In mass casualties due to lightning strikes, implement a reverse triage system as victims are often easily resuscitated and have good survival rates.

Due to autonomic dysfunction patients may initially present with fixed and dilated pupils, therefore this is not an accurate indicator for death.

• Lightning produces a DC current.
• Often travels over body surface, therefore internal injuries are uncommon.
• Types of lightning strikes include:
  • Direct strike.
  • Contact injury: lightning strikes object that is being touched by victim.
  • Side flash injury: lightning strikes nearby object and flashes over to victim.
  • Ground strike: lighting strikes the ground and the current passes through the victim, often entering one leg and exiting the other.
• Ground strikes are the most common.

• Diagnosis is made based on clinical presentation and history.
• Presence of Lichtenberg figures is diagnostic.

Clinical Features  

• Cardiac arrest is usually due to asystole.
• Non-specific ECG changes include QT-prolongation, T-wave inversion and ST changes.
• Neurological findings include transient loss of consciousness, amnesia, headache, paresthesias, muscle weakness and keraunoparalysis.
• Keraunoparalysis is a temporary paralysis of the extremities unique to lightning injuries that is accompanied by blue, mottled, and cold skin, and pulseless. 
  • It usually resolves within a couple of hours . 
  • If pallor or pulselessness persist, consider compartment syndrome.

Burns are mostly superficial and only a small percentage represent full-thickness burns.  

Cutaneous Burn Patterns:  

• Linear: Due to sweat vaporization as lightning travels over the skin, typically a partial thickness burn.  
• Punctiform: Due to current passing from deep to superficial tissue as it exits the body, often found on the feet.  
• Feathering/Lichtenberg figure.  

Lichtenberg Figure. Open Access, https://openi.nlm.nih.gov/detailedresult?img=PMC4763624_IJD-61-109-g002&query=&req=4 (1). Assess for tympanic membrane rupture and cataracts which are common ocular and audiological findings

• Investigations 
  • ECG 
  • CBC, BMP, urinalysis, LFTs, coagulation panel, CK, troponin
  • +/- relevant imaging
  • Neuroimaging for patients with altered mental status, coma or focal neurological deficits

• ACLS and ATLS protocols.
• There will often be return of spontaneous cardiac activity with ongoing respiratory arrest, therefore ensure adequate ventilation and oxygenation.
• Early consultation with Burn Physician via Patient Transfer Network.
• For burns meeting Major Burn Criteria:  
  • Initiate fluid resuscitation with crystalloids starting at 3cc/kg/%TBSA in the first 24hrs with first 50% given within 8 hours post-burn.  
  • Aim for a urine output of 50-100cc/hr . 
  • No evidence for use of diuretics to achieve target urine output . 
  • Consider escharotomy for full-thickness circumferential burns (in discussion with Burn Physician).  
• For burns not meeting Major Burn Criteria:  
  • Clean with saline soaked sterile gauze and cover with sterile dressings.  
  • Cool burns, but avoid inducing hypothermia.  
  • Tetanus as needed. 
• Rhabdomyolysis: IV crystalloid fluid to maintain a urine output of ≥1cc/kg/hr.  
• Manage fractures and dislocations appropriately.  

• Hospital admission for suspected direct strikes, loss of consciousness, chest pain, dyspnea, cranial burns, leg burns, burns >10% TBSA, persistent neurological deficits and pregnancy.

Burn Centre referral for lightning strike injuries. 

All patients with normal vital signs, ECG, bloodwork and urinalysis should be observed for 12-24hrs.  

Following observation for 12-24hrs, all patients with normal vital signs, ECG, bloodwork and urinalysis can be safely discharged home.  

1. Burns : Emergency Care BC 

   Key Information  

   BC Burn Centers:  

   Vancouver General Hospital
   Royal Jubilee Hospital
   BC Children’s Hospital (<16 years old) 
   

   Patient Transfer Network: (604) 215-5911 or Toll Free 1-866-233-2337 
   

   Core EM Electric and Lightning Injuries:  https://coreem.net/podcast/episode-1-0-electrical-and-lightning-injuries/ 

   CanadiEM: https://canadiem.org/crackcast-episode-142-electrical-lightning-injuries/ 

   
   

1. Van Ruler R, Eikendal T, Kooij F, Tan ECTH. A shocking injury: A clinical review of lightning injuries highlighting pitfalls and a treatment protocol. Injury. 2022;53(10):3070-3077.  

   https://doi.org/10.1016/j.injury.2022.08.024. 

   
   

2. Dheansa B, Hagiga A. Electrical injuries. BMJ Best Practices. Updated November 22, 2023. Accessed December 11, 2023 

   https://bestpractice.bmj.com/topics/en-gb/655 

   
   

3. Davis C, Engeln A, Johnson EL, McIntosh SE, Zafren K, Islas AA, et al. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Lightning Injuries: 2014 Update. Wilderness Environ Med. 2014;25(4):S86-S95.  

   https://doi.org/10.1016/j.wem.2014.08.011 

   
   

4. Image Reference:  

   Dutta B. Photograph showing the characteristic of “Lichtenberg figure.”. 2016. Available from: doi: 10.4103/0019-5154.174062. [Accessed February 11, 2024].