Lightning injuryMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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684 items

☷ Legend

01Approach to the Critical Patient/attcp75

Immediate priorities

›High risk lightning presentation

›Immediate collapse

›Transient respiratory arrest with secondary hypoxic cardiac arrest

›Ventricular fibrillation or asystole

›Reverse triage for multiple victims

›Apneic or pulseless patients prioritized first

›Prolonged resuscitation reasonable with lightning

›Trauma plus medical dual pathway

›Concomitant blunt trauma from blast or fall

›Concomitant burns and dysrhythmia risk

›Airway and breathing

›Intubation triggers

›Persistent apnea

›Refractory hypoxemia

›GCS 8 or less

›Severe agitation interfering with care

›Ventilation targets

›SpO2 94 to 98 percent

›End tidal CO2 35 to 45 mmHg

›Cervical spine precautions

›High energy mechanism

›Altered mental status

›Circulation and rhythm

›Immediate monitoring

›Continuous ECG monitoring

›Defibrillator pads in place for unstable presentation

›Shock evaluation

›Hemorrhagic shock from trauma

›Neurogenic shock from spinal cord injury

›Cardiogenic shock from dysrhythmia or myocardial dysfunction

›Vascular access

›Two large bore IV lines

›Intraosseous access if no IV within 90 seconds

›Temperature and environment

›Hypothermia risk

›Wet clothing removal

›Active rewarming for core temperature under 35 C

›Hyperthermia risk

›Active cooling for temperature 40 C or higher

Key decision points

›Need for resuscitation bay

›Cardiac arrest or peri arrest

›Any rhythm instability

›Any hypotension with altered mental status

›Severe neurologic deficit

›Focal deficit

›Seizure

›Persistent altered mental status

›Significant burns

›TBSA 10 percent or higher

›Full thickness burn concern

›Circumferential extremity burn

›Observation versus admission

›Telemetry need

›Abnormal ECG

›Chest pain

›Syncope

›Cardiac arrest

›Significant burn

›Significant rhabdomyolysis risk

›Trauma imaging pathway

›High risk fall

›Head strike with symptoms

›Spine pain or neurologic deficit

PITFALLS

›Common misses

›Tympanic membrane rupture

›Otalgia

›Hearing loss

›Delayed cataract and retinal injury

›Visual changes after discharge

›Rhabdomyolysis without large burns

›Dark urine

›Muscle pain

›Keraunoparalysis misread as spinal cord injury

›Transient weakness and sensory loss

›Cool pulseless appearing limb with recovery over hours

02History/hx72

Focused lightning history

›Exposure context

›Mechanism category

›Direct strike

›Side flash

›Ground current

›Contact injury

›Upward streamer

›Location and environment

›Open field

›Water exposure

›Shelter type

›Time since strike

›Witnessed collapse

›Estimated downtime

›Cardiorespiratory symptoms

›Loss of consciousness

›Duration

›Post event confusion

›Chest pain

›Exertional similarity

›Pleuritic component

›Palpitations

›Onset after strike

›Associated syncope

›Dyspnea

›Persistent apnea episode history

›Aspiration concern

›Neurologic symptoms

›Headache

›Thunderclap pattern

›Persistent vomiting

›Weakness or numbness

›Symmetry

›Ascending pattern

›Seizure

›Witnessed tonic clonic activity

›Postictal phase

›Memory gaps

›Retrograde amnesia

›Anterograde amnesia

›Injury pattern clues

›Fall or blast trauma

›Height

›Impact sites

›Burns and skin findings

›Painful burn areas

›Clothing damage

›Ear and eye symptoms

›Hearing loss

›Tinnitus

›Vision loss

›Photophobia

Risk modifiers

›Comorbidities

›Cardiac disease

›Heart failure

›Coronary disease

›Channelopathy history

›Neurologic disease

›Seizure disorder

›Prior stroke

›Kidney disease

›Baseline creatinine history

›Medications

›QT prolonging agents

›Antipsychotics

›Macrolides

›Anticoagulants

›DOAC use

›Warfarin use

›Pregnancy status

›Gestational age

›Abdominal pain or vaginal bleeding

03Physical Exam/exam66

Primary survey findings

›Vital signs and perfusion

›Hemodynamic instability

›SBP under 90 mmHg

›Tachycardia with poor perfusion

›Respiratory compromise

›RR over 30

›SpO2 under 90 percent on room air

›Cardiac and lung exam

›Dysrhythmia signs

›Irregular pulse

›Bradycardia with hypotension

›Heart failure signs

›Crackles

›Elevated JVP

›Neurologic status

›GCS

›Trend over time

›Sedation confounders

›Focal deficits

›Cranial nerves

›Motor asymmetry

›Sensory level

›Spinal cord signs

›Hyperreflexia

›Priapism

›Bladder retention

Secondary survey focus

›Skin and burn pattern

›Lichtenberg figures

›Fern like erythema

›Self limited hours to days

›Thermal burns

›Entry or exit like focal burns

›Contact points at metal objects

›Circumferential burn concern

›Distal pain

›Distal paresthesia

›Delayed cap refill

›Musculoskeletal and compartments

›Long bone injury

›Deformity

›Point tenderness

›Compartment syndrome

›Pain out of proportion

›Pain with passive stretch

›Tense compartments

›Ear exam

›Tympanic membrane integrity

›Perforation

›Hemotympanum

›Eye exam

›Visual acuity

›Baseline comparison

›New deficit

›Pupils

›Anisocoria

›Afferent defect

›Corneal findings

›Abrasion

›Foreign body

PITFALLS

›Keraunoparalysis

›Transient limb weakness

›Rapid onset after strike

›Resolution within hours

›Peripheral vasospasm findings

›Cool mottled extremity

›Weak pulses with later normalization

04Differential Diagnosis/ddx47

Life threats to exclude

›Cardiac arrest and dysrhythmia

›Ventricular fibrillation

›ICD 10 I49.01

›Ventricular tachycardia

›ICD 10 I47.20

›Complete heart block

›ICD 10 I44.2

›Intracranial injury from fall or blast

›Intracranial hemorrhage

›ICD 10 I62.9

›Concussion

›ICD 10 S06.0X0A

›Spine injury

›Cervical fracture

›ICD 10 S12.9XXA

›Spinal cord injury

›ICD 10 S14.109A

›Thoracic trauma

›Pneumothorax

›ICD 10 J93.9

›Pulmonary contusion

›ICD 10 S27.329A

›Rhabdomyolysis and AKI

›Rhabdomyolysis

›ICD 10 M62.82

›Acute kidney failure

›ICD 10 N17.9

›Burn injury

›Burn unspecified body region

›ICD 10 T30.0

›Effects of lightning

›ICD 10 T75.0XXA

Mimics and associated conditions

›Electrical injury not lightning

›Electric current exposure

›ICD 10 W86.XXXA

›Heat illness at outdoor event

›Heat exhaustion

›ICD 10 T67.5XXA

›Hypothermia after storm exposure

›Hypothermia

›ICD 10 T68.XXXA

›Acute coronary syndrome

›NSTEMI

›ICD 10 I21.4

›Stroke

›Acute ischemic stroke

›ICD 10 I63.9

05Laboratory Tests/lt52

Core labs for moderate to severe presentations

›Metabolic and renal

›Electrolytes and creatinine

›Potassium mmol/l for hyperkalemia risk

›Creatinine trend for AKI

›Bicarbonate

›Metabolic acidosis from shock or rhabdomyolysis

›Glucose

›Hypoglycemia mimic for altered mental status

›Muscle injury and hemolysis

›Creatine kinase

›Rhabdomyolysis screening

›Serial trend every 6 to 8 hours when elevated

›AST and ALT

›Muscle injury contribution to transaminitis

›Cardiac injury

›High sensitivity troponin

›Chest pain or abnormal ECG

›Rising pattern for myocardial injury

›Hematology and coagulation

›Complete blood count

›Trauma bleeding concern

›Leukocytosis nonspecific stress marker

›INR and aPTT

›Anticoagulant use

›Major trauma pathway

›Urine testing

›Urinalysis

›Heme positive with few RBC as myoglobin clue

›Specific gravity for hydration status

›Urine myoglobin

›Supportive for rhabdomyolysis when available

Point of care and targeted tests

›Blood gas and lactate

›Venous or arterial blood gas

›pH and PaCO2 mmHg for ventilatory failure

›Severe acidosis trigger for escalation

›Lactate

›Shock marker

›Trend response to resuscitation

›Pregnancy testing

›hCG

›Any patient with pregnancy potential

›Guides fetal monitoring pathway

Interpretation pitfalls

›Cardiac biomarkers

›Troponin elevation mechanisms

›Demand ischemia from arrest

›Direct myocardial injury

›Single normal troponin

›Limited early sensitivity after immediate event

›Urine heme

›Heme positive with no RBC

›Myoglobin possibility

›Hemolysis possibility

06Diagnostic Tests/dt68

Scoring Systems

›Triage and severity tools

›Trauma activation criteria

›Hypotension

›GCS under 13

›High risk mechanism fall or blast

›Burn size estimation

›Rule of nines adult

›Lund and Browder chart pediatrics

›Rhabdomyolysis risk stratification

›CK over 5000 IU per l high AKI risk

›Rising creatinine high AKI risk

›ECG based risk grouping

›Low risk ECG

›Normal sinus rhythm

›No ischemic changes

›High risk ECG

›Dysrhythmia

›Conduction block

›ST segment changes

MRI

›Neuro axis evaluation

›Brain MRI indications

›Persistent focal deficit with normal CT

›Persistent altered mental status with unclear cause

›Spine MRI indications

›Objective myelopathy signs

›Persistent sensory level

›Suspected ligamentous injury with normal CT

›Limitations

›Unstable patient incompatibility

›Time delay in resuscitation setting

›Head and spine imaging

›CT head noncontrast

›Head trauma with symptoms

›New seizure

›Persistent altered mental status

›CT cervical spine

›Neck pain

›Neurologic deficit

›High risk mechanism with unreliable exam

›Chest and abdomen imaging

›CT chest abdomen pelvis trauma protocol

›High energy fall

›Abdominal tenderness

›Thoracic trauma signs

›CT angiography indications

›Suspected major vascular injury from blast trauma

›Limb ischemia not consistent with keraunoparalysis

›CT pearls

›Normal CT head

›Does not exclude delayed neurologic sequelae

›Normal CT spine

›Does not exclude spinal cord concussion or ligamentous injury

Ultrasound

›POCUS applications

›eFAST

›Free fluid assessment in unstable trauma

›Pneumothorax assessment

›Cardiac ultrasound

›Pericardial effusion assessment in arrest

›Global systolic function assessment in shock

›Vascular ultrasound

›Arterial flow assessment when limb ischemia suspected

›DVT assessment when prolonged immobilization

›Ultrasound limitations

›Operator dependence

›Quality variability

›Documentation requirements

›Negative eFAST

›Does not exclude retroperitoneal bleeding

07Disposition/dispo46

Level of care criteria

›ICU indications

›Cardiac arrest

›Post ROSC care

›Targeted temperature management consideration per local protocol

›Unstable dysrhythmia

›Recurrent ventricular arrhythmia

›Bradycardia with hypotension

›Respiratory failure

›Persistent apnea episodes

›Mechanical ventilation

›Severe rhabdomyolysis

›Hyperkalemia mmol/l elevation

›Rising creatinine with oliguria

›Telemetry admission indications

›Abnormal ECG

›ST changes

›QT prolongation

›Conduction block

›Chest pain

›Troponin elevation

›Ongoing symptoms

›Syncope

›Unexplained collapse

›Significant burns

›TBSA 10 percent or higher

›Full thickness concern

›Observation unit criteria

›Normal initial ECG

›Brief monitoring period per local protocol

›Repeat ECG if symptoms evolve

›Mild symptoms only

›Normal neurologic exam

›No significant trauma

Discharge criteria

›Safe discharge conditions

›Normal ECG

›No dysrhythmia on monitoring

›No concerning symptoms

›Normal neurologic exam

›Resolution of transient symptoms

›Reliable follow up

›No significant trauma

›Imaging negative when indicated

›Pain controlled with oral meds

›Low rhabdomyolysis concern

›CK not rising

›Normal renal function trend

08Treatment/t134

Cardiac arrest and dysrhythmias

›Resuscitation pathway

›ACLS per current AHA guidance

›Early defibrillation for VF or pulseless VT

›High quality CPR with minimal interruptions

›Respiratory arrest focus

›Assisted ventilation to prevent secondary hypoxic arrest

›Early airway placement when feasible

›Post ROSC bundle

›SpO2 94 to 98 percent

›PaCO2 35 to 45 mmHg

›MAP 65 mmHg or higher

›Unstable bradycardia

›Atropine

›Atropine IV 1 mg

›Repeat every 3 to 5 minutes

›Maximum 3 mg

›Transcutaneous pacing

›Symptomatic bradycardia refractory to atropine

›Sedation if time and perfusion allow

›Epinephrine infusion

›Epinephrine IV infusion 2 to 10 microg per minute

›Titrate to perfusion targets

›Continuous ECG monitoring

›Narrow complex tachycardia

›Adenosine

›Adenosine IV 6 mg rapid push

›Second dose 12 mg rapid push

›Avoid in irregular wide complex rhythm

›Ventricular dysrhythmia

›Amiodarone for VF or pulseless VT refractory to shocks

›Amiodarone IV 300 mg

›Additional dose 150 mg

›Follow with infusion per ACLS protocol

›Magnesium for torsades

›Magnesium sulfate IV 2 g

›Repeat dosing per recurrence

›QT prolongation correction strategy

Rhabdomyolysis and kidney protection

›Fluid strategy

›Isotonic crystalloid

›Normal saline IV bolus 10 to 20 ml per kg for hypovolemia

›Maintenance infusion guided by urine output

›Urine output targets

›Adults 1 to 2 ml per kg per hour

›Pediatrics 1 to 2 ml per kg per hour

›Electrolyte management

›Hyperkalemia protocol if potassium elevation mmol/l

›Calcium gluconate IV 3 g

›Repeat for persistent ECG changes

›Continuous ECG monitoring

›Insulin regular IV 10 units

›Dextrose IV 25 g

›Glucose recheck every 30 to 60 minutes

›Salbutamol inhaled 10 to 20 mg nebulized

›Tachycardia monitoring

›Additive to insulin effect

›Hypocalcemia

›Avoid routine calcium replacement in rhabdomyolysis unless symptomatic

›Calcium replacement for seizures or arrhythmia

›Compartment syndrome mitigation

›Limb elevation at heart level

›Avoid excessive elevation with ischemia concern

›Frequent neurovascular checks

›Surgical consultation triggers

›Progressive pain with passive stretch

›Diminishing pulses not due to vasospasm

Burns and wound care

›Burn care basics

›Cooling and cleaning

›Cool running water for superficial thermal burns

›Avoid ice application

›Dressings

›Nonadherent dressing for partial thickness burns

›Moist wound environment

›Tetanus prophylaxis

›Tdap if not up to date

›TIG for unknown or incomplete vaccination with dirty wound

›Burn center referral triggers

›Full thickness burn

›Any size

›High risk functional areas

›Hands feet face genitalia major joints

›Specialized care requirement

›Functional outcome risk

›Circumferential extremity burn

›Escharotomy consideration

›Distal ischemia risk

›Infection prevention

›Systemic antibiotics

›Not routine for uncomplicated burns

›Indicated for cellulitis or invasive infection signs

Pain control and sedation

›Analgesia options

›Acetaminophen

›Acetaminophen PO 1000 mg

›Maximum 4000 mg per 24 hours

›Lower maximum in liver disease

›Ibuprofen

›Ibuprofen PO 400 mg

›Repeat every 6 hours

›Avoid in significant AKI risk

›Fentanyl

›Fentanyl IV 25 microg

›Repeat every 5 to 10 minutes

›Titrate to pain control

›Morphine

›Morphine IV 2 mg

›Repeat every 5 to 10 minutes

›Avoid in hypotension

›Agitation and procedures

›Ketamine

›Ketamine IV 0.2 mg per kg

›Repeat dosing for analgesia

›Airway monitoring

›Midazolam

›Midazolam IV 1 mg

›Repeat every 2 to 3 minutes

›Respiratory depression monitoring

Eye and ear injury management

›Eye care

›Irrigation for debris exposure

›Normal saline until symptom relief

›Fluorescein exam for abrasion

›Ophthalmology consultation triggers

›Decreased visual acuity

›Hyphema

›Suspected globe injury

›Delayed complications counseling

›Cataract risk

›Retinal injury risk

›Ear care

›Tympanic membrane rupture

›Keep ear dry

›Avoid otic drops unless prescribed

›ENT referral triggers

›Vertigo

›Facial weakness

›Persistent hearing loss

09Special Populations/sp41

Pregnancy

›Maternal and fetal priorities

›Maternal stabilization first

›ABCs prioritized

›Left lateral tilt for hypotension reduction

›Fetal assessment

›Viable gestation fetal monitoring per local protocol

›Obstetrics consultation

›Rh status consideration

›Rh immunoglobulin for trauma with Rh negative status per local protocol

›Imaging considerations

›CT when maternal life threat

›Do not delay indicated imaging

›Shielding when feasible

›MRI use

›Preferred for neuro axis when stable

›Avoid gadolinium unless essential

Geriatric

›Higher complication risk

›Baseline cardiac disease

›Lower threshold for telemetry

›Lower threshold for troponin testing

›Anticoagulant use

›Lower threshold for CT head

›Bleeding risk assessment

›Medication adjustments

›Opioid sensitivity

›Lower initial dosing

›Delirium monitoring

Pediatrics

›Weight based resuscitation

›Fluids

›Isotonic crystalloid 10 to 20 ml per kg bolus

›Reassess after each bolus

›Analgesia dosing

›Acetaminophen PO 15 mg per kg

›Ibuprofen PO 10 mg per kg

›Telemetry thresholds

›Lower threshold for monitoring

›Unwitnessed event

›Any syncope

›Nonaccidental trauma consideration

›History mismatch

›Suspicious injuries

10Background/b38

Epidemiology

›Lightning injury patterns

›Seasonal clustering

›Warm weather peak

›Outdoor activity association

›Mechanism distribution

›Ground current common mechanism

›Direct strike less common but higher severity

›Mortality drivers

›Immediate cardiopulmonary arrest

›Secondary trauma injuries

Pathophysiology

›Electrical energy effects

›Depolarization

›Cardiac conduction disruption

›Respiratory center disruption

›Blast and barotrauma

›Tympanic membrane rupture

›Blunt trauma from shock wave

›Thermal effects

›Superficial flash burns

›Deep tissue injury possible without large surface burn

›Keraunoparalysis mechanism

›Autonomic mediated vasospasm

›Transient limb ischemia appearance

›Rapid recovery typical

Therapeutic Considerations

›Resuscitation principles

›Early ventilation emphasis

›Respiratory arrest primary event in some cases

›Prevent secondary hypoxic arrest

›Dysrhythmia readiness

›Early defibrillation availability

›Continuous monitoring for delayed arrhythmia

›Rhabdomyolysis prevention

›Early fluids

›Reduce myoglobin nephrotoxicity

›Maintain renal perfusion

›Hyperkalemia anticipation

›ECG monitoring

›Repeat electrolytes with rising CK

11Patient Discharge Instructions/pdi28

copy discharge instructions

›Lightning injury discharge guidance

›Wound care

›Keep dressings clean and dry

›Daily gentle cleaning with soap and water for minor burns

›Hydration

›Increased oral fluids unless restricted by clinician

›Monitor urine color for darkening

›Activity

›Avoid strenuous exercise for 48 to 72 hours

›Gradual return if no symptoms

›Return to ED now for red flags

›Chest pain

›Palpitations

›Fainting

›Shortness of breath

›New weakness or numbness

›Severe headache

›Seizure

›Confusion worsening

›Decreasing urine output

›Dark cola colored urine

›Increasing burn pain redness swelling or pus

›Vision changes

›Hearing loss or drainage from ear

›Follow up

›Primary care within 48 to 72 hours

›Ophthalmology referral if any vision symptoms

›ENT referral if hearing symptoms persist

12References/r17

Clinical guidelines and evidence sources

›Core guidelines

›American Heart Association Guidelines for CPR and ECC 2025

›Adult advanced life support section

›Defibrillation and medication algorithms

›American Heart Association Focused Update on ACLS 2023

›Updated evidence for cardiac arrest interventions

›Applies to lightning arrest resuscitation framework

›Wilderness Medical Society Practice Guidelines for prevention and treatment of lightning injuries 2014 update

›Reverse triage recommendation

›Telemetry and organ system based management recommendations

›Emergency medicine resources

›ACEP wilderness medicine lightning injury review

›ED evaluation emphasis on ATLS and ACLS framework

›Admission for persistent neurologic cardiac or vascular abnormalities

›Annals of Emergency Medicine review of electrical shock and lightning strike

›Aggressive resuscitation recommendation

›Cardiopulmonary arrest focus

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.