Electrical Injuries

Stephen Hunt Stanford University Medical Center 22 April 2013

Electrical Injury

Epidemiology Mechanisms of injury Associated injuries Management Prognosis

22 April 2013

Epidemiology:

Account for ~ 3% all burn-related injuries Estimated 3,000 annual admits to burn units ~ 1/3 fatal - about 1,000 US deaths annually Bimodal distribution ~1/3 children <6 yrs (electric cords & wall outlets) ~2/3 miners, construction, & electrical workers Common cause occupational deaths Lightning responsible for ~300 injuries, 100 deaths

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Physics Review

I = V/R (Ohms Law - current) Intensity expressed in amperes (A) DC - lightning, rails, autos, batteries AC - most power lines, buildings
E = IVT (Joules law - thermal energy) E = I2RT
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Mechanisms of Injury

Direct effect of electrical current Thermal burns (conversion I->E) Mechanical Trauma Post-trauma sequelae

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Direct effects of current

I = V/R In general, type & extent of injury depends on current intensity (amps) Type of current (DC vs AC), current pathway, and duration of current also influence severity of injury As current generally not known, injuries often classified into high V ( > 1,000V) vs low V Cardiac, neurologic and respiratory systems most susceptible to direct effects Skin is the resistor most effecting severity of injury Wet skin has lower R (~1K ohm) vs. dry or thick skin (>100K ohm), resulting in greater current flow
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Thermal (Burn) Injuries

Heat (E) = IVT = I2RT Type & extent of injury depends on current intensity (I) R varies significantly between tissues Tissues with high R (e.g., bone), generate more heat, resulting in osteonecrosis and deep tissue periosteal burns, esp surrounding long bones Skin also has high R, thus entry/exit wounds Decreasing R (e.g., wet skin) results in lower thermal injury, but higher current conductance Coagulation of muscle, fat, vessels (i.e., the Bovie) Duration of current exposure (T) DC typically shorter duration, because single muscle spasm causes victim to be thrown from the source
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Mechanical Trauma

Trauma can result from fall or muscle contraction Classic example is shock wave of lightning causing blast injuries Even at low V, tetanic muscle contraction can result in bone fx Cord injury can result from severe muscle contraction, w/o any external signs of trauma Can result in vascular compromise Acute hypotension should always prompt search for thoracic or intra-abdominal bleeding
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Post-trauma sequelae

Crush injury syndrome (rhabdomyolysis, myoglobinuria) Multi-organ ischemic injury 2o/2 vascular coagulation or dissection Hypovolemic shock 2o/2 massive 3rd spacing Iatrogenic injuries from acute resuscitation Abdominal compartment syndrome ARDS
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Associated Injuries I

Respiratory System Suffocation 2o/2 tetanic muscle contractions Respiratory arrest 2o/2 direct injury to RCC Cardiovascular System Asystole (more likely if DC or high V) Arrhythmias (more likely AC) (~15% pts) Ventricular fibrillation most common fatal arrhythmia Myocardial necrosis (thermal effect) Anoxic injury 2o/2 respiratory arrest Neurological System Direct effects include LOC, autonomic dysfunction, amnesia, temp paralysis (keraunoparalysis) Cord injury 2o/2 spine fx 2o/2 muscle contractions Peripheral motor/sensory losses (long-term sequelae)
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Associated Injuries II

Skin (~57% low V fatalities; ~96% high V fatalities)* Superficial, partial or full thickness thermal burns Degree of external injury can underestimate internal injury & vice-versa Muscle Necrosis 2o/2 severe contraction or thermal injury Compartment syndrome 2o/2 edema from deep injury & 3rd spacing Skeletal Osteonecrosis 2o/2 thermal injury Fx 2o/2 muscle contraction or blunt trauma
*Wright, et al, J Foren Sci, 1980

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Associated Injuries III

Renal Pigment-induced renal failure Hypovolemia 2o/2 3rd spacing can lead to prerenal GI Injury rare, most commonly Curlers ulcers HEENT Cataracts can develop up to 2 years after Hearing loss from 8th nerve injury Damage to any organ system 2o/2 blunt trauma Damage to any organ system 2o/2 vascular damage

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Associated Injuries

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Koumbourlis, Crit Care Med 2002

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Lichtenberg Figures

Rare pathognomonic flower-like branching skin lesions in persons struck by lightning Caused by flashover effect of non-penetrating current Rapidly fade, not typically serious

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Management I

Standard ABCDEs of any major trauma Pulmonary Low threshold for intubation, as respiratory failure common Cardiac Serial monitoring if high V, abnormal ECG, LOC, respiratory arrest, or PMH of CV dysfunction Neuro C-spine and log-roll precautions; CT head & spine often warranted Thorough serial neurological exams, as vessel coagulation can result in late sequelae

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Management II

Musculoskeletal Thorough evaluation for fractures Serial evaluations of limbs for compartment syndrome requiring emergent decompression Even in absence of compartment syndrome, persistent aciduria or myoglobinuria may require limb amputation Skin Early debridement and later reconstruction Antibiotic prophylaxis (controversial) Renal Fluid resuscitation key, as 3rd spacing common & myoglobinuria 2o/2 rhabdomyolysis can cause ARF
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Management III

GI Ulcer prophylaxis, as gastric ulcers (Curlings ulcers) can develop Ileus uncommon, but should prompt evaluation for other injury Serial evaluation of liver, pancreatic, & renal function for traumatic/anoxic/ischemic injury Judicious management of fluid and electrolytes to avoid acidosis and compartment syndromes

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Prognosis

Highly variable, depending on severity of both initial injury and subsequent complications High morbidity/mortality in patients with multisystem organ failure Advances in surgical interventions (early excision, fasciotomy, skin grafts, etc) have improved

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References

DM Mozingo & BA Pruitt. 1998. Electric Injury. in Fundamentals of Surgery, 1st ed, JE Niederhuber, pp 194-195. DS Pinto & PF Clardy. 2007. Environmental electric injuries. Upto-Date, accessed 06/01/2007. TN Pham & NS Gibran. 2007. Thermal & Electrical Injuries. Surg Clin N Am 87:185-206. AC Koumbourlis. 2002. Electrical Injuries. Crit Care Med 30:S424-S430. C Spies & RG Trohman. 2006. Electrocution & Life-Threatening Electrical Injuries. Ann Intern Med 145:531-537.

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