Lightning Injuries Treatment & Management

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.^[8]

While in the past it has been reported that a lightning strike can slow the body's physiologic processes, enabling it to survive prolonged arrest, there is no concrete evidence for this scenario. Patients with dysrhythmia who typically have a poor prognosis (eg, those with asystole) may recover. Aggressive and persistent resuscitation is indicated. The goal of this resuscitation is to oxygenate the brain and heart until spontaneous circulation is restored.

Remember that no place outside is safe when thunderstorms are in the area. National lightning safety guidelines indicate that significant risk continues for 30 minutes after the last lightning is seen or thunder is heard. If it is judged that there is no risk of continuing danger of lightning injury to emergency medical services (EMS), 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 from being thrown by involuntary muscle contraction. (Obviously, an alert, minimally injured patient can help to decide if this is necessary.) Resuscitation or supportive care, including, advanced cardiac life support (ACLS), can then proceed as indicated based on clinical status,.

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.

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.

If a group of persons is struck by lightning, attention should be directed 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.

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 symmetrical 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.

Electrocardiographic changes

Electrocardiographic changes observed following lightning accidents probably stem from primary electrical injury or burns of the myocardium without coronary artery occlusion.^[15] 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. 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 electrical 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.

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.

Do not assume that lightning injuries are like high-voltage injuries and treat them as such (eg, fluid loading, mannitol administration, alkalinization of the urine, transfer to burn units) in the absence of deep burns.

Anecdotal reports of survival with prolonged CPR started in the field have been received, but the overall prognosis remains extremely poor in these situations.^[74]

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. If lightning causes asystole, a sinus rhythm may be spontaneously reestablished in some cases. If respiratory arrest is prolonged and support is not provided, however, the patient may go into a secondary cardiac arrest caused by ventricular fibrillation.

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) can be made.

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.

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

Consultations

Consultations are based on physical findings and 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.

Transfer

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

Follow-up

If the patient 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.

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.^{[17, 75]}

Nonsteroidal anti-inflammatory drugs (NSAIDs), as well as narcotics, are often used for the acute pain. 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 by the patient's symptoms.

Burn surgeons administer NSAIDs, vitamin C 1 g/day and vitamin E 400 U/day to decrease scarring from electrical injuries. Vitamin C and vitamin E are hypothesized, but not proven, to be effective against other injuries as well, such as nerve damage. 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.

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 surgery 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.

Even after repair of the ear, the patient may report continuing and irritating tinnitus from eighth nerve damage, as well as problems with balance and dizziness.

The vast majority of patients do not need inpatient admission and few need cardiac monitoring. Routine and supportive care is administered to patients as indicated by physical findings. Sometimes, however, chronic pain syndromes, neuromuscular injury, and neurocognitive injuries, which are significant and life changing, occur in a patient who initially seemed to be only minimally injured.

Obviously, persons who have been severely injured by lightning require hospital admission, often to an intensive care unit. There is nothing special or specific regarding the care of such patients; care is routine, being carried out as indicated by the injuries. Rehabilitation may be prolonged and extensive for the more seriously injured patient.

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. A patient who has suffered significant blunt trauma as a result of the lightning strike should be admitted to the appropriate trauma service and setting for further management.

Predicting the possibility or severity of any given lightning strike is impossible. Altering the course of injury, once set in motion, is also difficult. Therefore, preventive measures and education for individuals at risk are the most effective methods of minimizing lightning-related mortality and morbidity.^{[8, 42]}

Guidelines by the Lightning Safety Group (LSG) have been published in the Annals of Emergency Medicine.^[42] In 2000, some of the LSG authors were invited by the National Oceanic and Atmospheric Administration (NOAA) to become founding members of National Lightning Safety Awareness Week (LSW). The LSW website is now the premier reference for lightning safety in the world. It includes links to media and teacher sections, the support group, children’s games and curricula, free downloadable educational and safety materials, statistics and individual injury reports for the last several years, and multiple links other related lightning sites. Over the last decade, members have given thousands of interviews to the media, educating broadcasters and the public in lightning injury prevention. Lightning safety guidelines now appear in almost every sports, scouting, coaches, and public venue in the United State.

The US National Collegiate Athletic Association (NCAA) has been an active partner in this, with guidelines for their coaches since 1997.^[36] Multiple professional and college-level games, including those being televised, have been delayed or called for lightning risk in the last decade. High schools have adopted similar guidelines for lightning stoppage.

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. Formerly, the National Weather Service (NWS) issued severe storm or thunderstorm warnings upon danger of (1) straight-line winds exceeding 60 miles per hour, (2) hail three fourths of an inch or larger in diameter, or (3) tornadolike gusts. In the last decade, largely in response to LSW team efforts, many offices now report the possibility of “dangerous lightning” as well. However, lightning safety continues to be primarily an individual responsibility, requiring individual decisions for prevention.

One exception to the individual responsibility caveat is if 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. The NCAA handbook’s section on lightning injury prevention policy is particularly useful for parents, who can present a copy to their children's team managers to spur lightning safety planning. The LSW Web site has many resources for teaching lightning safety. Another resource is www.Struckbylightning.org, which has safety information for children and parents.^[37]

Event planners should be more proactive and may need to monitor the weather hours to days in advance of an event. A number of online, real-time services may be accessed or subscriptions purchased. Some will warn via cell phones or other electronic devices, which is particularly handy for camps and large, outdoor sports venues. Users of these services should ensure they are using real-time data, not reports that are often delayed by 10-30 minutes. 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 can be done surprisingly inexpensively, particularly if planned in the initial construction. More stadia and large venues are establishing lightning safety plans, warnings, signage, and other appropriate means of preventing lightning injuries. Look for this material in programs or brochures. If it is not present in lightning-prone areas, ask management about it so that those who run the venue are spurred to carry out appropriate planning.

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.

Individual preparation

No place outside is safe when thunderstorms are in the area. Do not resume outside activity for 30 minutes after thunder is last heard or lightning is last seen.

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 preplanning of activities. Also be aware of local thunderstorm patterns. For instance, 1-5 pm is a common time for thunderstorms to occur on mountain slopes; 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.

Evacuation

When lightning is seen or thunder is heard, danger is present. A simple safety-teaching tool is, "When thunder roars, go indoors."^[35] Lightning may travel as far as 10-12 miles anywhere around a thunderstorm; clouds need not be overhead and rain need not be present for a lightning strike to occur.

Safer areas

Common safety precautions during thunderstorms include remaining inside a metal-topped and enclosed vehicle or a steel-framed building or other substantial habitable building because these have plumbing and wiring that act as a Faraday cage, diverting lightning from the inhabitants. Rented school buses distributed around a large outdoor venue make excellent shelters during activities such as golf tournaments, concerts, and marathons.^[42]

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 of high areas, such as ridges and mountains, when thunderstorms are likely.

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 strikes. Lightning can travel through water; thus, swimming, boating, and bathing should be avoided during a thunderstorm.

Avoid the 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. Side flashes from telephones, plumbing fixtures, and appliances connected to the outside by metal conductors have injured people inside buildings.

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.

Activities should not be resumed until 30 minutes after the last lightning bolt is seen or thunder is heard.^{[5, 35]} The phrase "Half an hour since thunder roars, now it’s safe to go outdoors!" can be used to teach when it is safe to resume activities. This strategy provides about a 90-95% confidence interval.

Home protection systems

Lightning rods do not divert or prevent lightning strikes but serve as the contact point for lightning protection systems that provide a path along which lightning can travel.

Each year, thousands of homes and other properties are damaged and destroyed by lightning. Home lightning damage accounts for more than a quarter of a billion dollars’ worth of damage in the United States alone. State and local building codes include requirements for those structures that require protection. Damage to electronics and the cost and time of replacing data on hard drives has become the major loss to most home and business owners. This can be averted by unplugging electronics from wall units. Common surge protectors and power strips are almost always inadequate for protection from lightning surges, even if they claim to be effective on the packaging.