Introduction
Lightning's power has been a subject of awe since primitive times. Ancient Greeks saw it as an expression of the wrath of Zeus. Since lightning is caused by common meteorological conditions, anyone is a potential victim. Lightning strikes the earth more than 100 times each second and 8 million times per day. Worldwide, approximately 50,000 thunderstorms occur per day that may result in forest fires and injury to animals and people.
The National Weather Service estimates that 100,000 thunderstorms occur in the United States each year. Lightning is evident in all thunderstorms. A cloud-to-ground lightning strike is the most destructive form of lightning and occurs when the electrical difference between a thunder cloud and the ground overcomes the insulating properties of the surrounding air. The danger of lightning may not be apparent to an individual because lightning has struck 10 miles away from the rain of a thunderstorm.1
In the United States, cloud-to-ground lightning strikes occur approximately 30 million times each year.2 In the United States, lightning strikes are most common in Florida and along the southeastern coast of the Gulf of Mexico.3 Data from the National Oceanic and Atmospheric Administration (NOAA) identified an average of 93 deaths and 257 injuries attributable to lightning from 1959 to 1990.4
Lightning injury is the second most common cause of weather-related death in the United States (behind flash floods).5 According to data from NOAA, in the years from 1959 to 1994, lightning was responsible for over 3,000 deaths and nearly 10,000 casualties. The actual number of lightning casualties may be higher because up to 50% may go unreported. Lightning kills more people each year than hurricanes, volcanoes, blizzards, and earthquakes combined.
Thunderstorms and lightning are most common from June through September. Lightning strikes usually occur in the afternoon and evening, coinciding with times when people are active and outdoors. Hikers, campers, golfers, and other outdoor sports enthusiasts most often sustain lightning injuries. Lightning injuries are more common in rural or exposed environments than in the city, where high buildings have metal frames and lightning-protection devices. Most lightning injuries occur in areas with the greatest number of thunderstorms, such as the South; Rocky Mountain area; Gulf Coast; and Ohio, Mississippi, and Hudson river valleys. Following the worldwide interest in mobile phones, concerns arose that mobile phones may enhance the risk of lightning strike. NOAA has indicated that lightning is not attracted to people carrying mobile phones.
The most important characteristic features of lightning injuries are multisystem involvement and widely variable severity. This article discusses the physics of lightning and the pathophysiology and treatment of lightning injuries.6 Because persons struck by lightning have a better chance of survival than persons who experience cardiopulmonary arrest from other causes, resuscitation for persons struck by lightning must be instituted immediately, followed by a comprehensive treatment program of the other systemic manifestations.7
Physics of Lightning
A natural phenomenon
Lightning is a natural atmospheric electrical discharge that occurs between regions of net positive and net negative electric charges. Usually, it is associated with cumulonimbus (thunder) clouds, but it may occur in nimbostratus clouds, snowstorms, or in the erupting gas of an active volcano. A complex sequence of events leads to a lightning discharge in a thunderstorm.
Updrafts of air drawing moisture from the upper atmosphere result in rapid cooling and formation of ice particles. Constant updrafts and downdrafts associated with storm formation cause these particles to collide rapidly, building up static electrical energy. A net positive charge develops in the upper levels of the clouds at an altitude of approximately 10 km and a temperature of about -45°C. Subsequently, a net negative charge develops in the lower levels of the clouds at an altitude of approximately 5 km and a temperature of about -15°C. Although the earth is usually negatively charged, an area of positive charge exists 2 km beneath the storm cloud (+5°C). When the potential difference exceeds the insulating properties of air, a lightning flash occurs.
Streak lightning
A flash of cloud-to-ground streak lightning is initiated by an electric breakdown between the positive and negative charge regions. A faint luminous process descends in regular steps (typically 50 m long at intervals of 0.05 ms in a downward branching fashion toward the ground). This initial flow of electricity, the leader stroke, reaches the ground in approximately 20 ms. The diameter of the stepped leader ranges from a few centimeters to a few meters. Within the leader is a current-carrying core 1-2 cm in diameter.
As the branching process nears the ground, an upward discharge termed the pilot stroke completes the path of ionization approximately 50 m above the surface of the earth. At this moment of junction, the cloud is short-circuited to the ground, and the major electric discharge, a luminous return stroke of high current, occurs. Following the initial stroke, secondary leader and return strokes frequently occur. Lightning tends to strike tall objects because, although the earth‘s normal electric field runs in equipotential planes parallel to its surface, these planes are elevated over trees, hills, and tall buildings.
Lightning is seen moving only from cloud to earth because the energy needed to ionize the air is so great that it is the brightest portion of the strike. Furthermore, its relatively slow speed (1-2 x 106 meter/second) in reaching the earth makes it easier to see. The extreme speed (2-5 x 107 meter/second) of the return stroke prevents its visualization, yet it may be perceived as an instantaneous brightening of the pathway or stroke. The upstroke reaches the cloud base in 0.07 ms, while the downward propagating stepped leader traverses the same distance in 20 ms.
Thunder
Air that is crossed by lightning is heated rapidly, and the cylindrical column expands at supersonic speeds. Within a meter or two, the shock wave decays to a sound wave, thunder, which comes from the entire channel length, producing a series of sounds described as peals, claps, rolls, and rumbles. Because light travels at 186,000 miles/second and sound travels at 1100 feet/second, the time elapsed between the flash and thunder permits calculation of the minimum distance to the flash. Duration of the rumble provides the minimum estimate of the length of the air channel; however, thunder rarely is heard at distances greater than 15 miles because of such factors as terrain, atmospheric temperature, and wind shear.
The power of lightning is awesome, an estimated 10,000-200,000 amperes (A) of current and 20 million to 1 billion volts. A current of 100,000 A can shift blocks of stone weighing 5 tons, and rocks weighing 50 pounds may be thrown 20 yards or more.
Types of lightning
Streak lightning, described earlier, is the most frequent type of lightning and accounts for human injuries. Another type, sheet lightning, travels within a cloud and gives the cloud the appearance of a white sheet. Several rare forms of lightning are ribbon and bead lightning. These are forms of ground discharge with a flash consisting of several strokes. Ribbon lightning occurs when the channel is blown perpendicular to the line of sight by the wind, displacing subsequent strokes. Consequently, the flash appears as a ribbon of several strokes. In bead lightning, the main lightning flash breaks into luminous sections, or beads, as the light intensity of the channel decays.
The most rare and mysterious form of lightning is ball lightning.8 A mix of fire and electricity concentrated in a fireball with a diameter of 20 cm, ball lightning commonly appears suddenly, even in indoor conditions, during a thunderstorm. It moves quickly for several meters, can change direction, and ultimately disappears. It has a life span of several seconds. Its color is quite variable, and it often results in an explosion.
On rare occasions, passengers and crews have witnessed a long ball traveling down the center of an airplane.9 These glowing balls of electrical energy have been reported to dissipate quietly at the rear of the airplane or to exit with a loud bang, leaving residual burn marks on the interior of the plane. These differing final exits may be related to the range of the energy content of the glowing balls. Cherington et al reported a coronal discharge and ball lightning–induced injury to a flight attendant on an airplane.9 As a result of this lightning-related event, the flight attendant sustained a demyelinating injury of the brain, the symptoms of which resolved after 22 months.
Mechanisms of Injury
Lightning causes injury through 5 basic mechanisms: direct strike, flash discharge (splash), contact, ground current (step voltage), and blunt trauma.
Direct strikes
Direct strikes occur when the victims are outside and, often, carrying metal objects, such as an umbrella. Metal worn in the hair (eg, a hairpin) increases the chances of a direct strike compared with a metal object worn lower on the body. Although not always fatal, direct strikes are associated with high morbidity because they frequently involve the head. Lightning strikes near the head may enter the eyes, ears, and mouth to cause multiple problems.
Flash discharge
More commonly, the victim is struck by a flash discharge from another struck object. This type of "splash" injury occurs, for example, when someone seeks shelter beneath a tree that subsequently is struck by lightning. Because the resistance to direct current flow in the air between the tree and victim is less than that to direct current flow in the tree, and lightning seeks the path of least resistance, it will jump from the tree to the victim. Splash injury also occurs from person to person when several people are standing close together.
Contact
Contact injury occurs when a person is touching an object that is either directly hit or splashed by lightning.
Ground current
Lightning also can result in harmful ground current that causes mass casualties in fields or other open areas. Severity of ground current injuries decreases with distance from the point of the lightning strike. Ground is a good insulator, while a person is a good conductor; therefore, a person standing with his feet spread may create a potential difference large enough to create a circuit between the legs and ground. This method of injury, with its increased electric conduction, may account for the high mortality (30%) of lightning victims with leg burns and for the fact that burns to the arms and trunk are not important predictors of mortality.
Blunt trauma
Blunt trauma occurs when a person is thrown by a massive opisthotonic contraction caused by the lightning strike.
Flashover
An interesting phenomenon termed flashover may protect victims from the damaging effects of lightning.10 Because electric current normally travels along the outside of a metal conductor, most lightning energy actually may be conducted around the outside of the victim's body, vaporizing moisture on the skin and blasting apart clothes and shoes. This dissipation of electric energy in flashover produces less injury than would similar levels of electric current flowing directly through the body.
When current does enter the body, it passes through tissues with the least resistance. Nerves, blood vessels, muscle, and connective tissue have high fluid and electrolyte content and are affected most commonly. Although it is often not possible to document which mechanism of lightning injury was involved in a particular case, such knowledge does not influence patient care.
Pathophysiology
Lightning causes death in 30% of its victims and permanent sequelae in up to 70% of survivors.11 Death from lightning injury is unrelated to sex, age, and the presence of trunk and arm burns. Factors that appear related to a fatal outcome are leg burns, head burns, and immediate cardiopulmonary arrest.
Lightning injury differs from commercial high-voltage electric injury in several important ways.
- Duration of current flow in lightning injuries is usually brief (much less than 1 second), while duration of current flow is often prolonged for several minutes in alternating commercial electric current injury.
- Lightning is direct current; most commercial electrical current is alternating.
- Lightning produces a significantly greater temperature and current than high-voltage electricity; however, duration of contact influences the type and severity of injury to a larger extent than current strength.
- Lightning injury often has a component of flashover, which diverts current around the body rather than through it; commercial electric injury does not. Consequently, myoglobinuria, renal failure, and compartment syndrome occur much more rarely from lightning injury than from commercial electric injury.
- Lightning also has a shock wave component that can cause injury; this is usually not a factor in commercial electric injury.
As lightning follows the shortest route between contact points of the human body, it may involve vital structures in its path. Almost every organ system is vulnerable. A wide variety of complications can result from damage to these organ systems, and specific sequelae dictate the choice of therapy.
Cardiovascular Injury
Persons struck by lightning show evidence of multisystem derangement, yet the most dramatic effects involve the cardiovascular and central nervous systems. Lightning can be considered the ultimate in cosmic cardioversion, producing atrial and ventricular arrhythmias, myocardial injury, and vasomotor responses.12
The direct current of lightning depolarizes the entire myocardium at once, causing a single systolic contraction followed by a variable period of asystole (primary cardiac arrest). Cardiac activity usually returns spontaneously, first at a markedly bradycardic rate and then slowly increasing in speed. Rhythm may deteriorate from apnea resulting from paralysis of the respiratory center in the medulla. Development of hypoxia leads to secondary cardiac arrest with ventricular fibrillation.
Cardiopulmonary arrest
Cardiopulmonary arrest is the most common cause of death in lightning victims.12 Primary cardiac arrest results from direct current to the heart, while secondary cardiac arrest results from paralysis of the respiratory center in the brainstem. Duration of respiratory paralysis rather than primary cardiac arrest determines mortality.
Treatment at scene
- Immediate resuscitation: Immediate resuscitation of the person struck by lightning greatly influences prognosis. If a witness to the accident is present, he or she should initiate resuscitation at the scene. The rescuer first should check the person's responsiveness. If a spinal cord injury is suspected, stabilize the person's head during assessment of the level of consciousness. Evidence of head injury or tenderness or hematomas of the neck or back should alert the rescuer to the possibility of an injury to the spinal cord. In such cases, stabilize the head until the person is secured to a long backboard by emergency medical technicians.
- Altered level of consciousness: If the person has an altered level of consciousness or is unresponsive, the rescuer should assess ventilatory impairment. Kneeling at the person's side, the rescuer places his or her cheek close to the person's mouth. While listening and feeling for breathing, the rescuer should watch the movement of the bared chest. Movement of the chest wall should be synchronous and symmetric with each ventilation. Satisfactory air exchange is evidence of adequate ventilation.
- Inadequate ventilation: The most common cause of inadequate ventilation in the unconscious victim is blockage of the pharynx by the relaxed tongue. This airway obstruction is relieved by the modified jaw thrust maneuver that moves the jaw forward and lifts the tongue from the posterior pharyngeal wall with minimal movement of the spinal cord. Ideally, emergency medical technicians should continue resuscitation with telemeter monitoring throughout transport to the advanced life support facility. If a group of persons is struck by lightning, direct attention to those with no signs of life, because the others will probably recover, although burns or injuries may need treatment. Immediate cardiopulmonary resuscitation and prevention of anoxic death are essential, but 77% of these patients die despite these resuscitative efforts.
- Electrocardiographic changes: Electrocardiographic changes observed following lightning accidents probably stem from primary electric injury or burns of the myocardium without coronary artery occlusion.13 Autopsy studies of victims of lightning injuries have demonstrated epicardial hemorrhages and a peculiar spiral malformation of the myocardial fibers. Electrocardiographic evidence for direct myocardial damage includes changes typical for acute myocardial infarction, with ST segment elevation, T-wave inversion, and prolongation of the QT interval. Fortunately, these electrocardiographic changes usually resolve without serious cardiac complications, but they may be associated with serious cardiac sequelae. Prompt symptomatic improvement has occurred after the intravenous administration of diuretics. Several months after injury, usually no evidence of cardiac dysfunction is seen, and the patient's exercise tolerance returns to normal.
- Vasomotor spasm: Vasomotor spasm is the local response of the vasculature to electric current from direct sympathetic stimulation. Vasoconstriction may be so prolonged and intense that it causes early and severe loss of pulses and mottled, cool extremities. This vasoconstriction is usually self-limited and resolves within hours. Occasionally, the intense vasomotor response in a victim struck by lightning may be associated with transient paralysis of an arm or leg. The paralysis is considered the result of temporary ischemia of the peripheral nerves. In a lightning injury patient with peripheral vascular disease, prolonged vasospasm may lead to thrombosis and necessitate intervention with heparin, aspirin, or dipyridamole.
- Transient hypertension: Transient hypertension may occur and usually requires no short-term therapy. However, hypertension that persists 12-72 hours after the lightning strike responds to beta-blockers.
Central Nervous System Injury
Damage to the central nervous system (CNS) is the second most debilitating group of lightning injuries.14 CNS injuries from lightning include amnesia and confusion (86%), immediate loss of consciousness (72%), weakness, intracranial injuries (eg, epidural and subdural hematomas, intraventricular hemorrhages), and brief aphasia after regaining consciousness.
Neurologic Sequelae
Neurologic sequelae of lightning injury result either from electric current or mechanical trauma.
Electric current
The immediate effect of the electric current of a lightning strike on the CNS is an altered level of consciousness that varies from disorientation with retrograde amnesia to loss of consciousness. In the most severe cases, paralysis of the respiratory center may occur and cause sudden death. Occasionally, the injury is so devastating that rapid onset of cerebral edema with brainstem herniation occurs. Cerebral edema can be managed with fluid restriction, mannitol, furosemide, or a combination thereof. Treatment of increased intracranial pressure includes hyperventilation to maintain partial pressure of carbon dioxide (PCO2) at 30-35 mm Hg and hyperosmolar agents. Steroids provide little benefit in reducing intracranial pressure. Monitoring the patient's intracranial pressure can assess the benefits of these treatments.
Mechanical trauma
Mechanical trauma from a fall after lightning strike also can account for neurologic sequelae. Lightning may cause the victim to fall to the floor with sufficient force to cause skull fracture and an intracranial hematoma. Because a comatose or semicomatose state may follow the lightning strike, it is often difficult to distinguish coma resulting from electric shock from intracranial hematoma until lateralizing signs develop.
Paralysis
Fortunately, most patients with injuries caused by lightning do regain consciousness. However, more than half of all patients injured by lightning experience transient motor paralysis (69% incidence of paralysis of upper extremities, 30% incidence of lower extremities), usually sparing the ventilatory center. Complete extremity paralysis from lightning injury is known as keraunoparalysis and is associated with sensory loss and cyanosis. Total resolution of paralysis usually occurs in minutes to days. If paralysis does not improve, suspect other causes, such as direct spinal cord injury or blunt injury from a fall. Isoenzyme fraction creatine phosphokinase-BB (CPK-BB) may be elevated following lightning accidents that result in cerebral anoxia. The significance of this finding is uncertain, because a correlation has not been found between an increase in CPK-BB and the extent of brain injury.
Psychological sequelae
Psychological sequelae of lightning injury have caused significant morbidity.14 Survivors of lightning injury report heightened anxiety states, hyperirritability, memory deficits, aphasia, sleep disturbance, and posttraumatic stress disorder. These symptoms also are found in patients with blunt head trauma, yet the sleep disturbance and memory difficulties are more severe than those caused by blunt brain injury.Other Manifestations
Eyes and adnexa
Lightning can injure the eye and its adnexa.15 Disruption of the autonomic nervous system causes dilated and/or nonreactive pupils. This reaction to lightning strike is usually short-term and should not be used as an indicator of brain death in patients who have been injured by lightning.
Cataracts are the most common intraocular lesions caused by lightning.16 Two types of cataracts are seen: (1) an ordinary traumatic cataract develops shortly after the injury from a concussion that results in minute tears of the lens capsule, and (2) the other type of cataract is characteristic of an injury from either lightning or high-voltage current. A high-voltage current produces anterior subcapsular changes, while lightning causes opacities in both anterior and posterior capsules. The cataract may appear within the first few days or as late as 24 months postinjury and is usually bilateral. Generally, opacification develops more rapidly after lightning injury than after commercial high-voltage electric injury.
Retinal involvement after lightning injury is less frequently documented, though chorioretinal atrophy, macular cyst, papilledema, hemorrhage, and detachment have been noted. Macular cyst can be diagnosed with optical coherence tomography. Consequently, consider the possibility of retinal damage when evaluating the visual potential of a patient who has developed a cataract following a lightning strike.
Lid lesions caused by lightning vary from a partial-thickness burn to ulcerated necrotic lesions. Conjunctival chemosis frequently occurs, and corneal lesions vary from transitory punctate keratitis to severe interstitial keratitis. Iridocyclitis may be mild or short-lived or more severe and chronic. Paresis of accommodation also may occur following a lightning strike.
Ears
Although injury to the ear is relatively rare in electric accidents from electric current, it occurs in more than one half of patients with lightning injury.17 Lightning can injure the ear through 2 mechanisms, direct and blast effects. The direct effect of lightning results from passage of the electric current. In lightning-damaged ears, substantial ear damage and hearing loss are common. Temporal bone pathology shows tympanic membrane rupture, middle ear and mastoid effusion of pus and blood, total rupture of Reissner membrane, degeneration of the stria vascularis and organ of Corti, edema of the intracanalicular portion of the facial nerve, herniation of a portion of cerebellum into the internal auditory meatus, and a possible microfracture of the otic capsule. These lightning-damaged ears often are associated with other injuries (eg, burns of the skin, acromioclavicular joint separation).
Perforation of the tympanic membrane occurs in more than half of patients injured by lightning. This injury often occurs while using the telephone during a thunderstorm and is caused by the blast effect, basilar skull fracture, or direct burn damage from lightning. Ruptured tympanic membranes from lightning regenerate well without surgical intervention.
Occasionally, unilateral hearing loss can occur without other trauma after lightning injury.18 An audiogram shows typical nerve-type hearing loss. The tympanic membrane is intact but markedly inflamed. Hearing disability is temporary, and recovery occurs in 9 months.
Treatment of lightning-damaged ears
- Immediate treatment of lightning-damaged ears includes cleaning blood and debris from the external auditory canal and aural hygiene.
- Otic drops can be used unless the patient has cerebrospinal fluid otorrhea.
- Prudence dictates delaying operating on unresolved tympanic membrane perforations for at least 6 months for several reasons. Edema, burning, and charring of the ear canal may interfere with tympanoplasty, and spontaneous healing may occur. A delay also may reveal partial ossicular necrosis and discontinuity, which can be corrected at the time of tympanoplasty.
- Following tympanoplasty or spontaneous healing of the tympanic membrane, prolonged observation for a blast-induced cholesteatoma is advised.
- Implants of squamous epithelium from the drum may be blown into the promontory where they proliferate and cause cholesteatoma. Management of peripheral facial nerve palsy involves frequent stimulation to see if the nerve is injured and if surgical decompression or repair is necessary.
Skin
Skin injuries from lightning vary from cutaneous injury to that typically caused by high-voltage commercial electricity.19 Skin injuries are affected by the type of clothing, amount of moisture on the skin, and presence of metal on the body. Burn injuries frequently are surprisingly superficial. Discrete entry and exit points rarely are seen with lightning injury.
Six types of burns are caused by lightning: feathering, linear, punctate, thermal, contact, and flash.
- An almost pathognomonic cutaneous feature known as feathering or lightning prints comprises linear, fernlike, superficial skin markings (also called keraunographic marks) that disappear after several days.19 These cutaneous manifestations of lightning injury usually consist of erythematous streaks that do not blanch on diascopy. Erythema begins to fade in 4-6 hours with no residual skin changes. This bizarre cutaneous manifestation is probably related to the flashover phenomenon, from the transmission of static electricity along the superficial vasculature. Recognition of this sign may save the life of an unaccompanied comatose patient and should signal the need for immediate resuscitation if a victim is not breathing and has no pulse.
- Linear burns are partial-thickness burns, 1-4 cm wide, that occur over moisture-rich areas of the body, such as beneath the breasts, down the mid chest, and in the midaxillary line. These first- and second-degree burns present minutes to hours after the lightning strike and result from vaporization of sweat into steam on the patient's body.
- Punctate burns are multiple, closely spaced, discrete, circular full-thickness burns that result from current passing through dry skin. They are a few millimeters to a centimeter in diameter and resemble cigarette burns.
- Thermal burns result when lightning ignites clothing.
- Contact burns occur when metal, such as jewelry, zippers, or belt buckles, contact the skin during lightning strike. Both thermal and contact burns may be full-thickness burns.
- Flash burns are superficial burns that result in brown discoloration of the skin.
Full-thickness burns rarely result from lightning accidents. However, lightning occasionally may cause an electric burn from direct current flow with clinical manifestations similar to those from a commercial high-voltage electric injury. Extensive burn scars following lightning burns may develop into squamous cell carcinoma (Marjolin ulcer). Therapy for burn injuries should include cleansing the burn wound with poloxamer 188, followed by treatment with a topical antimicrobial cream containing polymyxin (10,000 U/g), nystatin (4000 U/g), and nitrofurantoin (0.3%). Tetanus prophylaxis is mandatory, as the wound is considered tetanus prone. When full-thickness burns are evident, excision of the devitalized skin followed by the application of autogenous split-thickness skin grafts is recommended.
Musculoskeletal system
Lightning may injure the musculoskeletal system either by mechanical trauma or by passage of the electric current.20 When someone is struck by lightning, current may produce a violent muscular contraction that throws the victim several feet, possibly causing fractures and/or dislocations of the extremities. Fractures of the skull, ribs, extremities, and spine have been reported.
As current passes through tissue, electric energy is converted to heat that may be sufficient to damage muscle tissue. Muscle necrosis has potentially severe local (compartmental syndrome) and systemic (rhabdomyolysis) sequelae, although this is less frequent than in commercial electric injuries.
Gastrointestinal system
Gastrointestinal (GI) complications of lightning injuries are similar to those following any major trauma.21 Most common is gastric atony with gastric dilatation, for which placement of a sump nasogastric tube is mandatory to decompress the stomach and remove swallowed air. (Click here to see eMedicine’s illustrated guide to placing a nasogastric tube.) Another complication seen in victims of lightning injury is GI bleeding. GI perforation is a rare complication of lightning injury. Buffering the gastric secretions with antacids and administering cimetidine may prevent this. In 2 unusual fatal cases of lightning strike, autopsy findings showed hemorrhage and necrosis in the pancreas.
Pregnancy
Effect of lightning injury in pregnancy varies. Of 11 pregnant women struck by lightning, approximately one half of the pregnancies resulted in full-term live births without evidence of birth defects. One fourth of the pregnancies resulted in neonatal deaths, and one fourth resulted in stillbirths or deaths in utero.22,23
Scientific bases for the selection of glovesAt the scene of the lightning injury, the emergency medical technician and paramedics should wear emergency medical examination gloves with a glove hole leakage rate of 1% rather than examination gloves used in the hospital, which have a glove hole leakage rate of 4% (as required by the Food and Drug Administration [FDA]).24
During surgery, the surgeon should wear sterile surgical gloves without cornstarch. In 2008, 13 health professionals filed a citizen's petition with the FDA to ban cornstarch powder on all medical gloves.25 Cornstarch has been documented as promoting wound infection and causing serious peritoneal adhesions and granulomatous peritonitis, and it is a well documented vector of the latex allergy epidemic.
The FDA allows 1.5% of surgical gloves to have holes. These holes allow blood with deadly viral infections to be transmitted between the patient and the surgeon. Consequently, the Biogel double-glove hole indication system should be used to detect the location and presence of holes in the gloves, allowing the surgeon to change the gloves when a hole is detected.26 After surgery has begun, one of the major causes of glove holes is surgical needle penetration, which can be detected by the double-glove hole indication system.
In collaboration with Dr. Robert Zura of Duke Medical Center, the authors have developed a poster entitled: A Demonstration of How the Biogel Patented Puncture Indication System Works When Immersed in Water or Saline.
Poster for the Biogel puncture indication system.
This poster can be framed and placed in the operating room as a guide to the appropriate use of the double-hole indication system during surgery. Copies of the poster can be obtained by contacting Mr. Milt Hinsch at Milt.Hinsch@biogelusa.com.
Prevention
The best treatment of lightning accidents is prevention. Common safety precautions during thunderstorms include remaining inside a closed car or in a steel-framed building away from doors and windows, fireplaces, and metal objects such as pipes, sinks, radiators, and plug-in electrical appliances. Many consider the telephone safe from lightning, but lightning strikes during telephone calls caused 4 deaths and 36 injuries from 1959 to 1965. Side flashes to people from telephones, plumbing fixtures, and appliances connected to the outside by metal conductors have injured people inside buildings.
Whatever reaches highest into the air offers lightning a quick and easy path to the ground. When outside and unable to find shelter, maintain distance from tall trees, hilltops, or other exposed areas. A person caught outside in the open without cover should crouch on the ground with his or her limbs close together. Dry caves, ditches, and valleys may provide some protection from lightning strike. Lightning can travel through water; thus, swimming, boating, and bathing should be avoided during a thunderstorm.
Monitoring of a radius around a park district, municipality, or sporting event to warn people of approaching thunderstorms can potentially decrease the number of lightning injuries. A warning siren alerts people to impending lightning danger in time to evacuate the outdoor complex.
The lightning rod, invented by Benjamin Franklin in 1752, has undergone remarkably few changes. It protects buildings by transferring lightning flashes down a conductor into a grounding system in the earth. Lightning strikes through an airplane are not unusual and generally cause little or no damage. One exception was the loss of a commercial airplane in December 1963.
Unfortunately, meteorologic agencies in the United States and around the world, which issue warnings and forecasts with the goals of reducing casualties and property damage from severe weather, issue warnings for only 3 of the 4 important causes of storm-related fatalities: tornadoes, hurricanes, and floods. These agencies do not issue warnings about lightning.
Because lightning flashes strike the ground approximately 25,000,000 times per year in the United States, the National Weather Service cannot practicably alert every individual to every flash. Consequently, avoidance of lightning injury usually becomes an individual responsibility, wherein each person must become familiar with and follow lightning safety rules.27 These lightning safety guidelines were summarized by Zimmermann et al.27 Their warnings were based on the guidelines drafted by the Lightning Safety Group in 1998. However, following these guidelines does not guarantee the prevention of all lightning injuries.
The National Athletic Trainers' Association has recently developed a position statement that recognizes a proactive approach to lightning safety, including the implementation of a lightning safety policy that identifies safe locations for shelter from the lightning hazard. Local weather forecasts, the National Oceanic and Atmospheric Administration (NOAA), weather radios, and the Weather Channel should be monitored before any outdoor event takes place to determine whether a thunderstorm is forecast. If a thunderstorm is predicted, the group may decide to cancel or postpone the event or may choose to plan indoor activities.28
For excellent patient education resources, visit eMedicine's Environmental Exposures and Injuries Center and Burns Center. Also, see eMedicine's patient education articles Lightning Strike and Thermal (Heat or Fire) Burns.
Multimedia
 | Media file 1: Poster for the Biogel puncture indication system. |
Keywords
lightning injuries, thunder, thunderstorms, lightning-protection devices, cumulonimbus, thundershower, physics of lightning, lightning strike, streak lightning, sheet lightning, ribbon lightning, bead lightning, ball lightning, direct strike, flash discharge (splash), contact, ground current (step voltage), blunt trauma, flash-over, cardiovascular injury, cardiopulmonary arrest, inadequate ventilation, neurological manifestations, motor paralysis, psychological sequelae, ocular trauma, hearing loss, leg burns, muscle injury, head burns, vasomotor spasm
transient hypertension, lightning cataract, perforation of the tympanic membrane, discrete skin entry and exit burns, feathering, linear, punctate thermal burn, contact burn, flash burn, mechanical musculoskeletal system trauma, gastric atony, gastric dilatation, prevention, National Oceanic and Atmospheric Administration, NOAA, National Weather Service, lightning rod, National Athletic Trainers' Association, powder-free double-glove hole indication system
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References
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Further Reading
Keywords
lightning injuries, thunder, thunderstorms, lightning-protection devices, cumulonimbus, thundershower, physics of lightning, lightning strike, streak lightning, sheet lightning, ribbon lightning, bead lightning, ball lightning, direct strike, flash discharge (splash), contact, ground current (step voltage), blunt trauma, flash-over, cardiovascular injury, cardiopulmonary arrest, inadequate ventilation, neurological manifestations, motor paralysis, psychological sequelae, ocular trauma, hearing loss, leg burns, muscle injury, head burns, vasomotor spasm
transient hypertension, lightning cataract, perforation of the tympanic membrane, discrete skin entry and exit burns, feathering, linear, punctate thermal burn, contact burn, flash burn, mechanical musculoskeletal system trauma, gastric atony, gastric dilatation, prevention, National Oceanic and Atmospheric Administration, NOAA, National Weather Service, lightning rod, National Athletic Trainers' Association, powder-free double-glove hole indication system
