Electrical & Lightning Injury

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Red flags

• Lightning is a brief, MASSIVE DIRECT CURRENT event — it depolarises the entire myocardium simultaneously and produces ASYSTOLE, not ventricular fibrillation. VF is the dominant rhythm in man-made AC electrical injury. This single distinction drives triage, resuscitation and prognosis
• REVERSE TRIAGE in mass-casualty lightning strike — the apparently dead (apnoeic, pulseless, dilated pupils) are the PRIORITY, not the lowest priority. They are often in primary respiratory arrest from medullary paralysis; their still-viable heart will restart once oxygenation is restored. Resuscitate the dead-appearing victims FIRST
• Fixed and dilated pupils after lightning are an AUTONOMIC phenomenon, NOT brain death. Lightning causes massive autonomic disruption; never declare brain death or withdraw care on the basis of pupil signs in a lightning victim
• LICHTENBERG FIGURES (ferning) are PATHOGNOMONIC of lightning injury and are essentially never seen in man-made electrical injury. Their presence confirms a lightning mechanism even when no witness is available
• KERAUNOPARALYSIS — transient limb paralysis, numbness, pulselessness and pallor following a lightning strike — resolves spontaneously over hours. Do NOT mistake it for spinal cord injury or vascular catastrophe, and do not rush to thrombolytic or vascular surgery
• Prolonged CPR may succeed in lightning injury — the arrest is often driven by respiratory arrest (medullary paralysis) with a recoverable myocardium. Ventilate and continue compressions far longer than in a normothermic primary cardiac arrest
• TBSA grossly UNDERESTIMATES tissue injury in high-voltage electrical injury — deep muscle, nerve and vessel damage extend far beyond the visible cutaneous burn. Suspect and actively look for compartment syndrome; the operation is FASCIOTOMY, not escharotomy alone