Ep 125 Electrical Injuries – The Tip of the Iceberg

This is Part 2 of EM Cases main episode podcast on Burn, Inhalational and Electrical Injuries. In Part 1 Dr. Joel Fish and Dr. Maria Ivankovic and Anton discussed wound care, resuscitation and airway management of the burn and inhalation injury patient, with a segment on awake intubation by George Kovacs. Electrical injuries are rare, representing less than 1% of burn center admissions. So there is a paucity of robust evidence for the management of these patients. Nonetheless, in this podcast we’ll give you the tools to help risk stratify electrical injuries, give some guidance on fluid resuscitation, describe immediate management of acute complications and make you aware of the potential delayed complications that must be anticipated. We will answer questions such as: When you see a skin lesion after an electrical injury, the tip of the iceberg, how can you predict clinically what kind of iceberg lies beneath the skin? How are lightning strike injuries different than household or industrial electrical injuries when it comes to potential injuries and management? What are the immediate life-threats that we need to know how to identify and manage in the first hour? How do you best workup the cardiac complications of electrical injuries? Which patients with electrical injuries need cardiac monitoring? And how long do you need to observe patients in the ED for? Are there any good admission criteria for electrical injury patients? How is fluid management different for the patient with a scalding burn or inhalational injury as opposed to electrical injury? And what are the important potential delayed injuries that we need to aware of before sending a patient home after an electrical injury, and many more... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Lorraine Lau, edited by Anton Helman June, 2019 Cite this podcast as: Helman, A. Electrical Injuries - The Tip of the Iceberg. Emergency Medicine Cases. June, 2019. https://emergencymedicinecases.com/electrical-injuries. Accessed [date] Go to part 1 of this 2-part podcast on burn, inhalational, and electrical injuries As discussed in the previous episode, one of the most important principles to remember with any burn or electrical injury patient is that they are a trauma patient first. Follow your primary and secondary survey as you normally would for any trauma, and only then attend to the burns and electrical injuries. There is no way to clearly measure the extent of injury and internal damage caused by electrical injuries. This is an “iceberg injury” – what you see may not be what you get. You may find yourself "fighting the invisible enemy". Be vigilant and suspicious of physical findings that don’t quite fit the clinical picture. Risk stratification of electrical injuries Factors that help predict the extent of the injury include: * Voltage * AC or DC * Duration of contact and * Degree of wetness/humidity of the environment. Low voltage (<600V) such as household or office exposures are generally lower risk injuries. High voltage (>600V) such as industrial setings, subway rails, power lines are generally higher risk injuries. Alternating Current (AC) causes prolonged contraction and release of muscle preventing full release from electrical source and hence longer duration of contact and more tissue damage compared to direct Current (DC). Lightning strikes (up to 1 billion V) are DC with very brief contact (milliseconds) with surprisingly high survival rates of 70-90%, but up 80% of survivors sustain long-term morbidity.