Acute Care

ACLS: Electric and Lightning Injuries

Background

1. Definition
   • Injuries resulting from direct effects of current from
     • Lightning
     • DC/AC current
2. Synopsis
   • Site and severity of trauma determined by
     • Magnitude of energy delivered
     • Voltage
     • Resistance to current flow
     • Type of current
     • Duration of contact with source
     • Current pathway
   • Electric Shock (View image)
     • High-tension current generally causes more serious injuries
     • Fatal electrocution can occur with household current
       • 110 V in U.S. and Canada
       • 220 V in Europe
     • Alternating current (60 cycles/sec) may cause prolonged exposure
       • Causes tetanic skeletal muscle contractions
       • Prevents self-release from source
         • "Locks" victim to current source
       • Also increases likelihood of current flow through heart during relative refractory period
         • Analogous to R-on-T phenomenon
         • Can precipitate V-Fib
   • Lightning Injuries
     • Mortality is 30%
       • About 24,000 deaths world-wide
       • USA about 40 deaths/yr
     • Up to 70% have significant morbidity
     • Death primarily due to V-Fib (View image) or Asystole (View image)
       • Lightning acts as a huge DC shock
         • Depolarizes entire myocardium
         • Essentially a huge defibrillation
       • Cardiac automaticity may return, BUT
       • Respiratory arrest may continue due to:
         • Thoracic muscle spasm
         • Suppression of respiratory center
       • Secondary arrest occurs due to hypoxia
     • Secondary cardiovascular effects
       • Extensive catecholamine release and autonomic stimulation
         • Hypertension
         • Tachycardia
         • Nonspecific ECG changes
           • QT interval prolongation
           • Transient T-wave inversion
         • Myocardial necrosis
           • CK-MB levels rise
     • Neurologic injuries
       • Brain hemorrhage and edema
       • Small vessel and neuronal injury
       • Hypoxic encephalopathy

Treatment Overview

1. Initial/Prep/Goals
   • This topic was last reviewed in 2010 AHA/ECC Guidelines, and management recommendations have not changed
   • Victims most likely to die if they have immediate arrest and no treatment is provided
   • Excellent chance of recovery if:
     • No cardiac or respiratory arrest OR
     • Respond to immediate treatment
   • When multiple victims are struck:
     • "Reverse Triage"; Priority of treatment is those in arrest
     • Respiratory arrest
       • May require only O2 and ventilation
         • Prevents secondary arrest
     • Cardiac arrest: (See: Flowchart Illustration AHA Algorithm Flowchart)
       • Early, aggressive, and persistent treatment
       • HIGH success rates
       • May be successful even if prolonged time before resuscitation

Modifications to BLS (2010 AHA/ECC Guidelines)

1. MAKE SURE shock hazard is gone
2. Vigorous measures, even if patient appears dead
   • Many victims are young and have a good chance for survival
3. If spontaneous circulation absent
   • BLS - including chest compressions/AED use
4. Maintain C-Spine stabilization if likelihood of head/neck trauma
5. Remove smoldering clothes/shoes/belts
6. Be aware that there may be other injuries
   • Fractures/internal injuries
     • From being thrown/falling
     • From tetanic muscle contractions

Modifications to ACLS (2010 AHA/ECC Guidelines)

1. Ensure that scene is safe
2. Unresponsive patients may be in respiratory or cardiac arrest
3. CRITICAL ACTIONS
   • Quickly start CPR, defibrillate if needed
   • Airway control
     • May be difficult if facial burns
       • Intubate early even if spontaneous respirations
       • Facial burns are at risk for airway edema
   • Prompt CPR
   • Defibrillation (if indicated)
4. If significant tissue destruction/hypovolemic shock
   • Rapid IV fluid administration
     • Counteract hypovolemic shock/third spacing
5. Serious injury may underlie apparently minor injuries
6. Transport all patients to hospital

Related Topics

• ACLS: Cardiac Arrest Algorithm

References

1. Jensen JD, Thurman J, Vincent AL. Lightning Injuries. StatPearls. Available at: https://www.ncbi.nlm.nih.gov/books/NBK441920/. [Accessed February 2021]
2. Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2015;132:S414-S435
3. Neumar RW, Otto CW, Link MS, et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 12: Adult Advanced Cardiovascular Life Support. Circulation, 2010;122:S829-S861
4. Panchal AR, Bartos JA, Cabanas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Oct 2020;142(16 Suppl 2):S366-S468

Contributor(s)

1. Ward, Toussaint, MD
2. Ho, Nghia, MD

Updated/Reviewed: February 2021