Lightning and Electrical Injuries

HIGH-YIELD FACTS
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• Even low-voltage electrical injuries can be fatal and often show no external burns.
• Higher-energy electrical injury can cause massive muscle damage and release of myoglobin. Without
adequate early fluid resuscitation, myoglobinuric acute kidney injury can occur.
• Sufficient fluid should be administered to maintain a urine flow of 1 to 1.5 mL/kg/h, 2 mL/kg/h until the
urine is myoglobin-free.
• Lip and oral commissure burns are initially bloodless and nearly painless, but as the eschar separates in
1 to 2 weeks, severe bleeding can occur as the labial artery is uncovered.
• Resuscitation of the apparently dead is the rule with lightning injuries.
• When Thunder Roars, Go Indoors. Every person should learn and teach this preventive action.

ELECTRICAL INJURIES
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Electrical injuries are not common but can be frightening, devastating, and life changing. They may result in
massive tissue destruction, changes in growth patterns, and neurologic injury, including chronic pain
syndromes, permanent cognitive deficits, and high disability rate, affecting the child’s ability to learn and
become a productive adult. Most victims are male. Children at most risk are exploring toddlers (12–30
months). They are more likely to suffer low-voltage injuries because they suck on extension cords or stick
things into electrical outlets. Adolescents who often engage in risk-taking behavior may have injuries resulting
from contact with utility poles or high-voltage power lines.1–2

The old teaching on electrical injuries involves consideration of voltage, amperage, tissue resistance, current
type, duration, and pathway (Kouwenhoven’s factors). Voltage is the difference in electric potential energy
between two points and is divided arbitrarily into low and high voltage, with breakpoint at 1000
volts. Amperage is a measure of the rate of flow of electrons and is measured in amperes. Resistance is a
measure of the difficulty of electron flow through a given substance. Resistance is measured in ohms.3

The body is composed of different tissues, which express a different resistance to the flow of electrical
current. However, the body behaves like a volume conductor.4 Thus body parts exposed to the same current
intensity and duration may show different degrees of heat-generated tissue injury. For a given energy, more
severe injuries will occur in smaller cross-sectional areas than the same energy flowing through body parts
with larger cross-sectional areas such as a thigh or the trunk.5 Damage can be especially high at the joints,
where the low-resistance tissues (muscle) are minimized and higher-resistance tissues (tendons, bone, and
cartilage) are maximal. Damage to internal organs may be more diffuse and hard to appreciate initially
because of the larger cross-sectional diameter of the torso.4,5

When the body is part of an electrical circuit, the skin is the primary resistor to electric current flowing into
the body. Resistance is highly variable according to the thickness, age, and moisture,2 which may explain
the clinical or forensic findings in electrical injury.6 Overall, thickly calloused skin will have higher resistance
and tend to sustain greater thermal damage at the site of contact, but it impedes the flow of energy internally.
Resistance is tremendously lessened if the skin is wet with sweat or rainwater. Wet skin may show little or
no local thermal damage, but it allows the majority of the energy to flow internally to the heart or other vital
structures. This explains why a “bathtub” injury may show no external signs of injury while causing cardiac
arrest.6

Current type may be either alternating or direct. Alternating current (AC) is much more dangerous than direct
current (DC) at the same voltage (ventricular fibrillation was 10 times more frequent and acute myocardial
infarction was 3 times more frequent in animal models).7 Household circuits in the United States (110/220
V) operate at 60 cycles per second (cps) and 50 cps in many foreign countries, frequencies at which
neuromuscular function continues indefinitely, leading to tetany. Because the flexors of the hand are stronger
than the extensors, the hand gripping an AC electrical source (called the “no-let-go” phenomenon) prolongs
the duration of exposure to the electrical current,8 unlike DC exposure, which produces a sole convulsive
contraction that expels or launches the person away from the current source. Increased duration tends to
result in increased damage until the tissue is coagulated, charred, or mummified.4 The effect of tetanic
contraction is also related to the amperage applied—the margin between the household amperage (0.001–
0.01 A) that causes a buzz but usually little harm, and that capable of causing respiratory arrest (0.02–0.05
A) and ventricular fibrillation (0.05–0.10 A) is narrow.2

Even though it has been considered that the current pathway would allow determining the organs involved,
it is important to remember that the current will flow with no discretion through different tissues and corporal
segments, since the body behaves like a volume conductor.4 Also, the difficulty in differentiating the source
and ground injuries, the pathway does not determine any difference between complications and
mortality.9,10 Therefore, the emergency physician and trauma surgeon must give priority to the outcome, not
the current pathway.4

Electrical field strength has been a concept that explains and predicts electrical injury severity more
accurately than the factors mentioned above.8,11 When 20 kV are applied to a 6-ft man, causing current to
ground, an internal electrical field strength of approximately 10 kV/m is generated. When a child chews on
an electric cord and suffers a lip burn, the field strength is approximately the same: 110 volts applied to 1 cm
of a child’s lip generates a field strength of 11 kV/m.4 While no one would classify the child’s injury as “high”
voltage, it is a high electrical field strength and it produces the same tissue destruction in a small, localized
area that “high voltage” would produce in a 6-ft man (Fig. 139-1).
FIGURE 139-1.
Electrical field effect.

In developing countries, there are large numbers of deaths in the home, both because families tend to
consider household current to be “safe” and because there is little prehospital care available.12–14 However,
the electrical field strength and presence of AC in low-voltage exposure could explain a greater number of
deaths due to low-voltage household accidents compared to high-voltage exposure in workplaces or on the
street.12,13
MECHANISMS OF INJURY
Several common mechanisms of injury exist (Table 139-1). There is a pure electrical mechanism which is
produced due to direct contact with the electrical source or grounding points or when being part of the circuit
indirectly, when energy jumps from a source to a nearby person (electric arc). An electrical field may cause
cell membrane disruption (electroporation), protein transmembrane configuration changes, or induce a
transmembrane electric action potential.8,11 Cell death occurs due to alteration of the intracellular milieu and
the failure to restore homeostasis, which is not produced immediately post electrical discharge but over an
extended period of time. The more vulnerable cells are the muscle and nerve cells, which explains many of
the clinical findings in these patients.3

A second mechanism (electrothermal) produces the immediate death of tissues due to its thermal effects, by
the transformation of electrical energy into thermal energy.3,4,8 According to Joule’s law of heating, heat
produced is equal to the product of the square of the current, resistance of the conductor, and the duration
of time for which it flows (heat = current2 × resistance × time). This process is responsible for the coagulative
necrosis and tissue desiccation, mainly in high voltage injuries.

A third mechanism (thermoacoustic) is produced by an electric arc, which is an electric current between two
points separated by a gas, and it is characterized by light, pressure wave, and very high temperature capable
of melting or vaporizing most materials.8 Burns may be caused by the heat of the arc itself, electrothermal
heating due to current flow by indirect contact, or by flames if clothing is secondarily ignited. Blunt injury
occurs by blast effect, and in DC o high voltage exposure by fall or thrown. Fractures or dislocations may
occur.

TABLE 139-1Mechanisms of Electrical Injury

Contact injury
Flash burn
Arc burn
Secondary ignition
Concussive force
Blunt trauma

ANATOMIC SITES OF INJURY

Clinical manifestations of electrical injury are highly variable. While electrical injuries are often classified
under burns, higher-energy injuries may more closely resemble crush injuries caused by muscle destruction,
compartment syndromes, and myoglobin production. Some victims of electrical injury may have very little
external damage while sustaining serious underlying tissue damage.

Burns are found in nearly all non–water-related electrical injuries.1 However, absence of burns does not rule
out exposure to electricity. The most common areas of injury are the hand, skull, and foot.1 Subcutaneous
tissues, muscle, nerves, and blood vessels also suffer thermal damage. Tissue that initially appears viable
may later die because of the electrothermal mechanism as well as ischemia caused by vascular wall damage,
edema, and thrombosis, which may affect either inflow or outflow of blood to tissue.3
A common injury for very young children is incurred by sucking on the ends of extension cords, resulting in
severe orofacial injuries. Burns are often full thickness, involving the lips and oral commissure.15,16 These
burns are initially bloodless and painless. As the eschar separates in 2 to 3 weeks, severe bleeding can occur
from damage to the labial, facial, or even carotid arteries. There can be alveolar bone damage and germinal
tooth loss, growth retardation, devitalization of teeth, and microstomia from extensive scarring.

Cardiac effects occur when current passes directly through the heart, and it can induce ventricular
tachycardia, ventricular fibrillation, or asystole. A wide variety of arrhythmias can occur, including
supraventricular tachycardia, extrasystoles, right bundle branch block, and complete heart block. The most
common electrocardiographic (ECG) abnormalities are sinus tachycardia and nonspecific ST-T wave
changes. Most rhythm disturbances are temporary.17 Myocardial infarction and ventricular perforation have
been reported. Syncope, as a cardiac or neurologic manifestation, occurs in up to 33% of the children
affected.18

Vascular injuries include thrombosis, vasculitis with necrosis of large vessels, vasospasm, and late
aneurysm formation. Maximal decrease in blood flow will occur in the first 36 hours. Strong peripheral pulses
do not guarantee vascular integrity.3

Acute renal failure may occur from hypoxia and hypovolemia during resuscitation in combination with
myoglobin released by extensively damaged muscle or hemoglobin from hemolysis.19 In rhabdomyolysis,
myoglobin becomes concentrated along the renal tubules, a process that is enhanced by volume depletion
and renal vasoconstriction mediated by the activation of the renin–angiotensin system, vasopressin, and the
sympathetic nervous system. The myoglobin precipitates when it interacts with the Tamm–Horsfall protein,
a process favored by acidic urine.20 Kidney damage may also occur from blunt trauma, hypotension, hypoxic
ischemic injury, cardiac arrest, and hypovolemia. Oliguria, albuminuria, hemoglobinuria, and renal casts may
be seen transiently.

Neurological Injuries: Immediate CNS effects include loss of consciousness, seizure, agitation, amnesia,
deafness, seizures, visual disturbance, and sensory complaints. Vascular and blunt injury damage may result
in epidural, subdural, or intraventricular hemorrhage. Within several days, the syndrome of inappropriate
antidiuretic hormone secretion (SIADH) may lead to cerebral edema and herniation. Peripheral nerve injury
from vascular damage, thermal effect, or direct action of current may occur, and it can be progressive. A
variety of autonomic disturbances may also occur. Late involvement of the spinal cord may produce
ascending paralysis, amyotrophic lateral sclerosis, transverse myelitis, or incomplete cord
transection.21 Cataracts can be seen in any electrical injury involving the head or neck. Victims may suffer
depression, flashbacks, attention deficit disorder, sleep problems, and other cognitive difficulties that can
affect learning and school performance as well as social function within the family or school.22

Passage of current through the abdominal wall can cause Curling’s ulcers in the stomach or duodenum.
Other injuries described include evisceration, stomach or intestinal perforation, esophageal stricture, and
electrocoagulation of the liver or pancreas.23
Blunt trauma or tetanic muscle contractions can cause fractures or dislocations. Amputation of an extremity
is necessary in 35% to 60% of survivors of high-energy injury caused by extensive underlying injuries.
Infections frequently occur in necrotic tissue.

MANAGEMENT
Prehospital Care
Extrication is extremely dangerous until the power source is disconnected. Victims should be treated both as
burn victims and as blunt trauma patients, with special attention given to spinal immobilization. Transport to
a health care facility should not be delayed.24,25

Several reports have shown that most deaths occur at the scene of the accident due to cardiac arrest with
asystole, arrhythmias such as tachycardia or ventricular fibrillation, or secondary to hypoxia from respiratory
arrest due to compromise of the respiratory center at the brain stem or oxygenation and ventilation disorder
caused by respiratory muscle tetany.10,26 These patients may benefit from early cardiopulmonary
resuscitation measures either by lay personnel or prehospital systems.27 In events with multiple victims, the
main priority is the critical patient even without vital signs. Given the common absence of related pathologies
and young age, these patients may show good prognosis, even in long resuscitation processes.18,27