General:

• Can be Alternating Current (AC) or Direct Current (DC)
• Enormous amount of voltage
• REVERSE TRIAGE: tend to patients in arrest first 

5 Mechanisms of Injury:

• Direct Strike: Ocular/ Ear Symptoms; Flashover Phenomenon (electricity travels over body surface)
• Side Flash: Hits nearby object then goes through the air (~15 feet) and can injure multiple people at once
• Contacting other object hit by lightning
• Ground Current
• Upward Steamer

Injuries:

• CNS:
• Keraunoparalysis: 
• Temporary, lasts a few hours; Lower extremities > Upper extremities 
• Cool, blue, pulseless extremity secondary to spasm 
• mimics spinal cord injury or compartment syndrome 
• Anterograde amnesia
• Peripheral Nerve Damage 
• Cardiac:
• Primary cardiac arrest from direct strike: asystole
• Secondary cardiac arrest from respiratory arrest 
• MSK:
• Fractures, shoulder dislocations
• Rhabdomyolysis and Compartment Syndrome ARE RARE!
• Cutaneous Burns:
• Punctate "cigarette butt" burn
• Linear burns follow areas of sweat concentration
• Lichetenberg Figures: pathognonmonic, transient feathering 
• Ocular
• Cataracts: usually bilateral and can be delayed by weeks to years after event
• Anisocoria
• ENT: Tympanic Membrane perforation 

Schmidhauser T, Azzola A (2011) Images in clinical medicine. Lichtenberg figures. N Engl J Med365(26):e49.References:Price T,Cooper M.“Electrical and Lightning Injuries.”In: Rosen's Emergency MedicineConcepts and Clinical Practice.7th ed.Philadelphia, PA:Elsevier; 2010: 1893-1902.BaileyC. “Electrical and Lightning Injury” In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, MecklerGD, Cline DM. eds.Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eNewYork, NY: McGraw-Hill; 2016