Overall Standards: An electrocardiogram
(ECG) should be performed on all patients who sustain electrical injuries (high
and low voltage) (ABA Practice Guidelines; J Burn care Res 2006; 27).
Overall Guidelines:
1. Children and adults who sustain
low-voltage electrical injuries, have no ECG abnormalities, no history of loss
of consciousness, and no other indications for admission (ie, soft-tissue
injury), can be discharged from the emergency room.
2. All patients with history of loss of
consciousness or documented dysrhythmia either before or after admission to the
emergency room should be admitted for telemetry monitoring. Patients with ECG
evidence of ischemia should be admitted and placed on cardiac monitors
(monitoring for 24 hours has been reported in several studies).
3. Creatine kinase enzyme levels,
including MB fraction, are not reliable indicators of cardiac injury after
electrical burns and should not be used in decisions regarding patient
disposition. Insufficient data exists on troponin levels to formulate a
guideline.
4. Alkalinization of the urine is not
necessary in all patients.
5. Maintain UOP.
Overall Options: Electrical injuries
can result in potentially fatal cardiac dysrhythmias. The need for cardiac
evaluation and subsequent cardiac monitoring are critical components in
electrical burn management. Most patients who sustain electrical injuries
undergo ECG evaluation, and patients with documented dysrhythmias, cardiac
ischemia, or history of loss of consciousness will be admitted to the hospital
for further evaluation and monitoring. However, the appropriate cardiac
diagnostic tests and the indications for hospital admission, necessity of
cardiac monitoring, and appropriate duration of cardiac monitoring have not
been well established.
Upper Extremity
Standards: Insufficient
data exist to support a treatment standard for this topic.
Upper Extremity
Guidelines:
1. Patients with high-voltage
electrical injury to the upper extremity should be referred to specialized burn
centers experienced with these injuries as per American Burn Association
referral criteria.
2. Indications for surgical
decompression include progressive neurologic dysfunction, vascular compromise,
increased compartment pressure, and systemic clinical deterioration from
suspected ongoing myonecrosis. Decompression includes forearm fasciotomy and
assessment of muscle compartments. The decision to include a carpal tunnel
release should be made on a case-by-case basis.
Upper Extremity
Options: There
are several methods to evaluate the injured extremity. Compartment pressures
may be measured as an adjunct to clinical examination. Pressures greater than
30 mm Hg, or tissue pressure reaching within 10 to 20 mm Hg of diastolic
pressure, may be used as evidence of increased compartment pressure and
potential deep-tissue injury, indicating the need for surgical decompression in
the appropriate clinical setting. Technetium-99m pyrophosphate scan may be used
as an adjunct to clinical examination at centers experienced with this
technology. Doppler flow meter can be used as an adjunct to assess extremity
perfusion. It should not be relied on as the sole indicator of deep-tissue
viability and adequate perfusion.
