A 34-year-old roofer is brought to the emergency department due to an electrical injury. He was maneuvering an extended ladder when it contacted an overhead power line. The patient is alert and cooperative but has no recollection of the accident. Temperature is 37.8 C (100 F), blood pressure is 124/80 mm Hg, pulse is 92/min, and respirations are 20/min. Examination reveals that bilateral hands are charred, leathery, and insensate, and large, open wounds are present on the soles of both feet. ECG shows normal sinus rhythm. Based on these findings, the patient is at greatest risk for developing which of the following complications over the next several days?

Question

A 34-year-old roofer is brought to the emergency department due to an electrical injury.  He was maneuvering an extended ladder when it contacted an overhead power line.  The patient is alert and cooperative but has no recollection of the accident.  Temperature is 37.8 C (100 F), blood pressure is 124/80 mm Hg, pulse is 92/min, and respirations are 20/min.  Examination reveals that bilateral hands are charred, leathery, and insensate, and large, open wounds are present on the soles of both feet.  ECG shows normal sinus rhythm.  Based on these findings, the patient is at greatest risk for developing which of the following complications over the next several days?

Quizplus · Accepted Answer

Explanation: This patient whose ladder contacted an overhead power line became part of the pathway for electricity traveling from the power line to the ground, likely entering his hands (eg, charred, insensate hands) and exiting his feet (eg, large, open wounds on his soles). In patients with high-voltage electrical injuries, tissue damage occurs from both the direct injury caused by electricity and from the secondary conversion of electrical energy to thermal energy. Because bone (with its high resistance to electrical current) generates the most heat as current passes through the body, thermal injury to internal tissues surrounding the bone (eg, skeletal muscle) often exceeds the visible injury to external tissues (eg, skin). Skeletal muscle necrosis in patients with high-voltage electrical injuries often leads to the following clinical features: Acute compartment syndrome from intracompartmental muscle swelling Rhabdomyolysis, with leakage of muscle contents, including heme pigment, into the circulation Heme pigment-induced acute kidney injury (eg, intratubular cast formation) Patients should be monitored for these conditions and should receive aggressive IV fluid resuscitation. Because of the risk of hyperkalemia from rhabdomyolysis, potassium-containing IV fluids should be avoided. (Choices A and D) Electrical current that injures the brain can result in seizures or, very rarely, brain herniation (eg, from severe brain damage and subsequent increased intracranial pressure). However, neither is likely in this patient because of the lack of evident brain injury (ie, patient is alert and cooperative) and because of the current's path from the overhead power line (hands) to the ground (feet). (Choice B) The most common cardiac complication of electrical injury is interruption of normal cardiac impulse conduction, resulting in arrhythmias (eg, ventricular fibrillation) or cardiac arrest. Acute cardiac tamponade is more commonly caused by chest trauma (blunt or penetrating) and/or aortic dissection. (Choice E) Severe tissue injury, as occurred in this patient, often causes acute coagulopathy that is both consumptive (from tissue factor activation of the coagulation pathway) and dilutional (from aggressive fluid resuscitation), resulting in thrombocytopenia rather than thrombocytosis. Educational objective: High-voltage electrical injuries frequently cause more severe damage to internal structures (eg, muscle) than external structures (eg, skin). Skeletal muscle necrosis is a frequent complication that can result in acute compartment syndrome, rhabdomyolysis, and heme pigment-induced acute kidney injury. References: High-voltage electrical injury complicated by compartment syndrome and acute kidney injury with successful limb salvage: a case report and review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/29787959) Electrical injuries in the emergency department: an evidence-based review. (http://www.ncbi.nlm.nih.gov/pubmed/30358379)

A 34-Year-Old Roofer Is Brought to the Emergency Department Due