Lightning strike is a high-energy environmental injury with a mortality rate up to 30% and significant morbidity in up to 70% of survivors. [1-2] The primary cause of death is simultaneous cardiac and respiratory arrest. [3] Approximately 100 deaths and 400 injuries occur annually in the United States, predominantly in young, active individuals during outdoor activities between May and September. [4] Mechanisms include direct strike, side splash, contact injury, ground current, and upward streamer.
The following figure demonstrates the pathognomonic Lichtenberg figures — transient, fern-like cutaneous markings that are diagnostic of lightning strike and resolve within 24 hours. [3]
1. History
- Mechanism: Direct strike, side splash (current jumps from nearby object), contact (touching struck object), ground current (most common), or upward streamer
- Setting: Outdoor activity during thunderstorm — hiking, sports, farming, fishing, golf; also telephone use during storms [6]
- Loss of consciousness: Duration and whether witnessed; retrograde amnesia is extremely common [2][7]
- Symptoms to characterize: Confusion, amnesia, headache, chest pain, palpitations, dyspnea, vision or hearing changes, tinnitus, extremity weakness/numbness, pain
- Timing: Immediate vs. delayed symptom onset (delayed cardiac and neurologic effects reported up to 3 days) [3][8]
- Important negatives: No loss of consciousness, no chest pain, no syncope, no weakness, no visual changes
2. Alarm Features
- Cardiac arrest (asystole or VF) — the leading cause of immediate death [3]
- Respiratory arrest persisting after ROSC (medullary paralysis outlasts cardiac automaticity recovery → secondary arrest if ventilation not supported) [3]
- Loss of consciousness or persistent altered mental status [3]
- Cranial burns — predict 3-fold increase in mortality and 2x risk of cardiac arrest [3]
- Direct strike to the head — higher fatality rate [3]
- Focal neurologic deficits — may indicate intracranial hemorrhage (basal ganglia, brainstem) [3]
- Hemodynamic instability, cardiogenic shock [3][9]
- Tympanic membrane rupture with hearing loss [10]
- Rhabdomyolysis with risk of acute renal failure [11]
3. Medications
- Resuscitation: Standard ACLS pharmacotherapy (epinephrine, amiodarone for refractory VF/VT) [3][12]
- Amiodarone: Used successfully for lightning-induced atrial fibrillation with ventricular tachycardia [8]
- Tetanus prophylaxis: Administer per standard burn/wound protocol [7]
- Analgesics: Appropriate pain management for burns and musculoskeletal injuries
- Antibiotics: For contaminated wounds or burns as indicated [7]
- No specific antidote or targeted pharmacotherapy exists for lightning injury; treatment is supportive [2]
- Caution: Avoid medications that prolong QT interval given the risk of QT prolongation from the strike itself [3][13]
4. Diet
- No specific dietary triggers or recommendations unique to lightning injury
- Hydration: Aggressive IV fluid resuscitation is critical, particularly if rhabdomyolysis is present (target urine output 1–2 mL/kg/hr)
- Monitor and correct electrolyte abnormalities — hypokalemia and hypocalcemia are common [10]
5. Review of Systems
- Cardiovascular: Chest pain, palpitations, dyspnea, syncope
- Neurologic: Headache, confusion, amnesia, seizures, weakness, numbness, paresthesias, gait instability
- Ophthalmologic: Vision changes, photophobia, eye pain (cataracts may develop days to years later) [3]
- Otologic: Hearing loss, tinnitus, vertigo, ear pain (tympanic membrane perforation) [10]
- Psychiatric: Anxiety, sleep disturbance, emotional lability, depression, PTSD symptoms [3]
- Musculoskeletal: Myalgias, back pain (from fall/blast), dark urine (myoglobinuria)
- Dermatologic: Burns, skin markings, clothing damage
6. Collateral History and Family History
- Witnesses: Critical for establishing mechanism (direct vs. splash vs. ground current), duration of unresponsiveness, bystander CPR provided
- Scene details: Indoor vs. outdoor, proximity to struck object, water exposure, metal objects worn
- Multiple casualties: Lightning can injure multiple people simultaneously — apply reverse triage (prioritize those who appear dead, as they have the best chance of survival with resuscitation) [1][12]
- Family history: Generally not relevant to acute management; however, pre-existing cardiac conditions (long QT syndrome, Brugada) may complicate interpretation of post-strike ECG
7. Risk Factors
- Outdoor activities during thunderstorms (sports, farming, hiking, fishing, construction) [4]
- Geographic: Open fields, elevated terrain, near tall isolated objects (trees)
- Temporal: May–September; 10 AM–7 PM peak [4]
- Male sex (approximately 2:1 male predominance) [7]
- Young age — most victims are young, active individuals [7]
- Occupational: Outdoor workers (agriculture, construction, military)
- Proximity to metal objects or telephone/landline use during storms [6][14]
8. Differential Diagnosis
- High-voltage electrical injury: Longer contact time, deeper tissue destruction, higher amputation rate — distinct from lightning's brief, flashover mechanism [2]
- Cardiac arrest from other causes: Must consider primary cardiac event (MI, arrhythmia) if lightning strike is unwitnessed
- Stroke/intracranial hemorrhage: If found with focal deficits and no clear history of strike
- Seizure disorder: Post-ictal confusion may mimic lightning injury presentation
- Blast injury (explosion): Similar mechanism of barotrauma, TM perforation, pulmonary contusion
- Heat stroke: Outdoor setting, altered mental status — but no burns or Lichtenberg figures
- Assault/trauma: Unwitnessed event with burns and altered mental status
9. Past Medical History
- Pre-existing cardiac disease: Arrhythmia history, structural heart disease, pacemaker/ICD (device may be damaged by strike)
- Seizure disorder: May confound neurologic assessment
- Psychiatric history: Baseline for comparison given high rates of post-strike neuropsychiatric sequelae [3][15]
- Prior lightning or electrical injury: Increases index of suspicion for cumulative neurologic damage
10. Physical Exam
- Vital signs: Labile blood pressures and autonomic instability are common; tachycardia or bradycardia; hypothermia possible [3]
- Skin:
- Lichtenberg figures — pathognomonic fern-like, branching erythematous pattern; appears within 1 hour, resolves <24 hours; not a true burn [3]
- Linear burns — partial-thickness along sweat lines (axillae, inframammary folds) [3]
- Punctate burns — clustered small full-thickness burns, especially at toes ("tip-toe sign") [3]
- Contact burns — from heated metal objects (belt buckles, jewelry, zippers) [3]
- Singed body hair — pathognomonic finding, more common than Lichtenberg figures [16]
- Neurologic: GCS, pupil reactivity (fixed dilated pupils may be transient and NOT a reliable sign of death in lightning), motor/sensory exam, cerebellar testing
- HEENT: Otoscopy for TM perforation; fundoscopy for retinal injury; visual acuity
- Cardiovascular: Heart sounds, peripheral pulses (vasospasm may cause transient pulselessness)
- Musculoskeletal: Assess for fractures from fall/blast/muscular contraction; compartment syndrome
- Spine: Full spinal immobilization until cleared — blunt trauma from blast effect is common [12][17]
11. Lab Studies
- CBC, BMP (electrolytes — watch for hypokalemia, hypocalcemia) [10]
- Troponin (serial) — may be elevated with myocardial injury; however, troponin has limited predictive value for arrhythmia risk stratification [18-19]
- CK / CK-MB — assess for rhabdomyolysis and myocardial injury [13]
- Urinalysis — myoglobinuria (dark/tea-colored urine)
- Lactate — elevated lactate is an independent risk factor for arrhythmia [19]
- Coagulation studies — if concern for DIC or significant trauma
- ABG/VBG — if respiratory compromise
- Renal function — monitor for acute kidney injury from rhabdomyolysis [11]
12. Imaging
- CT head without contrast: Indicated for all patients with loss of consciousness or persistently abnormal neurologic exam — rule out intracranial hemorrhage (basal ganglia, brainstem predilection) [3]
- CT C-spine: If blunt trauma mechanism or unable to clinically clear
- Chest X-ray: Evaluate for pulmonary contusion, pneumothorax, rib fractures from blast effect [10]
- Echocardiography: If hemodynamically unstable, elevated troponin, or ECG abnormalities — assess for wall motion abnormalities, pericardial effusion, Takotsubo cardiomyopathy [9][13]
- Coronary angiography: ST elevation may be present but coronary arteries are often normal — clinical judgment required [3]
- Imaging is unnecessary for asymptomatic patients with normal exam and normal ECG
13. Special Tests
- Continuous cardiac monitoring: Minimum 24 hours for symptomatic patients, those with abnormal ECG, loss of consciousness, or direct strike [3][20-21]
- Formal audiometry: If hearing loss or tympanic membrane perforation
- Ophthalmology consultation with slit-lamp exam: For all high-risk strikes and any visual complaints — cataracts may develop 2 days to 4 years post-injury [3]
- Compartment pressure measurement: If clinical concern for compartment syndrome (tense extremity, pain with passive stretch)
- Neuropsychological testing: Consider in follow-up for cognitive complaints [3]
14. ECG
- Obtain 12-lead ECG on all lightning strike patients [1][3]
- Expected findings:
- Sinus tachycardia or sinus bradycardia (most common rhythm after ROSC) [3][22]
- QT prolongation — associated with direct strikes [13]
- ST elevation — may mimic STEMI but coronary angiography often normal [3]
- T-wave inversions (transient) [13]
- Atrial fibrillation [3][8]
- Dangerous patterns:
- Asystole or ventricular fibrillation — primary arrest rhythms [3]
- Ventricular tachycardia — may be delayed onset [8]
- New conduction abnormalities (bundle branch blocks)
- Most ECG changes resolve within 3 days, but delayed-onset arrhythmias have been reported [3][8]
15. Assessment
Lightning strike is a multisystem injury with primary lethality from simultaneous cardiac and respiratory arrest. [3] Key clinical pearls:
- Reverse triage: In mass casualty lightning events, prioritize patients who appear dead — cardiac automaticity often recovers but respiratory arrest persists, so early ventilation can prevent secondary arrest [1][3][12]
- Burns are typically superficial and less severe than high-voltage electrical injuries; deep tissue destruction and amputations are rare [2-3]
- Victims do NOT carry residual charge — safe to touch and resuscitate immediately [3]
- Fixed dilated pupils are NOT a reliable sign of death — may be transient from autonomic dysfunction; do not use to withhold resuscitation [12]
- Severity stratification: Direct strikes carry highest mortality; ground current injuries are most common but least severe [3]
- Complications to anticipate: Delayed arrhythmias (up to 3 days), delayed cataracts (days to years), progressive myelopathy (weeks to months), neuropsychiatric dysfunction (days to weeks) [3]
16. Treatment Plan
Initial Stabilization
- Airway/Breathing: Prioritize ventilatory support — respiratory arrest outlasts cardiac arrest; failure to ventilate causes secondary cardiac arrest [3]
- Circulation: Standard ACLS for cardiac arrest; aggressive and prolonged resuscitation is warranted given the young age and absence of underlying cardiac disease in most victims — survival with intact neurologic function is well-documented even after prolonged arrest [3][12][23]
- C-spine immobilization: Assume spinal injury until cleared [12]
- IV fluid resuscitation: Aggressive crystalloid if rhabdomyolysis suspected; target UOP 1–2 mL/kg/hr [7]
Cardiac
- Continuous telemetry monitoring for minimum 24 hours in symptomatic patients [3][20]
- Treat arrhythmias per standard ACLS protocols; amiodarone for VT/AF [8]
- Most cardiac dysfunction (including severe cardiomyopathy/Takotsubo) is reversible within 72 hours [9][13]
Burns
- Superficial burns: Standard wound care; most heal without grafting [3]
- Full-thickness burns (uncommon): Burn surgery consultation; only ~10% require skin grafting [3]
- Tetanus prophylaxis [7]
Neurologic
- CT head for LOC or abnormal neuro exam [3]
- Supportive care; neurorehabilitation for permanent deficits [3]
- Neurology referral for delayed-onset symptoms (progressive myelopathy, neuropathy) [3]
Ophthalmologic
17. Disposition
Admission Criteria
- Cardiac arrest or any arrhythmia
- Loss of consciousness or persistent altered mental status
- Abnormal ECG
- Significant burns (>20% TBSA or full-thickness)
- Elevated troponin or CK suggesting myocardial injury/rhabdomyolysis
- Hemodynamic instability or autonomic dysfunction
- Neurologic deficits
- Direct strike mechanism [1][3]
ICU Admission
- Post-cardiac arrest
- Cardiogenic shock / hemodynamic instability
- Intracranial hemorrhage
- Respiratory failure
- Severe rhabdomyolysis with AKI
Discharge Criteria
Specialist Consultation Triggers
- Cardiology: Persistent arrhythmia, cardiomyopathy, elevated troponin
- Neurology: Focal deficits, seizures, delayed neurologic symptoms
- Ophthalmology: Any visual complaints or high-risk strike
- Burns/Trauma surgery: Significant burns, compartment syndrome
- Psychiatry: Acute behavioral disturbance or PTSD symptoms
18. Follow-Up / Return Precautions
- Follow-up timing: PCP within 1–2 weeks; ophthalmology within 1–2 weeks for high-risk patients; cardiology and neurology as indicated
- Delayed cataracts: May develop 2 days to 4 years post-injury — counsel patients to report any vision changes [3]
- Delayed neurologic syndromes: Progressive myelopathy (weakness, sensory loss) can develop weeks to months later; delayed onset of epilepsy, neuropathy possible up to 5 years [3][24]
- Neuropsychiatric sequelae: Depression, insomnia (68%), anxiety (62%), PTSD (33%), memory/concentration deficits — typically develop days to weeks post-injury [3][15]
- Autonomic instability: Labile blood pressures may persist weeks to months [3]
- Chronic pain: Most common long-term complication in some series [7]
- Return precautions: Seek immediate care for chest pain, palpitations, syncope, new weakness/numbness, vision changes, seizures, severe headache, dark urine, or worsening confusion
- Support resources: Lightning Strike and Electric Shock Survivors International (www.lightning-strike.org) [3]
- Expected recovery: Death is rare if the patient survives the initial strike; most cardiac dysfunction resolves within 72 hours; burns typically heal well; however, neuropsychiatric morbidity can be substantial and prolonged [3][13][15]
References
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2. Emergent Care of Lightning and Electrical Injuries. — Cooper MA. Seminars in Neurology. 1995.
3. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Lightning Injuries: 2014 Update. — Davis C, Engeln A, Johnson EL, et al. Wilderness & Environmental Medicine. 2014.
4. National Athletic Trainers' Association Position Statement: Lightning Safety for Athletics and Recreation. — Walsh KM, Bennett B, Cooper MA, et al. Journal of Athletic Training. 2000.
5. Lichtenberg Figures Due to a Lightning Strike. — Domart Y, Garet E. The New England Journal of Medicine. 2000.
6. Lichtenberg Figures: Cutaneous Manifestation of Phone Electrocution From Lightning. — Mahajan AL, Rajan R, Regan PJ. Journal of Plastic, Reconstructive & Aesthetic Surgery : JPRAS. 2007.
7. Epidemiology, Morbidity, Mortality and Treatment of Lightning Injuries in a Turkish Burns Units. — Aslar AK, Soran A, Yildiz Y, Isik Y. International Journal of Clinical Practice. 2001.
8. Delayed Onset of Atrial Fibrillation and Ventricular Tachycardia After an Automobile Lightning Strike. — Drigalla D, Essler SE, Stone CK. The Journal of Emergency Medicine. 2017.
9. Takotsubo Cardiomyopathy Following Lightning Strike. — Dundon BK, Puri R, Leong DP, Worthley MI. Emergency Medicine Journal : EMJ. 2008.
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15. Acute and Long-Term Clinical, Neuropsychological and Return-to-Work Sequelae Following Electrical Injury: A Retrospective Cohort Study. — Radulovic N, Mason SA, Rehou S, Godleski M, Jeschke MG. BMJ Open. 2019.
16. A 15-Year Review of Lightning Deaths in Germany-With a Focus on Pathognomonic Findings. — Bingert R, Bremer L, Büttner A, et al. International Journal of Legal Medicine. 2024.
17. Lightning Injuries. — Whitcomb D, Martinez JA, Daberkow D. Southern Medical Journal. 2002.
18. Arrhythmias and Laboratory Abnormalities After an Electrical Accident: A Single-Center, Retrospective Study of 333 Cases. — Seyfrydova M, Rokyta R, Rajdl D, Huml M. Clinical Research in Cardiology : Official Journal of the German Cardiac Society. 2023.
19. Prevalence and Risk Factors of Developing Cardiac Arrhythmia in Patients Presenting to the Emergency Department With Electrical Injuries. — Yazıcı R, Bulut B, Genç M, et al. PloS One. 2025.
20. Electrical Cardiac Injuries: Current Concepts and Management. — Waldmann V, Narayanan K, Combes N, et al. European Heart Journal. 2018.
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22. Risk of Cardiac Arrhythmias After Electrical Accident: A Single-Center Study of 480 Patients. — Pilecky D, Vamos M, Bogyi P, et al. Clinical Research in Cardiology : Official Journal of the German Cardiac Society. 2019.
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