Electrical Injury¶

Category: Trauma Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf; UCLA EMT Ultimate Study Guide (2026) Last updated: 2026-04-04

Overview¶

Electrical injuries cause tissue damage through heat generated along the current path, direct cellular electroporation (disruption of cell membranes), and tetanic muscle contractions. The external burns are often deceptively small compared to the internal damage. Current travels through the body along the path of least resistance (nerves, blood vessels, muscles) — entrance and exit wounds mark the electrical path, but all tissue between them is at risk.

High-voltage (>1000V) injuries (industrial, downed power lines) cause more severe injury than low-voltage (<1000V, household current). Lightning strikes are a special case: massive direct current discharge with different injury patterns. All electrical injuries require cardiac monitoring and hospital evaluation.

Key Points¶

Scene safety is paramount — do not approach a downed power line or patient in contact with a live source; call the electric company; approach only after confirmed power-off by utility workers
Extent of injury is often hidden — small entry/exit wounds can have massive internal muscle necrosis (rhabdomyolysis)
Cardiac arrest is a primary cause of death from electrical injury — arrhythmias, especially VF, are common; AED should be applied immediately
Rhabdomyolysis from muscle destruction can cause acute kidney failure — aggressive IV fluid resuscitation is a hospital priority
Fractures are common from tetanic muscle contractions during electrocution — the current causes all muscles to contract simultaneously, potentially fracturing bones; also look for fall-related trauma
Spinal injury must be considered — particularly with high-voltage or lightning injuries
Lightning-strike injuries require triage priority to the pulseless patient (reverse triage) — lightning victims in arrest can be successfully resuscitated

Assessment Relevance¶

History (history-taking): - MOI: Voltage (household vs. high-voltage), AC vs. DC, duration of contact, indoor vs. outdoor, any associated fall - SAMPLE: Cardiac history, medications (anticoagulants), loss of consciousness (duration) - Identify entry and exit wounds — helps define the path of current through the body

Physical exam (secondary-assessment): - Primary assessment: LOC, airway, breathing, circulation; cardiac arrest may be delayed after apparent initial recovery - Entrance and exit wounds: typically small, dry, sometimes with central charring - All tissue between entry/exit: burns, neurological deficits, vascular injury - Skin: superficial/deep burns along current path; not always visible externally - Musculoskeletal: extremity deformities from tetanic contractions; crepitus - Neuro: altered LOC, paresthesias, weakness (neurological injury) - Cardiac: arrhythmias on monitor; any rhythm disturbance post-electrical injury requires evaluation - Eyes and ears: cataracts (delayed, but ruptured tympanic membranes can occur acutely with lightning)

Procedures¶

Scene safety first (scene-size-up): confirm power is off before approaching; identify if still active source present; call utility company if needed
Primary assessment (primary-assessment): LOC, airway, breathing; apply AED immediately if arrest suspected
If cardiac arrest: follow cardiac-arrest-aed protocol
Spinal immobilization if indicated by MOI (spinal-immobilization-supine)
Dress burns with dry sterile dressings — do not apply electrodes to burned skin
Remove constricting clothing and jewelry — edema will develop
Immobilize if associated fractures suspected
Transport to burn center if available — electrical injuries require specialized burn center care
Continuous cardiac monitoring during transport
IV/IO large bore isotonic solution; aggressive fluid resuscitation for burns/rhabdomyolysis (ALS scope)
Reassessment (reassessment): serial cardiac monitoring; monitor for delayed arrhythmias

NM Protocol Notes¶

From NM EMS Treatment Guidelines (2022) — Electrical Injury:

EMT-B and all levels scope: - Assess scene for safety — turn off power if safely possible; otherwise call electric company - Identify characteristics of electrical source to communicate to receiving facility - Primary assessment; airway, breathing, circulation management - Apply dry dressing to wounds - Remove constricting clothing and jewelry (additional swelling anticipated) - Immobilize if associated trauma suspected - Transport to burn center whenever possible — electrical injuries involve considerable hidden tissue damage - Obtain history and vital signs - Place on cardiac monitor (all levels); record rhythm strip - If cardiac arrest: follow Medical Cardiac Arrest Guidelines - Enroute: large bore IV/IO isotonic solution; infuse at rate to maintain adequate vital signs - Administer fluid resuscitation per Burn Guidelines (Parkland formula)

NM protocol note on destination: Electrical injury patients should be taken to a burn center whenever possible since these injuries can involve considerable tissue damage beyond what is visible.

ALS medications: Pain management per general trauma guidelines (Morphine, Fentanyl) if hemodynamically stable.

NREMT Relevance¶

Scene safety is the first priority — never approach an active electrical source
Electrical entry/exit wounds underestimate total tissue damage
Cardiac monitoring required — VF and arrhythmias are the immediate cause of death
Rhabdomyolysis: muscle breakdown → dark "tea-colored" urine; requires aggressive fluid resuscitation (hospital priority)
Spinal immobilization consideration for high-voltage or lightning injuries
Lightning: reverse triage — treat pulseless patients first (highest survival potential)

NREMT Differentiators¶

KEY DIFFERENTIATOR — External Wounds vs. Internal Damage: Entry and exit burns are typically small, dry, and deceptively minor-looking. All tissue between entry and exit wounds is at risk — muscle, nerves, and vessels along the current path can be completely destroyed with no visible external sign. Assume massive internal injury from any high-voltage contact regardless of wound appearance.

KEY DIFFERENTIATOR — Lightning: Reverse Triage: In standard MCI triage, pulseless patients are tagged black (expectant). Lightning is the exception: pulseless lightning victims should be treated first — their arrest is from a direct electrical cardiac event and they have a higher survival potential with immediate CPR/AED than other arrest victims. Treat the pulseless lightning victim first.

Voltage categories and injury patterns:

Type	Voltage	Key Injuries	Priority
Household AC	<1,000V	Arrhythmias, burns, tetanic contractions	Transport with cardiac monitoring
High-voltage	>1,000V	Massive internal burns, rhabdomyolysis, spinal injury from fall/contraction	Burn center; highest priority
Lightning DC	Varies (very high, brief)	Cardiac arrest, neurological, tympanic membrane rupture, cataracts (delayed)	Treat pulseless FIRST (reverse triage)

KEY DIFFERENTIATOR — Rhabdomyolysis: Massive electrical current destroys muscle cells → myoglobin released into bloodstream → filtered by kidneys. Presenting sign: dark, tea-colored or cola-colored urine. Requires aggressive IV fluid resuscitation to prevent acute kidney failure — hospital priority. EMT-B identifies and transports; IV fluids are ALS scope.

scene-size-up — scene safety is the cardinal first step in electrical injury
cardiac-arrest-aed — VF from electrical injury; AED and CPR management
burns — thermal burns from electrical injuries; TBSA estimation; Parkland formula
spinal-immobilization-supine — spinal precautions for high-voltage or fall-related injuries
shock — hemodynamic management; fluid resuscitation
primary-assessment — airway, breathing, circulation in unconscious electrical injury patient
start-triage — lightning = reverse triage; treat pulseless patients first

Sources¶

raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Electrical Injury protocol (p. 76)