#EMConf: Lightning Injuries


  • 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


  • 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