Lightning Injuries

Ovid: 5-Minute Sports Medicine Consult, The

Lightning Injuries
Justin A. Classie
Chad A. Asplund
  • 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).
  • 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


Ongoing Care
Follow-Up Recommendations
Patient Monitoring
  • Victims usually benefit from support network:
    • Lightning Strike and Electric Shock Survivors
  • 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:
Dependent on mechanism of lightning strike and subsequent systemic involvement
994.0 Effects of lightning

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