Electrical Injuries in the Emergency Department: An Evidence-Based Review

Table of Contents

 

A patient presenting to the ED after an electric shock is a potential multisystem trauma patient. All body systems can be affected by electrical injury: musculoskeletal, cardiac, vascular, respiratory, and neurologic. History and physical examination will be the best indicators of the extent of injury.

What are the cutaneous markers for deep tissue injury?

How should you prioritize traumatic injury over burn injury?

What do the entrance/exit points tell you about which body system may be injured?

What are the chances for DVT following deep vascular burn?

What are the chances for neurologic injury, including deafness, paresthesia, and delayed depression?

All patients will need an ECG, but who requires cardiac monitoring? Who can be discharged?

Should you use the Parkland formula for fluids?

Should you give prophylactic antibiotics?

How should patients with Taser injuries be managed?

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
   1. Varied Tissue Resistance to Electricity
   2. Relating Voltage and Current to Tissue Injury
6. Differential Diagnosis
   1. Cutaneous Injury
   2. Musculoskeletal Injury
   3. Cardiovascular Injury
   4. Respiratory Injury
   5. Vascular Injury
   6. Neurological Injury
   7. Other Injuries
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
9. Diagnostic Studies
   1. Electrocardiogram
   2. Laboratory Testing
   3. Diagnostic Imaging
10. Treatment
    1. Minor Injuries
    2. Major Electrical Injuries
11. Special Populations
    1. Pediatric Patients
    2. Pregnant Patients
    3. Patients With Taser (Electrical Control Device) Injuries
    4. Lightning Strikes
12. Controversies
13. Disposition
14. Summary
15. Risk Management Pitfalls for Electrical Injuries in the Emergency Department
16. Time- and Cost-Effective Strategies
17. Case Conclusions
18. Clinical Pathway for Emergency Department Management of Electrical Injuries
19. Tables and Figures
    1. Table 1. Physical Effects at Selected Currents
    2. Table 2. Effects of Low-Voltage Versus High-Voltage Electrical Shock
    3. Table 3. Indications for Cardiac Monitoring After Electrical Injury
    4. Figure 1. Flash Burns in a High-Voltage Injury
    5. Figure 2. High-Voltage Burn
    6. Figure 3. An Electrical Control Device Used by Law Enforcement
    7. Figure 4. Lichtenberg Figures
20. References

Abstract

Electrical injuries can be caused by exposure to current from low-voltage and high-voltage sources as well as lightning strikes, and the circumstances of the exposure will dictate management strategies. Human tissues have varying resistance characteristics and susceptibility to damage, so injuries may be thermal, electrical, and/or mechanical, potentially causing burns, thrombosis, tetany, falls, and blast injury. This issue reviews the types of trauma seen with electrical injury and how body systems can be affected by occult or delayed effects, and the optimal evidence-based resuscitation and management strategies associated with each.

Case Presentations

You arrive to work at the regional burn center’s ED, and a nurse pulls you into resuscitation bay 1. Paramedics have presented with a thirtysomething man in cardiac arrest. He had been helping his daughter build a curious device called a Jacob’s ladder—a homemade machine that creates an electrical arc. His presenting rhythm was asystole but by the time of his arrival in the ED, he is in ventricular fibrillation. You wonder if his cardiac arrest is related to the device, and what your next best step is...

As you start work, you wonder where your end-of-shift colleague is. The question is answered when the curtain for bay 2 is pulled back and you see her intubating a young man. She tells you he arrived by ambulance for “burn care.” He fell 12 feet to the ground after his mop pole touched a power line above the semi-trailer he was cleaning. There are minor burns to his hands and chest wall, but more worrisome is the pink fluid draining from his ears and nose. As you assess the patient, you wonder how best to prioritize the patient's workup...

Just as you sit down, a nurse tells you that he has put another electrical injury patient in bay 3; the patient is a 24-year-old man who accidently touched an electrical socket and was thrown backwards to the floor. He didn't hit his head, but he complains of feeling “tingly” all over and slightly nauseated. His vital signs are: blood pressure, 130/ 86 mm Hg; respiratory rate, 16 breaths/min; heart rate, 68 beats/min; and oxygen saturation, 100% on room air. He has no past medical history and a normal physical exam. The nurse asks if he should get an ECG and send a troponin; you wonder...what is best practice?

Introduction

Patients with electrical injury pose unique diagnostic and therapeutic challenges that emergency clinicians must not miss. Each year, approximately 10,000 patients present to United States emergency departments (EDs) with electrical burns or electric shock,¹ with fatalities declining from around 1000 per year in the early 2000s to 565 in 2015,² likely because of improved occupational protections.³ An estimated 4% of burn center admissions are due to electrical burns.⁴ Most electrical injuries are due to household or occupational exposures.^1,2 There is a trimodal distribution of patients with electrical injuries; young children are affected most often by household current, adolescent males by high-risk behavior (eg, playing near high-voltage current sources), and adult males by occupational exposure.^5-8 Lightning strikes are a subset of electrical injuries with unique features. In the United States, between 25 and 50 people die each year from lightning strikes.²

Electrical injuries can affect every organ system and can cause thermal, electrophysiological, traumatic, and metabolic derangement. Patients may resemble ordinary cardiac, trauma, or burn victims, making recognition challenging, and history is sometimes difficult to obtain. Management of these cases has evolved over time, especially in recommendations for cardiac monitoring and ear, nose, and throat (ENT) care for pediatric oral electrical burns. This issue of Emergency Medicine Practice reviews the current evidence for diagnosis and management of electrical injuries, focusing on recognition of life-threatening and occult injury.

Critical Appraisal of the Literature

A literature search was performed using Ovid and MEDLINE^® for the period between 1966 to 2018, with the terms emergency, electrical injury, electrocution, and lightning. This provided a list of 477 articles that was narrowed to 88 after initial review. Some resources were identified from article reference lists, and some articles with redundant or outdated information were excluded. The experimental evidence pertaining to electrical injuries is limited, and most clinical practice is based on expert opinion and observational studies. The most recent statistical information was obtained directly from United States governmental survey and statistical data or from occupational and advocacy organizations. Practice guidelines are limited and based on expert opinion, case studies, and observational studies.

Risk Management Pitfalls for Electrical Injuries in the Emergency Department

1. “I sent the patient with a low-voltage minor electrical burn home and told her she was fine (she was!). She came back to the ED 2 weeks later and is angry because she developed dizziness and paresthesia in her fingers.”

Electrical injuries have a high incidence of delayed neurological sequelae,⁴¹ with studies noting between 25% and 80% of patients reporting neurological complaints after electric shock.^39,40 It is important to give specific, detailed discharge instructions, including return precautions for numbness, dizziness, weakness, and mental status changes.

6. “The 2-year-old had a small burn on his face after playing with an electrical cord. There was no airway involvement, and I sent him home to follow up with a burn specialist. Then 24 hours later, he came back bleeding profusely from the mouth…that airway was touch-and-go.”

Oral burns in children who chewed on an electrical cord have up to 24% incidence of bleeding from the labial artery. Proper initial management is controversial, but ENT consultation should be obtained, and if the patient goes home, you must give strict discharge instructions and set patient/family expectations for the possibility of bleeding.^48,49

10. “This high-voltage injury patient came to the ED with 10% total body surface area burns. I followed the Parkland formula for fluids, but she stayed hypotensive and, during her hospital course, developed acute renal failure. I thought that formula was solid for taking care of a burn patient.”

Electrical burns on the skin do not necessarily give a clear picture as to how much tissue was actually damaged by thermal and electrical energy. Isotonic IV fluids sufficient to maintain urine output at 1.0 to 1.5 cc/kg/ hr must be given to these patients. Continue fluid resuscitation until you reach that urine output and urine myoglobin has cleared. Fluid requirements may be much higher than specified by the Parkland formula. CK levels and myoglobinuria should be monitored.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

1. US Consumer Product Safety Commission. National Electronic Injury Surveillance System (NEISS) Query Results. 2016. Available at: https://www.cpsc.gov/cgibin/NEISSQuery/home.aspx. Accessed October 10, 2018. (Government database)
2. The Fire Protection Research Foundation. Multiple cause of death, 1999-2015 results form. Available at: https://wonder.cdc.gov/controller/datarequest/D77. Accessed October 10, 2018. (Government database)
3. National Fire Protection Association. Occupational Injuries from Electrical Shock and Arc Flash. 2018. Available at: https://www.nfpa.org/News-and-Research/Fire-statistics-and-reports/Research-reports/Electrical-safety/Occupational-Injuries-from-Electrical-Shock-and-Arc-Flash-Events. Accessed October 10, 2018. (Research foundation report)
4. American Burn Association. Burn incidence fact sheet. 2016; http://ameriburn.org/who-we-are/media/burn-incidence-fact-sheet/. Accessed October 10, 2018. (Data from National Burn Repository)
5. Electrical Safety Foundation International. ESFI Occupational Injury and Fatality Statistics. 2017; http://www.esfi.org/workplace-injury-and-fatality-statistics. Accessed October 10, 2018. (Industry data)
6. Glatstein MM, Ayalon I, Miller E, et al. Pediatric electrical burn injuries: experience of a large tertiary care hospital and a review of electrical injury. Pediatr Emerg Care. 2013;29(6):737-740. (Retrospective study; 36 patients)
7. Rai J, Jeschke MG, Barrow RE, et al. Electrical injuries: a 30-year review. J Trauma. 1999;46(5):933-936. (Retrospective study; 185 patients)
8. Talbot SG, Upton J, Driscoll DN. Changing trends in pediatric upper extremity electrical burns. Hand (NY). 2011;6(4):394-398. (Retrospective study; 48 patients)
9. Biegelmeier P. New knowledge on the impedance of the human body. In: Bridges J, Ford G, Sherman I, et al, eds. Electrical Shock Safety Criteria: Proceedings of the First International Symposium on Electrical Shock Safety Criteria. New York, NY: Pergamon Press/Elsevier; 1985:115-132. (Conference proceedings)
10. Fish R. Electric shock, part I: physics and pathophysiology. J Emerg Med. 1993;11(3):309-312. (Review article)
11. Fish R. Electric shock, part II: nature and mechanisms of injury. J Emerg Med. 1993;11(4):457-462. (Review article)
12. Faes TJ, van der Meij HA, de Munck JC, et al. The electric resistivity of human tissues (100 Hz-10 MHz): a meta-analysis of review studies. Physiol Meas. 1999;20(4):R1-R10. (Meta-analysis of 6 studies; 103 data points)
13. Haim A, Zucker N, Levitas A, et al. Cardiac manifestations following electrocution in children. Cardiol Young. 2008;18(5):458-460. (Retrospective study; 52 patients)
14. Rollman GB, Harris G. The detectability, discriminability, and perceived magnitude of painful electrical shock. Percept Psychophys. 1987;42(3):257-268. (Quasi-experimental study design; 40 patients)
15. Cabanes J. Physiological effects of electric currents on living organisms, more particularly humans. In: Bridges J, Ford G, Sherman I, et al, eds. Electrical Shock Safety Criteria: Proceedings of the First International Symposium on Electrical Shock Safety Criteria. New York, NY: Pergamon Press/Elsevier; 1985:7-24. (Conference proceedings, original research; animal and bench work)
16. Fish RM, Geddes LA. Conduction of electrical current to and through the human body: a review. Eplasty. 2009;9:e44. (Clinical review)
17. Dalziel C, Lee W. Reevaluation of lethal electric currents. IEEE Transactions on Industry & Gen Applications. 1968;IGA-4(5):467-476. (Original research, quasi-experimental; 167 and 162 patients in 2 series)
18. Kranjc M, Kranjc S, Bajd F, et al. Predicting irreversible electroporation-induced tissue damage by means of magnetic resonance electrical impedance tomography. Sci Rep. 2017;7(1):10323. (Original research, bench work; 11 tissue samples)
19. Arnoldo BD, Purdue GF, Kowalske K, et al. Electrical injuries: a 20-year review. J Burn Care Rehabil. 2004;25(6):479-484. (Retrospective study; 700 patients)
20. US Department of Energy. Electrical Safety -- DOE Technical Standards Program [Standard]. 2013. Available at: https://www.standards.doe.gov/standards-documents/1000/1092-BHdbk-2013. Accessed October 10, 2018. (Government guidelines)
21. Buja Z, Arifi H, Hoxha E. Electrical burn injuries. an eight-year review. Ann Burns Fire Disasters. 2010;23(1):4-7. (Retrospective study; 182 patients)
22. Elloso MS, Cruz JJV. A review of electrical burns admitted in a Philippine tertiary hospital burn center. Burns Open. 2017;1(1):20-24. (Retrospective study; 706 patients)
23. Tomkins KL, Holland AJA. Electrical burn injuries in children. J Paediatr Child Health. 2008;44(12):727-730. (Retrospective study; 22 patients)
24. Blackwell N, Hayllar J. A three year prospective audit of 212 presentations to the emergency department after electrical injury with a management protocol. Postgrad Med J. 2002;78(919):283-285. (Prospective study; 212 patients)
25. Huang WC, Chiu YH, How CK, et al. Posterior comminuted scapular fracture induced by a low-voltage electric shock. Am J Emerg Med. 2010;28(9):1060.e1063-e1064. (Case report; 1 patient)
26. Chandra N, Siu C, Munster A. Clinical predictors of myocardial damage after high voltage electrical injury. Crit Care Med. 1990;18(3):293-297. (Quasi-experimental study; 24 patients)
27. Waldmann V, Narayanan K, Combes N, et al. Electrical cardiac injuries: current concepts and management. Eur Heart J. 2017;39(16):1459-1465. (Review and case series; 2 patients)
28. Gursul E, Bayata S, Aksit E, et al. Development of ST elevation myocardial infarction and atrial fibrillation after an electrical injury. Case Rep Emerg Med. 2015;2015:953102. (Case report; 1 patient)
29. Fineschi V, Di Donato S, Mondillo S, et al. Electric shock: cardiac effects relative to non fatal injuries and post-mortem findings in fatal cases. Int J Cardiol. 2006;111(1):6-11. (Analysis of case series; 32 patients)
30. Bailey B, Gaudreault P, Thivierge RL. Cardiac monitoring of high-risk patients after an electrical injury: a prospective multicentre study. Emerg Med J. 2007;24(5):348-352. (Retrospective study; 134 patients)
31. Hansen SM, Riahi S, Hjortshøj S, et al. Mortality and risk of cardiac complications among immediate survivors of accidental electric shock: a Danish nationwide cohort study. BMJ Open. 2017;7(8):e015967. (Retrospective study; 11,462 patients)
32. Searle J, Slagman A, Maass W, et al. Cardiac monitoring in patients with electrical injuries. An analysis of 268 patients at the Charité Hospital. Dtsch Arztebl Int. 2013;110(50):847-853. (Retrospective study; 268 patients)
33. Celebi A, Gulel O, Cicekcioglu H, et al. Myocardial infarction after an electric shock: a rare complication. Cardiol J. 2009;16(4):362-364. (Case report; 1 patient)
34. Oliva PB, Breckinridge JC. Acute myocardial infarction with normal and near normal coronary arteries. Documentation with coronary arteriography within 12 1/2 hours of the onset of symptoms in two cases (three episodes). Am J Cardiol. 1977;40(6):1000-1007. (Case series; 2 patients)
35. Hunt JL, McManus WF, Haney WP, et al. Vascular lesions in acute electric injuries. J Trauma. 1974;14(6):461-473. (Quasi-experimental study; 11 patients)
36. Pannucci CJ, Osborne NH, Jaber RM, et al. Early fasciotomy in electrically injured patients as a marker for injury severity and deep venous thrombosis risk: an analysis of the National Burn Repository. J Burn Care Res. 2010;31(6):882-887. (Retrospective study; 1469 patients)
37. Wahl WL, Brandt MM, Ahrns KS, et al. Venous thrombosis incidence in burn patients: preliminary results of a prospective study. J Burn Care Rehabil. 2002;23(2):97-102. (Prospective study; 30 patients)
38. Wibbenmeyer LA, Hoballah JJ, Amelon MJ, et al. The prevalence of venous thromboembolism of the lower extremity among thermally injured patients determined by duplex sonography. J Trauma. 2003;55(6):1162-1167. (Prospective study; 148 patients)
39. Singerman J, Gomez M, Fish JS. Long-term sequelae of low-voltage electrical injury. J Burn Care Res. 2008;29(5):773-777. (Retrospective study; 38 patients)
40. Bailey B, Gaudreault P, Thivierge RL. Neurologic and neuropsychological symptoms during the first year after an electric shock: results of a prospective multicenter study. Am J Emerg Med. 2008;26(4):413-418. (Prospective cohort study; 86 patients)
41. Tondel M, Blomqvist A, Jakobsson K, et al. [Immediate and delayed outcomes after electrical injury. A guide for clinicians]. Lakartidningen. 2016 Dec 1;113. (Descriptive study and review of Swedish national data; 300 patients)
42. Varghese G, Mani MM, Redford JB. Spinal cord injuries following electrical accidents. Paraplegia. 1986;24(3):159-166. (Retrospective; 116 patients)
43. Arevalo JM, Lorente JA, Balseiro-Gomez J. Spinal cord injury after electrical trauma treated in a burn unit. Burns. 1999;25(5):449-452. (Case report; 1 patient)
44. Platen S, Backhaus R, Kirzinger L, et al. P29. Transversal spinal cord lesion after electrical injury. Clin Neurophysiol.126(8):e111. (Case report; 1 patient)
45. Marques EG, Junior GA, Neto BF, et al. Visceral injury in electrical shock trauma: proposed guideline for the management of abdominal electrocution and literature review. Int J Burns Trauma. 2014;4(1):1-6. (Review)
46. Baranwal VK, Satyabala K, Gaur S, et al. A case of electric cataract. Med J Armed Forces India. 2014;70(3):284-285. (Case report; 1 patient)
47. Modayil PC, Lloyd GW, Mallik A, et al. Inner ear damage following electric current and lightning injury: a literature review. Eur Arch Otorhinolaryngol. 2014;271(5):855-861. (Meta-analysis; 35 articles)
48. Canady JW, Thompson SA, Bardach J. Oral commissure burns in children. Plast Reconstr Surg. 1996;97(4):738-744. (Descriptive study; 24 patients)
49. Thomas SS. Electrical burns of the mouth: still searching for an answer. Burns. 1996;22(2):137-140. (Review and case report; 5 patients)
50. Morrison M, Woollard M. Outcome of asymptomatic electric shock victims requesting an emergency ambulance. Prehosp Emerg Care. 2004;8(4):400-404. (Retrospective study; 52 patients)
51. Murphy P, Colwell C, Pineda G, et al. A shocking call. Prehospital assessment and management of electrical injuries and lightning strikes. EMS Mag. 2010;39(2):46-50. (Clinical review)
52. Callaway CW, Soar J, Aibiki M, et al. Part 4: Advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2015;132(16 Suppl 1):S84-S145. (Expert consensus)
53. Motawea M, Al-Kenany AS, Hosny M, et al. Survival without sequelae after prolonged cardiopulmonary resuscitation after electric shock. Am J Emerg Med. 2016;34(3):e671-e672. (Case report; 1 patient)
54. Marcus MA, Thijs N, Meulemans AI. A prolonged but successful resuscitation of a patient struck by lightning. Eur J Emerg Med. 1994;1(4):199-202. (Case report; 1 patient)
55. Hsueh YY, Chen CL, Pan SC. Analysis of factors influencing limb amputation in high-voltage electrically injured patients. Burns. 2011;37(4):673-677. (Retrospective study; 82 patients)
56. Kim SH, Cho GY, Kim MK, et al. Alterations in left ventricular function assessed by two-dimensional speckle tracking echocardiography and the clinical utility of cardiac troponin I in survivors of high-voltage electrical injury. Crit Care Med. 2009;37(4):1282-1287. (Prospective study; 20 patients)
57. Ketenci IE, Duymus TM, Ulusoy A, et al. Bilateral posterior shoulder dislocation after electrical shock: a case report. Ann Med Surg (Lond). 2015;4(4):417-421. (Case report; 1 patient)
58. Costa Santos D, Barros F, Frazao M, et al. Pre-burn centre management of the airway in patients with face burns. Ann Burns Fire Disasters. 2015;28(4):259-263. (Retrospective study; 136 patients)
59. Esnault P, Prunet B, Cotte J, et al. Tracheal intubation difficulties in the setting of face and neck burns: myth or reality? Am J Emerg Med. 2014;32(10):1174-1178. (Prospective study; 134 patients)
60. Avni T, Levcovich A, Ad-El DD, et al. Prophylactic antibiotics for burns patients: systematic review and meta-analysis. BMJ. 2010;340:c241. (Meta-analysis; 17 trials)
61. Barajas-Nava LA, Lopez-Alcalde J, Roqué i Figuls M, et al. Antibiotic prophylaxis for preventing burn wound infection. Cochrane Database Syst Rev. 2013(6):CD008738. (Cochrane review; 36 randomized controlled trials, 2117 participants)
62. Coban YK. Infection control in severely burned patients. World J Crit Care Med. 2012;1(4):94-101. (Review article)
63. Pannucci CJ, Diaz JA, Wahl WL. Temporal changes in DVT risk after electrical injury. J Burn Care Res. 2011;32(3):442-446. (Retrospective study; 77 patients)
64. Gifford GH Jr, Marty AT, MacCollum DW. The management of electrical mouth burns in children. Pediatrics. 1971;47(1):113-119. (Historical expert consensus article)
65. Jaffe R, Fejgin M. Accidental electric shock in pregnancy: a prospective cohort study. Am J Obstet Gynecol. 1997;177(4):983-984. (Prospective study; 32 patients)
66. Awwad J, Hannoun A, Fares F, et al. Accidental electric shock during pregnancy: reflection on a case. AJP Rep. 2013;3(2):103-104. (Case report; 1 patient)
67. Goldman RD, Einarson A, Koren G. Electric shock during pregnancy. Can Fam Physician. 2003;49:297-298. (Review)
68. Haileyesus T, Annest JL, Mercy JA. Non-fatal conductive energy device-related injuries treated in US emergency departments, 2005-2008. Inj Prev. 2011;17(2):127-130. (Retrospective study; 75,000 patients per year)
69. Le Blanc-Louvry I, Gricourt C, Touré E, et al. A brain penetration after Taser injury: controversies regarding Taser gun safety. Forensic Sci Int. 2012;221(1-3):e7-e11. (Case report; 1 patient)
70. Zipes DP. Sudden cardiac arrest and death following application of shocks from a TASER electronic control device. Circulation. 2012;125(20):2417-2422. (Case report; 1 patient)
71. Zipes DP. TASER electronic control devices can cause cardiac arrest in humans. Circulation. 2014;129(1):101-111. (Case reports; 8 patients)
72. Kunz SN. Biases in TASER research. Am Heart J. 2012;163(3):e7-e8. (Review)
73. Kroll MW, Lakkireddy DR, Stone JR, et al. TASER electronic control devices and cardiac arrests: coincidental or causal? Circulation. 2014;129(1):93-100. (Response article)
74. White MD, Ready JT, Kane RJ, et al. Examining cognitive functioning following TASER exposure: a randomized controlled trial. Appl Cog Psych. 2015;29(4):600-607. (Randomized controlled trial; 142 patients)
75. Coad F, Maw G. TASERed during training: an unusual scapular fracture. Emerg Med Australas. 2014;26(2):206-207. (Case report; 1 patient)
76. Cherington M. Lightning injuries. Ann Emerg Med. 25(4):516-519. (Practice guidelines)
77. Pfortmueller CA, Yikun Y, Haberkern M, et al. Injuries, sequelae, and treatment of lightning-induced injuries: 10 years of experience at a Swiss trauma center. Emerg Med Internat. 2012;2012:167698. (Retrospective study; 9 patients)
78. Gluncic I, Roje Z, Gluncic V, et al. Ear injuries caused by lightning: report of 18 cases. J Laryngol Otol. 2001;115(1):4-8. (Case series; 18 patients)
79. McIntyre WF, Simpson CS, Redfearn DP, et al. The lightning heart: a case report and brief review of the cardiovascular complications of lightning injury. Indian Pacing Electrophysiol J. 2010;10(9):429-434. (Case report; 1 patient)
80. Aslan S, Yilmaz S, Karcioglu O. Lightning: an unusual cause of cerebellar infarction. Emerg Med J. 2004;21(6):750-751. (Case report; 1 patient)
81. Emet M, Caner I, Cakir M, et al. Lightning injury may cause abrupt cerebral salt wasting syndrome. Am J Emerg Med. 2010;28(5):e641-e643. (Case report; 1 patient)
82. Rahmani SH, Faridaalaee G, Jahangard S. Acute transient hemiparesis induced by lightning strike. Am J Emerg Med. 2015;33(7):984.e1-3. (Case report; 1 patient)
83. Ward NJ, Little JH, Higgins GL 3rd. Man with confusion and resolved paralysis. Lightning strike injury. Ann Emerg Med. 2012;59(4):335-340. (Case report; 1 patient)
84. Emet M, Aslan S, Cakir Z, et al. Subcortical parenchymal and right lentiform nucleus haemorrhages in a lightning victim. Hong Kong J Emerg Med. 2009;16(3):172-175. (Case report; 1 patient)
85. ten Duis HJ, Klasen HJ, Reenalda PE. Keraunoparalysis, a ‘specific’ lightning injury. Burns Incl Therm Inj. 1985;12(1):54-57. (Case report; 1 patient)
86. Whitcomb D, Martinez JA, Daberkow D. Lightning injuries. South Med J. 2002;95(11):1331-1334. (Case report and review)
87. American Burn Association, American College of Surgeons. Guidelines for the operation of burn centers. J Burn Care Res. 2007;28(1):134-141. (Practice guidelines)
88. Tagami T, Matsui H, Fushimi K, et al. Prophylactic antibiotics may improve outcome in patients with severe burns requiring mechanical ventilation: Propensity score analysis of a Japanese nationwide database. Clin Infect Dis. 2016;62(1):60-66. (Retrospective study; 2893 patients)