eMedicine Specialties > Emergency Medicine > Environmental

Lightning Injuries: Follow-up

Author: Mary Ann Cooper, MD, Professor, Department of Emergency Medicine, University of Illinois at Chicago
Contributor Information and Disclosures

Updated: Jun 12, 2009

Follow-up

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 NOT 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 significant 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).

Inpatient & Outpatient Medications

• 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 2007-08).²⁵ 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.26
  • 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 is, "When thunder roars, go indoors."¹⁸
  • Lightning may travel as far as 10-12 miles anywhere around a thunderstorm; clouds need not be overhead and rain need not be present.
• Safer areas⁶
  • 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 other wet areas such as beaches; 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.
  • Avoid metal door and window frames, as they can build up a substantial static charge. While this may not technically be a lightning injury, it is still precipitated by the lightning event.
• Resumption of activity: Activities should not be resumed until 30 minutes after the last lightning bolt is seen or thunder is heard.^2,18 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 
  • 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

Medicolegal 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

• Search for CME/CE on This Topic »

• Lightning Injuries (Trauma)
• Burns, Lightning Injuries (Plastic Surgery)

• Environmental Exposures and Injuries Center
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• Lightning Strike Symptoms
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