Environmental Emergencies 215

ELECTRICAL BURNS, ELECTROCUTION AND LIGHTNING STRIKE

Lightning strike

DIAGNOSIS

1 Lightning strike can deliver from 300 000 to over 100 000 000 V DC in a few
milliseconds, most of which passes over the surface of the body ‘external
flashover’.

2 Death is secondary to cardiac or respiratory arrest (as in industrial and
domestic electrical injuries).
(i) The commonest rhythm in cardiac arrest is asystole, as opposed
to VF with a high-voltage injury.
(ii) Overall mortality is up to 30%, with 70% of survivors sustaining
significant morbidity.

3 Lightning strike can produce a wide range of clinical effects:
(i) Full-thickness contact burns usually to the head, neck and
shoulders.
(ii) Respiratory arrest secondary to thoracic muscle spasm and
depressed respiratory drive
(a) this may persist even after return of spontaneous circulation,
and may lead to secondary hypoxic arrest.
(iii) Cardiac arrest secondary to depolarization of the entire
myocardium.
(iv) Massive autonomic stimulation with hypertension, tachycardia
and myocardial necrosis.
(v) Neurological deficits ranging from initial loss of consciousness,
sensorineural deafness and vestibular dysfunction to peripheral
nerve damage, intracerebral haemorrhage, cerebral oedema and
transient total body or limb paralysis (keraunoparalysis).
(vi) Arborescent, feathery cutaneous burns presenting within the
first 6 h post injury, known as Lichtenberg figures or lightning
flowers.
(vii) Miscellaneous injuries including tympanic membrane rupture,
corneal defects, retinal detachment and optic nerve damage.

4 Send bloods for FBC, U&Es, LFTs, CK, blood sugar and G&S.

5 Perform an ECG and request trauma X-rays such as chest and pelvis, and CT
scan of the head and cervical spine as indicated clinically.
(i) Non-specific ECG changes include QT prolongation and T wave
inversion.

Warning: do not take fixed dilated pupils as an indicator of death after

! lightning strike. Full recovery is possible.