Electrical Injuries and Lightning Strikes

Electrical injuries and lightning strikes are significant yet often misunderstood risks faced by professionals and the public alike. These incidents can result in complex traumatic injuries that extend beyond the visible damage. In this post, we will delve into the mechanics, risks, and essential EMS responses for such injuries, based on expert insights.

Understanding Electrical Injuries

Electrical injuries can be broadly categorized based on the voltage and the resulting damage to the body. Generally, injuries are more severe with higher voltages. On a fundamental level, injuries from electrical sources can be categorized into thermal injuries (burns) and neurological injuries due to the disruption of cellular functions.

Types of Electricity: AC vs. DC

Electricity can be categorized into alternating current (AC) and direct current (DC). AC is commonly used in household and industrial settings, characterized by its changing direction. DC, on the other hand, flows in one direction and is typical in batteries and lightning strikes.

  • Alternating Current (AC): AC is notorious for causing prolonged muscle contraction, leading to an inability to release the electrical source, known as “let-go current.” This can result in severe injuries due to extended contact time.
  • Direct Current (DC): Lightning strikes are a form of DC, delivering a massive voltage in a very short time. Despite the high voltage, the brief contact duration often prevents uniform fatality, though it can cause significant injuries.

Types of Electrical Injuries

  1. High Voltage vs. Low Voltage
    • High Voltage: Anything above 1,000 volts. Common sources include industrial power lines and some heavy-duty appliances. Can cause extensive damage beyond the entry and exit points. High voltage injuries often result in deep tissue burns, muscle damage, and potentially fatal complications.
    • Low Voltage: Less than 1,000 volts. Typical sources are household appliances and gadgets. Typically results in localized injuries, such as burns and muscle contractions. Can become more serious if contact time is prolonged.
  2. Arcing and Flash Burns
    • Arcing happens when electrical current jumps through the air and can cause superficial thermal burns.
    • Flash burns occur when the current superheats the air, leading to a blast effect that can cause thermal injuries.

Injury Patterns in Electrical Injuries

Electrical injuries can cause a variety of injury patterns, often more severe than they appear superficially:

  1. Burns: Both at entry and exit points and along the current’s path through the body.
  2. Muscle and Nerve Damage: The current can cause severe muscle contractions, leading to rhabdomyolysis and nerve damage.
  3. Cardiac and Respiratory Effects: Disruption of cardiac conduction can result in arrhythmias, while diaphragmatic paralysis can lead to respiratory issues.
  4. Secondary Injuries: Patients might suffer traumatic injuries from falls or being thrown by the electrical force.

Key Principles of Electrical Injury Management

  1. Scene Safety
    Before anything else, ensure scene safety. Downed power lines and other electrical hazards can be life-threatening not only to the patient but also first responders. Ground level voltage differentials can cause “step potential,” where even stepping off a vehicle can complete a circuit.
  2. Initial Patient Assessment and Management
    • Immediate Life Threats: Focus on ACLS (Advanced Cardiac Life Support) over ABLS (Advanced Burn Life Support) initially. Cardiac arrhythmias and respiratory arrests are primary threats due to electrical conduction disruptions.
    • Polytrauma Awareness: Electrical injuries can cause patients to be thrown, fall from heights, be stroke by flying objects like exploding trees, and exposure to many other sources of trauma. Even tetanic muscle contractions can lead to fractures or joint dislocations. Always consider potential spinal injuries and other trauma.
    • Thermal Injuries: Smaller visible burns might mask deeper, more severe injuries. Ensure thorough examination to spot all potential injury sites.
    • Evaluate for Hidden Injuries: Thoroughly assess for entry and exit wounds and consider potential internal injuries. If you identify two contact points realize electricity likely travelled between the two points and structures inbetween may be injured.
    • Cardiac Monitoring: Initial EKG monitoring is crucial. Patients with low voltage injuries showing no loss of consciousness and a normal EKG are unlikely to develop delayed arrhythmias. Higher voltage injuries may require longer telemetry monitoring.
    • Neurological Sequelae: Electrical injuries can cause CNS and PNS damages, including neuropathy, cognitive dysfunction, emotional disturbances, even paralysis. An initial through neurologic exam is important.

Specific Considerations for Lightning Strikes

Lightning strikes are a unique subset of electrical injuries with some distinct characteristics:

  • Massive Voltage but Short Duration: Lightning involves immense voltage (up to billions of volts) but for a fraction of a second. This fact sometimes spares patients the expected thermal damage.
  • Diverse Injury Mechanisms:
    • Direct Strike: The lightning hits the person directly.
    • Side Flash: Lightning strikes a nearby object, and the current jumps to the person.
    • Ground Current: The electrical charge travels through the ground to the victim.
    Clinical Management of Lightning Strikes
  • Reverse Triage: Initially unresponsive, apneic patients might still have good survival potential if promptly given CPR and ventilatory support due to the transient nature of electrical conduction blockades in lightning incidents.
  • Look for Lichtenberg Figures: These fern-like patterns on the skin indicate lightning injuries but might not always be present.

Long-Term Effects and Follow-Up

While some patients may seem asymptomatic initially, electrical exposures carry risks of long-term complications:

  • Neurological Issues: Changes in mood, chronic pain, and CNS changes can manifest weeks or months post-injury.
  • Muscle and Joint Issues: Continued pain and muscle weakness or stiffness.
  • Cardiac Monitoring: Ongoing assessment for delayed arrhythmias is essential.


Electrical injuries and lightning strikes are complex and require a diligent, multi-faceted approach to care. Safety, rapid identification of life threats, and continuous monitoring are essential for managing these emergencies. Understanding the prolonged impact, even in seemingly mild cases, ensures better long-term outcomes for patients.

Stay safe, and always approach electrical injury scenes with caution and comprehensive evaluation.


  • North Carolinians for Fireworks Safety (Check their resources for preventing firework-related injuries)
  • For more information on electrical injuries and comprehensive EMS protocols, visit the Descript Help Center: https://help.descript.com

Stay alert, stay informed.

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