LIGHTNING

Strikes are capricious, often ignoring the “rules” and behaving quite differently from electrical powerline injuries

In the US 49 deaths per year on average, less in past 8 years associated with greater awareness of prevention. Estimated mortality from a strike 10%. Only 5% of strikes are direct, so most involve spread of electricity through some intermediary, meaning that if you’re outdoors, it’s hard to escape risk

Mechanisms of injury:

  • Preferential transmission throughout the nervous system, peripheral, central, and autonomic
  • Cardiac arrest
  • Skin burns, usually minor
  • Barotrauma, eg. ruptured eardrum, concussion
  • Direct trauma from fall
  • Projectile-related trauma, eg rocks, shards of wood

With injury, most have confusion, amnesia, headache, muscle ache, brief deafness and/or blindness, numbness. There may be loss of consciousness, duration correlating with severity of CNS injury. 70% have a temporary paralysis lasting mins-days. A self-limited cardiac “standstill” +/- respiratory arrest can commonly occur, so if victim examined immediately after strike, one can wait 1-2 mins before starting CPR. Full cardiorespiratory arrest is the worst possible result. Fixed and dilated pupils are not necessarily a sign of brain death and may be autonomic. A cold, blue extremity may be vasospasm, and can be observed.

Treatment: do a reverse triage and tend to the apparent dead first with CPR. (Victims are safe to touch immediately.) Resuscitation likely futile after 20 minutes. Otherwise, do a thorough assessment for injuries like fractures needing splinting, lacerations. If victim looks OK, they don’t need evacuation

Prevention based on fact that no place outdoors is safe in an electrical storm. Lightning can strike up to 10 miles away from the source cloud, the distance thunder can just be heard, so the sky can be blue above. Don’t wait for the rain

Lightning more likely to hit objects that are tall, isolated, pointed like trees, towers, or YOU

Water is a great conductor eg. wet ground, engaged in boating, fishing

Seek shelter in a storm: only enclosed metal vehicles and substantial, habitable (ie. with plumbing and electrical wiring) buildings qualify. One may leave 30 mins after last lightning or thunder. Don’t touch wired appliances, plumbing during the storm

Particularly high risk activities are athletic events in open fields, golf, partly due to denial

Longterm disability common, up to 75%, especially sleep and memory disturbance, psychiatric issues, chronic musculoskeletal pain