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Three Part Question

In [patients who have sustained a household voltage electrical injury with normal initial ECG] is [admission for monitoring] necessary to [reduce the risk of sudden death from cardiac arrhythmias]?

Clinical Scenario

A 30 year old male elctrician attends the emergency department having suffered an electrical shock while servicing a washing machine. There was no water involved.

Search Strategy

Medline 1966-10/03 using the OVID interface.
[exp electric injuries OR exp burns, electric OR electric injuries.mp OR electrocution.mp] AND [exp monitoring, physiologic OR monitoring.mp]

Search Outcome

102 papers found of which 96 were irrelevant. The remaining 6 papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Fatovich DM & Lee KY, 1991, Australia	20 patients exposed to 240 volts AC electric supply	Observational study, literature review	Initial ECG, cardiac monitor	2/20 abnormal, no new abnormality detected	Retrospective, no statistical analysis
Cunningham P, 1991, Australia	70 patients exposed to 240 AC electric supply	Observational study, survey of management policy	Initial ECG, cardiac monitor	11/59 abnormal, 6 deaths, no new abnormality detected	Retrospective analysis, no statistical analysis
Bailey B et al, 1995, Canada	151 children (8 months to 18 years) exposed to 120 or 240 volts AC electric supply	Observational study	Initial ECG, cardiac monitor	1/113 abnormal, no new abnormality detected	Retrospective, missing data
Garcia CT et al, 1995, USA	Patients aged less than 21 years exposed to minor (<1000 volts) electrical injury	Observational study	Initial ECG, cardiac monitor	2/53 abnormal, no new abnormality detected	Retrospective, missing data
Wallace BH et al, 1995, USA	26 children exposed to 120 or 240 volts AC electric supply	Observational study	Initial ECG, cardiac monitor	1/17 abnormal, no new abnormaility detected	Retrospective
Blackwell N & Hayllar J 2002 Australia	202 patients presenting to an Emergency Department in Australia. Patients were seen and underwent a 6 hour protocol to rule out any significant injury. A large number of patients came from a single industrial source. 186 patients with 196 injuries were included (some turned out not to be electrocuted ).	Prospective cohort study	No of patients with normal ECG who went to have adverse event	No episodes	3% of patients did not complete 6 hours of monitoring. Many patients attended as a result of company policy at a nearby facility. This may be a different group from other EDs.
			Number of patients with abnormal ECG opn arrival	8/196 had ECG abnormalities on arrival
Wilson CM & Fatovitch DM, 1998 Australia	40 children presenting to an emergency department following electrical injury.	Observational	Number with abnormal ECG on arrival	1/40	Children only
			Number who subsequently developed ECG abnormality	none

Comment(s)

While there are numerous case reports in the literature of dysrythmias developing after both 240 and high voltage electrical injury no studies have shown onset of dysrythmias after initial assessment. Only observational studies were identified looking at household electrical injury and late onset cardiac arrythmias.

Editor Comment

Search updated on 10/03. New papers added.

Clinical Bottom Line

Routine cardiac monitoring is not required after household voltage electrical injury if the patient is asymptomatic and has nomral initial electrocardiography. Asymptomatic patients involved in minor electrical events do not require investigation or admission.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Fatovich DM, Lee KY. Household electrical shocks: who should be monitored? Med J Aust 1991;155(5):301-303.
2. Cunningham PA. The need for cardiac monitoring after electrical injury. Med J Aust 1991;154(11):765-766.
3. Bailey B, Gaudreault P, Thiverge RL, et al. Cardiac monitoring of children with household electrical injuries. Ann Emerg Med 1995;25(5):612-617.
4. Garcia CT, Smith GA, Cohen DM, et al. Electrical injuries in a pediatric emergency department. Ann Emerg Med 1995;26(5):604-608.
5. Wallace BH, Cone JB, Vanderpool RD, et al. Retrospective evaluation of admission criteria for paediatric electrical injuries. Burns 1995;21(8):590-593.
6. Blackwell N, Hayllar J. A three year prospective audit of 212 presentations to the emergency department after electrical injury with a management protocol. Postgraduate Medical Journal 2002;78:283.
7. Wilson CM, Fatovitch DM. Do children need to be monitored after electric shocks? Journal of Paediatrics & Child Health 1998;34:474-476.