Chapter 97

• Aggressive and prolonged life support maneuvers should be performed as necessary on all electrical injury patients in the first few hours.
• All patients are to be considered to have multisystem injuries, including cervical spine fracture, until such injuries are eliminated diagnostically.
• Intravenous fluid resuscitation should not be underestimated.
• Most patients should be monitored for cardiac dysrhythmias for 24 to 48 hours after injury, particularly if electrocardiographic abnormalities were present or persist.
• The preservation of renal function depends largely on adequate volume resuscitation. If urine is visibly discolored by myoglobin, then renal function may depend on supplemental therapies.
• The neurologic examination should be monitored carefully for seizure activity, which should be treated if it develops.
• Early recognition and decompression of compartment syndromes are critical for maximizing extremity salvage and long-term function.
• Adequate wound care necessitates complete débridement of nonviable tissue followed by wound closure as expeditiously as possible.

Electrical shock is one of the leading causes of work-related injury, comprising 7% of all workplace fatalities. Typical victims of high-voltage electrical injury are young industrial workers or linemen usually between the ages of 20 and 34 years, with 4 to 8 years experience on the job. Immediate death can result from cardiac dysrhythmia, central respiratory arrest, or asphyxia due to tetanic contraction of the muscles of respiration. If victims survive the initial cardiopulmonary or central nervous system (CNS) insult, they then may face potential limb- and life-threatening sequelae from cutaneous injury, internal tissue destruction, and organ system dysfunction. The distribution of the tissues and organs damaged depends on the path of the injury current. Frequently, the injury is complicated by associated blunt trauma when the patient falls from a height or is thrown by the force of the electric current.

When the voltage is less than 1000 V, direct mechanical contact usually is required for electrical contact. For high voltages (>1000 V), arcing usually initiates the electrical contact. Most electrical injuries are due to low-voltage (<1000 V) electrical shock. Whereas low-voltage shocks carry a significant risk of electrocution-induced cardiac arrest, high-voltage shock injury is characterized by extensive tissue damage rather than electrocution. Approximately 3% to 4% of all U.S. hospital burn unit admissions are for electrical injury, mostly a result of high-voltage (>1000 V) shocks.

The duration of contact with the high-voltage power source and the distribution of electric current are important factors in the magnitude of the injury. If the contact is brief (i.e., <0.5 s), cell damage can occur through nonthermal components of electrical injury, called electroporation.1 If the contact is longer, both heating caused by electrical conduction (joule heating) and electroporation play important roles. Prolonged contact can lead to thermal burning of tissues in the current path. The electric current distribution across the tissues between the surface contact points depends on the electrical conductivity of the various tissues and on the variation in electrical field intensity. Usually, current density is greatest at the contact points. Once the current travels away from the contact points into the subcutaneous tissues, the tissues with the least electrical resistance, i.e., muscle, nerve, and blood vessels, will have the largest current densities and will experience the most rapid heating.2

Many cells, such as muscle and nerve cells, use electrical signals to control their function. The application ...

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