Management of a high-voltage electrical injury

This is a high-voltage electrical injury with a hand-to-foot current pathway, myoglobinuria and haemodynamic compromise. The small entry wound understates the injury — the deep tissue damage, the rhabdomyolysis and the compartment syndrome are the threats. The patient was also likely thrown from the crane, so a full trauma assessment is run in parallel.^[2]

(a) Assessment and investigations. Resuscitate first by the trauma primary survey (ABCDE) with cervical-spine control — the throw and the fall generate blunt injury independently of the shock. Establish two large-bore intravenous cannulae, give high-flow oxygen, attach continuous cardiac monitoring, and take bloods for urea and electrolytes, creatine kinase, troponin, myoglobin, a venous gas (for the acidosis and the potassium), and a group and hold. Send urine for dipstick and microscopy — the dark red-brown urine with a positive blood dipstick but no red cells on microscopy is myoglobinuria and confirms rhabdomyolysis. A 12-lead ECG is mandatory on arrival; CK is repeated at intervals because it peaks after the injury.^[2]

(b) Fasciotomy — indication and timing. Examine all four limbs neurologically and vascularly on arrival and re-examine at intervals. Compartment syndrome complicating deep high-voltage necrosis is a clinical diagnosis: pain on passive stretch out of proportion to the injury, a tense woody compartment, paraesthesia and progressive motor deficit, supported by a compartment pressure within 30 mmHg of the diastolic blood pressure. Fasciotomy is the definitive treatment and is time-critical — 18 hours is the maximum burn-to-fasciotomy window for limb salvage (mean 18 hours salvaged versus 20.38 hours amputated), with worse outcomes beyond it.^[7] Call the surgical or the burns team the moment deep injury is suspected, not after the limb is pulseless.

(c) Cardiac monitoring. Because this is a high-voltage contact with abnormal ECG changes and haemodynamic compromise, the patient is admitted for at least 24 hours of continuous telemetry. The 4 to 6 hour rule applies only to the asymptomatic low-voltage exposure with a normal ECG; here the voltage, the symptoms and the ECG all mandate admission. Ventricular fibrillation is treated with the standard ALS algorithm — prolonged, aggressive cardiopulmonary resuscitation is justified in the young, otherwise-fit electrical-injury victim.^[2]

Run the rhabdomyolysis therapy in parallel: aggressive intravenous isotonic crystalloid to a goal urine output around 300 mL per hour, guided by serial CK and electrolytes; bicarbonate, mannitol and loop diuretics have no strong supporting evidence and are not routine.^{[5] [8]} Treat hyperkalaemia aggressively. Give titrated opioids for analgesia, update tetanus, and transfer to a burns or a trauma centre once stabilised.