Lightning Injuries Clinical Presentation

Updated: Sep 17, 2021
  • Author: Mary Ann Cooper, MD; Chief Editor: Joe Alcock, MD, MS  more...
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Lightning injuries are obvious if they occur in a group setting with witnesses present. However, lightning injuries can be difficult to diagnose if the person presents without witnesses, is unable to relate the details of his or her injury, or is found dead in a field, mountain side, or street. [4, 29, 100]

Often, the person can relate what happened. However, it is common for the person to have anterograde amnesia or confusion. [4, 29] While the person may be able to carry on a reasonably coherent social conversation, giving demographic and billing data, the examiner may also observe that he or she repeats the same questions multiple times or may not remember events in the emergency department (ED). More disturbing symptoms such as not recognizing a family member should draw suspicion for malingering or other litigious behavior.


Physical Examination

Each patient must receive a complete physical examination, including a neurologic assessment and a thorough examination of the skin for wounds and burns. Physical presentation may vary from mild disorientation with no immediate physical signs to cardiac arrest (the only direct cause of death) and anoxic brain injury. Conscious patients most often report muscle aches, dysesthesias, headaches, weakness, or other neurologic/musculoskeletal problems. [4, 29, 105, 108]

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

  • Cold, mottled, pulseless extremities - A sign of vasomotor instability that may cause first responders not finding a pulse
  • Confusion, amnesia, paralysis, and loss of consciousness
  • Temporary hearing loss or tympanic membrane rupture - Caused by concussive shock wave
  • Hypotension - Usually from vasomotor instability and spasm but spinal cord injuries and other more common causes should be ruled out
  • Prolonged paresis or paralysis of the extremities - Indicates possible spinal cord injuries
  • Fixed and dilated pupils - Typically a result of transient autonomic disturbances, not serious head injuries; pupillary areflexia and dilatation therefore cannot be used as a reason to stop resuscitation
  • Lichtenberg figures - Rare but pathognomonic of lightning injury; also known as ferning pattern or keraunographic markings [115] or other singeing of hair or clothing
  • Clothing that is singed, shredded, or blown apart; shoes that appear to be exploded from the inside; magnetized watches, zippers, or other metal objects; streaming and cuprification of brass grommets or zippers.


Because lightning injuries occur most commonly outdoors, often in wilderness or where the person may lie wet and exposed for a period, hypothermia should be ruled out.

Cardiorespiratory symptoms

Cardiorespiratory arrest is the only known direct cause of death. Lightning may send the heart into momentary asystole, from which the heart often spontaneously recovers. Autonomic nervous system control of cardiac rhythm has been shown to be affected by lightning. In some cases, respiratory arrest may last longer than the initial cardiac arrest and a secondary cardiac arrest from hypoxia, from more serious brain injury prolonging the respiratory arrest, or from other unknown causes may occur. [4, 24, 27, 29]

QT prolongation is the most common electrocardiogram (ECG) abnormality, which generally resolves over several months and does not commonly require treatment. Other ECG abnormalities should receive standard treatments. [4, 24, 27, 29, 98, 116]

Neurologic symptoms

The immediate effect of the electrical 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 or significant anoxic brain injury if the person is resuscitated. [4, 27, 29] Rarely, the injury is so devastating that rapid onset of cerebral edema with brainstem herniation occurs. If the patient is unconscious, suspect and investigate anoxic brain injury or underlying brain injury. Contusion and intracranial hemorrhage have been reported. [99, 104, 105, 108]

Cerebral edema should be managed in the standard way.

Patients who are awake are usually able to carry on reasonably appropriate social conversation. Later, disabling neurocognitive deficits like people with concussive or blunt brain injury are recognized that may not be apparent until survivors attempt to return to their previous work and are unable to process new information, organize their activities, and multitask. [4, 117]

Acute pain, numbness, or other dysesthesias may be reported. Chronic pain syndromes may develop from lightning injuries and may be due to nerve injury, sympathetic nervous system injury, spinal cord injury, or other causes. [2, 4, 29]

Sympathetic nervous system injury may acutely cause vascular spasm; temporary paralysis and mottling of an extremity (keraunoparalysis); transient self-limited hypertension; and late problems with positive tilt test results, vertigo or dizziness, hypertension, and pain syndromes. [2, 4, 109, 110]

Mechanical trauma from a fall after a lightning strike can also account for neurologic sequelae. Rarely, lightning may cause the victim to fall or be thrown with sufficient force to cause skull fracture and intracranial hemorrhage. Because a comatose or semicomatose state may follow the lightning strike, it is often difficult to distinguish coma resulting from electrical shock from intracranial hematoma until lateralizing signs develop.


Because lightning contact with the skin is brief, deep burns are rare. [4, 26, 118] If burns occur, they should be treated like any other high-voltage injury, including ruling out myoglobinuria. Discrete entry and exit points are rarely seen with lightning injury.

The following types of burns are caused by lightning:

  • Feathering (Lichtenberg figures, keraunographic markings)
  • Linear
  • Punctate - Multiple, closely spaced, discrete, circular, usually full-thickness burn that results from current passing through dry skin; a few millimeters to a centimeter in diameter; resembles a cigarette burn
  • Thermal - Results when lightning ignites or melts clothing; can be a full-thickness burn
  • Contact - Occurs when metal, such as jewelry, zippers, or belt buckles, contacts the skin during a lightning strike; can be a full-thickness burn or can actually "tattoo" metal, such as a necklace, into the skin
  • Flash - Superficial burn that results in brown discoloration of the skin

An almost pathognomonic cutaneous feature known as feathering or lightning prints consists of linear, fernlike, superficial skin markings (also called keraunographic marks) that usually disappear after several days. [4, 29, 119] 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. Keraunographic markings are probably related to the flashover phenomenon, from the transmission of 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 usually partial-thickness, 1-4 cm wide, that occur on sweat/rain-covered areas of the body, such as beneath the breasts or mid chest, and in the midaxillary line. These burns present minutes to hours after the lightning strike and result from vaporization of sweat or rainwater into steam on the patient's body. These can be treated as any other superficial burn.

Although full-thickness burns rarely result from lightning in developed countries, lightning occasionally causes a more typical electrical burn from long continuous current flow, with clinical manifestations like those from a commercial, high-voltage electrical injury. There is one report of scarring following lightning burns turning into squamous cell carcinoma (Marjolin ulcer) but no other evidence that lightning causes any type of cancer. [120]

Therapy for more severe burn injuries should include cleansing the burn wound, followed by treatment with a topical antimicrobial cream containing polymyxin (10,000 U/g), nystatin (4000 U/g), and nitrofurantoin (0.3%) or other burn cream. Tetanus prophylaxis should be updated. Any devitalized skin should be excised and autogenous, split-thickness skin grafts considered.

In developing countries where marginal housing is the norm, keraunoparalysis may prevent victims from escaping subsequent fires, resulting in much more severe thermal injuries that can be managed with standard burn treatments. [3, 78]

Blunt injury

Concomitant myoglobinuria should be considered if blunt injury is present. Fractures are uncommon and occur more rarely in lightning injuries than in high-voltage injuries.

Organ contusions, pulmonary hemorrhage, pneumothorax, and cardiac contusions have been reported but are rare. If the patient has a history of a fall or being thrown a distance, investigate for fractures and blunt injuries. A patient may also have experienced explosive trauma and shrapnel effects if he or she was close to an object that has been exploded by lightning. [2, 4, 7, 29]

Musculoskeletal system

Lightning may injure the musculoskeletal system either by mechanical trauma or by passage of the electrical current. [121] Fractures of the skull, ribs, extremities, and spine have been reported but are rare. Long-term musculoskeletal pain can occur.

As current passes through tissue, electrical energy is converted to heat that can rarely damage muscle tissue. Muscle necrosis causing compartmental syndrome or rhabdomyolysis and renal failure are extremely rare, occurring much less frequently than in commercial electrical injuries. [122]

Eyes and adnexa

Lightning can injure the eye and its adnexa. [123, 124] Nearly every type of eye injury has been reported with lightning injury, including cataracts, macular holes, retinal separation, and iritis. [103] Cataracts may be an early or late sequela of lightning injury, as are chronic pain syndromes, sleep disturbance, and severe headaches.

Disruption of the autonomic nervous system can cause 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.

Cataracts are the most common intraocular lesions caused by lightning. [124] Two types of cataracts are seen: (1) an ordinary traumatic cataract that develops shortly after the injury from a concussion that results in minute tears of the lens capsule and (2) a type of cataract that is characteristic of an injury from either lightning or high-voltage current. In the latter, a high-voltage current produces anterior subcapsular changes, while lightning causes opacities in the anterior and posterior capsules. The cataract most commonly appears within the first few days or weeks but has been reported as late as 24 months postinjury and is often bilateral. Generally, opacification develops more rapidly after lightning injury than after commercial high-voltage electrical injury.

Retinal involvement after lightning injury is less frequently documented, although chorioretinal atrophy, macular holes, macular cyst, papilledema, hemorrhage, and detachment have been noted. Retinal damage should also be investigated 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 and short-lived or more severe and chronic. Paresis of accommodation may occur following a lightning strike.


In contrast to direct electrical current accidents, lightning commonly causes ear injuries, occurring in up to half the patients. [2, 4, 29, 102] Direct electrical injury and blast effects can injure the ear. In lightning-damaged ears, substantial ear damage and hearing loss are common, as are tinnitus and other eighth nerve symptoms, including dizziness and unsteadiness. [29]

Temporal bone pathology shows tympanic membrane rupture, middle ear and mastoid effusion of blood, total rupture of the 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 may be associated with other injuries (eg, burns of the skin, acromioclavicular joint separation).

Tympanic membrane rupture occurs in more than half of more severely injured patients but should always be sought in lesser injuries as well. [2, 4, 29] This injury is caused by the blast effect, basilar skull fracture, or direct burn damage from lightning. Simple ruptures of the tympanic membranes from lightning usually heal well without surgical intervention.

Occasionally, unilateral hearing loss can occur without other trauma after lightning injury. [39] An audiogram often shows typical nerve-type hearing loss. The tympanic membrane is intact but markedly inflamed. Hearing disability may be temporary or permanent.

Almost all lightning survivors report chronic tinnitus as one of their most irritating sequelae.



Serious lightning injuries involve primarily cardiac arrest and neurologic injury in developed countries. [2, 96, 97, 98, 105, 111] Otologic injury and cutaneous burns have also been noted as frequent sequelae of these events. [38, 95, 97, 103, 104] Cataract formation resulting from lightning injury typically occurs within days to weeks of injury.

Major complications are rare in mild and moderate lightning injuries, although musculoskeletal discomfort and subjective sensations of paresthesias, irritability, and other nonspecific neurologic sequelae may be present. In severe lightning injury, with CPR required in the field, permanent neurologic deficit and hypoxic injury frequently occur.

Complications of being struck by lightning include the following:

  • Chronic pain syndromes
  • Neuromuscular and musculoskeletal pain
  • Neurocognitive deficits, including short-term and working memory deficits; difficulty accessing, processing, and incorporating new information; attention deficit, personality change, distractibility, decreased executive function, and loss of ability to multitask—similar to postconcussive syndrome
  • Isolation or depression
  • Sympathetic nervous system dysfunction, including positive tilt tests and hypertension
  • Dizziness, balance problems, tinnitus, nausea, and other eighth cranial nerve symptoms
  • Sleep disorders
  • Symptoms similar to postconcussion syndrome (eg, headaches, nausea, confusion)
  • Atypical seizure disorders
  • Pituitary or hypothalamic damage with secondary endocrine effects

Cardiopulmonary complications include the following:

  • Transient hypertension
  • Electrocardiographic changes
  • Myocardial injury
  • Congestive heart failure
  • Dysrhythmia
  • Transient asystole
  • Atrial fibrillation
  • Ventricular fibrillation
  • Frequent premature ventricular contractions
  • Respiratory complications
  • Apnea
  • Hypoxemia

Damage to the CNS is the second most debilitating group of lightning injuries. [105] Neurologic complications include the following:

  • Immediate loss of consciousness
  • Keraunoparalysis lasting minutes to hours
  • Amnesia and confusion
  • Retrograde amnesia
  • Hemiplegia, aphasia
  • Coma
  • Seizures
  • Intraventricular hemorrhage
  • Hematomas

Vascular complications include the following:

  • Vasomotor instability
  • Arterial spasm
  • Vasoconstriction
  • Vasodilatation

Ophthalmic complications include the following:

  • Cataracts
  • Macular holes
  • Corneal lesions
  • Hyphema
  • Iritis
  • Vitreous hemorrhage
  • Retinal detachment
  • Optic nerve injury

Otologic complications include the following [38] :

  • Ruptured tympanic membrane
  • Temporary hearing loss
  • Disruption of the bones of hearing
  • Dizziness, instability, and tinnitus from eighth cranial nerve damage

Photophobia, difficulty with noise and crowds, lack of appetite, nausea, headache, and other concussionlike symptoms are common in the first weeks postinjury.

More acute and severe GI complications of lightning injuries resemble those following any major trauma and tend to occur only in the most severely injured patients. [125, 126] Most common is gastric atony with gastric dilatation, for which placement of a nasogastric tube is required to decompress the stomach and remove swallowed air. Another complication seen in victims of lightning injury is GI bleeding, albeit a very rare complication. GI perforation is another rare complication of lightning injury. [125, 127] Buffering the gastric secretions with antacids and administering cimetidine may prevent this. In two unusual fatal cases of lightning strike, autopsy findings showed hemorrhage and necrosis in the pancreas.