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Lightning Injuries: Treatment & Medication

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

Updated: Jun 12, 2009

Treatment

Prehospital Care

Any time EMS is called for an acute lightning injury, there is almost certainly an ongoing risk of lightning injury to the rescue team as the weather system continues that they should be aware of (see Deterrence/Prevention).   

If there is no risk of continuing danger to the rescuers, 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 being thrown by involuntary muscle contraction. Obviously, an alert, minimally injured patient can help decide if this is necessary. Resuscitation or supportive care can then proceed as indicated based on clinical status including advanced cardiac life support [ACLS].

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.

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 [see Patient Education for contact information]).

Consultations

Consultations are based on physical findings. Consultations 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.

Medication

Nonsteroidal anti-inflammatory drugs (NSAIDs) for the first few days may decrease long-term neurologic damage. Although no studies have examined this, NSAIDs are the only medications available for lightning injuries at this time. Use of long-term ibuprofen, vitamin C (1 g/d), and vitamin E (400 U/d) have been shown to decrease long-term injury and scarring with electrical injury. Whether these free radical scavengers have any effect with lightning is unknown but since they are in routine doses, there is probably little harm in their use. 

One report has addressed the use of high-dose steroids administered for optic neuritis caused by lightning based on the presumed efficacy originally reported for spinal cord injury treatment with high-dose steroids. No controlled studies have been performed to show whether there is any efficacy.  

Nonsteroidal anti-inflammatory drugs

These are used as prophylaxis to prevent long-term neurologic damage and to treat chronic pain syndromes that may develop from sympathetic nervous system injuries caused by lightning.


Ibuprofen (Motrin, Advil, Ibuprin)

Inhibits inflammatory reactions and pain, probably by decreasing the activity of the enzyme cyclooxygenase, which results in prostaglandin synthesis.

Adult

400-600 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 10-20 mg/kg/d divided PO tid/qid
Start at lower end of dosing range and titrate upward to maximum of 2.4 g/d
>12 years: Administer as in adults

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy


Naproxen (Anaprox, Aleve)

Used for the relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of the enzyme cyclooxygenase, which results in prostaglandin synthesis.

Adult

500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

More on Lightning Injuries

Overview: Lightning Injuries
Differential Diagnoses & Workup: Lightning Injuries
Treatment & Medication: Lightning Injuries
Follow-up: Lightning Injuries
References

References

  1. Lopez RE, Holle RL, Heitkamp TA. Lightning casualties and property damage in Colorado from 1950 to 1991 based on storm data. Weather and Forecasting. 10:114-126.

  2. Cooper MA, Andrews CJ, Holle RL. Lightning injury. In: Auerbach. Wilderness Emergencies. CV Mosby; 2006:chap3. [Full Text].

  3. Bier M, Chen W, Bodnar E, Lee RC. Biophysical injury mechanisms associated with lightning injury. NeuroRehabilitation. 2005;20(1):53-62. [Medline].

  4. Cooper MA. A fifth mechanism of lightning injury. Acad Emerg Med. Feb 2002;9(2):172-4. [Medline].

  5. Cooper MA. Lightning injuries: prognostic signs for death. Ann Emerg Med. Mar 1980;9(3):134-8. [Medline].

  6. [Guideline] Zimmermann C, Cooper MA, Holle RL. Lightning safety guidelines. Ann Emerg Med. Jun 2002;39(6):660-4. [Medline][Full Text].

  7. Cherington M. Closing the gap on the actual numbers of lightning casualties and deaths. Preprints, 11th Conference on Applied Climatology, Dallas, January 10-15. Boston: 1999.

  8. Andrews CJ, Cooper MA, Darveniza M. Lightning Injuries: Electrical Medical, and Legal Aspects. 1992.

  9. Andrews CJ, Darveniza M. Telephone-mediated lightning injury: an Australian survey. J Trauma. May 1989;29(5):665-71. [Medline].

  10. Cooper MA. Emergent care of lightning and electrical injuries. Semin Neurol. Sep 1995;15(3):268-78. [Medline][Full Text].

  11. Cooper MA, Holle R, Andrews C. Field J, ed. Electrical Current and Lightning Injury, The Textbook of Emergency Cardiovascular Care and CPR. Lippincott, Williams & Wilkins; ACLS for the Experienced Provider, AHA/ACEP; 2009:498-511.

  12. Cooper MA, Johnson SA. Cardiopulmonary resuscitation and early management of the lightning strike victim. In: Ornato JP, Peberdy MA. Cardiopulmonary Resuscitation. Humana Press; 2005.

  13. Cooper, MA. Lightning Injury Homepage. Lightning Injury. Available at www.uic.edu/labs/lightninginjury or www.uic.edu/~macooper. several articles in PDF as well as complete world bibliography on lightning injury. [Full Text].

  14. Cherington M. Spectrum of neurologic complications of lightning injuries. NeuroRehabilitation. 2005;20(1):3-8. [Medline].

  15. Cooper MA, Kotsos T, Gandhi MV. Acute Autonomic and Cardiac Effects of Simulated Lightning Strike in Rodents. Society for Academic Emergency Medicine. Atlanta, Ga: 2001.

  16. Cooper MA, Marshburn S. Lightning Strike and Electric Shock Survivors, International. NeuroRehabilitation. 2005;20(1):43-7. [Medline].

  17. Jost WH, Schonrock LM, Cherington M. Autonomic nervous system dysfunction in lightning and electrical injuries. NeuroRehabilitation. 2005;20(1):19-23. [Medline].

  18. Lightning Safety. NWS Lightning Safety. Available at http://www.lightningsafety.noaa.gov/. Accessed April 16, 2009.

  19. Marshburn S. Lightning strike and electric shock survivors, international. LSESSI. Available at www.lightning-strike.org. Accessed April 1, 2009.

  20. Primeau M, Engelstatter GH, Bares KK. Behavioral consequences of lightning and electrical injury. Semin Neurol. Sep 1995;15(3):279-85. [Medline].

  21. Yarnell PR. Neurorehabilitation of cerebral disorders following lightning and electrical trauma. NeuroRehabilitation. 2005;20(1):15-8. [Medline].

  22. Lammertse DP. Neurorehabilitation of spinal cord injuries following lightning and electrical trauma. NeuroRehabilitation. 2005;20(1):9-14. [Medline].

  23. Capelli-Schellpfeffer M. Roadblocks to return to work after electrical trauma. NeuroRehabilitation. 2005;20(1):49-52. [Medline].

  24. Holle RL, Lopez RE. A comparison of current lightning death rates in the U.S. with other locations and times. Preprints, International Conf on Lightning and Static Electricity. Sept 16-18, B. 2003;paper 103-34.

  25. National College Athletic Association. Sports Medicine Handbook 2007-08. National College Athletic Association. www.StruckbyLightning.org. 12. [Full Text].

  26. Utley M. StruckbyLightning.org. Available at www.StruckbyLightning.org. Accessed April 16, 2009.

  27. Holle RL, Lopez RE, Zimmermann C. Updated recommendations for lightning safety. Bulletin of the American Meteorological Society. 1999;80:2035-41.

  28. Holle RL, Murphy MJ, Lopez RE. Distances and times between cloud-to-ground flashes in a storm. Preprints, Intl Conf on Lightning and Static Electricity, Blackpool, UK, Royal A. 2003.

  29. Cooper MA. Myths, miracles, and mirages. Semin Neurol. Dec 1995;15(4):358-61. [Medline][Full Text].

  30. Primeau M. Neurorehabilitation of behavioral disorders following lightning and electrical trauma. NeuroRehabilitation. 2005;20(1):25-33. [Medline].

  31. Selvaggi G, Monstrey S, Van Landuyt K, Hamdi M, Blondeel P. Rehabilitation of burn injured patients following lightning and electrical trauma. NeuroRehabilitation. 2005;20(1):35-42. [Medline].

  32. Norman ME, Albertson D, Younge BR. Ophthalmic manifestations of lightning strike. Surv Ophthalmol. Jul-Aug 2001;46(1):19-24. [Medline].

Further Reading

Keywords

electrical injuries, lightning injury, lightning strike, lightning stroke, direct lightning strike, side splash lightning strike, contact voltage lightning strike, ground current effect, lightning burns, keraunoparalysis, vascular spasm, neurologic damage, autonomic instability, neurological injury, anoxic brain injury, autonomic nervous system injury, peripheral nervous system injury

Contributor Information and Disclosures

Author

Mary Ann Cooper, MD, Professor, Department of Emergency Medicine, University of Illinois at Chicago
Mary Ann Cooper, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, American Meteorological Association, Illinois State Medical Society, National Lightning Safety Institute, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Edmond A Hooker II, MD, DrPH, FAAEM, Assistant Professor, Department of Health Services Administration, Xavier University; Associate Clinical Professor, Department of Emergency Medicine, University of Louisville; Assistant Clinical Professor, Department of Emergency Medicine, Wright State University
Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

James Steven Walker, DO, MS, Clinical Professor of Surgery, Department of Surgery, University of Oklahoma Health Sciences Center
James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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