Electrical Injury

ElectricityChildren are often more susceptible to environmental exposures and injuries. We have previously discussed injuries related to submersions, heat-related illness and hyperthermia, thermal burn, and hypothermia. Essentially, no matter what environment a child is in, there is usually a potential hazard nearby.  One of the most ubiquitous potential hazards is electricity. Now let us take a minute to digest a morsel of information about Electrical Injury.

 

Electrical Injury: Voltage Matters

  • Electrical injuries and burns are a worldwide problem.
  • Most commonly affects small children and teenagers (as well as adults). [Glatstein, 2013]
    • Small children often encounter household electricity – so low voltage. [Arasli Yilmaz, 2015]
    • Teenagers (particularly males with poor decision making capacity due to high testosterone to common sense ratio) may expose themselves to high voltage outside of the home. [Arasli Yilmaz, 2015; Celik, 2004]
  • Tissue damage is dependent upon voltage, type of current, amperage, tissue resistance, and time of exposure.
  • In general, exposure to high voltage is associated with higher morbidity and mortality. [Arasli Yilmaz, 2015]
  • Low Voltage refers to electricity up to 1,000 Volts
    • Most frequent cause of electric burns.
    • Most often leads to minor injury and no serious complications.
  • High Voltage refers to > 1,000 Volts
    • Associated with greater risk of direct injuries from electrical charge.
    • Also associated with greater risk for related polytrauma.
    • May cause muscle tetany leading to patient’s inability to let go of electrical source.

 

Electrical Injury: Injuries

  • Injuries can range from minor to life-threatening.
  • All tissues can be affected by the electric current passing through them. [Arasli Yilmaz, 2015]
  • Cardiac arrest can occur due to exposure to high voltage
    • Cardiac arrhythmia
    • Diaphragm muscle paralysis
  • Cardiac conduction abnormalities
    • ST changes, heart blocks, prolonged QTc, SVT, and a-fib.
    • May evolve over time due to necrosis of the myocardium cardiac nodes, conduction pathways, or coronary arteries. [Arasli Yilmaz, 2015]
  • Tissue burn
    • Unlike thermal burns, visible appearance of necrosis may be misleading.
    • May only have small area involved on surface, but extensive injury exists.
    • Usually do not require skin-grafting: commonly partial thickness or less.[Alemayehu, 2014]
  • Compartment Syndrome from edema caused by local tissue injury.
  • Hepatic injury
  • Vasospasm
    • Delayed thrombosis or necrosis can occur.
    • Delayed aneurysm formation or hemorrhage may also happen.
  • Associated Injuries
    • Trauma related injuries from fall
    • Rhabdomyolysis from tissue destruction or compartment syndrome

 

Electric Injury: Evaluation

  • Low Voltage Exposure
    • Most often have only minor injuries (ex, superficial 1st degree burn).
    • If no concerning features (ex, prolonged exposure, wet skin, concerning medical history), do not benefit from extensive testing or hospitalization. [Arasli Yilmaz, 2015; Zubair, 1997]
    • ECGs are not likely to find any abnormalities and may not need to be mandatory. [Glatstein, 2013]
    • Personally, I have low threshold for ECG and short period of observation in ED.
  • High Voltage Exposure
    • ECG should be obtained.
    • Continuous cardiac monitoring is recommended if there is an abnormal ECG, concerning past medical history, or other concerning features (ex, prolonged exposure, wet skin, loss of consciousness).
    • Basic laboratory studies should include creatine kinase levels, renal function, LFTs, and urinalysis. [Arasli Yilmaz, 2015]
    • Need a thorough trauma evaluation, including FAST and Imaging as needed.
    • Wounds should be covered with sterile gauze and antibiotic ointment (unless you are transferring to a Burn Center, in which case discuss with accepting facility as they will often prefer only sterile gauze until they are able to see the wounds).
    • Indications to transfer to tertiary Burn Center are similar to thermal burns. [Glatstein, 2013]
  • Admission is encouraged for:
    • High voltage exposure
    • Presence of entry and exit wounds
    • Neurologic instability
    • Cardiovascular instability
    • Large area of burn
    • Burns that prevent adequate oral hydration

 

Electric Injury: Oral Burns

  • One unique entity that affects children (particularly < 5 years of age) is electrical burns due to bitting a live wire from an electric appliance or mouthing the female end of a connected extension cord. [Umstattd, 2016]
  • Injury pattern consists of burn to the oral commissure.
  • Can lead to poor outcomes, both functionally and aesthetically.
    • The low voltage nature of these injuries typically spares the deep tissues.
    • Can injury local labial artery and develop significant bleeding, even in a delayed fashion when scab sloughs off. [Zubair, 1997]

 

References

Umstattd LA1, Chang CW2. Pediatric Oral Electrical Burns: Incidence of Emergency Department Visits in the United States, 1997-2012. Otolaryngol Head Neck Surg. 2016 Jul;155(1):94-8. PMID: 27048673. [PubMed] [Read by QxMD]

Arasli Yilmaz A, Köksal AO, Özdemir O, Acar M, Küçükkonyali G, Inan Y, Çelik S, Güveloğlu M, Andiran N, Günbey S. Evaluation of children presenting to the emergency room after electrical injury. Turk J Med Sci. 2015;45(2):325-8. PMID: 26084122. [PubMed] [Read by QxMD]

Alemayehu H1, Tarkowski A2, Dehmer JJ1, Kays DW2, St Peter SD1, Islam S3. Management of electrical and chemical burns in children. J Surg Res. 2014 Jul;190(1):210-3. PMID: 24698499. [PubMed] [Read by QxMD]

Glatstein MM1, Ayalon I, Miller E, Scolnik D. Pediatric electrical burn injuries: experience of a large tertiary care hospital and a review of electrical injury. Pediatr Emerg Care. 2013 Jun;29(6):737-40. PMID: 23714758. [PubMed] [Read by QxMD]

Talbot SG1, Upton J, Driscoll DN. Changing trends in pediatric upper extremity electrical burns. Hand (N Y). 2011 Dec;6(4):394-8. PMID: 23204966. [PubMed] [Read by QxMD]

Celik A1, Ergün O, Ozok G. Pediatric electrical injuries: a review of 38 consecutive patients. J Pediatr Surg. 2004 Aug;39(8):1233-7. PMID: 15300534. [PubMed] [Read by QxMD]

Rabban JT1, Blair JA, Rosen CL, Adler JN, Sheridan RL. Mechanisms of pediatric electrical injury. New implications for product safety and injury prevention. Arch Pediatr Adolesc Med. 1997 Jul;151(7):696-700. PMID: 9232044. [PubMed] [Read by QxMD]

Zubair M1, Besner GE. Pediatric electrical burns: management strategies. Burns. 1997 Aug;23(5):413-20. PMID: 9426911. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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