You are in: eMedicine Specialties > Trauma > Multiorgan Trauma Management Lightning InjuriesArticle Last Updated: Jun 19, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc H Scott Bjerke is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, and Wilderness Medical Society Editors: Marc D Basson, MD, PhD, Chief of Surgery, John D Dingell VA Medical Center; Professor, Department of Surgery, Wayne State University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School; Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine; John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital Author and Editor Disclosure Synonyms and related keywords: lightning strikes, lightning flashes, lightning-related fatalities, direct strike, side flash, ground strike, flashover INTRODUCTIONSection 2 of 10
  Historically, lightning has been viewed as a sign of the anger of the gods from Greek and Norse mythology, and, as such, many myths have arisen regarding the risk, care, and outcome from lightning injuries. Much of our early colonial understanding of electricity and conduction came from the experiments of Benjamin Franklin playing with a kite in a thunderstorm. Nearly 8 million lightning flashes occur every day worldwide. While only a small percentage cause property damage, and an even smaller percentage cause a risk of human injury, when lightning does strike, it captures the attention of the public, the news media, and the medical profession. It is estimated that 1000-2000 persons are struck by lightning every year in the United States. Approximately 150-300 lightning-related fatalities occur per year, making lightning strikes the second most common cause of death from isolated environmental or natural phenomena. In environmental injuries, only floods cause more human death. According to the US Centers for Disease Control and Prevention, approximately 100 of every 500 fatalities caused by electricity are the result of lightning strikes. Although lightning injuries are related to common electrical injuries, significant differences exist in the pathophysiology and injury patterns, and these factors must be considered to provide the best possible care to persons with lightning injuries. ProblemWhile rare, serious lightning injuries are likely to primarily cause cardiac and neurologic injury. Otologic injury and cutaneous burns have also been noted as frequent sequelae of these events. Cataract formation resulting from lightning injury typically occurs within days to weeks of injury. This complication has been reported as late as 2 years afterward but commonly occurs within the first week. The injuries differ from those resulting from high-voltage direct current because lightning injuries usually do not cause significant tissue destruction along the path of grounding of the current. Lightning strikes are usually diffuse and do not commonly cause injuries similar to those received from 110-volt or 220-volt electrical currents. Blunt physical injury is much more likely to accompany lightning injuries when compared to electrical injuries, so medical personnel should also screen lightning victims for occult blunt trauma. Because a strike can be variable and diffusely spread over the body, most authors characterize lightning injuries as mild, moderate, or severe.
FrequencyLightning causes serious injuries in 1000-1500 individuals every year worldwide. Persons struck typically are males aged 15-44 years. Most injuries occur during May through September. The National Center for Health Statistics documents the majority of US deaths occur in the South and the Midwest, with Florida and Texas leading the list. Approximately one quarter of the deaths are work related. The case fatality rate is reported to be 10-32%, or 0.23 deaths per 1 million persons annually. Some reports suggest as many as 74% of survivors experience permanent injury and sequelae. More recent literature suggests the percentage with permanent injury is much less; however, there continues to be controversy over the long-term effects in general. An international support group called the Lightning Strike and Electric Shock Survivors International has been created and is led by a physician who is currently researching these injuries. Most lightning associated deaths are caused by cardiac arrest. Forensic physicians must also consider lightning strike in the differential diagnosis of sudden unexpected death in persons found outside. The most common minor injury reported is rupture of the tympanic membranes. Superficial burns and eye injuries are the most frequently reported injuries. The most common chronic sequela reported is cataract formation. PathophysiologyThe primary causes of lightning injuries are extreme temperatures and electromechanical forces. The 3 classes of lightning strikes are direct strike, side flash ("splash"), or ground strike.
Lightning causes damage to a wide range of bodily systems through several mechanisms as follows:
ClinicalIndications of lightning injury noted on physical examination include the following:
RELEVANT ANATOMYSection 3 of 10
Understanding the conduction system of the heart and nervous system is helpful in understanding both the initial and prolonged effects of a lightning strike. CONTRAINDICATIONSSection 4 of 10
No contraindications exist for treating a person who has a lightning injury other than obvious death for a prolonged period. Although anecdotal reports of survival with prolonged CPR started in the field have been received, the overall prognosis remains extremely poor in these situations. WORKUPSection 5 of 10
Lab Studies
Imaging Studies
Other Tests
TREATMENTSection 6 of 10
Medical therapyTypically, all lightning strike victims who do not experience cardiac or respiratory arrest survive; therefore, normal triage priorities do not pertain to these individuals. Immediate attention should be directed to the resuscitation of those patients in respiratory or cardiac arrest. After a lightning strike, the body's physiologic processes have been theorized to slow metabolic activities, enabling it to survive prolonged arrest. Patients with dysrhythmia who typically have a poor prognosis (such as those with asystole) may recover. Accordingly, aggressive and persistent resuscitation is indicated. The goal of this resuscitation is to oxygenate the brain and heart until spontaneous circulation is restored. Resuscitation dosages and administration schedules for cardiac medications are the same as for persons with cardiac arrest from other causes. Initial treatment should begin with assessment and stabilization of ABCs. Persons who have been struck by lightning should be treated as trauma patients, with close attention to cervical spine immobilization. Lightning causes asystole, and a sinus rhythm is spontaneously reestablished in some cases. If respiratory support is not provided, however, the patient may go into a secondary cardiac arrest caused by ventricular fibrillation. Each patient must receive a complete physical examination, including a neurologic assessment and a thorough examination of the skin for wounds and burns. Pupillary areflexia and dilatation result from autonomic dysfunction and cannot be used as a reason to stop resuscitation. ECG, CK, myocardial muscle CK isoenzyme (CK-MB) or troponins, and urinalysis usually can detect deep tissue damage or cardiac injury. Surgical therapyNo surgical therapy is indicated initially. Rarely, persons with severe lightning injuries may require fasciotomies for extremity compartment syndromes or escharotomies for third-degree burns. Preoperative detailsPatients requiring surgery for any reason after a lightning injury should have adequate intravenous access and cardiac monitoring throughout the procedure. Follow-upFor excellent patient education resources, visit eMedicine's Environmental Exposures and Injuries Center. Also, see eMedicine's patient education article Lightning Strike. COMPLICATIONSSection 7 of 10
Major complications are rare in mild and moderate injury, although subjective sensations of paresthesias, irritability, and other nonspecific neurologic sequelae may be present, depending on the location and intensity of the strike. In severe injury with CPR required in the field, both permanent neurologic deficit and hypoxic injury are common. OUTCOME AND PROGNOSISSection 8 of 10
Overall, patients' outcomes and prognoses after most lightning strikes are very good. Many individuals struck by lightning are young and healthy and recover from the strike with minimal or no residual damage. In patients who endured a severe strike, the potential for permanent and debilitating neurologic and cardiac injury is greater. FUTURE AND CONTROVERSIESSection 9 of 10
Predicting the possibility or severity of any given lightning strike is impossible; therefore, preventive measures and education for those individuals at risk are the most effective methods of minimizing the mortality and morbidity of these injuries. REFERENCESSection 10 of 10
Article Last Updated: Jun 19, 2006 |
