Guideline sources The following summarized guidelines for the evaluation and management of lightning injury are prepared by our editorial team based on guidelines from the Wilderness Medical Society (WMS 2014). 1 Guidelines 1. Diagnostic investigations Cardiac evaluation: obtain a screening ECG and echocardiography in high-risk patients once evacuated, including patients experiencing a direct strike or patients complaining of chest pain or dyspnea. B Show 3 more Neurologic evaluation: check the central pulse before starting CPR since keraunoparalysis may mimic a pulseless victim. Obtain hospital observation for keraunoparalysis. Recognize that this phenomenon typically resolves spontaneously but may indicate more serious underlying trauma. B Show 5 more Dermatologic evaluation: recognize that a transient "ferning" or "feathering" pattern known as the Lichtenberg figure is pathognomonic for lightning strikes. Recognize that it is not a burn, https://web.pathway.md/diseases/rec6H9ApcaFnqjlYF 1/3 6/29/23, 5:52 AM Lightning injury Pathway although its pathogenesis remains controversial, and this finding generally presents within 1 hour of the lightning strike and resolves in < 24 hours. Recognize that no histological change or damage has been found on biopsy although pigment changes in the deeper layers of the skin may persist. Do not offer treatment for these figures but evaluate for other effects of the lightning strike. B Show 2 more Ophthalmologic evaluation: obtain ophthalmologic evaluation in all survivors of a high-risk lightning strike and for any victim developing vision loss as soon as medically feasible. B Otolaryngologic evaluation: obtain initial evaluation for tympanic membrane integrity in all lightning strike victims. Follow-up patients with hearing loss by an otolaryngologist. B 2. Medical management Resuscitation: initiate resuscitation in victims of lightning strike immediately if the scene otherwise is deemed safe. Recognize that these victims do not carry residual electrical charge. Use the basic and advanced life support algorithms, including trauma when appropriate, as the standard of care. Follow current advanced life support guidelines for lightning victims requiring resuscitation. B Triage and evacuation: Initiate ventilation support as soon as possible since the ROSC precedes resolution of respiratory arrest. Use a "reverse triage" system for lightning victims giving priority initially to patients without vital signs or spontaneous respirations. Use a reverse triage strategy in instances of multiple lightning casualties. B Evacuate patients with high-risk indicators immediately after the scene is determined to be safe for rescuers. Triage and evacuate lower-risk lightning injuries and other casualties based on their injuries and overall medical condition. B 3. Specific circumstances Pregnant patients: evacuate pregnant patients > 20 weeks of gestation struck by lightning to a hospital for lightning-associated injury screening and fetal monitoring. Do not obtain fetal monitoring for pregnancies < 20 weeks of gestation as they are not considered viable. B 4. Preventative measures Thunderstorm safety: advise waiting a minimum of 30 minutes after hearing the last thunderclap before resuming outdoor activity to allow for the trailing edge of the thunderstorm to move the estimated 16 km (10 miles) needed to establish an appropriate buffer zone. B Show 9 more https://web.pathway.md/diseases/rec6H9ApcaFnqjlYF 2/3 6/29/23, 5:52 AM Lightning injury Pathway Clinical findings Symptoms Past medical history Chest pain Burns Confusion Cerebral salt wasting Headache Hypertension Hearing loss Intracerebral hemorrhage Limb paresthesia Stroke Loss of consciousness Subarachnoid hemorrhage Memory impairment Neurological exam Paresthesia Seizure Altered mental status Shortness of breath Keraunoparalysis Weakness Limb paralysis Sensorineural hearing loss Vital signs Head and neck exam Tachycardia Tympanic membrane rupture Ocular exam Integument exam Corneal burn Hyphema Lichtenberg figures Retinal detachment Limb discoloration Vitreous hemorrhage Limb pallor Cardiac exam Cardiac arrest ECG findings AF Prolonged QT interval St-segment elevation References 1. Chris Davis, Anna Engeln, Eric L Johnson et al. Wilderness Medical Society practice guidelines for the prevention and treatment of lightning injuries: 2014 update. Wilderness Environ Med. 2014 Dec;25 4 Suppl):S86 95. Open https://web.pathway.md/diseases/rec6H9ApcaFnqjlYF 3/3