Severe electrical burns

Electrical burn severity

Severity is determined by the voltage, current and type of current, duration of contact and resistance at contact points. High voltage electrical injuries (>1000Volts) meet the Victorian State Trauma System’s Major Trauma criteria. 

Low-voltage injuries 

Usually sustained in domestic (240V single phase AC) or industrial (415V 3 phase AC) settings. In general, low-voltage injuries are associated with localized areas of tissue destruction. 

High-voltage injuries

High-voltage electrical injuries occur as a result of contact with overhead powerlines and other sources of high-voltage electrical currents. High Voltage Electrical injuries tend to be characterized by deep, extensive tissue damage with three general patterns of injury: 

  • ‘true’ electrical injury caused by current flow 
  • electrical arc injury caused by the arc of current from source to object 
  • flame injury from the ignition of clothes etc 

High-voltage injuries are commonly associated with other traumatic injuries. 

How to treat electrical burns

The following considerations apply in the early management of a patient with an electrical injury

Cardiac monitoring

Electrical injuries may result in a variety of cardiac arrhythmias, including asystole and ventricular fibrillation which manifest very soon after injury. 

CPR should be initiated for those in cardiac arrest 

Aggressive Management of Myoglobinuria

Muscle damage can result in myoglobinuria and haemoglobinuria. These pigments can exacerbate acute renal failure. Prompt diuresis will help to protect against pigment deposition in the renal tubules and kidney damage. 

If pigment is evident in the urine, intravenous fluids should be increased to create a urine output of 75 – 100 mls/hr to ‘flush’ the kidneys. Diuretics may be required as an adjunct. 

Additional fluid resuscitation

Fluid resuscitation requirements in an electrical burn are usually more than that indicated by the extent of the cutaneous burn. Muscle damage that is not immediately evident can cause fluid loss which is not accounted for by the standard Parkland formula. It is important to always titrate fluid resuscitation according to urine output goals. 

Management of compartment syndrome

Patients with high-voltage electrical injuries are at risk of developing compartment syndrome. Damaged muscle swells and the high pressure within the investing fascia can obliterate blood flow and result in further muscle necrosis. 

  • Elevate affected areas to help to minimise swelling 

Signs of compartment syndrome:

  • ‘tight’ muscle compartments in limbs 
  • pain at rest 
  • increased pain on passive extension of digits 
  • decreased distal sensation 
  • decreased distal perfusion 

If multi-compartment fasciotomy is required, consult with Adult Retrieval Victoria and the appropriate Burn Service before proceeding