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Clinical Summary

Lightning produces injury from high voltage, heat production, and explosive shock waves. Direct injuries include cardiorespiratory arrest, cardiac arrhythmias, and neurologic abnormalities such as seizures, deafness, confusion, amnesia, blindness, and paralysis. The patient may suffer contusions from the shock wave or from opisthotonic muscle contractions. Chest pain and muscle aches are common. One or both tympanic membranes (TMs) rupture in more than 50% of victims. Cataracts are usually a delayed occurrence. Hematologic abnormalities including disseminated intravascular coagulation have been described. Fetal demise may occur.

Burns may result from vaporization of sweat or moist clothing, heating of clothing and metal objects such as climbing equipment, belt buckles or bra wiring, and direct effects of the strike. Linear burns and punctate burns are thermal burns. Feathering burns, also known as ferning or Lichtenberg figures, are not actual burns but likely represent superficial bruising. They are pathognomonic for lightning injury.

Diagnosis of lightning injury is straightforward when there is a thunderstorm, when there are witnesses to the strike, or when there are typical physical findings. Lightning on relatively sunny days (without thunder) striking a lone victim may produce a confusing picture. The scattering of clothing and belongings may mimic an assault. Side flashes from metal objects and wiring may produce indoor victims during storms.

FIGURE 16.25

Linear Lightning Burns. Linear burns from lightning are due to thermal effects. (Photo contributor: William Barsan, MD.)

FIGURE 16.26

Linear Lightning Burns. Linear lightning burns along the leg and foot of a strike victim. (Photo contributor: Sheryl Olson, RN, BSN, CCRN.)

FIGURE 16.27

Punctate Lightning Burns. Punctate burns due to lightning are partial- or full-thickness thermal burns that range from a few millimeters to a centimeter in diameter. They are multiple and closely spaced. (Photo contributor: Arthur Kahn, MD.)

Management and Disposition

Care begins with the ABCs (airway, breathing, circulation). In the ED, a thorough history and physical examination should be performed to identify associated injuries. Asymptomatic patients, including those with feathering, who have a normal ECG may be observed for several hours and discharged with referral to neurology, ophthalmology, and otorhinolaryngology because delayed sequelae are common. Patients with mild injuries should be admitted for neurologic and cardiovascular monitoring, with specialty consultation as needed. Patients with significant injuries should be admitted to a referral hospital with a full range of specialty services.

Pearls

  1. The amount of damage to the exterior of the body does not predict the amount of internal injury.

  2. Since lightning most commonly produces cardiac standstill by means of massive direct current countershock, prompt spontaneous return of normal heart rhythm, by ...

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