Case of the Month
January 2007

43-year-old male, electrical shock

Dispatch
"Engine 2, Medic 14 to a 43-year-old male, electrical shock"

En route your crew discusses the following considerations:

• Scene safety -  is there an electrical threat to the crew?
• Entry and exit wounds
• Cardiac considerations

While en route the dispatcher advises that the patient is conscious, but feels lightheaded. 

Scene Size-up
You arrive at the scene of a single family home. The garage door is open and a woman is waving you over to the patient. The patient is sitting on the floor of the garage, near an open electrical panel. It appears he has been working on the panel as some wires are hanging out of it. There are no wires on the ground; however, the patient is near the exposed wires hanging from the panel.

Initial Assessment
As you reach the patient’s side you notice his skin is mildly pale and moist. His breathing is somewhat rapid and he seems anxious. You immediately move him away from the panel, being careful of the exposed wires. It appears he has a burn on the palm of his left hand.  He complains of pain in his left hand and in his right foot.  He also complains of a vague discomfort throughout his body. 
Your partner completes an initial assessment:

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?

• Types of treatment needed for this patient
• Further steps for evaluation
• Consideration of the need for ALS care

Initial Treatment
You decide that the patient is SICK based on the mechanism of the injury, skin signs and a rapid, irregular heart rate. High flow oxygen and obtaining an event history become the priority. The ALS unit is updated via radio.  
You apply a non-rebreathing mask at 12 liters per minute and continue your assessment. 

Physical Exam
Your partner gives you the following information:

Event History
The patient states that he was wiring a new circuit for his oven. He exposed a 220 volt wire in preparation of attaching it to a breaker. He slipped and began to fall. Instinctively he tried to stop his fall and grabbed a hot wire. He said he could feel the shock, but could not let go of the wire. He believes he sustained current for about three to five seconds. At first it was difficult to breath, but that has subsided. He now feels anxious and has discomfort in his hand and foot.

SAMPLE

Second Set of Vital Signs

Further Evaluation and Treatment
Once vitals and oxygen are addressed your team focuses on secondary exam and wound care. The hand and foot are fully exposed and bandaged with dry dressings.  Attention is given to the possibility of other electrical exit wounds and fractures caused by muscular contractions. The neck and spine are also given special attention. No other injuries are found or suspected and the crew updates the responding ALS unit. Upon arrival the ALS unit places the patient on a heart monitor and discovers he is in atrial fibrillation. An IV line is started and the patient is transported to the hospital without incident. 

A Few Words About Electrical Injuries
Electrical injuries account for about 20,000 emergency department visits a year and about 1000 deaths. 60% of these incidents are caused by low voltage contacts (less than 500 volts). Low voltage exposures carry a very low mortality; however can still result in serious injuries.  As would be expected, high voltage contacts are more likely to result in serious electrical burns (both external and internal), compartment syndrome, cardiac arrhythmias, and sudden death by cardiac or respiratory arrest, among other serious issues.

Severity of injury is only partially determined by the voltage of the shock. Some of the other factors that influence degree of injury include:

• Duration of contact
• Entry and exit points
• Physiology of the individual
• Moisture level of the skin at the contact point
• Type of current (alternating [AC] vs. direct [DC])

Do not change your treatment due to the duration of the contact, the voltage level or any other factor; patient care should be based on the presentation of the patient. All patients must be evaluated and treated with the following in mind:

• Removal to a safe location
  • Scene safety is paramount — do not become a victim yourself — no not touch an energized patient!
• ABC’s
• Neck and Spine precaution
  • Electrical injuries are often accompanied by falls, and occasionally by contraction fractures
• Oxygen therapy may ease cardiac dysrhythmias
• Cardiac monitoring
• Wound treatment
  • Burns at the entry and exit points
• Pain Management
• Rapid transport to an appropriate facility
  • Not all hospitals are well versed in the treatment of electrical injuries.  Strongly consider transport to a Trauma or Burn center.

A good history of the event, including voltage, amperage, duration of contact and current type (AC vs. DC), may help the receiving medical facility in determining their treatment plan, however this fact finding should not slow the patient’s care or transport if they are Sick.

More information about electrical injuries can be found at the websites below.

View more information on electrical burns
eMedicine.com (external link)

View more information on electrical injuries
nlm.nih.gov (external link)

View more information on electrical injuries
merck.com (external link)