Originally published at Pediatric EM Morsels on February 17, 2017, updated on July 30, 2017. Reposted with permission.
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Children 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
- 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
- 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 anelectric appliance or mouthing the female end of aconnected 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]