Management of Lightning Strike Injury
Lightning strike victims should receive immediate resuscitation with priority given to respiratory and cardiac arrest, as patients who do not suffer these complications or who respond to immediate treatment have an excellent chance of recovery. 1
Initial Assessment and Resuscitation
Scene Safety
- Ensure the power source is disconnected before touching the patient to prevent further injury
- Remove any glyceryl trinitrate patches or ointments from the chest wall to prevent explosions 2
Primary Survey
Airway and Breathing:
- Consider traditional A-B-C approach (rather than C-A-B) due to the hypoxic nature of lightning injuries 1, 2
- Early intubation for patients with facial, mouth, or anterior neck burns, even if breathing spontaneously, due to risk of rapid soft-tissue swelling 1, 2
- Confirm tube placement by visualizing the glottis, listening to bilateral breath sounds, and watching for symmetrical chest expansion 2
Circulation:
- Begin high-quality CPR if pulseless
- Apply standard ACLS protocols for cardiac arrhythmias 1, 2
- Be aware that intrinsic cardiac automaticity may spontaneously restore organized cardiac activity, but respiratory arrest may continue 1
- Monitor for delayed cardiac arrhythmias, including atrial fibrillation and ventricular tachycardia 3
Disability:
Exposure:
Special Considerations in Lightning Strike Management
Multiple Victims Protocol
- Reverse triage: Unlike conventional triage, prioritize patients in respiratory or cardiac arrest when multiple victims are struck simultaneously 1, 6, 5
- Victims who appear dead should receive immediate attention as they have the highest potential for recovery with prompt intervention 6
Fluid Management
- Initiate rapid IV fluid administration for victims with significant tissue destruction 1
- Maintain adequate diuresis to facilitate excretion of myoglobin, potassium, and other byproducts of tissue destruction 1
Burn Management
- Apply cold tap water (15° to 25°C) to burn sites to reduce edema, pain, and depth of injury 2
- Continue cooling until pain is relieved, monitoring for hypothermia in patients with extensive burns 2
- Leave burn blisters intact and cover loosely with sterile dressing 2
Cardiac Monitoring
- Continuous cardiac monitoring for at least 24-48 hours due to risk of delayed arrhythmias 3
- Be prepared to treat atrial fibrillation and ventricular tachycardia, which may develop hours after the initial injury 3
Disposition
Criteria for Hospital Admission
- All patients with lightning strike should be admitted for observation, even if initially asymptomatic 3
- Patients with the following require ICU admission:
- Cardiac arrhythmias
- Respiratory distress
- Significant burns
- Altered mental status
- Evidence of neurological injury
Termination of Resuscitation Considerations
- Resuscitation should be continued unless there is evidence of injuries obviously incompatible with life (e.g., decapitation) 1
- Consider termination of resuscitation after at least 30 minutes of unsuccessful resuscitative efforts in traumatic cardiopulmonary arrest 1
Pitfalls to Avoid
- Don't underestimate low-voltage injuries; even household current can cause fatal electrocutions 1, 2
- Don't assume patients are stable if initially asymptomatic; delayed cardiac arrhythmias can occur hours after the strike 3
- Don't forget to assess for and manage associated trauma from falls or being thrown by the lightning strike 7
- Don't neglect continuous cardiac monitoring, even in patients who appear stable 3
- Don't use conventional triage principles when dealing with multiple lightning strike victims 6, 5
Lightning strike injuries require prompt, aggressive management with attention to both immediate life threats and potential delayed complications. With proper care, many victims can survive with good outcomes, particularly when respiratory and cardiac support are provided early.