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cardio.post-arrest.electrocution.v1PRODUCTION
cardio.post-arrest.electrocution.v1

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

cardiologyacuteadult
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12/12 authored

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Detailed

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

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electrical etiology + voltage class + pathway documented

Patient inputs (20)

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

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)

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

Witnessed + bystander CPR + low-flow time → favorable neuro prognosis (AHA 2020); CAHP/OHCA score inputs

High-voltage typically asystole; low-voltage AC typically VF; lightning often asystole that reverts spontaneously then deteriorates to secondary VF/asystole from hypoxia

CPR duration → ECPR eligibility (ARREST PMID 33308475 — <60 min low-flow); neuro prognosis weighting

Electrical shock often produces tetanic muscle contraction → fall from height or blast injury → C-spine + head + long-bone injuries; mandates trauma evaluation

AKI from myoglobinuria + post-arrest hypoperfusion; baseline + serial trending q6-12h drives renal-replacement consideration; KDIGO 2012 staging

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)

Cardiac contusion + coronary spasm both produce troponin elevation; rise pattern helps distinguish electrical-injury myocardial damage from concomitant ACS triggered by stress

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)

Myoglobinuria → pigment nephropathy → AKI; dipstick "blood" positive without RBCs on microscopy = myoglobinuria pattern; quantitative serum or urine myoglobin available in many centers

Tissue hypoperfusion + anaerobic metabolism from deep-tissue ischemia + post-arrest perfusion debt; clearance trajectory drives prognosis (SCAI 2022 PMID 35718438)

Hyperkalemia from cell-membrane damage + rhabdo + AKI; potentially massive if severe rhabdo; correct to 4-4.5 with insulin/glucose ± dialysis if refractory

Aspiration / pneumothorax from CPR / inhalation injury / blast pattern; baseline for ARDS evolution

MAP ≥65 target post-ROSC; hypovolemia from third-spacing / burn shock common with high-voltage; SCAI staging if shock

TTM target 33-37.5 °C × 24h (TTM2 PMID 34133859); not contraindicated by burn injury but coordinate with burn center

Avoid hyperoxia: SpO2 92-98% (AHA 2020 Class IIa); inhalation injury possible if arc/blast exposure

Tetanic contraction-related fall → C-spine + head injury; AMS post-ROSC mandates CT head; cervical immobilization until cleared

LV/RV function for cardiac contusion vs post-arrest stunning; baseline for serial follow-up

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Severity triggers (4)

4 need judgement
  • informationallife_threateningcompartment_syndrome_post_electrocution
    Firm/tense extremity compartment + pain out of proportion + decreased pulses + paresthesia + measured pressure >30 mmHg or delta-P <30 mmHg
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_hyperkalemia_above_6_with_rhabdo_aki
    Serum K >6.0 with ECG changes (peaked T waves, widened QRS) in setting of rhabdo + AKI post-electrocution
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererhabdomyolysis_with_aki_post_electrocution
    CK >5000 U/L with rising creatinine and / or myoglobinuria in post-electrocution patient — myoglobinuric AKI (Bosch 2009 PMID 19571284; KDIGO 2012 §5.4)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretransient_av_block_or_qtc_prolongation_post_electrocution
    New AV block (any degree) or QTc >500 ms on serial ECG within first 24h post-electrocution — Spies 2006 PMID 17143257
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Electrical-injury post-arrest phenotype — IVF rhabdo bundle + cardiac conduction surveillance + post-ROSC standard bundle (AHA 2020 + Spies 2006 + Bosch 2009 + KDIGO 2012)
axis: electrocution_post_arrest_phenotype
Selected axis "Electrical-injury post-arrest phenotype — IVF rhabdo bundle + cardiac conduction surveillance + post-ROSC standard bundle (AHA 2020 + Spies 2006 + Bosch 2009 + KDIGO 2012)" by default fallback (first axis)
  • norepinephrine
    first line
    vasopressor_alpha1_beta1
    0.05-0.5 µg/kg/min titrate MAP ≥65 • IV • continuous
    triggers: post_rosc_vasoplegia, burn_shock_with_distributive_component
    SOAP-II PMID 20200382; first-line post-ROSC vasoactive
    rxcui 7512
  • amiodarone
    first line
    class_iii_antiarrhythmic
    300 mg IV bolus → 150 mg if recurrent → 1 mg/min × 6h → 0.5 mg/min × 18h • IV • standard ACLS dosing
    triggers: recurrent_vf_pvt_post_electrocution, sustained_vt_with_pulse
    AHA 2020 ACLS Class IIb; standard cadence (no hypothermia adjustment unless TTM in deep-cool phase)
    rxcui 703
  • epinephrine
    first line
    inotrope_chronotrope_vasopressor
    1 mg IV q3-5 min during arrest • IV • standard ACLS
    triggers: cardiac_arrest, pea_asystole_during_index_arrest
    AHA 2020 ACLS
    rxcui 3992
  • sodium bicarbonate
    add on
    alkalinizing_agent
    150 mEq in 1 L D5W at 150-250 mL/h to target urine pH ≥6.5 • IV • continuous infusion
    triggers: myoglobinuria_with_acidic_urine, severe_metabolic_acidosis_with_rhabdo
    KDIGO 2012 §5.4 — urinary alkalinization for myoglobinuric AKI prevention; controversial Class IIb but commonly used; monitor pH + bicarb + Ca
    rxcui 8591
  • calcium gluconate
    first line
    electrolyte_membrane_stabilizer
    1-3 g IV over 5-10 min • IV • as needed for hyperkalemia ECG changes
    triggers: hyperkalemia_with_ecg_changes, severe_hyperkalemia_above_6_5
    KDIGO 2020 hyperkalemia — membrane stabilization within minutes; precedes shifting therapies
    rxcui 1908
  • insulin regular
    first line
    short_acting_insulin
    10 units IV with 25 g D50 • IV • as needed for hyperkalemia
    triggers: hyperkalemia_above_6_0_persistent_after_calcium
    KDIGO 2020 hyperkalemia — intracellular K shift; monitor glucose q1h × 4-6h
    rxcui 253182
  • magnesium sulfate
    add on
    electrolyte_anti_arrhythmic
    1-2 g IV • IV • one-time + repeat for TdP
    triggers: torsades_de_pointes_post_electrocution_qtc_prolongation, long_qt_unmasked
    AHA 2020 ACLS Class IIa for TdP; QTc prolongation common in first 24h post-electrocution
    rxcui 6585
  • propofol
    first line
    sedative_iv_anesthetic
    5-50 µg/kg/min • IV • continuous; titrate RASS
    triggers: post_rosc_intubation_ttm
    PADIS 2018
    rxcui 8782
  • fentanyl
    first line
    opioid_analgesic
    25-200 µg/h • IV • continuous
    triggers: post_rosc_intubation_ttm, burn_pain_management, shivering_control
    PADIS 2018; analgesia + shivering suppression for TTM
    rxcui 4337
  • tranexamic acid
    add on
    antifibrinolytic
    1 g IV over 10 min • IV • within 3h of bleeding onset
    triggers: concomitant_traumatic_bleeding_from_fall, hemorrhagic_shock_co_existing
    CRASH-2 PMID 20554319 if traumatic bleeding co-existing with electrocution
    rxcui 10691

outpatient playbook — drug actions (2)

  1. 1. continue channelopathy regimen if unmasked
    rxcui 6918
    nadolol or metoprolol per indication • PO • daily
    trigger: channelopathy or persistent QTc/arrhythmia
    HRS 2017
  2. 2. continue HF GDMT if structural CM
    rxcui 1656328
    sacubitril-valsartan + carvedilol + spironolactone + SGLT2i max tolerated • PO • as scheduled
    trigger: structural CM HFrEF
    ACC/AHA 2022 HF 4-pillar

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ROSC after electrical-injury cardiac arrest (high-voltage industrial, lightning, or low-voltage household AC); High-voltage (>1000 V) industrial exposure or lightning strike with cardiac arrest — asystole most common (AHA 2020 §electrical injury); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Post-cardiac-arrest care — electrical-injury-induced arrest** (cardio.post-arrest.electrocution.v1).
Phenotype framing: 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)
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **Electrical-injury post-arrest phenotype — IVF rhabdo bundle + cardiac conduction surveillance + post-ROSC standard bundle (AHA 2020 + Spies 2006 + Bosch 2009 + KDIGO 2012)**.
1. norepinephrine 0.05-0.5 µg/kg/min titrate MAP ≥65 IV continuous (vasopressor_alpha1_beta1, first line) — SOAP-II PMID 20200382; first-line post-ROSC vasoactive
2. amiodarone 300 mg IV bolus → 150 mg if recurrent → 1 mg/min × 6h → 0.5 mg/min × 18h IV standard ACLS dosing (class_iii_antiarrhythmic, first line) — AHA 2020 ACLS Class IIb; standard cadence (no hypothermia adjustment unless TTM in deep-cool phase)
3. epinephrine 1 mg IV q3-5 min during arrest IV standard ACLS (inotrope_chronotrope_vasopressor, first line) — AHA 2020 ACLS
4. sodium bicarbonate 150 mEq in 1 L D5W at 150-250 mL/h to target urine pH ≥6.5 IV continuous infusion (alkalinizing_agent, add on) — KDIGO 2012 §5.4 — urinary alkalinization for myoglobinuric AKI prevention; controversial Class IIb but commonly used; monitor pH + bicarb + Ca
5. calcium gluconate 1-3 g IV over 5-10 min IV as needed for hyperkalemia ECG changes (electrolyte_membrane_stabilizer, first line) — KDIGO 2020 hyperkalemia — membrane stabilization within minutes; precedes shifting therapies
6. insulin regular 10 units IV with 25 g D50 IV as needed for hyperkalemia (short_acting_insulin, first line) — KDIGO 2020 hyperkalemia — intracellular K shift; monitor glucose q1h × 4-6h
7. magnesium sulfate 1-2 g IV IV one-time + repeat for TdP (electrolyte_anti_arrhythmic, add on) — AHA 2020 ACLS Class IIa for TdP; QTc prolongation common in first 24h post-electrocution
8. propofol 5-50 µg/kg/min IV continuous; titrate RASS (sedative_iv_anesthetic, first line) — PADIS 2018
9. fentanyl 25-200 µg/h IV continuous (opioid_analgesic, first line) — PADIS 2018; analgesia + shivering suppression for TTM
10. tranexamic acid 1 g IV over 10 min IV within 3h of bleeding onset (antifibrinolytic, add on) — CRASH-2 PMID 20554319 if traumatic bleeding co-existing with electrocution

Setting playbook (outpatient) — Long-term cardiology / EP / nephrology surveillance; ICD management if channelopathy or structural CM; mental health long-term; occupational medicine if work-related
11. continue channelopathy regimen if unmasked nadolol or metoprolol per indication PO daily — channelopathy or persistent QTc/arrhythmia (HRS 2017)
12. continue HF GDMT if structural CM sacubitril-valsartan + carvedilol + spironolactone + SGLT2i max tolerated PO as scheduled — structural CM HFrEF (ACC/AHA 2022 HF 4-pillar)

Non-pharmacologic actions:
- ICD/WCD adherence
- Workplace safety + PPE long-term
- Family CPR/AED ongoing
- Mental health long-term

AVOID / contraindication checks:
- Beta_blocker_avoid_acute_cardiogenic_shock (AHA 2020)
- Succinylcholine_avoid_severe_rhabdo_with_hyperkalemia (anesthesia consensus)
- Nephrotoxic_drug_avoid_evolving_aki (KDIGO 2012)
- Nsaid_avoid_aki_or_rhabdo (KDIGO 2012)

Monitoring

Regimen monitoring:
- continuous ecg telemetry x 24h for transient conduction block (AHA 2020 + Spies 2006)
- serial ecg q4-6h x 24h for qtc av block evolution (Spies 2006 PMID 17143257)
- serial troponin q3-6h x 24h (4th UDMI 2018)
- CK q6h until peak then q12h until downtrending (Bosch 2009 PMID 19571284)
- BMP q6h + K + Mg + Ca + bicarb (rhabdo electrolyte derangement)
- urine output hourly target 1-2 mL/kg/h (KDIGO 2012 §5.4)
- urine pH q2-4h if alkalinizing target pH above 6.5 (KDIGO 2012)
- compartment exam q4h x 24h then q8h (orthopedic literature)
- continuous core temp via bladder or esophageal probe during TTM (TTM2)
- continuous EEG for 24-48h (Sandroni 2021)
- NSE at 24h 48h 72h (Sandroni 2021)
- lactate q2-4h until normalized (SCAI 2022)

Setting (outpatient) monitoring:
- Quarterly BP + weight + symptom score
- Annual ECG + Holter if channelopathy
- Annual echo if HFrEF

Follow-up plan: 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
- Close-out criterion: cardiology + nephrology + rehab + mental health + occupational follow-up booked

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term cardiology / EP / nephrology surveillance; ICD management if channelopathy or structural CM; mental health long-term; occupational medicine if work-related

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 for chronic HFrEF

Escalation triggers (move to higher acuity):
- ICD therapy delivered → urgent EP; consider catheter ablation per VANISH (PMID 27149033) if structural substrate
- EF declining despite GDMT → advanced HF eval

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Firm/tense extremity compartment + pain out of proportion + decreased pulses + paresthesia + measured pressure >30 mmHg or delta-P <30 mmHg
- [LIFE_THREATENING] Serum K >6.0 with ECG changes (peaked T waves, widened QRS) in setting of rhabdo + AKI post-electrocution
- [SEVERE] CK >5000 U/L with rising creatinine and / or myoglobinuria in post-electrocution patient — myoglobinuric AKI (Bosch 2009 PMID 19571284; KDIGO 2012 §5.4)

Citations

- AHA 2020 ACLS / Post-Cardiac-Arrest Care electrical injury § + Spies 2006 narrative review + Koumbourlis 2002 + KDIGO 2012 AKI + KDIGO 2020 hyperkalemia + TTM2 + HYPERION + Sandroni 2021 neuroprog [PMID:33081530](https://pubmed.ncbi.nlm.nih.gov/33081530/)
- Cited evidence (PMID 17143257) [PMID:17143257](https://pubmed.ncbi.nlm.nih.gov/17143257/)
- Cited evidence (PMID 12528783) [PMID:12528783](https://pubmed.ncbi.nlm.nih.gov/12528783/)
- Cited evidence (PMID 19571284) [PMID:19571284](https://pubmed.ncbi.nlm.nih.gov/19571284/)
- Cited evidence (PMID 34133859) [PMID:34133859](https://pubmed.ncbi.nlm.nih.gov/34133859/)

Last reconciled with current guidelines: 2026-05-15.
References
  • AHA 2020 ACLS / Post-Cardiac-Arrest Care electrical injury § + Spies 2006 narrative review + Koumbourlis 2002 + KDIGO 2012 AKI + KDIGO 2020 hyperkalemia + TTM2 + HYPERION + Sandroni 2021 neuroprog — PMID:33081530
  • Cited evidence (PMID 17143257) — PMID:17143257
  • Cited evidence (PMID 12528783) — PMID:12528783
  • Cited evidence (PMID 19571284) — PMID:19571284
  • Cited evidence (PMID 34133859) — PMID:34133859