Makindo Medical Notes

⚡ About

Lightning strikes are life-threatening electrical emergencies caused by the passage of extremely high-voltage direct current (DC) through the body. Although mortality is lower than with other electrical injuries (as many victims are briefly stunned and recover), survivors often sustain severe neurological, cardiac, and cutaneous injuries. Unique features such as Lichtenberg figures make lightning strikes clinically recognisable.

🌩️ Aetiology

• Massive energy discharge: > 10 million volts of DC electricity transmitted in milliseconds.
• Energy may pass directly through the body, over the skin (flashover), or via ground current (“step voltage”).
• Associated with environmental exposure: open fields, water sports, mountaineering.

🩺 Clinical Features

• Skin: Fern-shaped Lichtenberg figures 🌿 (pathognomonic), flash burns, or superficial burns; clothing often shredded or blown off.
• Cardiac: Asystole and ventricular fibrillation are common initial rhythms; arrhythmias may develop later.
• Neurological: Loss of consciousness, seizures, cerebral oedema, keraunoparalysis (transient paralysis with pallor and pulseless limbs that later resolves).
• ENT/Ocular: Ruptured tympanic membranes 👂, cataracts 👁️, retinal damage.
• Other trauma: Secondary blunt injuries from falls, blast effect, or being thrown.

🔍 Differentials

• High-voltage industrial electrical burns.
• Environmental collapse: heat stroke, hypothermia.
• Mechanical trauma (fall, blunt impact) unrelated to lightning current itself.

🧪 Investigations

• Bloods: FBC, U&E, ABG, CK (for rhabdomyolysis), Troponin.
• ECG & continuous monitoring: To detect arrhythmias or myocardial injury.
• Urinalysis: Myoglobinuria if rhabdomyolysis present.
• Imaging: CT head if loss of consciousness or focal neurology; trauma imaging as indicated.

💊 Management

• Resuscitation: Immediate CPR if cardiac arrest – unlike usual triage, lightning victims with no signs of life should be prioritised as outcomes may be good with early resuscitation.
• Airway & Breathing: Secure airway if reduced GCS; high-flow O₂.
• Circulation: IV fluids to maintain BP and protect kidneys, but avoid fluid overload (cerebral oedema risk).
• Cardiac monitoring: Admit to CCU/ICU for arrhythmia surveillance.
• Renal protection: Monitor urine output, alkalinise urine if myoglobinuria present.
• Surgery: Debridement of necrotic tissue or fasciotomy if compartment syndrome suspected.
• Supportive: Analgesia, tetanus prophylaxis, psychological support (PTSD common).

💡 Key Pearls

• 🌿 Lichtenberg figures are diagnostic and fade within hours – photograph for documentation.
• ⚡ Multiple victims possible → “mass casualty” approach needed.
• 🫀 Unlike routine cardiac arrests, lightning arrests are often due to primary asystole with respiratory arrest → early ventilation + CPR saves lives.

📚 References

• UpToDate: Lightning Injuries
• NEJM Review – Lightning Injuries