Electrical & Chemical Burns

Also known as Electrical injury · High voltage burn · Chemical burn · Hydrofluoric acid burn · Alkali burn · Rhabdomyolysis electrical

Electrical and chemical burns in ICU: high-voltage (over 1000 V) electrical injury penetrates deep tissues not captured by cutaneous TBSA — delayed arrhythmia (monitor at least 24 h unless low-voltage, no syncope, normal ECG), rhabdomyolysis with urine-output goal 1 mL/kg/h, surgical decompression not escharotomy; lightning (asystole that often restarts, persistent medullary respiratory arrest, reverse triage, Lichtenberg pseudo-burns, keraunoparalysis); chemical burns (immediate copious lavage; hydrofluoric acid — fluoride binds calcium and magnesium — calcium gluconate gel and IV calcium; phenol — low-molecular-weight PEG; white phosphorus — irrigation, prevent air contact, no copper sulphate).

high23 referencesUpdated 5 Oct 202617 min readSource-verified · Oct 2026

Checked against its sources on 8 Oct 2026

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The one-line answer

Electrical and chemical burns are not thermal burns — the visible surface is the tip of an iceberg. In electrical injury the current penetrates deep tissues that cutaneous burn formulae do not account for, so TBSA is a dangerous underestimate; the priorities are cardiac monitoring (selected patients need monitoring for at least 24 hours), urine-output-guided fluids (1 mL/kg/h in adults — above the thermal target of 0.5 to 1 mL/kg/h), and surgical decompression of compartment syndromes. In chemical injury the agent keeps damaging tissue until it is diluted away, so the priority is immediate copious water lavage — begun at the scene it significantly reduces full-thickness injury and more than doubles the speed of recovery. Hydrofluoric acid is the killer: death has been reported from a concentrated burn of just 2.5 per cent body surface area, and the standard first aid is water rinsing followed by 2.5 per cent calcium gluconate gel.^[2]^[4]^[7]^[8]^[12]^[11]

Meet the patient

A 34-year-old linesman is brought to the ED after contacting an 11,000 V overhead AC line. Bystanders did CPR, paramedics found him in ventricular fibrillation, one 200 J shock restored a rhythm. On arrival he is intubated, there is a small charred entry wound on his right palm and a large exit wound on his left foot, and the urine draining from his catheter is dark red-brown.^[2]

The cutaneous TBSA looks trivial — a few percent. It is the most dangerous underestimate in burns: high voltage (over 1000 V) penetrates deep tissues, the myonecrosis and secondary compartment syndromes drive rhabdomyolysis that compromises renal function, and these patients often develop acute kidney injury requiring dialysis. The surface wound is a distraction; the deep injury, the arrhythmia, and the rhabdomyolysis are what will kill him.^[2]

References23Show

[1]Bittner EA, Shank E, Woodson L, et al. Acute and perioperative care of the burn-injured patient Anesthesiology, 2015.PMID 25485468
[2]Culnan DM, Farner K, Bitz GH, et al. Volume Resuscitation in Patients With High-Voltage Electrical Injuries Ann Plast Surg, 2018.PMID 29461290
[3]Scharman EJ, Troutman WG Prevention of kidney injury following rhabdomyolysis: a systematic review Ann Pharmacother, 2013.PMID 23324509
[4]Waldmann V, Narayanan K, Combes N, et al. Electrical cardiac injuries: current concepts and management Eur Heart J, 2018.PMID 28444167
[5]van Ruler R, Eikendal T, Kooij FO, et al. A shocking injury: A clinical review of lightning injuries highlighting pitfalls and a treatment protocol Injury, 2022.PMID 36038387
[6]Fish RM, Geddes LA Conduction of electrical current to and through the human body: a review Eplasty, 2009.PMID 19907637
[7]Greenhalgh DG, Cartotto R, Taylor S, et al. A Prospective, Randomized, Multicenter Trial Comparing Lactated Ringer's Alone or With 5% Albumin for Resuscitation of Large Burns The Acute Burn ResUscitation Multicenter Prospective Trial 2 (ABRUPT2) Ann Surg, 2026.PMID 42144653
[8]Leonard LG, Scheulen JJ, Munster AM Chemical burns: effect of prompt first aid J Trauma, 1982.PMID 7077702
[9]Walsh K, Hughes I, Dheansa B Management of chemical burns Br J Hosp Med (Lond), 2022.PMID 35377199
[10]Roblin I, Urban M, Flicoteau D, et al. Topical treatment of experimental hydrofluoric acid skin burns by 2.5% calcium gluconate J Burn Care Res, 2006.PMID 17091088
[11]Höjer J, Personne M, Hultén P, et al. Topical treatments for hydrofluoric acid burns: a blind controlled experimental study J Toxicol Clin Toxicol, 2002.PMID 12507055
[12]Ramesh S, Nathan B, Vt A, et al. Hydrofluoric Acid Fatality from Dermal Exposure J Emerg Med, 2025.PMID 41205306
[13]Fang H, Wang GY, Wang X, et al. Potentially fatal electrolyte imbalance caused by severe hydrofluoric acid burns combined with inhalation injury: A case report World J Clin Cases, 2019.PMID 31667189
[14]Sawhney CP, Kaushish R Acid and alkali burns: considerations in management Burns, 1989.PMID 2736051
[15]Ritenour AE, Morton MJ, McManus JG, et al. Lightning injury: a review Burns, 2008.PMID 18395987
[16]Kemp Bohan PM, Coulthard SL, Yelon JA, et al. Solid Metal Chemical and Thermal Injury Management Mil Med, 2025.PMID 39190559
[17]Burd A, Noronha FV, Ahmed K, et al. Decompression not escharotomy in acute burns Burns, 2006.PMID 16527416
[19]Kumar A, Srinivas V, Sahu BP Keraunoparalysis: What a neurosurgeon should know about it? J Craniovertebr Junction Spine, 2012.PMID 23741121
[20]McIntyre WF, Simpson CS, Redfearn DP, et al. The lightning heart: a case report and brief review of the cardiovascular complications of lightning injury. Indian Pacing Electrophysiol J, 2010.PMID 20930961
[21]Barqouni L, Abu Shaaban N, Elessi K Interventions for treating phosphorus burns. Cochrane Database Syst Rev, 2014.PMID 24896368
[22]Monteiro-Riviere NA, Inman AO, Jackson H, et al. Efficacy of topical phenol decontamination strategies on severity of acute phenol chemical burns and dermal absorption: in vitro and in vivo studies in pig skin. Toxicol Ind Health, 2001.PMID 12479505
[23]Testa J, Chambers A, Cumpston K Is Low Molecular Weight Polyethylene Glycol Used for Decontamination of Dermal Phenol Exposures? J Occup Environ Med, 2026.PMID 41396257
[24]Kelly A, Chan S, Wood MJ Hydrofluoric Acid Cutaneous Burns: A Systematic Review of Emergency Management and General Surgical Sequelae. Cureus, 2026.PMID 41798656