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Electrical injuries, guideline, paediatrics, RHCG (1085)

Objectives

Guidance for the assessment and management of electrical injuries in children and young people under 16

Audience

Medical and nursing staff caring for children presenting with electrical injuries. Emergency Medicine, PICU, Plastic Surgery, Cardiology

Presentation with electrical injury is rare and depending on the underlying voltage, injures can range from small cutaneous burns to significant internal organ damage and musculoskeletal injury.1 In the paediatric population 2 age peaks are seen; children under 6 years and adolescents aged between 13 to 18 years.1, 2 

Significant injuries are known to occur even in the absence of large burns or other obvious signs of external or internal injury.

A systematic literature review was performed to identify international standards and current clinical guidelines.3, 4, 5

Treatment algorithm

Treatment of electrical injuries algorithm (pdf for printing)

Definitions

Low Voltage

<1000V – usually from domestic power supply (UK domestic 230V, workshops 380V).

Alternating Current (AC) - causes tetany, patient “locked on” to source, increasing energy delivered to the body.

  • Cutaneous burns from contact points
  • Less likely to cause deep tissue injury
  • Cardiac arrhythmias with immediate cardiac arrest possible

 

High Voltage

 >1000V - Overhead power lines (38,000V) / Railway lines (15-25,000V)/ Lightning strike (10 to 100 millionV).

Direct Current (DC) - causes single muscle contraction, throwing patient from source increasing risk of trauma. Risk of significant deep tissue injury despite comparatively small cutaneous burn

  • Direct contact with source causes entrance/exit injuries and risk of significant injury.
  • Full thickness cutaneous burns, rhabdomyolysis, compartment syndrome, periosteal burns, osteonecrosis, myocardial damage and dysrhythmia.
  • Indirect contact with source causes Arc/flash injuries from nearby electrical discharge.
  • Can often be associated with trauma following falls or being thrown by the electrical discharge.

Important features of history

  • Nature of electricity
  • High/low voltage
  • Points and length of contact
  • Whether patient thrown from the source
  • Loss of consciousness- increase suspicion of HI or cardiac arrhythmia

Management of Low Voltage Injuries in the Emergency Department

ABCDE approach – unless suspicion of trauma

12 lead ECG – if abnormal follow management of high voltage injury- will require admission

Assessment and treatment of burns as per burns guideline (Note: Assess for burns at oral commissure in children – risk of sublingual haematoma)

Low voltage injuries can be considered for discharge if;

  • Absence of syncope
  • Normal 12 lead ECG
  • No secondary injuries requiring further management (burns or limb injuries etc.)
  • Safe location to be discharged to (e.g. Any concern of ongoing risk of injury at home)

*If does not meet above criteria discuss with senior decision maker for admission*

Management of High Voltage Injuries in the Emergency Department

  1. TRAUMA CALL + inform Plastic surgical SpR/Cons (prior to arrival of patient where possible)
  2. APLS approach

C-SPINE IMMOBILISATION

High index suspicion for spinal cord injury (convulsions/fall)

AIRWAY + BREATHING

Supplemental oxygen

Early senior anaesthetic review and consider intubation (uncut tube) if evidence airway burns

CIRCULATION

12 Lead ECG- non-specific ST changes, AF, VF/VT, asystole

Bedside ECHO if ECG abnormal

Continuous ECG monitoring

IV access and bloods – FBC, U+Es, bone profile, Mg, CK, troponin, myoglobin

IV fluid resuscitation - 0.9% NaCL target 1-1.5ml/kg/hr urine output

Urinary catheterisation

DISABILITY

GCS and hourly neuro obs

If GCS reduced consider head trauma, anoxia from arrhythmia, effect of electricity on brain

EXPOSURE

Assess extent of cutaneous burns – manage as per burns guideline

Full exposure including soles of feet and palms, looking for entry/exit points

Assess extremity injuries- fractures/dislocations

Assess for compartment syndrome – immediate plastics involvement for consideration of fasciotomies

Careful temperature management- low threshold for active temperature management above 39 degrees

Further management of High Voltage injuries

Imaging as indicated by findings of primary survey (note: small and large bowel most injured viscera with risk of abdominal compartment syndrome)

All require admission

For 24hr monitoring in Critical Care

Echo if not required in ED

6 hourly electrolytes/creatinine/CK

Special considerations – Notification of Concern

For all cases, regardless of high or low voltage injury, consider whether there is concern for the welfare of the child, whether there was suitable supervision, whether there is concern of future harm. If in doubt as to whether completing a notification of concern is appropriate please seek advice from a senior member of staff.

Editorial Information

Last reviewed: 31/05/2023

Next review date: 31/05/2026

Author(s): Dr Olivia Pittman (Emergency Medicine Trainee, RHC, Glasgow), Dr Helen Toner (Emergency Medicine Trainee, RHC, Glasgow). Correspondence author - Dr Marie Spiers (Consultant in Paediatric Emergency Medicine, RHC, Glasgow)..

Version: 1

Approved By: RHC ED Clinical Governance Group. Care of Burns in Scotland Steering Group

Document Id: 1085

References
  1. Spies C, Trohman RG. Narrative review: Electrocution and life-threatening electrical injuries. Annals of Internal Medicine. 2006 Oct 3;145(7):531-7.
  2. Czuczman AD, Zane RD, Cooper MA, Daley BJ. Electrical injuries: A review for the emergency clinician. Emergency Medical Practice. 2009;11(10):1-24.
  3. Arnoldo B, Klein M, Gibran NS. Practice guidelines for the management of electrical injuries. Journal of Burn Care & Research. 2006;27(4):439-47.
  4. Dechent D, Emonds T, Stunder D, Schmiedchen K, Kraus T, Driessen S. Direct current electrical injuries: A systematic review of case reports and case series. Burns. 2020;46(2):267-78.
  5. Perth Children’s Hospital. Electrical Injuries.  [Accessed June 21st 2022].