今日の臨床サポート

電撃傷

著者: 遠藤拓郎 国際医療福祉大学医学部救急医学

監修: 志賀隆 国際医療福祉大学 医学部救急医学/国際医療福祉大学病院 救急医療部

著者校正/監修レビュー済:2021/12/15
患者向け説明資料

概要・推奨   

  1. 電撃傷とは体内に高電流が流れることによって生じる損傷をいう。電流によるジュール熱が深部組織を損傷する「真性電撃傷」と、衣服火災などによる「電気火傷(熱傷)」がある。
  1. 真性電撃傷の患者における心筋損傷において、CK/CK-MBやトロポニンなどの心筋バイオマーカーは参考とし、他の臨床所見とあわせて診断することが推奨される(推奨度1)
  1. 電撃傷の患者で意識消失や不整脈が見られた場合には、心電図所見で虚血を疑う場合には、心電図の継続モニタリングが推奨される(推奨度1)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
遠藤拓郎 : 特に申告事項無し[2022年]
監修:志賀隆 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 2021年秋の改訂では、熱傷診療ガイドライン 改訂第 3 版(2021年7月)から、特にCQ8特殊熱傷の電撃症の該当部分を追加した。熱傷診療ガイドラインでは、これまで電撃傷の項目は含まれていなかったが、改訂第3版においては、電撃症の受傷早期の管理、治療に焦点を絞ったCQとして、CQ8-1モニタリングの必要性、8-2減張切開の必要性についての検討内容が含まれたので、その内容を反映した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. わが国での詳細な報告はないが、米国では電撃傷での入院患者数は、全熱傷入院患者の約3%に当たる約3,000人/年であり、約1,000人/年が死亡している[1]
  1. 約2/3が建設業・電気事業就労者である[1]
  1. 体内に高電流が流れることによって生じる損傷をいう。電流によるジュール熱が深部組織を損傷する真性電撃傷と、衣服火災などによる電気火傷(熱傷)がある。真性電撃傷では体表面の創と重症度は必ずしも一致しない[2]
  1. 交流1,000V以上を高電圧、交流1,000V未満を低電圧による損傷とする[3]。また雷撃傷は別に考える。
 
雷撃傷と高電圧/低電圧損傷の比較

それぞれで臨床症状が異なるため受傷機転、電圧量の確認が必要となる。

 
電撃傷の損傷機序

感電。高エネルギー電撃に伴う様々な損傷機序。1,000Vを超える電圧の(アークによる)感電は、まず機械的な接触から始まる。接触点の高温により全層熱傷が生じる。次に、電流が四肢を通過することで、筋肉と神経膜が電気的に破壊される。数秒間にわたる接触では、重度の深部熱傷が生じる。高エネルギーのアークによる感電では、鈍的外傷を引き起こす衝撃波をもたらす。

 
  1. 以降、「真性電撃傷」について記載する。
問診・診察のポイント  
  1. 電流斑(電流出入口部の潰瘍、炭化・凝固壊死)を形成することがある(<図表>)が、電流出入口部の抵抗と接触面積により創の程度は異なるため、重症度は創の大きさに一致しない。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

V García-Sánchez, P Gomez Morell
Electric burns: high- and low-tension injuries.
Burns. 1999 Jun;25(4):357-60. doi: 10.1016/s0305-4179(98)00189-2.
Abstract/Text From January 1993 to December 1997, 179 patients with electrical injuries were admitted to our burn unit. There were 55 patients with high-tension injuries and 124 patients with low-tension injuries. A high incidence of amputation (42%) is one of the characteristic sequelae of high-tension injuries, but no patients in this group of burns died. Early and serial debridement of necrotic tissue is our treatment of preference. The patient needs extensive rehabilitation and psychiatric support.

PMID 10431986
Brett Arnoldo, Matthew Klein, Nicole S Gibran
Practice guidelines for the management of electrical injuries.
J Burn Care Res. 2006 Jul-Aug;27(4):439-47. doi: 10.1097/01.BCR.0000226250.26567.4C.
Abstract/Text
PMID 16819345
Seong Hwan Kim, Goo-Yeong Cho, Min-Kyu Kim, Woo-Jung Park, Jong-Hyun Kim, Hong Euy Lim, Sang Yup Lim, Chol Shin
Alterations in left ventricular function assessed by two-dimensional speckle tracking echocardiography and the clinical utility of cardiac troponin I in survivors of high-voltage electrical injury.
Crit Care Med. 2009 Apr;37(4):1282-7. doi: 10.1097/CCM.0b013e31819c3a83.
Abstract/Text OBJECTIVE: There has been limited study regarding the effects of high-voltage electrical injury on left ventricular (LV) function, as well as the clinical utility of using cardiac troponin I (cTnI) to assess such injuries. We investigated changes in LV function by using two-dimensional speckle tracking imaging, and we also studied the clinical utility of cTnI for predicting myocardial damage in survivors of high-voltage electrical injury.
DESIGN: Prospective clinical study.
SETTING: Burn care unit and echocardiography laboratory of a university hospital.
PATIENTS: Twenty male patients surviving a high-voltage electrical injury.
INTERVENTIONS: From July 2006 to October 2007, 20 patients suffering from high-voltage electrical injury were prospectively evaluated. A serial echocardiogram was obtained from each patient on hospital days 1, 3, and 7. Serum cTnI levels were drawn at baseline and every 6 hours for the first 24 hours. All parameters of the study patients were compared with age-, sex-, and body mass index-matched healthy controls.
MEASUREMENTS AND MAIN RESULTS: On the day of admission and during follow-up, there were no significant differences in LV dimension, stroke volume index, LV fractional shortening, LV ejection fraction, or peak systolic strain as compared with the controls. In contrast to the peak systolic strain, the peak systolic strain rate was significantly increased at baseline and during follow-up for the patient group. There were no significant differences in LV systolic function parameters between the two groups according to the level of cTnI.
CONCLUSION: The current study demonstrates that LV dysfunction after high-voltage electrical injury is uncommon, and that the serum cTnI level does not seem to be a useful diagnostic test for predicting impairment of LV contractility in patients who did not experience cardiac arrest or fatal arrhythmia.

PMID 19242352
D P Luz, L S Millan, M S Alessi, W F Uguetto, A Paggiaro, D S Gomez, M C Ferreira
Electrical burns: a retrospective analysis across a 5-year period.
Burns. 2009 Nov;35(7):1015-9. doi: 10.1016/j.burns.2009.01.014. Epub 2009 Jun 7.
Abstract/Text This study aims to review the experience, at an institution, with patients who suffered electrical burns and study the peculiar characteristics of this type of burn as well as its complications and epidemiological aspects. The study includes medical records of patients with electrical burns who were admitted to the Burn Unit of Hospital das Clínicas in São Paulo, Brazil, from November 2001 to October 2006. They were classified into four categories: high voltage (> or =1000 V), low voltage (<1000 V), 'flash burn' (in which there is no electrical current flow through the body of the patient) and burns caused by lightning. The complications were more severe and common in the high-voltage group, while longer hospital stays and more complex surgical procedures due to the greater depth of burns were also observed in this group. High-voltage burns are mainly labour-/occupation-related. The majority of the patients were young men at the beginning of their professional lives. This factor generates an important socio-economic impact due to the high incidence of sequelae, resulting in amputations, rendering them unable to maintain their occupations.

PMID 19501979
G F Purdue, J L Hunt
Electrocardiographic monitoring after electrical injury: necessity or luxury.
J Trauma. 1986 Feb;26(2):166-7.
Abstract/Text It has been common practice to perform routine electrocardiographic (EKG) monitoring of electrically burned patients for the first 24 hours following injury. Is this monitoring necessary, or is it a luxury based on remote probabilities? The records of 48 consecutive patients admitted with high-voltage (greater than 1,000 volts) electrical injuries were reviewed with respect to history of a cardiac event in the field, EKG abnormalities on admission, and the presence of cardiac arrhythmias during the first postinjury day. No serious arrhythmias occurred in any patients who had a normal EKG on admission. It was concluded that routine cardiac monitoring after a high-voltage injury should be individualized based on history of loss of consciousness, documentation of an arrythmia, or an abnormal EKG.

PMID 3944840
C T Garcia, G A Smith, D M Cohen, K Fernandez
Electrical injuries in a pediatric emergency department.
Ann Emerg Med. 1995 Nov;26(5):604-8.
Abstract/Text STUDY OBJECTIVE: To examine the spectrum of electrical injuries and develop guidelines for management.
DESIGN: Retrospective review of charts compiled during a 6-year period (1988 through 1993).
SETTING: Pediatric emergency department.
PARTICIPANTS: Seventy-eight patients seen for electrical injuries.
RESULTS: Fifty-four percent of patients were boys, and the mean age of the patients was 5.3 years. Eighty-two percent sustained burns. We divided patients into those who were involved in major electrical current events (n = 8) (water contact and high voltage) and minor electrical current events (n = 70) (injury sustained while placing an object in an outlet or touching/plugging in a cord or during oral contact with a cord). Of the minor events, all burns (n = 61) involved less than 1% of body surface area. Eighteen patients sustained second-degree burns, and 19 sustained third-degree burns. Of the eight major-event patients, one had abnormal ECG/rhythm strip findings, two had abnormal urinalysis results, and six had abnormal levels of creatine phosphokinase. All eight were admitted. Of the 70 minor-event patients, 2 of 53 had abnormal ECG/rhythm strip findings, 1 of 48 had abnormal urinalysis results, and 2 of 40 had abnormal creatine phosphokinase levels. Thirty-six of the 70 minor-event patients were admitted. Patients involved in major events were more likely to undergo studies (P = .002), to have an abnormal result (P = .000008), and to be hospitalized (P = .008). In minor-event patients, hospitalization was limited to observation and the fitting of oral appliances.
CONCLUSION: Children involved in electrical events are usually exposed to low-voltage household current resulting in minor injury. Asymptomatic children with minor electrical injuries do not require laboratory evaluation or hospitalization.

PMID 7486370
Shruti Chudasama, Jeremy Goverman, Jeffrey H Donaldson, John van Aalst, Bruce A Cairns, Charles Scott Hultman
Does voltage predict return to work and neuropsychiatric sequelae following electrical burn injury?
Ann Plast Surg. 2010 May;64(5):522-5. doi: 10.1097/SAP.0b013e3181c1ff31.
Abstract/Text Voltage has historically guided the acute management and long-term prognosis of physical morbidity in electrical injury patients; however, few large studies exist that include neuropsychiatric morbidity in final outcome analysis. This review compares high (>1000 V) to low (<1000 V) voltage injuries, focusing on return to work and neuropsychiatric sequelae following electrical burn injury. Patients with electrical injuries admitted to the University of North Carolina Jaycee Burn Center between 2000 and 2005 were prospectively entered into a trauma database, then retrospectively reviewed. Patients were divided into 4 cohorts: high voltage (>1000 V), low voltage (<1000 V), flash arc, and lightning. Demographics, hospital course, and follow-up were recorded to determine physical and neuropsychiatric morbidity. Differences among cohorts were tested for statistical significance. Over 5 years, 2548 patients were admitted to the burn center, including 115 patients with electrical injuries. There were 110 males and 5 females, with a mean age of 35 years (range, 0.75-65 years). The cause of the electrical injury was high voltage in 60 cases, low voltage in 25 cases, flash arc in 29 cases and lightning in 1 case. The mean total body surface area burn was 8% (range, 0%-52%). The etiology was work-related electrical injury in 85 patients. Mean follow-up period was 352 days with 13 (11%) patients lost to follow-up. Patients with high voltage injuries had significantly larger total body surface area burn, longer ICU stays, longer hospitalizations, and significantly higher rates of fasciotomy, amputation, nerve decompression and outpatient reconstruction, with 4 cases of renal failure and 2 deaths. In spite of these differences, high and low voltage groups experienced similar rates of neuropsychiatric sequelae, limited return to work and delays in return to work. Final impairment ratings for the high and low voltage groups were 17.5% and 5.3%, respectively. Electrical injuries often incur severe morbidity despite relatively small burn size and/or low voltage. When comparing high and low voltage injuries, similarities in endpoints such as neuropsychiatric sequelae, the need for late reconstruction, and failure to return to work challenge previous notions that voltage predicts outcome.

PMID 20395807
Jennifer Singerman, Manuel Gomez, Joel S Fish
Long-term sequelae of low-voltage electrical injury.
J Burn Care Res. 2008 Sep-Oct;29(5):773-7. doi: 10.1097/BCR.0b013e318184815d.
Abstract/Text In North America, electrical injuries result in approximately 20,000 emergency department visits every year. They are the most common form of occupationally related burn injury, and the fifth leading cause of occupational fatality in the United States. The purpose of this study was to determine the long-term sequelae of low-voltage electrical burn injuries. A retrospective hospital chart review was conducted among electrical burn patients, admitted to a regional adult burn centre or a rehabilitation hospital between January 1, 2002 and December 31, 2003, to find new symptoms documented at follow-up visits. Telephone interviews were conducted to a random sample of these patients to document symptoms that had occurred since the injury. Thirty-eight of 39 electrical patient charts were reviewed, one was excluded because of a lack of follow-up notes. There were 35 (92%) men and three (8%) women with a mean age (+/-SD) of 45.4 +/- 13.4 years, and 8.9 +/- 10.5% total body surface area. The majority (97.4%) were work-related injuries, most of them (58%) because of low-voltage (<1000 V), most frequently electrical flash burns (55%). Neurological (81.6%) and psychological (71%) symptoms were the most common sequelae. The most frequent neurological symptoms were numbness (42%), weakness (32%), memory problems (32%), paresthesia (24%), and chronic pain (24%). The most common psychological symptoms were anxiety (50%), nightmares (45%), insomnia (37%), and flashbacks (37%) of the event. There were more patients with numbness (19 vs 59%) and nightmares (25 vs 59%) in the low-voltage group. Patients with more neurological symptoms also have more psychological symptoms. Eleven patients interviewed, reported a high incidence of neurological (82%), general (54%), and psychological (54%) symptoms, which occurred at 5.3 months, 1.7 months, and 1.5 months, respectively, after the electrical injury (EI). Electrical injured patients experience many physical and psychological sequelae after their injuries. Many of these symptoms are nonspecific, and they often do not appear until several months after the injury. Low-voltage EI produced more frequent long-term sequelae than high-voltage injuries. Frequent patient monitoring and prompt intervention of progressive changes after EI may improve the physical, psychological, and psychosocial recovery of these patients.

PMID 18695615
Fatih Mehmet Mutlu, Haluk Duman, Yakup Cil
Early-onset unilateral electric cataract: a rare clinical entity.
J Burn Care Rehabil. 2004 Jul-Aug;25(4):363-5.
Abstract/Text Electrical injury may result in cataracts, which usually occur bilaterally. In this report, we present a rare complication of such an injury presenting as a unilateral cataract in a 33-year-old woman with a painless but gradual worsening of vision in her left eye 3 weeks after sustaining a high-voltage electrical injury. A cataract did not develop in the right eye during 26 months of follow-up. The patient underwent successful cataract surgery with an excellent return of vision. Electrical injuries may result in the formation of a unilateral cataract and therefore an ophthalmic examination should be performed regularly in the early recovery period of such injuries. Cataract surgery with intraocular lens implantation results in an excellent return of vision in patients with electrical cataract who do not have any other ocular damage.

PMID 15247836
S Jain, V Bandi
Electrical and lightning injuries.
Crit Care Clin. 1999 Apr;15(2):319-31.
Abstract/Text Electricity and lightning can cause injury in a variety of ways, some of which may remain hidden from the unsuspecting physician until it is too late. Prompt and, if necessary, prolonged resuscitation are of proven benefit. Particular attention must be paid to the patient who suffers high-voltage injury, and deep electrothermal burns on damage to vital organs should be excluded. Uncommonly late sequelae are seen, and such patients require appropriate care.

PMID 10331131
Benoit Bailey, Pierre Gaudreault, Robert L Thivierge
Cardiac monitoring of high-risk patients after an electrical injury: a prospective multicentre study.
Emerg Med J. 2007 May;24(5):348-52. doi: 10.1136/emj.2006.044677.
Abstract/Text OBJECTIVE: To report our experience monitoring patients with previously identified theoretical risk factors of significant electrical injury.
METHODS: Patients who presented to one of 21 emergency departments between October 2000 and November 2004 were eligible to be enrolled in a prospective observational cohort study if after an electric shock they had one of several risk factors (transthoracic current, tetany, loss of consciousness or voltage source > or =1000 V) and therefore needed cardiac monitoring.
RESULTS: Of the 134 patients enrolled, most were monitored because of transthoracic current (n = 60), transthoracic current and tetany (n = 39), tetany (n = 10), or voltage > or =1000 V (n = 10). There were 15/134 (11%) patients with abnormal initial ECGs. No patient developed potentially lethal late arrhythmia during the 24 hours of cardiac monitoring.
CONCLUSION: Although only patients deemed at risk of late arrhythmias were monitored, none developed potentially lethal late arrhythmias. Asymptomatic patients with transthoracic current and/or tetany and a normal initial ECG do not require cardiac monitoring after an electrical injury with voltage <1000 V and no loss of consciousness.

PMID 17452703

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