Lightning Injuries

By admin Last updated Oct 8, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Lightning Injuries

Justin A. Classie

Chad A. Asplund

Basics

Description

Injury from lightning strike has variable severity
Individuals need to adhere to proper precautions. Lightning safety remains primarily an individual responsibility that requires individual decisions for prevention.
3rd most common environmental cause of death after heat-related injury and floods (1)
Mechanism of injury:
- Direct strike: The charge of lightning may pass through or over the person's body. Passing over the body, or “flashover” phenomenon, causes less damage than a strike that passes directly through the individual.
- Side flash: Lightning strike “jumps” from an object to the victim.
- Contact injury: The victim is in contact with an object that is struck.
- Ground current: Current will flow across 2 separate points on the victim on the ground; most frequent occurrence; ∼40–50% of lightning injuries (1)
- Blunt injury: Caused by shock wave production and/or muscle contractions produced (2,3)
Lightning injures are caused by:
- High voltage
- Heat production
- Explosive force
- Blunt trauma
May all cause:
- Head injury
- Burns
- Fractures
- Neurological problems
- Contusions
- Hematologic abnormalities
- Cardiopulmonary injuries (2,4)

Risk Factors

Lightning incidence increases as you move closer to the equator.
Tropical and subtropical areas of the world have a higher rate of injuries and fatalities.
Improvements in a region's economic system, urbanization, and housing decreases lightning victim incidence:
- Secondary to advancements in plumbing and wiring providing protection
3 factors determine whether something is statistically more likely to be hit by lightning:
- Isolation
- Height
- Narrowness of the tip of the object facing the cloud:
  - Only 1st 2 apply to humans (1)

General Prevention

Formalize a lightning safety policy.
Identification of a chain of command, a weather watcher, and a means to monitor forecast
Designate safe locations within a building with plumbing and wiring that aid in grounding the building:
- Cars are a safe location as long as you are not in contact with metal frame.
Use flash to bang (“30–30” rule): If the time between a visible lighting flash and associated thunder bang is 30 sec or less, all involved should have already sought out appropriate shelter:
Lightning may strike as far as 10 miles in any direction.
At least 10% of lightning hits when blue sky is visible
Wait 30 min after last lightning or thunder strike before resuming activity. Postpone or suspend activity if thunderstorm is imminent.
Avoid using plumbing facilities and landline phones during a thunderstorm (good conductors of electricity).
Avoid highest point in area (ie, trees).
Keeping participants and patrons aware of lightning safety procedures (when lightning strike seems imminent, assume lightning-safe position). See “Patient Education” section (3,4).

Diagnosis

Confirmatory history from bystanders or rescuers of the circumstances of the injury
Cardiac asystole:
- Due to direct current injury
- May resolve spontaneously as the heart's intrinsic automaticity resumes
Respiratory arrest:
- Due to paralysis of medullary respiratory center
- May persist longer than cardiac asystole and lead to hypoxic-induced ventricular fibrillation
Acute myocardial infarction rare
Shock:
- Neurogenic (spinal injury)
- Hypovolemic (trauma-related hemorrhage)
Mottled or cold extremities due to autonomic vasomotor instability:
- Usually resolves spontaneously in a few hours
Confusion
Memory defects
Alteration of level of consciousness (>70% of cases)
Flaccid motor paralysis
Seizures
Fixed dilated pupils may be evident; however, fixed and dilated pupils may be a manifestation of the lightning injury and not indicative of true neurologic function, and should not be used as an indication in these patients to stop the resuscitative efforts.
Blunt trauma:
- To the head or spine
- Fractures, dislocations, muscle tears, and compartment syndromes
Ruptured tympanic membrane with ossicular disruption (up to 50%); also temporary hearing loss due to shock wave/thunder
Burns:
- Discrete entrance and exit wounds uncommon
- Thermal burns due to evaporation of water on skin, ignited clothing, heated metal objects (buckles/jewelry)
Feathering (fern-like pattern) “burns” (Lichtenberg figures):
- Cutaneous imprints from electron showers that track over skin
- Pathognomonic of lightning injury
- Resolve within 24 hr
Cataracts occur days to years postinjury
Corneal lesions
Intraocular hemorrhages
Retinal detachment

Physical Exam

Lichtenberg figures (superficial feathering or ferning pattern on skin)
Punctate burns
Linear burns (2,4)

Differential Diagnosis

Consider lightning strike in unwitnessed falls, cardiac arrests, or unexplained coma in an outdoor setting.
Other causes of coma, cardiac dysrhythmia or trauma:
- Hypoglycemia
- Intoxication
- Drug overdose
- Cardiovascular disease
- Cerebrovascular accident

P.359

Treatment

Pre-Hospital

In cases with multiple lightning injuries, treat the patients who are not moving 1st, as they are in need of Advanced Trauma Life Support management.
Typically, all lightning strike victims who do not experience cardiac or respiratory arrest survive. Normal triage properties are reversed in this case.
You should treat those who are not moving 1st, as the resuscitation should be directed to those with cardiac or respiratory arrest.
Survey scene for safety (ie, continued lightning strikes)
ABCs (airway, breathing, circulation)
Perform basic life support.
Use advanced life support as necessary (4).
Activate emergency protocol.
Move victim to safe location.
Conduct primary and secondary survey.
Calculate and treat specific injury (ie, apnea, asystole, hypothermia, shock, fractures, and burns) (3).

ED Treatment

Treatment should be directed towards life-threatening injuries (ie, cardiopulmonary arrest, neurological deterioration, or severe burns).
Continue supportive measures.
Evaluate and treat for hypothermia and shock (3).
Evaluate and treat for fractures and/or burns (3).
Obtain laboratory tests, including urinalysis, CBC, electrolytes, serum myoglobin, blood urea nitrogen, creatinine, creatine phosphokinase with cardiac isoenzymes, and ECG (2).
ECG finding: Prolonged QT, generally resolves without treatment

Medication

Medications for pain relief if no other significant pathology noted

Additional Treatment

Referral to specialist will depend on type and severity of symptoms after lightning strike.

Additional Therapies

It has been hypothesized, yet not proven, that burn surgeons may use vitamin C and vitamin E to decrease scarring for electrical burns.

In-Patient Considerations

Initial Stabilization

ABCs
Standard Advanced Cardiac Life Support measures for cardiac arrest
Diligent primary and secondary survey for traumatic injuries:
- Maintain cervical spine precautions until cleared
Treat altered mental status with glucose, naloxone, or thiamine if person found down with unexplained history of injury and unconscious; not true if lightning strike witnessed
Hypotension requires volume expansion, pressor agents, and recognition on any source of bleeding.

Admission Criteria

All victims need to be transported to hospital and evaluated in the emergency department.
Standard of care for any complications noted (ie, chest pain, seizures, respiratory distress)
Large majority of lightning strike victims are not admitted.
Provide reassurance once cleared and all further evaluations if indicated (1,4)

Ongoing Care

Follow-Up Recommendations

Patient Monitoring

Victims usually benefit from support network:
- Lightning Strike and Electric Shock Survivors http://lightning-strike.org
- http://www.struckbylightning.org/
Neuropsychology battery of testing as indicated for mental status assessment (2)

Patient Education

All persons must understand the severity of a threatening storm:
- Know warning signs of imminent lightning strike (3):
  - Hair standing on end
  - “Bacon sizzling” sounds
- Assume safe position if this occurs: Crouch with feet together, weight on balls of feet, head lowered while covering ears
Lightning myths that are NOT true (4):
- Metal attracts lightning: Despite popular belief, nothing attracts lightning.
- Rubber tires protect you in a car: While you are protected in a car, tires have nothing to do with it.
- Dangerous to make contact with victims of lightning strike
- Lightning never strikes same location twice.
- Lighting always hits the highest object.
- No place outside is totally safe when thunderstorms are in the area.
National Weather Service: www.lightningsafety.noaa.gov

Prognosis

Dependent on mechanism of lightning strike and subsequent systemic involvement

Complications

Headache
Sleep disorders
Irritability
Psychomotor impairment
Sympathetic nervous system dysfunction
Posttraumatic stress disorder (2)

References

1. Cooper MA. eMedicine, June 12, 2009. Lightning injuries.

2. DeFranco MJ, Baker III CL, DaSilva JJ, et al. Environmental Issues for Team Physicians. Am J Sports Med. 2008;36:2234–2235.

3. Walsh KM, Bennett B, Cooper MA, et al. National Athletic Trainers' Association Position Statement: Lightning Safety For Athletics and Recreation. J Athl Train. 2000;35:471–477.

4. Zafren K, Durrer B, Herry JP, et al. Lightning injuries: prevention and on-site treatment in mountains and remote areas. Official guidelines of the International Commission for Mountain Emergency Medicine and the Medical Commission of the International Mountaineering and Climbing Federation. Resuscitation. 2005;65:369–372.

Additional Reading

Cooper MA, Andrews CJ, Holle RL, et al. Lightning injuries. In: Auerbach PS, ed. Wilderness medicine. 4th ed. St. Louis: Mosby, 2001:73–110.

Holle RL, Lopez RE, Howard KW, et al. Safety in the presence of lightning. Semin Neurol. 1995;15:375–380.

Bennett BL, Holle RL, Lopez RE. Lightning safety guideline 1D. 2009–2010 National Collegiate Athletic Association Sports Medicine Handbook. Overland Park, KS: National Collegiate Athletic Association; 2009–2010:12–14.

Codes

ICD9

994.0 Effects of lightning