Definition of Lightning injuries

Lightning injuries: A major source of injury and death from the environment, lightning is one of the top 3 causes of death from environmental origins. (The other top environmental killers are floods and extreme temperatures.) Lightning is neither a direct current nor an alternating current. It is a unidirectional, massive, current impulse with several return strokes back to the cloud. Once connection from the cloud is made, a tremendously large current impulsively flows for an incredibly short time.

Uniqueness of lightning -- The most important difference between lightning and high-voltage electrical injuries is the duration of exposure to the current. Lightning has only brief contact with the skin. There is not enough time to allow skin burns. Internal burns and renal failure play a small part in the injury pattern from lightning. Cardiac and respiratory arrest, vascular spasm, and neurologic damage play a much greater role.

Immediate effects -- The immediate effect of a lightning strike tends to be ventricular asystole rather than fibrillation. While the heart rhythm will often pick up again, the respiratory arrest that accompanies the cardiac arrest may be prolonged and result in a secondary cardiac arrest. Other injuries caused by blunt trauma or ischemia from vascular spasm, such as myocardial infarction or spinal artery syndromes, occasionally may occur.

Long-term effects -- The number of survivors of lightning injury is estimated to be between 10-20 times larger than the number of fatalities. Survivors may have ongoing problems that are not easy to quantify or treat, including neuropsychological and neurocognitive changes, chronic pain syndromes, chest pain, sympathetic nervous system dysfunction, sleep disorders, severe continuing headaches, and cardiac effects. The survivors tend to be young, employed, family people who suffer loss of income and disability and become a large cost for the community.

Place and time -- In addition to outdoor fatalities caused by lightning, there are a number of people injured indoors every year, including victims of telephone-mediated strikes. While recreational pursuits predominate in the injuries and fatalities, nearly one-third of the injuries are work-related, on-the-job injuries.

The most common days of injury are Sundays, Saturdays, and Wednesdays, probably reflecting the recreational activities on the weekends. The most common time of day to be injured by lightning is from noon to 6 PM, with 6-12 PM following, related not only to when thunderstorms occur but also to when people are most likely to be outdoors.

The most dangerous times for lightning injury are those in which the victim underestimates the likelihood of being hit -- before the storm (lightning may hit as far as 10 miles in front of a thunderstorm) or after the storm appears over (but is not).

Gender -- In the US, males were found to be 4 to 5 times more likely to be injured and killed by lightning than females. This is not because of any physiologic differences, but purely is related to males' increased exposure, due to outdoor activities or work.

Age -- The highest number of incidence tends to occur in people under 16 years and in people aged 26-35 years. Few people over 50 years are injured since they are less often engaged outdoors.

Indoor exposures -- Lightning may hit, or hit close to, a structure or recreational facility and be transmitted into the building through the plumbing, electrical wiring, windows, EMS/fire dispatch radio, and other methods. Structures that are not habitable (e.g., golf structures, picnic shelters, small sheds) are at increased risk of lightning injury because they are not properly protected and they have the singular effect of increasing the functional height of the individuals sheltering under them. In some instances, lightning protection standards, which adequately protect the structure, may actually increase the risks of persons under them being injured for side-flash and grounding reasons.

Telephone exposure -- Injuries to persons using the telephone or telephone headsets, such as those who take phone orders, are relatively common due to the telephone system not being grounded to the structure's electrical system. The telephone becomes the conduit for the charge to get in or escape from the structure (and person).

Blunt injuries -- These may occur because of muscular contractions, which may throw the victim many yards, or cause the victim to fall from a height. Blunt injury also may occur from the almost instantaneous expansion and contraction of the air near the lightning column. Physical: Physical presentation may vary from cardiac arrest (the only direct cause of death) to mild disorientation with no acute physical signs.

Cardiorespiratory arrest -- Cardiorespiratory arrest is the only known direct cause of death from lightning. Lightning acts as cosmic defibrillation. It sends the heart into momentary asystole (stops it beating momentarily). The heart often spontaneously recovers. Unfortunately, the respiratory arrest usually lasts much longer so that a secondary cardiac arrest from hypoxia (oxygen deficit) may occur.

Neurologic status -- The awake patient usually is able to carry on reasonably appropriate social conversation. However, they still may have disabling neurocognitive deficits similar to those suffering blunt head injuries. These may not be apparent until the person tries to return to their previous work and is unable to process new information, organize their activities, and perform other tasks.

Pain -- There may be pain, numbness, or other abnormal sensations. Chronic pain syndromes may develop from lightning injuries, often due to sympathetic nervous system injury.

Sympathetic nervous system -- Sympathetic nervous system injury may cause vascular spasm, temporary paralysis and mottling of an extremity, transient hypertension, late problems with positive tilt tests, vertigo/dizziness, and pain syndromes.

Brain injury -- If the victim is unconscious, there may be underlying brain injury.

Deep burns -- Since lightning only has extremely brief contact with the skin, deep burns are quite rare. If they do occur, these electrical burns should be treated like any other high voltage injuries.

Superficial burns -- Burns from lightning may be linear, punctate, or fernlike. They may be secondary to metal heating, such as necklaces, coins in the pocket, or cleats on the bottom of athletic shoes.

Ear drum -- Rupture is common and may occur from direct current entry (often, burns to the canal or disruption of the ossicles) from concussive/explosive force or from basilar skull fracture.

Risk factors -- The risk factors include being out in bad weather without knowing the forecast, not paying attention to the weather, not having an evacuation plan, or not following the plan. Certain areas geographically are more prone to lightning, such as mountain ridges between 3-5 PM, parts of Florida and the Gulf Coast, the East Coast, and along major river valley areas.

Treatment -- Resuscitation is the top immediate priority. Next comes immobilization for fractures.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to prevent long-term neurological damage and to treat chronic pain syndromes that may develop from sympathetic nervous system injuries caused by lightning. The NSAIDs used include ibuprofen (Motrin, Advil, Ibuprin), ketoprofen (Oruvail), and naproxen (Anaprox, Aleve).

Prevention of lightning injuries -- Awareness of weather forecasts before outdoor activities are begin with appropriate evacuation/shelter plans made beforehand. Awareness of local thunderstorm patterns (i.e., 3-5 PM on mountain slopes is a common time for thunderstorms to occur.)

Individuals are ultimately responsible for their own safety and for that of any children in their care. The courts are beginning to rule on "Duty to Warn" for golf courses, large recreation facilities (stadiums), and other large facilities.

Evacuation -- When lightning is seen or thunder is heard, there is danger. Lightning may travel as far as 10-12 miles in front of a thunderstorm; clouds need not be overhead and rain need not be present.

Shelter -- If possible, shelter should be in a substantial or habitable building or in a metal-topped enclosed vehicle.

School buses -- are excellent shelters for golf tournaments or other outdoor activities.

Stay away from -- trees, small shelters, bleachers (wood or metal), fences, towers, and other current transmitting structures; get out of the water, pools, and wet areas; get off high areas, such as ridges and mountains, when thunderstorms are likely.

Avoid use of -- telephones, electronic equipment, or any contact with conductive surfaces inside a structure (e.g., plumbing, doing the dishes) during a thunderstorm.

Resumption of activity -- Activities should not be resumed until 30 minutes after the last lightning bolt is seen or thunder is heard. This provides about a 90-95% confidence interval.

A simple safety teaching tool for children is, "If you can see it, FLEE it, if you can hear it, CLEAR it."