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Lightning injury

Lightning injuries are injuries caused by a lightning strike.[4] Initial symptoms may include heart asystole and respiratory arrest.[1] While the asystole may spontaneously resolve fairly rapidly, the respiratory arrest is typically more prolonged.[1] Other symptoms may include burns and blunt injuries.[1] Of those who survive, about 75% have ongoing health problems as a result, such as cataracts and hearing loss.[1] If death occurs it is typically from either an abnormal heart rhythm or respiratory failure.[1]

Lightning injury
Other namesEffects of lightning
Multiple lightning bolts strike a populated area.
SpecialtyEmergency medicine
TypesDirect strikes, side splash, contact injury, ground current[1]
CausesLightning strike[1]
Diagnostic methodBased on history of the injury and examination[1]
PreventionAvoiding the outdoors during a thunderstorm;[2] sheltering in a fully-enclosed structure;[3] if still outdoors, assuming 'lightning position' before a strike[3]
TreatmentCPR, artificial ventilation[1]
Frequency240,000 a year[1]
Deaths24,000 a year[1]

Lightning injuries are divided into direct strikes, side splash, contact injury, and ground current.[1] Ground current occurs when the lightning strikes nearby and travels to the person through the ground.[1] Side splash makes up about a third of cases and occurs when lightning strikes nearby and jumps through the air to the person.[1] Contact injury occurs when the person is touching the object that is hit.[1] Direct strikes make up about 5% of injuries.[1] The mechanism of the injuries may include electrical injury, burns from heat, and mechanical trauma.[1] Diagnosis is typically based on history of the injury and examination.[1]

Prevention includes avoiding being outdoors during a thunderstorm, and sheltering in a fully enclosed structure (such a closed building or metal car).[2][5] If being outdoors is unavoidable, bringing the feet and knees together is recommended (if possible, while crouching low in the 'lightning position'— crouched low, hands over ears, feet touching if possible) so as to provide only one point of contact with the ground.[2][5] When indoors the use of devices connected to electrical outlets and contact with water is not recommended.[2] Among those who appear in cardiac arrest and have no central pulse, cardiopulmonary resuscitation (CPR) should be started.[1] In those who have a central pulse but are not breathing artificial ventilation, such as mouth to mouth, is recommended.[1][6]

As of 2019, it has been estimated that lightning injuries occur 240,000 times a year with 24,000 deaths.[1] Areas with mountainous terrain and moisture-heavy airflow, such as Central Africa, have the highest rates of lightning strikes.[3] Among pregnant women who are hit by lightning, the death of the fetus occurs in about half.[1] In the United States, about 1 in 10,000 people are hit by lightning during their lifetime.[1] Males are affected four times more often than females.[1] The age group most commonly affected is 20 to 45 years old.[1]

Signs and symptoms

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A person who was affected by a nearby lightning strike. Note the slight branching redness traveling up the victim's leg from the effects of the current.

Common injuries caused by lightning include: muscle pains, broken bones, cardiac arrest, confusion, hearing loss, seizures, burns, behavioral changes, and ocular cataracts.[4][3] Loss of consciousness is very common immediately after a strike.[7]

Lightning burns result from energy caused by lightning strikes, and are characterized by a unique pattern of skin lesions. These tree-like lesions resemble feathering or ferning, and are also called Lichtenberg figures.[8] The marks are formed when capillaries beneath the skin rupture due to the electrical discharge and they usually appear "within hours" of the strike though they tend to disappear within a few days. They also generally occur on the upper body.[9] The brief duration of the exposure frequently limits the damage to the outer layer of skin.[10]

The intense heat generated by a lightning strike can burn tissue, and cause lung damage, and the chest can be damaged by the mechanical force of rapidly expanding heated air.[4]

Just as heat can cause expanding air in the lungs, the explosive shock wave created by lightning (the cause of thunder) can cause concussive and hearing damage at extremely close range. Other physical injury can be caused by objects damaged or thrown by the lightning strike. For example, lightning striking a nearby tree may vaporize sap, and the steam explosion often causes bark and wood fragments to be explosively ejected.

Lightning strikes can also induce a transient paralysis known as 'keraunoparalysis'.[3] Signs and symptoms of keraunoparalysis include lack of pulse, pallor or cyanosis, and motor and sensory loss in the extremities. However, keraunoparalysis usually resolves within a few hours.[3]

Pathophysiology

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Although the current flow of a lightning strike occurs only over a short period, the current has an extremely high voltage of some 30 million volts.[11] Lightning is neither a DC or an AC current but best described as a unidirectional massive current impulse of electrons.[11]

Lightning strikes are grouped in four categories: direct strikes, side splash, contact injury, and ground current.[1]

  • Direct strike: lightning directly hits the person
    • Orifice entry: may occur if lightning strike occurs near the head entering eyes, ears and mouth to flow internally
  • Side splash: lightning jumps from the location of primary strike to a nearby person
  • Contact injury: injury that occurs when a person is touching an object on the pathway of lightning
  • Ground current: lightning strikes nearby and the current travels through the ground to the person

Lightning injury may occur by these electrical mechanisms or by secondary blunt trauma as a result of the strike.[12]

Diagnosis

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Diagnosis is typically based on history of the injury and examination.[1]

Prevention

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See also: Lightning strike § Personal safety

Preventing lightning injury involves avoiding being outdoors during a thunderstorm.[2][3] While no place is entirely safe from lightning strikes, it is recommended to seek shelter in a substantial, fully-enclosed building (preferably with electrical attachments and plumbing) or a closed metal vehicle, such as a car.[3][5][13] If being outdoors is unavoidable, staying away from metal objects (including fencing and power lines), sheets of water (ponds, lakes, etc.), tall structures, and open, exposed areas (including high ground, hills, etc.) is strongly recommended.[2][3] It is dangerous to shelter under isolated trees, cliffs or other rocks.[2] Lying on the ground is also dangerous.[2] When a lightning strike seems imminent, a 'lightning position' can be taken by "sitting or crouching with knees and feet close together to create only one point of contact with the ground" (with the feet off the ground if sitting; if standing is necessary, the feet have to be touching).[5] Signs of an impending strike nearby can include a crackling sound, sensations of static electricity in the hair or skin, the standing of hair on end, the pungent smell of ozone, or the appearance of a blue haze around persons or objects (St. Elmo's fire).[14][3] For large groups of people, it is recommended that individuals spread out to avoid mass casualties.[3][13] When indoors, the use of devices connected to electrical outlets and contact with water is discouraged.[2]

In the United States, recreational fishing poses the greatest risk of death from lightning of any activity, accounting for 10 percent of all lightning deaths between 2006 and 2019.[15]

Organized groups and individuals are encouraged to prepare lightning safety plans in advance.[3] Specific tips are available for various situations, such as outdoor recreation, boating and other water activities, and organized sporting events.[2]

Treatment

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Immediate

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The most critical injuries are cardiac arrest and respiratory failure. This will often require prompt emergency care.[7] It is safe to provide care immediately, as the affected person will not retain an electrical charge after the lightning has struck, contrary to popular belief.[6][16]

Many people who are unconscious and appear lifeless die of suffocation.[5] Chances of survival may be increased if cardiopulmonary resuscitation (CPR) is started immediately, and continued without interruption until return of spontaneous circulation (ROSC).[17]

Long-term

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A complete physical examination by paramedics or physicians may reveal ruptured eardrums. Ocular cataracts may later develop, sometimes more than a year after an otherwise uneventful recovery. Long-term injuries are usually neurological in nature, including memory deficit, mood disturbance, and fatigue.[18][19]

Prognosis

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Approximately 10% of lightning strikes are lethal.[1] Survivors of lightning strike may suffer long-term injury or disability.[20]

Epidemiology

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Main article: Lightning strike § Epidemiology

It is estimated that lightning injuries occur 240,000 times a year with 24,000 deaths.[1] Among pregnant women who are hit by lightning, the death of the fetus occurs in about half.[1] In the United States about 1 in 10,000 people are hit by lightning during their lifetime.[1] Males are affected four times more often than females.[1] The age group most commonly affected is 20 to 45 years old.[1]

References

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  1. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag Jensen JD, Vincent AL (January 2019). "Lightning Injuries". StatPearls. PMID 28722949.
  2. ^ a b c d e f g h i j "Lightning Safety Tips". CDC. 23 January 2019. Retrieved 11 November 2019.
  3. ^ a b c d e f g h i j k l Davis C, Engeln A, Johnson EL, et al. (December 2014). "Wilderness Medical Society practice guidelines for the prevention and treatment of lightning injuries: 2014 update". Wilderness & Environmental Medicine. 25 (4 Suppl): S86–95. doi:10.1016/j.wem.2014.08.011. PMID 25498265.
  4. ^ a b c Mallinson T (2013). "Understanding the correct assessment and management of lightning injuries". Journal of Paramedic Practice. 5 (4): 196–201. doi:10.12968/jpar.2013.5.4.196.
  5. ^ a b c d e Ritenour AE, Morton MJ, McManus JG, Barillo DJ, Cancio LC (August 2008). "Lightning injury: a review". Burns: Journal of the International Society for Burn Injuries. 34 (5): 585–594. doi:10.1016/j.burns.2007.11.006. ISSN 0305-4179. PMID 18395987. S2CID 19198991.
  6. ^ a b "First Aid Recommendations Lightning". CDC. 23 January 2019. Retrieved 11 November 2019.
  7. ^ a b Mallinson T (2010). "Lightning Injuries". Focus on First Aid (16): 15–16. Archived from the original on 11 March 2012. Retrieved 2010-09-30.
  8. ^ "DynaMed". www.dynamed.com. Retrieved 2019-11-25.
  9. ^ "How do you recover from being struck by lightning?". BBC News. 8 August 2013. Retrieved 9 August 2013.
  10. ^ "Lightning Injuries - Injuries and Poisoning". Merck Manuals Consumer Version. Retrieved 2019-11-25.
  11. ^ a b Auerbach, Paul S. (2011). Advanced wilderness life support : prevention, diagnosis, treatment, evacuation (7th ed.). Utah: Wilderness Medicine Society. ISBN 978-0-615-49608-5. OCLC 829392080.
  12. ^ O'Keefe KP, Semmons R (2018). Electrical and Lightning Injuries in Rosen's emergency medicine: concepts and clinical practice (9th). St. Louis, Missouri: Mosby. pp. 1765–1772.
  13. ^ a b Auerbach PS (May 1992). "Wilderness medicine epidemiology". Journal of Wilderness Medicine. 3 (2): 111–112. doi:10.1580/0953-9859-3.2.111. ISSN 0953-9859. S2CID 72099106.
  14. ^ US Department of Commerce N. "Lightning Safety". www.weather.gov. Retrieved 11 March 2023.
  15. ^ Jensenius JS Jr (2020). "Detailed Analysis of Lightning Deaths in the United States from 2006 through 2019" (PDF). National Lightning Safety Council.
  16. ^ "Lightning Myths". National Weather Service. Retrieved July 6, 2024.
  17. ^ Dayton, L (1993). "Science: Secrets of a bolt from the blue", New Scientist, 18 December 1993.
  18. ^ Ritenour AE, Morton MJ, McManus JG, Barillo DJ, Cancio LC (August 2008). "Lightning injury: A review" (PDF). Burns. 34 (5): 585–594. doi:10.1016/j.burns.2007.11.006. PMID 18395987. S2CID 19198991. Archived (PDF) from the original on February 3, 2022.
  19. ^ NOAA Lightning Safety Facts
  20. ^ Sanford A, Gamelli RL (2014), "Lightning and thermal injuries", Neurologic Aspects of Systemic Disease Part II, Handbook of Clinical Neurology, vol. 120, Elsevier, pp. 981–986, doi:10.1016/b978-0-7020-4087-0.00065-6, ISBN 978-0-7020-4087-0, PMID 24365365

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