Lightning-strike Injury

Abstract

Although lightning-strike injury is uncommon, it is the cause of death in more people in the United States annually than any other natural disaster. Consequently, the emergency medicine specialist and intensivist should be familiar with the special problems of a lightning-strike victim. Lightning is a massive electrical discharge that results from a complex sequence of atmospheric events. When this massive electrical discharge strikes a human being, it causes predictable cardiac and neurological injuries. Synchronous myocardial contraction occurs at the moment of impact and is followed by a variable period of asystole. Prolonged asystole may cause ischemia and ventricular fibrillation. Alternatively, ventricular fibrillation may occur primarily if the electrical discharge strikes during the vulnerable period of the cardiac cycle. Unconsciousness, depression of respiratory efforts, and seizures are also immediate consequences of lightning strike. Respiratory arrest is presumed to be a consequence of inhibition of the medullary respiratory center. Retrograde and antegrade amnesia, confusion, disorientation, and vasomotor instability with transient paralysis of usually the lower extremities are commonly seen in lightning-strike victims. Other complications occur more variably, but should be carefully sought by the responsible clinician. These include burns at the exit and entrance sites of the lightning strike, eye injuries (e.g., cataracts, corneal lesions, intraocular bleeding), and rupture of the tympanic membrane. Besides describing the pathophysiology of these and other consequences of lightning strike, a comprehensive approach to the initial and long-term management of the lightning-strike victim is discussed.

Lightning Injuries: Don't Be Confused

“…Many authors present reviews that are either a rehash of multiple case reports that conclude with unscientific and unproved recommendations or a compilation of the existing and often flawed literature that propagates misconceptions and repeats unproved recommendations; original references are often improperly searched and reviewed [1][2][3][4]. To explain the principles of physics that apply to electrical phenomena, many authors choose to use examples of high-voltage electrical injuries because they graphically illustrate these principles.…”

“…In their article in this issue of the Journal [4], Hiestand and Colice fall victim to most of these pitfalls. Although they are to be applauded for their attempts to cover the topic, they have included too many ancillary areas such as low-voltage injuries and electroshock therapy, which at best add little to the clinician's perspective and at worst potentially confuse the issues and lead to further misconceptions about the types of injuries seen in victims of lightning strike as well as the appropriate therapy.…”

“…The burns that accompany lightning injuries are seldom more than &dquo;skin deep.&dquo; They may be linear (see Fig 6 of Hiestand and Colice's article [4]), punctate (see Fig 7), arborescent (see Fig 8), or secondary to the heating of metal objects that are in close contact with the victim's skin. Although there have been a few reports over the last century of exploded or deep burns, these are quite rare and are probably from &dquo;hot&dquo; lightning.…”

“…The supposition that there is a &dquo;golden period&dquo; between a primary and secondary arrest is just that but it has been touted since Taussig's article [1]. Hiestand and Colice [4] are in good company in their error. According to a Boy Scout at the scene, the victim had a pulse.…”

“…The basis for this and her recommendation that &dquo;artificial resuscitation should be continued for days or weeks&dquo; seems to be based on a single case report from 1959 by Ravitch and colleagues [12] in which a 10-year-old boy was struck by lightning (unknown if by a direct hit). It is also as likely that there is something magic (e.g., the concept of suspended animation mentioned by Hiestand and Colice [4] and other sources) about lightning as it is that Ravitch's patient gained a higher IQ because he was struck by lightning. However, the patient suffered what appeared to be a secondary arrest a few minutes later at a hospital and was resuscitated within four minutes with open-chest massage and intracardiac epinephrine.…”