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Focused History: Were there any witnesses to your injury? If so, what did they see? (may confirm
electrocution and suggest possible associated injuries.) Do you have any pain, numbness, tingling, or other
abnormal sensations or feelings? (directs you to areas of injury for closer evaluation and monitoring on serial
exams.) Have you had any change in urine color or frequency? (decreased quantity and/or frequency of urine,
and Coke or tea-colored urine may suggest renal failure due to rhabdomyolysis).
Objective: Signs
Using Basic Tools: Approach patient as any other trauma victim, performing primary and secondary surveys.
Assess for evidence of blunt trauma to head, neck and spinal column, chest, abdomen, and musculoskeletal
system (fractures, dislocations). Include thorough eye and ear exams. Assess for Compartment Syndrome*.
Superficial “fern-like” burns of the skin are indicative of lightning injury. Severe electrical burns may occur with
“entrance” and “exit” wounds and extensive tissue damage along the path of the electrical current. Injured
muscle releases large amounts of myoglobin that may damage the kidneys. This may be seen clinically as
dark tea or coke-colored urine.
*Compartment syndrome may jeopardize the survivability of a limb and results from swelling within tight fascial
compartments of the extremities causing compression of nerves and blood vessels. Compartment syndrome
may be characterized by the “7 Ps”, the last two of which are ominous findings:
- Pain out of proportion to visible injury
- Pain worsened with passive stretch of the involved muscles
- Pressure palpable over the compartment
- Paralysis or weakness of affected muscles
- Paresthesias in distribution of affected compartmental nerves
- Pallor
- Pulselessness
Compartment Syndrome Management 8-
Using Advanced Tools: Lab: Presumptively diagnose myoglobinuria if positive for blood on urine dipstick
and no red blood cells visible on microscopic urine exam. Monitor EKG and cardiac status. RBC count
and hemoglobin &/or hematocrit as trauma baseline labs; repeat if patient’s condition deteriorates or fails to
improve (look for evidence of occult hemorrhage &/or hemolysis).
Assessment:
Differential Diagnosis
Consider traumatic head injury &/or stroke as causes of prolonged altered level of consciousness or coma.
Consider internal bleeding (chest, abdomen, GI) as cause of unexplained hypotension.
Plan:
Treatment
Primary: Resuscitate patient following ABCs and cervical-spine control as per BLS/ACLS & ATLS protocols.
Establish IV access. Give oxygen and assist ventilation as needed. Perform meticulous wound and burn care.
Give antibiotics (e.g., ampicillin/sulbactam 1.5-3 gm IV q 6 hrs, or ceftriaxone 1-2 gm IV q 24 hrs, or
ciprofloxacin 200-400 mg IV q 12 hrs) if fever or other sign of infection develops. Tetanus prophylaxis is
essential. Due to variable extent and depth of burns, burn formulas are not helpful. Closely monitor I & O
and titrate IV fluids (normal saline or lactated Ringers) to maintain urine output at 0.5-1 ml/kg/hour (consider
Foley catheter and/or NG tube).
Empiric: If patient develops evidence of myoglobinuria, increase IV fluids to maintain urine output twice
normal at 1-2 ml/kg/hour (~60-150 ml/hr). Alkalinizing the urine aids in solubility and excretion of myoglobin.
Add 1-3 ampules of sodium bicarbonate to each liter of IV normal saline or lactated Ringers. Monitor urine
pH with urine dipsticks and adjust amount of bicarb to keep pH greater than 6.5 (add more bicarb to increase
urine pH; less to decrease). Monitor lung sounds and jugular veins for evidence of induced pulmonary
edema. Consider also giving furosemide (Lasix) 20-60 mg IV titrated to achieve and maintain diuresis,
and/or mannitol 12.5 gm IV bolus followed by infusion at 12.5 gm/hour. Do not allow patient to become