Electrical, Lightning and Blast Injuries

Lightning

Electrical  and most lightning burns have an entrance and exit point, lightning flash injuries do not.  Look for ferning in lightning injuries.

Progressive tissue necrosis is common, these injuries are an “iceberg”, what you see initially is just the tip.  Muscle destruction, myoglobinemia progressing to rhabdomyolysis.  Bone has the highest resistance and the heat generated burns the surrounding tissues from the inside.

Secondary Injuries

Ruptured TMs, spinal fractures at multiple levels, Bilateral scapular fractures, internal organ injuries, long-bone fractures, internal organ injuries, intracranial bleeding, seizures, cardiac arrhythmias, and cardiac arrest

Delayed Effects

Cataracts, neuropathic pain syndromes, transverse myelitis, syndrome similar to post-concussive

Electrical

Cardiac monitoring of high-risk patients after an electrical injury: a prospective multicentre studyEmerg Med J 2007;24:348–352. Objective: To report our experience monitoring patients with previously identified theoretical risk factors of significant electrical injury. Methods: Patients who presented to one of 21 emergency departments between October 2000 and November 2004 were eligible to be enrolled in a prospective observational cohort study if after an electric shock they had one of several risk factors (transthoracic current, tetany, loss of consciousness or voltage source >1000 V) and therefore needed cardiac monitoring. Results: Of the 134 patients enrolled, most were monitored because of transthoracic current (n = 60), transthoracic current and tetany (n = 39), tetany (n = 10), or voltage >1000 V (n = 10). There were 15/134 (11%) patients with abnormal initial ECGs. No patient developed potentially lethal late arrhythmia during the 24 hours of cardiac monitoring. Conclusion: Although only patients deemed at risk of late arrhythmias were monitored, none developed potentially lethal late arrhythmias. Asymptomatic patients with transthoracic current and/or tetany and a normal initial ECG do not

Blast Injuries

Changing a solid to gas causes something small to become something very large.

Type I-Blast Injury

Eardrums: 15% incidence of ruptured eardrums with 15 psi; disruption of ossicles also can occur; ear injuries low priority

Lungs: at 75 psi, 50% incidence of pulmonary injuries (e.g., pneumothorax, pneumomediastinum); level of injury depends on whether mouth open or closed and whether victim facing blast; explosion in enclosed space common mechanism of overpressure injuries; tension pneumothorax can develop over time, but victims usually have pure “dropped lung”; place chest tube; may have associated pulmonary contusions; Hammond’s crunch indicates pneumomediastinum or pneumopericardium (Hammond crunch alone not indicator for hyperbaric therapy); coughing against closed glottis during Müller’s maneuver can drop lung, or blow out bleb (most common cause of barotrauma); can feel air tracking up out of mediastinum behind the scalenes before it can be seen on radiograph; lateral chest x-ray more sensitive than anteroposterior (AP)  Look for pneumothoraces at knob, r and l heart border, along the aorta, look for sub-q air in the soft tissue and neck.

Consider air embolism from R>L shunting.  Patients may need hyperbarics.

Gastrointestinal (GI) injuries: barotrauma of large bowel and transverse colon most common; multifocal hemorrhage and perforation; by time GI manifestations occur, patient likely in intensive care unit (ICU); usually do not need operative intervention

Central nervous system (CNS) injuries: altered mental status; embolus; consider hyperbaric therapy

Type II-Projectile Injury

Type III-Deceleration Injury

Type IV-Dirty Bomb, Chemicals and  Contaminants

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