Lightning Strike Injury

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]

• 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

• 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]

• 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]

• 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]

• 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

• 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

• 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]

• 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

• 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

• 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]

• 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]

• 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

• 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]

• 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]

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]

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

• [3]

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

• normal ECG[18][20][22]

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

• 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]

1. A Shocking Injury: A Clinical Review of Lightning Injuries Highlighting Pitfalls and a Treatment Protocol. — van Ruler R, Eikendal T, Kooij FO, Tan ECTH. Injury. 2022.

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.

10. Six Cases of Collective Lightning-Induced Arc Explosion Injuries: A Case Report. — Xiao H, Qiu Y, Li Y, Wang W, Li CQ. The American Journal of Emergency Medicine. 2025.

11. Acute Polyneuropathy Due to Lightning Injury. — Hawkes CH, Thorpe JW. Journal of Neurology, Neurosurgery, and Psychiatry. 1992.

12. Electrical Shock and Lightning Strike. — Fontanarosa PB. Annals of Emergency Medicine. 1993.

13. Cardiovascular Effects of Lightning Strikes. — Lichtenberg R, Dries D, Ward K, Marshall W, Scanlon P. Journal of the American College of Cardiology. 1993.

14. Telephone-Related Lightning Injury. — Johnstone BR, Harding DL, Hocking B. The Medical Journal of Australia. 1986.

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.

21. Neurologic, Psychiatric, and Cardiovascular Complications in Children Struck by Lightning. — Kotagal S, Rawlings CA, Chen SC, Burris G, Npuriouri S. Pediatrics. 1982.

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.

23. Cardiac Arrest Secondary to Lightning Strike: Case Report and Review of the Literature. — Rotariu EL, Manole MD. Pediatric Emergency Care. 2020.

24. Neurological Symptoms and Disorders Following Electrical Injury: A Register-Based Matched Cohort Study. — Nielsen KJ, Carstensen O, Kærgaard A, Vestergaard JM, Biering K. PloS One. 2022.