Basal ganglia, brainstem predilection for hemorrhage
Progressive myelopathy from ascending vascular injury
Keraunoparalysis
Transient paralysis from autonomic vasospasm
Resolves within hours
Cutaneous effects
Lichtenberg figures: superficial electron shower, not a true burn
Flash burns from ignited clothing
Contact burns from metal objects
Barotrauma
Thunder and shockwave cause tympanic membrane perforation
Pulmonary contusion from blast
Vertebral fractures from muscular tetanic contraction
Therapeutic Considerations
Resuscitation philosophy
Aggressive prolonged resuscitation is the standard of care
Young, otherwise healthy victims
Fixed dilated pupils are NOT a contraindication to resuscitation
Survival with intact neurologic function after prolonged arrest is well-documented
Prioritize ventilation over circulation
Respiratory arrest outlasts cardiac arrest
Secondary cardiac arrest from hypoxia is preventable
Cardiac management principles
Most arrhythmias are transient and self-limiting
Continuous monitoring for minimum 24 hours
Delayed arrhythmias documented up to 3 days
Cardiac dysfunction (even severe) typically reversible within 72 hours
Expectant supportive management before permanent device implantation
Avoid premature ICD implantation in acute phase
QT prolongation management
Lightning strike causes QT prolongation
Avoid all QT-prolonging medications in the acute phase
Monitor QTc on serial ECGs
Electrolyte correction reduces QT prolongation
Correct potassium to >3.5 mmol/L
Correct magnesium to >0.85 mmol/L
Rhabdomyolysis management principles
Aggressive IV crystalloid is cornerstone of treatment
Prevent myoglobin-induced acute tubular necrosis
Target urine output 1–2 mL/kg/hr
Monitor for AKI with serial creatinine
Evidence base
No randomized controlled trials exist for lightning injury management
Management is based on case series, expert consensus, and wilderness medicine guidelines
Wilderness Medical Society 2014 guidelines are the primary evidence-based reference
European Heart Journal 2018 review (Waldmann et al.) guides cardiac management
Patient Discharge Instructions
copy discharge instructions
You were treated for a lightning strike injury
Return to the Emergency Department immediately if you develop any of the following
Chest pain, palpitations, or racing heart
Feeling faint or losing consciousness
Shortness of breath
New weakness or numbness in any extremity
Vision changes including blurring or loss of vision
Seizure or convulsions
Severe worsening headache
Dark or tea-colored urine
Confusion or worsening mental status
Follow-up appointments scheduled
See your family doctor within 1–2 weeks
Neuropsychiatric symptoms including anxiety, sleep problems, and memory difficulty are common and may develop over days to weeks
Report any new or worsening symptoms
Ophthalmology appointment within 1–2 weeks if recommended
Eye complications including cataracts can develop from 2 days to 4 years after the strike
Report any changes in vision immediately
Cardiology and neurology follow-up as arranged
Expected recovery information
Skin markings (Lichtenberg figures) will fade and disappear within 24 hours
They are not true burns and require no wound care
Minor burns should be kept clean and dry with the dressings provided
Return if any sign of infection: redness spreading, pus, fever
Mood changes, anxiety, sleep problems, and memory difficulty are very common after lightning strike
PTSD, depression, and cognitive difficulties can persist for months
Support group available: Lightning Strike and Electric Shock Survivors International (www.lightning-strike.org)
Autonomic nervous system symptoms
Fluctuating blood pressure and heart rate may occur for weeks to months
Chronic pain is a common long-term complaint
Activity and safety instructions
No outdoor activities during thunderstorms
If caught outdoors, move indoors or to a hard-topped vehicle immediately
Avoid tall isolated trees, open fields, and hilltops
Do not use landline telephones during thunderstorms
No driving until cleared by your physician if you had any loss of consciousness or confusion
References
Guidelines and Key Sources
van Ruler R, Eikendal T, Kooij FO, Tan ECTH. A Shocking Injury: A Clinical Review of Lightning Injuries Highlighting Pitfalls and a Treatment Protocol. Injury. 2022. PMID 36038387
Primary comprehensive clinical review used for this protocol
Covers pathophysiology, alarm features, diagnosis, and treatment
Davis C, Engeln A, Johnson EL, et al. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Lightning Injuries: 2014 Update. Wilderness and Environmental Medicine. 2014.
Primary evidence-based guideline for field and emergency management
Covers prevention, triage, and acute treatment
Waldmann V, Narayanan K, Combes N, et al. Electrical Cardiac Injuries: Current Concepts and Management. European Heart Journal. 2018. PMID 28444167
Cardiac management framework for lightning and electrical injuries
Covers arrhythmia monitoring, cardiac biomarkers, and device management
Landmark Studies
Lichtenberg R, Dries D, Ward K, Marshall W, Scanlon P. Cardiovascular Effects of Lightning Strikes. Journal of the American College of Cardiology. 1993. PMID 8426021
Established cardiac monitoring standards post-lightning
Documented transient and permanent cardiac effects
Dundon BK, Puri R, Leong DP, Worthley MI. Takotsubo Cardiomyopathy Following Lightning Strike. Emergency Medicine Journal. 2008. PMID 18573973
Documented reversible cardiomyopathy from lightning
Supports expectant management over early device implantation
Kotagal S, Rawlings CA, Chen SC, Burris G, Npuriouri S. Neurologic, Psychiatric, and Cardiovascular Complications in Children Struck by Lightning. Pediatrics. 1982. PMID 6927248
Established pediatric lightning injury spectrum
Seyfrydova M, Rokyta R, Rajdl D, Huml M. Arrhythmias and Laboratory Abnormalities After an Electrical Accident: A Single-Center Retrospective Study of 333 Cases. Clinical Research in Cardiology. 2023. PMID 37526697
Elevated lactate identified as independent risk factor for arrhythmia
Informs laboratory risk stratification
Fontanarosa PB. Electrical Shock and Lightning Strike. Annals of Emergency Medicine. 1993. PMID 8434837
Early comprehensive emergency medicine review
Established core clinical assessment framework
Radulovic N, Mason SA, Rehou S, Godleski M, Jeschke MG. Acute and Long-Term Clinical, Neuropsychological and Return-to-Work Sequelae Following Electrical Injury: A Retrospective Cohort Study. BMJ Open. 2019. PMID 31092649
Long-term neuropsychiatric outcome data
Informs follow-up planning and patient counseling
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