contractions andmay sustain mechanical trauma in addition to electrical injury. If a person does manage to hold on to a high-voltage source, severe tissue damage occurs.

CLINICAL FEATURES OF ELECTRICAL INJURY

Electric current can induce immediate cardiac dysrhythmias, respiratory arrest, and seizures. Current thattraverses the chest vertically (hand to foot or head to toe) or horizontally (hand to hand) can producearrhythmias and respiratory arrest.

CARDIAC DYSRHYTHMIAS

Fatalities due to asystole or ventricular fibrillation usually occur prior to arrival in the ED.5 Asymptomaticpatients with normal ECGs on arrival to the hospital do not develop later dysrhythmias aer low-voltage

(<1000 V) injuries.9,10,11,12,13 However, nerve and deep-muscle injuries are relatively common followingcontact with voltages >400 V. Therefore, carefully examine for peripheral nervous system and CNS functionand burns, and check for elevated serum creatine phosphokinase.

CNS, SPINAL CORD, AND PERIPHERAL NERVOUS SYSTEM INJURY

Neurologic impairment is common in electrical injuries, occurring in approximately 50% of patients with

high-voltage injuries.2 Nerve tissue has the lowest resistance in the body, encouraging electrical passagethrough these tissues and causing associated damage. Given the multisystem dysfunction present in manyelectrical injury patients, document a neurologic exam, if possible, before intubation and sedation.

Brain Injury

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Electrocution can result in a broad range of CNS dysfunction. Transient loss of consciousness is common andmay be followed by seizures. Victims may be confused and agitated or deeply comatose and require airwayprotection. Patients may also demonstrate focal neurologic deficits such as quadriplegia, hemiplegia,aphasia, or visual disturbances. Obtain head and cervical spine CT to rule out traumatic etiologies for these

deficits; MRI may be necessary for purely electrical damage. Electrical injury can cause blindness14 due to

occipital lobe injury as well as direct injury to the optic nerve.15,16 Neurologic deficits may be transient, but

survivors may have persistent diiculties with attention, working memory, and learning.17

Spinal Cord Injury

Spinal cord injury can occur in up to 8% of high-voltage electrical injuries.18 Spinal cord injuries can be the

result of compressive vertebral fractures, sometimes at multiple levels.19 However, damage can also occurdue to purely electrical damage without fractures, through direct cellular damage as well as vascular

injury.20 With electrical trauma, initial spinal cord MRI results do not necessarily correlate with prognosis.

MRI findings may be normal in electrical trauma patients with permanent spinal cord injury,21,22,23 although

newer MRI imaging protocols may detect abnormalities silent on standard MRI.24 With mechanical trauma,emergency MRI aer spinal cord injury provides accurate prognostic information regarding neurologicfunction.

Neurologic deterioration can occur days to months aer the initial injury25,26,27 and generally hasincomplete resolution. There is a motor predominance in deficit in most of these cases. Delayed onset ofspinal cord dysfunction may be due to progressive vascular injury (especially to the spinal artery branchsupplying the anterior horn cells) or delayed cell membrane damage via the cumulative eect of free radicals

(electroporation), leading to progressive demyelination.21,28 The clinical features may take the form of

transverse myelitis, amyotrophic lateral sclerosis, or a Guillain-Barré–like illness.29

Peripheral Nerve Injury

Peripheral nerve injuries oen involve the hands aer the individual touches a power source. Paresthesias

may be immediate and transient or delayed in onset, appearing up to 2 years aer injury.2,30 Extensiveperipheral nerve damage may occur with minimal thermal injury. Electrical contact with the palm produces

median or ulnar neuropathy more oen than radial nerve injury.31 Brachial plexus lesions have also beenreported. Persistent symptoms related to peripheral nerve damage can occur despite normal results on

nerve conduction studies.32

CUTANEOUS BURNS

Cutaneous burns are oen seen at the electrical contact areas (oen referred to as entry and exit wounds inthe case of DC current, or contact wounds in the case of AC current). Many seriously injured patients haveburns on either the arm or skull, paired with burns on the feet. Burns are typically painless, gray to yellow,

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depressed areas. Most patients with burns from electrical injury need admission and care by a burnspecialist. See chapter 216 for detailed discussion of management of cutaneous burns.

ORTHOPEDIC INJURY

Fractures may be caused by tetanic muscle contractions or associated falls. Fractures may be missed oninitial assessment due to altered mental status and the overall severity of systemic illness. A comprehensivetertiary survey should be performed when clinically feasible to detect orthopedic injuries. Although fracturesare more likely to result from high-voltage injury, fractures of the wrist, forearm, humerus, femoral necks,shoulders, and scapulae have been reported from exposure to household voltages (120 to 220 V AC) without

associated trauma.7,33,34 Posterior shoulder dislocations are commonly seen with electrical injury.

VASCULAR AND MUSCLE INJURY

Vascular and muscle injuries occur most commonly in the setting of high-voltage injury, such as power linecontact. Electric current passing along peripheral arteries may cause early spasm and persistent deficits in

endothelial and smooth muscle function,35 as well as subsequent thrombosis, stenosis, or aneurysmformation. Because of concomitant vascular and muscular destruction, patients with high-voltage shocks areat significant risk for development of compartment syndrome, even if the contact (or arcing) lasted <1second. Compartment syndrome has also been noted in patients with injuries from 120 V AC or higher whosustain contact for longer than a few seconds. Patients typically exhibit ongoing muscle pain with

movement.6

Contact with >1000 V, prehospital cardiac arrest, crush injury, and full-thickness skin burns are associatedwith significant tissue damage requiring surgical intervention. Fasciotomy and amputation are frequent

sequelae of high-voltage injuries, occurring in 29% and 41% of patients in one study.36 High-voltageelectrical injury is associated with rapid loss of body fluids into the areas of tissue damage, requiringaggressive resuscitation.

COAGULATION DISORDERS

Thermal injury or tissue necrosis from electric current can cause a variety of coagulation disorders. Low-grade disseminated intravascular coagulation may be a result of hypoxia, vascular stasis, rhabdomyolysis,and release of procoagulants from damaged tissue. Transient coagulopathies have also been reported with

high-voltage injury, including acquired, transient factor X deficiency.37 Electrical injury may unmask

underlying vascular injury and has been reported in association with ischemic stroke at low voltage.38

BLAST INJURY

Electric arcs in the industrial environment or near a power line can produce a strong blast pressure, similar to

those seen in other types of explosions.39 Cognitive complaints following blast injury may resemble those

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that result from moderate mechanical head trauma. Mechanisms of brain injury include mechanical traumarelated to the blast and arterial air emboli associated with blast-related alveolar disruption (see chapter 7,"Bomb, Blast, and Crush Injuries").

INHALATION INJURY

Chemical toxins such as ozone can be produced by coronas and arcs. Acute eects of ozone exposure includemucous membrane irritation, temporarily reduced pulmonary function, and pulmonary hemorrhage andedema. Fires and explosions associated with electric incidents may lead to inhalation of carbon monoxideand other toxic substances.

OCULAR INJURY

Electrical shock can cause a wide range of ocular trauma, most commonly to the cornea (epithelialerosion/defect, keratitis, scarring), as well as uveitis, retinal detachment, macular edema, optic nerve

damage, and intraocular bleeding and thrombosis.15,40,41 Obtain a full ophthalmologic evaluation for anyelectric shock patient with an ocular complaint to document related injury. Cataract formation has been

described weeks to years aer electrical injury to head, neck, or upper chest.7 Cataracts have also occurredaer electric arc or flash burns.

AUDITORY INJURY

The auditory system may be damaged by current or by hemorrhage in the tympanic membrane, middle ear,cochlea, cochlear duct, and vestibular apparatus. Delayed complications include mastoiditis, sinusthrombosis, meningitis, and brain abscess. Hearing loss may be immediate or develop later as a result ofcomplications. Hearing should be briefly checked in the ED, with follow-up formal testing arranged for anypatient who appears to have a deficit.

GI INJURY

Pain due to bowel perforation and intra-abdominal hemorrhage may be attributed to more obvious

coexisting injuries.42 There are reports in the literature of lethal intra-abdominal injuries from electric currentthat were found only at autopsy. Ileus may develop in association with spinal cord injury.

SCENE AND PREHOSPITAL CARE

Table 218-3 outlines prehospital care of the patient with electrical injury.

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TABLE 218-3

Scene and Prehospital Care

Stay at least 10 m (32 ) from downed power lines, jumping power lines, and support structures.

Turn o the source of electricity prior to rescue, if possible.

If electrical source cannot be quickly turned o, take precautions to prevent electrical injury to the rescuer.

Wear gloves and shoes rated for the power line voltage.

Initiate rescue breathing and resuscitation eorts while injured person is still on pole, if no contact with

source of electricity is assured.

Maintain spinal immobilization of injured person, if possible.

RESCUER SAFETY

Stay away from downed power lines. The scene of a high-voltage electric incident contains many hazards forrescue personnel. Power lines are almost never insulated, although a line may appear to be insulatedbecause of atmospheric contaminants deposited on the line over time. Electrocution is possible whenwalking on ground near a downed power line because of voltage gradients in the ground. Stay at least 10 m(32 ) from downed power lines. Even this distance is not without risk.

Reapplication of voltage to downed lines sometimes occurs as circuit breakers automatically reset, whichmakes the lines physically jump many feet with great force. This danger may be mitigated by placing a heavyobject over the line, but this maneuver itself is fraught with risk.

Support structures may be electrically alive. Metal cables that support telephone and power poles arenormally grounded, but may be energized if they are broken or disconnected from a ground attachment andcontact is made with a nearby power line.

Victims still in contact with a source of voltage may transmit an electric current to would-be rescuers. It isbest first to turn o the source of electricity if it can be done quickly. If this cannot be done quickly,precautions must be taken to prevent electrical injury to the rescuer. With voltages above about 600 V, drywood and other materials may conduct significant amounts of electric current and therefore cannot be usedto remove the person from a voltage source. A rescuer standing on the ground touching any part of a vehiclethat is in contact with a power line is likely to be killed or seriously injured. Electric shock is not prevented inthis situation by the rescuer's wearing rubber gloves and boots, unless these are designed for the voltagepresent and have been recently tested for insulation integrity. Persons inside a vehicle in contact with apower line are likely to be killed as they step out of the vehicle and may also receive a shock if they touchobjects at dierent potentials inside the vehicle.

SCENE RESUSCITATION AND STABILIZATION

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Rescue breathing for line workers in respiratory arrest on utility power poles should be initiated by rescuerswhile the injured individual is still on the pole as long as the injured worker and rescuers are no longer incontact with the energized line. As soon as the patient is lowered to the ground, chest compressions can bedone if there is cardiac and respiratory arrest.

Low-voltage AC can produce ventricular fibrillation by direct stimulation of the heart, or it can occur aerseveral minutes of respiratory arrest resulting from paralysis of respiratory muscles (Table 218-2). High-voltage AC and DC are more likely to produce transient ventricular asystole. Asystole sometimes revertsspontaneously to normal sinus rhythm with pulses, but prolonged apnea may continue. Apnea with pulsessometimes occurs in linemen working above the ground near high-voltage lines. Supporting respirationsabove ground may be all that is needed to stabilize the patient. Maintain vigorous resuscitation eorts forcardiac arrest from electric shock, because there may be insignificant tissue damage despite the potentially

lethal dysrhythmia.43

Maintain spinal immobilization during resuscitation to the extent possible, because spinal fractures can becaused by tetanic muscle contractions, falls, and other secondary trauma.

ED DIAGNOSIS AND TREATMENT

Provide the usual evaluation (airway, breathing, circulation) and resuscitation for major trauma victims.Maintain spinal immobilization during resuscitation until adequate imaging and examination can be done.

Treat cardiac arrhythmias according to accepted advanced life support guidelines. Institute ED cardiac

monitoring for patients with high-voltage injuries as well as all symptomatic patients.9,10 Cardiaccomplications are more common in patients with high-voltage injuries and in those with loss ofconsciousness and include ventricular and atrial dysrhythmias, bradydysrhythmias, and QT-interval

prolongation.44,45,46 Admission for cardiac monitoring is not needed for asymptomatic patients with normalECG on presentation aer a low-voltage electrical injury.

Assess for tissue damage and identify associated complications. A careful vascular and neurologicexamination of involved extremities is important. Normal findings on initial assessment do not excludeserious injury or the possibility of delayed spinal cord injury following high-voltage contact.

Focus next on systematic assessment and treatment, especially for injuries specific to or common inelectrical injury, as outlined in Table 218-4. Laboratory and radiographic evaluation of high-voltage injuriesshould follow standard trauma guidelines (see chapters in Section 21, "Trauma," and Section 22, "Injuries toBones and Joints").

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*Refer to chapter 216, "Thermal Burns."

TABLE 218-4

Assessment and Treatment of Complications Associated with Electrical Injuries

Organ or System Assessment/Treatment/Comments

Circulatory Start with Parkland fluid resuscitation formula.*

Renal Initiate fluid resuscitation.

Myoglobinuria Initiate fluid resuscitation†

Central and peripheral

nervous

Order head CT if mental status is abnormal; assess for spinal cord and peripheral

nerve injury.

Skin Assess and treat cutaneous burns.*

Musculoskeletal Perform careful assessment of spine, pelvis, long bones, and joints.

Assess for compartment syndrome and need for fasciotomy.

Vascular Spasm may occur leading to delayed thrombosis, aneurysm formation, or muscle

damage.

Coagulation Treat coagulation disorders by eliminating the precipitating factor through early

surgical debridement.

If bleeding is present, replace coagulation factors.‡

Lungs Assess for inhalation injury, carbon monoxide, or alveolar injury from blast.

Eyes Document complete eye examination.

Delayed cataracts may develop.

Ears Assess for blast injury.

Document hearing.

Middle and inner ear disorders and hearing loss may occur.

GI Intra-abdominal injury may occur from current or blast.

Lips and oral cavity Watch for delayed bleeding.

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†Refer to chapter 89, "Rhabdomyolysis."

‡Refer to chapter 254, "Trauma in Adults."

In the case of low-voltage injuries, laboratory testing and imaging are usually not required unless the patientis symptomatic or has abnormal physical examination findings. Symptoms such as chest pain, palpations,loss of consciousness, altered mental status, confusion, weakness, dyspnea, abdominal pain, burn withsubcutaneous damage, vascular compromise, or abnormal results on ECG require further testing.

FLUID RESUSCITATION

Fluid resuscitation guided by the Parkland formula (4 mL/kg multiplied by the percentage of body surfacearea burned, administered over 24 hours) is a reasonable starting point in fluid management. Extensive deeptissue damage resulting from high-voltage injury may be present even when the cutaneous burn seemslimited. Therefore, fluid requirements are oen greater than predicted by the Parkland formula and physicalexamination.

MYOGLOBINURIA

Patients with suggestive symptoms or high-voltage injury should be monitored for the onset of compartmentsyndrome, rhabdomyolysis, and renal failure. If myoglobinuria is suspected, institute aggressive IV fluidresuscitation to maintain a urinary output of between 1 and 2 mL/kg/h, with attention to correction andprevention of electrolyte abnormalities. Evidence of eectiveness of sodium bicarbonate is not welldocumented. Initial IV rate in the adult is up to 1.5 L/h (more if there is hypotension or obvious blood loss).Maintain a high urine output until serum creatine kinase level is less than five times normal or urinemyoglobin measurements return to normal. Monitor serum, not urine, pH. Urine pH measurements areinfluenced by hemochromogens in the urine and, therefore, may not be useful.

Prognostic factors associated with the need for a fasciotomy within 24 hours of injury are (1) myoglobinuria,

(2) burns over 20% of total body surface area, or (3) a full-thickness burn over 12% body surface area.36

Presence of any one of these three factors is predictive of development of the need for fasciotomy.

GI INJURY

GI injuries should be suspected in all patients with a history of electrical burns to the abdominal wall ormechanical trauma associated with the electrical injury. Table 218-5 summarizes an approach to GI injury.

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TABLE 218-5

GI Injury in Electrocution

When to Suspect GI Injury

Electrical burns of the abdominal wall

History of a fall, nearby explosion, or other mechanical trauma

Evaluation

US and CT

Surgical consult as indicated

Treatment

Ileus: nasogastric tube insertion

Stress (Curling) ulcer prophylaxis: histamine-2 blockers, antacids, proton pump inhibitors

Monitoring for development of ileus, bowel perforation, hemorrhage, and other delayed complications

Surgical management as appropriate

DISPOSITION AND FOLLOW-UP

LOW-VOLTAGE INJURIES <600 V

Although there is no universally accepted protocol for management and disposition of patients with low-voltage injuries, in general, asymptomatic patients who sustain an electric shock of ≤240 V AC can be

discharged home if they have a normal ECG on presentation and normal examination findings.9,10 Patients

who feel unwell or have any new ECG abnormality should be monitored for 6 hours and reassessed.9,10

HIGH-VOLTAGE INJURIES

All patients having contact with ≥600 V AC should be admitted for observation, even if there is no apparentinjury. Routine cardiac monitoring is not required unless the patient is symptomatic or the initial ECGfindings are abnormal. Low-voltage injury patients with symptoms beyond superficial skin injury orabnormal lab/ECG results may have systemic injury and require admission as well. Patients with extensivecutaneous burns should be transferred to a specialized burn center aer initial trauma stabilization. This is

especially true in children.47

SPECIAL POPULATIONS

PREGNANT WOMEN

In addition to the measures recommended above, in pregnant women beyond 20 to 24 weeks of gestation,monitor fetal heart rate and uterine activity for at least 4 hours because of the possibility of mechanical

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trauma related to the electric shock and electrical discharge to the fetus.48,49,50

CHILDREN

Children are more likely to sustain household current electrical injury than high-voltage injury. Overalloutcome appears to be better, including a lower incidence of amputation and fasciotomy than in adults,

although skin gras may be required (25% in one 10-year study of pediatric burn center referrals).47

Oral and Lip Burns

Serious oral injury can occur in a child who places the end of a power cord in the mouth. The electric fieldand current flow created between the two wires near the end of the cord can produce high temperatures andsignificant tissue damage. Most injuries are unilateral, involving the lateral commissure, tongue, and/or

alveolar ridge4,51,52 (Figure 218-1). Systemic complications of oral burns are uncommon. Vascular injury tothe labial artery is not immediately apparent because of vascular spasm, thrombosis, and overlying eschar.Severe bleeding from the labial artery occurs in up to 10% of cases when the eschar separates, usually aer 5days. For this reason, children with this injury are sometimes admitted to the hospital. However, some

authors believe that outpatient management is adequate in the right circumstances.53 If the parents arereliable, can monitor the child, and can be shown how to control bleeding, outpatient management may beconsidered. Parents should be educated that bleeding may occur up to 2 weeks aer injury. Prior todischarge, however, specialty consultation should be obtained and follow up secured, because of the risk ofdeforming scar formation during the healing process, in which new cells tend to migrate medially, reducingthe span of mouth opening. Splinting and other measures are oen needed to prevent the development ofthis deformity and dysfunction. Home care includes saline or hydrogen peroxide rinses and gentle swabbingto debride necrotic tissue and promote formation of healthy granulation tissue. Topical application ofpetrolatum-based antibiotics may have a soothing eect.

FIGURE 218-1.

Oral burn in a child from power cord. A 2-year-old boy sustained a third-degree burn to the commissure ofthe mouth aer biting down on an electrical cord. This photograph was taken 3 days aer initial treatment.[Reproduced with permission from Shah BR, Lucchesi M: Atlas of Pediatric Emergency Medicine. © 2006 byMcGraw-Hill, Inc., New York.]

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Hand Wounds

Children who sustain hand wounds from electrical outlet injuries with no other injury and no evidence ofcardiac or neurologic involvement can be discharged aer local wound care is provided and careful follow upensured. A child with a home situation of equivocal safety or reliability should be admitted.

LIGHTNING INJURIES

Lightning causes approximately 500 injuries each year in the United States, with an average of 51 deaths per

year over the last 20 years (1984 to 2013).54 Lightning fatalities constitute fewer than 3% of weather-related

deaths, which are more commonly due to extreme heat or cold.55 Lightning fatalities are most common in

fishermen, but also occur in other outdoor recreational activities such as golf and camping.54 Lightninginjury reporting is inexact and biased toward the more severe and fatal events. Approximately 70% to 90% ofpersons struck by lightning survive, but as many as three quarters of these survivors have permanent

sequelae.56,57

Lightning most oen occurs during thunderstorms in association with large cumulonimbus clouds. However,

approximately 10% of lightning occurs without rain and when the sky is blue.58 In addition, lightning canoccur during dust storms, sandstorms, tornados, hurricanes, snowstorms, and nuclear explosions, and in theclouds over volcanic eruptions. Lightning injuries can also occur while riding in airplanes. Lightning injuryassociated with indoor telephone use during lightning storms has been reported. A study in Australia

identified up to 80 such injuries yearly without any reported fatalities.59

Even though lightning is electrical energy, lightning injuries dier substantially from high-voltage electricalinjuries seen in association with human-generated sources. There are dierences in injury patterns, injury

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severity, and emergency treatment48,60,61 (Table 218-6).

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TABLE 218-6

Comparison of Lightning and Electrical Injuries

Factor Lightning High-Voltage AC Low-Voltage AC

Current

duration

10 μs to 3 ms Generally brief (1–2 s), but

may be prolonged

0.3 s or many minutes

Typical

voltage and

current range

10 million to 2 billion V, 10 to

200,000 A

600–200,000 V, <1000 A <600 V, usually <20–30 A

Current

characteristics

Unidirectional (DC) Alternating (AC) Alternating (AC)

Current

pathway

Skin flashover; deeper

pathways can result in burns

Horizontal (hand to

hand), vertical (hand to

foot)

Horizontal (hand to

hand), vertical (hand to

foot)

Tissue

damage

Superficial and minor if no

deep-tissue pathway

Deep-tissue destruction Sometimes deep-tissue

destruction

Initial rhythm

in cardiac

arrest

Asystole Asystole more than

ventricular fibrillation

Ventricular fibrillation

Renal

involvement

Myoglobinuria is uncommon,

and renal failure is rare

Myoglobinuria and renal

failure are relatively

common

Myoglobinuria and renal

failure occur occasionally

Fasciotomy

and

amputation

Rarely necessary Relatively common Sometimes necessary

Blunt injury Caused by explosive shock

wave that can throw the person

and cause eardrum rupture

Caused by falls, being

thrown from current

source, tetanic

contractions

Caused by tetanic

contraction, falls, being

thrown from current

source

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Abbreviations: AC = alternating current; DC = direct current.

Factor Lightning High-Voltage AC Low-Voltage AC

Immediate

cause of death

Prolonged apnea, blunt injury,

deep-tissue burns

Prolonged apnea,

ventricular fibrillation,

blunt injury, deep-tissue

burns

Ventricular fibrillation,

prolonged apnea, blunt

injury

PATHOPHYSIOLOGY

Lightning oen travels over the surface of the body in a phenomenon called flashover and is therefore lesslikely to cause internal cardiac injury or muscle necrosis than is human-generated electrical energy. Wet skinmay actually decrease the risk of internal injury, helping the current travel along the outside of the body.Flashover explains how victims may survive a lightning strike with little or no injury. Lightning causesinternal injury through blunt mechanical force, current flow through the body, and other mechanisms. Thelarge current flow in lightning creates a pulsed magnetic field that can induce current flow in a nearby

person62 and can produce destructive eects.

Lightning emits brief but intense thermal radiation that produces rapid heating and expansion of thesurrounding air. Tympanic membrane perforation and internal organ contusion may occur. Vaporization of

sweat from the skin can occur with tearing of clothing, giving the appearance of an assault.63 Lightning mayinflict thermal injury as moisture on the victim's skin is transformed into steam, as electric current flowsthrough deeper tissues, and through resistance heating of metal objects on the body or in clothing pockets.Lightning may melt metallic objects on the victim. Lightning can be conducted along metal fences,bleachers, plumbing pipes, and other structures. Intense photic stimulation may damage the retina orproduce cataracts.

STUNNING (KERAUNOPARALYSIS)

Neurologic and muscular "stunning," referred to as keraunoparalysis, can follow lightning strike and may

initially produce a variety of neurologic signs and symptoms.64 Keraunoparalysis is associated withsuccessful resuscitation aer cardiorespiratory arrest. In cases of keraunoparalysis that resolve within anhour, there can be lower limb weakness that is greater than upper limb weakness. Other extremity-relatedsigns and symptoms include sensory abnormalities, pallor, coolness, and diminished and absent pulses.

Excessive autonomic nervous system stimulation may be responsible for these transient symptoms.65 Insome cases, keraunoparalysis persists for a longer time. In such cases, there is typically amnesia and"neurotic" behavior that slowly clears over a week. More persistent and sometimes permanent sequelae can

include muscular weakness and pain, photophobia, and disturbances of neurologic control.62

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TYPES OF LIGHTNING STRIKES

Lightning strikes in a number of dierent ways, some of which injure multiple victims. A direct strike occurswhen the victim is struck directly by the lightning discharge. A side flash occurs when a nearby object isstruck and current then traverses through the air to strike the victim. A side flash may injure multiple victimsat once, as when a group huddles close to a structure that is struck. A contact strike occurs when lightningstrikes an object the victim is holding and current is transferred from the object through the person to theground. Lightning injury from indoor telephone use during a lightning storm is an example of contact strike.A ground current occurs when lightning hits the ground and current is transferred through the ground tonearby victims. The amount of electrical voltage and current decrease as the distance between the victimand strike point increases. This ground current can create a stride potential or step voltage between thevictim's separated feet. The foot closer to the strike point will experience a higher electrical potential thanthe foot further away. Therefore, electric current can enter one foot, travel up that leg, through the torso, anddown the other leg and exit the other foot. This can result in isolated neurovascular injury to the legs.Recently, a fih mechanism, in which a weak upward streamer does not become connected to the completed

lightning channel, was implicated in a fatal lightning injury.66

Immediate cardiac arrest from lightning strike results from depolarization of the myocardium and sustainedasystole. Immediate respiratory arrest aer lightning strike may be a result of depolarization and paralysis ofthe medullary respiratory center. Both cardiac and respiratory arrest may be present without evidence ofexternal injury. Although cardiac automaticity may spontaneously return, concomitant respiratory arrestmay persist and lead to a secondary hypoxic cardiac arrest. The duration of apnea, rather than the durationof cardiac arrest, appears to be the critical prognostic factor. Prolonged respiratory support with frequentmonitoring of pulses can be eective in this situation.

CARE AT THE SCENE

Lightning can produce multiple victims because of multiple lightning strikes, stride potentials, and side

flashes.60 In contrast to patients with cardiac arrest caused by mechanical trauma, persons with lightninginjury who appear to be dead (in respiratory arrest, with or without cardiac arrest) should be treated first.Such victims may have little physical damage, and they have a reasonable chance of successful resuscitation.Use of automated external defibrillators and other defibrillators along with CPR can be lifesaving. ProlongedCPR is sometimes successful.

During a storm, power lines may fall to the ground as a result of high winds, lightning-related damage topower lines and their support structures, and vehicular damage to power line support structures. Therefore,a person thought to have been hit by lightning may actually have been shocked by the stride potentialrelated to a nearby power line lying on the ground. If a downed power line is found, safety precautions areimportant. Physical findings suggestive of lightning injury may be subtle or nonexistent. Therefore,information about the scene of the accident may be just as informative as examination of the patient.

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ED DIAGNOSIS AND TREATMENT

The usual advanced cardiac and trauma treatment principles apply, including assessment and stabilizationof the airway, breathing, and circulation. Lightning victims in cardiac arrest have a better prognosis than

those in cardiac arrest from coronary artery disease, so aggressive resuscitative eorts are indicated.43

Hypotension is not an expected finding following lightning injury and warrants an investigation for

hemorrhagic blood loss. A careful secondary examination should be done to detect occult injuries.67

Cutaneous burns may help identify the current path and suggest potential organ injury. Initial ancillarystudies include CBC, serum electrolyte levels, creatinine level, BUN level, glucose level, creatine kinase level,urinalysis, and ECG. Imaging studies (plain radiography, US, or CT) should be performed as dictated bysuspected injuries. Other ancillary studies may be indicated depending on clinical circumstances.

CARDIAC EFFECTS

In the victim with spontaneous circulation, hypertension and tachycardia are common findings, presumablybecause of sympathetic nervous system activation. Specific treatment is usually not necessary, becauseblood pressure and pulse rate will spontaneously decrease. Cardiac eects reported aer lightning injuryinclude global depression of myocardial contractility, coronary artery spasm, pericardial eusion, and atrialand ventricular arrhythmias. The ECG may show acute injury with ST-segment elevation and QT-intervalprolongation. T-wave inversions may be seen, especially in the presence of neurologic injury. Myocardialinfarction aer lightning injury is unusual. CPR, automated external defibrillators, and other resuscitative

measures should be used promptly.43 Prolonged resuscitative eorts are sometimes successful.

NEUROLOGIC INJURY

Many lightning-strike victims are rendered unconscious or have temporary lower extremity paralysis.Seizures may result from the passage of electric current through the brain or may be the result of mechanicalbrain injury or hypoxia. The most lethal neurologic injuries involve heat-induced coagulation of the cerebralcortex, development of epidural or subdural hematoma, and intracerebral hemorrhage.

Autonomic dysfunction caused by lightning may produce pupillary dilation or anisocoria not related to braininjury, and these signs have no prognostic significance in comatose lightning-strike victims. Most neurologicinjury related to lightning strike can be classified as immediate and transient or delayed and permanent,although some eects may be immediate and permanent. Transient eects that typically resolve in 24 hoursinclude loss of consciousness, confusion, amnesia, and extremity paralysis. Delayed and oen progressivedisorders include seizures, muscular atrophy and amyotrophic lateral sclerosis, parkinsonian syndromes,

progressive cerebellar ataxia, myelopathy with paraplegia or quadriplegia, and chronic pain syndromes.28

Lightning can cause intracranial injury directly when passing through the head, as well as by secondarytrauma. Therefore, CT scan is indicated in cases of coma, altered mental status, or persistent headache orconfusion.

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VASCULAR EFFECTS

Vasomotor spasm in an extremity is sometimes seen as a local response to lightning exposure. Possiblemechanisms include sympathetic nervous stimulation, local arterial spasm, and ischemia of peripheralnerves. Skin color changes, from white to blue to red, may occur in extremities aer lightning strike. Suchchanges are presumably from cycles of vasoconstriction and vasodilatation, with pallor and cyanosisfollowed by hyperemia. Severe vasoconstriction is thought to be responsible for loss of pulses, mottling ofskin, coolness of extremities, loss of sensation, and paralysis due to ischemia of peripheral nerves. Asvasoconstriction resolves spontaneously, these signs and symptoms oen resolve. Because skeletal muscleinjury is rare in lightning strike, compartment syndromes are less likely. If doubt exists, the presence ofcompartment syndrome and the need for fasciotomy may be confirmed by measurement ofintracompartmental pressures and close clinical monitoring.

OCULAR INJURY

Ophthalmic injuries are common in lightning-strike victims, and lightning-induced cataracts are the most

frequently observed ocular sequelae.68 Cataracts caused by lightning are usually bilateral. Cataractformation without evidence of current flow through the head or eyes, such as aer brief exposure to anelectric arc, has been described. Perhaps this is a result of damage of the lens by radiant energy. Cataractsmay form weeks to years aer the lightning injury. Lightning can aect any part of the eye, producinghyphema, vitreous hemorrhage, corneal abrasion, uveitis, retinal detachment or hemorrhage, macular holes,and optic nerve damage. A patient with discomfort or visual changes deserves a careful examination withfollow-up.

AUDITORY INJURY

Blast eect producing tympanic membrane rupture is relatively common. Victims sustaining lightning strikevia a conventional corded telephone are at higher risk for otologic injury, including persistent tinnitus,

sensorineural deafness, ataxia, vertigo, and nystagmus.59 In patients who are sleeping with an ear or eye onthe ground near a lightning strike, temporary deafness or blindness can result.

MUSCULOSKELETAL INJURY

A variety of skeletal fractures can be seen from the blunt force injury associated with lightning strike. Intensemyotonic contractions can produce shoulder dislocations. Rhabdomyolysis aer lightning strike is unusual.Spinal fractures can be caused by tetanic muscle contractions, as well as by falls and other secondarytrauma. Therefore, maintain spinal immobilization during retrieval and resuscitation, to the extent possibleunder the circumstances, until spinal stability can be assessed. Because spinal fractures oen occur atmultiple levels in the same patient, image the entire vertebral column when a fracture is found at one level.

CUTANEOUS INJURY

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There are six main dermatologic manifestations of lightning injury. Lichtenberg figures are consideredpathognomonic for lightning strike and consist of a superficial feathering or ferning pattern (Figure 218-2).These figures are the result of electron showering over the skin and are not true thermal burns; theydisappear within 24 hours. Flash burns are similar to those found in arc welders, appearing as milderythema, and may involve the cornea. Punctate burns (Figure 218-3) look similar to cigarette burns in thatthey are usually <1 cm and are full-thickness burns. Contact burns occur when metal close to the skin isheated from the lightning current. Superficial erythema and blistering burns have been described. Linearburns, <5 cm wide, occur in areas of skin folds such as the axilla or groin. Contact wounds characteristic ofelectrical injury from human-produced sources are not commonly seen in lightning injuries. Cutaneouswounds are treated with customary wound or burn care, including tetanus prophylaxis, irrigation,debridement, and dressing.

FIGURE 218-2.

Lichtenberg figures with lacy ferning pattern seen on the upper chest. [Reproduced with permission fromKnoop KJ, Stack LB, Storrow AB: The Atlas of Emergency Medicine, 2nd ed. © 2002 by McGraw-Hill, Inc., NewYork.]

FIGURE 218-3.

Punctate lightning burns. [Reproduced with permission from Knoop KJ, Stack LB, Storrow AB: The Atlas ofEmergency Medicine, 2nd ed. © 2002 by McGraw-Hill, Inc., New York.]

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PREVENTION

Safety recommendations include anticipating possible lightning storms (using resources such as theNational Oceanic and Atmospheric Administration Weather Radio) and seeking safe shelter indoors whenlightning is first seen or thunder is heard. Safer shelters include large structures with plumbing or electricalwiring, and fully enclosed metal vehicles. Dangerous locations to avoid include trees and other tallstructures, open fields, open vehicles, and other open structures. During lightning storms, it is important to

avoid being in or near water and to avoid contact with metal or wire fences and other conductive objects.58

DISPOSITION AND FOLLOW-UP

Patients should be carefully assessed for injuries. ECG and other monitoring is indicated as for any electricshock. Admission should be considered for most patients with persistent muscle pain, as well as those withpersistent neurologic, cardiac rhythm, or vascular abnormalities. Follow-up is recommended to assessdelayed eects of lightning, even for patients with no apparent injury.

SPECIAL POPULATIONS

In some cases, fetal injury and death have been noted to follow lightning strike with little or no maternalinjury. One review reported that among 11 pregnant women who survived being struck by lightning, there

were five cases of fetal death in utero, abortion, stillbirth, or neonatal death.49 Abruptio placentae has alsobeen reported. Monitoring of maternal uterine activity and fetal heart rate is recommended for at least 4hours aer a lightning strike to a pregnant woman. Such monitoring will alert the physician to thedevelopment of abruptio placentae, which can occur following any physical trauma.

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INJURY DUE TO ELECTRONIC CONTROL DEVICES

Electronic control devices (also known as conductive energy devices), such as the cattle prod, stun gun, andthe Taser®, can lead to injuries. Approximately 11% of "legal intervention injuries" (i.e., injuries sustainedwhile being taking into custody) are related to electronic control devices, and the incidence is increasing. Thevast majority of patients injured by electronic control devices are treated and released, but 6% are

hospitalized.69 TASER International, Inc. (Scottsdale, AZ), produces a series of devices that deliver high-voltage, low-amperage electrical pulses, typically at 10 to 20 cycles per second (subtetanic rate). The pulsesare designed to induce involuntary muscle contraction, neuromuscular incapacitation, and/or pain. The

likelihood of electrical injury is minimal; 70,71,72,73 however, reports have been published attributing cardiac

arrest to these devices.74,75 In addition, falls or other forceful movements resulting from electric current canlead to injury, as can use in flammable and other hazardous environments. Some devices shoot wires withfishhook-like barbs on the ends that penetrate and hook into the skin; penetrating injuries can result fromthis mechanism.

CLINICAL FEATURES

Most electronic control device injuries are limited to superficial punctures, minor lacerations, and cutaneous

burns. Reported significant injuries have included skull penetration,76 eye perforation,77,78 retinal

detachment,79 testicular torsion,80 miscarriage,81 and pneumothorax,80 as well as blunt trauma from fallsand burns. Burns may occur when electronic control devices are used in flammable environments or used toincapacitate someone on a hot surface.

Clinical evaluation should address the underlying agitation underlying the use of the electronic controldevice. Patients may be agitated due to stimulant intoxication or other causes of medical delirium (includingalcohol withdrawal or thyroid storm) and should be fully evaluated for both the underlying cause and themetabolic consequences of delirium, including hyperthermia, electrolyte abnormalities, rhabdomyolysis,

and acidosis.82

TREATMENT AND DISPOSITION

Cardiac monitoring and other testing is not needed just because an electronic control device has been used.An initial ECG should be obtained if the patient is symptomatic. A series of human studies have suggestedthat electronic control devices do not cause or worsen hyperthermia, hyperkalemia, hypoxia, acidosis, and a

variety of other problems oen seen with in-custody deathsm,83,84,85,86 but many underlying medicalconditions may be at play in the patient who has required electronic control device discharge for restraint.The physician should try to determine why the electronic control device was used and obtain a history of thepatient's behavior. Careful evaluation and monitoring are needed in the ill-appearing patient with thedierential considerations of agitated delirium.

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1.

2.

3.

4.

5.

6.

7.

8.

Patients who have calmed down, have no history of loss of consciousness or significant cardiac disease, andappear well can usually be discharged with no ECG or other testing beyond vital signs and a physicalexamination.

Patients with a history of severe agitation may be discharged if they have calmed down, maintained stablevital signs for 2 hours, and have a normal 12-lead ECG, electrolytes, arterial blood gas, and creatinephosphokinase. Those with abnormal labs, a history of loss of consciousness or significant underlyingcardiac disease, and abnormalities on ECG should be admitted for further observation.

REFERENCES

http://www.ameriburn.org/2014NBRAnnualReport.pdf. (National Burn Repository annual report.)Accessed January 13, 2015.

Arnoldo BD, Purdue GF, Kowalske K, Helm PA, Burris A, Hunt JL: Electrical injuries: a 20-year review. JBurn Care Rehabil 25: 479, 2004.

[PubMed: 15534455]

Electrical Safety Foundation International: Workplace Injury and fatality statistics, 2003-2010.http://esfi.org/index.cfm/page/Workplace-Electrical-Injury-and-Fatality-Statistics,-2003-2010/cdid/12396/pid/3003. Accessed January 13, 2015.

Koumbourlis AC: Electrical injuries. Crit Care Med 30 (11 Suppl): S424, 2002. [PubMed: 12528784]

Wick R, Gilbert JD, Simpson E, Byard RW: Fatal electrocution in adults—a 30-year study. Med Sci Law 46:166, 2006.

[PubMed: 16683472]

Kowalski-Trakofler K, Barrett E: Reducing non-contact electric arc injuries: an investigation of behavioraland organizational issues. J Safety Res 38: 597, 2007.

[PubMed: 18023645]

Fish RM: Electric injury, part I: treatment priorities, subtle diagnostic factors, and burns. J Emerg Med 17:977, 1999.

[PubMed: 10595883]

Fish RM: Electric injury, part II: specific injuries. J Emerg Med 18: 27, 2000. [PubMed: 10645833]

6/11/2019

26/33

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

Blackwell N, Hayllar J: A three year prospective audit of 212 presentations to the emergency departmentaer electrical injury with a management protocol. Postgrad Med J 78: 283, 2002.

[PubMed: 12151571]

Bailey B, Gaudreault P, Thivierge RL: Cardiac monitoring of high-risk patients aer an electrical injury: aprospective multicentre study. Emerg Med J 24: 348, 2007.

[PubMed: 17452703]

Searle J, Slagman A, Maaß W, Möckel M: Cardiac monitoring in patients with electrical injuries. Ananalysis of 268 patients at the Charité Hospital. Dtsch Ärztebl Int 110: 847, 2013.

[PubMed: 24399026]

Akkaş M, Hocagil H, Ay D, Erbil B, Kunt MM, Ozmen MM: Cardiac monitoring in patients withelectrocution injury. Ulus Travma Acil Cerrahi Derg 18: 301, 2012.

[PubMed: 23138995]

Claudet I, Maréchal C, Debuisson C, Salanne S: Risk of arrhythmia and domestic low-voltage electricalinjury. Arch Pédiatrie Organe O Sociéte Fr Pédiatrie 17: 343, 2010.

[PubMed: 20189784]

Pérez-Molina I, Velázquez-Pérez JM, Mondéjar-Marín B, Navarro-Muñoz S, Pedrosa-Guerrero A, Alvarez-Tejerina A: Neurological sequelae following electrocution. A case report and review of the literature. RevNeurol 43: 610, 2006.

[PubMed: 17099853]

Bae EJ, Hong IH, Park SP, Kim HK, Lee KW, Han JR: Overview of ocular complications in patients withelectrical burns: an analysis of 102 cases across a 7-year period. Burns 39: 1380, 2013.

[PubMed: 23688678]

Zablocki GJ, Hagedorn CL: Chorioretinal atrophy aer electrical injury. Digit J Ophthalmol 17: 40, 2011. [PubMed: 23362394]

Ramati A, Pliskin NH, Keedy S et al.: Alteration in functional brain systems aer electrical injury. JNeurotrauma 26: 1815, 2009.

[PubMed: 19323610]

Arévalo JM, Lorente JA, Balseiro-Gómez J: Spinal cord injury aer electrical trauma treated in a burnunit. Burns 25: 449, 1999.

[PubMed: 10439155]

6/11/2019

27/33

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

Kazda O, Holík F: Multiple compressive fractures of the spine caused by electric current injury. Rozhl Chir51: 743, 1972.

[PubMed: 4637387]

Johl HK, Olshansky A, Beydoun SR, Rison RA: Cervicothoracic spinal cord and pontomedullary injurysecondary to high-voltage electrocution: a case report. J Med Case Rep 6: 296, 2012.

[PubMed: 22974044]

Ko SH, Chun W, Kim HC: Delayed spinal cord injury following electrical burns: a 7-year experience. Burns30: 691, 2004.

[PubMed: 15475144]

Ratnayake B, Emmanuel ER, Walker CC: Neurological sequelae following a high voltage electrical burn.Burns 22: 574, 1996.

[PubMed: 8909765]

Kingsly PM, Dhanraj P, Gupta A: Recovery aer spinal cord injury due to high tension electrical burns: a5-year experience. Burns 34: 888, 2008.

[PubMed: 17904747]

Ohn SH, Kim DY, Shin JC et al.: Analysis of high-voltage electrical spinal cord injury using diusiontensor imaging. J Neurol 260: 2876, 2013.

[PubMed: 24002417]

Breugem CC, Van Hertum W, Groenevelt F: High voltage electrical injury leading to a delayed onsettetraplegia, with recovery. Ann N Y Acad Sci 888: 131, 1999.

[PubMed: 10842627]

Bariar LM, Ahmad I, Aggarwal A, Menon RK: Myelopathy following high voltage electrical injury: a casereport. Burns 28: 699, 2002.

[PubMed: 12417170]

Reisner AD: Delayed neural damage induced by lightning and electrical injury: neural death, vascularnecrosis, and demyelination? Neural Regen Res 9: 907, 2014.

[PubMed: 25206909]

Reisner AD: Possible mechanisms for delayed neurological damage in lightning and electrical injury.Brain Inj 27: 565, 2013.

[PubMed: 23473007]

6/11/2019

28/33

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

Anderson ML, O'Riordan J: Guillain-Barre syndrome-like illness in association with electrical shockinjury. BMJ Case Rep October 17, 2013.

[PubMed: 24136915]

Kim HM, Ko Y-A, Kim JS, Lim SH, Hong BY: Neurological complication aer low-voltage electric injury: acase report. Ann Rehabil Med 38: 277, 2014.

[PubMed: 24855625]

Kwon KH, Kim SH, Minn YK: Electrodiagnostic study of peripheral nerves in high-voltage electrical injury.J Burn Care Res 35: e230, 2014.

[PubMed: 23877148]

Kowalske K, Holavanahalli R, Helm P: Neuropathy aer burn injury. J Burn Care Rehabil 22: 353, 2001. [PubMed: 11570537]

Peyron PA, Cathala P, Vannucci C, Baccino E: Wrist fracture in a 6-year-old girl aer an accidental electricshock at low voltages. Int J Legal Med April 15, 2014. [Epub ahead of print]

Stone N, Karamitopoulos M, Edelstein D, Hashem J, Tucci J: Bilateral distal radius fractures in a 12-year-old boy aer household electrical shock: case report and literature summary. Case Rep Med 2014: 235756,2014.

[PubMed: 24511315]

Park K-H, Park WJ, Kim M-K et al.: Alterations in arterial function aer high-voltage electrical injury. CritCare 16: R25, 2012.

[PubMed: 22326053]

Cancio LC, Jimenez-Reyna JF, Barillo DJ, Walker SC, McManus AT, Vaughan GM: One hundred ninety-five cases of high-voltage electric injury. J Burn Care Rehabil 26: 331, 2005.

[PubMed: 16006840]

Mascarenhas A, Eusébio M, Freitas O, Almeida T: Acquired-transient factor X deficiency in a teenagerwith extensive burns. BMJ Case Rep February 17, 2011.

[PubMed: 22707501]

Chen W-H, Chui C, Lui C-C, Yin H-L: Ischemic stroke aer low-voltage electric injury in a diabetic andcoagulopathic woman. J Stroke Cerebrovasc Dis 21: 913, 2012.

[PubMed: 22265234]

Capelli-Schellpfeer M, Miller GH, Humilier M: Thermoacoustic energy eects in electrical arcs. Ann N YAcad Sci 888: 19, 1999.

6/11/2019

29/33

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

[PubMed: 10842616]

Izzy S, Deeb W, Peters GB, Mitchell A: Isolated optic nerve oedema as unusual presentation of electricinjury. BMJ Case Rep October 15, 2014.

[PubMed: 25320254]

Korn BS, Kikkawa DO: Images in clinical medicine. Ocular manifestation of electrical burn. N Engl J Med370: e6, 2014.

[PubMed: 24450916]

Haberal M, Uçar N, Bayraktar U, Oner Z, Bilgin N: Visceral injuries, wound infection and sepsis followingelectrical injuries. Burns 22: 158, 1996.

[PubMed: 8634129]

Soar J, Perkins GD, Abbas G et al.: European Resuscitation Council Guidelines for Resuscitation 2010Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidentalhypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution.Resuscitation 81: 1400, 2010.

[PubMed: 20956045]

Arrowsmith J, Usgaocar RP, Dickson WA: Electrical injury and the frequency of cardiac complications.Burns 23: 576, 1997.

[PubMed: 9568327]

Varol E, Ozaydin M, Altinbas A, Dogan A: Low-tension electrical injury as a cause of atrial fibrillation: acase report. Tex Heart Inst J 31: 186, 2004.

[PubMed: 15212136]

Yew KL: Electrocution induced symptomatic bradycardia necessitating pacemaker implantation. HeartViews 15: 49, 2014.

[PubMed: 25104983]

Alemayehu H, Tarkowski A, Dehmer JJ, Kays DW, St Peter SD, Islam S: Management of electrical andchemical burns in children. J Surg Res 190: 210, 2014.

[PubMed: 24698499]

Fish RM: Electric injury, part III: cardiac monitoring indications, the pregnant patient, and lightning. JEmerg Med 18: 181, 2000.

[PubMed: 10699519]

Fatovich DM: Electric shock in pregnancy. J Emerg Med 11: 175, 1993. [PubMed: 8505523]

6/11/2019

30/33

50.

51.

52.

53.

54.

55.

56.

57.

58.

59.

60.

61.

Awwad J, Hannoun A, Fares F, Ghazeeri G: Accidental electric shock during pregnancy: reflection on acase. AJP Rep 3: 103, 2013.

[PubMed: 24147245]

Donly KJ, Nowak AJ: Oral electrical burns: etiology, manifestations, and treatment. Gen Dent 36: 103,1988.

[PubMed: 3063594]

Banks K, Merlino PG: Minor oral injuries in children. Mt Sinai J Med N Y 65: 333, 1998. [PubMed: 9844360]

Garcia CT, Smith GA, Cohen DM, Fernandez K: Electrical injuries in a pediatric emergency department.Ann Emerg Med 26: 604, 1995.

[PubMed: 7486370]

http://www.lightningsafety.noaa.gov/fatalities.htm. (National Weather Service: Lightning safety, 2014.)Accessed January 13, 2015.

http://www.cdc.gov/nchs/data/nhsr/nhsr076.pdf. (Centers for Disease Control and Prevention: CDCNational Health Statistics Report. 2014.) Accessed January 13, 2015.

Cherington M: Central nervous system complications of lightning and electrical injuries. Semin Neurol15: 233, 1995.

[PubMed: 8570925]

Muehlberger T, Vogt PM, Munster AM: The long-term consequences of lightning injuries. Burns 27: 829,2001.

[PubMed: 11718985]

Zimmermann C, Cooper MA, Holle RL: Lightning safety guidelines. Ann Emerg Med 39: 660, 2002. [PubMed: 12023712]

Andrews CJ: Telephone-related lightning injury. Med J Aust 157: 823, 1992. [PubMed: 1454020]

Carte AE, Anderson RB, Cooper MA: A large group of children struck by lightning. Ann Emerg Med 39:665, 2002.

[PubMed: 12023713]

Whitcomb D, Martinez JA, Daberkow D: Lightning injuries. South Med J 95: 1331, 2002. [PubMed: 12540003]

6/11/2019

31/33

62.

63.

64.

65.

66.

67.

68.

69.

70.

71.

72.

Bier M, Chen W, Bodnar E, Lee RC: Biophysical injury mechanisms associated with lightning injury.Neurorehabilitation 20: 53, 2005.

[PubMed: 15798357]

Lifschultz BD, Donoghue ER: Deaths caused by lightning. J Forensic Sci 38: 353, 1993. [PubMed: 8454996]

Ten Duis HJ, Klasen HJ, Reenalda PE: Keraunoparalysis, a "specific" lightning injury. Burns Incl ThermInj 12: 54, 1985.

[PubMed: 4063869]

Cherington M: Spectrum of neurologic complications of lightning injuries. Neurorehabilitation 20: 3,2005.

[PubMed: 15798349]

Cooper MA: A fih mechanism of lightning injury. Acad Emerg Med 9: 172, 2002. [PubMed: 11825846]

Cooper MA: Emergent care of lightning and electrical injuries. Semin Neurol 15: 268, 1995. [PubMed: 8570929]

Norman ME, Albertson D, Younge BR: Ophthalmic manifestations of lightning strike. Surv Ophthalmol46: 19, 2001.

[PubMed: 11525786]

Haileyesus T, Annest JL, Mercy JA: Non-fatal conductive energy device-related injuries treated in U.S.emergency departments, 2005-2008. Inj Prev 17: 127, 2011.

[PubMed: 21257680]

Ideker RE, Dosdall DJ: Can the direct cardiac eects of the electric pulses generated by the TASER X26cause immediate or delayed sudden cardiac arrest in normal adults? Am J Forensic Med Pathol 28: 195,2007.

[PubMed: 17721165]

Bozeman WP, Hauda WE, Heck JJ, Graham DD, Martin BP, Winslow JE: Safety and injury profile ofconducted electrical weapons used by law enforcement oicers against criminal suspects. Ann Emerg Med53: 480, 2009.

[PubMed: 19157651]

Gardner AR, Hauda WE, Bozeman WP: Conducted electrical weapon (TASER) use against minors: ashocking analysis. Pediatr Emerg Care 28: 873, 2012.

6/11/2019

32/33

73.

74.

75.

76.

77.

78.

79.

80.

81.

82.

83.

[PubMed: 22929134]

Dawes DM, Ho JD, Sweeney JD, Lundin EJ, Kunz SN, Miner JR: The eect of an electronic control deviceon muscle injury as determined by creatine kinase enzyme. Forensic Sci Med Pathol 7: 3, 2011.

[PubMed: 20683680]

Zipes DP: Sudden cardiac arrest and death following application of shocks from a TASER electroniccontrol device. Circulation 125: 2417, 2012.

[PubMed: 22547671]

Zipes DP: TASER electronic control devices can cause cardiac arrest in humans. Circulation 129: 101,2014.

[PubMed: 24396013]

Chandler J, Martin BP, Graham DD: TASER® injury to the forehead. J Emerg Med 44: e67, 2013. [PubMed: 21945507]

Hoskin AK, Mackey DA: Eye injuries and tasers. Med J Aust 201: 89, 2014. [PubMed: 25045981]

Li JY, Hamill MB: Catastrophic globe disruption as a result of a TASER injury. J Emerg Med 44: 65, 2013. [PubMed: 21570244]

Sayegh RR, Madsen KA, Adler JD, Johnson MA, Mathews MK: Diuse retinal injury from a non-penetrating TASER dart. Doc Ophthalmol Adv Ophthalmol 123: 135, 2011.

[PubMed: 21909993]

Ordog GJ, Wasserberger J, Schlater T, Balasubramanium S: Electronic gun (Taser) injuries. Ann EmergMed 16: 73, 1987.

[PubMed: 3800082]

Mehl LE: Electrical injury from Tasering and miscarriage. Acta Obstet Gynecol Scand 71: 118, 1992. [PubMed: 1316038]

Gross ER, Porterieko J, Joseph D: Rhabdomyolysis and oliguric renal failure aer use of TASER®: is itreally safe? Am Surg 79: E337, 2013.

[PubMed: 24351337]

Ho JD, Dawes DM, Bultman LL, Moscati RM, Janchar TA, Miner JR: Prolonged TASER use on exhaustedhumans does not worsen markers of acidosis. Am J Emerg Med 27: 413, 2009.

[PubMed: 19555610]

6/11/2019

33/33

84.

85.

86.

Ho JD, Dawes DM, Heegaard WG, Miner JR: Human research review of the TASER electronic controldevice. Conf Proc IEEE Eng Med Biol Soc 2009: 3181, 2009.

[PubMed: 19964797]

Ho JD, Miner JR, Lakireddy DR, Bultman LL, Heegaard WG: Cardiovascular and physiologic eects ofconducted electrical weapon discharge in resting adults. Acad Emerg Med 13: 589, 2006.

[PubMed: 16551780]

Vilke GM, Sloane CM, Suecool A et al.: Physiologic eects of the TASER aer exercise. Acad Emerg Med16: 704, 2009.

[PubMed: 19594461]

USEFUL WEB RESOURCES

American Burn Association: Advanced Burn Life Support—http://www.ameriburn.org/BurnCenterReferralCriteria.pdf

Electrical Safety Foundation International—www.esfi.org

National Weather Service: Lightning Safety—http://www.lightningsafety.noaa.gov/

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