November 21, 2016

Originally from south Florida, John Creagh is no stranger to random electrical storms and, after a stint in the ED at the University of Miami School of Medicine, the injuries they incur. So when asked to present at Grand Rounds at the Johns Hopkins Children’s Center in Baltimore, where he is a pediatric resident, it was only natural for him to choose the acute care and management of electrical injuries as his topic.

“Electrical injuries don’t happen that frequently up here so I thought it would be good to look at the literature and figure out what pediatricians need to look for and how they should treat patients,” says Creagh.

What did he learn?

• Across the country, electrical injuries result in 3,000 hospital admissions each year. Adult electrical injuries tend to occur in occupational settings, but in children, who account for 20 percent of electrical injuries, they occur most often in the home, with exposure to electrical outlets and wires the most common cause. Significant morbidity, including facial deformities, has been reported in cases of children who have bitten electrical cords.
• Electrical injuries are generally classified by the power source (lightning or electrical), voltage (high or low) and current (alternating or direct). The primary determinant of injury is the amount of current flowing through the body. Depending on the voltage, current, pathway, duration of contact and type of circuit, electrical burns can cause a variety of injuries from minimal to severe multi-organ involvement. Forty percent of serious electrical injuries result in death.
• The direct effect of electrical current on body tissues includes asystole, the life-threatening absence of electrical activity in the heart. Electrical energy can also be converted to thermal energy, resulting in burns, or trigger electroporation, which can cause slow cellular death and tissue necrosis. Blunt mechanical injury can result from a blast effect or a fall related to electrocution.
• Morbidity and mortality are largely affected by the particular type of electrical contact involved. High-voltage injuries often produce severe burns and blunt trauma. Skin injuries include superficial, partial-thickness and full-thickness burns;  so-called “kissing burns,” or flexor burns on skin adjacent to joints; and tattoo-like Lichtenberg burns from lightning.
• Cardiac manifestations include arrhythmia in 15 percent of electrical injuries, asystole and ventricular fibrillation. Fatal arrhythmia may occur from horizontal current (hand to hand) and vertical current (head to foot). Delayed arrhythmia sinus tachycardia and premature ventricular contractions are common in electrical injuries.
• Neurologic effects include loss of consciousness, autonomic dysfunction, respiratory depression, weakness, paralysis, and keraunoparalysis, a temporary paralysis specific to lightning injuries and characterized by blue, mottled and pulseless extremities.
• Renal injuries include rhabdomyolsis, which can lead to acute kidney failure, from an electrical shock or lightning strike. Musculoskeletal injuries include periosteal burns, acute compartment syndrome and tissue necrosis. Vascular injuries include delayed arterial thrombosis, aneurysm and rupture secondary to medial coagulation and necrosis.
• In assessing electrical injuries, external injury doesn’t predict internal injury. Burns are often ultimately much worse than they initially appear in the ED. “You could look great but that doesn’t mean there’s not an arrhythmia or acute kidney injury,” says Creagh. “Alternatively, you could have really bad third-degree burns and be perfectly fine.”
• Pediatricians who may come across multiple lightning victims should follow a reverse-triage approach with aggressive and prolonged CPR—in other words, first treat the patients who are pulseless and unresponsive. “You actually prioritize people who appear deceased,” says Creagh. “They’re probably not. It’s just that their entire system needs to be reset.”
• For patients without prolonged unconsciousness or cardiac arrest, the prognosis for recovery is excellent. People who experience low-voltage injuries with cardiac or respiratory arrest may recover completely with immediate CPR on the scene.

The take home message for pediatricians?

“If you’re a community pediatrician and someone comes to you after being electrocuted, do an immediate ECG and, if anything appears abnormal, immediately refer the patient to the ED,” he says. “If the ECG  looks totally normal for the age of the child, it’s generally OK to send the child home unless you have any doubts about what you’re seeing. Some patients may develop arrhythmias after a normal ECG.”