DO NOT TOUCH THE PATIENT UNTIL THE POWER SOURCE HAS BEEN CONFIRMED OFF. Contact with the patient while power is active = rescuer becomes second victim. This is the most common cause of multiple electrical injury casualties.
Shout — announce the danger to bystanders; keep clear
Approach only when safe — power confirmed OFF by authorised person
Free from source — only after power is off; use non-conductive material if needed to separate patient from source (dry wood, rubber)
Evaluate and treat — ABC once patient is free and area is safe
AC vs DC Current
Feature
AC (Alternating Current)
DC (Direct Current)
Household supply
Yes (50–60 Hz)
No (batteries, rails)
Mechanism of muscle effect
Tetanic muscle contraction — "can't let go" — prolongs contact with source
Single convulsive muscle contraction — often throws victim away from source
Cardiac effect
More likely to cause VF
More likely to cause asystole
Relative danger
More dangerous at same voltage
Less dangerous but still lethal at high voltage
AC current "can't let go" phenomenon: tetanic contraction of flexor muscles locks the hand onto the conductor, extending the duration of contact and the total energy delivered to the body.
Deep internal injuries; significant rhabdomyolysis; compartment syndrome; arc burns
Ultra-high voltage
>100,000 V (transmission lines)
Flash-over often occurs — internal injury may be less than expected; extensive surface burns
External wounds are a poor guide to internal injury. Entry wound is typically small and charred; exit wound is larger and explosive. The path of current through the body causes internal damage far exceeding the external appearance.
Entry and Exit Wounds
Entry wound: small, charred, well-demarcated; typically at point of contact with source
Exit wound: larger, explosive, irregular; where current earthed (usually foot/hand touching ground)
Electrical current travels through the body following the path of least resistance: blood vessels, nerves, muscles (muscle has lower resistance than bone)
Internal injuries (cardiac, vascular, nerve, muscle) may far exceed external appearance
Look carefully for hidden exit wounds — check both hands, feet, and all skin surfaces
Arc burns: occur without direct contact — temperature of electrical arc is 3,000–20,000°C; causes flash burns to exposed skin
Cardiac Assessment
Ventricular fibrillation (VF) = most common immediate cardiac cause of death in electrical injury
Immediate 12-lead ECG for all electrical injury patients
Continuous cardiac monitoring minimum 24 hours for high-voltage injuries or symptomatic patients
Arrhythmias: VF, VT, bundle branch block, ST changes, prolonged QT
Low-voltage (household current) injury with normal initial ECG and asymptomatic patient: can discharge after 4–6 hours monitoring with safety-net advice.
Rhabdomyolysis Assessment
High-voltage injuries cause massive muscle damage through direct electrical heating
CK peaks at 24–48 hours — check at presentation and repeat 12-hourly until declining
Wound care — entry and exit wounds: assess depth; tetanus prophylaxis
Ophthalmology review — if periorbital burns or history of facial arc exposure
Burn Management
Electrical burns are usually full-thickness at entry and exit points
Do NOT use standard burn fluid resuscitation formulae (Parkland/Muir-Barclay) for electrical injuries — they underestimate total body fluid requirements (deep muscle injury not reflected in surface burn area)
Debridement by burns surgeon; potential for free flap reconstruction at entry/exit wounds
Tetanus prophylaxis — all burn and electrical injury patients
Infection monitoring: electrical burns prone to wound infection (devitalised tissue)
Compartment Syndrome Management
High-voltage electrical injuries cause deep muscle oedema → compartment syndrome
5 Ps: Pain on passive stretch (earliest and most important), Pallor, Paraesthesia, Paralysis, Pulselessness
Compartment pressure >30 mmHg (or within 30mmHg of diastolic) → emergency fasciotomy
Fasciotomy by burns/plastic surgeon — may require limb salvage vs amputation decision
Hourly limb neurovascular observations essential in high-voltage injuries
Do NOT elevate affected limb (reduces perfusion pressure)
Delayed Complications
Complication
Timing
Notes
Cataracts
Weeks to months after injury
Electrical current passes through lens → oxidative damage; both anterior and posterior subcapsular cataracts; ophthalmology follow-up for all electrical injury patients
Significant psychological trauma; flashbacks, anxiety, depression; refer to psychology
Vascular aneurysm
Weeks to months
Electrical current can damage vessel walls → delayed aneurysm formation or thrombosis
All patients with significant electrical injury should have ophthalmology review at 6 weeks post-injury and 6–12 months to screen for delayed cataract development.
Lightning Injury — Special Considerations
Lichtenberg figures — pathognomonic fern-like branching skin markings from lightning; not true burns; resolve within hours to days; diagnostic of lightning strike
Keraunoparalysis — transient paralysis and sensory changes following lightning strike; may mimic spinal cord injury; usually resolves spontaneously over hours
Lightning current is DC with extremely short duration — causes massive single contraction often throwing victim
Barotrauma from thunder: tympanic membrane rupture, otolith injury
Reverse triage: in multiple lightning casualties, ARRESTED patients are treated FIRST (good survival with prompt defibrillation; unlike other MCI scenarios)
Pregnant victims: foetal loss is common even when mother survives — foetal cardiac arrest, placental abruption
AKI from Rhabdomyolysis
Myoglobin precipitates in renal tubules → tubular obstruction and toxicity
Prevention: aggressive IV fluid resuscitation targeting UO ≥1 mL/kg/hour
Urine alkalinisation with sodium bicarbonate reduces myoglobin precipitation
If AKI develops: nephrology consultation; haemodialysis if hyperkalaemia, fluid overload, or severe acidosis
CK monitoring until declining — correlates with AKI risk
Electrical Injury in GCC Construction Industry
GCC construction sites represent one of the highest-risk environments for electrical injury globally. Migrant workers from South and Southeast Asia constitute the majority of affected victims.
High-voltage power lines on construction sites — inadequate clearance during crane operations
Temporary electrical installations with inadequate insulation and earthing
Wet working conditions (concrete pouring, water supply works) increase conductivity
Lack of lockout/tagout (LOTO) procedures when working on electrical systems
Language barriers — safety instructions not understood or followed
OSHAD (Abu Dhabi), SASO (Saudi), MOL (Qatar) electrical safety regulations exist but enforcement is variable
Labour Camp Electrical Safety
Overcrowded labour camps with overloaded electrical sockets — multiple extension leads daisy-chained create fire and electrocution risks
Self-modification of electrical appliances by workers — illegal and dangerous
Power cuts and voltage fluctuations — workers may illegally bypass safety switches
Oil and gas industrial facilities — high-voltage electrical systems; strict OSHAD/OSHA regulations for arc flash protection
Transformer and substation incidents — extremely high-voltage arc injuries with massive internal injury
Do NOT use standard Parkland formula for fluid resuscitation in electrical burns — underestimates deep muscle injury
A small entry wound does NOT mean a minor injury — internal injury may be massive
Lichtenberg figures are NOT true burns — they resolve spontaneously; do NOT treat as burns
In lightning MCI: OPPOSITE of standard triage — arrested patients are treated FIRST
GCC Clinical Practice Insights
OSHAD Electrical Safety Regulations in Abu Dhabi +
OSHAD (Abu Dhabi Occupational Safety and Health Centre) Code of Practice for Electrical Safety requires: LOTO (Lockout/Tagout) procedures for all electrical work, mandatory arc flash risk assessment for tasks near energised equipment, personal protective equipment (arc flash suits), regular electrical safety inspections, and competent person requirements for electrical maintenance. Nurses occupational health assessors in Abu Dhabi must be familiar with these regulations when reviewing workplace electrical injury reports.
Cardiac Monitoring Protocols for Electrical Injury in GCC ERs +
DHA emergency department protocols for electrical injury recommend: 12-lead ECG on arrival for all electrical injuries, continuous cardiac monitoring for ≥24 hours for high-voltage injuries or any ECG abnormality, and cardiology consultation for troponin elevation or arrhythmia. Low-voltage (domestic 220V AC) injuries with normal ECG, no loss of consciousness, and no symptoms may be discharged after 4–6 hours of observation with safety-net advice.
Rashid Hospital Burns Unit — GCC Electrical Burns Referral +
Rashid Hospital's Burns Unit in Dubai is one of the largest burns centres in the MENA region. Electrical burns with significant entry/exit wounds, deep tissue involvement, or requiring fasciotomy should be referred to a designated burns centre. Transfer criteria include: high-voltage injuries, all hand electrical burns (complex reconstruction needed), extensive arc burns, and chemical + electrical combined injuries.
Lightning Strike Emergencies in GCC — Desert and Open-Air Events +
While rare in the GCC's predominantly dry desert climate, lightning strikes do occur during spring and winter thunderstorms (particularly in UAE, Oman, and Saudi Arabia). Wadi hikers, outdoor stadium events, and desert safari participants are at risk. Nurses working at outdoor mass gathering events (F1 Abu Dhabi, outdoor concerts, camel racing) should know lightning safety protocols including: seek shelter immediately, avoid trees and high ground, and apply reverse triage principles if multiple casualties occur.
Practice MCQs
Q1. A construction worker is found in contact with a live electrical cable. A nurse happens to be nearby. What is the FIRST action?
Correct answer: B — Scene safety is the absolute first priority in electrical injury. Touching the patient while the power source is active will cause the nurse to become a second victim. The power MUST be confirmed off by an authorised person (electrician or power company). Water MUST NOT be used near live electricity. Only after confirming the area is safe should the nurse approach and begin assessment and resuscitation.
Q2. Why is alternating current (AC) considered more dangerous than direct current (DC) at the same voltage?
Correct answer: C — At 50–60 Hz (standard household AC frequency), current causes repeated stimulation of muscles causing sustained tetanic contraction. Flexor muscles of the hand grip the conductor tightly — the victim literally "cannot let go." This prolongs exposure time, delivers more energy to the body, and increases the likelihood of VF and internal injury. DC usually causes a single convulsive contraction that throws the victim away from the source.
Q3. A patient after high-voltage electrical injury develops dark brown urine and oliguria 6 hours after admission. CK is 18,000 IU/L. What is the most appropriate management?
Correct answer: C — Dark urine + oliguria + CK 18,000 = rhabdomyolysis with AKI developing. Aggressive IV fluid resuscitation (normal saline or Ringer's) targeting UO ≥1 mL/kg/hour is the cornerstone of management. Furosemide is CONTRAINDICATED in early rhabdomyolysis — it reduces renal blood flow and concentrates myoglobin in tubules. Bicarbonate alkalinises urine, reducing myoglobin precipitation. Nephrology should be involved early for potential RRT.
Q4. Six months after a significant electrical injury, a patient reports gradual blurring of vision. Slit lamp examination reveals posterior subcapsular opacities bilaterally. What is the most likely cause?
Correct answer: C — Electrical cataracts are a recognised delayed complication of significant electrical injury. Current passing through the ocular lens causes oxidative damage and protein denaturation, leading to posterior subcapsular opacities (characteristically bilateral). Onset is typically 6 weeks to 12 months after injury. This is why all significant electrical injury patients should have ophthalmology follow-up at 6 weeks and 12 months.