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Lightning Injuries

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

Updated: Feb 26, 2009

Introduction

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. Although only a small percentage of these 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.1 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.1,2

According to the US Centers for Disease Control and Prevention (CDC), approximately 100 of every 500 fatalities caused by electricity are the result of lightning strikes.3 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.4

For excellent patient education resources, visit eMedicine's Environmental Exposures and Injuries Center. Also, see eMedicine's patient education articles Lightning Strike and Electric Shock.

Problem

Although rare, serious lightning injuries are likely to primarily cause cardiac and neurologic injury.5,6,7 Otologic injury and cutaneous burns have also been noted as frequent sequelae of these events.6,8,9,10,11 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. 

Lightning 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 (V) or 220-V electrical currents. Blunt physical injury is much more likely to accompany lightning injuries when compared with electrical injuries; therefore, medical personnel should also screen lightning victims for occult blunt trauma.6

Because a lightning strike can be variable and diffusely spread over the body, most authors characterize lightning injuries as mild, moderate, or severe.

  • Mild lightning injury is rarely associated with superficial burns, but persons struck often report loss of consciousness, amnesia, confusion, tingling, and numerous other nonspecific symptoms. Lightning burns are invariably superficial and have little or no deep-tissue damaging effects.
  • Moderate lightning injury may cause seizures, respiratory arrest, or cardiac standstill, which spontaneously resolves with resumption of normal cardiac activity. Much of the symptomatology mirrors that of mild lightning injury, except superficial burns are much more common, both initially and in a delayed fashion. These patients may have lifelong symptoms of irritability, sleep disorders, and paresthesias.
  • Patients with severe lightning injury usually present with cardiopulmonary arrest, which is often complicated by a prolonged period in which they did not receive cardiopulmonary resuscitation (CPR). This delay is attributable to the fact that these individuals are often in an isolated location when injured. Survival is rare in this group unless a bystander expeditiously begins CPR.

Frequency

Worldwide, lightning causes serious injuries in 1000-1500 individuals every year. Persons struck are typically males aged 15-44 years. Most injuries occur between May and September. The National Center for Health Statistics documents the majority of US deaths by lightning strikes occur in the South and the Midwest, with Florida and Texas leading the list.1 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.1

Some reports suggest as many as 74% of survivors experience permanent injury and sequelae.9 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.5,6,7 Forensic physicians must also consider lightning strike in the differential diagnosis of sudden unexpected death in persons found outside.12,13 The most common minor injury reported is rupture of the tympanic membranes.14 Superficial burns and eye injuries are the most frequently reported injuries.6,9,10,11 The most common chronic sequela reported is cataract formation.

Pathophysiology

The 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.

  • Direct strikes cause maximum injury, because the entire charge of the lightning passes through or over the person's body. Due to the short duration of contact during a lightning strike, often not enough voltage is transferred to break the insulating effect of the skin; therefore, the charge typically passes along the surface of the body in a process known as "flashover." When the charge merely passes over the victim's body, less damage occurs.
  • Side flash occurs when the lightning jumps from the primary strike area to the victim.
  • A ground strike occurs when the charge hits the ground in proximity to the victim. In this instance, if a potential difference exists between the victim's legs, the current enters the body through 1 leg and exits through the other. This is known as step voltage. The extent of injury depends on a number of variables, including amperage, voltage, current pathway, length of contact, resistance of the body, and the victim's relationship to discharging electrical fields.

Lightning causes damage to a wide range of bodily systems through several mechanisms as follows:

  • Cardiopulmonary complications
    • Transient hypertension
    • Electrocardiographic changes
    • Myocardial injury
    • Congestive heart failure
    • Dysrhythmia
    • Transient asystole
    • Atrial fibrillation
    • Ventricular fibrillation
    • Frequent premature ventricular contractions
    • Respiratory complications
    • Apnea
    • Hypoxemia
  • Neurologic complications
    • Loss of consciousness
    • Confusion
    • Paraplegia, quadriplegia
    • Retrograde amnesia
    • Hemiplegia, aphasia
    • Coma
    • Seizures
    • Intraventricular hemorrhage
    • Hematomas
    • Keraunoparalysis
  • Vascular complications
    • Vasomotor instability
    • Arterial spasm
    • Vasoconstriction, vasodilatation
  • Dermatologic complications - Cutaneous burns
  • Ophthalmic complications
    • Cataracts
    • Corneal lesions
    • Hyphema
    • Iritis
    • Vitreous hemorrhage
    • Retinal detachment
    • Optic nerve injury
  • Otologic complications8
    • Ruptured tympanic membrane
    • Temporary hearing loss
  • Intra-abdominal complications
    • Gastric perforation15

Presentation

Indications of lightning injury noted on physical examination include the following:

  • Cold, pulseless extremities are a sign of vasomotor instability.
  • Confusion, amnesia, paralysis, and loss of consciousness are a result of the direct passage of current through the brain.
  • Temporary hearing loss is caused by the shock wave created by the accompanying thunder.
  • Hypotension most likely signals intra-abdominal or thoracic hemorrhage, fractured pelvis, extremity fractures, rupture of internal organs, or spinal cord injuries.
  • Prolonged paresis or paralysis of the extremities indicates possible spinal cord injuries.
  • Fixed and dilated pupils are typically a result of transient autonomic disturbances, not serious head injuries.
  • Lichtenberg figures, also know as ferning pattern, may be noted in the skin of lightning strike victims.16

Relevant Anatomy

Understanding the conduction system of the heart and nervous system is helpful in understanding both the initial and prolonged effects of a lightning strike.

Contraindications

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.17

Workup

Laboratory Studies

  • Routine blood work findings in mild or moderate lightning injury are usually within reference ranges. Blood work should include complete blood cell (CBC) count, creatine kinase (CK) with isoenzymes, routine urinalysis, and urine or serum myoglobin levels. Screening for myoglobin should be performed on the initial evaluation and admission to the hospital, but results are unlikely to be positive except in the most severe lightning strikes.18
  • With neurologic symptoms, the isoenzyme of CK with brain subunits (CK-BB band) may be elevated, but this has not been proven to be of major prognostic significance.
  • Patients admitted to the hospital may also benefit from blood electrolyte determinations, blood urea nitrogen (BUN), creatinine levels, and serial CK determinations.

Imaging Studies

  • In the case of blunt trauma or blast injury, plain x-rays should be considered for all contused or injured areas, including the cervical spine and chest.
  • Computed tomography (CT) scanning of the head is indicated in patients with a loss of consciousness, both to detect any injury directly caused by the lightning strike and to exclude secondary blunt trauma to the head and cerebral tissues.
  • Magnetic resonance imaging (MRI) may be helpful in cases of lightning injuries with neurologic sequelae that persist beyond the first 24 hours.19

Other Tests

  • Early electrocardiography (ECG) is frequently performed, but findings may be normal for the first 24-48 hours. Conduction abnormalities or evidence of subepicardial ischemia is common in more severe strikes.
  • Electromyography (EMG) and electroencephalography (EEG) may be helpful later in the course of injury, but they are rarely helpful in the immediate postinjury period.

Treatment

Medical Therapy

Typically, 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.18

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 the ABCs (airway, breathing, circulation). 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 Therapy

No surgical therapy is indicated initially in cases of lightning injuries. Rarely, persons with severe lightning injuries may require fasciotomies for extremity compartment syndromes or escharotomies for third-degree burns.

Preoperative Details

Patients requiring surgery for any reason after a lightning injury should have adequate intravenous access and cardiac monitoring throughout the procedure.

Complications

Major complications are rare in mild and moderate lightning injuries, 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 lightning injury with CPR required in the field, both permanent neurologic deficit and hypoxic injury are common.

Outcome and Prognosis

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 Controversies

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.2,18

Recommendations by the Lightning Safety Group of the American Meteorological Group have been published in the Annals of Emergency Medicine, and additional work by this group may help further educate the public and medical personnel, thereby minimizing future risk.2 Work and research by support groups, such as the Lightning Strike and Electric Shock Survivors International, may also expand our understanding of both the initial effects and the chronic effects of lightning injury.

References

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Keywords

lightning injuries, lightning burns, lightning, electrical injuries, electrical burns, lightning strikes, lightning flashes, lightning-related fatalities, direct strike, side flash, ground strike, flashover

Contributor Information and Disclosures

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, MD, FACS 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
Disclosure: Nothing to disclose.

Medical Editor

Marc D Basson, MD, PhD, MBA, Professor, Chair, Department of Surgery, Michigan State University
Marc D Basson, MD, PhD, MBA is a member of the following medical societies: American College of Surgeons and American Gastroenterological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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
Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, 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
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

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