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Electrical & Lightning

Injuries
Carly Thompson
EM-Resident
April 9, 2009
Outline
Electrical Injuries Lightning
Definitions Pathophysiology of
Epidemiology and Lightning
Physics Specific Injuries:
Physiologic Effects of Lightning
Electricity ED Management
Specific Injuries Cases
ED Management of
Electrical Injuries
Cases
Electric Injuries
Definitions
Electric shock response
Electrocution death
Electrical injury
tissue damage
Electrical burn
cutaneous injury
550 Electrocutions / Year in USA (1998)
50% of low-voltage <1000 V AC no visible burns or marks
100 Lightning Deaths / Year USA
Underestimate?
17 000 Electric Injuries / Year USA
300 Lightning Injuries / Year USA
Epidemiology
3 Groups at Risk for Electrical Injuries:
Toddlers
Adolescents
Electrical Workers (1/10 000 deaths/year)

Lightning Injuries
Risks:
- Transportation: Car, plane, water
- Storms or blue sky!
Mortality:
- 0.5 / million in US 8.8 / million rural SA
- 70-90% survival rate
- 75% of survivors will have sequelae
Physics 101
Electric flow / current = Amp
Electric potential difference = Volts
Resistance = Ohms
Conductors: high fluid, electrolyte content nerves and
blood vessels, sweaty skin, saliva, muscle
Insulators: high resistance bone, dry skin
Ohms Law
I (Current) = V (Voltage) / R (Resistance)
Current is directly proportional to potential difference, and inversely
proportional to resistance.
Example = Grasp 120V source, with 1000Ohms resistance = 120mAmps
Types of Current
What are the two types of current?
AC/DC
How did the band AC/DC gain their name?
They saw it on the back of their older sisters
sewing machine.

AC alternating current
Homes, usually 60Hz
DC direct current
Batteries, lightning
Physiologic Effects
Related to amount duration, type,
path
Current travels along multiple
paths, not only path of least
resistance
Nerves and blood vessels least
resistance
Muscles have most flow due to
greatest area
Nerves have higher current
density -> significant injury
Effect of Current
Effect Current Path Minimum Current
60 Hz AC
mAmp
Tingling sensation, Through intact skin 0.5-2
minimal perception
Pain threshold Through intact skin 1-4
Inability to let go: tetany From hand, through 6-22
decreases resistance forearm into trunk
Respiratory arrest: fatal Through chest 18-30
if prolonged
V Fib Through chest 70-4000
Ventrical asystole, if Through chest >2000
current stops sinus
rhythm may resume
Physics 102
Electrical energy -> deposited as heat
Heat causes the most tissue damage
Joules Law
Energy = I2 x R x time
Energy = (V2 x time) / R
Therefore the heating of tissues increases according to the square of
the applied voltage, and is directly proportional to the time the
voltage is applied.
Electricity
Power Line: 7620V
Lines outside house: 220 / 240V
Subway: 660V

High Voltage Injury


>1000 V
Severe skin burns

Low Voltage Injury


Cutaneous burns often minimal with household voltage,
unless several secs contact
Electrical burns absent in 40% of low voltage deaths
110V can cause V fib
Trivia
What was AC/DCs first album?
What is considered high voltage?
>1000 V
Cardiovascular Injuries
1 cause of death from electrocution
Low-voltage -> v fib
High-voltage AC and DC -> transient asystole
Also: ST, PACs, PVCs, a fib, 1st / 2nd AV block
Vigorous resuscitation!!!
Victims are often young without CVD
Not possible to predict outcome based on rhythm
Vascular injury -> spasm -> delayed thrombosis
or aneurysm formation, compartment syndrome
CNS and Peripheral Nerve Injuries

50% have impairment (high-voltage)


Transient LOC
Agitation, confusion,
Coma
Seizures
Quadriplegia, hemiplegia, paresthesias
Aphasia, visual disturbances
Spinal Cord Injuries
Vertebral fractures multilevel!
Delayed injury
ascending paralysis
complete or incomplete cord
transverse myelitis
MRI results not closely correlated to outcome
Eye and Ear
Eye Injuries
Cataract formation weeks to years later
Retinal detachment, corneal burns, intraocular
hemorrhage, intraocular thrombosis

Ear Injuries
Late complications of hemorrhage into TM,
middle ear, etc. -> mastoiditis, sinus thrombosis,
meningitis, brain abscess
Hearing loss immediate or late
Cutaneous Wounds
Entry / exit wounds painless, gray

Treatment
Cleansing, Td
Silver sulfadiazine
Mafenide
Full-thickness burns penetrates eschar
<25% BSA only inhibits carbonic anhydrase, painful
Observe for neurovascular compromise, compartment
syndrome
Splint extremities, early surgical debridement, vascular
reconstruction and skin graft
Flexor Crease Burns
Orthopedic Injuries / MSK
Fractures 2 to tetany, falls
Shoulder dislocation (voltages >110V)
Muscle +++heat -> periosteal burns,
osteonecrosis
Severe arterial spasm -> compartment
syndrome
Muscle breakdown -> rhabdomyolysis ->
myoglobinuria and renal failure
Blast and Inhalational Injuries
Blast Injuries
Strong blast pressure -> head injury, mechanical
trauma, arterial air emboli

Inhalational Injuries
Ozone -> mucous membrane irritation,
decreased pulmonary function, pulmonary
hemorrhage, edema
Carbon monoxide, etc. assoc. with fires
GI Injuries
Suspect in patients with burns of abdo
wall, or trauma
Lethal injuries reported only at autopsy
Gastric ulcers Curlings ulcers
Fluid resuscitation -> abdominal
compartment syndrome with restrictive
surface burns
DIC
May be due to thermal injury or tissue
necrosis
Low-grade DIC from hypoxia, vascular
stasis, rhabdomyolysis, release of
procoagulants
Tx: eliminate precipitating factor by early
surgical debridement
FFP or cryo as needed
Oral Burns
Children
Unilateral
Lateral commissure, tongue, alveolar ridge
Systemic complications rare
Vascular injury to labial artery
Severe bleeding 10% cases
Occurs 5 days 2 weeks when eschar
separates
Oral Burns
Treatment
Admission monitoring
Outpatient reliable parents, who can be shown
how to control bleeding, consideration?

Saline rinses, swabs to debride necrotic tissue


Petrolatum-based Abx for soothing effect
Specialty consultation splinting / surgical
procedures to prevent deformity and dysfunction
Tasers
Sinusoidal electrical impulses 10-15Hz
High voltage 50 000V for Taser
Low Amps and low average energy
2001-2007 245 deaths after Taser
Injuries
R on T phenomenon -> v fib
Pacemaker or ICD malfunction
Death more likely with concomitant drug use (PCP,
cocaine), trauma from struggle, preexisting CAD
Ocular injuries
Other: burns, lacs, rhabdo, testicular torsion,
miscarriage
Accident Scene: Rescuer Safety
Downed Power Lines
Electrocution possible, recommend 9m away (3m may
be enough)
Reapplication of voltage may occur -> jumping power
lines

Victims
Victims in contact with source may be active
Voltage >600V -> dry wood, rubber boots may conduct
electricity
Persons inside vehicle in contact with power line, likely
to be killed if they step out
ED Treatment
Resuscitation
ABCs as per trauma
ACLS
Spinal immobilization
Careful physical exam!

Investigations
Labs: High-voltage, extensive burns, evidence of
systemic injury
CBC, lytes, Cr, BUN, CK, serum / urine myoglobin
Imaging as indicated, clear spines
ED Treatment
Fluid Resuscitation
Fluid requirements > Parklands formula
Visible damage < internal damage!
Initial fluid bolus: 20-40mL/kg/ 1st hr
Considerations:
Fluid load to prevent rhabdomyolysis
Avoiding over-resuscitation in patients with
restrictive burns on abdomen -> prevent
compartment syndrome
Disposition
Admission:
In contact >600V
Symptoms (CP, palp, LOC, confusion, weakness,
dyspnea, abdo pain)
Signs (weakness, burns with subcut damage, vascular
compromise)
Ancillary changes (ECG, CK, myoglobinuria)
Cardiac monitoring: If ECG abnormal

No Admission:
Household voltage injury 100-220V in adult +
Neglibible risk for delayed arrhythmias +
Asymptomatic, normal ECG and normal exam -> d/c
Electric Injury in Pregnancy
Increased rate of fetal damage or loss after
apparent harmless contact
Monitor x 4 hours in women >20-24 weeks GA
Monitor >24 hours if LOC, ECG abN, hx of CVD
Fetal ultrasonography at presentation, then at 2
weeks
No proof that monitoring or tx can influence
outcome
Electric Injury in Children
Children with only hand wounds from outlet, but no
cardiac or neurologic involvement can be d/c home with
wound care
Consider admission if equivocal home safety or reliability
Guidelines for ECG in children:
Tetany
Decreased skin resistance by water or burns
Unwitnessed event
Guidelines for cardiac monitoring x 24 hours:
Past cardiac hx
LOC
Voltage >240V
Abnormal ECG
Cardiac Monitoring in Children
Bailey et al. (2000). Experience with guidelines for
cardiac monitoring after electrical injury in
children. Am J Emerg Med; 18(6):671-5.
July 1994 June 1998
Tertiary pediatric teaching hospital
224 cases
Cardiac monitoring on 13% (all normal)
No morbidity 0/172 patients
No mortality 0/224
Case 1
30 yo M electric worker
Found down at steel plant
Thermal burn lateral head
Presenting in asystolic arrest

What do you do?


How long do you continue treatment?
Case 1 Contd
Thoughts . . .
Resuscitation as per ACLS
Spinal precautions
Vigorous resuscitation as patient is young and
otherwise healthy, heart may spontaneously
regain automaticity

Conclusion . . .
45 minutes in ED resuscitation no cardiac
activity
Code called
Case 2
Summary: Electrical Injuries
Low-voltage <600V -> may be D/C if
asymptomatic
Immediate cause of death: V Fib
Children: oral burns consider labial artery bleed
? admission
High-voltage >1000V -> admit for observation
and cardiac monitoring
Asystole, treat cardiac arrest vigorously
Deep tissue destruction with high fluid needs
Myoglobinuria and renal failureis common
Trauma: thrown
Immediate cause of death: Apnea
Trivia
Name a team, a song and a runner who all
have something in common with lightning.

Tampa Bay Lightning


Lightning Crashes Live
Usain Lightning Bolt
http://www.youtube.com/watch?v=GIKYWl
APHVQ
Pathophysiology
Different injury pattern, severity, tx
Lightning = extremely high-voltage DC
Brief, intense, thermal radiation producing
rapid heating and expansion of
surrounding air
Flashover = less likely to cause internal
cardiac injury or muscle necrosis
TM perforation, internal contusion, tear
clothing, melt metal, intense photic injury
Factor Lightning High-Voltage AC Low-Voltage AC
Current Duration 1-3ms Often brief 1-2s, may be Prolonged
prolonged
Typical voltage and 10 million 2 billion V; 600-70 000 V; <1000 A <600 V; usually < 20-30
current range 20 000 200 000 A
A
Current characteristics Unidirectional (DC) Alternating (AC) Alternating (AC)
Current pathway Skin flashover Horizontal or vertical Horizontal or vertical
Tissue damage Superficial, minor Deep tissue destruction Sometimes deep tissue
destruction
Initial rhythm in arrest Asystole Asystole > V fib V fib
Renal involvement Myoglobinuria is Myoglobinuria and renal Myoglobinuria and renal
uncommon, renal failure common failure occasionally
failure rare
Fasciotomy and Rarely necessary Relatively common Sometimes necessary
amputation
Blunt injury Explosive effect with Being thrown from Tetanic contraction or
shock wave current source or falls
falls
Immediate cause of Prolonged apnea Apnea V Fib
death
Mechanism of Injury
Direct strike direct contact
Side flash hits nearby object
Contact strike hits object being held
Ground current through ground
Upward streamer weak streamer
Cardiac Injury
Htn, tachycardia sympathetic activation
Depolarization -> sustained asystole
Other:
global myocardial contractility depression
coronary artery spasm
pericardial effusion
atrial and ventricular arrhythmias
ECG: acute injury ST elevation, long QT, T
wave inversion (neurologic injury)
MI is unusual
Cardiac automaticity may return spontaneously
Respiratory Issues
Respiratory arrest
Due to paralysis of medullary resp centre
Critical prognostic factor
Neurologic Injury
Common Injuries:
ALOC
Temporary lower extremity paralysis
Seizures
Lethal injuries: heat-induced coagulation of cortex,
epidural / subdural, ICH
Autonomic dysfunction: mydriasis, anisicoria
Immediate and transient effects:
LOC, confusion, amnesia, paralysis - keraunoparalysis
Delayed and progressive effects:
Seizures, spinal muscular atrophy, ALS, parkinsonian
syndromes, progressive cerebellar ataxia, myelopathy with
paraplegia or quadriplegia, chronic pain
Neurologic Injury
Indications for CT:
Coma
ALOC
Persistent headache
Confusion
Neurologic Injuries
Spinal Cord Injuries
Fractures may be caused by tetany, falls,
secondary trauma
Maintain spinal precautions
Image entire column due to multilevel
fractures
Neurologic Injuries
Ocular
Lightning-induced cataracts
Also: hyphema, vitreous hemorrhage,
abrasions, uveitis, retinal detachment or
hemorrhage, optic nerve damage

Auditory
TM rupture
Strike along phone: persistent tinnitus,
sensorineural deafness, ataxia, vertigo,
nystagmus
Cutaneous Injuries
Lictenberg Figures
Superficial ferning
Disappear in 24 hours
Pathognomonic for
lightning strike
Cutaneous Injuries
Flash burns: erythema
Punctate burns: cigarette burns <1cm full-
thickness
Contact burns: metal close to skin
Superficial erythema and blistering burns
Linear burns: <5cm wide in skin fold
Entrance and exit wounds - rare
Rescuer Safety
Beware of the lightning strike victim that may
truly be the victim of knocked down power lines

Look for evidence of lightning: hx of electric


storm, blast effect, torn clothing, melted objects,
melted nylon cloths, burned vegetation

Triage: Those who are sickest treat first!


ED Management
ABCs, IV, O2, monitor
Hypotension is an unexpected finding warrants
investigation
Careful exam for secondary injuries, burns,
current path
Labs: CBC, lytes, BUN, Cr, glucose, CK, urine
for myoglocin
ECG
Imaging as indicated
Disposition
Admission for observation recommended
No neuro injuries, normal ECG, monitoring
-> may consider d/c home
Neurologic and ophthalmic referral
recommended
Pregnancy Considerations
Fetal injury and death more common even
after little or no maternal injury (amniotic
fluid)
Review: 11 women who survived lightning
5 cases of fetal or neonatal death
Abruption can occur
Ultrasonography recommended
Maternal uterine activity and fetal HR
monitor x 4 hours
Case 3
You are working at Foothills one stormy
afternoon, and there is a soccer game
going on at McMahon Stadium . . .

You get a patch . . .


32 German Soccer Players Get
Zapped
3 Patients
Patient 1: Full cardiac and respiratory
arrest. Apparently a direct strike. Has
Lichtenburg figures.

Patient 2: Altered, shallow breathing,


mottled, deformity to R femur.

Patient 3: Complaining of paralysis to


legs, flash burns to torso.
Case 3 Contd
How do you triage these patients?

In contrast to multiple victim events


caused by mechanical trauma . . .
Persons with lightning injury who appear
dead (resp +/- cardiac arrest) should be
treated first!!!
Summary: Lightning Injuries
Lightning is extremely high-voltage DC
CV: Causes asystole in arrest
Neuro: Apnea from medulla injury,
MSK: Explosive effect of shock wave
Cutaneous: Lichtenberg figures
Tx: ABCs, treat sickest first (even ?dead!)
Get ocular and neuro assessment
Admission for observation
Thanks!
Thanks also to Marc Francis and
James Huffman for pictures and
cases!