Lightning Injury - Triage and Resuscitation

Key Points

• Lightning victims do not remain electrically charged and can be touched once the scene is safe.
• Reverse triage is appropriate in multiple-victim lightning incidents.
• Ventilation is crucial because cardiac activity may return before respiratory drive.
• Use standard CPR and defibrillation for arrest.
• Lichtenberg figures are transient skin markings, not full-thickness burns.
• Tympanic membrane rupture and vestibular symptoms are common.
• Transient limb paralysis and pulselessness may reflect keraunoparalysis rather than structural vascular injury.
• Delayed neurologic, auditory, and ocular complications require follow-up.

Algorithm

1. Ensure scene safety and move victims away from continued strike risk.
2. In a multiple-casualty event, rapidly identify apneic or pulseless victims for reverse triage.
3. Begin CPR, rescue ventilation, and defibrillation as indicated.
4. After ROSC, support ventilation until respiratory drive is reliable.
5. Assess for trauma, neurologic deficits, burns, hearing injury, and ocular symptoms.
6. Obtain ECG and monitor high-risk patients.
7. Treat specific complications such as fractures, rhabdomyolysis, dysrhythmia, or respiratory failure.
8. Arrange disposition and specialty follow-up based on persistent cardiac, neurologic, auditory, ocular, or traumatic findings.

Clinical Synopsis & Reasoning

Lightning produces injury through direct strike, side splash, ground current, contact, and blast effects. The electrical pulse is brief but can depolarize the myocardium and respiratory center. Cardiac activity may recover before respiratory drive, so untreated apnea can cause secondary hypoxic cardiac arrest even after spontaneous circulation returns. This physiology explains why immediate ventilation is particularly important.

A lightning victim does not retain an electrical charge and is safe to touch once the scene is safe from further strikes. In a mass casualty event, prioritize patients without vital signs because those breathing spontaneously often survive without immediate advanced intervention. Begin CPR and ventilation promptly for arrest. Cervical-spine precautions are appropriate when blast or fall mechanism suggests trauma, but routine immobilization should not delay resuscitation.

After initial stabilization, perform a head-to-toe evaluation for dysrhythmia, chest pain, neurologic deficits, burns, fractures, dislocations, tympanic-membrane injury, and ocular symptoms. Characteristic Lichtenberg figures are transient fern-like skin markings and are not true burns. Tympanic rupture is common and may coexist with vestibular injury. Neurologic findings can be immediate and transient, such as keraunoparalysis with cold, pulseless-appearing limbs caused by vasospasm, or delayed cognitive and neuropathic syndromes. Patients with loss of consciousness, abnormal ECG, chest pain, direct strike, or significant symptoms deserve monitored evaluation.

Treatment Strategy & Disposition

Move the patient from ongoing lightning hazard without exposing rescuers to an active storm. Provide standard CPR with effective ventilation when needed. Use AED or defibrillation according to rhythm. Prolonged ventilatory support may be necessary even after spontaneous circulation returns because respiratory-center dysfunction can persist. Treat shock and trauma using usual principles, but avoid assuming that absent peripheral pulses in a cool weak limb necessarily indicate vascular disruption until keraunoparalysis and vasospasm are considered.

Burns are generally smaller in surface area than high-voltage industrial electrical injuries but can occur at contact points, from heated clothing or metal, or from secondary fire. Treat associated trauma, rhabdomyolysis, or compartment syndrome when present rather than applying a single electrical-injury protocol to every patient. Persistent dysrhythmia, ischemic ECG changes, or cardiovascular instability warrants telemetry and cardiac evaluation.

Disposition depends on symptoms and risk. Asymptomatic patients with a normal examination and no high-risk features may be discharged after appropriate evaluation according to local protocol. Admit or observe patients with cardiac arrest, abnormal ECG, persistent neurologic deficits, significant burns or trauma, pregnancy concerns, or respiratory compromise. Arrange ophthalmologic follow-up for visual symptoms or significant exposure because cataracts and other ocular injury can be delayed. Hearing loss, tinnitus, and vertigo warrant ear evaluation.

Epidemiology / Risk Factors

• Outdoor workers, hikers, athletes, and people on or near water are at increased exposure risk.
• Most lightning injuries are not from a direct strike.
• Neurologic symptoms are among the most frequent complications in survivors.
• Fatality risk falls substantially when effective bystander resuscitation is immediate.

Investigations

Common Findings

Pharmacology

Prognosis / Complications

• Survival after lightning cardiac arrest can be unexpectedly good with rapid CPR and ventilation.
• Transient neurologic deficits may resolve, but chronic pain, cognitive, or neuropathic symptoms can persist.
• Ocular cataracts can develop later.
• Severe hypoxic injury after prolonged apnea drives poor neurologic outcome.

Patient Education / Counseling

• Follow local lightning-safety guidance and seek substantial shelter rather than isolated trees or exposed ridges.
• Report persistent memory problems, weakness, numbness, hearing loss, tinnitus, vertigo, or visual changes after discharge.
• Explain that delayed symptoms do not necessarily mean a new strike and may be sequelae of the original injury.
• Patients with significant exposure should avoid driving or hazardous activity until neurologic and vestibular symptoms are resolved.
• Family members should know to seek emergency care for syncope, palpitations, chest pain, or worsening neurologic symptoms.

Notes

Lightning triage differs from conventional disaster triage because some victims who appear dead may be successfully resuscitated, while spontaneously breathing victims often remain stable enough to wait briefly. This reversal is based on the unusual electrical and respiratory physiology of lightning injury.

A normal external skin examination does not rule out significant neurologic or cardiopulmonary injury. Conversely, dramatic Lichtenberg figures do not indicate deep tissue destruction and should not be treated as conventional burns.

References

1. Wilderness Medical Society Clinical Practice Guidelines for Lightning Injuries — Link
2. 2025 AHA Guidelines for CPR and ECC — Link