1. First responders should remove the patient from the electricity source while avoiding injury themselves.
2. In cases of cardiac arrest due to arrhythmia after electrical injury, follow advanced cardiac life support (ACLS) protocol and provide hemodynamic monitoring if spontaneous circulation returns.
3. Small skin contact points (cutaneous burns) can hide extensive soft tissue damage. Observe the patient closely for clinical signs of compartment syndrome (refer to the Circumferential Burns section above, and the Extremity Compartment Syndrome3 for discussion of escharotomy/fasciotomy). Tissue that is obviously necrotic must be surgically debrided. Note that escharotomy, which relieves the tourniquet effect of circumferential burns, will not necessarily relieve elevated muscle compartment pressure due to myonecrosis associated with electrical injury; therefore fasciotomy is usually required.
4. Compartment syndrome and muscle injury may lead to rhabdomyolysis, causing pigmenturia and renal injury. Pigmenturia typically presents as red-brown urine. In patients with pigmenturia, fluid resuscitation requirements are much higher than those predicted for a similar-sized thermal burn. Isotonic fluid infusion should be adjusted to maintain UOP 75-100 mL/hr in adult patients with pigmenturia. If the pigmenturia does not clear after several hours of resuscitation consider IV infusion of mannitol, 12.5 g per liter of lactated Ringer’s solution, and/or sodium bicarbonate (150 mEq/L in D5W). These infusions may be given empirically; it is not necessary to monitor urinary pH. In patients receiving mannitol (an osmotic diuretic), close monitoring of intravascular status via CVP and other parameters is required.