Electrical injury and lightning strike

Manage now— do this, in order

• Separate the patient from the current before resuscitation begins: low voltage — switch off at the mains or unplug, attempting separation beforehand only from a dry insulating surface with a dry non-conducting object; high voltage — NOBODY approaches until the line is confirmed de-energised and earthed, since high-tension current arcs across air and spreads through the ground around a fallen conductor. Lightning is the exception — the casualty carries no residual charge.
• Begin resuscitation on every victim — clinical findings of death are deceptive and unreliable — and continue longer than instinct suggests: these are typically young patients with structurally normal hearts whose arrest is electrical, not ischaemic. With several lightning casualties triage is REVERSED: treat the apparently dead first — those breathing and conscious have already survived.
• Arrest by current type: low-voltage AC means VF — defibrillate immediately, adult 150–200 J biphasic, paediatric 4 J/kg; adrenaline 1 mg IV/IO after the third shock then every 3–5 minutes; amiodarone 300 mg IV after the third shock and 150 mg after the fifth (paediatric: adrenaline 10 microgram/kg — 0.1 mL/kg of 1:10 000 — every 3–5 minutes; amiodarone 5 mg/kg). DC and lightning mean asystole — compressions and adrenaline with relentless attention to ventilation: respiratory arrest outlasts cardiac arrest, so a patient whose rhythm returns must continue to be ventilated.Doctor / NurseNot available at your setup — Defibrillator.
• Full trauma protocol — airway with cervical spine control, breathing, circulation, disability, exposure — and remove rings, bangles, watches and tight footwear at once, before the limb swells. Secure the airway early where soot, singed nasal hair, hoarseness, stridor or facial burns predict swelling, before oedema makes intubation impossible; avoid suxamethonium with established muscle necrosis or hyperkalaemia — rocuronium 1 mg/kg IV or vecuronium 0.1 mg/kg IV.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
• Fluid — the formula is the opening bid, urine output is the prescription: burns over 15% TBSA need crystalloid by Parkland (4 mL/kg × %TBSA in the first 24 hours, half in the first 8 hours from injury) with Hartmann's/Ringer's lactate or 0.9% sodium chloride — but in electrical injury Parkland systematically under-estimates because destroyed tissue lies beneath the skin. Shock bolus: adult 500 mL over 15 minutes; child 20 mL/kg (children also get normal maintenance in addition). Catheterise with an hourly chart recording urine colour; targets: adult 1–2 mL/kg/h (~2 mL/kg/h while urine is pigmented), child at least 1 mL/kg/h, infants at least 2 mL/kg/h.Doctor / Nurse
• Treat hyperkalaemic ECG changes at once — peaked T waves, flattened P waves, broadening QRS or a sine wave signal imminent arrest (see chart): calcium gluconate 10% adult 10–30 mL IV over 5–10 minutes repeated if the ECG does not improve (child 0.5 mL/kg, maximum 20 mL); then soluble insulin 10 units in 25 g glucose IV over 15–30 minutes with glucose monitored for 6 hours (child 0.1 unit/kg with 2 mL/kg of 10% glucose over 30 minutes); plus nebulised salbutamol adult 10–20 mg (child 2.5 mg under 25 kg, else 5 mg).Doctor / Nurse
• Examine every limb in the current pathway, plus both forearms and both lower legs, at least hourly: fasciotomy for any compartment syndrome; escharotomy for a constricting eschar of extremity, neck or chest, or a circumferential full-thickness trunk burn causing ischaemia or ventilatory restriction. Pending operation: release all constricting items and circumferential dressings down to skin, keep the limb at heart level — never elevated (elevation lowers perfusion pressure to already ischaemic tissue) — and maintain analgesia and normovolaemia.Doctor / Nurse
• Analgesia — routinely under-given because the skin looks unimpressive: morphine 2–5 mg IV slowly every 5–10 minutes to effect, monitoring respiratory rate and saturation (child 0.1 mg/kg IV slowly, titrated); fentanyl 1 microgram/kg IV titrated as alternative; paracetamol 1 g IV/orally 6-hourly, maximum 4 g/24 h (child 15 mg/kg 6-hourly); ondansetron 4 mg IV (child 0.1 mg/kg, maximum 4 mg). Never NSAIDs with rhabdomyolysis, hypovolaemia or rising creatinine; never prophylactic systemic antibiotics.Doctor / Nurse
• Wound care and surveillance: cool fresh thermal/flash burns under running water ~20 minutes, then stop cooling and start warming (environment ≥30°C where burns exceed 20% TBSA — a cold large-burn patient becomes coagulopathic); leave blisters over ordinary partial-thickness burns intact; topical antibiotics with a loose non-adherent dressing; update tetanus prophylaxis in all. Re-evaluate wounds at 24–72 hours and repeatedly — electrical wounds declare late and extend. For at least the first 24 hours: hourly urine output with colour, hourly compartment checks, and 12-lead ECG at 6 and 24 hours with potassium, creatinine, CK, blood gas and full blood count in parallel.Doctor / NurseNot available at your setup — Serum electrolytes, Arterial blood gas.