Thursday, August 13, 2020

Lightning Strike Emergencies Part 2: Trauma Approach

Image Credit: Piqsels
Vivek Abraham, MD
PGY-1, Orthopedic Surgery

Additional Authors:
Ivan Yue, MD
PGY-1, Emergency Medicine
Naval Medical Center San Diego
AAEM/RSA Publications and Social Media Committee

Alexander Li, MD
PGY-1, Orthopedic Surgery
Naval Medical Center Portsmouth

Lightning strike triage and cardiac resuscitation was previously covered in part 1. Abnormal cardiac rhythms are the most common fatal complications of lightning strikes, but other complications of lightning strikes can cause high morbidity and mortality if left untreated. This article will go over injury patterns that may be seen and diagnosed in the emergency room.

This paper was guided by the Wilderness Medicine Society’s (WMS) lightning injury treatment guidelines. Specific recommendations regarding trauma and relevant to the emergency physician are further explored.

Traumatic Injuries by System:

Like cardiovascular injuries sustained from a lightning strike, neurologic injuries have a wide range from minor transient changes to life threatening. With severe or permanent neurologic injury, there are few successful treatments and long-term rehabilitation care is often required.

Lightning strikes can cause transient symptoms such as loss of consciousness, headache, paresthesias, and memory loss.Transient paralysis, also referred to as keraunoparalysis, has also been reported, typically with the lower limbs affected more than the upper limbs.1 It is believed that transient paralysis occurs due to vascular spasm secondary to stimulation of the autonomic nervous system. Reports also describe patients experiencing symptoms of lack of peripheral pulse, cyanosis, and motor and/or sensory loss. Therefore, it is vital to check a central pulse prior to starting basic life support (BLS)/advanced life support (ALS). The WMS recommends that patients suffering from keraunoparalysis be admitted to the hospital for further monitoring, as this condition typically resolves within hours, but further traumatic injuries should be ruled out.

Permanent neurologic damage can occur immediately or delayed after a lightning strike.1 With immediate injuries, if patients suffer cardiopulmonary arrest, they can develop hypoxic encephalopathy. The electric charge from a strike preferentially affects the basal ganglia and brainstem and can cause intracranial hemorrhage with a direct strike. Other permanent neurologic conditions that can develop include cerebral salt wasting, cerebral infarction, and peripheral nerve lesions.2 With delayed cases, patients can develop myelopathies, notably in the cervical and thoracic regions, months after the initial strike. The WMS recommends that all patients receive computerized tomography scan of their head if there was loss of consciousness or persisted neurologic changes.

Patients can develop a pattern known as Lichtenberg figure, which is a ferning pattern on the skin that presents 1 hour after a strike and may last as many as 24 hours.3 It is not a burn and there are no histologic changes in the skin, so there is no treatment for this.

Burns are common injuries, and include linear, punctate, and full thickness burns. Linear burns result from water or sweat being superheated and searing this skin. Punctate burns are usually on the toes and develop from the charge exiting the body, further showing the importance of a thorough physical exam on lightning strike patients. Full thickness burns typically result from the melting of fabric or direct contact with metal on the patient’s skin.4 These injuries should be treated in the same manner as any burn.

Damage to the eye is common due to trauma, vasoconstriction, and heat. Cataracts can develop as few as two days after injury.5 The WMS recommends that all high-risk patients be seen by Ophthalmology immediately, especially if vision loss is present.

Rupture of the tympanic membrane (TM) is common following blast and electric injury, and should be evaluated in every lightning strike patient.6 With uncomplicated TM rupture, these can be managed conservatively. The electric current can also cause microhemorrhages and microfractures of deeper ear structures, causing permanent hearing loss. For these patients, prompt follow up with an otolaryngologist is recommended.

Psychiatric and Neurocognitive:
There are reports of patients suffering from cognitive disabilities, such as memory loss and reduced problem solving.7 Additionally, patients can develop psychiatric conditions including depression, emotional lability, and change in behavior. These conditions develop days to weeks after a lightning strike, and referral to specialized mental health care is recommended.

There are only a handful of cases reported of lightning strikes of pregnant patients. Because the fetus is surrounded by conductive amniotic fluid, it is more likely to be injured than the pregnant patient.8 Patients can also experience uterine rupture or induction of labor.9 It is recommended that pregnant patients greater than twenty weeks gestation undergo formal fetal evaluation by an obstetrician, whereas the fetus is considered non-viable in women less than twenty weeks gestation and do not require monitoring in the emergent setting.

Rhabdomyolysis and compartment syndrome are further known complications of lightning strike as a sequelae of direct tissue insult.10 A focused musculoskeletal physical exam in addition to monitoring urine output, electrolytes, creatinine, and early suspicion for compartment syndrome are noncontroversial approaches to rhabdomyolysis.

Trauma is a common complication of lightning strikes that the emergency physician must be able to recognize and treat. The WMS guidelines stress the importance of prevention of lightning strike injuries as well. These include seeking shelter immediately, avoiding ridges/summits, and avoiding standing near tall or metal objects. However, if caught in a lightning storm and one has nowhere to go, they should adopt the “lightning position,” which is a full squat on toes with heels touching and hands over ears. If traveling with a group, people should be spaced at least 20 feet apart to avoid lightning jumping person to person.11 Finally, removing any metal equipment is recommended as well.

While future research in this field is difficult due to the sporadic nature of lightning strikes, reporting and reviewing more case series will be extremely helpful in the future in order to identify more trends and develop robust treatment algorithms for these patients. Emergency clinicians can help by not only providing excellent guideline-directed health care, but also by doing their part in educating patients and engaging with public health initiatives.


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  2. Emet M, Caner I, Cakir M, Aslan S, Cakir Z. Lightning injury may cause abrupt cerebral salt wasting syndrome. Am J Emerg Med. 2010;28(5):640.e1-3.

  3. Cherington M, Mcdonough G, Olson S, Russon R, Yarnell PR. Lichtenberg figures and lightning: case reports and review of the literature. Cutis. 2007;80(2):141-3.

  4. Herrero F, García-morato V, Salinas V, Alonso S. An unusual case of lightning injury: a melted silver necklace causing a full thickness linear burn. Burns. 1995;21(4):308-9.

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  6. Gluncić I, Roje Z, Gluncić V, Poljak K. Ear injuries caused by lightning: report of 18 cases. J Laryngol Otol. 2001;115(1):4-8.

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  8. Flannery DB, Wiles H. Follow-up of a survivor of intrauterine lightning exposure. Am J Obstet Gynecol. 1982;142(2):238-9.

  9. Guha-ray DK. Fetal death at term due to lightning. Am J Obstet Gynecol. 1979;134(1):103-5.

  10. Navarrete N. Severe rhabdomyolysis without renal injury associated with lightning strike [published correction appears in J Burn Care Res. 2014 Jan-Feb;35(1):120. Aldana, Norberto Navarrete [corrected to Navarrete, Norberto]]. J Burn Care Res. 2013;34(3):e209-e212. doi:10.1097/BCR.0b013e31825adc98

  11. Davis C, Engeln A, Johnson EL, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of lightning injuries: 2014 update. Wilderness Environ Med. 2014;25(4 Suppl):S86-95.

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