Electrical Injury

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 submersionsheat-related illness and hyperthermiathermal 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 QTcSVT, 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 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]

 

References

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]

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US Probe: Ultrasound for Shoulder Dislocation and Reduction

Written by: Jacqueline Tin MD, Cailey Simmons MD, Jared Ditkowsky MD (Emergency Resident Physicians, Icahn School of Medicine at Mount Sinai), Stephen Alerhand, MD (@SAlerhand – Instructor of EM and Ultrasound Fellow, Icahn School of Medicine at Mount Sinai)  // Edited by: Manpreet Singh, MD (@MPrizzleER – Assistant Professor in Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center)

CASE

23 year-old female with a history of prior shoulder dislocations presents to the ED after sustaining a shoulder injury while playing basketball earlier in the day. The patient reports she was going up for a rebound with her harm outstretched overhead. She heard her shoulder pop and was immediately unable to move her shoulder due to pain.

Physical exam is remarkable for deformity and tenderness at the right shoulder joint. Her arm is held in abduction and external rotation.

You are concerned for an anterior shoulder dislocation. You prepare the room for conscious sedation, with all the medications, protocols, and checklists at the ready. Then you call over one physician to administer the ketamine and monitor the cardiopulmonary status, another physician to assist you in physically relocating the shoulder, and a nurse to assist with medications and keep a timesheet.

The ketamine is administered and you wait for the patient’s dissociation. Somewhat surprisingly, it takes more ketamine that expected to achieve the required condition, during which time the patient has a brief period of apnea requiring your colleague to perform a jaw-thrust. Eventually, you attempt to reduce the shoulder, and after awhile of pulling and tugging, you think that the shoulder might be back in—but you are not sure.

WHAT NOW?

You have two options:

  1. Wait for the sedation to wear off and send the patient around the corner to x-ray (or perform a portable x-ray).
    • If reduced, great.
    • If not reduced, then you (and your colleagues) have to repeat the whole time-consuming and potentially dangerous process all over again.
  2.  ULTRASOUND!

INTRODUCTION/ANATOMY

The glenohumeral joint is comprised of a shallow ball-in-socket articulation with a large range of motion and minimal tendinous support on its inferior aspect; consequently, it is prone to dislocation. Comprising about 50% of major joint dislocations and 200,000 ED visits each year, glenohumeral dislocation is a common patient presentation to the ED (1-3). The incidence of anterior shoulder dislocation far outweighs that of posterior. While anterior dislocations are generally caused by a force pushing the humeral head inferior to the glenoid fossa, posterior dislocations are generally due to internal rotation and adduction (i.e. caused by trauma, electrical shock and seizure) (4).

Typically, plain film radiography is utilized to diagnose shoulder dislocation and evaluate for fractures. However pre-reduction radiographs may be unnecessary if fracture risk is low (i.e., young age, history of multiple dislocations, atraumatic mechanism). Relative to radiography, POCUS potentially allows for greater diagnostic efficiency, improved accuracy for detection, and a decreased error rate (5-9). In a prospective observational study of 73 patients, POCUS was 100% sensitive and specific for the diagnosis of dislocation (3). Furthermore, POCUS can be used to help guide intra-articular anesthetic injections (10), and evaluate whether attempts at reduction have been successful in real time.

APPROACH

• Stand behind the patient’s affected shoulder.
• Support the patient’s elbow inferiorly while the humerus is in adducted position.
• Find the scapular spine and palpate laterally just until you reach the glenohumeral space.
• Place curvilinear probe (or high frequency linear-array probe, depending on patient habitus) in transverse position parallel and just inferior to the scapular spine with probe marker to patient’s left


• Continue to move laterally until you find the glenoid and have a good view of the humeral head. You may need to adjust the depth so that both glenoid and humeral head are well visualized.

With the probe, consider giving an intra-articular lidocaine injection for pain control. This approach involves localizing the glenoid and humeral head. Sterilize the skin overlying the probe, place local anesthetic with small bore needle. Next, using the ultrasound transducer in long axis if in plane view, guide a 20G spinal needle into the joint space. Inject approximately 20 cc lidocaine 1% and wait 10-20 minutes before proceeding with reduction (2,5,10).

Video demonstration of intra-articular injection injection (courtesy of Brown EM): https://youtu.be/nMWzK0QNFxw

FINDINGS

The humeral head will appear as a circular structure immediately lateral to the glenoid fossa (see figure A). If the shoulder is not dislocated, the patient should freely internally and externally rotate the arm while adducted and movement of the humeral head in the glenoid fossa should be clearly visualized (7).


.
With anterior dislocations, the humeral head will be seen deeper on the screen.


.
Posterior dislocations will appear more superficial on the screen as the dislocation is closer to the probe. (see figure B). Further, there may be some hyperechoic area suggesting hemarthrosis when there is a shoulder dislocation (5,6).

Video on POCUS in shoulder dislocations (courtesy of MGH US): https://www.youtube.com/watch?v=duUlvLTwCY4

CONCLUSION

POCUS is a valuable tool to aid in the diagnosis and management of shoulder dislocation. From preliminary studies, POCUS can be used to reliably diagnose dislocation, aid in intra-articular joint injections, and confirm successful relocation.

References

1. Wolfson AB, Hendey GW, Ling LJ, Rosen CL, Schaider JJ, Sharieff GQ. Harwood-Nuss’ Clinical Practice of Emergency Medicine. Lippincott Williams & Wilkins; 2012.
2. Marx, John A, Robert S. Hockberger, Ron M. Walls, Michelle H. Biros, Daniel F. Danzl, Marianne Gausche-Hill, Andy Jagoda, Louis Ling, Edward Newton, Brian J. Zink, and Peter Rosen. Rosen’s Emergency Medicine: Concepts and Clinical Practice. , 2014. Chapter 53, 618-642.e2
3. Gottlieb M, Russell F. Diagnostic Accuracy of Ultrasound for Identifying Shoulder Dislocations and Reductions: A Systematic Review of the Literature. Western Journal of Emergency Medicine. 2017;18(5):937-942. doi:10.5811/westjem.2017.5.34432.
4. Kowalsky MS, Levine WN. Traumatic posterior glenohumeral dislocation: classification, pathoanatomy, diagnosis, and treatment. Orthop Clin North Am. 2008;39(4):519-33-viii.
5. Abbasi S, Molaie H, Hafezimoghadam P, et al. Diagnostic accuracy of ultrasonographic examination in the management of shoulder dislocation in the emergency department. Ann Emerg Med. 2013:1-6.
6. Beck S, Chilstrom M. Point-of-care ultrasound diagnosis and treatment of posterior shoulder dislocation. Am J Emerg Med. 2013;31(2):449.e3-449.e5.
7. Blakeley CJ, Spencer O, Newman-Saunders T, et al. A novel use of portable ultrasound in the management of shoulder dislocation. Emerg Med J. 2009;26(9):662-663.
8. Kowalsky MS, Levine WN. Traumatic posterior glenohumeral dislocation: classification, pathoanatomy, diagnosis, and treatment. Orthop Clin North Am. 2008;39(4):519-33-viii.
9. Weishaupt, D., Berbig, R., Prim, J., & Brühlmann, W. (1997). Sonographische Befunde nach Schulterluxation. Ultraschall in der Medizin, 18(03), 129-133
10. Emergency Ultrasound: Musculoskeletal Shoulder Dislocation. Emergency March;48(3):128-129- Author(s): Jehangir Meer, MD Sierra Beck, MD Todd Taylor, MD – http://www.mdedge.com/emed-journal/article/107209/imaging/emergency-ultrasound-musculoskeletal-shoulder-dislocation

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The EM Educator Series: Post-Partum Complications…

Author: Alex Koyfman, MD (@EMHighAK) // Editor: Brit Long, MD (@long_brit)

Welcome to this week’s EM Educator Series. These posts provide brief mini-cases followed by key questions to consider while working. The featured questions provide important learning points for those working with you, as well as vital items to consider in the evaluation and management of the specific condition discussed. This post discusses several components of sepsis evaluation and management in the ED, followed by key references.

 

Mini-case #2: I’m post-partum and don’t feel right

A 25-year-old female two weeks post-partum presents with vision changes, severe headache, and right upper quadrant pain. She is hypertensive and appears in pain.

 

Considerations:

1) Post-partum complications presenting to ED setting: red flags to look for

2) Identification and management of pre-eclampsia / eclampsia

3) Identification and management of peripartum cardiomyopathy

4) Are postpartum patients at higher risk for venous thromboembolic disease? The thoughtful approach and work-up.

5) Infectious diseases affecting the post-partum patient

 

Suggested resources:

http://www.emdocs.net/hellp-pregnancy-complications-postpartum-period/

1) Pre-eclampsia/eclampsia

http://www.emdocs.net/preeclampsia-and-eclampsia-common-pitfalls-in-diagnosis-and-management/

https://coreem.net/podcast/episode-113-0/

https://coreem.net/core/preeclampsia-and-eclampsia/

2) Peripartum cardiomyopathy

https://lifeinthefastlane.com/ccc/peripartum-cardiomyopathy/

https://wikem.org/wiki/Peripartum_cardiomyopathy

3) Thromboembolic disease

http://www.emcurious.com/blog-1/2014/10/2/pulmonary-embolism-in-pregnancy

https://emergencymedicinecases.com/episode-7-medical-and-surgical-emergencies-in-pregnancy/

http://blog.ercast.org/pulmonary-embolism-in-pregnancy/

4) Infectious

http://www.emdocs.net/hellp-pregnancy-complications-postpartum-period/

http://www.emdocs.net/postpartum-endometritis-ed-setting-presentation-evaluation-management/

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