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A shocking injury: A clinical review of lightning injuries highlighting pitfalls and a treatment protocol

Open AccessPublished:August 17, 2022DOI:https://doi.org/10.1016/j.injury.2022.08.024

      Abstract

      Introduction

      Lightning strikes have high morbidity and mortality rates. Thousands of fatalities are estimated to be caused by lightning worldwide, with the number of injuries being 10 times greater. However, evidence of lightning injuries is restricted to case reports and series and nonsystematic reviews. In this clinical review, we systematically select, score, and present evidence regarding lightning injuries.

      Material and methods

      We performed a systematic search for reviews and guidelines in the PubMed, Embase (OvidSP), MEDLINE (OvidSP), and Web of Science databases. All publications were scored according to the Levels of Evidence 2 Table of the Oxford center for Evidence-Based Medicine. The reviews were also scored using the scale for the quality assessment of narrative review articles (SANRA) and guidelines from the Appraisal of Guidelines for Research & Evaluation (AGREE II).

      Results

      The search yielded 536 articles. Eventually, 56 articles were included, which consisted of 50 reviews, five guidelines and one overview. The available reviews and guidelines were graded as low to moderate evidence. Most damage from lightning injuries is cardiovascular and neurological, although an individual can experience complications with any of their vital functions. At the scene, initial treatment and resuscitation should focus on those who appear to be dead, which is called the reverse triage system. We proposed an evidence-based treatment protocol for lightning strike patients.

      Conclusion

      It is vital that every lightning strike patient is treated according to standard trauma guidelines, with a specific focus on the possible sequelae of lighting injuries. All emergency healthcare professionals should acknowledge the risks and particularities of treating lighting strike injuries to optimize the care and outcomes of these patients. Our evidence-based treatment protocol should help prehospital and in-hospital emergency healthcare practitioners to prevent therapeutic mismanagement among these patients.

      Keywords

      Introduction

      Lightning strikes an estimated 50–100 times per second worldwide, of which 20% result in actual ground strikes [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Geary S.P.
      • Spencer T.
      • Tilney P.V.
      A 26-year-old man struck by lightning.
      ,
      • Davis C.
      • Engeln A.
      • Johnson E.L.
      • McIntosh S.E.
      • Zafren K.
      • Islas A.A.
      • et al.
      Wilderness medical society practice guidelines for the prevention and treatment of lightning injuries: 2014 update.
      ]. Thousands of fatalities are estimated to occur annually due to lightning, with the number of injuries being 10 times greater [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Geary S.P.
      • Spencer T.
      • Tilney P.V.
      A 26-year-old man struck by lightning.
      ,
      • Davis C.
      • Engeln A.
      • Johnson E.L.
      • McIntosh S.E.
      • Zafren K.
      • Islas A.A.
      • et al.
      Wilderness medical society practice guidelines for the prevention and treatment of lightning injuries: 2014 update.
      ,
      • Okafor U.V.
      Lightning injuries and acute renal failure: a review.
      ]. Data on lightning mortality rates in India support these estimations, where 1755 lightning deaths occur on average each year [
      • Holle R.L.
      A summary of recent national-scale lightning fatality studies.
      ]. Nevertheless, presentation at a healthcare facility seems rare. Retrospective studies of large hospitals have indicated that each year, approximately 1 in 35,000–40,000 patients is hospitalized due to lightning [
      • Pfortmueller C.A.
      • Yikun Y.
      • Haberkern M.
      • Wuest E.
      • Zimmermann H.
      • Exadaktylos A.K.
      Injuries, sequelae, and treatment of lightning-induced injuries: 10 years of experience at a swiss trauma center.
      ,
      • Tolouie M.
      • Farzan R.
      A six-year study on epidemiology of electrical burns in Northern Iran: is it time to pay attention?.
      ,
      • Glatstein M.M.
      • Ayalon I.
      • Miller E.
      • Scolnik D.
      Pediatric electrical burn injuries: experience of a large tertiary care hospital and a review of electrical injury.
      ]. With the current data, it remains difficult to conclude anything regarding the exact number of lightning strike patients, who eventually present at the emergency department.
      Why lightning injuries are underreported remains unknown. However, lightning can inflict serious damage on victims. Lightning can expose the body to over 1000,000 Vs and 10,000–200,000 As, which is classified as a high voltage injury [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Zack F.
      • Rothschild M.A.
      • Wegener R.
      Blitzunfall – Energieübertragungsmechanismen und medizinische Folgen.
      ,
      • Whitcomb D.
      • Martinez J.A.
      • Daberkow D.
      Lightning injuries.
      ]. The most critical difference from other high voltage injuries is the duration of exposure. A person's exposure to lightning is very short, typically lasting from 1/1000 s to 1/10 s [
      • Okafor U.V.
      Lightning injuries and acute renal failure: a review.
      ,
      • Whitcomb D.
      • Martinez J.A.
      • Daberkow D.
      Lightning injuries.
      ,
      • Roberts S.
      • Meltzer J.A.
      An evidence-based approach to electrical injuries in children.
      ]. Because of this short exposure period, only a small amount of energy is transferred internally, while the majority of the energy flows externally over the victim's body, which is also known as the “flashover” effect [
      • Okafor U.V.
      Lightning injuries and acute renal failure: a review.
      ,
      • Whitcomb D.
      • Martinez J.A.
      • Daberkow D.
      Lightning injuries.
      ,
      • Ritenour A.E.
      • Morton M.J.
      • McManus J.G.
      • Barillo D.J.
      • Cancio L.C.
      Lightning injury: a review.
      ]. Due to the flashover effect, a person can actually survive a lightning strike. However, this effect also causes a much more serious injury pattern compared with other high voltage injuries, and lightning injuries have a 5–10 times higher estimated morbidity rate [
      • Rotariu E.L.
      • Manole M.D.
      Cardiac arrest secondary to lightning strike: case report and review of the literature.
      ,
      • Koumbourlis A.C.
      Electrical injuries.
      ].
      In addition to the electrical current, patients can be injured by the extreme temperature of lightning or through a blast wave [
      • Zack F.
      • Rothschild M.A.
      • Wegener R.
      Blitzunfall – Energieübertragungsmechanismen und medizinische Folgen.
      ]. Strike temperatures are reported to rise as high as 30,000 °C [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Zack F.
      • Rothschild M.A.
      • Wegener R.
      Blitzunfall – Energieübertragungsmechanismen und medizinische Folgen.
      ]. A blast wave causes injury through an explosion occurring in the air around the lightning channel. The electrical current often contributes to severe damage in patients, whereas severe injuries caused by blast waves or high temperature are rarer [
      • Ritenour A.E.
      • Morton M.J.
      • McManus J.G.
      • Barillo D.J.
      • Cancio L.C.
      Lightning injury: a review.
      ].
      Lightning injuries can be classified through seven mechanisms, which are presented in Table 1 [
      • Okafor U.V.
      Lightning injuries and acute renal failure: a review.
      ,
      • Zack F.
      • Rothschild M.A.
      • Wegener R.
      Blitzunfall – Energieübertragungsmechanismen und medizinische Folgen.
      ,
      • Ritenour A.E.
      • Morton M.J.
      • McManus J.G.
      • Barillo D.J.
      • Cancio L.C.
      Lightning injury: a review.
      ,
      • Thomson E.M.
      • Howard T.M.
      Lightning injuries in sports and recreation.
      ,
      • O'Keefe Gatewood M.
      • Zane R.D
      Lightning injuries.
      ,
      • Blumenthal R.
      Lightning and the forensic pathologist.
      ].
      Table 1Types of lightning strike mechanisms.
      Mechanism
      1 Direct strikeLightning strikes the victim and the current passes through the body. Entry and exit wounds are often found.
      2 Contact injuryLightning strikes an object that is touched by the victim.
      3 Side flash injuryLightning strikes a nearby object (e.g., a tree) and flashes over to the victim.
      4 Ground strike

      (most common)
      Lightning strikes the ground and passes to the victim. The current enters the body through one leg and exits through the other.
      5 Upward streamCurrent flows through the body from the ground upwards.
      6 Blast injurySuch injuries occur through a blast wave, through an explosion of nearby structures (which can cause penetrating injuries), or through the victim falling or being thrown.
      7 Phone electrocutionA bolt of lightning that strikes a telephone line can cause an electrical surge to shoot through the wires and enter a handset. Nowadays, the odds of this are extremely small due to the use of wireless phones.
      Which type of injury will occur in a lightning strike victim is determined by the type of mechanism, current (A), path of current flow across the body, duration of contact, and individual vulnerability [
      • O'Keefe Gatewood M.
      • Zane R.D
      Lightning injuries.
      ]. Due to the many determinants, injuries vary significantly between individuals. Therefore, it is crucial to have a clear overview and sound understanding of these injuries. Considering the low documented incidence (some case reports and case series), assessing lighting strike patients and treating their injuries are challenging. The guidelines for treating lightning injuries remain poor and hardly any contain recommendations based on a systematic review of existing evidence. Therefore, the aim of this clinical review is to present the best available evidence regarding the epidemiology, clinical presentation, treatment, and sequalae of lightning injuries from the past 30 years as well as to highlight pitfalls in the approaches to these patients. Then, this clinical review provides an evidence-based treatment protocol, which could be of great use to all emergency healthcare professionals in the prehospital and in-hospital setting.

      Materials and methods

      Search strategy and study selection

      We performed a systematic database search for reviews and guidelines in the PubMed, Embase (OvidSP), MEDLINE (OvidSP), and Web of Science databases. The search strategies are listed in Appendix A. Furthermore, a global search was performed on Google Scholar and UpToDate using the terms “lightning injuries,” “lightning injuries review,” and “medical aspects lightning injuries” to find additional articles. One author (RR) performed this screening. Articles with publication dates after January 1990 up to April 2022 were reviewed if written in Dutch, English, or German. Because of the many case reports and series, which varied significantly in injury presentation, the search was limited to reviews and guidelines. Articles were screened based on their title, abstract, and full-text and were discussed with a second author (ET). Articles were included if they contained relevant information regarding the epidemiology, clinical presentation, treatment, or sequalae of lightning injuries. Additional articles were screened for inclusion through cross-referencing the shortlisted articles.

      Article quality assessment

      The quality of the articles was assessed according to the Levels of Evidence 2 Table of the Oxford center for Evidence-Based Medicine (OCEBM) [

      OCEBM Levels of Evidence Working Group*. “The Oxford Levels of Evidence 2”. Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653. * OCEBM Levels of Evidence Working Group = Jeremy Howick, Iain Chalmers (James Lind Library), Paul Glasziou, Trish Greenhalgh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, Hazel Thornton, Olive Goddard and Mary Hodgkinson (2011).

      ]. With the exception of two articles, all reviews were nonsystematic narrative reviews. These reviews could be considered level 5 evidence or even as nonevidence because of the lack of a systematic methodology. Only one set of included guidelines contained recommendations based on a systematic literature review (published in 2018), and therefore, it was scaled as level 1 evidence. Because of the low evidence quality of the articles, the recommendations in this articles should be used with caution. To provide a more detailed description of the quality of the included reviews and guidelines, reviews were also scored using the scale for the quality assessment of narrative review articles (SANRA) [
      • Baethge C.
      • Goldbeck-Wood S.
      • Mertens S.
      SANRA—A scale for the quality assessment of narrative review articles.
      ] and guidelines from the Appraisal of Guidelines for REsearch & Evaluation (AGREE II) [

      AGREE Next Steps Consortium (2017). The AGREE II Instrument [Electronic version]. Retrieved from http://www.agreetrust.org.

      ]. All scores, as well as the most critical characteristics of each article, are listed in Appendix B. When different articles presented conflicting information, their total included references and their quality scores were used as a tool to decide the quality of the information and their contribution to this review.

      Results

      In total, 536 articles were found through the systematic literature search. After duplicates were removed, 231 articles were screened. Eventually, 56 articles were included. Fig. 1 presents a PRISMA chart of the literature search.
      Fig 1
      Fig. 1PRISMA chart of the literature search.

      Prevention of and misconceptions about lightning

      For the sake of prevention, we wish to address some misconceptions about lightning as well as to provide safety tips, which we gleaned from the reviewed articles. Table 2 shows an overview of the misconceptions and safety tips. We feel that this is important to do because misconceptions could lead to inadequate risk mitigation before a lightning strike as well as inadequate treatment after one occurs.
      Table 2Lightning facts and safety tips.
      Lightning factsLightning safety tips

      Epidemiology

      Based on patient data, men are four to five times more likely to be struck by lightning than women and victims are mostly healthy young individuals [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Ritenour A.E.
      • Morton M.J.
      • McManus J.G.
      • Barillo D.J.
      • Cancio L.C.
      Lightning injury: a review.
      ,
      • O'Keefe Gatewood M.
      • Zane R.D
      Lightning injuries.
      ,
      • Schlein S.M.
      • Marcolini P.G.
      • Marcolini E.G.
      Wilderness neurology.
      ,
      • Hinkelbein J.
      • Spelten O.
      • Wetsch W.A.
      [Lightning strikes and lightning injuries in prehospital emergency medicine. relevance, results, and practical implications].
      ,
      • Cherington M.
      Neurologic manifestations of lightning strikes.
      ,
      • García Gutiérrez J.J.
      • Meléndez J.
      • Torrero J.V.
      • Obregón O.
      • Uceda M.
      • Gabilondo F.J.
      Lightning injuries in a pregnant woman: a case report and review of the literature.
      ]. Worldwide, most incidents occur during the summer months and in the afternoon or early evening [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Ritenour A.E.
      • Morton M.J.
      • McManus J.G.
      • Barillo D.J.
      • Cancio L.C.
      Lightning injury: a review.
      ,
      • O'Keefe Gatewood M.
      • Zane R.D
      Lightning injuries.
      ,
      • Hinkelbein J.
      • Spelten O.
      • Wetsch W.A.
      [Lightning strikes and lightning injuries in prehospital emergency medicine. relevance, results, and practical implications].
      ,
      • Cherington M.
      Neurologic manifestations of lightning strikes.
      ,
      • García Gutiérrez J.J.
      • Meléndez J.
      • Torrero J.V.
      • Obregón O.
      • Uceda M.
      • Gabilondo F.J.
      Lightning injuries in a pregnant woman: a case report and review of the literature.
      ,
      • Lederer W.
      • Kroesen G.
      [Emergency treatment of injuries following lightning and electrical accidents].
      ,
      • Lederer W.
      • Wiedermann F.J.
      • Cerchiari E.
      • Baubin M.A.
      Electricity-associated injuries II: outdoor management of lightning-induced casualties.
      ]. Furthermore, 9–30% of injuries are multi-casualty incidents [
      • Whitcomb D.
      • Martinez J.A.
      • Daberkow D.
      Lightning injuries.
      ,
      • Hinkelbein J.
      • Spelten O.
      • Wetsch W.A.
      [Lightning strikes and lightning injuries in prehospital emergency medicine. relevance, results, and practical implications].
      ,
      • García Gutiérrez J.J.
      • Meléndez J.
      • Torrero J.V.
      • Obregón O.
      • Uceda M.
      • Gabilondo F.J.
      Lightning injuries in a pregnant woman: a case report and review of the literature.
      ,
      • Fontanarosa P.B.
      Electrical shock and lightning strike.
      ]. Most injuries occur outdoors where ground strikes or side flash injuries are most common. With ground strikes injuries the lightning strikes the ground and passes to the victim. The current enters the body through one leg and exits through the other. With side flash injuries the lighting strikes a nearby object and flashes over to the victim. About 50% of injuries are ground strike injuries, while side flash injuries contribute from 30% to ≤50% of total injuries. Direct strikes contribute from 3% to 5% of injuries and contact injuries only 1–2% [
      • Davis C.
      • Engeln A.
      • Johnson E.L.
      • McIntosh S.E.
      • Zafren K.
      • Islas A.A.
      • et al.
      Wilderness medical society practice guidelines for the prevention and treatment of lightning injuries: 2014 update.
      ,
      • Thomson E.M.
      • Howard T.M.
      Lightning injuries in sports and recreation.
      ,
      • Schlein S.M.
      • Marcolini P.G.
      • Marcolini E.G.
      Wilderness neurology.
      ,
      • DeFranco M.J.
      • Baker C.L.
      • DaSilva J.J.
      • Piasecki D.P.
      • Bach B.R.
      Environmental issues for team physicians.
      ]. With a direct strike the lightning hits the victim instantly, while with contact injuries the lightning strikes an object that is touched by the victim. Although direct strike injuries are uncommon, they have the highest mortality rates [
      • Davis C.
      • Engeln A.
      • Johnson E.L.
      • McIntosh S.E.
      • Zafren K.
      • Islas A.A.
      • et al.
      Wilderness medical society practice guidelines for the prevention and treatment of lightning injuries: 2014 update.
      ,
      • Gruhn K.M.
      • Knossalla F.
      • Schwenkreis P.
      • Hamsen U.
      • Schildhauer T.A.
      • Tegenthoff M.
      • et al.
      [Neurological diseases after lightning strike : lightning strikes twice].
      ,
      • Cooray V.
      • Cooray C.
      • Andrews C.J.
      Lightning caused injuries in humans.
      ]. Approximately 10–30% of all lightning injuries result in death [
      • Okafor U.V.
      Lightning injuries and acute renal failure: a review.
      ,
      • Whitcomb D.
      • Martinez J.A.
      • Daberkow D.
      Lightning injuries.
      ,
      • Ritenour A.E.
      • Morton M.J.
      • McManus J.G.
      • Barillo D.J.
      • Cancio L.C.
      Lightning injury: a review.
      ,
      • Rotariu E.L.
      • Manole M.D.
      Cardiac arrest secondary to lightning strike: case report and review of the literature.
      ,
      • O'Keefe Gatewood M.
      • Zane R.D
      Lightning injuries.
      ,
      • Zafren K.
      • Durrer B.
      • Herry J.P.
      • Brugger H.
      Lightning injuries: prevention and on-site treatment in mountains and remote areas. official guidelines of the International Commission for Mountain Emergency Medicine and the Medical Commission of the International Mountaineering and Climbing Federation (ICAR and UIAA MEDCOM).
      ,
      • Hinkelbein J.
      • Spelten O.
      • Wetsch W.A.
      [Lightning strikes and lightning injuries in prehospital emergency medicine. relevance, results, and practical implications].
      ,
      • Lederer W.
      • Kroesen G.
      [Emergency treatment of injuries following lightning and electrical accidents].
      ,
      • DeFranco M.J.
      • Baker C.L.
      • DaSilva J.J.
      • Piasecki D.P.
      • Bach B.R.
      Environmental issues for team physicians.
      ,
      • Gruhn K.M.
      • Knossalla F.
      • Schwenkreis P.
      • Hamsen U.
      • Schildhauer T.A.
      • Tegenthoff M.
      • et al.
      [Neurological diseases after lightning strike : lightning strikes twice].
      ,
      • Cooray V.
      • Cooray C.
      • Andrews C.J.
      Lightning caused injuries in humans.
      ,
      • Forster S.A.
      • Silva I.M.
      • Ramos M.L.
      • Gragnani A.
      • Ferreira L.M.
      Lightning burn–review and case report.
      ,
      Part 8: advanced challenges in resuscitation section 3: special challenges in ECC: 3G: electric shock and lightning strikes.
      ,
      • Spies C.
      • Trohman R.G.
      Electrocution and life-threatening electrical injuries.
      ]. Worldwide, mortality is estimated to be 0.2–1.7 deaths per million people per year, but the incidence differs per region [
      • Ritenour A.E.
      • Morton M.J.
      • McManus J.G.
      • Barillo D.J.
      • Cancio L.C.
      Lightning injury: a review.
      ,
      • Forster S.A.
      • Silva I.M.
      • Ramos M.L.
      • Gragnani A.
      • Ferreira L.M.
      Lightning burn–review and case report.
      ]. A recent study by Holle presented published data of mortality rates per country [
      • Holle R.L.
      A summary of recent national-scale lightning fatality studies.
      ]. Africa topped the list with mortality rates up to 84 deaths per million people per year, followed by countries in Asia and North and South America. Mortality rates in Europe were the lowest with an average of 0.1–0.4 deaths per million people per year. This discrepancy in mortality rates is due to the lack of lightning-safe facilities and fewer fully enclosed metal-topped vehicles, higher rates of labor-intensive agriculture, lack of awareness, and poor medical treatment in less developed countries [
      • Holle R.L.
      A summary of recent national-scale lightning fatality studies.
      ].

      Clinical presentation

      Although clinical presentation in lightning strike victims varies greatly per individual, signs and symptoms of lightning strike victims are explained by the current following the path of least resistance. Nerves have the least resistance, followed by blood, muscles, skin, fat, and bones [
      • Schlein S.M.
      • Marcolini P.G.
      • Marcolini E.G.
      Wilderness neurology.
      ,
      • Mason A.D.
      • Crockett R.K.
      When lighting strikes... a case report and review of the literature.
      ,
      • Lederer W.
      • Kroesen G.
      [Emergency treatment of injuries following lightning and electrical accidents].
      ,
      • Gruhn K.M.
      • Knossalla F.
      • Schwenkreis P.
      • Hamsen U.
      • Schildhauer T.A.
      • Tegenthoff M.
      • et al.
      [Neurological diseases after lightning strike : lightning strikes twice].
      ,
      • Forster S.A.
      • Silva I.M.
      • Ramos M.L.
      • Gragnani A.
      • Ferreira L.M.
      Lightning burn–review and case report.
      ,
      • Edlich R.F.
      • Farinholt H.M.
      • Winters K.L.
      • Britt L.D.
      • Long W.B.
      Modern concepts of treatment and prevention of lightning injuries.
      ]; this may explain why neurological and cardiovascular damage are the most common and severe forms among these patients. In contrast to other high voltage injuries, burns are mostly not severe due to the short exposure time of patients [
      • Cherington M.
      Neurologic manifestations of lightning strikes.
      ,
      • Lederer W.
      • Kroesen G.
      [Emergency treatment of injuries following lightning and electrical accidents].
      ]. Table 3 presents which injuries are observed.
      Table 3Clinical characteristics of a lightning victim.
      ORGAN SYSTEMINJURIESIMPORTANT NOTES
      CardiovascularOften: Cardiac and respiratory arrest, hypertension, tachycardia, and non-specific ECG changes (QT prolongation, T-wave inversion and ST alteration) [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Geary S.P.
      • Spencer T.
      • Tilney P.V.
      A 26-year-old man struck by lightning.
      ,
      • Davis C.
      • Engeln A.
      • Johnson E.L.
      • McIntosh S.E.
      • Zafren K.
      • Islas A.A.
      • et al.
      Wilderness medical society practice guidelines for the prevention and treatment of lightning injuries: 2014 update.
      ,
      • Whitcomb D.
      • Martinez J.A.
      • Daberkow D.
      Lightning injuries.
      ,
      • Thomson E.M.
      • Howard T.M.
      Lightning injuries in sports and recreation.
      ,
      • García Gutiérrez J.J.
      • Meléndez J.
      • Torrero J.V.
      • Obregón O.
      • Uceda M.
      • Gabilondo F.J.
      Lightning injuries in a pregnant woman: a case report and review of the literature.
      ,
      • Lederer W.
      • Wiedermann F.J.
      • Cerchiari E.
      • Baubin M.A.
      Electricity-associated injuries II: outdoor management of lightning-induced casualties.
      ,
      • Forster S.A.
      • Silva I.M.
      • Ramos M.L.
      • Gragnani A.
      • Ferreira L.M.
      Lightning burn–review and case report.
      ,
      Part 8: advanced challenges in resuscitation section 3: special challenges in ECC: 3G: electric shock and lightning strikes.
      ,
      • Cooper M.A.
      Emergent care of lightning and electrical injuries.
      ].

      Rare: Myocardial infarction, necrosis, reduced ejection fractions, and myocardial contusion [
      • Geary S.P.
      • Spencer T.
      • Tilney P.V.
      A 26-year-old man struck by lightning.
      ,
      • Davis C.
      • Engeln A.
      • Johnson E.L.
      • McIntosh S.E.
      • Zafren K.
      • Islas A.A.
      • et al.
      Wilderness medical society practice guidelines for the prevention and treatment of lightning injuries: 2014 update.
      ,
      • Whitcomb D.
      • Martinez J.A.
      • Daberkow D.
      Lightning injuries.
      ,
      • Thomson E.M.
      • Howard T.M.
      Lightning injuries in sports and recreation.
      ,
      • O'Keefe Gatewood M.
      • Zane R.D
      Lightning injuries.
      ,
      • Galster K.
      • Hodnick R.
      • Berkeley R.P.
      Lightning strike in pregnancy with fetal injury.
      ,
      • Lederer W.
      • Wiedermann F.J.
      • Cerchiari E.
      • Baubin M.A.
      Electricity-associated injuries II: outdoor management of lightning-induced casualties.
      ,
      • Forster S.A.
      • Silva I.M.
      • Ramos M.L.
      • Gragnani A.
      • Ferreira L.M.
      Lightning burn–review and case report.
      ,
      Part 8: advanced challenges in resuscitation section 3: special challenges in ECC: 3G: electric shock and lightning strikes.
      ,
      • Browne B.J.
      • Gaasch W.R.
      Electrical injuries and lightning.
      ].
      Neurologic
      DermatologicBurns are mostly superficial and only 5–10% are full-thickness burns. Burns are classified as:
      RenalAcute renal failure (ARF) due to rhabdomyolysis/myoglobinuria and muscle breakdown is rare but must be excluded [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Geary S.P.
      • Spencer T.
      • Tilney P.V.
      A 26-year-old man struck by lightning.
      ,
      • Roberts S.
      • Meltzer J.A.
      An evidence-based approach to electrical injuries in children.
      ,
      • Blumenthal R.
      Lightning and the forensic pathologist.
      ,
      • Mason A.D.
      • Crockett R.K.
      When lighting strikes... a case report and review of the literature.
      ,
      • DeFranco M.J.
      • Baker C.L.
      • DaSilva J.J.
      • Piasecki D.P.
      • Bach B.R.
      Environmental issues for team physicians.
      ,
      • Gentges J.
      • Schieche C.
      Electrical injuries in the emergency department: an evidence-based review.
      ,
      • Fish R.M.
      Electric injury, part III: cardiac monitoring indications, the pregnant patient, and lightning.
      ].
      • -
        3–15% of those suffering major strike injuries develop ARF
        • Okafor U.V.
        Lightning injuries and acute renal failure: a review.
        .
      Ear>50% of patients have auditory and/or balancing organ damage with (bilateral) tympanic membrane rupture in >50% as well [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Geary S.P.
      • Spencer T.
      • Tilney P.V.
      A 26-year-old man struck by lightning.
      ,
      • Davis C.
      • Engeln A.
      • Johnson E.L.
      • McIntosh S.E.
      • Zafren K.
      • Islas A.A.
      • et al.
      Wilderness medical society practice guidelines for the prevention and treatment of lightning injuries: 2014 update.
      ,
      • Okafor U.V.
      Lightning injuries and acute renal failure: a review.
      ,
      • Zack F.
      • Rothschild M.A.
      • Wegener R.
      Blitzunfall – Energieübertragungsmechanismen und medizinische Folgen.
      ,
      • Whitcomb D.
      • Martinez J.A.
      • Daberkow D.
      Lightning injuries.
      ,
      • Koumbourlis A.C.
      Electrical injuries.
      ,
      • O'Keefe Gatewood M.
      • Zane R.D
      Lightning injuries.
      ,
      • Schlein S.M.
      • Marcolini P.G.
      • Marcolini E.G.
      Wilderness neurology.
      ,
      • Hinkelbein J.
      • Spelten O.
      • Wetsch W.A.
      [Lightning strikes and lightning injuries in prehospital emergency medicine. relevance, results, and practical implications].
      ,
      • Mason A.D.
      • Crockett R.K.
      When lighting strikes... a case report and review of the literature.
      ,
      • Cherington M.
      Neurologic manifestations of lightning strikes.
      ,
      • Lederer W.
      • Kroesen G.
      [Emergency treatment of injuries following lightning and electrical accidents].
      ,
      • Edlich R.F.
      • Farinholt H.M.
      • Winters K.L.
      • Britt L.D.
      • Long W.B.
      Modern concepts of treatment and prevention of lightning injuries.
      ]. Transient vertigo is the most frequent vestibular symptom
      • Modayil P.C.
      • Lloyd G.W.
      • Mallik A.
      • Bowdler D.A.
      Inner ear damage following electric current and lightning injury: a literature review.
      . Inner ear damage is more rare, but can cause sensorineural hearing loss
      • Modayil P.C.
      • Lloyd G.W.
      • Mallik A.
      • Bowdler D.A.
      Inner ear damage following electric current and lightning injury: a literature review.
      .
      - Always check the tympanic membrane.

      Ocular50% of patients have eye injuries with (bilateral) cataract as most present injury [
      • Roberts S.
      • Meltzer J.A.
      An evidence-based approach to electrical injuries in children.
      ,
      • Ritenour A.E.
      • Morton M.J.
      • McManus J.G.
      • Barillo D.J.
      • Cancio L.C.
      Lightning injury: a review.
      ,
      • Koumbourlis A.C.
      Electrical injuries.
      ,
      • Lederer W.
      • Kroesen G.
      [Emergency treatment of injuries following lightning and electrical accidents].
      ,
      • Cooray V.
      • Cooray C.
      • Andrews C.J.
      Lightning caused injuries in humans.
      ,
      • Edlich R.F.
      • Farinholt H.M.
      • Winters K.L.
      • Britt L.D.
      • Long W.B.
      Modern concepts of treatment and prevention of lightning injuries.
      ,
      • Kumar A.
      • Srinivas V.
      • Sahu B.P.
      Keraunoparalysis: what a neurosurgeon should know about it?.
      ].
      FetalThe low number of cases reported and their poor monitoring does not allow the drawing of conclusions [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Davis C.
      • Engeln A.
      • Johnson E.L.
      • McIntosh S.E.
      • Zafren K.
      • Islas A.A.
      • et al.
      Wilderness medical society practice guidelines for the prevention and treatment of lightning injuries: 2014 update.
      ,
      • Koumbourlis A.C.
      Electrical injuries.
      ,
      • García Gutiérrez J.J.
      • Meléndez J.
      • Torrero J.V.
      • Obregón O.
      • Uceda M.
      • Gabilondo F.J.
      Lightning injuries in a pregnant woman: a case report and review of the literature.
      ].
      • -
        There are no important notes, because no conclusions can be drawn from the literature regarding fetal injury.
      BluntFractures and internal organ damage are rare [
      • Zack F.
      • Rothschild M.A.
      • Wegener R.
      Blitzunfall – Energieübertragungsmechanismen und medizinische Folgen.
      ,
      • Zimmermann C.
      • Cooper M.A.
      • Holle R.L.
      Lightning safety guidelines.
      ,
      • Lederer W.
      • Kroesen G.
      [Emergency treatment of injuries following lightning and electrical accidents].
      ].

      Treatment

      Given the highly variable clinical presentation of a lightning strike victim, treatment should follow standard trauma guidelines according to Advanced Trauma Life Support (ATLS) [
      • Geary S.P.
      • Spencer T.
      • Tilney P.V.
      A 26-year-old man struck by lightning.
      ,
      • DeFranco M.J.
      • Baker C.L.
      • DaSilva J.J.
      • Piasecki D.P.
      • Bach B.R.
      Environmental issues for team physicians.
      ,
      • Forster S.A.
      • Silva I.M.
      • Ramos M.L.
      • Gragnani A.
      • Ferreira L.M.
      Lightning burn–review and case report.
      ,
      Part 8: advanced challenges in resuscitation section 3: special challenges in ECC: 3G: electric shock and lightning strikes.
      ]. Additionally, it is crucial to present the risks and particularities in the treatment of these patients.

      Diagnosis at scene

      When diagnosis is unclear, critical clues pointing to lightning injuries are unexplained burns, specific sequelae such as Lichtenberg figures (Fig. 2), singed hair, torn clothes, molten metal, and tympanic membrane ruptures [
      • Okafor U.V.
      Lightning injuries and acute renal failure: a review.
      ,
      • Zack F.
      • Rothschild M.A.
      • Wegener R.
      Blitzunfall – Energieübertragungsmechanismen und medizinische Folgen.
      ,
      • Koumbourlis A.C.
      Electrical injuries.
      ,
      • Hinkelbein J.
      • Spelten O.
      • Wetsch W.A.
      [Lightning strikes and lightning injuries in prehospital emergency medicine. relevance, results, and practical implications].
      ,
      • Conrad L.
      Clinical update on lightning injuries.
      ].
      Fig 2
      Fig. 2Lichtenberg figure. Used with permission from Mahajan AL, Rajan R, Regan PJ. Lichtenberg figures: cutaneous manifestation of phone electrocution from lightning. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2008;61:111–3. © Elsevier.

      Reverse triage

      Apart from immediate cardiac arrest, lightning strike does not usually cause any immediately life-threatening injuries. This suggests that victims who are not in cardiac arrest upon arrival will most likely not die within the next 30–60 min [
      • O'Keefe Gatewood M.
      • Zane R.D
      Lightning injuries.
      ,
      • Cooper M.A.
      Emergent care of lightning and electrical injuries.
      ,
      • Blancher M.
      • Albasini F.
      • Elsensohn F.
      • Zafren K.
      • Hölzl N.
      • McLaughlin K.
      • et al.
      Management of multi-casualty incidents in mountain rescue: evidence-Based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM).
      ,
      • Lewis A.M.
      Understanding the principles of lightning injuries.
      ]. Initial treatment and resuscitation should therefore be focused on those who appear dead, which is called reverse triage [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Geary S.P.
      • Spencer T.
      • Tilney P.V.
      A 26-year-old man struck by lightning.
      ,
      • Zack F.
      • Rothschild M.A.
      • Wegener R.
      Blitzunfall – Energieübertragungsmechanismen und medizinische Folgen.
      ,
      • Rotariu E.L.
      • Manole M.D.
      Cardiac arrest secondary to lightning strike: case report and review of the literature.
      ,
      • Koumbourlis A.C.
      Electrical injuries.
      ,
      • Thomson E.M.
      • Howard T.M.
      Lightning injuries in sports and recreation.
      ,
      • O'Keefe Gatewood M.
      • Zane R.D
      Lightning injuries.
      ,
      • Zimmermann C.
      • Cooper M.A.
      • Holle R.L.
      Lightning safety guidelines.
      ,
      • Zafren K.
      • Durrer B.
      • Herry J.P.
      • Brugger H.
      Lightning injuries: prevention and on-site treatment in mountains and remote areas. official guidelines of the International Commission for Mountain Emergency Medicine and the Medical Commission of the International Mountaineering and Climbing Federation (ICAR and UIAA MEDCOM).
      ,
      • Hinkelbein J.
      • Spelten O.
      • Wetsch W.A.
      [Lightning strikes and lightning injuries in prehospital emergency medicine. relevance, results, and practical implications].
      ,
      • Mason A.D.
      • Crockett R.K.
      When lighting strikes... a case report and review of the literature.
      ,
      • Galster K.
      • Hodnick R.
      • Berkeley R.P.
      Lightning strike in pregnancy with fetal injury.
      ,
      • Lederer W.
      • Wiedermann F.J.
      • Cerchiari E.
      • Baubin M.A.
      Electricity-associated injuries II: outdoor management of lightning-induced casualties.
      ,
      • Fontanarosa P.B.
      Electrical shock and lightning strike.
      ,
      • Spies C.
      • Trohman R.G.
      Electrocution and life-threatening electrical injuries.
      ,
      • Browne B.J.
      • Gaasch W.R.
      Electrical injuries and lightning.
      ,
      • Blancher M.
      • Albasini F.
      • Elsensohn F.
      • Zafren K.
      • Hölzl N.
      • McLaughlin K.
      • et al.
      Management of multi-casualty incidents in mountain rescue: evidence-Based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM).
      ,
      • Jain S.
      • Bandi V.
      Electrical and lightning injuries.
      ,
      Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency cardiac care committee and subcommittees, American Heart Association. Part IV. Special resuscitation situations.
      ,
      • Conrad L.
      Clinical update on lightning injuries.
      ,
      • Kumar A.
      • Srinivas V.
      • Sahu B.P.
      Keraunoparalysis: what a neurosurgeon should know about it?.
      ,
      • Lewis A.M.
      Understanding the principles of lightning injuries.
      ,
      • Schissler K.
      • Pruden C.
      Pediatric electrical injuries in the emergency department: an evidence-based review.
      ].

      Initial assessment

      Initial assessment can proceed as usual. However, prehospital providers should keep in mind a few important aspects of the prehospital trauma care of a lightning strike patient:

      Hospitalization

      All patients should be presented to a hospital to rule out morbidity [
      • O'Keefe Gatewood M.
      • Zane R.D
      Lightning injuries.
      ,
      • Hinkelbein J.
      • Spelten O.
      • Wetsch W.A.
      [Lightning strikes and lightning injuries in prehospital emergency medicine. relevance, results, and practical implications].
      ,
      • Lederer W.
      • Kroesen G.
      [Emergency treatment of injuries following lightning and electrical accidents].
      ,
      • Lederer W.
      • Wiedermann F.J.
      • Cerchiari E.
      • Baubin M.A.
      Electricity-associated injuries II: outdoor management of lightning-induced casualties.
      ,
      • Gentges J.
      • Schieche C.
      Electrical injuries in the emergency department: an evidence-based review.
      ,
      • Schissler K.
      • Pruden C.
      Pediatric electrical injuries in the emergency department: an evidence-based review.
      ]. Furthermore, all patients should have an ECG, blood test and urinalysis. One should look specifically for QT prolongation, T-wave inversion and ST alteration. Minimum laboratory examinations should include a complete blood count, myoglobin, electrolytes, blood urea nitrogen, creatinine, creatine phosphokinase, creatine kinase-MB, coagulation panel, troponin and urinalysis, including a test for myoglobin on fresh urine [
      • Whitcomb D.
      • Martinez J.A.
      • Daberkow D.
      Lightning injuries.
      ,
      • Roberts S.
      • Meltzer J.A.
      An evidence-based approach to electrical injuries in children.
      ,
      • Thomson E.M.
      • Howard T.M.
      Lightning injuries in sports and recreation.
      ,
      • O'Keefe Gatewood M.
      • Zane R.D
      Lightning injuries.
      ,
      • DeFranco M.J.
      • Baker C.L.
      • DaSilva J.J.
      • Piasecki D.P.
      • Bach B.R.
      Environmental issues for team physicians.
      ,
      • Forster S.A.
      • Silva I.M.
      • Ramos M.L.
      • Gragnani A.
      • Ferreira L.M.
      Lightning burn–review and case report.
      ,
      • Cooper M.A.
      Emergent care of lightning and electrical injuries.
      ,
      • Schissler K.
      • Pruden C.
      Pediatric electrical injuries in the emergency department: an evidence-based review.
      ]. Lightning survivors with normal vital functions (i.e. heart rate, blood pressure and saturation), normal ECG, normal blood tests and normal urinalysis can safely be discharged after 12–24 h [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Cooray V.
      • Cooray C.
      • Andrews C.J.
      Lightning caused injuries in humans.
      ,
      • Cooper M.A.
      Emergent care of lightning and electrical injuries.
      ,

      Duane S Pinto P.F.C. Environmental and weapon-related electrical injuries. 2020.

      ]. However, patients with high-risk findings should stay for at least 24 h and be closely monitored in either a Medium Care Unit (MCU) or Intensive Care Unit (ICU) [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Davis C.
      • Engeln A.
      • Johnson E.L.
      • McIntosh S.E.
      • Zafren K.
      • Islas A.A.
      • et al.
      Wilderness medical society practice guidelines for the prevention and treatment of lightning injuries: 2014 update.
      ,
      • Okafor U.V.
      Lightning injuries and acute renal failure: a review.
      ,
      • Cherington M.
      Neurologic manifestations of lightning strikes.
      ,
      • Gruhn K.M.
      • Knossalla F.
      • Schwenkreis P.
      • Hamsen U.
      • Schildhauer T.A.
      • Tegenthoff M.
      • et al.
      [Neurological diseases after lightning strike : lightning strikes twice].
      ]. High-risk findings are suspected direct strike, loss of consciousness, chest pain, dyspnea, cranial burns, leg burns, burns >10% of total body surface area (TBSA), persisting neurological damage, and pregnancy. In hospital, treatment should mainly focus on repeated and ongoing assessments, as the physical findings and mental state of lightning strike patients tend to change considerably over the first few hours. Alteration in mental state or new focal neurologic deficit indicates the need to obtain additional imaging studies, like CT. Lab studies that were abnormal upon admission should be repeated. Other laboratories are obtained based upon diagnosis. Hyponatremia may result in brain edema. As lightning strike patients are already at risk of developing cerebral edema, close monitoring of the serum sodium levels and immediate correction of electrolyte abnormalities are therefore necessary. Lightning strike patients with traumatic brain injury may have indications for intracranial pressure monitoring. Furthermore, it is important to monitor fluid status in the severely burned lightning strike patient. Clinical signs of volume status, such as blood pressure, capillary refill, heart rate, color and turgor of the skin should be closely monitored for the first 24 h [
      • Jensen J.D.
      • Thurman J.
      • Vincent A.L.
      Lightning injuries. statpearls.
      ,
      • Davis C.
      • Engeln A.
      • Johnson E.L.
      • McIntosh S.E.
      • Zafren K.
      • Islas A.A.
      • et al.
      Wilderness medical society practice guidelines for the prevention and treatment of lightning injuries: 2014 update.
      ,
      • Zack F.
      • Rothschild M.A.
      • Wegener R.
      Blitzunfall – Energieübertragungsmechanismen und medizinische Folgen.
      ,
      • Whitcomb