Lightning strikes Lake Michigan, Chicago, Illinois. Photo credit: Vinhfield Ta

Lightning strikes are not uncommon, and kill 20-50 people per year in the U.S. (1) They can also be associated with significant morbidity.  The sequelae of a lightning victim is based on the 1) electrical injury, 2) thermal injury, and 3) mechanical injury.

Here are some key points to remember when someone has been struck by lightning: (2)

• Remove the patient and yourself from a dangerous environment and perform your basic ATLS (or ACLS) including ABC’s, O2 and cardiac monitoring.
• Cardiac Arrhythmia: The feared complication.  Patients can have asystole or V-Fib arrest, leading to loss of consciousness. Even if a patient has not had LOC, arrhythmias can be delayed, so the heart should be monitored in a medical setting.
• Respiratory Paralysis: Even if arrhythmia has not occurred or has resolved, paralysis of the diaphragm can lead to hypoxia and eventually cardiac arrest.  Support with intubation and mechanical ventilation as needed.
• Rhabdomyolysis: Thermal energy from the electrical shock can lead to significant tissue injury internally. The degree of internal injury can be underestimated by the external injury.  Tissue damage will release potassium and CPK, so be sure to assess/treat hyperkalemia, rhabdo, and AKI.
• Neurological symptoms: A variety of sensory, motor, and autonomic dysfunction can ensue. Keraunoparalysis can present as a blue, mottled, and pulseless extremity.
• Other sequalae include ophthalmologic (including cataracts) or otologic injury