ELECTRICAL INJURIES
AND
LIGHTNING STRIKES
Wendy J Marshall,
Marshall MD,
MD FACS
MAKE YOURSELF COMFORTABLE
ELECTRICAL VERSUS
LIGHTNING INJURY
• Electrical.
Electrical
Usually
U
ll A.C.
A C current.
t Prolonged
P l
d
duration --- tetanic contraction.
• Deep tissue damage
• Lightning.
Duration – instantaneous.
• Pathway – “flashover” – explosion type of injury.
INTENSITY OF CURRENT
• Contact voltage of industrial electrical shock
– 20 to 63 kilovolts
• Lightning strike – 300 kilovolts
• “External Flashover”
• Majority of the current passes over the
surface of the body
ELECTRICAL INJURY
• High resistance of skin transfers electrical
energy into heat.
heat
• This heat travels through the body and exits
th partt off th
the
the bbody
d th
thatt iis closest
l
t to
t th
the
ground
VERY COMMON
ENTRANCE WOUND
HIGH VOLTAGE ELECTRICAL CABLE
EXIT WOUNDS
COMPARTMENT SYNDROME
HEMATURIA
HIGH VOLTAGE ELECTRICAL CURRENT
LIGHTNING
• 2000 Thunderstorms Worldwide at anyy g
given
time.
• Lightning strikes the Earth > 100 times per
second.
d
LIGHTNING INJURIES
• One of the top three environmental-related
causes of death
• Second most common storm-related cause of
d th ((exceeded
death
d d only
l bby floods)
fl d )
• Deaths from lightning
g
g exceed deaths from
tornados, hurricanes, earthquakes
LIGHTNING
• Is a transient, massive electrical discharge
that most commonly originates from the
electrical charges separated in
thunderclouds.
thunderclouds
• 50% of lightning discharges remain within the
clouds.
ground
• 50% travel between the cloud & ground.
LIGHTNING
MECHANISM
•
•
•
•
Direct Strike
Side Flash ( under a tree )
C
Contact
voltage
l
( leaning
l i against
i a tree )
Ground current ( up
p through
g the ground
g
)
INJURY PATTERNS
CUTANEOUS LESIONS
• Depends on the current flow through or
over the skin
• Aborescent markings,
markings fernings,
fernings
keratiographic markings all describe the
pathognomic feather like skin markings.
• Lichtenberg Figures … resolve within 24
hours.
hours
ELECTRONIC DISCHARGE
LIGHTNING
Initial findings on the patients can be
minimal and VERY misleading
LIGHTNING INJURIES
MECHANISM OF INJURY
• IInjuries
j i can b
be caused
d bby both
b th electrical
l ti l
mechanisms of injury as well as mechanical
t
trauma
when
h the
th victim
i ti is
i th
thrown b
by muscle
l
contraction or suffers a fall.
BLUNT & EXPLOSIVE
EFFECTS
• Explosive effect of lightning
• Fractures. ( skull, ribs, extremities, spine.
)
• Explosive injuries typically occur in the
f t where
feet
h b
boots
t or socks
k may come
apart.
LIGHTNING STRIKE
LIGHTNING
TYPES OF INJURIES
•
•
•
•
•
•
•
Burns
p
y
Cardiopulmonary
Renal
Neurological extremities
Blunt trauma ( 8000*C Gas )
Otologic
Ophthalmologic
CUTANEOUS LESIONS
• Burns. Common. 63% incidence of multiple
burns.
burns
partial thickness. 1 – 4 cm width.
• Linear p
• Punctate burns. Partial or full thickness.
• Deep partial or full thickness burns. Usually
from the direct effect of the strike.
DIRECT STRIKE
EXIT WOUND
INTRACEREBRAL
HEMATOMAS
• Intracerebral hematomas have been
reported from “Direct
Direct Strikes
Strikes”
J.of Neurosurgery. 1985.
NEUROPATHOLOGICAL
CHANGES
• Petechial hemorrhages
• Subarachnoid blood
• Fissuring and splitting of the cortical layers
• Dilation of the subarachnoid space
p
• Intracranial hematomas
KERAUNOPARALYSIS
“LIGHTNING PARALYSIS”
•
Severe vasoconstriction and sensory
disturbances, loss of pulsations, blue “livid”
discoloration and paralysis of the extremities.
extremities
• Generally has disappeared within 24 hours.
OPHTHALMOLOGIC INJURY
•
•
•
•
•
•
Cataracts
U iti
Uveitis
Hyphema
yp
Vitreous hemorrhage
Optic atrophy
Retinal Detachment
LIGHTNING CATARACTS
•
Electrical current. Damage to the lens epithelium and capsule
•
Disruption of the osmotic barrier is responsible for the alterations in the lens proteins and
metabolism.
•
Lens opacities.
you see any changes
Variable time after injury
injury. Commonly 6 months before
EARS
• 50% have rupture of one or both
tympanic membranes
EAR INJURIES
• High pressure shock waves from thunder
ruptured tympanic membrane
• 30% hearing loss – disruption of the
ossicles
i l
% CSF otorchea/hemotympanism
y p
• 20%
AIRWAY OBSTRUCTION
SECONDARY TO LIGHTNING INJURY
• Flaccid muscles due to loss of gag reflex
• Aspiration of dentures
• Flaccid intercostal muscles
LUNGS
• Blast injury to the lungs.
• Pulmonary contusion with lacerations
MUSCULOSKELETAL
EFFECTS
• Extreme heat  cell rupture &
myonecrosis
• Rhabdomyolsis -- CPK
• Aortic & pericardial tears have been found
RENAL CHANGES
Muscle Necrosis 
Rhabdomyolsis
Hematuria versus Myoglobinuria ???
INTRAUTERINE LIGHTNING
• Uterus and amniotic fluid are good conductors.
• Lightning causes immediate uterine contractions
possible uterine rupture.
p
and p
• 10 reported cases of maternal lightning injury
• 5 viable infants
• 4 immediate abortions or loss of FHT
• 1 birth with fetal demise
WHAT IS THIS ????????
FIRST RESPONDER
• If you find someone with a lightning injury…
• It iis safe
f to
t ttouch
h iindividual
di id l
• Airwayy
• Standard ACLS & ATLS protocols
CARDIOPULMONARY
ARREST
• AGGRESSIVE ACLS for victims
“
“apparently”
tl ” dead
d d after
ft being
b i
struck by lightning.
TREATMENT
• Routine Trauma Care
• ABC’s
• Board and collar
• Resuscitate the dead
• Transport
PUPILLARY RESPONSES
• Common to get transient or permanent
autonomic disturbances
• Mydriasis, anisocoria, Horner’s syndrome,
failure of accommodation, loss of red reflex.
• Never use Pupillary responses to
discontinue resuscitative measures.
measures
LIGHTNING DEATHS
Asystole
A
t l / v. fib
Inhibition of brainstem,, respiratory
p
y center
MOSF
Arrythmias & MI
Pulmonary edema -- ARDS
Neurological, psychiatric injuries
LOC / Coma
RESIDUAL EFFECTS
• 70%
% of lightning
g
g survivors experience
p
residual effects
• Mostly the brain
• Neuropsychiatric, vision & hearing,
amnesia anxiety,
amnesia,
anxiety confusion
confusion, aphasia
aphasia,
seizures
• Develop
D l slowly,
l l becoming
b
i apparentt AFTER
the event
LONG TERM SEQUELAE
SYMPTOM
Sleep disturbance
Attention deficit
Headaches
Unable to work
Parasthesias
a ast es as
Depression
Nightmares
Muscle spasms
Arthritis
Decreased grip strength
ELECTRICAL
74%
68%
65%
54%
60%
63%
26%
63%
38%
51%
LIGHTNING
44%
41%
30%
29%
40%
0%
32%
12%
34%
19%
34%
REMEMBER
• ¾ of the people who survive a lightning
strike will suffer life-long severe
complications and disabilities
PREVENTION
• Don’t stand and lean against a tree so you
don’t g
get wet!
• Find the lowest part of the ground.
• Don’t
D ’t gett in
i a wett dit
ditch!
h!
• Don’t call all yyour friends on the telephone!
p
• Unplug electrical appliances
DURING A THUNDERSTORM
• Seek shelter in a building – roof, walls &
floor
• Stay inside an all-metal vehicle
• DO NOT STAY in a convertible, soft top car or
ride a bicycle
• Drop golf clubs, ski poles, umbrellas
STUPIDITY
THE END
•Thank
Thank You.
Yo