3. Electrical Injury (and Lightning Strike)

Quick Recap

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👁️ The skin wound lies about what's happening underneath

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🩹 Don't forget concurrent trauma from the fall

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❤️ ECG in everyone, but monitoring duration depends on risk

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🚨 High-voltage injury can cause compartment syndrome WITHIN the muscle itself

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💧 Fluid resuscitation follows the same principle as burns - the visible wound underestimates the real injury

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👀 Refer even low-voltage injuries for follow-up

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✅ Bottom line

Environmental System, Protocol 3/4. Built on ATLS 11th Edition (2023).

1. Classification

High voltage (>=1,000V) vs low voltage (<1,000V) — the central classification determining risk profile and monitoring intensity. The body serves as an incidental conductor of electrical energy, and the heat generated from tissue RESISTANCE causes additional thermal injury — differential heat generation between superficial and deep tissues allows relatively NORMAL-APPEARING overlying skin to coexist with DEEP MUSCLE NECROSIS — this is the central diagnostic trap of electrical injury: the visible skin wound routinely and significantly underestimates the true extent of deep tissue damage.

2. Clinical Recognition

Severe electrical injuries usually result in ACUTE CONTRACTURE of the affected extremity (tetanic muscle contraction during current passage). A clenched hand with only a small electrical contact wound should alert the clinician that a deep soft-tissue injury is likely and fasciotomy is necessary — a specific, high-value pattern-recognition clue given how deceptively minor the surface wound can appear.

Electrical injuries are often associated with FALLS and frequently occur at work — actively screen for concurrent blunt trauma (see Polytrauma protocol, Trauma System) from the fall itself, not just the electrical injury in isolation. Forced muscle contraction can cause skeletal and muscular damage independent of the thermal injury mechanism.

High-voltage injury patients should be assessed for mechanical trauma including SPINAL COLUMN AND SPINAL CORD INJURIES — the violent tetanic contraction itself can cause fractures/dislocations, warranting the same spinal motion restriction and workup principles as the Spinal Injury protocol (Trauma System).

Muscle injury can occur with FEW OUTWARD SIGNS — reinforcing the same underestimation principle established in Section 1; do not let a benign-appearing exam reassure against significant internal injury.

3. Immediate Stabilization (ABCDE)

Circulation — cardiac monitoring:

ECG in ALL patients as an adjunct to physical assessment.
Patients with NO loss of consciousness, minimal wound burden, and a NORMAL ECG may be safely discharged after LOW-voltage injury.
Prolonged cardiac monitoring reserved for: severe burn (deep and/or extensive), loss of consciousness, HIGH-voltage exposure (>=1,000V), or cardiac rhythm abnormalities on initial ECG.
Any patient with electrical injury who develops signs of AKI/renal failure should have a 12-lead ECG and continuous monitoring — the renal complication itself (Section 4) is a trigger for escalated cardiac surveillance, not just the electrical exposure alone.

Compartment syndrome — actively anticipate, do not wait for late signs:

Serially assess for compartment syndrome; electrical burns may necessitate fasciotomies — apply the same signs (pain out of proportion, pain on passive stretch, tense swelling, paresthesias) and "pulse loss is a LATE finding — do not wait for it" principle established in the Crush Injury and Acute Limb Ischemia protocols.
For high-voltage electrical injury specifically, compartment syndrome may develop WITHIN THE MUSCLE FASCIA COMPARTMENT itself — muscle compartment fasciotomy is necessary in this scenario, distinct from (though overlapping with) the general limb compartment syndrome framework.
A careful approach to pain management is necessary given pain out of proportion is a hallmark finding — AVOID regional anesthesia where possible in at-risk patients, since it can mask the evolving compartment syndrome signal (same principle as the Crush Injury protocol).

Checklist:

Voltage classification (high vs low, >=1,000V threshold) established

ECG obtained in ALL patients; prolonged monitoring applied per the specific criteria above

Concurrent blunt trauma from an associated fall actively screened for

Spinal injury workup pursued for high-voltage exposure given tetanic-contraction fracture/dislocation risk

Compartment syndrome serially assessed, with awareness it may occur WITHIN the muscle fascia specifically in high-voltage injury

Regional anesthesia avoided where compartment syndrome risk is present

Visible wound severity NOT used to estimate the true extent of deep tissue injury

4. Rhabdomyolysis and Renal Complications

Rhabdomyolysis from electricity traveling through muscle causes myoglobin release, risking AKI/renal failure (see the dedicated Rhabdomyolysis protocol, Renal System, for the full electrolyte/monitoring management framework).

If urine is DARK RED, assume hemochromogens are present; test for myoglobin to confirm where possible.

Fluid resuscitation calculation for electrical burn injury: 4 mL/kg/%TBSA — because visible surface injury GROSSLY UNDERESTIMATES the extent of deeper injury, this formula is applied even when the visible burn appears limited, mirroring the general burn Parkland-formula principle (see Burns protocol, Trauma System) but specifically adapted to account for electrical injury's deceptive surface appearance. As with thermal burns, divide by 16 to obtain the hourly rate.

Urine output targets are HIGHER when red-pigmented (myoglobinuric) urine is present: 100 mL/h in adults, 2 mL/kg/h in children (vs the standard 0.5 mL/kg/h burn resuscitation target) — once urine clears of red pigmentation, titrate fluids down to standard urine output targets. This elevated-target approach mirrors the general rhabdomyolysis management principle of promoting urinary flow to reduce myoglobin cast nephrotoxicity.

5. Investigations

ECG (mandatory in all patients), continuous cardiac monitoring per the criteria in Section 3, urine dipstick/myoglobin testing (dark red urine), CK trend, renal function, electrolytes (potassium, given rhabdomyolysis and cardiac arrhythmia risk), CT/imaging for concurrent trauma if a fall occurred, spinal imaging for high-voltage exposure, compartment pressure measurement if exam is unreliable or compartment syndrome is strongly suspected but not clinically obvious.

6. Lightning Injury — A Distinct High-Voltage Subtype

Lightning strikes are categorized alongside high-voltage electrical injury for transfer/consultation purposes (Section 7) — the massive, near-instantaneous energy discharge carries similar cardiac arrhythmia and multi-system injury risk to high-voltage contact injury, though the current pathway/duration characteristics differ (typically a brief flashover rather than sustained current passage). Apply the same ECG, monitoring, and compartment syndrome vigilance principles.

7. Burn Center Transfer Criteria (American Burn Association)

All HIGH-VOLTAGE (>=1,000V) electrical injuries and ALL lightning injuries warrant burn center consultation with strong transfer consideration.

Low-voltage (<1,000V) electrical injuries should still receive consultation and consideration for FOLLOW-UP at a burn center — specifically to screen for DELAYED symptom onset and vision problems (cataracts are a recognized delayed complication of electrical injury, particularly with current passage near the head/eyes), even when the acute presentation appears reassuring.

This mirrors the general Burns protocol's (Trauma System) referral framework, with electrical injury carrying its own specific listed criterion within that broader transfer decision structure.

8. Organ Support

Continuous cardiac monitoring per the risk-stratified criteria; aggressive fluid resuscitation targeting elevated urine output when myoglobinuria present (mirroring Rhabdomyolysis protocol principles); fasciotomy (including intramuscular-compartment-specific fasciotomy for high-voltage injury) per compartment syndrome assessment; standard ICU supportive care; RRT per standard AKI indications if renal failure develops.

9. Consultation Matrix

Consultation	Trigger	Timing
Burn Surgery/Burn Center	All high-voltage injury, lightning injury; consultation for all low-voltage injury	Immediate for high-voltage/lightning; timely for low-voltage
Orthopedic/Trauma Surgery	Compartment syndrome, concurrent fall-related trauma	Immediate
Cardiology	Significant arrhythmia, abnormal ECG requiring extended monitoring	As indicated
Ophthalmology	Delayed cataract screening, especially with head/eye current pathway	Follow-up, not necessarily acute

10. Monitoring Framework

Continuous ECG per the risk-stratified criteria, serial compartment/neurovascular limb exam, serial CK/myoglobin/renal function, urine output and color trend (targeting the elevated 100 mL/h adult goal while myoglobinuric), electrolytes (especially potassium).

11. Complications

Cardiac arrhythmia (immediate or delayed), compartment syndrome (including intramuscular, high-voltage-specific), rhabdomyolysis/AKI, concurrent blunt trauma from an associated fall, spinal fracture/dislocation from tetanic contraction, delayed cataracts, delayed neurologic complications. Prevention: universal ECG screening with risk-stratified monitoring duration, proactive compartment syndrome surveillance with a low threshold for fasciotomy, elevated urine output targets when myoglobinuria present, appropriate burn center consultation even for low-voltage injury given delayed-complication risk. Rescue: fasciotomy (including intramuscular compartment release), standard rhabdomyolysis/AKI management, standard arrhythmia management.

12. Escalation & De-escalation

Escalate: compartment syndrome signs (including intramuscular, high-voltage-specific) -> emergent fasciotomy; myoglobinuria -> elevated urine output target fluid resuscitation.

De-escalate: low-voltage injury with no LOC, minimal wound burden, normal ECG -> safe for discharge (with burn center follow-up consultation for delayed symptom/vision screening); high-voltage injury with normal monitoring period and no compartment syndrome -> standard step-down monitoring.

13. ICU Discharge Criteria

Cardiac monitoring period completed without arrhythmia, no ongoing compartment syndrome concern, myoglobinuria resolved with urine output targets normalized, renal function stable, concurrent trauma addressed, burn center follow-up arranged for delayed complication screening.

14. Documentation & Medicolegal Checklist

Voltage classification (high vs low, lightning) documented

ECG and monitoring duration rationale documented per the risk-stratified criteria

Concurrent trauma/fall screening documented

Compartment syndrome assessment documented, noting the intramuscular-specific risk in high-voltage injury

Fluid resuscitation calculation (4mL/kg/%TBSA) and elevated urine output target (if myoglobinuric) documented

Burn center consultation documented, including for low-voltage injury given delayed complication risk

15. Key Guidelines

American College of Surgeons. Advanced Trauma Life Support, 11th Edition Course Manual, 2023 (Chapter 9: Thermal Injuries, Electrical Injury section; Chapter 10: Musculoskeletal Trauma, Compartment Syndrome and Crush Syndrome sections).

16. Controversies

The precise monitoring duration for high-voltage injury without initial ECG abnormality is not rigidly standardized across sources, and institutional practice varies within the general "prolonged monitoring for high-voltage exposure" principle. The threshold for prophylactic vs reactive fasciotomy in high-voltage injury with equivocal compartment findings involves clinical judgment given the difficulty of assessing deep intramuscular compartments non-invasively.

17. References

American College of Surgeons. Advanced Trauma Life Support, 11th Edition Course Manual, 2023 (Chapter 9, Chapter 10).

See also: Burns (Trauma System) for the general burn/TBSA fluid resuscitation and burn center referral framework this protocol adapts; Rhabdomyolysis (Renal System) for the full myoglobinuria/AKI management detail; Crush Injury and Acute Limb Ischemia (Trauma/Vascular Systems) for the shared compartment syndrome recognition and fasciotomy principles; Spinal Injury (Trauma System) for the concurrent tetanic-contraction fracture/dislocation workup.