Dr. McCallister, an ED physician, thinks back to his childhood. Remember when I almost killed those two burglars when I got lost in New York? I should reach out to them. And why did I keep getting left places? Were my parents, like, super negligent? I never talked to them about that. Man, that bell-hop really looked like Rob Schneider. Was that Rob Schneider?
As he continues to drift off into the past, he recounts a particular moment from the burglary, when he electrocuted one of the burglars. Yet this time he ponders it from the standpoint of the physician he is today.
What are the mechanics behind electrical injury?
Electricity can flow in a DC (direct current) or AC (alternating current) circuit. DC is a direct flow of electrons, while in AC electrons change direction repeatedly at a certain frequency. All household circuits are AC, while examples of DC currents are the third rail in subways, power lines, or lightning. The reason this matters, if at all, is that AC current is more likely to cause dysrhythmia (i.e. ventricular fibrillation) and tetany resulting in the victim grasping the source and being unable to let go.
Does voltage matter?
High voltage injury is typically defined as anything above 1000V. Household electricity is typically at 120V or 240V, making it low voltage. Injury patterns differ depending on the voltage applied and duration of contact with the electrical source.
I think I used low voltage then turned it up to high voltage. What injuries did he likely sustain?
At low voltages, patients can still have cardiac dysrhythmias such as ventricular fibrillation. They may have respiratory arrest from chest wall muscle paralysis, and they will likely have superficial burns from any prolonged contact with the electricity if they have sustained tetany. At high voltages, patients are more likely to have asystole and deep thermal burns resulting in muscle, nerve and vascular damage; this, in turn, can lead to rhabdomyolysis and compartment syndrome. Mechanical trauma is also associated with electrical injury due to falls or violent muscle contractions.
Deep thermal burns
What work up and treatment would he need in the ED?
Management of high voltage injuries will follow ACLS and ATLS resuscitation guidelines. A thorough physical exam should be performed to evaluate for compartment syndrome, fractures, ruptured tympanic membranes, C-spine injury, and burns. Fluid resuscitation should follow guidelines for crush injuries rather than the Parkland formula.
Low voltage injuries will all require ECG, however testing beyond this will be based on patient’s symptoms. Basic lab testing including CK and UA to evaluate for rhabdomyolysis and myoglobinuria may be considered.
I wonder if he was sent home or admitted?
Patients with high voltage injuries should be transferred to a burn center after initial stabilization. Patients with low voltage injuries, no history of loss of consciousness, dysrhythmia, or serious injury requiring admission who also have a normal ECG may be discharged home.
Was that bell-hop really Rob Schneider?
Bailey, Caitlin. “Electrical and Lightning Injury” In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.newproxy.downstate.edu/content.aspx?bookid=1658§ionid=109412986. Accessed May 15, 2017.
Czuczman, Amanda and Richard Zane. “Electrical Injuries: A Review for the Emergency Clinician”. EB Medicine, Oct. 2009, Volume 11, Number 10. http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=423. Accessed May 15, 2017.