Lightning Strike Injuries 

Lightning injury is a high-voltage, short-duration electrical injury with unique pathophysiology. Unlike industrial electrical injuries (prolonged contact), lightning delivers millions of volts in microseconds, producing cardiac arrest and respiratory arrest as primary events.

Mechanism of Lightning Injury

1️⃣ Direct Strike

• Current passes directly through body
• Rare but often fatal

2️⃣ Side Flash (Splash)

• Lightning hits object → jumps to victim

3️⃣ Ground Current (Most Common)

• Lightning strikes ground → spreads radially
• Current enters one leg, exits the other

4️⃣ Contact Injury

• Touching struck object

5️⃣ Blast Injury

• Shock wave → barotrauma

 Physics Relevant for CCM

• Voltage: up to 300 million volts
• Current: up to 30,000–50,000 A
• Duration: microseconds
• Skin resistance rapidly decreases
• “Flashover phenomenon” → current travels over body surface

 Therefore:

• Deep muscle necrosis is LESS than industrial electrical injury
• Cardiac arrest is primary cause of death

Pathophysiology

1️⃣ Cardiac Effects (Most Important)

Lightning causes:

• Simultaneous depolarization of entire myocardium

Initial rhythm:

• Asystole (most common immediate arrest rhythm)

Then:

• SA node may recover spontaneously
• BUT respiratory arrest persists → secondary hypoxia → PEA

Cardiac rhythm may recover before respiration → prolonged apnea is common cause of death.

Arrhythmias:

• VF
• AF
• QT prolongation
• ST changes
• Myocardial contusion

2️⃣ Respiratory Effects

• Central respiratory center paralysis
• Medullary dysfunction
• Apnea may persist for minutes

 Immediate ventilatory support can be lifesaving.

3️⃣ Neurological Injury

Most common non-fatal complication.

A. Immediate

• LOC
• Confusion
• Amnesia
• Seizures
• Coma

B. Keraunoparalysis (Pathognomonic)

• Transient limb paralysis
• Pallor
• Pulselessness
• Cold extremity
• Usually resolves in hours

Mechanism: intense vasospasm + autonomic dysfunction

C. Long-term Neurological Complications

• Peripheral neuropathy
• Chronic pain
• Cognitive dysfunction
• PTSD
• Movement disorders

4️⃣ Skin Findings 

A. Lichtenberg Figures (Fern Pattern)

• Pathognomonic
• Superficial capillary rupture
• Disappear within 24 hours

B. Linear Burns

• From vaporized sweat

C. Punctate Burns

• Small entry/exit wounds

D. Thermal Burns

• From ignited clothing/metal

 Deep muscle necrosis uncommon (unlike industrial injury).

5️⃣ Musculoskeletal

• Rhabdomyolysis (less common than electrical injury)
• Fractures from tetanic contraction
• Shoulder dislocation
• Compartment syndrome (rare but possible)

6️⃣ ENT & Eye

• Tympanic membrane rupture (common)
• Sensorineural hearing loss
• Cataracts (delayed, weeks–months)
• Retinal detachment

Cause of Death

1. Immediate:
• Cardiac arrest (asystole)
• Respiratory arrest

2. Secondary:

• Hypoxic brain injury
• Trauma
• Falls
• Drowning

 ICU Management 

 1. Reverse Triage Principle (Very Important)

In mass casualty lightning:

• Patients appearing dead (no pulse, apnea)
• SHOULD be resuscitated first

Why?

• Cardiac rhythm may recover spontaneously
• Respiratory arrest is reversible

 This is opposite to usual triage.

 2. Airway & Breathing

• Early intubation
• Mechanical ventilation
• Treat apnea aggressively
• ABG monitoring

 3. Circulation

• Standard ACLS
• Defibrillate if VF
• Continuous ECG monitoring (at least 24 hrs if ECG abnormal)

Cardiac enzymes if:

• Chest pain
• ECG abnormality

Echo if:

• Suspected contusion

 4. Fluid Management

Unlike electrical injury:

• Massive fluid resuscitation often NOT required

If rhabdomyolysis:

• Target urine output 1–1.5 mL/kg/hr
• Alkalinization controversial
• Monitor CK

 5. Neurological Monitoring

• GCS trend
• Seizure management
• CT brain if persistent deficit
• MRI if spinal symptoms

 6. Trauma Assessment

Remember:

• Fall injuries common
• Spine immobilization

 Complications in ICU

Lightning vs High-Voltage Electrical Injury

 Prognostic Factors

Poor prognosis:

• Prolonged apnea
• Fixed dilated pupils (may be reversible!)
• Severe hypoxic brain injury
• Persistent coma

Good prognosis:

• Keraunoparalysis (usually reversible)
• Isolated cutaneous findings