Emergency & Toxicology

Electrical injury and lightning strike

Clinical Overview and When to Suspect Electrical Injury

— Low-voltage (<1000 V): household outlets (120/240 V), most pediatric mouth/cord injuries, often AC

— High-voltage (≥1000 V): power lines, industrial transformers, electrified rails — deep tissue injury, rhabdomyolysis, amputation risk

— Lightning: ultra-high voltage (millions of V) but ultra-short duration (microseconds); flashover phenomenon limits deep burns but causes cardiopulmonary arrest and CNS injury

— AC (alternating, household/industrial): causes tetanic muscle contraction → victim "locked" to source, prolonged contact, ~3× more dangerous than DC at same voltage

— DC (direct, lightning, batteries, defibrillators): single violent contraction, throws victim → blunt trauma

— Hand-to-hand or hand-to-foot current path (crosses heart/thorax)

— Loss of consciousness, confusion, or amnesia at scene

— Tetany, fall from height, or being thrown

— Wet skin or immersion (lowers resistance, increases current)

— Pediatric oral commissure burn (delayed labial artery bleed)

Electrical injury spans a spectrum from minor low-voltage household contact to high-voltage industrial trauma and lightning strike, each with distinct pathophysiology and disposition logic.

Classification by voltage:

Classification by current type:

Pathophysiology: tissue damage by direct electroporation, Joule heating, and arc/flash thermal burns. Current preferentially flows through low-resistance tissues (nerve, blood, muscle) — so internal injury vastly exceeds visible skin burns.

When to suspect serious injury despite minimal external findings:

Board pearl: The visible burn is the tip of the iceberg in high-voltage injury — always assume deep muscle necrosis, compartment syndrome, and rhabdomyolysis until ruled out with CK, urine myoglobin, and serial exams.

Step 3 management: Any patient with high-voltage exposure, lightning strike, transthoracic current path, LOC, ECG abnormality, or burn >10% BSA warrants ED evaluation, telemetry, and trauma/burn center consideration — even if they "feel fine."

Presentation Patterns and Key History

— Voltage source (outlet vs. power line vs. lightning) and AC vs. DC

— Duration of contact and whether victim was "locked on"

— Current path (entry/exit points — though "exit" is misleading in AC)

— Environment: wet, immersion, fall from height, blast, fire

— LOC, seizure, arrest at scene; bystander CPR; initial rhythm

— Tetanus status, comorbidities, pregnancy

— Often minimal symptoms; brief paresthesias, small contact burn

— Pediatric oral commissure burn from chewing extension cord — eschar forms, sloughs at 1–3 weeks → delayed labial artery hemorrhage

— Lineman or construction worker, arc flash, clothing ignition

— Deep entry/exit wounds (often hand and foot), charred eschar

— Associated blunt trauma from being thrown — c-spine, long bones, intracranial

— Severe pain disproportionate to skin findings → compartment syndrome

— Direct strike (highest mortality)

— Side flash/splash from nearby object

— Contact (touching struck object)

— Ground current/step voltage (most common; potential difference between feet)

— Upward streamer and blunt blast injury from shock wave

— Lichtenberg figures (fern-like, transient, pathognomonic — not true burns)

— Ruptured tympanic membranes (>50%)

— Cataracts (delayed, weeks–years)

— Keraunoparalysis: transient flaccid paralysis with mottled, pulseless cold extremities — resolves over hours

Critical history elements drive triage more than the wound itself:

Low-voltage household injury:

High-voltage industrial injury:

Lightning strike has 5 mechanisms — recognize all:

Lightning-specific findings:

Key distinction: In a mass-casualty lightning event, reverse triage — resuscitate the apparently dead first, because primary respiratory arrest from medullary stunning often outlasts cardiac arrest, and survival is excellent if ventilation is restored before secondary hypoxic cardiac arrest.

Board pearl: Lichtenberg figures on a hiker found unconscious in a storm = lightning strike confirmed even without witness.

Physical Exam Findings and Hemodynamic Assessment

— A/B: airway burns (facial/oral arc), inhalation injury if clothing ignited, respiratory arrest from diaphragmatic tetany or medullary injury

— C: pulse, rhythm, BP; check for arrhythmia, hypotension from rhabdo/third-spacing

— D: GCS, focal deficit, seizure; spinal precautions if fall or thrown

— E: full exposure, log-roll, look for entry/exit wounds (scalp, perineum, between toes)

— Entry wound: charred, depressed, leathery

— "Exit" wound: blown-out, explosive appearance

— Kissing burns at flexor creases (axilla, antecubital) from arc across joint

— Arc burns (no contact, just proximity) and flame burns from ignited clothing

— TBSA estimation underestimates severity — deep tissue damage exceeds surface

— Auscultate for arrhythmia; obtain immediate 12-lead ECG

— Asystole classic for DC/lightning; VF classic for AC household

— Mental status, cranial nerves, motor/sensory by dermatome and peripheral nerve

— Keraunoparalysis (lightning): bilateral lower-extremity flaccid paralysis, cold mottled pulseless limbs, sympathetic instability — mimics aortic dissection or cord injury but resolves in hours

— Spinal cord injury (delayed myelopathy possible weeks later)

— Palpate compartments (forearm, calf, thigh); pain on passive stretch = early compartment syndrome

— Distal pulses, cap refill, Doppler if needed

— Fracture or dislocation from tetanic contraction (classic: posterior shoulder dislocation, scapular fracture, vertebral compression)

— TM rupture (lightning), hyphema, corneal burn, later cataract

Primary survey (ATLS) drives initial exam — electrical injury is a trauma activation:

Skin/burn assessment:

Cardiac exam:

Neurologic exam:

Musculoskeletal/vascular:

Ophthalmologic and ENT:

CCS pearl: On the CCS case, immediately order cardiac monitor, IV access ×2 large bore, 12-lead ECG, CBC, BMP, CK, UA with myoglobin, troponin, lactate, type & screen, and trauma imaging as indicated — then reassess in 15-minute intervals.

Diagnostic Workup — Initial Labs, Imaging, ECG, Biomarkers

— Sinus tachycardia most common; nonspecific ST-T changes

— Arrhythmias: VF, VT, asystole, AF, heart block, prolonged QT

— New conduction delay (RBBB) may indicate myocardial injury

— Repeat ECG if symptoms change or after fluid resuscitation

— All high-voltage exposures, lightning strikes, LOC, abnormal initial ECG, transthoracic current path, or symptomatic patients → admit for 24 h telemetry

— Asymptomatic low-voltage exposure with normal initial ECG and exam → discharge from ED is appropriate

— Troponin: obtain if abnormal ECG, chest pain, hemodynamic instability, or high-voltage exposure. Elevation suggests myocardial contusion/necrosis from direct current injury — not coronary occlusion (do not reflexively cath)

— CK (often >5,000–100,000), urine myoglobin or dipstick positive for blood without RBCs on micro

— BMP for hyperkalemia (released from necrotic muscle), hyperphosphatemia, hypocalcemia, AKI

— Repeat CK q6–12h until trending down

— CBC, coags, lactate, ABG/VBG, LFTs, lipase (if abdominal current path), type & screen

— Pregnancy test (β-hCG) in reproductive-age women

— UA: myoglobinuria, hematuria

— Trauma series (CXR, pelvis) if fall or thrown

— CT head for LOC, AMS, headache, focal deficit

— CT c-spine for any mechanism suggesting cervical injury

— XR of joints with deformity (shoulder, hip — posterior dislocation classic)

— CT abdomen/pelvis if transabdominal current or peritoneal signs

12-lead ECG is mandatory in every electrical injury:

Continuous telemetry:

Cardiac biomarkers:

Rhabdomyolysis labs:

Other baseline labs:

Imaging:

Step 3 management: Order CK, BMP, UA, ECG, and troponin on every high-voltage or symptomatic electrical injury; lightning with arrest gets the full trauma + neuro workup.

Board pearl: A urine dip positive for blood with no RBCs on microscopy = myoglobinuria — start aggressive IV fluids immediately, even before CK results.

Diagnostic Workup — Advanced or Confirmatory Studies

— Indicated if elevated troponin, persistent arrhythmia, hypotension, or HF signs

— May reveal regional or global hypokinesis from direct myocardial electroporation — typically recovers

— Stryker needle or arterial-line manometer for suspected compartment syndrome

— ΔP = diastolic BP − compartment pressure; ΔP <30 mmHg → fasciotomy

— Do not wait for the classic "5 P's" — paresthesia and pain are early; pulselessness is late

— MRI brain/spine for persistent deficit, delayed myelopathy, or stroke-like presentation

— Lightning can cause basal ganglia hemorrhage, hypoxic encephalopathy, demyelination

— EEG if seizure, status epilepticus, or persistent altered mental status

— Slit-lamp for corneal burn, hyphema; baseline lens exam — cataracts develop weeks to years after high-voltage or lightning injury, especially with head/neck entry

— Otoscopy for TM rupture (lightning); audiogram for persistent hearing loss

— If inhalation injury suspected (singed nares, carbonaceous sputum, stridor, closed-space fire)

— For suspected vascular injury, delayed thrombosis, or in extremity with cool pulseless segment despite fasciotomy

— Critical in lightning victims with prolonged depressed mental status

— In the OR, depth of muscle necrosis is mapped — guides debridement

— Tc-99m pyrophosphate scan historically used to detect deep muscle necrosis (rarely used today)

Echocardiography:

Compartment pressure measurement:

Neuroimaging and EEG:

Ophthalmology consult:

Otolaryngology / audiology:

Bronchoscopy:

Angiography / CTA:

Continuous video EEG and serial neuro exams:

Wound assessment under anesthesia:

Key distinction: Troponin elevation after electrical injury reflects direct myocardial injury, not ACS — cath lab activation is rarely appropriate unless ECG and clinical picture strongly suggest plaque rupture; manage supportively with telemetry and echo.

Board pearl: Always document a baseline ophthalmologic exam in high-voltage and lightning patients — cataract is a recognized late complication and a litigation/disability issue.

Risk Stratification and First-Line Management Logic

— Low-voltage, asymptomatic, normal ECG, normal exam, no LOC, no transthoracic path, not pregnant: discharge home with return precautions

— Low-voltage with symptoms, abnormal ECG, transthoracic path, or pregnant: telemetry × 24 h

— High-voltage (≥1000 V) or lightning: admit; trauma/burn center if significant burn, deep injury, or arrhythmia

— Cardiac arrest, large burn, compartment syndrome, AKI, AMS: ICU

— Even minor shock → fetal monitoring for ≥4 h if ≥20 weeks gestation; obstetric consult; consider longer monitoring if transabdominal current

— Fetal mortality higher than maternal in significant shocks

— Standard Parkland formula underestimates needs in electrical injury because of deep muscle necrosis

— Titrate to urine output 1–1.5 mL/kg/h (vs. 0.5 in thermal) until myoglobin clears

— Use LR; avoid hypotonic fluids

— Aggressive crystalloid; consider urinary alkalinization (controversial — bicarb to urine pH >6.5) if severe

— Avoid mannitol unless oliguric and volume-replete; monitor K+ closely

Disposition algorithm at the ED:

Pediatric oral commissure burn: outpatient with strict precautions for delayed labial artery bleed at 1–3 weeks; parents instructed to pinch lip for 10 min and present to ED if bleeding occurs

Pregnancy:

Burn center referral criteria (ABA) apply: electrical burns of any size, full-thickness >5% BSA, partial-thickness >10%, burns to face/hands/feet/perineum/joints, inhalation injury

Fluid resuscitation logic:

Rhabdomyolysis prevention:

CCS pearl: On CCS, the cadence for a high-voltage case is: primary survey → IV/O2/monitor → ECG → labs including CK → aggressive LR titrated to UOP 1–1.5 mL/kg/h → trauma/burn imaging → admit telemetry or ICU → reassess every 1–2 h with repeat CK, K+, creatinine, UOP.

Step 3 management: Don't anchor on the burn — the management priority is airway, arrhythmia, rhabdo, and compartment syndrome, in that order.

Pharmacotherapy — First-Line Drug Regimen

— Lactated Ringer's IV, bolus 20–30 mL/kg, then titrated infusion to UOP 1–1.5 mL/kg/h in adults with rhabdomyolysis; 1.5–2 mL/kg/h in children

— Continue until urine clears of myoglobin (urine no longer tea-colored, CK trending down)

— IV opioids (morphine, fentanyl, hydromorphone) — pain often severe and underestimated

— Avoid NSAIDs acutely due to AKI risk from rhabdomyolysis

— Follow ACLS: defibrillate VF/pulseless VT, epinephrine 1 mg q3–5 min, amiodarone 300 mg

— For stable arrhythmias, amiodarone or lidocaine; correct electrolytes first (K+, Mg++, Ca++)

— Atropine and transcutaneous pacing for symptomatic bradycardia/AV block

— Hyperkalemia: calcium gluconate (membrane stabilization), insulin/D50, albuterol, sodium bicarbonate, loop diuretic, kayexalate or patiromer; dialysis for refractory K+ or AKI with uremia/volume overload

— Hypocalcemia: usually do not replete unless symptomatic (tetany, seizure, prolonged QT) — calcium can deposit in necrotic muscle and rebound hypercalcemia is common

— Tdap if last booster >5 years (contaminated wound) or unknown status; TIG if unimmunized

— No prophylactic systemic antibiotics for burns alone

— Topical (silver sulfadiazine, mafenide acetate) per burn unit; mafenide preferred for eschar penetration but causes metabolic acidosis (carbonic anhydrase inhibitor)

— Systemic antibiotics only for documented infection, cellulitis, or peri-operative coverage

Fluid resuscitation is the cornerstone:

Analgesia:

Arrhythmia management:

Electrolyte correction:

Tetanus prophylaxis:

Antibiotics:

DVT prophylaxis: LMWH once bleeding/surgical concerns addressed (immobile burn patient is high risk)

Stress ulcer prophylaxis: PPI/H2 blocker for ICU/large burn patients (Curling ulcer)

Board pearl: Do not chase asymptomatic hypocalcemia in early electrical injury — the calcium is sequestered in injured muscle and will be released, causing later hypercalcemia.

Step 3 management: First-line drug therapy in significant electrical injury = LR, opioid analgesia, Tdap, treat hyperkalemia, ACLS for arrhythmia — antibiotics are not prophylactic.

Procedures and Invasive Management

— Indicated for clinical compartment syndrome or measured ΔP <30 mmHg

— High-voltage forearm and lower-extremity injuries often require prophylactic fasciotomy because deep muscle necrosis precedes overt pressure rise

— Carpal tunnel release frequently accompanies forearm fasciotomy

— Delays >6 h dramatically increase amputation rate

— For circumferential full-thickness burns of trunk (restricts ventilation), extremities (vascular compromise), or neck

— Bedside incisions through eschar into subcutaneous fat along mid-lateral lines

— Serial OR debridement every 24–48 h until viable tissue

— Amputation rates 35–60% in high-voltage upper-extremity injury

— Definitive coverage with skin grafts, flaps after demarcation

— Indicated for refractory hyperkalemia, uremia, severe acidosis, volume overload, or oliguric AKI from myoglobinuria unresponsive to fluids

— CRRT preferred in unstable patients

— Lightning arrest: prolonged CPR justified — neurologic recovery possible despite extended downtime because of "metabolic suspension"

— Defibrillation per ACLS; secure airway early — apnea may persist after cardiac recovery

— Early intubation if facial/oral burns, stridor, inhalation injury, or large fluid resuscitation anticipated (airway edema worsens over 24 h)

— Burn surgery, orthopedics (fractures), vascular (thrombosis), neurosurgery (intracranial), ophthalmology

Fasciotomy:

Escharotomy:

Debridement and amputation:

Renal replacement therapy:

Cardiopulmonary resuscitation specifics:

Airway management:

Surgical consults:

Hyperbaric oxygen: not routinely indicated; consider for concomitant CO poisoning from fire

CCS pearl: For a high-voltage forearm injury with rising CK, tense compartments, and pain on passive finger extension — order emergent surgical consult for fasciotomy before pulses disappear; pulselessness is a late finding.

Board pearl: Reverse triage in lightning mass-casualty events: resuscitate the "dead" first — primary apnea is recoverable if ventilation is restored quickly.

Special Populations — Elderly and Renal/Hepatic Impairment

— Higher baseline cardiac comorbidity → lower threshold for telemetry and echo even after low-voltage exposure

— Reduced physiologic reserve for fluid resuscitation; titrate to UOP but watch for pulmonary edema — consider invasive monitoring or bedside ultrasound for volume status

— Falls from electrical injury frequently cause occult hip fracture, subdural hematoma, c-spine injury — image liberally

— Polypharmacy: review for QT-prolonging meds (amiodarone, antipsychotics, SSRIs, fluoroquinolones, ondansetron) that compound arrhythmia risk

— Anticoagulants/antiplatelets: heightened risk of intracranial hemorrhage after fall — reverse if indicated (PCC for warfarin, andexanet/4F-PCC for DOACs)

— Burns appear deeper; healing slower; higher graft failure rate; aggressive wound care and nutrition support

— Baseline AKI risk magnified by myoglobinuria — earlier nephrology involvement and lower threshold for RRT

— Fluid resuscitation still required but with closer monitoring; consider CRRT for combined volume and clearance needs

— Avoid nephrotoxins: NSAIDs, IV contrast (use carefully if trauma imaging essential), aminoglycosides

— Coagulopathy compounds trauma bleeding — check INR, transfuse FFP for active bleeding

— Drug dosing: reduce or avoid hepatically cleared opioids (morphine metabolites accumulate in renal failure too); fentanyl preferred in both renal and hepatic dysfunction

— Acetaminophen dosing reduced (max 2 g/day in significant cirrhosis)

— Already-anuric patient cannot use UOP as endpoint — monitor CK trend, K+, and dialyze for clearance; volume target lower

Elderly considerations:

Skin fragility:

Chronic kidney disease:

Hepatic impairment:

Dialysis patients:

Step 3 management: In the older adult after electrical injury, expand the workup to include CT head and c-spine, hip imaging if any fall mechanism, medication reconciliation, and cardiac echo even when the initial trauma exam seems reassuring.

Board pearl: Fentanyl is the safest opioid in combined renal-hepatic impairment after electrical injury.

Special Populations — Pregnancy and Pediatrics

— Even minor shocks can cause fetal demise — uterus and amniotic fluid are excellent conductors; fetus is at risk even when mother is asymptomatic

— Higher fetal mortality with hand-to-foot path (current crosses uterus)

— Management ≥20 weeks: continuous external fetal monitoring for ≥4 h; extend to 24 h if contractions, abnormal tracing, abdominal pain, vaginal bleeding, decreased fetal movement, or transabdominal current

— Obstetric consultation for all pregnant electrical injury patients

— Rh status: administer RhoGAM to Rh-negative mothers with any abdominal trauma

— Imaging: shield uterus when possible but do not withhold indicated imaging — diagnostic radiation < 50 mGy is safe in pregnancy

— Lightning strike in pregnancy carries high fetal mortality; aggressive maternal resuscitation is best fetal therapy

— Oral commissure burn from chewing extension cord — classic toddler injury

· Initial wound looks deceptively benign with pale eschar

· Eschar sloughs at 1–3 weeks → labial artery hemorrhage, can be life-threatening

· Outpatient management with strict parent education: pinch lip continuously for 10 minutes and return immediately if bleeding

· Plastic surgery follow-up for cosmetic/functional repair, microstomia prevention with oral splints

— Low-voltage household contact in asymptomatic child with normal ECG: discharge after observation

— Higher risk of cardiac arrest with hand-to-hand path (small body habitus)

— Suspect non-accidental injury in unusual or inconsistent histories — mandatory reporting if suspected

— Weight-based dosing; LR 20 mL/kg boluses; UOP target 1.5–2 mL/kg/h

— Pediatric burn center referral for any electrical burn

Pregnancy:

Pediatrics:

Pediatric resuscitation specifics:

Key distinction: Unlike adults, pregnant patients with even trivial shock require fetal monitoring and OB consult — fetal vulnerability vastly exceeds maternal symptoms.

Board pearl: Pediatric oral commissure burn → educate parents about delayed labial artery bleed at 1–3 weeks, the classic exam question.

Complications and Adverse Outcomes

— Acute arrhythmia (VF, asystole, AF, AV block, prolonged QT)

— Myocardial injury with troponin elevation, regional wall motion abnormality — usually recovers

— Delayed arrhythmia rare beyond 24–48 h if initial ECG and telemetry normal

— AKI from myoglobinuria, hypovolemia, direct tubular injury

— Hyperkalemia, metabolic acidosis, need for RRT

— Rhabdomyolysis; compartment syndrome; amputation

— Fractures and dislocations from tetanic contraction or fall — posterior shoulder dislocation, vertebral compression, scapular fracture

— Immediate: LOC, seizure, intracerebral hemorrhage, spinal cord injury, keraunoparalysis

— Delayed (days to years): peripheral neuropathy, transverse myelitis, ALS-like syndromes, chronic pain, cognitive impairment, depression, PTSD, sleep disturbance

— Lightning survivors have a recognized chronic neurocognitive syndrome with attention, memory, and mood symptoms

— Cataract (weeks to years post-injury, particularly with head/neck contact)

— Corneal burn, hyphema, optic neuropathy, macular hole

— TM rupture (>50% in lightning), sensorineural hearing loss, vertigo, tinnitus

— Inhalation injury, ARDS, contusion from blast/fall, aspiration during seizure

— Arterial thrombosis, intimal injury, delayed aneurysm

— Infection (group A strep, Pseudomonas, Clostridium), poor healing, contractures, hypertrophic scarring, heterotopic ossification

— Curling ulcer (stress), ileus, mesenteric injury with transabdominal path, pancreatitis

— PTSD, depression, anxiety — particularly after lightning; affect quality of life more than physical scars

Cardiac:

Renal:

Musculoskeletal:

Neurologic:

Ophthalmologic:

ENT:

Pulmonary:

Vascular:

Wound:

GI:

Psychiatric:

Board pearl: Cataracts can develop months to years after high-voltage or lightning injury — schedule ophthalmology follow-up as part of discharge planning, especially with head/neck current paths.

When to Escalate Care — ICU, Consult, Inpatient Triage

— Cardiac arrest, sustained arrhythmia, persistent hemodynamic instability

— Mechanical ventilation, large-volume resuscitation, refractory acidosis

— Severe rhabdomyolysis (CK >5,000 rising), oliguric AKI, need for RRT

— Burn TBSA >20%, inhalation injury, intubation

— Compartment syndrome post-fasciotomy, multi-extremity injury

— Persistent altered mental status, status epilepticus, ICH

— Asymptomatic high-voltage exposure with normal ECG, monitored 24 h

— Stable rhabdo with adequate UOP and trending labs

— Low-voltage with transient ECG abnormality, transthoracic path, LOC, or pregnancy

— Low voltage, asymptomatic, normal physical exam and ECG

— No LOC, no transthoracic current path, no pregnancy

— Reliable follow-up and return precautions understood

— Burn surgery: any electrical burn meeting ABA criteria

— Trauma surgery: high-voltage with mechanism for blunt injury

— Orthopedics: fractures, dislocations, compartment syndrome

— Cardiology: persistent arrhythmia, elevated troponin, abnormal echo

— Nephrology: AKI requiring RRT

— Neurology/neurosurgery: ICH, cord injury, refractory seizure

— Ophthalmology: baseline and serial exams in high-voltage/lightning

— OB: any pregnant electrical injury patient

— Plastic surgery: pediatric oral commissure, reconstruction

— Psychiatry/PTSD support: lightning survivors particularly

ICU admission criteria:

Telemetry/step-down (not ICU):

Outpatient discharge appropriate if all are true:

Specialty consults:

Burn center transfer: arrange early via ABA criteria; stabilize ABCs and arrhythmia first

CCS pearl: In the CCS sim, escalate to ICU immediately for any patient with persistent arrhythmia, intubation, large burns, or oliguric rhabdo; consult burn surgery and trauma surgery in parallel, not sequentially — clock matters.

Step 3 management: The patient who looks well after low-voltage exposure with a normal ECG can usually go home; the transthoracic path, pregnancy, or LOC changes that disposition decisively.

Key Differentials — Same-Category (Trauma/Burn) Causes

— Surface injury usually correlates with depth; no deep muscle necrosis disproportionate to skin

— No arrhythmia risk, no rhabdomyolysis unless very large TBSA

— Parkland formula adequate; UOP target 0.5 mL/kg/h

— Acid (coagulation necrosis, self-limited) vs. alkali (liquefaction, progressive)

— Treatment: copious irrigation; specific antidotes (calcium gluconate for HF acid)

— No cardiac monitoring needed unless systemic toxicity

— Thermal injury from arc heat without conduction through body

— Manage as thermal burn; lower arrhythmia/rhabdo risk, but consider deep injury if proximity was close

— From fire in closed space; carbonaceous sputum, singed nares, hoarseness

— Risk of airway edema, CO poisoning, cyanide toxicity (smoke from synthetic materials)

— Manage with early intubation, 100% O₂, hydroxocobalamin if cyanide suspected

— Primary (pressure wave: TM rupture, pulmonary contusion, bowel perforation), secondary (penetrating), tertiary (blunt), quaternary (burns, toxins)

— Lightning produces small blast component

— Same final pathway as electrical (rhabdo, AKI, compartment syndrome) but without arrhythmia

— Management overlap: aggressive fluids, monitor K+, fasciotomy

— Outdoor exposure overlap with lightning victims found in storms

— Rewarm before declaring death: "not dead until warm and dead"

— Lightning: brief, often asystole initially, lower deep-burn rate, flashover, Lichtenberg figures, TM rupture, keraunoparalysis

— AC high-voltage: prolonged, VF, deep muscle necrosis, amputation

Thermal burn (flame, scald, contact):

Chemical burn:

Flash/arc burn without current passage:

Inhalation injury:

Blast injury:

Crush injury:

Frostbite / hypothermia:

Lightning vs. high-voltage AC:

Key distinction: A patient with severe rhabdomyolysis, AKI, and compartment syndrome but no arrhythmia or cardiac biomarker elevation and intact mentation suggests crush injury rather than electrical — history clarifies, but management overlaps substantially.

Board pearl: Surface burn extent underestimates severity in electrical injury and overestimates it in chemical alkali — both deserve respect, for opposite reasons.

Key Differentials — Other-Category Causes

— ACS, primary VF, hereditary long QT, hypertrophic cardiomyopathy, Brugada

— Distinguish by history (witnessed strike vs. collapse during exertion), Lichtenberg figures, burn pattern

— Empiric workup overlaps: ECG, troponin, echo, electrolytes

— Witnessed seizure during storm could be misattributed to lightning or vice versa

— EEG, neuroimaging, drug screen clarify

— Lightning can directly cause both; or coincidental fall mistaken as primary event

— CT head differentiates; serial neuro exam crucial

— Acute severe chest/back pain with lower-extremity pulse deficit mimics keraunoparalysis

— CTA chest distinguishes; D-dimer rarely useful in trauma context

— Fall from height during electrical event vs. direct cord injury from current

— MRI distinguishes; both warrant spine precautions

— Sympathomimetic toxidrome with arrhythmia, hyperthermia, rhabdo, AMS

— TCA overdose: wide QRS, seizure, arrhythmia — give bicarbonate

— Cocaine: ACS, arrhythmia, rhabdo

— Volume status, mental status, lactate, infectious source distinguish

— Outdoor collapse, hyperthermia, AMS, rhabdo — overlap with lightning

— Core temperature, history, lack of burn or strike evidence distinguish

— From smoke inhalation in associated fire — get carboxyhemoglobin and lactate

— In low-voltage exposures with no objective findings

— Rare but described; inconsistent history, no objective burn, normal ECG

Out-of-hospital cardiac arrest (non-electrical):

Seizure with postictal state:

Stroke / intracranial hemorrhage:

Aortic dissection:

Spinal cord injury (traumatic):

Drug intoxication / overdose:

Severe sepsis with rhabdomyolysis:

Heat stroke:

Carbon monoxide / cyanide poisoning:

Psychogenic non-epileptic spell or syncope:

Munchausen / factitious electrical injury:

Step 3 management: In the unwitnessed collapse with burn-like marks, work up ACS, stroke, and toxicology in parallel — don't tunnel on the presumed electrical mechanism if the story doesn't fit.

Key distinction: Keraunoparalysis (transient, resolves in hours, with sympathetic findings) vs. true cord injury (persistent, MRI changes) — observation distinguishes early.

Secondary Prevention, Discharge Medications, Long-Term Plan

— Analgesia: short-course opioid plus acetaminophen; avoid NSAIDs if AKI risk

— Tdap if not updated; TIG if unimmunized with contaminated wound

— Topical burn care: silver sulfadiazine or bacitracin per wound type

— DVT prophylaxis if discharging immobile patient on a brief course

— Treat anxiety/sleep disturbance: short course of trazodone or SSRI initiation if PTSD symptoms emerge — refer to mental health

— Daily dressing changes, signs of infection (erythema, drainage, fever), pain escalation

— Sun protection on healing skin for 12 months to prevent hyperpigmentation

— If troponin was elevated or arrhythmia occurred: outpatient cardiology, echo at 4–6 weeks, ambulatory monitor if symptomatic

— Discharge with home pulse/BP log if borderline

— If AKI: nephrology, recheck BMP and urinalysis at 1–2 weeks; monitor proteinuria

— Baseline exam during admission; follow-up at 3, 6, 12 months for cataract surveillance (high-voltage and lightning); annual thereafter for years

— Follow-up at 1 month for TM rupture; most heal spontaneously; surgical repair if persistent perforation at 3 months

— Lineman, electrician: review lockout-tagout, PPE, arc-flash garments, refresher training; report to OSHA/employer

— Household: GFCI outlets, childproof outlet covers, cord management, no electrical appliances near water

— Lightning safety: 30-30 rule (seek shelter if thunder <30 s after lightning; wait 30 min after last thunder); avoid open fields, tall isolated trees, water, metal objects

— Screen for PTSD, depression at follow-up; lightning survivors particularly benefit from early counseling and support group referral (e.g., Lightning Strike & Electric Shock Survivors International)

Discharge medications and prescriptions:

Wound care education:

Cardiac follow-up:

Renal follow-up:

Ophthalmology:

Audiology:

Occupational safety / prevention counseling:

Mental health:

Step 3 management: Discharge bundle = wound care, Tdap, analgesia, ophthalmology referral, mental health screening, occupational/home safety counseling, and scheduled follow-up at 1–2 weeks.

Board pearl: Long-term cataract surveillance is the often-forgotten secondary prevention step after high-voltage and lightning injury.

Follow-Up, Monitoring Parameters, Rehab and Counseling

— 1–2 weeks: PCP visit — wound check, pain control, medication reconciliation, mental health screen, return-to-work assessment

— 1 month: burn surgery for wound progression, scar management; audiology if TM rupture

— 3 months: ophthalmology, neurology if persistent symptoms, PT/OT progress

— 6 and 12 months: ophthalmology (cataract), cardiology if indicated, neurocognitive assessment

— Annual: ophthalmology surveillance for several years in lightning and high-voltage survivors

— Wound healing, range of motion, pain scores

— Cardiac symptoms, BP, exercise tolerance

— Renal function (BMP) if prior AKI

— Neurocognitive function (MoCA), mood (PHQ-9, GAD-7, PCL-5 for PTSD)

— Visual acuity, lens exam

— Hearing acuity, tinnitus

— PT/OT: range of motion, strengthening, fine motor (especially hand burns), gait training after lower-extremity injury

— Compression garments for hypertrophic scars (start when wounds closed)

— Splinting to prevent contractures

— Amputee rehab with prosthetic fitting for high-voltage amputations

— Return-to-work planning, occupational therapy assessment, employer accommodations

— Workers' compensation paperwork for occupational injuries

— Disability evaluation if permanent impairment

— Sexual function (autonomic dysfunction, body image)

— Family/caregiver education on neurocognitive sequelae, mood changes

— Lightning safety education for outdoor workers/recreationists

— Driving safety after seizure (state-mandated reporting in some jurisdictions; typically 6-month seizure-free interval)

— Documented mental health screening, cataract surveillance, and burn rehab attendance are increasingly tracked

Follow-up cadence:

Monitoring parameters at each visit:

Rehabilitation:

Vocational rehabilitation:

Counseling topics:

Quality measures (value-based care):

Step 3 management: A structured 1-week, 1-month, 3-month, 6-month, 1-year follow-up cadence with attention to ophthalmology, neurocognition, and mental health distinguishes complete care from incomplete care after significant electrical injury.

Board pearl: Driving restrictions apply after any seizure from electrical injury — counsel and document.

Ethical, Legal, and Patient Safety Considerations

— Suspected child abuse: pediatric electrical burns with inconsistent history (e.g., immersion-pattern injury claimed as accident, multiple contact burns of different ages) — report to child protective services; mandatory in all 50 states

— Elder abuse / vulnerable adult: similar mandates

— Workplace injury: OSHA reporting for serious occupational electrical injuries within 24 h (employer responsibility), but clinicians should document occupational mechanism clearly

— Suspected suicide attempt by electrocution: psychiatric evaluation, safety planning, reporting per state law

— Patient with altered mental status after lightning strike — emergency exception applies for life-saving care; surrogate decision-maker for non-emergent procedures (amputation, complex reconstruction)

— Patient with persistent neurocognitive impairment may need decision-making capacity assessment before discharge planning or rehab placement

— Pregnant patient: dual obligation to mother and fetus; mother's autonomy takes precedence in competent adult

— Discharging the asymptomatic low-voltage patient without ECG documentation, or without educating about delayed labial artery bleed in pediatric oral burn — both are board-classic litigation traps

— Failing to schedule ophthalmology follow-up for cataract surveillance after high-voltage exposure

— Inadequate handoff of pending labs (CK trend) when transferring to burn center

— Mechanism, voltage source, current path, duration, witnessed events

— Initial vitals, ECG, exam — including baseline neurologic and ophthalmologic

— Discussions of risks, benefits, and follow-up plan

— Use GFCI outlets in healthcare settings to prevent inpatient electrical injuries

— Electrical safety in OR (electrocautery burns), MRI suite (projectile injury)

— Tasers and stun guns: medical clearance protocols vary; document ECG and observation

— Prolonged CPR is justified in lightning arrest given potential for neurologic recovery; however, after appropriate resuscitative effort, withdrawal-of-care discussions follow standard ethical frameworks with surrogate decision-makers

Mandatory reporting:

Informed consent edge cases:

Transition-of-care risks (high Step 3 yield):

Documentation essentials:

Patient safety / system issues:

End-of-life considerations:

Step 3 management: Build the discharge plan around mandatory reporting checks, capacity assessment if needed, scheduled follow-up handoff, and explicit return precautions — this is the audit-proof care plan.

Board pearl: Pediatric oral commissure burn discharged without delayed-bleed counseling is a recurring medicolegal and exam scenario — document the conversation.

High-Yield Associations and Rapid-Fire Clinical Facts

AC > DC danger at equivalent voltage because tetany prevents release

AC arrhythmia: VF classic; DC/lightning arrhythmia: asystole classic

Lichtenberg figures: pathognomonic for lightning; transient, not true burns; resolve in 24 h

Keraunoparalysis: transient flaccid paralysis with sympathetic instability after lightning — resolves in hours

Reverse triage in lightning mass-casualty: resuscitate the apparently dead first

TM rupture in >50% of lightning strikes — examine ears

Cataract: delayed weeks to years; high-voltage and lightning, especially head/neck path

Oral commissure burn: pediatric, delayed labial artery bleed 1–3 weeks later

Posterior shoulder dislocation: classic from tetanic contraction (also from seizure)

Compartment syndrome: pain on passive stretch is early; pulselessness is late

Urine dip positive for blood without RBCs = myoglobinuria

UOP target 1–1.5 mL/kg/h in rhabdomyolysis (vs. 0.5 in thermal burn)

Hypocalcemia early, hypercalcemia late — don't aggressively replete asymptomatic hypocalcemia

Parkland formula underestimates fluid needs in electrical injury

Mafenide acetate penetrates eschar but causes metabolic acidosis (carbonic anhydrase inhibitor)

Silver sulfadiazine is the standard topical; avoid in G6PD deficiency, sulfa allergy, near term pregnancy

GFCI outlets prevent low-voltage household electrocution

30-30 rule: shelter if thunder <30 s after lightning; wait 30 min after last thunder

Pregnancy + shock = OB consult and fetal monitoring even if mom is asymptomatic

Fentanyl safest opioid in renal-hepatic impairment

Burn center referral: any electrical burn meeting ABA criteria

Lightning survival can be high with prompt CPR — primary apnea, secondary cardiac arrest

Tetanus prophylaxis indicated for nearly all electrical burns

Fasciotomy >6 h delay drastically increases amputation rate

Board pearl: Memorize the AC→VF, DC→asystole, AC→tetany lock-on, lightning→flashover/Lichtenberg quartet — vignettes hinge on these associations.

CCS pearl: For any high-voltage CCS case, set monitor cadence to q15 min for first hour, q1 h thereafter and reorder CK, BMP, UOP every 6 h until stable.

Board Question Stem Patterns

— High-voltage AC, transthoracic path, deep entry/exit wounds, normal-appearing skin between

— Best answer: aggressive LR titrated to UOP 1–1.5 mL/kg/h, early fasciotomy, telemetry/ICU

— Distractor: Parkland formula calculation alone (underestimates)

— Lichtenberg figures = lightning

— Best answer: ATLS, prolonged CPR if arrested, supportive care, ophthalmology and audiology referral

— Distractor: extensive surgical debridement (lightning rarely causes deep burns)

— Pediatric oral commissure burn

— Best answer: discharge with parental counseling about delayed labial artery hemorrhage in 1–3 weeks; plastic surgery follow-up

— Distractor: immediate surgical excision; admission to ICU

— Best answer: continuous external fetal monitoring ≥4 h, OB consult, Rh status check

— Distractor: reassure and discharge

— Compartment syndrome

— Best answer: emergent fasciotomy (do not wait for pulse loss or compartment pressures if clinical picture is clear)

— Best answer: emergent dialysis for refractory hyperkalemia with AKI

— Treat hyperkalemia bridging measures simultaneously (calcium, insulin/D50, bicarb)

— Best answer: resuscitate the apneic/pulseless first (reverse triage)

— Best answer: discharge home with return precautions — no admission needed

— Best answer: echo, telemetry, supportive care — not cardiac catheterization

— Best answer: ophthalmology referral for cataract

Stem 1 — Lineman thrown from pole:

Stem 2 — Hiker found unconscious after thunderstorm with fern-like skin marks:

Stem 3 — Toddler with charred lip after chewing extension cord:

Stem 4 — Pregnant woman with mild shock from hair dryer at 26 weeks:

Stem 5 — Construction worker with high-voltage forearm injury, tense forearm, pain on finger extension:

Stem 6 — High-voltage patient with CK 50,000, K+ 6.8, oliguria despite fluids:

Stem 7 — Lightning mass casualty, multiple victims:

Stem 8 — Asymptomatic adult after low-voltage shock, normal ECG and exam:

Stem 9 — Patient with troponin elevation after high-voltage injury:

Stem 10 — Survivor at 6-month follow-up with new blurry vision:

Board pearl: When the stem includes "transthoracic current path," "tetanic lock-on," or "thrown from source," the correct disposition is admit with telemetry/ICU, regardless of how well the patient looks.

One-Line Recap

— AC → VF + tetanic lock-on; DC/lightning → asystole + throw injury; lightning → Lichtenberg figures, TM rupture, keraunoparalysis

— Admit and telemeter any patient with high voltage, lightning, transthoracic path, LOC, abnormal ECG, or pregnancy; discharge asymptomatic low-voltage with normal ECG

— Fluids to UOP 1–1.5 mL/kg/h, fasciotomy for compartment syndrome (clinical or ΔP <30), dialysis for refractory hyperkalemia/AKI, Tdap, opioid analgesia, no prophylactic antibiotics

— Reverse triage for lightning mass casualties — resuscitate the dead first

— Discharge bundle: wound care, mental health screen, ophthalmology referral for cataract surveillance, structured follow-up at 1 week, 1 month, 3 months, 6 months, 1 year, plus mandatory reporting for suspected pediatric abuse and parental counseling for delayed labial artery hemorrhage in oral commissure burns

Electrical injury and lightning strike are deceptive: the visible burn dramatically underestimates internal damage, and the right framework is ATLS → ECG/telemetry → aggressive LR to UOP 1–1.5 mL/kg/h → vigilance for arrhythmia, rhabdomyolysis, compartment syndrome, and delayed ocular/neurocognitive sequelae, with reverse triage for lightning arrest and tailored disposition by voltage, current path, and special population.

High-yield recap bullets:

Step 3 management: When the vignette pivots from "what happened" to "what next," remember that the longitudinal plan — cataract surveillance, neurocognitive screening, occupational safety counseling, and PTSD support — is what separates a Step 2 answer from a Step 3 answer.

Board pearl: If you remember only one thing: the surface burn lies — manage the patient as if every electrical injury hides deep muscle necrosis, an arrhythmia, and a cataract waiting to happen.