TRAUMA NOTEBOOK
HOT TOPICS: ELECTRICAL INJURIES EMERGENCY DEPARTMENT
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Author: Kathryn Moore, DNP, APRN-BC, CNE, FCCM, CCRN, CEN, ACNP-BC, ANP-BC, GNP-BC, Atlanta, GA Section Editor: Kathryn Moore, DNP, APRN-BC, CNE, FCCM, CCRN, CEN, ACNP-BC, ANP-BC, GNP-BC
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Kathryn Moore is Clinical Associate Professor, Director of the Evans Center and Simulation Lab, Adult-Gerontology Acute Care Nurse Practitioner Specialty Coordinator, and Adult-Gerontology Primary Care Nurse Practitioner Specialty Coordinator, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA. For correspondence, write: Kathryn Moore, DNP, APRN-BC, CNE, FCCM, CCRN, CEN, ACNP-BC, ANP-BC, GNP-BC, Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road, NE, Office 348, Atlanta, GA 30322; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.06.006
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effect is respiratory arrest, and the most commonly seen indirect injury is brain ischemia or anoxia resulting from cardiac arrest. 3,5 To address these life-threatening consequences, cardiac monitoring should be initiated and airway issues should be addressed immediately. In addition, a computed tomography (CT) scan of the head is indicated to assess the brain for potential damage either from the fall or from an ischemic or anoxic injury. 3,5 In some instances the ischemic/anoxic injury to the brain may not manifest for several days, but when a baseline CT scan is obtained in the emergency department, changes are easily noted. In addition to the potentially life-threatening cardiac and neurologic injuries associated with electrical injuries, respiratory arrest is a common cause of death in persons who sustain electrical injuries. Although the lungs sustain no specific injuries as a result of the electrical injury, respiratory arrest can occur either as a result of a direct injury to the respiratory center in the brain or as an indirect result of cardiac arrest or tetanic contractions of the respiratory muscles. 3,5 Damage to the skin will vary from local erythema to profound full-thickness burns. 3,5 Limited contact of short duration and low voltage generally results in injury ranging from local erythema to first-degree burns. Electrical injuries capable of causing second- and third-degree burns are generally of sufficient voltage and duration to also cause ventricular fibrillation. 3,5 Because high-voltage current often flows through internal pathways and is easily conducted along blood vessels, nerves, and muscles, it is difficult to predict the underlying tissue damage associated with an electrical injury. 3,5 The resuscitation calculations used in thermal burns are generally inadequate because the tissue damage is not visible in terms of either percentage of body burned or the degree to which it is burned. A common complication of severe tissue and muscle damage is rhabdomyolysis. Urine color, character, and quantity can often serve as a volume resuscitation guide in persons with rhabdomyolysis. 3,5 When a patient with electrical injuries is admitted to the emergency department, the acute phase of care should include an electrocardiogram, cardiac profile, urinalysis for myoglobin, a complete blood cell count, and radiographic studies as appropriate for suspected or known injuries. Resuscitation in the emergency department should
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n this third installment dealing with burn care, the topic is electrical injury. Electrical burns are classified as either high or low voltage. Low-voltage burns of less than 1000 volts generally result in less severe injuries, whereas high-voltage burns of more than 1000 volts have a much greater risk of severe injury. 1 The typical highvoltage injury includes injuries to fat, muscle, and potentially even bones, and therefore electrical injuries have the potential for devastating consequences. 1 Electrical injuries may be caused by human-made or generated electricity or by lightning. A relatively small percentage— less than 7%—of all burn injuries are electrical injuries, but electrical injuries have a 40% fatality rate and are the fourth leading cause of injury-related occupational death. 2,3 Lightning injuries are the second leading cause of weather-related death and predominantly affect males. 4 Electrical injury manifests as a multisystem injury and should be managed as such. The major body systems affected include the cardiovascular system, the nervous system, the respiratory system, and the integumentary system. The cardiovascular system and the nervous system are the 2 systems with the greatest potential to cause immediate life-threatening disruptions. In terms of resistance to the flow of current, the nerves and blood have the least resistance of the body tissues. 3,5 When electricity or lightning contacts the human body and passes through the heart, there is a high likelihood of cardiac arrhythmias and direct myocardial infarction. Electricity tends to cause ventricular fibrillation, whereas lightning is more likely to cause ventricular asystole. 3,5 As for the nervous system, the most commonly seen direct
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72 74 76 78 80 82 84 86 88 90 92 94 96 98 100 102 104 106 108 110 112 114 116 118 120 122 124 126 128 130 132 134 136 138 140 142 144 146 148 150 152 154 156 158
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2. Cawley JC, Homce GT. Occupational electrical injuries in the United 194 States, 1992-1998, and recommendations for safety research. J Safety Res. 196 2003;34(3):241-248. 198
include adequate volume resuscitation and placement of a urinary catheter to monitor urine output. The urine output can serve as an initial guide to resuscitation. Other markers of major organ function, including liver, pancreas and renal panels, should be obtained. Obtaining a blood gas value can guide resuscitation and provide markers for shock. 3,5,6 Although electrical injuries account for a small portion of burn injuries, the consequences of an electrical injury are potentially deadly. Immediate and appropriate care in the emergency department is a major key to survival, successful recovery, and postrecovery quality of life.
3. Koumbourlis AC. Electrical injuries. Crit Care Med. 2002;30(11 Suppl):S424–S430. 200 4. Jensenius JS. A detailed analysis of lightning deaths in the United States 202 from 2006 through 2014. http://www.lightningsafety.noaa.gov/fatalities/ 204 analysis06-14.pdf. Accessed June 23, 2015. 206 5. Cooper MA. Emergent care of lightning and electrical injuries. Semin 208 Neurol. 1995;15(3):268-278. 210 6. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S829-S861.
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1. Sanford A, Gamelli RL. Lightning and thermal injuries. Handb Clin Neurol. 2014;120:981-986.
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Submissions to this column are encouraged and may be sent to Kathryn Moore, DNP, APRN-BC, CNE, FCCM, CCRN, CEN, ACNP-BC, ANP-BC, GNP-BC [email protected]
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JOURNAL OF EMERGENCY NURSING
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HOT TOPICS: ELECTRICAL INJURIES EMERGENCY DEPARTMENT
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4
IN THE
Author: Kathryn Moore, DNP, APRN-BC, CNE, FCCM, CCRN, CEN, ACNP-BC, ANP-BC, GNP-BC, Atlanta, GA Section Editor: Kathryn Moore, DNP, APRN-BC, CNE, FCCM, CCRN, CEN, ACNP-BC, ANP-BC, GNP-BC
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Kathryn Moore is Clinical Associate Professor, Director of the Evans Center and Simulation Lab, Adult-Gerontology Acute Care Nurse Practitioner Specialty Coordinator, and Adult-Gerontology Primary Care Nurse Practitioner Specialty Coordinator, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA. For correspondence, write: Kathryn Moore, DNP, APRN-BC, CNE, FCCM, CCRN, CEN, ACNP-BC, ANP-BC, GNP-BC, Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road, NE, Office 348, Atlanta, GA 30322; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.06.006
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effect is respiratory arrest, and the most commonly seen indirect injury is brain ischemia or anoxia resulting from cardiac arrest. 3,5 To address these life-threatening consequences, cardiac monitoring should be initiated and airway issues should be addressed immediately. In addition, a computed tomography (CT) scan of the head is indicated to assess the brain for potential damage either from the fall or from an ischemic or anoxic injury. 3,5 In some instances the ischemic/anoxic injury to the brain may not manifest for several days, but when a baseline CT scan is obtained in the emergency department, changes are easily noted. In addition to the potentially life-threatening cardiac and neurologic injuries associated with electrical injuries, respiratory arrest is a common cause of death in persons who sustain electrical injuries. Although the lungs sustain no specific injuries as a result of the electrical injury, respiratory arrest can occur either as a result of a direct injury to the respiratory center in the brain or as an indirect result of cardiac arrest or tetanic contractions of the respiratory muscles. 3,5 Damage to the skin will vary from local erythema to profound full-thickness burns. 3,5 Limited contact of short duration and low voltage generally results in injury ranging from local erythema to first-degree burns. Electrical injuries capable of causing second- and third-degree burns are generally of sufficient voltage and duration to also cause ventricular fibrillation. 3,5 Because high-voltage current often flows through internal pathways and is easily conducted along blood vessels, nerves, and muscles, it is difficult to predict the underlying tissue damage associated with an electrical injury. 3,5 The resuscitation calculations used in thermal burns are generally inadequate because the tissue damage is not visible in terms of either percentage of body burned or the degree to which it is burned. A common complication of severe tissue and muscle damage is rhabdomyolysis. Urine color, character, and quantity can often serve as a volume resuscitation guide in persons with rhabdomyolysis. 3,5 When a patient with electrical injuries is admitted to the emergency department, the acute phase of care should include an electrocardiogram, cardiac profile, urinalysis for myoglobin, a complete blood cell count, and radiographic studies as appropriate for suspected or known injuries. Resuscitation in the emergency department should
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n this third installment dealing with burn care, the topic is electrical injury. Electrical burns are classified as either high or low voltage. Low-voltage burns of less than 1000 volts generally result in less severe injuries, whereas high-voltage burns of more than 1000 volts have a much greater risk of severe injury. 1 The typical highvoltage injury includes injuries to fat, muscle, and potentially even bones, and therefore electrical injuries have the potential for devastating consequences. 1 Electrical injuries may be caused by human-made or generated electricity or by lightning. A relatively small percentage— less than 7%—of all burn injuries are electrical injuries, but electrical injuries have a 40% fatality rate and are the fourth leading cause of injury-related occupational death. 2,3 Lightning injuries are the second leading cause of weather-related death and predominantly affect males. 4 Electrical injury manifests as a multisystem injury and should be managed as such. The major body systems affected include the cardiovascular system, the nervous system, the respiratory system, and the integumentary system. The cardiovascular system and the nervous system are the 2 systems with the greatest potential to cause immediate life-threatening disruptions. In terms of resistance to the flow of current, the nerves and blood have the least resistance of the body tissues. 3,5 When electricity or lightning contacts the human body and passes through the heart, there is a high likelihood of cardiac arrhythmias and direct myocardial infarction. Electricity tends to cause ventricular fibrillation, whereas lightning is more likely to cause ventricular asystole. 3,5 As for the nervous system, the most commonly seen direct
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WWW.JENONLINE.ORG
Master Proof ymen2799.pdf
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72 74 76 78 80 82 84 86 88 90 92 94 96 98 100 102 104 106 108 110 112 114 116 118 120 122 124 126 128 130 132 134 136 138 140 142 144 146 148 150 152 154 156 158
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164 166 168 170 172 174 176 178 180 182 184
2. Cawley JC, Homce GT. Occupational electrical injuries in the United 194 States, 1992-1998, and recommendations for safety research. J Safety Res. 196 2003;34(3):241-248. 198
include adequate volume resuscitation and placement of a urinary catheter to monitor urine output. The urine output can serve as an initial guide to resuscitation. Other markers of major organ function, including liver, pancreas and renal panels, should be obtained. Obtaining a blood gas value can guide resuscitation and provide markers for shock. 3,5,6 Although electrical injuries account for a small portion of burn injuries, the consequences of an electrical injury are potentially deadly. Immediate and appropriate care in the emergency department is a major key to survival, successful recovery, and postrecovery quality of life.
3. Koumbourlis AC. Electrical injuries. Crit Care Med. 2002;30(11 Suppl):S424–S430. 200 4. Jensenius JS. A detailed analysis of lightning deaths in the United States 202 from 2006 through 2014. http://www.lightningsafety.noaa.gov/fatalities/ 204 analysis06-14.pdf. Accessed June 23, 2015. 206 5. Cooper MA. Emergent care of lightning and electrical injuries. Semin 208 Neurol. 1995;15(3):268-278. 210 6. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S829-S861.
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REFERENCES
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1. Sanford A, Gamelli RL. Lightning and thermal injuries. Handb Clin Neurol. 2014;120:981-986.
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Submissions to this column are encouraged and may be sent to Kathryn Moore, DNP, APRN-BC, CNE, FCCM, CCRN, CEN, ACNP-BC, ANP-BC, GNP-BC [email protected]
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JOURNAL OF EMERGENCY NURSING
Master Proof ymen2799.pdf
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