Lightning Injuries

Question 1

What is the pathophysiology of lightning injuries?

Answer 1

• Lightning is responsible for multiple injuries and deaths each year. It is caused by an electric charge generated within thunderclouds that may become cloud-to-ground lightning—the most dangerous form to people and structures. Most lightning-related injuries occur in the summer months during the afternoon and early evening because of increased thunderstorm activity and greater numbers of people spending time outside. Anyone without adequate shelter, including golfers, hikers, campers, beach-goers, and swimmers, is at risk.
• Lightning produces injury by directly striking a victim, splashing off a nearby object, or traveling through the ground. Although few people die after a lightning strike, many survivors are left with permanent disabilities.
• Lightning has an enormous magnitude of energy and a different current flow than a typical high-voltage electric shock. The duration of contact is nearly instantaneous, resulting in a flashover phenomenon—an effect that may account for the relatively low overall mortality rate. Because water is a conductor of electricity and current takes the path of least resistance to the ground, any wetness on the body increases the flashover effect of a lightning strike. Lightning flashover produces an explosive force that can injure victims directly and cause them to fall or to be thrown. The clothing and shoes of victims may be damaged or blown off in the process.

Question 2

What is all included in the assessment?

Answer 2

• Lightning injuries are classified as mild, moderate, or severe. Those with a mild injury may only be stunned or confused. Those with moderate injury may have confusion or be comatose, and experience temporary paralysis. Severely injured patients often experience cardiac arrest, as the cardiopulmonary and the central nervous systems are profoundly affected by lightning injuries. The most lethal initial effect of massive electrical current discharge on the cardiopulmonary system is cardiac arrest. Because cardiac cells are autorhythmic, an effective cardiac rhythm may return spontaneously. However, prolonged respiratory arrest from impairment of the medullary respiratory center can produce hypoxia and subsequently a second cardiac arrest. Therefore when attempting to manage multiple victims of a lightning strike, provide care to those who are in cardiopulmonary arrest first. Initiate resuscitation measures with immediate airway and ventilatory management, chest compressions, and other appropriate life support interventions.
• People with mild or moderate injury may be treated in a less emergent fashion. However, these victims can have serious myocardial complications, which may be indicated by electrocardiogram (ECG) and myocardial perfusion abnormalities such as angina and dysrhythmias. The initial appearance of mottled skin and decreased-to-absent peripheral pulses usually arises from arterial vasospasm and typically resolves spontaneously in several hours.
• Central nervous system (CNS) injury is common in lightning strike victims. Temporary paralysis, known as keraunoparalysis, affects the lower limbs to a greater extent than the upper limbs. This condition usually resolves within hours, but the patient must be evaluated for spinal injury. Other signs, symptoms, and complications resulting from lightning strikes include cataracts, tympanic membrane rupture, cerebral hemorrhage, depression, and posttraumatic stress disorder. Lightning strikes also cause skin burns, most of which are superficial and heal without incident. Patients may have full-thickness burns, charring, and contact burns from overlying metal objects. Tree-like branching or ferning marks on the skin called Lichtenberg figures or keraunographic markings are characteristic skin findings on those struck by lightning. These are not considered burns and are thought to be caused by the coagulation of blood cells in the capillaries.

Question 3

What can be taught to the patient regarding prevention of lightning injuries?

Answer 3

• Observe weather forecasts when planning to be outside.
• A lightning strike is imminent if your hair stands on end, you see a blue halo around objects, and you hear high-pitched or crackling noises. If you cannot move away from the area immediately, crouch on the balls of your feet and tuck your head down to minimize the target size; do not lie on the ground or make contact with your hands to the ground.
• Seek shelter when you hear thunder. Go inside the nearest building or an enclosed vehicle. Avoid isolated sheds and cave entrances. Do not stand under an isolated tall tree or structure (e.g., ski lift, flagpole, boat mast, power line) in an open area such as a field, ridge, or hilltop; lightning tends to strike high points. Instead, seek a low area under a thick growth of saplings or small trees.
• Leave water immediately (including an indoor shower or bathtub) and move away from any open bodies of water.
• Avoid metal objects such as chairs or bleachers; put down tools, fishing rods, garden equipment, golf clubs, and umbrellas; stand clear of fences, exposed pipes, motorcycles, bicycles, tractors, and golf carts.
• If inside a car with a solid hood, close the windows and stay inside. If in a convertible, leave the car at least 49 yards (45 meters) away and huddle on the ground.
• If inside a tent, stay away from the metal tent poles and wet fabric of the tent walls.
• If you are caught out in the open and cannot seek shelter, attempt to move to lower ground such as a ravine or valley; stay away from any tall trees or objects that could result in a lightning strike splashing over to you; place insulating material between you and the ground (e.g., sleeping pad, rain parka, life jacket).
• If inside a building, stay away from open doors, windows, fireplaces, metal fixtures, and plumbing.
• Turn off electrical equipment, including computers, televisions, and stereos to avoid damage.
• Stay off land-line telephones. Lightning can enter through the telephone line and produce head and neck trauma, including cataracts and tympanic membrane disruption. Death can result. Avoid use of cellular phones, which can transmit loud static that can cause acoustic damage.

Question 4

How should the patient be cared for prehospital?

Answer 4

Because of lightning’s powerful impact to the body, patients are at great risk for multisystem trauma. The full extent of injury may not be known until thorough monitoring and diagnostic evaluation can be performed in the hospital. Initial care includes spinal stabilization with priority attention to maintenance of an adequate airway, effective breathing, and circulation through standard basic and advanced life support measures. Cardiopulmonary resuscitation (CPR) is performed immediately when a patient is in cardiac arrest. If cardiopulmonary or CNS injury is present, skin burns are not the initial priority. However, if time and resources permit, a sterile dressing may be applied to cover the sites.

Victims of lightning strike are not electrically charged; the rescuer is in no danger from physical contact. Nonetheless, the storm can present a continued threat to everyone in the vicinity who lacks adequate shelter. Contrary to popular belief, lightning can and does strike in the same place more than once.

Question 5

How should the patient be cared for in the hospital?

Answer 5

Once in the acute care hospital setting, the focus of care is advanced life support management, including cardiac monitoring to detect cardiac dysrhythmias and a 12-lead ECG. The patient may require mechanical ventilation until spontaneous breathing returns. Collaborate with the interprofessional health care team to perform a thorough evaluation to identify obvious and occult (hidden) traumatic injuries because the patient may have suffered a fall or blast effect during the strike. A computed tomography (CT) scan of the head may be performed to identify intracranial hemorrhage. A creatine kinase (CK) measurement may be requested to detect skeletal muscle damage resulting from the lightning strike. In severe cases, rhabdomyolysis (circulation of by-products of skeletal muscle destruction) can lead to renal failure. Burn wounds are assessed and treated according to standard burn care protocols. Tetanus prophylaxis is necessary if the patient has experienced burns or any break in skin integrity. Some agencies transfer these victims to a burn center for follow-up management.