Diferencia entre revisiones de «Electrical injuries»

Sin resumen de edición
Sin resumen de edición
Línea 22: Línea 22:
==Clinical Features==
==Clinical Features==
===Immediate Effects===
===Immediate Effects===
#Cardiac dysrhythmias
#[[Cardiac dysrhythmias]]
#Respiratory arrest
#[[Respiratory arrest]]
#Seizures
#[[Seizures]]


===Cardiac Dysrhythmias===
===[[Cardiac Dysrhythmias]]===
#Fatalities due to asystole or V-fib usually occur prior to arrival
#Fatalities due to [[asystole]] or [[V-fib]] usually occur prior to arrival
##Most common dysrrhythmia at presentation is A-fib (V-fib is more common, but pts are dead PTA)
##Most common [[dysrrhythmia]] at presentation is [[A-fib]] ([[V-fi]]b is more common, but pts are dead PTA)
##Asymptomatic pts w/ normal ECGs do not develop later dysrhythmias after <1000V injuries
##Asymptomatic pts w/ normal [[ECGs]] do not develop later dysrhythmias after <1000V injuries


===Cardiovascular Injury===
===Cardiovascular Injury===
Línea 36: Línea 36:
##Aneurysm formation
##Aneurysm formation
#Coagulation necrosis of small vessels
#Coagulation necrosis of small vessels
##Can lead to compartment syndrome
##Can lead to [[compartment syndrome]]


===CNS Injury===
===CNS Injury===
#Occurs in 50% of pts w/ high-voltage injuries
#Occurs in 50% of pts w/ high-voltage injuries
#Brain injury ranges from transient LOC to CVA to respiratory arrest
#Brain injury ranges from transient LOC to [[CVA]] to [[respiratory arrest]]
#High voltage injuries involving head are frequently associated with coma and persistent vegetative state
#High voltage injuries involving head are frequently associated with coma and persistent vegetative state


===Orthopedic Injury===
===Orthopedic Injury===
#Forceful muscle contractions can cause fx and joint dislocations (especially shoulder)
#Forceful muscle contractions can cause [[fracture]] and [[joint dislocations]] (especially shoulder)
##May occur with voltages as low as 120V
##May occur with voltages as low as 120V
#Compartment Syndrome
#[[Compartment Syndrome]]
##Usually a/w high-voltage injuries
##Usually a/w high-voltage injuries
##May occur even with 120V shocks if contact is sustained for longer than few seconds
##May occur even with 120V shocks if contact is sustained for longer than few seconds
##Pt experiences ongoing muscle pain with movement
##Pt experiences ongoing muscle pain with movement
##Need for fasciotomy predicted by:
##Need for [[fasciotomy]] predicted by:
###Myoglobinuria
###Myoglobinuria
###Burns >20% BSA
###Burns >20% BSA
###Full-thickness burn >12% BSA
###Full-thickness [[burn]] >12% BSA
#Rhabdomyolysis
#[[Rhabdomyolysis]]
##Associated with:
##Associated with:
###Contact with >1000V
###Contact with >1000V
###Prehospital cardiac arrest
###Prehospital [[cardiac arrest]]
###Crush injury
###[[Crush injury]]
###Compartment syndrome
###[[Compartment syndrome]]
###Full-thickness skin burns
###Full-thickness skin [[burns]]


===Ocular Injury===
===Ocular Injury===
Línea 70: Línea 70:
#Check hearing in all pts
#Check hearing in all pts


===Cutaneous Burns===
===Cutaneous [[Burns]]===
#Often seen at electrical contact areas
#Often seen at electrical contact areas
##Seriously injured pts often have burns on either arm or skull + feet
##Seriously injured pts often have burns on either arm or skull + feet
Línea 82: Línea 82:
==Treatment==
==Treatment==
#Usual trauma evaluation and resuscitation applies
#Usual trauma evaluation and resuscitation applies
#Use Parkland formula as starting point for fluid resuscitation
#Use [[Parkland formula]] as starting point for [[fluid resuscitation]]
#Treat rhabdo and compartment syndrome in usual manner
#Treat [[rhabdo]] and [[compartment syndrome]] in usual manner
##If RBCs and/or myoglobin in UA, urine should be alkalinized at minimum of 2 cc/kg/hr until pigments eliminated<ref>Brandt CP, Yowler CJ, Fratianne RB. MetroHealth Medical Center Burn ICU Handbook (Not a policy manual), Cleveland, OH.</ref>
##If RBCs and/or myoglobin in UA, urine should be alkalinized at minimum of 2 cc/kg/hr until pigments eliminated<ref>Brandt CP, Yowler CJ, Fratianne RB. MetroHealth Medical Center Burn ICU Handbook (Not a policy manual), Cleveland, OH.</ref>
##Mannitol should be given early to prevent renal tubular damage
##[[Mannitol]] should be given early to prevent renal tubular damage
##High voltage injuries to the hand frequently require carpal tunnel decompression as soon as pt is stable for OR
##High voltage injuries to the hand frequently require carpal tunnel decompression as soon as pt is stable for OR


Revisión del 10:35 8 sep 2014

Background

  1. Tissue damage occurs via electrical energy, heat, and mechanical injury from trauma
    1. Skin, bone, tendon all have very high resistance
    2. Muscle, nerves, vasculature have lower resistance, more often damaged
  2. Types:
    1. Low-Voltage
    2. High-Voltage (>1000V), seen in industrial settings or transmission line injuries
      1. Associated with electrical burns
    3. Electric Arc
      1. Associated with high voltage sources
      2. May radiate enough heat to burn persons 10ft or more away from the arc
      3. Blast force may result in trauma
  3. Burn from biting an electric cord assoc w/ delayed labial bleeding (5d later) in ~10% of peds
  4. Direct (lightening) vs. alternating (household) current
    1. Alternating has combination of the following mechanisms
      1. Current arcs onto body, envelops surface of body, then arcs to lower electromotive potential (ground)
      2. Current flows through body tissues
    2. Direct current most often demonstrates flow-over phenomenon
      1. Lightening can reach 1-5 million volts, but current flows over the body and exits to the ground
      2. May result in little tissue damage, but cardiac dysrrhythmias are still of great concern

Clinical Features

Immediate Effects

  1. Cardiac dysrhythmias
  2. Respiratory arrest
  3. Seizures

Cardiac Dysrhythmias

  1. Fatalities due to asystole or V-fib usually occur prior to arrival
    1. Most common dysrrhythmia at presentation is A-fib (V-fib is more common, but pts are dead PTA)
    2. Asymptomatic pts w/ normal ECGs do not develop later dysrhythmias after <1000V injuries

Cardiovascular Injury

  1. Contraction band necrosis[1]
  2. Medial necrosis of large vessels
    1. Aneurysm formation
  3. Coagulation necrosis of small vessels
    1. Can lead to compartment syndrome

CNS Injury

  1. Occurs in 50% of pts w/ high-voltage injuries
  2. Brain injury ranges from transient LOC to CVA to respiratory arrest
  3. High voltage injuries involving head are frequently associated with coma and persistent vegetative state

Orthopedic Injury

  1. Forceful muscle contractions can cause fracture and joint dislocations (especially shoulder)
    1. May occur with voltages as low as 120V
  2. Compartment Syndrome
    1. Usually a/w high-voltage injuries
    2. May occur even with 120V shocks if contact is sustained for longer than few seconds
    3. Pt experiences ongoing muscle pain with movement
    4. Need for fasciotomy predicted by:
      1. Myoglobinuria
      2. Burns >20% BSA
      3. Full-thickness burn >12% BSA
  3. Rhabdomyolysis
    1. Associated with:
      1. Contact with >1000V
      2. Prehospital cardiac arrest
      3. Crush injury
      4. Compartment syndrome
      5. Full-thickness skin burns

Ocular Injury

  1. Cataract formation has been described weeks to years after electrical injury
    1. Document presence or absence of cataracts following all electrical injuries

Auditory Injury

  1. May be damaged by current or hemorrhage
  2. Check hearing in all pts

Cutaneous Burns

  1. Often seen at electrical contact areas
    1. Seriously injured pts often have burns on either arm or skull + feet
  2. Most pts w/ burns from electrical injury require admission and care by burn specialist

GI Injury

  1. Suspect in pts with:
    1. Electrical burns of abdominal wall
    2. History of a fall, nearby explosion, or other mechanical trauma

Treatment

  1. Usual trauma evaluation and resuscitation applies
  2. Use Parkland formula as starting point for fluid resuscitation
  3. Treat rhabdo and compartment syndrome in usual manner
    1. If RBCs and/or myoglobin in UA, urine should be alkalinized at minimum of 2 cc/kg/hr until pigments eliminated[2]
    2. Mannitol should be given early to prevent renal tubular damage
    3. High voltage injuries to the hand frequently require carpal tunnel decompression as soon as pt is stable for OR

Disposition

  1. Discharge
    1. Asymptomatic pts w/ normal ECG on presentation after a <600V injury
  2. Admit
    1. All pts with high-voltage injuries (even if asymptomatic)
    2. Pts w/ low-voltage injury if symptomatic (e.g. chest pain, burns, abnl ECG, abnl CK)

Source

  1. ↑ Koumbourlis AC. Electrical injuries. Crit Care Med. 2002 Nov;30(11 Suppl):S424-30.
  2. ↑ Brandt CP, Yowler CJ, Fratianne RB. MetroHealth Medical Center Burn ICU Handbook (Not a policy manual), Cleveland, OH.
Obtenido de «https://www.wikem.org/w/index.php?title=Electrical_injuries&oldid=23298»