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Electrical Injury and Burn Care: A Review of Best Practices
Electrical injuries are uncommon but can be dangerous and deadly not only for patients but also for responders.1–5 This article covers the nature of electricity, basics of electrical injury, general patient assessment and initial care.
Electrical shocks account for approximately 3% of all burn injures in the United States each year.1 Electrical burns can occur when a patient comes in contact with an electrical source. Depending on the resistance encountered, the nature of the source, the strength of the current and the contact time, the heat generated (Joule effect) may produce serious external and internal burn injuries. These can range from a mild shock to sudden cardiac arrest. Deep-tissue burns may occur anywhere along the path a current travels through the body. Evident surface burns may only comprise a small portion of the overall burn injury, and an injury’s full extent may not be immediately apparent.12
Scene safety is especially important with electrical injuries. These scenes may pose an ongoing danger of electrical shock to responders as well as the patient. Rescue should only be initiated and performed by those who have been trained appropriately and have the resources to attempt it safely. One aspect of scene safety is ensuring the patient is no longer in contact with the electrical source and, if necessary, delaying care until there is no obvious risk to responders.
For purposes of this work, an electric shock is defined as accidental or intentional contact with an electrical source or energized pathway (such as an electric wire) that results in energy transfer from the source to the patient. When that energy transfer produces a cardiac arrest, it is considered an electrocution.
Responding to an Electrical Accident
If the patient is still in contact with an energized source, do not touch them until the source has been removed or disconnected. If a responder comes in contact with the patient before the electrical source is disconnected, they may also receive a shock.
Following the primary survey,7 complete a head-to-toe physical examination that includes identifying the different contact points (surface burn sites), assess for fractures and neurological deficits also caused by the shock, and begin monitoring the patient’s cardiac rhythm. The electrical pathways of the heart may be interrupted, disturbed or damaged during electrical shock or electrocution.13–19 Cardiac damage can be manifested as dysrhythmias (to include VF),20 while CNS damage can result in seizures, paralysis and apnea.21
Examine the body for thermal burn injuries. Causes include contact points with the electrical source or ground and injuries from an arc or thermal wave. Burn injuries caused by an arc or thermal wave resemble and should be managed as thermal burn injuries associated with blasts.9 The particular pathway for electric current as it passes through the body will determine the tissues at risk. In addition to the voltage, resistance to the electric current and the duration of its exposure will determine the amount of energy converted to heat (the Joule effect). The greater the Joule effect, the greater the potential for external injury at contact points, as well as internal injury.
With electric current concentrated at contact points, significant thermal burn injuries are likely to be identified at these sites as well as contact points where the patient is grounded. Assess the extent of external burn injury by using a method such as the Rule of Nines or Lund and Browder. Signs and symptoms related to internal injuries may not be readily apparent and could develop in the hours following the injury.
During care and transport, ongoing activities includes cardiac monitoring, respiratory support and ongoing neurological assessment. Assess the extremities frequently for swelling, distal pulses/capillary refill, skin temperature and neurological (sensory and motor) function/deficits. Airway and respiratory assessment includes monitoring the saturation of arterial oxygen and (if indicated and available) end-tidal carbon dioxide.
One example of the internal injury that can be produced is compartment syndrome. Compartment syndrome can occur when significant underlying muscle tissue is involved. Internal swelling within an extremity can create neurocirculatory compromise distal to the injury site, placing the limb at risk. In the hours that follow an electrical injury, a surgeon may need to perform a fasciotomy (a surgical incision that cuts into the fascia following the length of the extremity where the burn is located) to restore perfusion. If the electric shock was significant enough to produce thermal burn on the skin’s surface, suspect internal injury. Continually reassess injured areas throughout care and alert the receiving hospital of any pertinent findings.
The transport destination should be a burn center or the closest appropriate hospital based on local guidelines.
Treatment
Initial care of the patient with an electrical injury includes airway management and support with supplemental oxygen as needed. If an invasive airway needs to be provided, endotracheal intubation is preferred over a blind-insertion airway device, but when in doubt, secure the airway.
For all patients with electrical injury, apply a cardiac monitor. A cardiac disturbance may manifest as changes evident on ECG.14 ECG monitoring is essential; treat dysrhythmias from an electric shock as if they were produced by a myocardial infarction. Although the most lethal arrhythmia is ventricular fibrillation, other cardiac abnormalities can occur, including damage to the sinoatrial or atrioventricular (AV) nodes that generate conduction abnormalities or ventricular ectopy. ECG changes can range from bradycardia with all varieties of heart block to ventricular dysrhythmias such as bigeminy or multifocal premature ventricular contractions (PVCs), VF and ventricular tachycardia (VT). There are multiple case studies in the scientific literature of patients who received an accidental electric shock having their resulting VF converted to a pulsatile rhythm by their implanted defibrillator.17
Most contact points develop full-thickness thermal burns and should be managed as such.8 Treat a contact or thermal burn with water for cooling, then cover it with a clean, dry dressing while administering pain medications as needed. Once the wound has cooled, limit further pain management to medications, not water. Fractures or dislocations may occur as indirect injuries and should be managed accordingly, including cervical spine assessment and immobilization as indicated.
Fluid resuscitation for a major electrical injury should begin at 500 mL/hr of lactated Ringer’s solution (or 0.9% sodium chloride solution if LR is unavailable) until a urinary catheter can be inserted. It is preferable to establish two large-bore intravenous lines and infuse 250 mL/hr per line for a total of 500 mL/hr. Once urine output can be evaluated and measured, adjust fluid resuscitation to target urine output, with a goal of 1.0 mL/kg per hour. If the urine is bright red, orange or brown, this indicates significant internal injury and associated muscle damage.
Note that insertion of a urinary catheter is not within the scope of practice for many EMS personnel. Nevertheless, once one has been placed, either in the field or at a hospital prior to transfer, the quantity of urine output should be the driving force behind adjusting IV fluid infusion.
Common Electrical Burns and Related Injuries
Direct injuries occur when a patient contacts an electrical source and is injured. Historically these injuries were described with the assumption that with an “entry” wound, that there must also be an “exit” wound. This led responders to falsely assume that electrical current enters the body at one point and exits at another. This idea has been abandoned. It is now understood there may be multiple points of contact and subsequent grounding, resulting in multiple sites with serious thermal burns. Points of contact may also generate one, two or several discrete or barely discernable areas of injury.
Concomitant (or indirect) injuries occur when a patient receives an injury associated with an electric shock. While these may not always include burns, they can nonetheless still produce grave damage and death. An example would be a patient falling from a ladder while attempting to disengage from an electrical source.25,26
Indirect injury can also occur from an arc, whereby electricity travels between two conductors and the energy is transmitted over to a person who is close to, but not in direct contact with, an electrical source.27–29 Additionally, a surge in electricity can result in an arc blast, or an explosion that produces superheated air (a thermal wave). This thermal wave can indirectly burn anyone who may be in the general area.
When the environment is combustible, such as a dust-filled area or where hydrocarbon vapors are present, an otherwise-harmless static discharge or spark can trigger an explosion. This can include igniting the vapors produced while pumping gasoline into a car, or dust in a location such as a sugar or pharmaceutical factory, all of which have proven to be dangerous.
Another type of indirect electrical injury is associated with what can be described as spontaneous combustion. This occurs when a patient is in contact with an electrical source and the joules of heat produced exceed the ignition point for the patient’s clothing or other combustible sources. A garment spontaneously ignites, resulting in thermal burn injury.28,30–35
Lightning strike injuries occur due to proximity (arc injury) or direct contact with a conduit for energy transfer. Imagine standing close to a tree that is struck by lightning: As the energy travels down the tree, it’s conducted to a person contacting it, or residual current arcs to someone standing nearby. If someone is in the immediate area, they can be injured or killed, depending on the amount of electricity that enters the body, the path taken by the current and relative resistance to the flow.30,36–38 Injuries from a lightning strike are less likely to produce significant burns and more likely to produce CNS disruption,21 ECG dysrhythmias, and arc or flash injuries.
High-voltage injuries may produce tetanic muscle contractures. This is a condition where one or more muscle groups violently contracts in reaction to the electric shock. Resulting injuries may include orthopedic fractures and joint dislocations.39–41
Common Causes for Electrical Injuries
Severe weather can damage overhead power lines.42–44 Electric shock and electrocutions have occurred with emergency responses to downed power lines, power company line workers restoring electricity, and homeowners who have improperly installed or used generators. Generators that are not properly grounded pose a contact risk. Without an effective ground, residual electrical current from the generator will search for a grounding source. When a person contacts a poorly grounded generator that is actively generating electricity, residual current may pass through them (as a conductor) from the generator to the ground.
Another home generator risk is that those connected directly into the home electrical system while still connected to the service line can backfeed the power line. The current surge in what is presumed to be a dead electrical line can lead to shock or electrocution for utility workers.
Workplace injuries are a common source of burns associated with electric shock injuries and electrocutions. Common scenarios involve utility workers, maintenance employees with lockout/tag-out failures, light rail and subway maintenance personnel, ground maintenance workers and the construction industry.31,45–50 Many other injuries and deaths occur from working on elevated platforms (e.g., tree trimming, installing decorations, maintenance of antenna equipment) that contact high-voltage lines.
Illegal activities are also a common source of electrical accidents. Scrap copper and aluminum wire are valuable commodities that can be recycled.51 They are often stolen. Most injuries arise from presumptions that lines are not energized or a power supply has been disconnected. Attempts to bypass disconnected electrical service have also resulted in electrical injury and electrocution.52 One of the more common methods of power theft is to use insulated pliers and insert two bent pieces of copper piping into the housing where a power meter was previously removed.
Unique Responder Risks
The defibrillation threat to responders is often overlooked due to the widespread transition from paddles to pads. Nevertheless, the defibrillator is an electrical DC source (for DC vs. AC, see sidebar) with sufficient energy to restart a fibrillating heart, and it remains essential to “clear” the patient before discharging the device. While using pads in lieu of the historical paddle and gel system has physically moved the responder away from immediate contact with the patient, it still requires the responder to clear and have an unobstructed view of the patient to ensure other responders are not contacting them.55–57
Overhead power lines downed at a vehicle collision may also represent a serious threat. In some circumstances the power supply is “looped” together, meaning power to the line is available from either side. For other lines, the circuit can be a “dead end” line, meaning power terminates at the end of the wire. Determining the flow of current is not a responsibility of the EMS responder and should be left to utility professionals. Consider a downed power line energized until you’re notified otherwise by such a professional.
Other dangers include power lines that may be down and remote from responders yet remain in contact with other conductors that would typically not be energized. These items, such as guy wires that counterbalance the weight of lines by securing the top of the power pole to the ground, can serve as deadly electrical conduits. Overhead utility lines may also include telephone and cable wires, and while these may not be high-voltage, they carry sufficient electric current to injure those who contact downed lines.
A retrospective study of firefighter fatalities completed in 2002 by the TriData Corp. included line-of-duty deaths from 1990–2000.10 During the 10-year period of the report, firefighters died of burns or combinations of burns with inhalation injury 8.4% of the time, and electrocution 1.8%. Only heart attack/cardiac arrest, trauma and asphyxiation were more likely to have contributed to an LODD. A sample of descriptions from a five-year period regarding the nature and types of electrical risks faced by responders has been included in Table 2.10
Of the cases in the report, the 1997 Marion, OH, accident highlights the dangers of downed power lines at the scene of a vehicle collision. A responder came in contact with an energized (high-voltage) power line while moving the patient to the ambulance. The electricity conducted through a total of 10 people at the scene, including the patient and responders. The conduction is believed to have followed multiple pathways from the responder who accidentally contacted the wire to others through either standing water or touching the stretcher (backboard), vehicle or each other. The patient was killed, as were three responders; six more sustained serious injuries.
Conclusion
Electrical accidents with injuries seldom occur. Yet when they do, they produce unique and challenging patient scenarios as well as a potential risk to responders. If in doubt about the safety of a scene, back out and await an “all clear” from utility professionals.
Injuries from electrical sources may include multiple thermal burns, dysrhythmias, fractures, internal injury and CNS damage. The initial impression may be confusing since the true extent may have only begun to unfold as the responder begins to assess the patient. Stay focused on what is present and continue to reassess based on the principles offered in this paper for the best outcome.
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Randy D. Kearns, DHA, MSA, NREMT-P (ret.), is a clinical assistant professor and director of the Burn Disaster Program within the Department of Surgery at the University of North Carolina School of Medicine. He’s also administrator of the EMS Performance Improvement Center within the UNC Department of Emergency Medicine.
Preston B. Rich, MD, MBA, FACS, in chief of acute-care surgery and a professor of surgery at the University of North Carolina School of Medicine.
Charles B. Cairns, MD, FACEP, FAHA, is professor and chair of emergency medicine at the University of North Carolina School of Medicine.
James H. Holmes, IV, MD, FACS, is director of the burn center at Wake Forest Baptist Medical Center and an associate professor of surgery at the Wake Forest University School of Medicine.
Bruce A. Cairns, MD, FACS, is director of the North Carolina Jaycee Burn Center and serves as the John Stackhouse Distinguished Professor of Surgery/Microbiology and Immunology at the University of North Carolina School of Medicine.
