1. Lightning Injuries Michael W. Dailey, MD Assistant Professor of Emergency Medicine Albany Medical College

2. Overview General Lightning Myths Severity of injuries Triage considerations Clinical Findings Long term effects Prevention

3. General 50,000 thunder storms and 8 million lightning strikes in any given day Lightning strikes earth more than 100 x a sec 1000 fatalities worldwide/year Recreational injuries are increasing but 25% of deaths and 29% of injuries are still employment related High Mountain environment = 5x more lightning strikes per year

4. Frequency of Injury and Death 150 - 250 deaths/year in the U.S. 4 - 5 times more injuries Lightning kills more people in the US each year than any other natural disaster –55% more deaths than tornadoes –41% more deaths that floods and hurricanes combined

5. Incidence of Lightning Injuries Most in the South, Rockies, along the Atlantic Coast, and in the river valleys of the Hudson, Ohio, and Mississippi Rivers Occur more often in thunderstorm season - May to September Occur more often in afternoon and early evening

6. Who Gets Struck? In early century most common in farmers Now, golfers, climbers, joggers and other outdoor athletes, and construction workers Lightning injuries tend to involve more than one victim 15 % of deaths occur in multiples of 2 15% occur in multiples of 3 or more

8. Lightning Production Warm, low pressure air moving through cool, high pressure air produces static The friction of moving air particles within the cloud causes ionization and complicated energy charges

10. Lightning Myths 1) Lightning is always fatal 2) “Spontaneous Combustion and Crispy Critters” 3) Lightning never strikes in the same place twice 4) Victims remain electrified 5) “Suspended Animation” 6) Lightning injuries are like other high voltage injuries

12. Lightning Truths Victims do not remain electrified Lightning is fatal 20 - 30% of the time Lightning rarely causes deep burns - < 5% Lightning frequently strikes the same place multiple times - Sears Tower = > 1000/yr No studies have shown outcomes of cardiac arrest are different from other mechanisms

13. Lightning vs. High Voltage Much less energy imparted in lightning strikes Therefore much less injury The body’s electrical system may be “short- circuited” resulting in cardiac and respiratory arrest, tinnitus, temp blindness,paralysis DO NOT see deep burns or myoglobinuria

15. Mechanism of Lightning Injury 1) Direct Strike 2) Contact - Person touching object struck 3) “Splash” - lightning jumps from its pathway and patient becomes pathway 4) Ground current - current spreading radially through the ground 5) Blunt injury

16. Severity of Injury 1) AC vs. DC 2) Duration 3) Voltage 4) Amperage 5) Resistance of Tissues 6) Pathway

17. Alternating and Direct Current AC - electron flow changes direction on cyclic basis ( household current = 60 cycles/sec) - More dangerous DC - no change in flow Lightning - oscillations are so rapid, in effect a direct current As DC - will cause asystole (not fibrillation)

18. Voltage, Amperage, and Duration Average voltage = 10-20 million volts High voltage wires =15,000 volts Amperage = 20,000 - 100 million Because duration is VERY short (1/10,000 - 1/1000 sec) the actual amount of energy delivered is very small –10,000,000 V x 1/1000 sec = 10,000 W-sec –15,000 V x 120 sec = 1,800,000 W-sec

19. Flash Over The short duration of lightning injury seldom allows energy time to break down skin and cause significant internal current flow or tissue damage Small amount of energy “leaks” internally, disrupting cardiovascular, pulmonary, and autonomic systems

21. Triage Considerations Major cause of death is cardio-respiratory arrest Concentrate on those in arrest Absence of arrest, pts are highly unlikely to die Ventilation is key if not in arrest

23. Head and Neck > 50% of victims have at least 1 tympanic membrane ruptured Skull fractures and C-spine Injuries Disruption of ossicles/mastoid Permanent Deafness Cataracts - corneal lesions, uveitis, retinal detachment

24. Cardiopulmonary Pulmonary Contusion/Hemorrhage Numerous Dysrhythmias Nonspecific ST changes – rarely true evidence of infarction Hypertension present early – resolves in 1 - 2 hours

25. Cardiopulmonary Arrest Lightning sends heart into asystole and paralyses respiratory center in brain Automaticity MAY lead to the heart restarting Respiratory paralysis lasts longer - leading to a secondary cardiac arrest IF THE PT IS VENTILATED - MAY AVOID SECONDARY ARREST!!!

26. Extremities Numerous fractures and dislocations reported Permanent paresis or paresthesias Keraunoparalysis - blue, mottled, cold, and pulseless extremities due to vascular spasm and sympathetic nervous system lability - usually clears in a few hours

27. Skin Burns are usually superficial if present at all deep burns occur in 5% Four types of superficial burns –Linear - from steam production and flashover –Punctate - appear as cigarette burns –Feathering - not true burns, electron showers –Thermal - from ignited cloths or metal

31. Other Injuries Neurologic –Sz, Deafness, Confusion/Amnesia, Blindness Concussion from shock wave Chest pain/muscle aches Blunt Abdominal Trauma Intracranial Hemorrhages

32. Delayed Injuries Peripheral neuropathy Decreased fine motor function Neuropsychologic changes –memory difficulties, depression, anxiety, insomnia,and PTSD From Hypoxic Cerebral Damage –Seizures and Severe Brain Damage From Vascular Spasm –Spinal Artery Syndromes

34. Prehospital Treatment Triage Considerations A,B,C,D,E - with special attention to those in cardiac arrest (standard treatment) Treatment of seizures is standard Treat Hypothermia (many pts are wet) IV access and fluids Expeditious, safe, transport

35. Hospital Treatment ECG and Cardiac Monitoring Labs –CBC, U/A, CPK with isos, appropriate X- rays/CT/MRI Admit for 24 hours - appropriate treatment of dysrythmias Those who DO NOT suffer cardiopulmonary arrest do well - those who do have a poor prognosis

37. Back Country Prevention Avoid high risk situations - BEFORE trip Try to seek shelter - tents are poor protection (metal poles and wet items in tent) Avoid lone trees, ridge tops, clearings Crouch down or kneel in forested area with small trees Sitting on pack may prevent step voltage

38. General Prevention If outdoors during thunderstorm, do not gather under trees Soccer fields, baseball diamonds and tennis courts are dangerous Get away from large open areas of land Greens are a bad choice Time for the 19 th hole!