Treatment of Lightning Related Injuries

I decided to take my pre-night shift nap outdoors yesterday.  This move proved largely ineffective as a few minutes after lugging my towel and stack of magazines to the pool the sound of thunder and flashes of lightning began to fill the skies.  I couldn't help but wonder, how do you treat lightning related injuries?

While it's a bit impractical to spend a lot of time focusing on the management and treatment of lightning strikes, lightning does kill more people each year in the United States than hurricanes, volcanoes, tornados and earthquakes combined.  Also, some of us as nurse practitioners will treat electrical injuries which are similar in nature.

Electrical and lightning related injuries range in severity from fatal to to minor and account for 3-4% of burns admitted to burn units.  Lighting differs from common electrical injuries in that one can never be sure the exact force of the injury.  Usually, lighting injuries are indirect- not the result of a lightning strike to the body.  Ground current effect, where energy from a lightning strike spreads out across the earth's surface, accounts for 40-50% of lightning related injuries.  Direct strikes account for only 3-5% of injuries.  Most injuries occur in the spring and summer months when people are more likely to be outdoors. 

Although being struck by lighting sounds like a serious situation with a poor prognosis, only 10% of lightning strike victims die, usually from immediate cardiac arrest.  Overall, outcomes with lightning related injuries are positive.  The most common lightning related injuries are ruptured tympanic membrane and superficial burns.   

Clinical Presentation

Usually, the victim of a lightning strike is able to recount the injury, however some individuals may suffer from amnesia or confusion.  Neurologic problems are the most commonly reported symptoms.  Patients may complain of muscle aches and weakness.  Medical providers must assess vascular status of the extremities making sure pulses are intact as lightning strikes can cause vascular instability.  

Confusion and focal weakness must be assessed as part of a thorough neurological exam to rule-out traumatic brain injury.  Prolonged paresthesia and paralysis may also indicate a spinal cord injury.  Temporary hearing loss may occur as a result of tympanic membrane rupture.  

Occasionally patients will exhibit Lichtenberg figures following a lightning strike, a ferning pattern on the skin.  More minor electric burns may also occur.  A lightning strike may  cause the individual to be thrown backward sustaining injuries related to falling as well.  

Overall, a lightning strike can potentially affect all systems of the body so a thorough evaluation must be done to assess injuries in individuals with lightning related injuries. 

Management and Outcome

If a lightning strike is witnessed and the individual experiences cardiac or respiratory arrest, immediate resuscitation should be initiated.  If there are multiple victims, assistance should be directed towards individuals suffering from cardiac or respiratory arrest as all other victims suffering more minor injuries will likely recover without complication.  Patients who do not experience arrest should be evaluated for head and spinal injury.  If suspected, the head should be stabilized and the patient placed on a backboard once paramedics arrive.  

Upon arrival to the emergency department, basic labs and an ECG may be necessary.  Labs should include a CK, urinalysis and urine or serum myoglobin levels to evaluate for muscle breakdown.  Routine labs in the majority of individuals with lightning related injuries will be normal.  The most common ECG change observed after a lightning strike is QT prolongation.  The level of QT prolongation seen does not usually require treatment and resolves over several months.  Imaging studies should be ordered as necessary to address physical exam findings.  

A thorough ENT exam, paying special attention to the tympanic membrane and eye is necessary.  Most tympanic membrane ruptures heal spontaneously but an ENT referral may be necessary in cases of delayed healing.  Lightning strikes can cause ocular problems such as cataract formation, retinal detachment and optic nerve dysfunction.  Patients with visual disturbances following a lightning strike shoud be evauated by an opthalmologist. 

A thorough exam of all body systems is key to evaluating lightning related injuries.  Most lightning strike victims suffer only minor injuries and recover quite well.  Typically, these individuals do not require hospital admission. 

Discussion

While you're more likely to be asked about your lightning strike treatment knowledge at the next cocktail party you attend than on the job, it's one of those things that's good to know...just in case.  Fortunately, most lightning strikes don't prove deadly and victims recover completely.  If you've got a bit of a morbid bent, check out struckbylightning.org for up-to-date statistics on U.S. lightning related injuries in the U.S. 

 

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