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cardio.post-arrest.electrocution.v1

Post-cardiac-arrest care — electrical-injury-induced arrest

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.post-arrest.core.v1 — narrowed to electrical-injury cardiac arrest cohort. High-voltage / lightning produces asystole; low-voltage AC produces VF via R-on-T mechanism during vulnerable T-wave window. Post-ROSC dominated by occult deep-tissue injury (rhabdomyolysis with myoglobinuric AKI), cardiac contusion, transient AV blocks / QTc prolongation, and fall-related trauma. Aggressive crystalloid resuscitation targeting UOP 1-2 mL/kg/h with consideration of urinary alkalinization (NaHCO3) for myoglobinuria; fasciotomy if compartment syndrome; standard ACLS + post-ROSC bundle + TTM 33-37.5 °C × 24h. Inherits manifest + design-brief pointer from parent. 5 setting playbooks (ed, icu, inpatient, transition, outpatient). 4 severity triggers: rhabdo with AKI, compartment syndrome, transient AV block / QTc prolongation, severe hyperkalemia. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute Phase E wave 9.

Entry points (3)

  • symptom
    ROSC after electrical-injury cardiac arrest (high-voltage industrial, lightning, or low-voltage household AC)
    rosc_after_electrical_injury_arrest
  • history
    High-voltage (>1000 V) industrial exposure or lightning strike with cardiac arrest — asystole most common (AHA 2020 §electrical injury)
    high_voltage_industrial_or_lightning_strike_with_arrest
  • history
    Low-voltage household AC (110/220 V, 50-60 Hz) with VF — R-on-T mechanism during vulnerable T-wave window (Spies 2006 PMID 17143257)
    low_voltage_ac_household_arrest_r_on_t_vf

Required inputs (20)

  • agerequired
    demographic • used at CONTEXT
    Pediatric vs adult electrical injury patterns differ (oral commissure burns in toddlers; occupational pattern in working-age adults); age also affects rhabdomyolysis tolerance + AKI risk
  • voltage_classrequired
    history • used at CONTEXT
    High-voltage (>1000 V) → asystole + extensive deep-tissue injury + multi-system trauma; low-voltage (<1000 V AC) → VF predominant; lightning → unique pattern (Lichtenberg figures, keraunoparalysis, asystole that often spontaneously reverts)
  • current_pathway_estimaterequired
    history • used at CONTEXT
    Hand-to-hand or hand-to-foot pathway = transthoracic current → highest cardiac arrest risk; estimating entry/exit wound location informs the deep-tissue injury workup
  • arrest_witnessedrequired
    history • used at CONTEXT
    Witnessed + bystander CPR + low-flow time → favorable neuro prognosis (AHA 2020); CAHP/OHCA score inputs
  • initial_rhythmrequired
    history • used at CONTEXT
    High-voltage typically asystole; low-voltage AC typically VF; lightning often asystole that reverts spontaneously then deteriorates to secondary VF/asystole from hypoxia
  • low_flow_time_minrequired
    history • used at CONTEXT
    CPR duration → ECPR eligibility (ARREST PMID 33308475 — <60 min low-flow); neuro prognosis weighting
  • fall_or_blast_associated_traumarequired
    history • used at CONTEXT
    Electrical shock often produces tetanic muscle contraction → fall from height or blast injury → C-spine + head + long-bone injuries; mandates trauma evaluation
  • sbprequired
    vital • used at TREATMENT
    MAP ≥65 target post-ROSC; hypovolemia from third-spacing / burn shock common with high-voltage; SCAI staging if shock
  • core_temprequired
    vital • used at TREATMENT
    TTM target 33-37.5 °C × 24h (TTM2 PMID 34133859); not contraindicated by burn injury but coordinate with burn center
  • spo2required
    vital • used at TREATMENT
    Avoid hyperoxia: SpO2 92-98% (AHA 2020 Class IIa); inhalation injury possible if arc/blast exposure
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Often normal initially after ROSC, but 25-50% develop transient AV blocks / QTc prolongation / ischemic patterns from coronary spasm in first 24h — serial ECGs at 4-6h interval (Spies 2006 PMID 17143257)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Cardiac contusion + coronary spasm both produce troponin elevation; rise pattern helps distinguish electrical-injury myocardial damage from concomitant ACS triggered by stress
  • ck_with_mbrequired
    lab • used at INITIAL_WORKUP
    CK-total marker for skeletal muscle injury → rhabdomyolysis; CK-MB can be misleading if total CK very high (skeletal contribution); CK >5000 U/L = high AKI risk threshold (Bosch 2009 PMID 19571284)
  • serum_myoglobin_or_urine_myoglobinrequired
    lab • used at INITIAL_WORKUP
    Myoglobinuria → pigment nephropathy → AKI; dipstick "blood" positive without RBCs on microscopy = myoglobinuria pattern; quantitative serum or urine myoglobin available in many centers
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Tissue hypoperfusion + anaerobic metabolism from deep-tissue ischemia + post-arrest perfusion debt; clearance trajectory drives prognosis (SCAI 2022 PMID 35718438)
  • creatininerequired
    lab • used at CONTEXT
    AKI from myoglobinuria + post-arrest hypoperfusion; baseline + serial trending q6-12h drives renal-replacement consideration; KDIGO 2012 staging
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    Hyperkalemia from cell-membrane damage + rhabdo + AKI; potentially massive if severe rhabdo; correct to 4-4.5 with insulin/glucose ± dialysis if refractory
  • cxr_post_electrocutionrequired
    imaging • used at INITIAL_WORKUP
    Aspiration / pneumothorax from CPR / inhalation injury / blast pattern; baseline for ARDS evolution
  • ct_head_and_c_spine_if_amfs_or_fall
    imaging • used at INITIAL_WORKUP
    Tetanic contraction-related fall → C-spine + head injury; AMS post-ROSC mandates CT head; cervical immobilization until cleared
  • echo_post_rosc
    imaging • used at INITIAL_WORKUP
    LV/RV function for cardiac contusion vs post-arrest stunning; baseline for serial follow-up

12-phase flow (12)

  1. 1FRAME
    Electrical-injury cardiac arrest — high-voltage / lightning typically asystole; low-voltage AC typically VF via R-on-T; post-ROSC dominated by occult deep-tissue injury (rhabdo + AKI), cardiac contusion, transient conduction abnormalities, and fall-related trauma; route to parent cardio.post-arrest.core.v1 for TTM + neuroprog
    inputs: voltage_class, current_pathway_estimate
    advance: electrical etiology + voltage class + pathway documented
  2. 2ENTRY
    Standard ACLS for index arrest; immediate scene-safety assessment (rescuer must not contact live source); C-spine immobilization given high fall-trauma incidence; full trauma evaluation in parallel with post-arrest care
    inputs: age, arrest_witnessed, fall_or_blast_associated_trauma
    advance: scene-safe + ACLS + trauma evaluation initiated
  3. 3CONTEXT
    Voltage class, current pathway, source contact duration, witnessed status, fall height, prior cardiac history, occupational vs household exposure, lightning-specific features (Lichtenberg figures, keraunoparalysis)
    inputs: initial_rhythm, low_flow_time_min, sbp, core_temp, spo2, creatinine, potassium
    advance: context complete + GOC + family + occupational injury reporting documented
  4. 4RED_FLAGS
    Rhabdomyolysis with rising CK + AKI; compartment syndrome (firm/tense compartment + pain out of proportion + decreased pulses + paresthesia); transient high-grade AV block; refractory hyperkalemia; refractory shock; concomitant traumatic injuries from fall; inhalation / arc-blast lung injury
    inputs: ck_with_mb, creatinine, potassium, sbp, ecg_12_lead
    actions: cardiogenic_shock
    advance: red flags screened + escalations triggered
  5. 5INITIAL_WORKUP
    ECG + serial troponin + CK ± myoglobin + BMP + lactate + ABG + CBC + coags + UA (myoglobinuria) + CXR + bedside echo + CT head/C-spine if AMS or fall + secondary survey for entry/exit wounds + compartment exam
    inputs: ecg_12_lead, troponin, ck_with_mb, serum_myoglobin_or_urine_myoglobin, lactate, potassium, cxr_post_electrocution
    actions: post_arrest_care, panel.cardiac, panel.renal
    advance: workup complete + AKI risk + cardiac injury + trauma + deep-tissue injury assessed
  6. 6BRANCHING_WORKUP
    STEMI on post-ROSC ECG → cath; recurrent VT/VF → EP / channelopathy workup unmasked by injury; ARDS post-blast → ARDSnet vent; compartment syndrome → fasciotomy; severe burns → burn-center transfer; inhalation injury → bronchoscopy
    actions: acs_pathway, wide_complex_tach
    advance: cardiac vs trauma vs burn vs renal branching decided
  7. 7DIFFERENTIAL
    Primary electrical-injury arrest (direct cardiac depolarisation) vs secondary (hypoxia from prolonged tetany, fall-trauma) vs unmasked underlying disease (LQTS, Brugada, ischemic) vs concomitant injury (TBI from fall, hemorrhagic shock)
    advance: primary vs secondary mechanism + unmasked etiologies established
  8. 8RISK_STRATIFICATION
    CAHP/OHCA scores partial applicability; CK trend + AKI stage drive renal-replacement decision; SCAI shock stage; burn-injury severity scoring (Lund-Browder if extensive cutaneous burn); GCS off sedation if delayed neuroprog window
    inputs: initial_rhythm, low_flow_time_min, sbp, lactate, ck_with_mb, creatinine
    actions: calc.map, calc.heart, calc.ckd_epi_2021, calc.cha2ds2vasc
    advance: risk class + AKI + burn severity + neuro prognosis documented
  9. 9TREATMENT
    Aggressive IVF target UOP 1-2 mL/kg/h for rhabdo prevention; consider urinary alkalinization with NaHCO3 if myoglobinuria + acidic urine (controversial but commonly used); fasciotomy if compartment syndrome; treat hyperkalemia (calcium + insulin/glucose ± dialysis); TTM 33-37.5 °C × 24h once stable; standard post-ROSC bundle (vasopressor → MAP ≥65, lung-protective vent, sedation); cardiac-cause-specific therapy if STEMI / channelopathy; burn-center transfer if extensive cutaneous burns
    inputs: sbp, core_temp, spo2, creatinine, potassium, ck_with_mb
    actions: protocol.cardiogenic_shock
    advance: IVF resuscitation + rhabdo bundle + TTM + post-ROSC bundle delivered
  10. 10DISPOSITION
    CICU vs MICU vs burn ICU per predominant problem (cardiac arrhythmia → CICU; AKI/rhabdo predominant → MICU; extensive burns → burn ICU); multidisciplinary team — cardiology + nephrology + burn surgery + trauma + neurology
    advance: unit + service-line ownership assigned
  11. 11MONITORING
    Continuous telemetry (capture transient AV blocks for first 24h) + arterial line + central line + Foley with hourly UOP target 1-2 mL/kg/h; CK q6h until peak documented + downtrending; BMP q6h with K + Cr + bicarb; serial troponin; serial neuro exams; multimodal neuroprog ≥72h post-rewarm (Sandroni 2021 PMID 33745427); compartment exam q4h × 24h then q8h
    inputs: ck_with_mb, creatinine, potassium
    actions: panel.renal, panel.cardiac
    advance: monitoring + rhabdo trajectory + neuroprog timeline documented
  12. 12FOLLOWUP
    Cardiology follow-up at 1-2 weeks for QTc + LV function reassessment; nephrology if AKI persists; PT/OT for deep-tissue + burn rehab; trauma surgery for fracture / spinal injuries; mental health (PTSD risk very high); occupational medicine + workers-comp documentation if work-related; family CPR/AED training; cardiac MRI if suspected channelopathy unmasked or persistent dysfunction
    advance: cardiology + nephrology + rehab + mental health + occupational follow-up booked