Lightning and Electrical Emergencies

Questions and Answers

Case: Four utility workers are assessing damage to a high-voltage power line transformer. One worker drops a wrench, creating an arc flash, with resultant flash of light and explosion. They are thrown. EMS arrives 7 minutes after the explosion to find three of the men in various stages of distress and a fourth man in cardiopulmonary arrest.

1 Which of the men should be the first to receive medical care?

The man in cardiopulmonary arrest should be attended to first. In mass casualty incidents involving electrical injury, especially for lightning strike injuries, which are particularly amenable to resuscitation, reverse triage may be appropriate.

2 What are the priorities for a first responder prior to transport?

First, an EMS provider must ensure personal safety by making sure they are not personally exposed to the electrical charge. Contrary to popular lore, standard rubber boots or jackets are not grounding or protective. Once the first responder has ensured their safety and discontinued electrical exposure for the victim, they should start resuscitation. EMS providers should assess circulation and cardiac rhythm as electrical forces may induce dysrhythmia or cardiac arrest. This can be done with a formal electrocardiogram (EKG) or with an automated external defibrillator (AED) to facilitate defibrillation and cardiopulmonary resuscitation (CPR). Simultaneously, while maintaining cervical spine stability given the risk of spinal cord injury even without obvious trauma, a first responder should maintain the airway and provide ventilatory support if needed. While fractures and other injuries are stabilized, fluids can then be started given the significant risk of rhabdomyolysis.

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