Pediatric emergency medicine trisk 1966 1966
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efforts to restore adequate cardiopulmonary and cerebral function, especially in
the lightning victim, may be appropriate in the context of bizarre neurologic
phenomena that inhibit ventilatory efforts, consciousness, or pupillary function.
The patient who fails to respond to resuscitative efforts over hours to days and
meets standard brain death criteria should be pronounced dead.
Any patient who sustains electrical injury needs a comprehensive physical
examination. Bleeding or edema from orofacial burns may compromise the upper
airway. The head, particularly eyes, and neck should be examined carefully for
evidence of trauma. The skin should be examined carefully for burns and bruises.
Limbs should be evaluated for pulses, perfusion, and motor and sensory function,
as well as for soft tissue swelling or evidence of fractures. Burns and deep tissue
injury may progress over hours to days, so repeated examination and monitoring
are important.
Neurologic evaluation is especially important in all but the most minor,
localized peripheral injuries. Level of consciousness and mental status should be
assessed and cranial nerve, cerebellar, motor, and sensory function should be
evaluated.
Children who have sustained minor household electrical injuries and are
asymptomatic usually do not require laboratory evaluation, cardiac evaluation, or
hospitalization. In cases of a high-tension injury or lightning strike, evaluation
should include ECG, CBC, CPK, troponin, BUN, creatinine, and urinalysis,
including urine myoglobin. Physical examination that reveals evidence of bruises,
bony tenderness, or distorted long bones should prompt appropriate radiographic
studies.
Most children who sustain burns of the oral commissure (usually after biting an
electrical cord) do not require extensive evaluation or admission. In cases of
severe orofacial burns, use of an artificial airway should be considered before
progressive edema leads to catastrophe. Mechanical ventilation may be necessary
to overcome CNS depression or primary lung involvement.
Patients with coma and loss of protective airway reflexes should be intubated
to avoid aspiration. Good oxygenation and ventilation adequate to maintain a
normal pH and PaCO 2 must be ensured. Seizure activity should be treated (see
Chapter 72 Seizures ).
The neck and back should be immobilized if the patient was thrown from the
site of injury. If the mechanism of injury was severe, a cervical collar should be
maintained in place despite normal cervical spine radiographs until more
definitive evaluation can be accomplished. If a child fails to regain consciousness
