AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Over the last century, records for environmental injuries and mortality indicate that lightning has consistently been one of the top 3 environment-related causes of death and the second most common storm-related cause of death, exceeded only by flash floods. In typical years, deaths from lightning have exceeded deaths from tornados, hurricanes, and earthquakes. Extreme temperatures, including winter weather and summer heat, are generally the most common environmental killers.

Ninety percent of lightning strikes from cloud to cloud; only about 10% of lightning strikes are from cloud to ground (CG). Lightning starts with short (30-50 m) spurts of static energy in a cloud. The lightning retreats back to its origin, refills the original channel, and branches at the end of the original channel to make a second generation of 30- to 50-m channels. Lightning continues with the retreats and new generations until the charge is either expended (intracloud lightning) or randomly works its way downward to make a cloud-to-ground flash.

Any object under or near the thundercloud will have an opposite charge induced in it, be it a television tower, a tree, a person, or a blade of grass. Multiple upward leaders of current rise from these objects. Most do not contact the main lightning channel but have sufficient energy to cause injury. Eventually, the downward leader may join one or more of the upward streamers to complete the lightning channel. At that point, a return stroke fills all of the branches and the lightning becomes visible.

Pathophysiology

Lightning cannot be classified as either direct current or alternating current. Lightning is not "scalable"—one cannot use their experience and knowledge of 110-volt lines or high-voltage injuries to predict what lightning will do. The physics of lightning is incredibly complex and substantially different from the physics of generated electricity.

Probably the most important difference between lightning and high-voltage electrical injuries from an injury standpoint is the duration of exposure to the current, which also affects the path it takes. While the energy may flow through the person for an incredibly brief period, usually the vast majority of lightning energy flashes around the person's body surface. Lightning has only brief contact with skin, and, in most instances, the contact is too brief to burn the skin substantially. Entry and exit are inappropriate terms to apply to lightning injuries. 

Lightning may injure an individual in 5 ways.

• Direct strike (approximately 3-5% of injuries)
• Side splash from another object (approximately 30% of injuries)
• Contact voltage from touching an object that is struck (approximately 1-2% of injuries)
• Ground current effect as the energy spreads out across the surface of the earth when lightning hits a distance away from the person (approximately 40-50% of injuries)
• Upward leader that does not connect with the downward leader to complete a lightning channel (approximately 20-25% of injuries)

As can be appreciated from the estimated distribution of injury mechanisms, few individuals experience the full energy of a lightning strike. Most of the energy is mediated by other factors including the ground, the tree, or other object that once hit transmits it to the person. In fact, less than one third of affected persons have signs of burns. When burns do occur, they are usually superficial.

Internal burns are rare. Myoglobinuria is rarely encountered in lightning injuries, whereas cardiac and respiratory arrest, vascular spasm, neurologic damage, and autonomic instability play a greater role. Blunt force injuries from falling, being thrown by muscle contractions, or barotrauma from the explosive force of a nearby lightning strike may occur.

Lightning strikes are primarily a neurologic injury that affects all 3 components of the nervous system: central, autonomic, and peripheral.

Frequency

United States

For the past 40 years, lightning has consistently been the second largest storm-related killer in the United States, with an annual mortality of 45-50 killed. Sources of lightning injury data (the National Center for Health Statistics and Storm Data) systematically underestimate the number of fatalities by 28-42% for 2 reasons. Much of the data is taken from newspaper accounts, so if the clipping-service budget is cut or if people struck by lightning do not make the news, they are not entered into the statistics. In addition, most survivors do not need to be admitted and do not show up in medical data banks. 

Many survivors do not seek immediate medical care and only come to the attention of medical personnel when they seek care for effects of the shock that have not resolved by a few days after their injury. Because injuries are so infrequently reported compared with fatalities, a rule of thumb developed from many studies is that injuries occur about 10 times more often than fatalities do.

Although most injuries occur outdoors, a number of people are injured indoors every year, including individuals who incur landline telephone-mediated strikes. Use of cell phones, iPods, and other portable electronic devices does not increase the risk of injury except by distracting the individual from paying attention to warning signs such as storm clouds and thunder.

Injuries range from tiny static electricity like exposures to cardiac arrest. No good statistics are available for the distribution of severity across the injured population. 

International

Compiling and recording statistics internationally is also a challenge because of the lack of a good reporting system.

Lightning is much more common near the equator. Total annual fatalities are estimated to be about 24,000, and annual injuries are estimated to be about 240,000 for the tropical and subtropical areas of the world, where lightning is most common and the economies tend to be more subsistent, agrarian, and labor intensive than they are in the more developed and temperate climates. In general, lightning injuries and deaths decrease in any country as the economic system, urbanization, and housing improve not only because direct numbers exposed to lightning decreases but because housing that contains plumbing and wiring provides substantial protection.  

Mortality/Morbidity

The lightning fatality rate is 8-10%. Cardiac arrest at the time of the injury is usually the cause of death; however, injury from blunt trauma (eg, falling down a slope) can also be a mechanism of injury or death.

• Lightning injury is a neurologic injury, affecting all 3 parts of the nervous system.
• • Brain – Neurocognitive changes, sleep disturbance, personality change, seizures, learning disability, postconcussive headaches, nausea, attention deficit, distractibility
  • Autonomic nervous system - Regulation of blood pressure and cardiac response (positive tilt test results, dizziness, hypertension), GI insult, impotence, sympathetically mediated pain syndromes
  • Peripheral nervous system - Chronic pain, sensory problems
• Often, these injuries are ongoing and not easy to quantify or to treat.
• Survivors tend to be young, employed, family people who suffer loss of income and disability and become a large cost for the community as well as substantially changing the family dynamics and economic productivity.
• Although lightning injuries during recreational activities tend to predominate in developed countries, nearly one third of US lightning injuries are work-related, on-the-job injuries. In less developed, more labor-intense agrarian societies, the proportion of work-related injuries and deaths is probably higher.
• The most common days of injury in the United States are on Saturdays, Sundays, and Wednesdays, probably reflecting the recreational activities on the weekends. The most common time of day to be injured by lightning is from noon to 6 pm, with 6 pm to midnight following, related to not only when thunderstorms occur but also to when people are most likely to be outdoors.

Race

No direct relationship to race is known to exist. An indirect relationship may be present based on employment or recreational activities.

Sex

In a US study from 1959-1994, males were 4.6 times more likely to be killed and 5.3 times more likely to be injured by lightning than females. This is not because of any physiologic differences but is a consequence of males' increased exposure to potential lightning-strike situations, such as outdoor activities or work, as well as probably to their higher level of risk-taking behaviors.

Age

The age groups with the highest incidence are people younger than 16 years and adults aged 26-35 years. Few adults older than 50 years are injured. This is probably related to the decreased chances of exposure of this age group during outdoor recreation or employment.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Lightning injuries are obvious if they occur in a group setting where witnesses are present. However, lightning injuries can be difficult to diagnose if the person presents without witnesses or is unable to relate the details of his or her injury.

Often, the person can relate what happened to them. However, it is common for the person to have anterograde amnesia or confusion. While the person may be able to carry on a reasonably coherent social conversation, giving demographic and billing data, the examiner may also observe that he or she repeats the same questions multiple times or may not remember events in the ED. More disturbing symptoms such as not recognizing a family member should be suspect.

Conscious patients most often complain of muscle aches, dysesthesias, and weakness, or other neurologic/musculoskeletal problems. 

• Outside exposures
• • Lightning may strike as far as 10 miles ahead of a thunderstorm, before the rain starts, or while the sky is still clear. At least 10% of lightning hits when blue sky is visible.
  • The most dangerous times for lightning injury are when the person underestimates the likelihood of being hit (ie, before the storm or at the apparent end of the storm).
• Risk factors
• • Only 3 factors determine whether something is statistically more likely to be hit by lightning: isolation, height, and narrowness of the tip of the object facing the cloud. Only the first 2 apply to people.
  • A common myth is that metal attracts lightning. Although metal easily conducts electrical energy once it is hit by lightning, metal does not attract lightning.
  • Cell phones, iPods, and other portable (not hard-wired) electronic devices do not increase the risk of injury except by distracting the individual from taking notice of nature's warning signs of dark clouds, thunder, and lightning. 
  • Clothing, footwear, wetness, or other physical factors do not affect whether someone is likely to be hit by lightning, although some factors may affect their likelihood of survival or injury pattern.
• Indoor exposures
• • In general, being inside a substantial, habitable building such as a house, library, or school is one of the safer areas to seek shelter. The increased safety is credited, in part, to the fact that these structures tend to have plumbing and wiring in them, acting as a Faraday cage to transmit any electricity around the inhabitants. Unfortunately, it is also true that lightning may hit or hit near a structure or recreational facility and be transmitted into the building through the plumbing, electrical wiring, emergency medical service (EMS) or fire dispatch radio, or other routes. This includes facilities with indoor pools, which should be evacuated using the same rules as outdoor pools. Individuals should avoid touching plumbing or objects that are electrically hard-wired to the structure's electrical system including computers and electronic games wired to televisions and computers.  
  • At the time of this writing, taking shelter in any structure that includes the word shelter (eg, bus shelter, sun shelter, park shelter, golf shelter, rain shelter) generally provides no protection. To date, national lightning-protection building codes (National Fire Protection Association: NFPA 780) address only physical protection of shelters but not for people using them. Many believe that these structures may substantially increase the risk of lightning injury by increasing the functional height of the individuals standing under them, by increasing the risk of a side flash or ground current from a transmitted stroke in structures with a lightning protection system, or by other mechanisms too long to go into in this discussion.
  • Being inside a fully enclosed metal vehicle is a very safe place due to the fact that electricity will flow along the outside of any metal structure that it hits, not due to the miniscule effect of rubber composite tires. While being inside a vehicle when it is hit has been likened to "being inside a garbage can where someone threw two cherry bombs" and may be quite unpleasant, there has never been a substantiated electrical injury to a person inside a vehicle unless they were touching a handheld radio hard-wired to those lightning rods on the outside of the car that we call antennas or some similar connection to the outside.
• Telephone injuries
• • Hard-wired telephones become the conduit for the charge to enter or to escape from the structure (and the person). Although the telephone system may be grounded adequately for electrical surge protection, lightning is too fast and strong for typical grounding systems to be effective and reaches the person before the circuit breaker or other protection can be effective.
  • Injuries to persons using telephones or telephone headsets, such as those who take phone orders, used to be common but have decreased substantially now that wireless systems are more ubiquitous.  
  • Older portable phones, seldom used now in the United States, were a rare source of lightning injury to people standing within a yard or so of the base station or charger. Those injuries were caused by the lightning jumping from the charger to anything close by and have little to do with the phone the person was carrying.
  • No lightning danger is inherent to cellular phones. Although many reports of lightning injuries involve people who are using cellphones, these reports represent the ubiquity of cellphone usage and of their users' inattentiveness to weather conditions and have nothing to do with the phones themselves.
  • In the past, acoustic injury was possible from the loud static noise in the earpiece of early portable phones, but, to date, acoustic damage involving cellular phones has not been reported.
• Blunt injuries
• • These injuries occur because of muscular contractions, which may throw the person many yards or cause the person to fall.
  • Barotrauma may also occur from the almost instantaneous expansion and contraction of the air near the column of a nearby lightning strike.

Physical

Physical presentation may vary from mild disorientation with no immediate physical signs to cardiac arrest (the only direct cause of death) and anoxic brain injury.

• Cardiorespiratory symptoms
• • Cardiorespiratory arrest is the only known direct cause of death but is still uncommon. Lightning acts as massive defibrillation, sending the heart into momentary asystole, from which the heart often spontaneously recovers. Autonomic nervous system control of cardiac rhythm has been shown to be affected by lightning. In addition, for unknown reasons, respiratory arrest usually lasts longer than the initial cardiac arrest; thus, a secondary cardiac arrest from hypoxia, from more serious brain injury prolonging the respiratory arrest, or from other unknown causes may occur.
  • Many changes may be observed on the ECG, but the most commonly reported is QT prolongation, which generally resolves over several months and does not commonly require treatment. The indicated treatment depends on the resulting abnormality.
• Neurologic symptoms
• • Patients who are awake are usually able to carry on reasonably appropriate social conversation. However, they may develop disabling neurocognitive deficits similar to those of people with blunt head injury, which may not be apparent until survivors attempt to return to their previous work and are unable to process new information, organize their activities, and multitask.
  • Acute pain, numbness, or other dysesthesias may be reported. Chronic pain syndromes may develop from lightning injuries and may be due to nerve injury, sympathetic nervous system injury, spinal column injury, or other causes.
  • Sympathetic nervous system injury may cause vascular spasm; temporary paralysis and mottling of an extremity (keraunoparalysis); transient hypertension, which usually does not need treatment; and late problems with positive tilt test results, vertigo or dizziness, tinnitus, hypertension, and pain syndromes.
  • If the patient is unconscious, suspect and investigate anoxic brain injury or underlying brain injury.
• Dermatologic symptoms
• • Deep burns: Because lightning usually has extremely brief contact with the skin, deep burns are rare. If burns occur, treat them like any other high-voltage injury, including investigating for myoglobinuria.
  • Superficial burns: Burns may appear linear (often secondary to vaporized sweat or rainwater), punctate, or in pathognomonic fernlike patterns. Burns may also be secondary to heating metal, such as necklaces, coins in the pocket, or cleats on the bottom of athletic shoes.
• Blunt injury
• • Consider concomitant myoglobinuria if blunt injury is present.
  • Fractures are uncommon and occur more rarely in lightning injuries than in high-voltage injuries. Being thrown tens of yards because of intense muscle contraction is frequently reported. If the patient has a history of a fall or being thrown a distance, investigate for fractures and blunt injuries.
  • Organ contusions, pulmonary hemorrhage, and cardiac contusions have been reported but are rare.
  • The ear is the sensory organ most commonly injured by lightning. Tympanic membrane rupture is common and may occur from concussive or explosive force, direct current entry (often associated with burns to the canal or disruption of the ossicles), or from basilar skull fracture. Hearing loss, tinnitus, and other eighth nerve symptoms are common.
  • Nearly every type of eye injury has been reported with lightning injury, including cataracts, macular holes, retinal separation, and iritis. Cataracts may be a late sequela of lightning injury, as are chronic pain syndromes, sleep disturbance, and severe headaches.

Causes

The primary risk factor is the failure to acknowledge that lightning poses a threat.  Lightning safety and injury prevention is not convenient. It involves being aware of weather predictions, sometimes changing plans, and proactively planning evacuation to safer areas and the time to reach them. No place outside is safe when thunderstorms are in the area. 

Lack of knowledge of lightning injury and its mechanisms also contribute to the risk. Many people try to finish one more inning or wait until rain begins before seeking shelter. This is often too late because lightning can travel as far as 10 miles in front of the thunderstorm clouds. The interstrike distance, depending on the local terrain and geography, may be as far as 5 ± 5 miles, for a range of 10 or more miles from the last seen stroke.

• Despite popular belief, nothing attracts lightning. The primary physical factors that make an object statistically more likely to be struck are isolation, height, and narrowness of the tip of the object facing the cloud. Only the first 2 factors apply to people.
• • Risk factors include being outside without knowing the weather forecast, not paying attention to the weather, or not having or following an evacuation plan.
  • While lightning can be seen hundreds of miles away on the Great Plains or not at all in heavily forested areas, thunder usually can be heard for about 10 miles away. By the time one hears thunder one is already in danger and should be seeking shelter or seeking a safer shelter. "When thunder roars, go indoors!" is the theme taught to children for injury prevention and is the theme of National Lightning Safety Awareness Week.
  • The only reason that cell phones and iPods are dangerous in thunderstorms is that they distract the individual from paying attention to the weather and hearing thunder, the primary warning signal for lightning. They do NOT attract lightning.
  • Although lightning during recreation accounts for the most injuries, a large number of lightning injuries, as many as one third in some studies, are work related. In addition, a measurable number of injuries occur inside structures every year.
  • Certain geographic areas are more prone to lightning, such as mountain ridges (between 1 pm and 6 pm), parts of Florida and the Gulf Coast, the Eastern Seaboard, and the major river valley areas of the Midwest. This primarily has to do with weather patterns, moisture content of the air, and updrafts.
• Hurricanes and, often, floods can be predicted days ahead of time, and tornadoes can be predicted minutes to hours in advance, allowing time for people to prepare, evacuate, or seek appropriate shelter. Small thunderstorm cells arise and disappear and lightning occurs far too often and unpredictably for the government to issue warnings for every event. The National Weather Service (NWS) issues severe storm or thunderstorm warnings upon danger of (1) straight-line winds faster than 60 miles per hour, (2) hail three-fourths inch or larger in diameter, or (3) tornadolike gusts.
• • Although more and more NWS offices in lightning-prone areas are warning of lightning risk, lightning safety remains primarily an individual responsibility that requires individual decisions for prevention.
  • Since 1997, the National Collegiate Athletic Association (NCAA) coach and sports medicine handbook has listed conditions under which practices and games should be called for lightning danger. The book clearly states that individuals who believe that their life is in danger should not be punished for exercising judgment and evacuating the field, despite coaches' objections. Multiple professional and college level games, including those being televised, have been delayed or called for lightning risk in the last decade.  
  • One exception to the individual responsibility caveat is when an adult such as a parent or coach or an organization such as a pool, school, park, or scouting organization is responsible for children. In those cases, the adult or organization is accountable and responsible for being aware of lightning safety rules, exercising prudent judgment, having an evacuation plan in mind, and exercising that plan when appropriate to protect the children from harm and injury.
  • Event planners should be more proactive and may need to monitor the weather hours to days in advance. A number of online, real-time services may be accessed or subscriptions purchased. Some will warn via cell phones, pagers, or other electronic devices, which is particularly handy for camps and large outdoor sports venues. Lightning safety plans should include safer areas for shelter, appropriate signage and written material in event programs, and clear warning signals with different "all clear" signals. 
  • Lightning protection for stadiums and other outdoor venues, including the Olympics, can be done surprisingly inexpensively, particularly if initially planned in the construction.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Cardiorespiratory arrest
CNS injury
Autonomic nervous system injury
Peripheral nervous system injury
Blunt trauma
Musculoskeletal injury
Acoustic injury
Barotrauma

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Perform specific laboratory examinations as directed by physical findings.
• Extensive muscle damage producing myoglobinuria is quite rare with lightning and can easily be screened with a dipstick of fresh urine. 
• CPK is generally minimally elevated, if at all, and has no linear or direct correlation with outcome.

Imaging Studies

• Perform imaging studies as directed by the physical findings. If a patient had loss of consciousness or presents with confusion or clouded consciousness, a noncontrast CT scan or MRI of the head is probably indicated to rule out intracranial bleeding or contusion of the brain. The vast majority of scans will be normal.
• Routine imaging is not warranted because most lightning survivors have reasonably minimal injury.

Other Tests

• Perform ECG as directed by physical findings. Many changes may be observed on the ECG, but the most commonly reported change is QT prolongation, which generally resolves over several months and does not commonly require treatment. The indicated treatment depends on the resulting abnormality. Unless ECG changes or cardiac-like chest pain is present, there admission for cardiac monitoring is not needed.
• A neuropsychological battery may be indicated later if the person reports memory loss, inability to process new information, and other cognitive difficulties.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

Any time EMS is called for an acute lightning injury, there is almost certainly an ongoing risk of lightning injury to the rescue team as the weather system continues that they should be aware of (see Deterrence/Prevention).   

If there is no risk of continuing danger to the rescuers, resuscitation can occur in the field. Otherwise, safe evacuation to the unit or a substantial building is indicated. Immobilization should be considered because of risk of blunt trauma from the lightning concussion or being thrown by involuntary muscle contraction. Obviously, an alert, minimally injured patient can help decide if this is necessary. Resuscitation or supportive care can then proceed as indicated based on clinical status including advanced cardiac life support [ACLS].

Automatic external defibrillators (AEDs) have been effectively used in a number of cases. Fluid loading and alkalinization of the urine is not warranted in the vast majority of cases.

Emergency Department Care

• Routine care should be performed for any complications such as seizures, chest pain, and other symptoms.
• Reasonable reassurance and referral for continuing problems/sequelae is indicated. The vast majority of lightning survivors do not need to be admitted.
• Referral to a support group (eg, Lightning Strike and Electric Shock Survivors, International [see Patient Education for contact information]).

Consultations

Consultations are based on physical findings. Consultations may include referral to a neurologist, cardiologist, ophthalmologist, otolaryngologist, or, rarely, a burn surgeon. Later consultations may include referral to a neuropsychologist, pain specialist, or psychiatrist.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Nonsteroidal anti-inflammatory drugs (NSAIDs) for the first few days may decrease long-term neurologic damage. Although no studies have examined this, NSAIDs are the only medications available for lightning injuries at this time. Use of long-term ibuprofen, vitamin C (1 g/d), and vitamin E (400 U/d) have been shown to decrease long-term injury and scarring with electrical injury. Whether these free radical scavengers have any effect with lightning is unknown but since they are in routine doses, there is probably little harm in their use. 

One report has addressed the use of high-dose steroids administered for optic neuritis caused by lightning based on the presumed efficacy originally reported for spinal cord injury treatment with high-dose steroids. No controlled studies have been performed to show whether there is any efficacy.  

Drug Category: Nonsteroidal anti-inflammatory drugs

These are used as prophylaxis to prevent long-term neurologic damage and to treat chronic pain syndromes that may develop from sympathetic nervous system injuries caused by lightning.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Obviously, the victim of lightning who is more severely injured will need admission, often to an intensive care unit. There is nothing special or specific to care of more severely injured lightning victims. Care is routine and as indicated by the injuries. 
• The vast majority of patients do need inpatient admission and few need cardiac monitoring. Administer routine and supportive care as indicated by physical findings.
• If a patient has evidence of cardiac dysrhythmias or myocardial infarction or has been revived from cardiorespiratory arrest, he or she should be admitted to the appropriate monitored setting.
• If the patient has suffered blunt trauma as a result of the lightning strike, he or she should be admitted to the appropriate trauma service and setting for further management.
• Rehabilitation may be prolonged and extensive for the more seriously injured victim. However, sometimes chronic pain syndromes, neuromuscular injury, and neurocognitive injuries, which are significant and life changing, may occur in the originally apparently minimally injured person.

Further Outpatient Care

• If the person continues to experience pain, dysesthesias, or other neurologic symptoms, referral to a neurologist or a pain specialist is appropriate.
• A neuropsychological battery may be helpful for patients who develop neurocognitive (eg, memory, processing, endurance, sleep disorders) problems.
• Other referrals may be appropriate, as indicated by the physical findings.
• Refer to Lightning Strike & Electric Shock Survivors International, Inc. or to Lightning Injury Research Program for more information (see Patient Education for more contact information).

In/Out Patient Meds

• NSAIDs as well as narcotics are often used for the acute pain. 
• Burn surgeons administer vitamin C 1 g/d and vitamin E 400 U/d to decrease scarring for electrical injuries. Vitamin C and vitamin E are hypothesized but not proven to be effective against other injury such as nerve injury as well. Whether they are effective for lightning survivors is not known. However, since they are in therapeutic and reasonable doses, their use if probably not contraindicated except by allergy.
• Aside from the use of NSAIDs, chronic pain management may include tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs), medications for adult attention deficit, neuroleptics, narcotics, sympathetic blockade, and other pain control measures, as indicated based on the patient's symptoms.

Transfer

• Transfer as appropriate for patient status and stability as well as for the capabilities of the treating facility.

Deterrence/Prevention

• www.lightningsafety.noaa.gov is the most up-to-date and comprehensive site on lightning safety. It also has free downloadable posters, children's games, curricula, videos, public service announcements by sports figures, links to other specialty sites, teacher and media sections, and other information.
• Preparation - pre-planning
• • Hurricanes and, often, floods can be predicted days ahead of time, and tornadoes can be predicted minutes to hours in advance, allowing time for people to prepare, evacuate, or seek appropriate shelter. Small thunderstorm cells arise and disappear and lightning occurs far too often and unpredictably for the government to issue warnings for every event. The National Weather Service (NWS) issues severe storm or thunderstorm warnings upon danger of (1) straight-line winds faster than 60 miles per hour, (2) hail three-fourths inch or larger in diameter, or (3) tornado-like gusts.
  • Although more and more NWS offices in lightning-prone areas are warning of lightning risk, lightning safety remains primarily an individual responsibility that requires individual decisions for prevention.
  • No place outside is safe when thunderstorms are in the area. 
  • Since 1997, the National Collegiate Athletic Association (NCAA) coach and sports medicine handbook has listed conditions under which practices and games should be called for lightning danger (see page 12 in Sports Medicine Handbook 2005-06 [updated edition to appear in 2008]). The handbook clearly states that individuals who believe that their life is in danger should not be punished for exercising judgment and evacuating the field, despite coaches' objections.  Multiple professional and college level games, including those being televised, have been delayed or called for lightning risk in the last decade.  
  • One exception to the individual responsibility caveat is when an adult such as a parent or coach or an organization such as a pool, school, park, or scouting organization is responsible for children. In those cases, the adult or organization is accountable and responsible for being aware of lightning safety rules, exercising prudent judgment, having an evacuation plan in mind, and exercising that plan when appropriate to protect the children from harm and injury. Copies of the NCAA handbook section on lightning injury prevention (see link immediately above) policy are particularly useful to parents for presenting to the children's team managers to spur lightning safety planning. Another resource is www.Struckbylightning.org, which has safety information especially for children and their adults.
  • Event planners should be more proactive and may need to monitor the weather hours to days in advance. A number of online, real-time services may be accessed or subscriptions purchased.  Some will warn via cell phones, pagers, or other electronic devices, which is particularly handy for camps and large outdoor sports venues. Lightning safety plans should include safer areas for shelter, appropriate signage and written material in event programs, and clear warning signals with different "all clear" signals. 
  • Lightning protection for stadia and other outdoor venues, including the Olympics, can be done surprisingly inexpensively, particularly if initially planned in the construction. 
• Individual preparation
• • No place outside is safe when thunderstorms are in the area. 
  • Be aware of weather forecasts before beginning outdoor activities. Make appropriate evacuation plans, identify safer locations beforehand, and include the time to reach them in pre-planning of activities.  
  • Be aware of local thunderstorm patterns. For instance, 1 pm to 5 pm is a common time for thunderstorms to occur on mountain slopes so that ascent and descent should be done before lightning risk is likely.
  • Although it is now "duty to warn" on US golf courses and lightning safety and injury prevention information is widespread in sports literature, park management and coach's materials, ultimately, individuals are responsible for their own safety and the safety of any children in their care.   
  • More stadia and large venues are establishing lightning safety plans, warning, signage, and other appropriate pre-planning to prevent injuries. Look for this material in programs or brochures. If it is not present in lightning prone areas, ask management about it so that they can be spurred to do appropriate planning. 
• Evacuation
• • When lightning is seen or thunder is heard, danger is present.
  • A simple safety teaching tool for children is, "When thunder roars, go indoors."
  • Lightning may travel as far as 10-12 miles in front of a thunderstorm; clouds need not be overhead and rain need not be present.
• Safer areas
• • If possible, obtain shelter in a substantial or habitable building or in a metal-topped enclosed vehicle. Rented school buses distributed around a large outdoor venue make excellent shelters during activities such as golf tournaments, concerts, and marathons.
  • Stay away from trees, bleachers (whether wood, plastic, or metal), fences, towers, other structures that transmit current, and any small or open structure that has the word shelter in it; get out of  water, pools, and wet areas; and stay off high areas, such as ridges and mountains, when thunderstorms are likely.
  • Avoid use of landline telephones, hard-wired electronic equipment, or any contact with conductive surfaces inside a structure (eg, plumbing, sinks, devices connected to electrical wiring) during a thunderstorm.
• Resumption of activity: Activities should not be resumed until 30 minutes after the last lightning bolt is seen or thunder is heard. This strategy provides about a 90-95% confidence interval.

Complications

• Chronic pain syndromes
• Neuromuscular pain
• Neurocognitive deficits including short-term memory loss, difficulty accessing or processing new information, attention deficit, personality change, distractibility, or loss of ability to multi-task
• Isolation or depression
• Sympathetic nervous system dysfunction
• Dizziness
• Sleep disorders
• Symptoms similar to postconcussion syndrome (eg, headaches, nausea, confusion)
• Atypical seizure disorders

Prognosis

• No good, long-term, controlled studies are available to indicate which conditions improve or progress to more serious disabilities or to give stratified prognoses for different subgroups of survivors.
• As with other injuries, the longer a person has a symptom or sign, the more likely each is to be permanent.
• As with other major life losses, the survivor and often their family should expect to go through the stages of loss including denial, anger, bargaining, depression, and finally acceptance. Often, with time, appropriate medical and family support, knowledge of the injury, and a sense of humor, the person learns to manage his or her pain and to accommodate neurocognitive disability and move on with life after 2-3 years. 
• As with other serious or disabling illness, lightning injury may afford the person a chance to reevaluate their talents and areas of interest and retrain in another field when they can no longer continue in their original work. 

Patient Education

• Education regarding prevention
• • "If thunder roars, go indoors!"
  • Do not resume activity for 30 minutes after thunder is last heard or lightning is last seen.
• Useful links
• • Lightning Strike and Electric Shock Survivors, International
    Phone: (910) 346-4708
    E-mail: info@lightning-strike.org 
  • Kids' Lightning Information and Safety
  • Lightning Injury Research Program
  • Lightning Safety
  • Struckbylightning.org
• For excellent patient education resources, visit eMedicine's Environmental Exposures and Injuries Center. Also, see eMedicine's patient education article Lightning Strike.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Assuming that lightning injuries are like high-voltage injuries and treating them as such (eg, fluid loading, mannitol administration, alkalinization of the urine, transfer to burn units) in the absence of deep burns
• Overreassurance of the survivor or the survivor's family

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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• Cooper MA, Kotsos T, Gandhi MV. Acute Autonomic and Cardiac Effects of Simulated Lightning Strike in Rodents. Society for Academic Emergency Medicine. Atlanta, Ga: 2001.
• Cooper MA, Marshburn S. Lightning Strike and Electric Shock Survivors, International. NeuroRehabilitation. 2005;20(1):43-7. [Medline].
• Cooper, MA. Lightning Injury Homepage. Lightning Injury. Available at www.uic.edu/labs/lightninginjury or www.uic.edu/~macooper. several articles in PDF as well as complete world bibliography on lightning injury. [Full Text].
• Holle RL, Lopez RE. A comparison of current lightning death rates in the U.S. with other locations and times. Preprints, International Conf on Lightning and Static Electricity, Sept 16-18, B. 2003;paper 103-34.
• Holle RL, Lopez RE, Zimmermann C. Updated recommendations for lightning safety. Bulletin of the American Meteorological Society. 1999;80:2035-41.
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• Lightning Safety. NWS Lightning Safety. Available at http://www.lightningsafety.noaa.gov/. Accessed October 23, 2007.
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• National College Athletic Association. Sports Medicine Handbook. National College Athletic Association; 2005-06:12. [Full Text].
• Utley M, Roeder WP, Jensennius J, Cooper MA. StruckbyLightning.org. www.StruckbyLightning.org. Available at www.StruckbyLightning.org. Accessed October 23, 2007.
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Article Last Updated: Jan 7, 2008