EMSC Connects

October 2019; Volume 8, Issue 10

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The Doc Spot - Allison "Hallie" Keller, Attending Physician, Life Flight Children’s Services Medical Director, Division of Pediatric Emergency Medicine at Pediatrics, Primary Children’s Hospital

Lightning and Electrical Injuries - Presented at the Sept 9th PETOS

Cases of electrical injury tend to follow these patterns:

  • Young children: electrical cords or outlets
  • Adolescents: high-voltage injuries from climbing trees or power lines
  • 2:1 male to female ratio in kids, 90% male in adults
  • >50% of lightning injuries occur during outdoor recreational activities

The amount of current flowing through the body determines the severity of the injury. Tissues with higher resistance (skin, bone, fat) tend to heat up and coagulate. Lower resistance tissues (nerves and blood vessels) transmit current. Dry skin has greater resistance than wet skin; lower voltage applied to wet skin can generate more current.

AC and DC Currents

  • Alternating current (AC) is found in most homes. It is cyclical and alternates at 60 cycles per second. AC repetitively stimulates muscle contraction causing victims to grasp the source which leads to a longer duration of exposure.
  • Direct current (DC) has a flow that remains constant. Examples are batteries, railway tracks, and car electrical systems. DC current causes a single muscle spasm that throws the victim from the source. While injuries are of shorter duration there is a higher likelihood of trauma.

Lightning Injuries

  • High voltage >1000 V (power lines 100,000 V) and lightning voltages exceed 10 million V.
  • Lightning strikes during thunderstorms kill more Americans each year than hurricanes or tornadoes.
  • Contrary to the saying, lightning can, and often does, strike the same place twice!
  • Lightning incidents often involve more than one victim. Ground current may spread the electricity to a group of people seeking shelter.
  • 10-30% of those struck by lightning die; 75% of survivors have permanent disabilities.
  • Most lightning-associated deaths occur within one hour of injury and are related to fatal arrhythmia or respiratory failure.

Lightning injury is caused by unidirectional massive current exposure (similar to DC) that lasts from 1/10 to 1/1000 of a second. Peak temperatures rise to 30,000 Kelvin (5x hotter than the sun). Rapid heating of the surrounding air generates a shock wave which causes mechanical trauma to the body. It is difficult to predict the course of current flow and the extent of injury. Surface findings often underestimate the extent of tissue damage.

Organ Involvement in Lightning Injury and Treatment Tips


  • Massive direct current shock can depolarize the entire myocardium.
  • Autonomic stimulation and catecholamine surge have additive effects on the heart and rhythm. Asystole is a common presenting rhythm. V-fib and V-tach are also common as is QT prolongation.
  • Spontaneous return of sinus rhythm has been noted after asystole.
  • Respiratory paralysis lasts longer and the return of spontaneous rhythm may degenerate to v-fib due to hypoxia. So, in lightning strikes with multiple casualties, treat the patients without signs of life first. Lightning strike victims who do not sustain cardiac arrest generally survive without intervention. We also recommend prolonged CPR even with asystole as the initial rhythm.


  • Damage to the central and peripheral nervous system
  • LOC, weakness/paralysis, respiratory arrest/depression, autonomic dysfunction
  • Keraunoparalysis = specific to a lightning injury with blue, mottled extremities (LE>UE), thought to be due to vascular spasm
  • Hypoxic encephalopathy, ICH, cerebral infarction, spinal fractures. Remember spinal precautions!
  • Ruptured TM, optic nerve injury, cataracts. Fixed and dilated pupils may NOT reflect severe brain injury.

  • Superficial burns are common (>85%), deep burns cause about 5%. This is due to the short duration of contact.
  • Flashover effect is when the current travels on the surface of the skin and is discharged to the ground (looks like a feather or a fern).
  • Punctate burns are multiple small, cigarette-like burns.
  • Linear burns (where sweat or water accumulate).
  • Burns can occur from metal objects touching skin.
  • The Parkland formula should NOT be used in lightning burns. Surface burns in electrical injuries may grossly underestimate the extent of internal injury. Utilize aggressive fluid resuscitation especially if there are signs of muscle necrosis. Fluid resuscitate for hypotension in transport.

Protocols in Practice - Burns Thermal/Electrical/Lightning

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Ask Our Doc

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything pediatric related? Shoot an email to the address below and look for her response in our next newsletter.


28th Annual Issues in Pediatric Care Conference

Thursday, Oct. 3rd, 8am to Friday, Oct. 4th, 4pm

81 North Mario Capecchi Drive, Salt Lake City, UT

This two-day conference is designed to provide an update of current or emerging pediatric health care issues. The program format for the conference is lecture designed to address a nursing and care provider audience ranging from acute in-patient to out-of-hospital care settings.

The conference will focus on new and changing diagnosis and treatment technologies including the challenges and rewards of providing nursing care to pediatric patients and their families. We will feature premier speakers discussing medical, surgical, and behavioral health-related topics across the broad spectrum of pediatric specialty care.

Register at https://intermountainhealthcare.org/calendar/pch/issues-in-pediatric-care/

Pediatric Education and Trauma Outreach Series (Petos)

Monday, Oct. 14th, 2-4pm

475 300 East

Salt Lake City, UT

Pediatric lectures for EMS. Face time with PCH attending physicians. These lectures occur monthly on the 2nd Monday of the month from 2-3 p.m. You may attend in person or watch the webinar. It will qualify for pediatric CME from the Utah Department of Health, Bureau of EMS and Preparedness. Access at https://intermountainhealthcare.org/locations/primary-childrens-hospital/classes-events/petos/

RSVPs are enabled for this event.

Looking for a PEPP Class?

EMSC Pediatric Education for Prehospital Providers

Register online at peppsite.org. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($18.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at eandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

Emergency Medical Services for Children, Utah Bureau of EMS and Preparedness

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.