"I f you can see it - flee it; if you can hear it - clear it."
TABLE OF CONTENTS
(1) Personal Lightning Safety
(2) Lightning Safety for Campers and Hikers
(3) Lightning Safety for Outdoor Sports Events
(4) Lightning Safety at Swimming Pools
(5) Vehicles and Lightning
(6) Boating-Lightning Protection
(7) Lightning Safety Group Recommendations
(8) Small Shelters and Safety From Lightning
(9) Lightning Injury Facts
(10) Emergent Care of Lightning and Electrical Injuries
(11 Behavioral Consequences of Lightning
and Electrical Injury
(12) Flash to Bang; Lightning Safety for Kids
Pages 2 – 3
Page 6 – 7
Pages 8 - 13
Page 14 - 18
Pages 18 – 20
Pages 21 - 28
Pages 29 – 46
Pages 47 - 59
Pages 60 - 62
PERSONAL LIGHTNING SAFETY TIPS
Teach this safety slogan: "I f you can see it - flee it; if you can hear it - clear it."
1.PLAN in advance your evacuation and safety measures. When you first see lightning or hear
thunder, activate your emergency plan. Now is the time to go to a building or a vehicle. Lightning
often precedes rain, so don't wait for the rain to begin before suspending activities.
2.IF OUTDOORS...Avoid water. Avoid the high ground. Avoid open spaces. Avoid all metal
objects including electric wires, fences, machinery, motors, power tools, etc. Unsafe places
include underneath canopies, small picnic or rain shelters, or near trees. Where possible, find
shelter in a substantial building or in a fully enclosed metal vehicle such as a car, truck or a van
with the windows completely shut. If lightning is striking nearby when you are outside, you
A. Crouch down. Put feet together. Place hands over ears to minimize hearing
damage from thunder.
B. Avoid proximity (minimum of 15 ft.) to other people.
3.IF INDOORS... Avoid water. Stay away from doors and windows. Do not use the telephone.
Take off head sets. Turn off, unplug, and stay away from appliances, computers, power tools, &
TV sets. Lightning may strike exterior electric and phone lines, inducing shocks to inside
4.SUSPEND ACTIVITIES for 30 minutes after the last observed lightning or thunder.
5.INJURED PERSONS do not carry an electrical charge and can be handled safely. Apply First
Aid procedures to a lightning victim if you are qualified to do so. Call 911 or send for help
Know Your Emergency Telephone Numbers
LIGHTNING SAFETY FOR CAMPERS AND HIKERS
published in "The Outdoor Network", vol ix, no.2, 1998
by Richard Kithil, President
National Lightning Safety Institute
…treat lightning like a snake: if you see it or hear it take evasive measures…
1.0 Summary. Some unexpected situations present extreme danger - an angry fer-de-lance, a
Class VI rapid, crumbling cornices and rotten rock - these can be perilous events. There is no
defense for lightning's "bolt-out-of-the-blue" occasional strike. But for the most part, lightning
safety is a risk management procedure. Early recognition of the lightning hazard, with an
awareness of defensive options, will provide high levels of safety.
COMMON MISCONCEPTIONS AND MYTHS.
1. Lightning never strikes twice… it strikes the Empire State Building in NYC some
22-25 times per year !
2. Rubber tires or a foam pad will insulate me from lightning… it takes about
10,000 volts to create a one inch spark. Lightning has millions of volts and easily
can jump 10-20 feet !
3. Lightning rods will protect my ropes course…lightning rods are "preferential
attachment points" for lightning. You do not want to "draw" lightning to any area
with people nearby.
4. We should get off the water when boating, canoeing or sailing…tall trees and
rocky outcrops along shore and on nearby land may be a more dangerous place.
5. A cave is a safe place in a thunderstorm…if it is shallow cave, or an old mine
with metallics nearby, it can be a deadly location during lightning.
2.0 Atmospheric Physics 101. At any one time around the planet, there are 2000 thunderstorms
and 100 lightning strikes to earth per second. The frequency of lightning increases in the lower
latitudes (closer to the equator), and in the higher altitudes (mountainous terrain). In the USA,
central Florida experiences some 10-15 lightning strikes per sq. km./yr. The Rocky Mountain west
has about two thirds this activity. Central Africa, parts of Southeast Asia, and the Latin American
mountain regions can experience two to three times as much lightning as central Florida.
Lightning leaders from thunderclouds proceed in steps of tens of meters, electrifying ground-based
objects as they approach the earth. Ground-based objects may launch lightning streamers to meet
these leaders. Streamers may be heard (some say they "sound like bacon frying") and seen (we
may notice our hair standing on end). A connecting leader-streamer results in a closed circuit
cloud-to-ground lightning flash. Thunder accompanying it is the acoustic shock wave from the
electrical discharge. Thus, thunder and lightning are associated with one another.
3.0 Flash/Bang. We all possess a first-class lightning detection device, built into our heads as
standard equipment. By referencing the time in seconds from seeing the lightning (the FLASH, or
"F" ) to hearing the accompanying thunder (the BANG, or "B"), we can range lightning's distance.
A "F" to "B" of five seconds equals lightning distance being one mile away. A "F" to "B" of ten =
two miles; a "F" to "B" of twenty = four miles; a "F" to "B" of thirty = six miles; etc.
New information shows successive, sequential lightning strikes (distances from Strike 1 to Strike
2 to Strike 3) can be some 6-8 miles apart. Taking immediate defensive actions is recommended
when lightning is indicated within 6-8 miles. The next strike could be close enough to be an
immediate and severe threat.
Lightning is a capricious and random event. It cannot be predicted with any accuracy. It cannot be
prevented. Advanced planning in the form of a risk management program is the best defense for
4.0 Standard lightning defenses. The eco-tourism environment is different from situations where
substantial buildings or fully enclosed metal vehicles are the recommended shelters. Lightning in
remote terrain creates dangerous conditions. Follow these guidelines:
LIGHTNING SAFETY TIPS.
AVOID: Avoid water. Avoid all metallic objects. Avoid the high ground. Avoid
solitary tall trees. Avoid close contact with others - spread out 15-20 ft. apart.
Avoid contact with dissimilar objects (water & land; boat & land; rock & ground;
tree & ground). Avoid open spaces.
SEEK: Seek clumps of shrubs or trees of uniform height. Seek ditches, trenches or
the low ground. Seek a low, crouching position with feet together with hands on
ears to minimize acoujstic shock from thunder.
KEEP: Keep a high level of safety awareness for thirty minutes after the last
observed lightning or thunder.
5.0 Medical treatment and symptoms. Treat the apparently dead first.
Immediately administer CPR to restore breathing. Eighty percent of lightning strike
victims survive the shock. Lightning strike victims do not retain an electric charge
and are safe to handle. Common lightning aftereffects include impaired eyesight
and loss of hearing. Electrical burns should be treated as other burns.
LIGHTNING SAFETY FOR OUTDOOR SPORTS EVENTS
Practice and training increase recreation performance. Similarly, preparedness can reduce
the risk of the lightning hazard. Lightning is the most frequent weather hazard impacting
athletics events. Baseball, football, lacrosse, skiing, swimming, soccer, tennis, track and
field events...all these and other outdoor sports have been visited by lightning.
Education is the single most important means to achieve lightning safety. A lightning safety
program should be implemented at every facility. The following steps are suggested:
1. A responsible person should be designated to monitor weather conditions. Local
weather forecasts - from The Weather Channel, NOAA Weather Radio, or local TV stations
- should be observed 24 hours prior to athletic events. An inexpensive portable weather
radio is recommended for obtaining timely storm data.
2. Suspension and resumption of athletic activities should be planned in advance.
Understanding of SAFE shelters is essential. SAFE evacuation sites include:
a. Fully enclosed metal vehicles with windows up.
b. Substantial buildings.
c. The low ground. Seek cover in clumps of bushes.
3. UNSAFE SHELTER AREAS include all outdoor metal objects like flag poles, fences and
gates, high mast light poles, metal bleachers, golf cars, machinery, etc. AVOID trees.
AVOID water. AVOID open fields. AVOID the high ground.
4. Lightning's distance from you is easy to calculate: if you hear thunder, it and the
associated lightning are within auditory range…about 6-8 miles away. The distance from
Strike A to Strike B also can be 6-8 miles. Ask yourself why you should NOT go to shelter
immediately. Of course, different distances to shelter will determine different times to
suspend activities. A good lightning safety motto is:
If you can see it (lightning) flee it; if you can hear it (thunder), clear it.
5. If you feel your hair standing on end, and/or hear "crackling noises" - you are in
lightning's electric field. If caught outside during close-in lightning, immediately remove
metal objects (including baseball cap), place your feet together, duck your head, and
crouch down low in baseball catcher's stance with hands on knees.
6. Wait a minimum of 30 minutes from the last observed lightning or thunder before
7. People who have been struck by lightning do not carry an electrical charge and are safe
to handle. Apply first aid immediately if you are qualified to do so. Get emergency help
LIGHTNING SAFETY AT SWIMMING POOLS
( Applies to Indoor and Outdoor Pools )
Lightning’s behavior is random and unpredictable. We recommend a
very conservative attitude towards it. Preparedness and quick
responses are the best defenses towards the lightning hazard.
Swimming pools are connected to a much larger surface area via underground water pipes,
gas lines, electric and telephone wiring, etc. Lightning strikes to the ground anywhere on
this metallic network may induce shocks elsewhere.
The National Lightning Safety Institute recommends the following swimming pool safety
1. Designate a responsible person as the weather safety lookout. That person
should keep an eye on the weather. Use a "weather radio" or the Weather
Channel or other TV program to obtain good localized advanced weather
2. When thunder and/or lightning are first noticed, use the Flash-To-Bang (F-
B) method to determine its’ rough distance and speed. This technique
measures the time from seeing lightning to hearing associated thunder. For
each five seconds from F-B, lightning is one mile away. Thus, a F-B of 10 =
2 miles; 15 = 3 miles; 20 = 4 miles; etc. At a F-B count of thirty, the pool
should be evacuated. People should be directed to safe shelter nearby.
3. Pool activities should remain suspended until thirty minutes after the last
thunder is heard. The distance from Strike A to Strike B to Strike C can be
some 5-8 miles away. And it can strike much farther away. Why take a
chance with lightning?
VEHICLES AND LIGHTNING
What happens when lightning strikes a vehicle? The answer, gleaned from anecdotal observations,
is all the way from "nothing" to "Wow ! What a mess…my car is a disaster."
Electrically speaking, at lightning's higher frequencies, currents are carried mostly on the outside
of conducting objects. A thick copper wire or a hollow-wall metal pipe will carry most of the
lightning on outer surfaces. This phenomenon is called Skin Effect. The same holds true for
lightning when it strikes metal vehicles: the outer surface carries most of the electricity. The
persons inside this steel box can be likened to protected by a partial Faraday Cage.
But, consistent with lightning's capricious nature, situations alter results. Is the car dry: one effect?
Is it wet: another effect? If the car made of fiberglass (a poor conductor) or is it a convertible, Skin
Effect principles may not work. [Corvette and Saturn owners please note.]
Some general recommendations include:
1. Personal Safety Issues: Reported incidents and related injuries make it clear that a person
inside a fully enclosed metal vehicle must not be touching metallic objects referenced to
the outside of the car. Door and window handles, radio dials, CB microphones, gearshifts,
steering wheels and other inside-to-outside metal objects should be left alone during close-
in lightning events. We suggest pulling off to the side of the road in a safe manner, turning
on the emergency blinkers, turning off the engine, putting one's hands in one's lap, and
waiting out the storm.
2. Heavy Equipment: Backhoes, bulldozers, loaders, graders, scrapers, mowers, etc. which
employ an enclosed rollover systems canopy (ROPS) are safe in nearby electrical storms.
The operator should shut down the equipment, close the doors, and sit with hands in lap,
waiting out the storm. In no circumstances, during close-in lightning, should the operator
attempt to step off the equipment to ground in an attempt to find another shelter. Very
dangerous Step Voltage and Touch Voltage situations are created when a "dual pathway to
ground" is created. Lightning voltages will attempt to equalize themselves, and they may
go through a person in order to do so.
Smaller equipment without ROPS is not safe. Small riding mowers, golf cars, utility
wagons are examples. Rubber tires provide zero safety from lightning. After all, lightning
has traveled for miles through the sky: four of five inches of rubber is no insulation
whatsoever. People should safely abandon this machinery and get into a safe shelter.
3. School buses. Metal buses are good Faraday Cages. Make sure all windows are closed and
the "hands on laps" rule is observed. Pull over and wait out the storm.
4. Damage. Reported damage to vehicles includes pitting, arcing, burning on both ext3erior
and interior places. See the below photographs, courtesy of Mr. Brown, of his Jeep
Cherokee which was struck by lightning. Cases have been reported of total destruction of
vehicle wiring, and associated electrical and electronic systems. Cases from police
departments report bad burns to the hands and mouth where officers were using radio
microphones when their vehicles were struck. Cases describe total blow-out of all four
tires in passenger cars. A video in our NLSI library shows a station wagon being struck by
lightning in a heavy rain storm, with no damage whatsoever occurring.
close-up or strike
roof strike closer to
strike on wheel
close-up strike near axel
Are you interested in a CD-ROM collection of lightning photographs? NLSI is publishing a
collection of high quality photographs for teachers, speakers and weather enthusiasts. Please let us
know of your interest
William J. Becker, Safety Consultant
Jacksonville Beach, FL
This document was extracted from the National Ag Safety Disc Safety Resource Directory.
This information is current as of Sept 1998.
"One minute the fisherman was sitting atop his elevated seat aboard his boat. The
next minute he was dead--the victim of a lightning bolt."
This was the lead paragraph in a recent Florida newspaper article. These
accidents can and do happen--and yet they need not.
Florida has more thunderstorms--and thus, more lightning strikes--than
any other state (see Figure 1). Only three states have a higher death rate
from lightning than Florida, and no state has more deaths or injuries.
Florida averages more than ten deaths and thirty injuries from lightning
per year. Approximately fifty percent of the deaths and injuries occur to
individuals involved in recreational activities, and nearly forty percent of
those are water-related: boating, swimming, surfing, and others.
Those who enjoy Florida's waters certainly should understand the
phenomena of thunderstorms--lightning and the precautions to take in
order to keep these activities pleasurable--and how to prevent tragedy.
Most lightning strikes occur in the afternoon--70 percent between noon and
6:00 p.m. As the air temperatures warm, evaporation increases. This warm,
moisture-laden air rises and evaporates, forming fluffy cumulus clouds. As more
moisture accumulates, the clouds darken and change into cumulus nimbus clouds-
-thunderstorm clouds--frequently, with a flattened top or anvil shape, reaching to
40,000 feet or more (see Figure 2).
The upper portion of the cloud develops a positive electrical charge, the lower
level a negative electrical charge. The air, because it is a poor conductor of
electricity, restricts the regular flow of electricity between these, attracting
While this phenomenon is occurring in the clouds, a similar phenomenon is
occurring on the surface.
Negative charges repel negative charges and attract positive charges. So, as a
thunder cloud passes overhead, a concentration of positive charges accumulates in and on all
objects below the cloud. Since these positive charges are attempting to reach the negative charge
of the cloud, they tend to accumulate at the top of the highest object around. On a boat that may be
the radio antenna, the mast, a fishing rod, or even you! The better the contact an object has with
the water, the more easil these positive charges can enter the object and race upward toward the
negative charge in the bottom of the cloud.
Lightning occurs when the difference between the positive and negative charges, the electrical
potential, becomes great enough to overcome the resistance of the insulating air and to overcome
the resistance of the insulating air and to force a conductive path
between the positive and negative charges. This potential may be as
much as 100 million volts. To help you understand the magnitude of
this voltage, the voltage needed in an automobile to cause a spark
plug to fire is only 15 to 200 vol s! And the spark plug gap is but a
fraction of an inch!
Lightning strikes represent a flow of current from negative to
positive, in most cases, and may move from the bottom to the top of
a cloud, from cloud to cloud, or most-feared, from cloud to ground
(see Figure 3). And when the lightning does strike, it will most often
strike the highest object in the immediate area. On a body of water,
that highest object is a boat. Once it strikes the boat, the electrical
charge is going to take the most direct route to the water where the
electrical charg will dissipate in all directions.
Let's consider a few possibilities. Lightning strikes the
ungrounded radio antenna on your boat. The metal antenna carries
the electrical charge to the radio, which does not have a good
conductor to the water. Your hand is on the radio, or on metal connected to the radio. Your feet are
on a wet surface, which is in contact with metal which extends through the hull of the boat to the
water. Your body may then become the best conductor for the electrical charge.
A second example is a sailboat. Lightning strikes the mast. The electrical current follows the
mast or wire rope to your hands, through your body to the wet surface, and then through the hull to
Or, while operating a motor boat, the lightning strikes you, passes through your body to the
motor, and then to the water.
Or, sitting in your aluminum or fiberglass rowboat, you are holding a graphite (a good
electrical conductor) fishing rod. The rod is struck by lightning. The electrical charge passes
through the rod, your body, then to the boat to the water.
In all four examples you could be seriously injured. You could be dead.
You need not even be in contact with the components of the boat struck by lightning. Unless
the components of the boat which could conduct electricity are bonded together and are adequately
grounded, there could be side flashes. A side flash occurs when the electrical charge jumps from
one component to another seeking a better path to ground. You might be that "better path."
MINIMIZE LIGHTNING STRIKE DAMAGE
Do not become a lightning target. Preferably stay off, and definitely get off, the water
whenever weather conditions are threatening. Check the weather. The National Weather Service
(NWS) provides a continuously updated weather forecast for Florida and its coastline via the
VHF/FM channels WX1 (162.550 MHz), WX2 (162.400 MHz), WX3 (162.475 MHz). Never go
boating without listening to this service. Their short-term forecasts are quite accurate, but small
localized storms might not be reported. Therefore, it is important that boaters learn to read the
Watch for the development of large well-defined rising cumulus clouds. Once they reach
30,000 feet the thunderstorm is generally developing. Now is the time to head for shore. As the
clouds become darker and more anvil-shaped, the thunderstorm is already in progress.
Watch for distant lighting. Listen for distant thunder. You may
hear the thunder before you can see the lightning on a bright day.
Seldom will you hear thunder more than five miles from its source.
That thunder was caused by lightning 25 seconds earlier. The
sound of thunder travels at one mile per five seconds (see Figure
You are two miles from shore. The thunderstorm which is now
five miles away is traveling in your direction at 20 miles per hour,
which means it could be overhead within 15 minutes. Can you
reach shore--two miles away--and seek shelter within that time?
You better move!
There is no such thing as lightning-proof boats, only lightning-
protected boats. All-metal ships are rarely damaged, and injuries or
deaths are uncommon. These ships are frequently struck, but the high conductivity of the large
quantities of metal, with hundreds of square yards of hull in direct contact with the water, causes
rapid dissipation of the electrical charge.
But small boats are seldom made of metal. Their wood and fiberglass construction do not provide
the automatic grounding protection offered by metal-hulled craft. Therefore, when lightning
strikes a small boat, the electrical current is searching any route to ground and the human body is
an excellent conductor of electricity!
Today's fiberglass-constructed small boats, especially sailboats, are particularly vulnerable to
lightning strikes since any projection above the flat surface of the water acts as a potential
lightning rod. In many cases, the small boat operator or casual weekend sailor is not aware of this
vulnerability to the hazards of lightning. These boats can be protected from lightning strikes by
properly designed and connected systems of lightning protection. However, the majority of these
boats are not so equipped.
Lightning protection systems do not prevent lightning strikes. They may, in fact, increase the
possibilities of the boat being struck. The purpose of lightning protection is to reduce the damage
to the boat and the possibility of injuries or death to the passengers from a lightning strike.
If you are considering the purchase of a new or used boat, determine if it is equipped with a
properly designed and installed lightning protection system. Such a system is generally more
effective and less costly than a system installed on a boat after it has been constructed.
LIGHTNING PROTECTION SYSTEM
The major components of a lightning protection system for a boat are an air terminal, main
conductor, and a ground plate. Secondary components are
secondary conductors, lightning arrestors, lightning protective
gaps, and connectors (see Figure 5).
The mast, if constructed of conductive material, a conductor
securely fastened to the mast and extending six inches above the
mast and terminating in a receiving point, or a radio antenna can
serve as the air terminal.
The main conductor carries the electrical current to the ground.
Flexible, insulated compact-stranded, concentric-lay-stranded or
solid copper ribbon (20- gauge minimum) should be used as the
The ground plate, and that portion of the conductor in contact
with the water, should be copper, monel or navel bronze. Other
metals are too corrosive. The secondary conductors ground major metal components of the boat to
the main conductor. However, the engine should be grounded directly to the ground plate.
Lightning arrestors and lightning protective gaps are used to protect radios and other electronic
equipment which are subject to electrical surges.
The connectors must be able to carry as much electrical current as other components of the
system. Further, the connections must be secure and noncorrosive.
On a large power boat or sailboat, a properly designed and grounded antenna could provide a
cone of protection. Presently, however, the vast majority of the radio antenna is totally unsuitable
for lightning protection. This is also true of the wires feeding the antenna. If the antenna is not
properly grounded, it may result in injury or death and cause considerable property damage.
Sailboats with portable masts, or those with the mast mounted on the cabin roof, are
particularly vulnerable as they are usually the least protected as far as grounding or bonding is
Ideally, an effective ground plate should be installed on the outside of all boats when the hulls
are constructed. Unfortunately, this is not often done. Such a ground plate would help
manufacturers design safer lightning protection systems for the boats.
LIGHTNING PROTECTION CODE
The National Fire Protection Association, Lightning Protection Code, suggests a number of ways
in which the boater can protect his boat and minimize damage if the boat is struck or is in the
vicinity of a lightning strike. These suggestions are summarized below:
A lightning protective mast will generally divert a direct
lightning strike within a cone-shaped radius two times the
height of the mast. Therefore, the mast must be of
sufficient height to place all parts of the boat within this
cone-shaped zone of protection (see Figure 6).
The path from the top of the mast to the "water" ground
should be essentially straight. Any bends in the conductor
should have a minimum radius of eight inches (see Figure
To provide adequate protection, the entire circuit from the
top of the mast to the "water" ground should have a
minimum conductivity equivalent to a No. 8 AWG copper
conductor. If a copper cable is used, the individual strands
should be no less than No. 17 AWG. Copper metal or strips
should be a minimum of No. 20 AWG.
Major metal components aboard the boat, within six feet of
the lightning conductor, should be interconnected with the
lightning protective system with a conductor at least equal to No. 8 AWG copper. It is
preferable to ground the engine directly to the ground plate rather than to an intermediate
point in the lightning protection system.
If the boat's mast is not of a lightning protective design, the associated lightning or
grounding connector should be essentially straight, securely fastened to the mast, extended
at least 6 inches above the mast and terminate in a sharp receiving point.
The radio antenna may serve as a lightning protective mast, provided it and all the
grounding conductors have a conductivity equivalent to No. 8 AWG copper and is
equipped with lightning arrestors, lightning protective gaps, or means for grounding during
electrical storms. Most antennas do not meet these requirements. The height of the antenna
must be sufficient to provide the cone-shaped zone of protection.
Antennas with loading coils are considered to end at a point immediately below the
loading coil unless this coil is provided with a protective device for by-passing the
lightning current. Nonconducting antenna masts with spirally wrapped conductors are not
suitable for lightning protection purposes. Never tie down a whip-type antenna during a
storm if it is a part of the lightning protection system. However, antennas and other
protruding devices, not part of the lightning protection sys em, should be tied down or
removed during a storm.
All materials used in a lightning protective system should be corrosion-resistant. Copper,
either compact-stranded, concentric-lay-stranded or ribbon, is resistant to corrosion.
The "water" ground connection may be any submerged metal surface with an area of at
least one square foot. Metallic propellers, rudders or hull will be adequate.
On sailboats, all masts, shrouds, stays, preventors, sail tracks and continuous metallic
tracks on the mast or boom should be interconnected (bonded) and grounded.
Small boats can be protected with a portable lightning protection system. This would
consist of a mast of sufficient height to provide the cone of protection connected by a
flexible copper cable to a submerged ground plate of at least one square foot. When
lightning conditions are observed in the distance, the mast is mounted near the bow and the
ground plate dropped overboard. The connecting copper cable should be fully extended
and as straight as possible. The boaters should stay low in the middle or aft portion of the
WHEN CAUGHT IN A STORM
Thunderstorms in Florida and over its coastal waters are frequently unpredictable. Even with the
best weather reports, along with constant and accurate observations of climatic conditions, boaters
can still be caught in open waters in a thunderstorm. Then, with or without a lightning protective
system, it is critical to take additional safety precautions to protect the boat's personnel. These
precautions during a thunderstorm are:
Stay in the center of the cabin if the boat is so designed. If no enclosure (cabin) is
available, stay low in the boat. Don't be a "stand-up human" lightning mast!
Keep arms and legs in the boat. Do not dangle them in the water.
Discontinue fishing, water skiing, scuba diving, swimming or other water activities when
there is lightning or even when weather conditions look threatening. The first lightning
strike can be a mile or more in front of an approaching thunderstorm cloud.
Disconnect and do not use or touch the major electronic equipment, including the radio,
throughout the duration of the storm.
Lower, remove or tie down the radio antenna and other protruding devices if they are not
part of the lightning protection system.
To the degree possible, avoid making contact with any portion of the boat connected to the
lightning protection system. Never be in contact with two components connected to the
system at the same time. Example: The gear levers and spotlight handle are both connected
to the system. Should you have a hand on both when lightning strikes, the possibility of
electrical current passing through your body from hand to hand is great. The path of the
electrical current would be directly through your heart--a very deadly path!
It would be desirable to have individuals aboard who are competent in cardiopulmonary
resuscitation (CPR) and first aid. Many individuals struck by lightning or exposed to
excessive electrical current can be saved with prompt and proper artificial respiration
and/or CPR. There is no danger in touching persons after they have been struck by
If a boat has been, or is suspected of having been, struck by lightning, check out the
electrical system and the compasses to insure that no damage has occurred.
Boating in Florida's waters is an enjoyable activity for many people. Keep it that way!
Listen to the weather reports! Learn to read the weather conditions. Heed these reports and
the conditions. Stay off or get off the water when weather conditions are threatening.
Install and/or maintain an adequate lightning protection system. Have it inspected
regularly. Follow all safety precautions should you ever be caught in a thunderstorm. By
using good judgement, it is less likely that first aid or CPR will be needed while boating.
National Fire Codes. Lightning Protection Code--NFPA 78; Fire Protection Standard for Motor Craft--NFPA
302, 14. National Fire Protection Association, Batterymarch Park, Quincy, MA 02269.
Standards and Recommended Practices for Small Craft. Standard E-4, Lightning Protection. American Boat
and Yacht Council, P.O. Box 806, Amityville, NY 11701.
Sitarz, Walter A. Boating Safety--Thunderstorms (MAP-5), Florida Sea Grant College
Program, University of Florida, Gainesville, FL 32605.
This publication, "Boating/Lightning Protection" (SGEB-7) replaces "Boating Safety/Thunderstorms"
(MAP-5), a Florida Sea Grant bulletin published December 1978 and is acknowledged as a source
of information for this bulletin
Lightning Safety Group Recommendations
On average, lightning causes more casualties annually in the US than any other storm related
phenomena, except floods. Many people incur injuries or are killed due to misinformation and
inappropriate behavior during thunderstorms. A few simple precautions can reduce many of
the dangers posed by lightning. In order to standardize recommended actions during
thunderstorms, a group of qualified experts from various backgrounds collectively have
addressed personal safety in regard to lightning, based on recently improved understanding of
This "Lightning Safety Group" (LSG) first convened during the 1998 American
Meteorological Society Conference in Phoenix, Arizona to outline appropriate actions under
various circumstances when lightning threatens.
The seemingly random nature of thunderstorms cannot guarantee the individual or group
absolute protection from lightning strikes, however, being aware of, and following proven
lightning safety guidelines can greatly reduce the risk of injury or death.
The individual is ultimately responsible for his/her personal safety and has the right to take
appropriate action when threatened by lightning. Adults must take responsibility for the safety
of children in their care during thunderstorm activity.
Safer Locations during Thunderstorms and Locations to Avoid
No place is absolutely safe from the lightning threat, however, some places are safer than
Large enclosed structures (substantially constructed buildings) tend to be much safer than
smaller or open structures.
The risk for lightning injury depends on whether the structure incorporates lightning
protection, construction materials used, and the size of the structure (see NFPA 780,
Appendix E & H).
In general, fully enclosed metal vehicles such as cars, trucks, buses, vans, fully enclosed
farm vehicles, etc. with the windows rolled up provide good shelter from lightning. Avoid
contact with metal or conducting surfaces outside or inside the vehicle.
AVOID being in or near:
High places and open fields, isolated trees, unprotected gazebos, rain or picnic shelters,
baseball dugouts, communications towers, flagpoles, light poles, bleachers (metal or
wood), metal fences, convertibles, golf carts, water (ocean, lakes, swimming pools, rivers,
When inside a building AVOID:
Use of the telephone, taking a shower, washing your hands, doing dishes, or
any contact with conductive surfaces with exposure to the outside such as metal
door or window frames, electrical wiring, telephone wiring, cable TV wiring,
Safety Guidelines for Individuals
Generally speaking, if an individual can see lightning and/or hear thunder he/she is
already at risk. Louder or more frequent thunder indicates that lightning activity is
approaching, increasing the risk for lightning injury or death. If the time delay
between seeing the flash (lightning) and hearing the bang (thunder) is less than 30
seconds, the individual should be in, or seek a safer location (see Safer Locations
during Thunderstorms and Locations to Avoid). Be aware that this method of
ranging has severe limitations in part due to the difficulty of associating the proper
thunder to the corresponding flash.
High winds, rainfall, and cloud cover often act as precursors to actual cloud-to-
ground strikes notifying individuals to take action. Many lightning casualties occur
in the beginning, as the storm approaches, because people ignore these precursors.
Also, many lightning casualties occur after the perceived threat has passed.
Generally, the lightning threat diminishes with time after the last sound of thunder,
but may persist for more than 30 minutes. When thunderstorms are in the area but
not overhead, the lightning threat can exist even when it is sunny, not raining, or
when clear sky is visible.
When available, pay attention to weather warning devices such as NOAA weather
radio and/or credible lightning detection systems, however, do not let this
information override good common sense.
Considerations for Small Groups and/or when the Evacuation Time is less than Ten minutes
An action plan must be known in advance by all persons involved (see
Important Components to an Action Plan, P.5). School teachers, camp counselors,
lifeguards, and other adults must take responsibility for the safety of children in
Local weather forecasts, NOAA weather radio, or the Weather Channel
should be monitored prior to the outdoor event to ascertain if thunderstorms are in
the forecast. Designate a responsible person to monitor forecasted weather as well
as to observe on-site developments to keep everyone informed when potential
Recognize that personal observation of lightning may not be sufficient;
additional information such as a lightning detection system or additional weather
information may be required to ensure consistency, accuracy, and adequate advance
Even though technology and instrumentation have proven to be effective,
they cannot guarantee safety. Instrumentation can be used to enhance warning
during the initial stages of the storm by detecting lightning in relation to the area of
concern. Advance notification of the storm's arrival should be used to provide
additional time to seek safety. Detectors are also a valuable tool to determine the
"All Clear" (last occurrence of lightning within a specified range), providing a time
reference for safe resumption of activities.
Safety Guidelines for Large Groups and/or when the Evacuation Time is more than Ten minutes
An action plan must be known in advance by all persons involved (see
Important Components to an Action Plan). Adults must take responsibility for the
safety of children in their care.
Local weather forecasts, NOAA weather radio, or the Weather Channel
should be monitored prior to the outdoor event to ascertain if thunderstorms are in
the forecast. During the event, a designated responsible person should monitor site
relative weather condition changes.
Personal observation of the lightning threat is not adequate; additional
information including detecting actual lightning strikes and monitoring the range at
which they are occurring relative to the activity is required to ensure consistency,
accuracy, and adequate advance warning.
Even though technology and instrumentation have proven to be effective,
they cannot guarantee safety. Instrumentation can be used to enhance warning
during the initial stages of the storm by detecting lightning in relation to the area of
concern. Advance notification of the storm's arrival should be used to provide
additional time to seek safety. Detectors are also a valuable tool to determine the
"All Clear" (last occurrence of lightning within a specified range), providing a time
reference for safe resumption of activities.
When larger groups are involved the time needed to properly evacuate an
area increases. As time requirements change, the distance at which lightning is
noted and considered a threat to move into the area must be increased. Extending
the range used to determine threat potential also increases the chance that a
localized cell or thunderstorm may not reach the area giving the impression of a
Remember, lightning is always generated and connected to a thundercloud
but may strike many miles from the edge of the thunderstorm cell. Acceptable
downtime (time of alert state) has to be balanced with the risk posed by lightning.
Accepting responsibility for larger groups of people requires more sophistication
and diligence to assure that all possibilities are considered.
Important Components of an Action Plan
Management, event coordinators, organizations, and groups should
designate a responsible, person(s) to monitor the weather to initiate the evacuation
process when appropriate. Monitoring should begin days and even hours ahead of
lightning threat. Depending on the number of individuals involved, a team of
people may be needed to coordinate the evacuation plan. Adults must take
responsibility for the safety of children in their care.
Safer sites must be identified beforehand, along with a means to route the
people to those locations. School buses are an excellent lightning shelter that can be
provided (strategically placed around various locations) by organizers of outdoor
events, with larger groups of people and larger areas, such as golf tournaments,
summer day camps, swim meets, military training, scout groups, etc.
The "All Clear" signal must be identified and should be considerably
different than the "Warning" signal.
The Action Plan must be periodically reviewed by all personnel and drills
Consider placing lightning safety tips and/or the action plan in game
programs, flyers, score cards, etc., and placing lightning safety placards around the
area. Lightning warning signs are effective means of communicating the lightning
threat to the general public and raise awareness.
A protocol needs to be in place to notify all persons at risk from the
First Aid Recommendations for Lightning victims
Most lightning victims can actually survive their encounter with lightning,
especially with timely medical treatment. Individuals struck by lightning do not
carry a charge and it is safe to touch them to render medical treatment. Follow these
steps to try to save the life of a lightning victim:
First: Call 911 to provide directions and information about the likely number of
Response: The first tenet of emergency care is "make no more casualties". If the
area where the victim is located is a high risk area (mountain top, isolated tree,
open field, etc.) with a continuing thunderstorm, the rescuers may be placing
themselves in significant danger.
Evacuation: It is relatively unusual for victims who survive a lightning strike to
have major fractures that would cause paralysis or major bleeding complications
unless they have suffered a fall or been thrown a distance. As a result, in an active
thunderstorm, the rescuer needs to choose whether evacuation from very high risk
areas to an area of lesser risk is warranted and should not be afraid to move the
victim rapidly if necessary. Rescuers are cautioned to minimize their exposure to
lightning as much as possible.
If the victim is not breathing, start mouth to mouth resuscitation. If it is
decided to move the victim, give a few quick breaths prior to moving them.
Determine if the victim has a pulse by checking the pulse at the carotid artery (side
of the neck) or femoral artery (groin) for at least 20-30 seconds. If no pulse is
detected, start cardiac compressions as well. In situations that are cold and wet,
putting a protective layer between the victim and the ground may decrease the
hypothermia that the victim suffers which can further complicate the resuscitation.
of little use: the victim is unlikely to recover if they do not respond within the first
few minutes. If the pulse returns, the rescuer should continue ventilation with
rescue breathing if needed for as long as practical in a wilderness situation.
However, if a pulse does not return after twenty t o thirty minutes of good effort,
the rescuer should not feel guilty about stopping resuscitation.
In wilderness areas and those far from medical care, prolonged basic CPR is
Avoid unnecessary exposure to the lightning threat during thunderstorm activity. Follow
these safety recommendations to reduce the overall number of lightning casualties. An
individual ultimately must take responsibility for his or her own safety and should take
appropriate action when threatened by lightning. School teachers, camp counselors,
coaches, lifeguards, and other adults must take responsibility for the safety of children in
their care. A weather radio and the use of lightning detection data in conjunction with an
action plan are prudent components of a lightning warning policy, especially when larger
groups and/or longer evacuation times are involved.
SMALL SHELTERS AND SAFETY FROM LIGHTNING
Richard Kithil, President, National Lightning Safety Institute
Vladimir Rakov, Ph.D., Dept. of Electrical and Computer Engineering, University of Florida
Small open shelters are common on golf courses, athletic fields, parks, roadside picnic areas, schoolyards,
and elsewhere. Many of these shelters are built to protect against rain or sun, not lightning. What can be done
to minimize risk for people inside them under direct and nearby lightning strike conditions? Although there is
no such thing as a lightning-proof small outdoor shelter, a properly designed and installed lightning
protection system may make a difference. Sometimes the difference is between life and death.
2. General Information on Lightning Protection of Structures
Basically, a lightning protection system for an ordinary structure includes (1) air terminals, (2) down
conductors, and (3) ground terminals. These three elements of the system must form a continuous conductive
path (actually at least two paths) for lightning current, with all connections between the elements typically
being accomplished by bolting or welding. The function of such a system is to intercept lightning and safely
direct its current to ground. If a structure has a metal roof and the thickness of this roof is 3/16 in. or greater,
the roof can play the role of the air terminals. The structural metal framework (including metal support posts)
can play the role of down conductors if it is electrically continuous. Sometimes the ground terminal is made
of a buried bare conductor wire encircling the structure (also called a loop conductor). Such grounding is
beneficial in that it additionally serves to intercept ground surface or underground electrical arcs that may
develop toward the structure from a nearby object (such as a tree) struck by lightning. The closer the
structure approaches a Faraday cage, the better its interior is protected from lightning effects.
3. Shelters Unprotected from Lightning
In the absence of the three-element lightning protection system described above, the structure should be
considered unprotected from lightning. Small shelters without lightning protection should be avoided during
thunderstorms, particularly if they are located in high areas (such as on a golf course hill) or near a tree or a
small group of trees dominating the area. If there is no better choice only shelters in relatively low areas
should be used, preferably surrounded by a large number of trees of approximately the same height. A
disclaimer statement should be posted on each unprotected shelter by the organization running the outdoor
facility. Such a disclaimer should include a clear statement that the structure does not offer protection from
lightning. It would also be appropriate here to include a concise guide for personal safety from lightning.
4. Shelters Protected from Lightning
A small shelter equipped with a properly designed and installed lightning protection system provides
reasonable protection from lightning. It is essential, however, that a person inside the shelter does not touch
any element of the lightning protection system and tries to position himself or herself at approximately the
same distance from all down conductors. . A small shelter, even one protected as described here, should be
viewed as the last resort option. Better protected shelters such as large buildings and all metal vehicles should
be sought instead when possible.
A properly protected small shelter should have at least one air terminal (or equivalent), at least two down
conductors on two diagonally opposite sides of the structure (four down conductors provide better lightning
protection than two conductors), and ground terminals connected to the down conductors. Two designs for
ground terminals in common soils can be recommended. The first one (see Fig. 1A) includes vertical ground
rods (not less than ½ in. in diameter and not less than 8 feet long), at least one for each down conductor,
interconnected by a loop conductor buried a few inches under the earth's surface. The second design for
ground terminals (see Fig. 1B) includes horizontal conductors, at least one for each down conductor, buried
at a depth of not less than 2 ½ feet and extending away from the shelter for at least ten feet beyond the roof
dripline. It also employs a loop conductor. In both designs, we suggest the addition of a buried metal mesh
within the shelter perimeter (rebar of the steel-reinforced concrete floor can be used too), connected to the
ground terminals. A floor made of asphalt, rock or wood may further reduce the lightning hazard for people
inside the shelter.
An alternative lightning protection system consists of grounded overhead wires suspended above the shelter
on separate poles. The loop conductor mentioned above can be employed here too.
Rod-type air terminals are usually solid (minimum diameter 3/8 in.) or tubular (minimum diameter 5/8 in.,
minimum wall thickness 0.033 in.) copper rods at least ten inches high. Air terminals should be placed on
ridges of pitched roofs and around perimeter of flat roofs or gently sloping roofs at intervals not exceeding 20
ft. The distance from each end of the ridge to the nearest air terminal should not exceed 2 ft. Down
conductors are usually in the form of stranded cables (minimum 17 AWG copper or 14 AWG aluminum). No
bend of a conductor should form an included angle of less than 90 degrees, nor should the radius of a bend be
less than 8 in. Down conductors should be covered with insulating material resistant to impact and climate
conditions to a height of at least 8 feet above ground. Air terminals and down conductors can also be made of
aluminum. Vertical ground rods are typically made of copper-clad steel or solid copper, and horizontal
conductors are typically stranded copper cables. Aluminum conductors should not be closer than three feet to
the earth for corrosion reasons. Bimetallic connectors should be employed to join aluminum conductors to
It is generally possible to find a local company that installs lightning protection on buildings and trees. Look
in the Yellow Pages for "Lightning Protection" and "Electrical Contractors." These companies should follow
the "Standard for the Installation of Lightning Protection Systems" (NFPA 780), which includes a one-
paragraph section devoted specifically to shelters (Section E-1.1, P.32). The Underwriters Laboratories
guideline is similar and is called "Installation Requirements for Lightning Protection Systems - UL96A."
1. NFPA 780, Standard for the Installation of Lightning Protection Systems (1997), National Fire Protection
Association, Quincy MA.
2. Installation Requirements for Lightning Protection Systems - UL96A (1998), Underwriters Laboratories,
3. NFPA 70 (1999), National Electrical Code, National Fire Protection Association, Quincy MA.
1. Richard Kithil is Founder and CEO of NLSI, the National Lightning Safety Institute. NLSI is a non-profit
consulting, education, and research organization. Tel. 303-666-8817, Fax 303-666-88786, Email:
2. Vladimir A. Rakov is a Professor of Electrical and Computer Engineering at the University of Florida Gainsville,
FL. He is the author or co-author of over 200 technical publications on various aspects of lightning and lightning
protection. Tel. 352-392-4242, Fax 352-392-8381, Email: email@example.com; website: http://plaza.ufl.edu/rakov
Lightning Injury Facts
Myths, Miracles, and Mirages
Mary Ann Cooper, MD
An article about both lightning and electrical injuries
Adapted from Seminars in Neurology, Volume 15, Number 4, December 1995
Copyright © 1995
(Permission for use on this page kindly granted by Thieme Medical Publishers Inc.)
Injuries from man-made, generated, or "technical" electricity have been reported for only about
150 years; but injuries from lightning must surely predate written records. Depictions of lightning
affecting people or events appear in writings and drawings from almost every ancient religion.
Although such an occurrence was sometimes interpreted as a positive sign of blessing, more often
it was seen as a sign of the god's warning or vengeance.
Priests, the earliest astronomers and meteorologists, became proficient at weather
prediction, interpreting changes in weather as omens of good or bad fortune, sometimes to the
advantage of their political mentors. Observations of lightning and other natural phenomena were
often used to decide matters of state, the scheduling of battles or other events. Lightning from the
east was usually seen as a good omen. This is reasonable because it is probably the end of a
storm. Lightning from the west was ominous, but also meant a storm was probably approaching.
Over the centuries, superstitions and myths have grown up about lightning that include
avoidance, protection, the types of injuries, and their treatment. In this article, I cannot be all
inclusive but will attempt to discuss some of the more common ideas, particularly those related to
the medical field, as well as some myths about injuries from the newer form of injury by generated
electricity. I will leave discussion of appropriate lightning and electrical protection to those who
are more knowledgeable in these areas and have been kind enough to write articles for these issues
Disclaimer: This article is not meant to be a scientific treatise but to be entertaining and
perhaps enlightening (no pun intended since it is a different spelling). I am giving my best reply to
these myths based on a composite of 20 years of experience, reading, and discussions with
patients, families, and professionals from many areas of expertise. I have had to reverse myself
enough times since I began investigating lightning injuries in 1977 to ever claim that I know all
there is to know about it and will be the first to encourage research into any of these questions. It
seems that everyone has a lightning story. I hope you will have fun reading this and investigating
these areas for yourself. Lightning and electrical injuries are fascinating and the myths that have
grown up about them are myriad. I invite you to collect your own. If you will be kind enough to
send them to me, I will forever be in your debt.
CLASSIFICATION OF MYTHS
Beliefs have grown up about these injuries that I will arbitrarily divide into the following groups:
1. Occurrence and demographics
2. Effects of the strike/types if injuries
a. Positive effects
b. Negative effects
3. Signifigance of the strike
OCCURRENCE AND DEMOGRAPHICS
"I will probably never treat a victim of a lightning injury in my practice because they are
so rare. "
False. It is true that injuries from electrical injuries are probably more common than lightning
injuries, especially when low-voltage injuries are included. Best estimates place lightning injuries
at somewhere between several hundred and a few thousand per yearn 4 It is common for the
victims to avoid medical care initially, hoping that the symptoms will subside in a few hours or
days. Most are not admitted to the hospital and thus do not become part of any state hospital
admission databank. Lopez and Holle have done some of the best studies on the epidemiology of
lightning injuries and I refer you to their articles in these issues and elsewhere. (5,6) It would be
unusual to meet a neurologist who has not had at least one patient with complaints referable to an
electrical event. Much research remains to be done into the best treatment, the differences
between these groups, and long-term effects.
"I will probably never treat a victim of a lightning injury in my practice because no one
lives to Tall about it."
False. In 1980, I published a study of collected literature and found only a 30% mortality.(7)
Andrews (8) repeated the study a few years later and calculated it slightly differently at 20%. Both
reviews would overestimate the mortality, as case reports will always be biased toward the more
severe or interesting cases. Although Holle and Lopez report figures somewhat differently, my
best guess on the mortality from lightning would be about 3 to 10% of all incidents. Projecting
from numbers of between 75 and 150 reported deaths per year (and many do not get coded
appropriately), there may be as many as 750 to 5000 injuries per year.
"Nowadays most lightning injuries occur on the golf course. "
False. Indeed, a large number are work-related. These include injuries to postal and construction
workers and persons using telephones that have not been properly grounded. (5) The numbers of
farmers injured has decreased farmers to work larger fields in better-protected vehicles. Injuries
during recreation have increased. They occur to joggers, hikers, and campers, as well as golfers. In
addition, a significant number of people are injured while participating in team sports.
"Some people can attract lightning."
Some have called themselves "human lightning rods," claiming that thunderstorms would
change course to find them or that they had been struck multiple times. Given my experience with
lightning victims, I must say that, although some may suffer little injury from a single strike, the
majority have some type of sequela. When one claims to have been hit 20 or more times, the odds
of being able to talk about it decrease logarithmically. Would any reasonable person not have
enough sense to learn to avoid lightning after the first couple of hits?
EFFECTS OF LIGHTNING STRIKE/ELECTRIC SHOCK
These effects are what these two issues of Seminars in Neurology are all about: we have tried to
address most of the questions that arise about electrical and lightning injuries, and the differences
between lightning and electrical injuries and their treatment have been discussed in other articles.
Because so little has been studied in these injuries, it is often difficult to sort out the
complaints that are real from those that are metaphysical, compensation-related, or due to normal
aging. As discussed in the article by Engelstatter and Primeau, (9) a marginally compensated
individual may see the injury as the precipitant for all subsequent problems in life. Although the
physical and cognitive complaints are sometimes vague and often do not show on standardized
testing, nevertheless, they present a consistent complex that is difficult to disbelieve after listening
to them for 15 years from people who have nothing to gain from their disability. Even the
complaints that we can objectify often have no good treatment, frustrating both the patient and the
Among the claims of positive effects of lightning strike (and sometimes electrical injury) are
the cures for persons who have been blind, deaf, or had serious illnesses. A few years ago there
was a very well-publicized case of an elderly gentleman who was cured of his blindness and
deafness by a lightning strike. Those of us who were consulted on this knew that these were
hysterical complaints suffered as a result of a truck accident many years before but forbade the
press to quote us out of respect for the gentleman.
I have had one call from another gentleman who asked if lightning could cause "hyper
sexuality" because after his lightning injury he could not seem to get enough sex. While there is a
neurological injury that can cause hypersexuality, more commonly lightning and electrical injury
causes impotence, as a result of either direct nerve or spinal cord injury or depression. There is one
published claim of improved intelligence on psychological testing after a prolonged cardiac arrest
in a pediatric patient. A woman in southern Illinois became psychic after suffering a lightning
strike while asleep in bed. Reportedly, her powers have been used by police agencies in locating
missing persons and solving cases.
If remissions or cures of serious illness have occurred, as some have claimed, praise God, and
I am happy for them and will not dispute their conclusions, but I cannot explain it by any medical
literature, only supposition.
The medical literature and medical practice are resplendent with examples of myths that grow
out of misread, misquoted, or misinterpreted information and that then continue to be propagated
without further investigation, particularly when the author is an individual well-respected for other
accomplishments. Not the least of these is the tenet that lightning victims who have
resuscitation prolonged for several hours may still successfully recover. This belief seems to be
grounded in the old idea of "suspended animation" the concept that lightning is capable of
shutting off systemic and cerebral metabolism, allowing rescuers a longer period in which to
resuscitate the patient. This concept, credited to the only article that Taussig ever wrote on
lightning, actually first appeared in an article that was published quite some time before hers. The
case recounted by Taussig that is the basis for this myth, when searched to its source, was a case
reported by Morikawa and Steichen, F. While it does show a somewhat longer resuscitation period
than usual, it is not as miraculous as reported in her paper or as propagated in subsequent
references to it.
On the other hand, in a study of lightning survivors, Andrews has shown increasing
prolongation of the QT interval, bringing up the theoretical possibility of toursades as a
mechanism for the suspended animation reports.' Theoretically, if lightning hit at the right instant
of the QRS interval, a toursades type of rhythm might occur, not only supplying minimal cerebral
perfusion, but also perhaps resolving spontaneously. Toursade certainly has a better prognosis
than fibrillation or asystole. There is new evidence from animal experiments to support the
teaching that respiratory arrest may persist longer than cardiac arrest. (13,14) This study, in which
Australian sheep were hit with simulated lightning strokes, showed histologic evidence of greater
damage to the respiratory centers than the cardiac center in the medulla. Prolonged assisted
ventilation may then, in some cases, be successful after cardiac activity has returned.
Among the myths about negative effects is the "crispy critter" myth.(3) This is the belief
that the victim struck by lightning bursts into flames or is reduced to a pile of ashes. In reality,
lightning often flashes over the outside of a victim, sometimes blowing off the clothes but leaving
few external signs of injury and few, if any, burns.
Two other myths held by the lay public as well as many physicians that are particularly
harmful to the lightning survivors are, "If you're not killed fly lightning you A be OK" and, "If
there are no outward signs of lightning injury, the injury can't be serious.(8) The medical
literature, by lack of follow-up case reports, implies that there are also few permanent sequelae of
lightning injury. However, in the last few years, it has become apparent that permanent sequelae
may and often do occur. In addition, both lightning and electrical victims with significant sequelae
may have no evidence of burns. While the effects of amperage and voltage have been studied in
animals, the effect of frequency, radio waves, and body impedance, as well as other effects, have
not been elucidated well enough for us to be able to explain many injuries.
A myth that is still prevalent today is that the victim of lightning retains the charge and is
dangerous to touch, since he is still "electrified " This idea has led to unnecessary deaths because
of delaying resuscitation efforts.
Many patients, particularly those without external signs of injury, have been told, most often
by medical professionals, that they have "internal burns" that are the cause of their problems. This
is both a misnomer and an oversimplification for the cellular, vascular, biochemical, or other types
of damage they may have incurred. So many questions need to be investigated in lightning and
"Lightning is a sign from God. "
I can claim no inside track on this one. Ancient Romans saw Jove's thunderbolts as a sign of
condemnation and denied burial rites to those killed by lightning. Andeans hold similar beliefs and
may ostracize the victim. In some cultures, medicines are made from stones that are believed to be
a result of lightning strike. Roman, Hindu, and Mayan cultures all have myths that mushrooms
arise from spots where lightning has hit the ground.(5)
In the poly-ethnic United States, belief in "fate" or "God's will" may affect how family,
friends, or coworkers relate to the victim or how the victim feels about himself and his recovery.
Some patients may have already consulted a healer before finally seeking the advice of a physician
and in rare instances it may be difficult to treat a patient unless the help of a shaman or priest is
employed to address the religious issues while the physician addresses the physical ones.
Several Roman emperors wore laurel wreathes and sealskin, which were believed to be
protective. Pliny taught that a sleeping person was safe from lightning. Some of the references at
the end of this article detail even more curiosities and myths.
"Wearing a rubber raincoat (substitute sneakers or other forms of clothing here) will
decrease my chances of being hit." Conversely: "Wearing cleated shoes increases my chances
of being struck."
False, and probably false. The first is easy to dispel: if lightning has burned its way through a
mile or more of air (which is a superb insulator), it is hardly logical to believe that a few
millimeters of any insulating material will be protective. The second is a subject of contention but
I tend to believe that there would be little effect from whatever is on the bottom of your feet.
Certainly metal on the bottom of the feet can heat up and cause secondary burns, but it is unlikely
to "draw" lightning to the person.
"I am safe in a car because the rubber tires protect me."
True and False. True because there have been no documented lightning deaths that have
occurred in a hard topped metal vehicle with the windows rolled up. However, the composite tires
have little, if any, part in this, for the same reasons as those just discussed with regard to
insulation. The safety has to do with the fact that electrical current travels along the outside of a
conductor (the metal body of the car) and dissipates to the ground through paths that include the
tires and the rainwater.
"Wearing metal in my hair increases my chances of being hit. "
Questionable, although opinions exist both ways. Hairpins (who uses those anymore?) may be
safe; metal helmets may not. The issue needs more study (and more publication). Kitigawa has
shown fairly conclusively with dummies that metal about the head does not increase the likelihood
of being hit (unless it projects far above the head, increasing the person's height).
"Carrying an umbrella increases my risk of being hit. "
True. Increasing your height by any amount increases your chances of being hit by a calculable
amount, although a prospective, population-based, double-blind, randomized study has not been
done to prove this, nor has the composition (metal versus composite or plastic) of the umbrella or
one-iron been studied. Other dangerous things to avoid: avoid being the highest object anywhere,
be it a beach, small open boat, pier, meadow, or ridge. Avoid being under a lightning rod (except
when inside a substantial habitable building that is protected) or standing near a metal fence,
underground pipes, or other metallic paths that can transmit lightning energy from a nearby strike.
Avoid swimming, because lightning energy can be transmitted through the water to you. Sailboats
should be equipped with adequate lightning protection systems.
"When outdoors, I should stay away from trees."
Mostly true. Certainly you should stay away from the tallest trees, which are more likely to be
hit and side-flash or splash to you. However, one would not want to become the tallest object in an
area by standing in a meadow, either. Making the shortest, smallest target is probably the best
answer if caught in the open. If you are in a forested area, it may be wise to pick an area of dense
growth of saplings or smaller trees, rather than either a large meadow or tall trees. If on a ridge,
get to a lower area.
Seeking shelter in a substantial building when possible is advisable. The sheds on golf courses,
unless adequately protected by a lightning mitigation system, are potentially more dangerous
because they offer height but little protection and lightning may splash from a hit to the shelter
onto the inhabitants.
"When lightning hits the ground nearby, it is 'grounded ' and I am safe. "
Totally and absolutely FALSE. Despite the fact that we call the earth a "ground," it is very
difficult to pump electricity into the ground. Most "earth" is a very good insulator. When
lightning hits the ground, it spreads out along the surface and first few inches of the ground in
increasing circles of energy called "ground current." If it contacts a fence or a water pipe or wire
entering a house it can be transmitted for quite a distance and cause injury to persons near these
paths. People, being bags of electrolytes, are better transmitters of electrical current than most
ground is, and many are injured by ground current effect each year as the lightning energy surges
up one leg that is closer to the strike and down the one further away.
"My mother always told me to stay off the telephone (out of the bath tub, away from
windows, unplug the appliances, etc.) during a thunderstorm. "
Good advice, if not always practical. Again, the ground current effect of energy transmitted into
the structure along wires or pipes may find the person a better conduit to ground.(3,4) Many
injuries occur every year to telephone users inside the home. One of the biggest new areas of
consumer fraud has to do with claims of loss of "valuable" databases on computers damaged by
"Lightning only occurs with thunderstorms."
Most people know to seek shelter once the storm clouds roll overhead. Few realize that one of
the most dangerous times for a fatal strike is before the storm. Lightning may travel as far as 10
km nearly horizontally from the thunderhead and seem to occur "out of the clear blue sky" or at
least when the day is still mostly sunny. The faster the storm is traveling and the more violent it is,
the more likely this is to occur. Another time underestimated for its potential danger is the end of a
"If we could just harness lightning we could use that to power the world for months. "
Uman eloquently explains the reason this cannot be done and is false in his book, All About
Lightning.(2) He makes two points: it is impractical to intercept a sufficient number of the
lightning strikes occurring in the world, and most of the energy in a lightning strike is converted to
thunder, heat, light, and radio waves. He notes, "If its total energy were available, a single
lightning flash would run an ordinary household light bulb for only a few months."(2)
"Lightning could be used for a military weapon. "
Again, Uman (2), a professor of electrical engineering who writes with wonderful clarity, is my
source. "In view of the awesome destructive power of modern weaponry, the military use of
lightning . . . would probably be more as a psychological than as a destructive weapon."(2)
And last but not least, "Lightning never strikes the same place twice."
In reality, the Empire State Building and the Sears Tower get hit thousands of times a year, as
do mountain tops and radio-television antennas. If the circumstances facilitating the original
lightning strike are still in effect in an area, then the laws of nature will encourage lightning strikes
to continue to be more prevalent there. After all, that is the reason that lightning protection
systems are required on many public buildings (including hospitals) by building codes.
Lightning and electrical injuries are fascinating and the myths that have grown up about them
are myriad. I invite you to collect your own. If you will be kind enough to send them to me, I will
forever be in your debt.
1. Prinz: Lightning in history. In Golde RH, ed. Lightning, Vol 1. San Francisco: Academic Press, pp1-20, 1977.
2. Uman MA. All about lightning. New York: Dover, pp 1-160, 1986.
3. Cooper MA, Andrews CJ: Lightning injuries. Auerbach P ed. Wilderness Medicine, Management of Wilderness
and Environmental Emergencies, 3rd ed. St. Louis: CV Mosby, pp 261-89, 1995.
4. Andrews CJ, Cooper, MA, ten Duis HJ, Sappideen C. The pathology of electrical and lightning injuries. In Wecht
CJ, ed. Forensic Sciences, release 19 update. New York: Matthew Bender & Co., 1995:23A-3-23A-165
5. Lopez RE, Holle RL, Heitkamp TA. Deaths, injuries, and property damage due to lightning in Colorado from 1950
to 1991 based on Storm Data. In National Oceanic and Atmospheric Administration Technical Memorandum ERL
6. Holle RL, Lopez RE, Ortiz R. et al. Cloud-to-ground lightning related to deaths, injuries and property damage in
central Florida. In Proceedings, International Conference on Lightning and Static Electricity, October 6~, Atlantic
City, NJ, FAA Report No. DOT/FAA/CT-92/20,66-1-66-12, 1992.
7. Cooper MA. Lightning injuries: prognostic signs for death. Ann Emerg Med 9:134-8, 1980.
8. Andrews CJ, Darveniza M, Mackerras D. Lightning injury a review of clinical aspects, pathophysiology and
treatment. Adv Trauma 4:241-52, 1989.
9. Primeau M, Engelstatter GH, Bares KK Behavioral consequences of lightning and electrical injury. Semin Neurol
10. Taussig H. "Death" from lightning and the possibiliq of living again. Ann Intern Med 68:1345-50, 1968.
11. Morikawa S. Steichen F. Successful resuscitation after "death" from lightning. Anesthesia 21:222-3, 1960.
12. Andrews CJ, Colquhoun DM, Darveniza M. The QT interval in lightning injury with implications for the
'cessation of metabolism' hypothesis.J Wilderness Med 4:155-66, 1993.
13. Andrews CJ, Darvenia M: Effects of lightning on mammalian tissue. Proceedings, 1989 International Conference
on Lightning and Stahc Electricity, Sept 26 28, Bath, England, 4A.4.1-4A.4.4, 1989.
14. Andrews CJ, Darveniza M. New models of the electrical insult in lightning strike. Proceedings, 9th International
Conference on Atmospheric Physics, St. Petersburg, Russia, 1992.
15. Lowy B. Amanita muscaria and the thunderbolt legend in Guatemala and Mexico. Mycologia 66:188-90, 1974.
16. Ackerman L. Personal communication, Price-Hollingsworth Company
Emergent Care of Lightning and Electrical Injuries
Mary Ann Cooper; M.D., FACEP.
Seminars in Neurology, Volume 15, Number 3, September 1995
Copyright © 1995
HISTORICAL PERSPECTIVE AND EPIDEMIOLOGY
While injuries from man-made, generated, or "technical" ' electricity have been reported for
less than 300 years, in juries from lightning must surely predate written r records Electrical burns
account for 4 to 6.5% of all admissions to burn units in the United States (1,2) and accounted for
approximately 800 fatalities per year in the United States from 1984 through 1987. It is estimated
that lightning causes 75 to 150 deaths per year, with 5 to 10 times more injuries. (3,4)
Most admissions of adults to burn centers from electrical injury are occupationally related.
Almost two thirds of the fatalities occur in people between the ages of 15 and 40 years. Young
children have a predisposition to injuries from low-voltage sources such as electric cords because
of their limited mobility within a relatively confined environment (5) whereas older children and
adolescents encounter electrical injury through various misadventures.
There is little literature on low voltage injuries or how their morbidity may differ from high
voltage injuries.') Because no agency requires reporting of lightning injuries and because many
persons do not seek treatment at the time of their injury, the incidence and frequency of injury and
death from lightning are difficult to determine. In years that do not include Hurricane Andrew (
1992), lightning killed more people in the United States annually than any other natural disaster
except flash floods, including hurricanes, volcanoes, blizzards, and earthquakes.(7)) Although
farmers used to be the primary victims of lightning, recreation-related injuries are now the more
frequent and studies have noted work-related injuries juries in as many as 30 to 63% of victims
annually. (7,8) Lightning incidents may involve more than one victim when the current "splashes"
to other individuals or, as ground current, spreads the electrical power throughout the area where a
group may be sheltered in a storm for a variety of factors that can affect the severity of the injury.'
PHYSICS OF INJURY
With high-voltage injuries, most of the injury appears to be thermal and most histologic
studies reveal coagulation necrosis consistent with thermal injury. (9,10) Lee and others have
proposed the theory of electroporation in which electrical charges too small to produce thermal
damage cause protein configuration changes threatening cell wall integrity and cellular function."
Some believe that there may also be magnetic effects on the tissue The factors that determine the
nature and severity of what is primarily burn injury when high-voltage current flows through the
human body are listed in Table 1. (4)
TYPE OF CIRCUIT
High-voltage direct current (DC) tends to cause a single muscle spasm, often throwing the
victim from the source, resulting in a shorter duration of exposure but increasing the likelihood of
traumatic blunt injury.
Alternating current (AC) is said to be about three times more dangerous than direct current
of the same voltage, because continuous muscle contraction, or tetany, occurs when the muscle
fibers are stimulated at between 40 and 110 times per second. The frequency of electrical
transmission used in the United States is 60 Hz. Tetany occurs even at very low amperages.
It has been customary to use the terms "entry' and "exit" to describe electrical injuries.
Particularly with AC, this is clearly a misnomer and the terms should correctly he "source" and
"ground." The hand is the most common site of contact as it grasps a tool coming into contact with
an electric source. Although all the muscles of the arm may be tetanically innervated by a shock,
the flexors of the hand and forearm are much stronger than the extensors so that the hand grips the
source of the current. At currents above the let-go threshold (6 to 9 mA), this can result in the
person's being unable to release the current source voluntarily, prolonging the duration of
Resistance is the tendency of a material to resist the flow of current. Although the exact
pathophysiology of electrical in- flow of current and is specific for a given tissue, depending on
the injury is not well understood, there is at least an appreciation on its moisture content,
temperature, and other physical
Table 1. Factors Determining Electrical Injury
Type of circuit
Resistance of tissues
Properties: The higher the resistance (R) of a tissue to the flow of current, the greater its potential
to transform electrical energy (1) to thermal energy (P) at any given current, as described by
P = I^2 X R
Nerves, designed to carry electrical signals, and muscle and blood vessels, because of their high
electrolyte and water content, are good conductors. Bone, tendon, and fat have a very high
resistance and tend to heat up and coagulate rather than transmit current. The other tissues of the
body are intermediate in resistance (Table 2). (14,15) Skin is the primary resistor to the flow of
current into the body (Table 3) (10) Much of the energy may be dissipated at the skin surface,
causing significant surface burns in a heavily calloused area, sometimes resulting in less deep
internal damage than would be expected if the current were delivered undiminished to the deep
tissues. Sweating can decrease the skin's resistance to 2500 to 3000 Q. Immersion in water can
reduce this further to 1200 to 1500 Ohms and thus allow more energy to flow through the body,
resulting in electrocution with cardiac arrest but no surface burns, such as in a bathtub injury
In general, the longer the duration of contact with high voltage current, the greater the degree of
tissue destruction. Although there is an extraordinarily high voltage and amperage with lightning,
the extremely short duration and the peculiar physics of lightning result in a very short flow of
current internally, with little, if any, skin breakdown and almost immediate flashover of current
around the body, usually resulting in little, if any, burning of tissues.(8,16))
Current, expressed in amperes, is a measure of the amount of energy that flows through an
object (Table 4). There is a very narrow range of safety with electric current between the threshold
of perception of current (0.2 to 0 4 mA) and let-go current (6 to 9 mA), the level at which a person
becomes unable to let go of the current source because of muscular tetany and becomes fixed to
the electrical source, lengthening the duration of contact. Thoracic tetany can occur at levels just
above the let-go current and result in respiratory arrest from the person's inability to move the
muscles of respiration. Ventricular fibrillation is estimated to occur at an amperage of 50 to 120
mA). (17) As the tissue breaks down under the energy of the current flow, its resistance may
change markedly, making it impossible to predict the amperage for any given electrical injury
Voltage is a measure of potential difference between two points. It is determined by the
electrical source. Electrical injuries are conventionally divided into high or low voltage using 500
or 1000 V as the most common dividing lines. Although both high and low voltage can cause
significant morbidity and mortality, high voltage has a greater potential for tissue destruction and
can be responsible for severe injuries leading to major amputations and tissue loss.
The pathway that a current takes determines the tissues at risk, the type of injury seen, and the
degree of conversion of electrical energy to heat regardless of whether high, low, or lightning
voltages are being considered. Current passing through the heart or thorax can cause cardiac
arrhythmias and direct myocardial damage. Current passing through the brain can result in
respiratory arrest seizures, direct brain injury, and paralysis. Current passing close to the eyes can
As current density increases, its tendency to flow through the less-resistant tissues is
overcome, so that it eventually flows through the tissues indiscriminately, treating the body as a
volume conductor, with potential destruction of all tissues in the current's path. Damage to the
internal structures of the body may be irregular, with areas of normal-appearing tissue next to
burned tissue and with damage to structures at sites distant from the apparent contact and ground
Probably the most important difference between light- and high-voltage electrical injuries is
the duration of exposure to the current. The mathematics of the rapid rise and decay of lightning
energy makes predicting lightning injury even more complicated than predicting man-made
electrical injury. The study of such massive discharges of such short duration is not well advanced,
particularly with regard to effects on the human body.
Lightning current may flow internally for an incredibly short time and cause short-circuiting of
the body's electrical systems, but it seldom causes any significant burns or tissue destruction
(3,15,18) Thus burns and myoglobinuric renal failure play a small part in the injury pattern from
lightning, whereas cardiac and respiratory arrest, vascular spasm, neurologic damage and
autonomic instability play a much greater role. (3,15 Lightning will tend to cause ventricular
asystole rather than fibrillation. Although automaticity causes the heart to begin beating again, the
respiratory arrest that often accompanies cardiac arrest may last long enough to cause secondary
deterioration of the rhythm to ventricular fibrillation and asystole, which is more resistant to
therapy than was the first arrest. (15,18) '9 The secondary arrest, just a theory in the past, has
recently been elegantly shown to occur experimentally in sheep. (16,18) Other injuries caused by
blunt trauma or ischemia from vascular spasm, such as myocardial infarction (20-27) spinal artery
syndromes, may occasionally occur. (28-30)
MECHANISMS OF INJURY
The mechanisms of electrical injury are listed in Table 5. It is often difficult to determine
which mechanism of injury has caused burns at the time of a patient's presentation to the
emergency department. This may make it difficult to assess the injury and offer a prognosis based
on history and physical examination alone. The most destructive indirect injury occurs when a
person becomes part of an electrical arc, since the temperature of an electrical arc is approximately
2500 degrees Celsius. (14) The arc may cause clothing to ignite and cause secondary thermal
burns. The electrical flash burn usually results in only superficial partial-thickness burns.
Blunt injury may occur in electrical injury as the person is thrown clear of the source by
intense muscular con traction or it may result from a fall from a height. The violent muscle spasms
associated with AC injuries can cause fractures and dislocations. (31.32)
Muscle damage may be spotty, with areas of viable and nonviable muscle found in the same
muscle group. Periosteal muscle damage may occur even though overlying muscle appears to be
Vascular damage is greatest in the media, possibly because of the diffusion of heat away from
the intima by the How of blood, but can lead to delayed hemorrhage when the vessel eventually
breaks down. (14,33,34) Intimal damage may result in either immediate or delayed thrombosis and
vascular occlusion as edema and clots form on the damaged internal surface of the vessel over a
period of days. (34) This injury is usually most severe in the small muscle branches, where blood
flow is slower. (35) This damage to small arteries in muscle, combined with mixed muscle
viability that is not visible to gross inspection, creates the illusion of "progressive" tissue necrosis.
Damage to neural tissue may occur from many mechanisms. Nerve tissue may show an immediate
drop in conductivity as it undergoes coagulation necrosis similar to that observed in muscle tissue.
In addition, it may suffer indirect damage as its vascular supply or myelin sheaths are injured. As
with other vascular damage and edema formation, signs of neural damage may develop
immediately or be delayed by hours to days.
The brain is frequently injured, because the skull is a common contact point. Histologic studies
of the brain have revealed focal l petechiae in the brain stem, widespread chromatolysis and
cerebral edema. (14)
Immediate death from generated electricity may be from asystole, ventricular fibrillation, or
respiratory paralysis, depending on the voltage and pathway.
Lightning injury may occur by five mechanisms (Table 6). The mechanism of injury of a direct
strike is self-evident . Recently, it has been postulated (20) and substantiated experimentally in
sheep (16,18,36) (18) 36) that lightning strikes near the head may enter orifices such as the eyes,
ears, and mouth to flow internally, as reported in the article by Andrews in this issue. This would
help to explain the myriad eye and ear symptoms and signs that have been reported with lightning
Injury from contact occurs when the person is touch- object that is part of the pathway of
lightning current, such as a tree or tent pole. Side flash or splash occurs as lightning jumps from its
pathway to a nearby person and adopts the person as its pathway. (3,28,33,37) 33 3'
Step voltage occurs as a result of lightning current spreading radically through the ground. A
person who has one foot closer than the other to the strike point will have a potential difference
between the feet so that a current may be induced through the legs and body. This is a frequent
killer of large livestock such as cattle and horses because of the distance between their hind legs
and forelegs. (3)
Blunt injury from lighting may occur as the person is thrown by the opisthotonic contraction
caused by current passing through the body and from the explosive/implosive fore c caused as the
lightning pathway is instantaneously superheated and then rapidly cooled after the passage of the
lightning is over. The heating is seldom long enough to cause severe burns but does cause rapid
expansion of air followed by rapid implosion of the cooled air as it rushes back into the void. (3)
Electrical injuries are usually self-evident from history and physical surroundings, except in
the case of bathtub accidents, where no burns occur, or of foul play. It is necessary to attempt to
differentiate between mechanisms of burn injury because flash burns have a much better prognosis
than arc or conductive burns. Injuries from blunt trauma and falls may also be present.
The differential diagnosis for lightning injuries is more complex, often because the incident is
unobserved (Table 7). It includes the differential for unconsciousness, paralysis, or disorientation
from a number of causes. (3) Evidence- of a thunderstorm or a witness to the lightning strike may
not be available. The presence of typical burn patterns, when present, may be helpful.
CLINICAL FINDINGS AND MANAGEMENT
RESUSCITATION AND TRIAGE AT THE SCENE
Once the accident scene is controlled, a quick initial assessment of the patient is indicated with
attention to the airway, breathing, and circulation. High-flow oxygen and intubation should be
provided if necessary. Cardiac monitoring is essential and, if the patient is in cardiac arrest,
standard advanced life support protocols should be instituted.
Electrical injury patients often require a combination of cardiac and trauma care, since they
often have blunt injuries and burns as well as cardiac damage. At least one large-bore intravenous
line of normal saline or Ringer s lactate solution should be started, with fluid resuscitation
dependent on the degree of apparent injury. Injury to the cervical spine should be presumed, and
protective measures provided until it can be excluded on the basis of history, physical
examination, or radiologic study. Use of a backboard, as with other trauma patients, is helpful for
both stabilization and transport. Any fractures should be splinted and burns dressed with clean, dry
dressings. An electrical injury should be treated like a crush injury rather than a thermal burn
because of the large amount of tissue damage under normal skin. No formula for optimal
intravenous fluids based upon percentage of burned body surface area can be counted on. A bolus
of 10 to 20 ml/kg of isotonic fluid can reasonably be given to a hypotensive patient.
The major cause of death in lightning injuries is cardiac arrest. In the absence of
cardiopulmonary arrest, patients are highly unlikely to die of any other cause."' Lightning acts like
a cosmic DC countershock, sending the heart into asystole. (3,16) Although automaticity may lead
to the heart s restarting, the respiratory arrest often lasts longer than the cardiac pause and may
lead to a secondary cardiac arrest with ventricular fibrillation from hypoxia. (3,19.33) If the
patient is properly ventilated during the time between the two arrests, the second arrest may
theoretically be avoided. Hypothermia should also be ruled out when patients have been soaked
EMERGENCY DEPARTMENT ASSESSMENT AND RESUSCITATION
The patient after an electrical injury is often unable to give a good history, either because of
the severity of injury and accompanying shock and hypoxia or because of unconsciousness or
confusion that often accompanies less severe in juries. History from bystanders and emergency
medical personnel regarding the type of electrical source, duration of contact, environmental
factors at the scene, and resuscitative measures provided can be helpful. Information on prior
medical problems, medication history, tetanus immunization status, and allergies should be
sought. Likewise, the patient after a lightning strike, as in other environmental emergencies, may
be unable to provide a history, and bystanders stories of the incident may be confused. Although it
is interesting to try to unravel the history, this is often difficult to do and may take unnecessary
time during the acute resuscitation phase. With both types of injuries, the patient may grossly
appear to be alert, oriented and able to repeat his history and give complaints, but this does not
preclude serious functional brain injury similar to that found with blunt head injury patients. All
patients receiving a high-voltage injury should be transported to a hospital and receive an
electrocardiogram (EGG), cardiac isoenzyme level study, urinalysis for myoglobin, complete
blood count (CBC), and other tests and radiographic studies as appropriate for their injuries.
Resuscitative efforts should be continued in the emergency department with adequate fluid
administration and insertion of a Foley catheter for the more severely injured electrical patient. If
rhabdomyolysis is present, appropriate treatment should be carried out, with a rate sufficient to
maintain a urine output of at least 1.0 to 1.5 ml/kg/hr when heme pigment is present in the urine
and 0.5 to 1.0 ml/kg/hr when it is not. Because burns from lightning and low-voltage sources
seldom involve deep tissues, myoglobinuria and the need for fluid loading, mannitol or furosemide
diuresis or fasciotomy for compartment syndromes are rare. (3,19,28.38) '9 If cardiac arrest or
suspected intracranial injuries occur in lightning patients, fluid restriction may actually be
desirable to avoid pulmonary edema and increased intracranial pressure. (3,19,39,40) Patients with
lightning and low-voltage injuries may present with little objective evidence of injury or,
alternately, cardiopulmonary arrest. After initial resuscitation of these patients, other conditions
may be identified. These are rarely life-threatening Such patients too may have significant residual
morbidity from pain syndromes or neurologic and cognitive damage that is similar to that
experienced with blunt head injury. (41-49) (see Primeau and Engelstatter in this issue of
HEAD AND NECK
The head is a common point of contact for high volt-injuries and the patient may exhibit burns
as well as neurologic damage. Cataracts develop in approximately 6 percent of cases of high-
voltage injuries and should be suspected whenever electrical injury has occurred in the vicinity of
the head. (50) Although cataracts may be present initially or develop shortly after the accident.
they more typically begin to appear months after the injury. Visual acuity and fun- examination
should be performed at presentation or as soon as practical for documentation. Referral to an
ophthalmologist familiar with electrical cataract formation may be necessary after the patient s
discharge from the hospital. (51,52)
Cataracts may also occur with lightning injuries but are probably less common. (3,19,54)
Clinical findings in lightning pa tie patients may include skull fractures. (3,28,29,54) Typanic
membrane rupture is frequently found h1 lightning patients and may be secondary to the shock
waves direct burn or basilar skull fracture. (3,19,55) Although most recover without serious
sequelae '9 disruption of the ossicles and mastoid (19,55) may occur as well as cerebrospinal fluid
otorrhea hematympanic and permanent deafness. (56-60) Other injuries to the eyes may include
corneal lesions, uveitis, iridocyclitis, vitreous hemorrhage, optic atrophy, retinal detach, and
chorioretinitis. Cervical spine injury may be caused by a fall or being thrown in either type of
Cardiac arrest either from asystole or ventricular fibrillation is a common presenting condition
in electrical accidents. Other observed presenting arrhythmias include sinus tachycardial transient
ST elevation reversible QT prolongation premature ventricular contractions atrial fibrillation and
bundle branch block. (33,65-68) Acute myocardial infarction has been reported but seems to be
relatively rare. (67, 69-71 Recent research has shown that damage to skeletal muscles may
produce an inordinate rise in the vtrsyinr creatine kinase (CK) MB fraction leading to a spurious
diagnosis of myocardial infarction in some settings.(7)
In lightning injuries cardiac damage or arrest caused by either the electric shock or induced
vascular spasm may occur. (2?) Lightning patients who do not have cardiopulmonary arrest at the
time of the strike generally do well with supportive therapy. (3,19) Those who have
cardiopulmonary arrest may have a poor prognosis particularly if there is hypoxic brain damage.
Numerous arrhythmias have been reported with light-injuries in the absence of cardiac arrest.
(3,14) Nonspecific ST-T wave-segment changes and prolonged QT interval may occur and serum
levels of cardiac enzymes are some- elevated. (3,38,73-75) '; Hypertension is often present
initially with lightning injury but usually resolves in an hour or two so that treatment is not usually
Although ECG changes and arrhythmias are common with electrical injuries large series of
patients have under gone anesthesia and surgical procedures in the first 48 hours of care without
cardiac complications. If the patient has none of the indications listed in Table 8 cardiac
monitoring probably is not necessary or can be safely discontinued after 12 hours of normal
rhythms. (39) Invasive monitoring such as for central venous pressure or intracranial pressure and
use of Swan-Ganz catheters should be guided by the patient s status. (40,76)
Table 8. Indications for Electrocardiographic Monitoring
Documented loss of consciousness
Arrhythmia observed in prehospital or emergency department setting
History of cardiac disease
Presence of significant risk factors for cardiac disease
Concomitant injury severe enough to warrant admission
Suspicion of conductive injury
Other than cardiac arrest the most devastating immediate injuries that can accompany an
electrical injury are burns. The most common sites of contact for the current include the hands and
the skull. The most common areas of ground are the heels. There may be multiple contact and
Because high-voltage current often flows internally and can create massive muscle damage
one should not attempt to predict the amount of underlying tissue damage from the amount of
cutaneous involvement or use the rule of nines for calculating fluid resuscitation. (15, 33)
Cutaneous burns should be covered with antibiotic dressings such as mafenide acetate
(Sulfamylon) or sulfadiazine silver (Silvadene). (77) (78) Mafenide is preferable for localized full-
thickness burns because of its better penetration. Sulfadiazine silver may be preferable for patients
with extensive burns: when Mafenide is used on more than 15 to 20% of the body electrolyte
abnormalities may occur because it inhibits carbonic anhydrase. Electrical burns are especially
prone to tetanus infection and patients should receive tetanus toxoid and tetanus immune globulin
on the basis of their immunization history. Clostridial myositis is common but prophylactic
administration of high-dose penicillin to prevent clostridial myonecrosis is controversial and
should be discussed with the managing surgeon or burn unit. In general systemic antibiotics are
usually not used unless there is infection proved by culture or biopsy.
A peculiar type of burn associated with electrical injury is the kissing burn which occurs at the
flexor creases as the electric current arcs causing arc burns on both flexor surfaces. (16) Extensive
underlying tissue damage is often present here where the current became concentrated in its
passage. Severe burns to the skull and occasionally to the aura have been reported. (79-82)
A special type of burn from low-voltage injuries is the mouth burns that occur secondary to
sucking on household electrical extension cords and are the most common electrical injury seen in
children under 4 years of age. (5) These burns usually represent local arc burns may involve the
oricularis oris muscle and are especially worrisome when the commissure is involved because of
the need for splint and the likelihood of cosmetic deformity. (83-85) A significant risk of delayed
bleeding from the labial artery exists when the eschar separates. (84, 85) s 8's Damage to
developing dentition has been reported and referral to an oral surgeon familiar with electrical
injuries is recommended. (83, 86)
With lightning injuries the skin may show no signs of injury initially. Deep burns occur in less
than 5% of the reported injuries.' As mentioned previously burns are usually superficial if present
at all. They may consist of four typeset l, l ~
1. Linear bums tend to occur in areas where sweat or water accumulates (for example, under the
arms or down the chest) (19)
2. Punctate burns appear like multiple small cigarette burns often with a heavier central
concentration in a rosette like pattern They seldom require grafting. (88)
3. Feathering burns are not true burns and actually show no damage to the skin itself. (87) They
seem to be a complex caused by electron showers induced by the lightning and make a fern pattern
on the skin.(87,89,90) They require no therapy. Regular thermal burns occur if the clothing is
ignited (88) or may be caused by metal that the person is wearing or carrying (87) that heats up
with the flashover
4. Combinations of all of these may occur. (3)
In high-voltage injuries muscle necrosis can extend to sites distant from the observed skin
injury and compartment syndromes can occur secondary to vascular ischemia and muscle edema.
With electrical injuries the thought in regard to damaged extremities is to favor early and
aggressive surgical management including early decompressive escharotomy fasciotomy carpal
tunnel release or even amputation of an obviously nonviable extremity. (2,5,91,94) Although it is
preferable to stabilize the patient prior to transfer to the operating room this is not always possible.
Extremities that have teen burned should be splinted in functional position to minimize edema
and contracture formation. The hand should be splinted in 35° to 45° extension at the
wrist 80° to 90° flexion at the metacarpophalaneals and almost full extension of the
proximal interphalaneal and distal interphalangeal joints to minimize the space available for
edema formation. (93) During the first several days of hospitalization frequent monitoring of the
neurovascular status of all extremities is essential.
Fractures of most of the long bones and spine (95) because of trauma associated with electrical
injury have been reported. Both posterior and anterior shoulder dislocations caused by tetanic
spasm of the rotator cuff muscles have been reported but do not seem to be as common as most
texts stress.''-" Numerous types of fractures and dislocations have been reported with lightning
Vascular damage from the electrical energy may be evident early or late (34,35) Because the
arteries are a high-flow system heat may be dissipated fairly well and result in little apparent initial
damage but thrombosis with subsequent thrombosis or rupture The veins on the other hand, arc a
low-flow system allowing the heat energy to cause more rapid Pulses and capillary refill should
be assessed and documented in all extremities, and neurovascular checks should be repeated x
This progressive vascular compromise can cause a burn that initially was assessed as a partial-
thickness burn develop into a full-thickness burn as the vascular supply to the area becomes
compromised. Progressive loss of muscle because of vascular ischemia downstream from
damaged vessels may lead to the need for repeated deep debridements.
Acutely, computed tomography (CT) or magnetic resonance imaging (MRI) is indicated to
rule out intracranial hemorrhage or other injury in any patient with neurologic deterioration or
clouded mental status. (19,76,96,96a,b,c) With high-voltage injuries, loss of consciousness may
occur but is usually transient unless there has been a significant head injury as well, although
prolonged coma with recovery has been reported. Patients may exhibit confusion, Pat affect, and
difficulty with short-term memory and concentration (see Primeau and Engelstatter in this issue of
Seminars). A seizure may occur after electrical injury as either an isolated event or part of a new-
onset seizure disorder. (4) Hypoxia and injury should be ruled out as causes of the seizure.
Neurologic symptoms may improve, but long-term disability is common.
Spinal cord injury may result from fractures of the cervical, thoracic, or lumbar spine (95, 97-
99) Neurologic damage in patients without evidence of spine injury seems to follow two patterns,
immediate and delayed. (97,98,100) Patients with immediate damage develop symptoms of
weakness and paresthesias within hours of the insult, although extremity weakness frequently goes
undiagnosed until ambulation is attempted. (41,97) Lower extremity findings are more common
than upper extremity findings. These patients have a good prognosis for partial or complete
recovery. Delayed neurologic damage may present from days to years after the insult. (The
question of causal connection is addressed elsewhere in this issue of Seminars.) The findings
usually fall into three clinical pictures: ascending paralysis, amyotrophic lateral sclerosis, or
transverse myelitis. (99) Although recovery has been reported, the prognosis is usually poor. (97)
With lightning, up to two thirds of the seriously injured patients have keraunoparalysis on
initial presentation, with lower and sometimes upper extremities that are blue, mottled, cold, and
pulseless because of vascular spasm and sympathetic nervous system instability. (19,101)
Generally, this clears within a few hours, although some patients may be left with permanent
paresis or paresthesias. (3,19,25,33) Paraplegia (2) intracranial hemorrhages (57,77,97) creatinine
kinase (CK) MB isoenzyme elevations, 3. 38, 73-75) 75 seizures, 89 and electroencephalographic
(EEG) changes have been reported.' The vast majority of lightning patients will behave as though
they have had electroconvulsive therapy, being confused and having anterograde amnesia for
several days after the incident. Loss of consciousness for varying periods is common. (19,103)
Peripheral nerve damage is common, and recovery is usually poor for all types of electrical
Table 9. Primary Complications and Causes of Death in Electrical Injuries in Temporal
Order of Occurrence
Hypoxia and electrolytes
Myoglobinuric renal failure
A syndrome of delayed muscle atrophy caused by electrical injury of the nerves has been
described even in the absence of cutaneous burns. (32)
Injury to the lungs may occur because of associated blunt trauma but is rare from electrical
current perhaps because air is a poor conductor. injury to solid visceral organs is rare but damage
to the pancreas and liver has been reported. (105) Injuries to hollow viscera including the small
intestine , (106,107) large intestine , (14,105) bladder (81,106) and gallbladder. (105) have also
been reported. With lightning pulmonary contusion and hemorrhage have been reported .
(29,108,109) Blunt abdominal injuries have been reported but are rare/ (3) None of the other
intraabdominal catastrophes associated with electrical injury has been reported with lightning
LOW VOLTAGE INJURIES
Evaluation of low-voltage injuries should include a good history because injury that initially
appears to be from a low-voltage source may turn out to have been caused by a discharge from a
capacitor (as in the repair of televisions and convection or microwave ovens) or other high-energy
source. Although burns from low-voltage sources are usually less severe than those from high-
voltage sources , (5,6,110,111) patients may still complain of paresthesias for an extended
period experience cardiac arrhythmias or develop cataracts if the shock occurs close to the face or
head. Low voltage mouth injuries in children were discussed in the section of this article on
The complications of high-voltage electrical burns are listed in Table 9. Cardiac arrest
generally occurs only with the initial presentation or as a final event after a long and complicated
Many of the complications are like those of thermal burns and crush injuries; they include
infection clostridial myositis and myoglobinuria The incidence of acute myoglobinuric renal
failure seems to have decreased since the institution of adequate fluid therapy. Fasciotomies or
carpal tunnel release may be necessary for treatment of compartment syndromes. (91-94) Tissue
loss and major amputations are common with severe high-voltage injuries and result in the need
for extensive rehabilitation.
A nasogastric tube should be placed in the seriously injured patient because of the risk of
adynamic ileus and stress ulceration. Ulcer prophylaxis with H(2) blockers or sucralfate (Carafate)
may be beneficial. Peritoneal ravage or abdominal CT scan may be indicated to rule out
intrabdominal injuries if the ileus seems to be prolonged or if the history and physical examination
A head CT or MRI scan is also indicated to rule out intracranial injuries and hemorrhage if the
patient s level of consciousness does not markedly improve during the emergent course.
Ophthalmologic documentation is important in those patients having injury upward from the
shoulders since they can develop cataracts.
Neurologic complications such as loss of consciousness difficulty with memory and
concentration (47-49) peripheral nerve damage (46,104) and delayed spinal cord syndromes may
occur. (41,95, 97-100) Damage to the brain may result in a permanent seizure disorder. (54)
Stress ulcers are the most common gastrointestinal complication after burn ileus Abdominal
injuries from ischemia vascular damage burns or associated blunt trauma may be missed initially,
14,81,105-111) The most common causes of hospital mortality are pneumonia sepsis, and
multiple organ failure because of the complexity of the injury.
Long-term psychiatric sequelae include body image changes marital problems inability to
continue working in the same profession and suicide. Treatment for lightning patients can usually
be based primarily on routine common-sense treatment of their presenting injuries with attention
and follow-up for the long term problems of pain and cognitive dysfunction. In the past patients
with lightning injuries have often been treated like those with high-voltage injuries. However
these injuries are distinctly different. High-voltage injuries tend to cause deep internal injuries
myoglobinurea renal failure shock and massive loss of tissue and function. Lightning injuries tend
to cause few external or internal burns and rarely cause myoglobinuria. There is usually little
tissue loss although there may certainly be permanent functional impairment. As a result treatment
of lightning patients rarely requires massive fluid resuscitation fasciotomies for compartment
syndromes mannitol and furosemide diuretics alkalinization of the urine amputations or large
repeated debridements. In fact most lightning patients particularly those with head injuries should
probably have their fluids restricted to decrease the likelihood of cerebral edema.
LABORATORY, ELECTROCARDIOGRAPHIC, AND RADIOLOGIC EVALUATION
The laboratory evaluation of the patient sustaining an electrical injury depends on the extent of
injury. All patients with evidence of conductive injury or significant surface burns should have the
following laboratory tests: CBC electrolyte level serum myoglobin blood urea nitrogen creatinine
level and urinalysis with special attention to myoglobinuria. Patients with severe electrical injury
or suspected intra-abdominal injury should also have obtained amylase aspartate and alanine
transaminases alkaline phosphatase and clotting indexes. (68) Sending blood for type and cross-
match should be considered, particularly if major debridement embridements may be necessary.
Arterial blood gas determinations arc indicated if the patient needs ventilatory interior or alkali
All patients should be evaluated for myoglobinuria a common complication of electrical
injury. A patient with an ortho-toluidine dipstick examinationa of the urine that is positive for
blood, but with no red blood cells seen on microscopic analysis, should be presumed to have
myoglobinuria and be treated accordingly. creatine kinase CK levels should be determined and
isoenzyme analysis performed Peak CK levels have been shown to predict the amount of muscle
injury, risk of amputation, and ultimate hospital stay; however, the clinical value of a single level
in the acute setting has not been established." Cardiac enzyme levels should be interpreted with
care in diagnosing myocardial infarction in the setting of electrical injury. The peak CK level is
not indicative of myocardial damage in electrical injury because of the large amount of muscle
injury. Although CK-MB fractions, ECG changes, thallium studies, angiography, and
echocardiography have correlated poorly in most reports of acute myocardial infarction,
(66,67,69) cases of infarction with all of these present have been reported. it' Recent human
studies have indicated that skeletal muscle cells damaged by electrical current can contain as much
as 20% to 25% CK-MB fraction, as opposed to the usual 2% to 3%, suggesting injured skeletal
muscle as the source of the elevated CK-MB fraction and not true myocardial injury." All patients
sustaining an electrical injury should receive cardiac monitoring in the emergency department and
an ECG regardless of whether the source was high or low voltage. Indications for admission for
ECG monitoring are listed in Table 8.'969
Radiographs of the cervical spine should be performed if spinal injury is likely. Radiographs
of any other areas in which the patient complains of pain or has an apparent deformity should be
performed. CT scan and MRI may be useful in evaluation of trauma and are essential for
evaluation of possible intracranial injuries, particularly if the patient does not show progressive
improvement in level of consciousness (56, 76, 96, 96c)
In lightning patients, studies should include CBC, urine for myoglobin (using the Quick visual
check and dipstick methods), and an ECG. Cardiac isoenzymes are indicated in patients with chest
pains, abnormal ECGs, or altered mental states. Other laboratory examinations may be indicated
by the severity of the patient's injuries (for example, arterial blood gas measurement if he or she is
on a ventilator). Radiographic studies, particularly cerebral scanning, may be indicated, again
depending on the individual patient's presentation and progress during evaluation and
All patients with significant electrical burns should be stabilized and transferred to a regional
burn center with expertise in electrical injuries, if possible. (94) In addition to burn care and
extensive occupational and physical rehabilitation, severely injured patients may need counseling
for themselves and their family because of the extensive life changes consequent to the injury.
Purely thermal burns should be treated as such and disposition made accordingly with
appropriate close follow-up.
Asymptomatic patients with low-voltage injuries in the absence of significant cutaneous
involvement changes or urinary heme pigment can probably be discharged safely will, reflect in
Indications for admission for 12 to 24 hour ECG monitoring are listed in Table 8. Any case in
which corporal conduction is suspected should probably be admitted for monitoring. Patients
should be informed of the potential for development of delayed cataracts, weakness, and
paresthesias, and appropriate referrals made if these develop.
Electrical injury during pregnancy from low voltage sources hits been reported to result in
stillbirth. (113) Obstetric consultation should probably obtained in all pregnant patients reporting
electrical injury, regardless of any symptomatology a the time of presentation. Patients in the
second and third trimesters should receive fetal monitoring and be followed as high-risk patients
for the remainder of their pregnancy. (114) First trimester patients should be informed of the risk
of spontaneous abortion and if no other inclinations for admission exist, may be discharged with
instructions for threatened miscarriage and close obstetric follow up. Prognosis for fetal survival
after lightning stroke varies. (3, 19) Consultation with other specialists may be indicated for otic
and ophthalmic damage, although these are usually' not emergent considerations.
Treatment of pediatric patients with oral burns is more controversial. There is good evidence
for cardiac injury, need for ECG monitoring, or occurrence of myoglobinuria in isolated oral
burns. In general, these patients need surgical and dental consultation for planning of debridement,
oral splinting, and, occasionally, reconstructive surgery. Since there is a 10% risk of delayed
hemorrhage from the labial artery, some centers recommend admission until separation of the
eschar occurs. Admission for observation and planning of definitive therapy is also recommended
by some centers. Treatment of patients with lightning injuries usually calls for simple common
sense and patience. Many of the signs, such as lower extremity paralysis and mottling and the
neurologic signs of confusion and amnesia, resolve with time and need only observation, provided
spinal cord and intracranial injuries have been ruled out. More severely injured lightning patients
may need both trauma and cardiology consultations although lightning injuries tend to be more of
a medical problem than a trauma problem in most cases.
High-voltage electrical injuries may be devastating, with extensive burns, cardiac arrest,
amputations, and long, complicated hospitalizations. Low-voltage injuries, after other pathologic
and high-voltage sources are ruled out, tend to be rather benign acutely although they may have
significant long-term morbidity, including chronic pain syndromes.
Lightning injuries affect 800 to 1000 persons per year.(9) In lightning injury, cardiac arrest is
the main cause of death, burns tend to be superficial, and injuries often are what one would expect
of short-circuiting or overloading the body's electrical systems (tinnitus, blindness, confusion,
amnesia, cardiac arrhythmias, and vascular instability).
Although high-voltage injuries may require the services of trauma Puma surgeons, in general,
therapy for low-voltage and lightning Jury is supportive and involves cardiac r resuscitation for
the more seriously injured and supportive care for the less severely injured. long-term problems
from sleep disturbances, anxiety attacks, pain syndromes, peripheral nerve damage, fear of storms
(for lightning patients), and diffuse neurologic and neuropsychological damage may occur in
electrical and lightning patients.(42) Other sequclae such as seizures or severe brain damage from
hi hypoxia during cardiac arrest and spinal artery syndrome vascular spasm are indirect results of
electrical and lightning injury.
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Behavioral Consequences of Lightning and Electrical Injury
Margaret Primeau, Ph.D., Gerolf H. Engelstatter, Ph.D., A.B.M.P., I.A.B.C.P.,
and Kimberly K Bares, M.S.
Seminars in Neurology, Volume 15, Number 3, September 1995
Copyright © 1995
Department of Psychology, Finch University of Health Sciences/The Chicago Medical School, North Chicago,
Illinois, and Carolina Psychological Health Services, Jacksonville, North Carolina
Immediate manifestations in survivors of lightning and electrical injuries include altered
consciousness, confusion, disorientation, and amnesia.(1,2) Subsequently, patients show either
normalization of mental status or sequelae ranging from headaches and distractibility to persistent
psychiatric disorder and dementia. (3,4) The fact of this variety has been recognized for a long
Behavioral effects have been described in numerous case reports (3); research, however, has
been relatively scant and subject to a number of shortcomings. (6) These include sampling bias
and heterogeneity, cross-sectional rather than longitudinal or prospective evaluation, and
inadequate assessment and analysis of premorbid factors and concurrent psychopathology. We are
as yet unable to predict from the "magnitude" of an electrical or lightning injury what the
combination or duration of behavioral sequelae will be among survivors. As these shortcomings
are remedied (6,8) knowledge of the prevalence and nature of morbidity will permit more effective
clinical care. At present, however, our understanding is only partial; clinicians, attorneys,
employers, and families continue to puzzle over the problems of lightning and electrical injury
patients, who in turn wonder what is wrong and who can help. In this article, we discuss selected
literature and present original findings with the aim to address four main questions:
1. What are the behavioral (cognitive and psychologic) sequelae among survivors of lightning
injury (LI) and electrical injury (EI)?
2. Do LI and EI differ in outcome?
3. What models of brain-behavior disturbance best describe morbidity in LI and EI?
4. What recommendations for assessment and treatment can we make?
Empirical studies that focus on assessment and outcome in LI and EI are described in Table 1
(4,7,9-16). Since the methods and findings are diverse, prevalence rates for various problems
remain to be clarified. A few studies assessed the frequency of self-reported problems in special
cohorts. For instance, Shaw and York-Moore (9) surveyed 28 of the 50 people injured by lightning
in the 1955 Ascot incident in England, and Andrews and Darveniza recently studied telephone-
mediated lightning injury in Australia among 132 persons contacted retrospectively (13) and 10
identified at the time of their injury.(14) In these reports, 10 to 20% of patients exhibited
psychologic problems. In contrast, from a consecutive series of electrical injury patients admitted
to a burn unit, Grossman et al (7) selected a sample of 16 characterized by intermediate severity
for a prospective study of psychiatric sequelae. They found "persistent neurobehavioral disorder"
in 75% of those whose injury was by direct current. In the remaining studies in Table 1, the
individuals came to attention because of their complications, and almost all of them showed
abnormalities such as depression and memory impairment. (4,10-12,15,16)
The neuropsychologic deficits associated with LI and EI tend to be nonspecific and to
resemble those of traumatic brain injury.(4,17) While disturbances of language, awareness, or
visuospatial functions seem to be rare, impairments of attention, concentration, verbal memory,
and new learning are very frequently identified.(7,10, 12,13,15,16) Survivors may thus experience
a reduced capacity to function, both occupationally and socially, and may complain of
forgetfulness, inefficiency, and inability to handle even mildly stressful situations. These new
obstacles and sense of loss may contribute to psychologic disorders, which in turn affect
The prediction of impairment from initial injury factors is imprecise. First, the subacute course
in LI and EI is quite variable, with some patients returning to premorbid status and others
experiencing persistent impairments. Progressive impairment has also been reported, such as the
cases with dementia listed in Table 1 from Daniel et al (4) and Troster and Ruff.(12) Second, such
variables as voltage level or whether loss of consciousness occurred do not correlate with
neuropsychologic profiles.(4,17) For example, case descriptions of LI indicate that neither cardiac
arrest nor gross central nervous system (CNS) lesions necessarily predict poor outcome.(18) Also,
although both of the EI patients described who deteriorated had sustained high-volt-age injuries
(more than 8000 V), such poor outcome was not the rule within high-voltage groups. For instance,
data from an archival study of 90 EI cases (19) suggested good outcome in 56% of patients
receiving high-voltage injuries (compared to 91% of patients receiving low-voltage injuries), at
least in terms of resolution of CNS symptoms observed during inpatient care.
In EI and LI cases with persistent cognitive deficits, poor memory is a common complaint, and
emotional distress is also prominent. In an investigation of memory functioning after EI, Bares
(20) compared 20 patients early in their course (between I and 57 days after injury) to 20 patients
with late sequelae (9 months to 4 years post-injury) on a 280 measure of verbal memory that
differentiates the components of acquisition, retention, and retrieval.(21) The groups were
matched on age, sex ratio, years of formal education, and estimated premorbid intelligence.
Within-group variability was high, and mean group differences on index scores were not
significant. Relative to normative expectations, however, 56% of subjects in the acute group and
68% of subjects in the post-acute group had component scores in the impaired range (lower than 1
standard deviation below the mean). Thus, both early and late EI were associated with a deficit in
verbal memory, with the late EI group tending to be worse. Acquisition and retrieval were more
affected than retention, as is seen in the so-called subcortical syndromes as well as in affective
disorders. When self-report of depression was analyzed, (22) the post-acute group showed a
significantly higher frequency of symptoms of depression, but this variable did not account for
memory performance. Furthermore, neither involvement in litigation nor history of loss of
consciousness ac-counted for memory results in this study, suggesting independence of memory
impairment from individual differences in initial injury, affective status, and money issues.
Taken together, these findings provide some support for the phenomenon of delayed or
progressive decline of cognitive and emotional functioning after EI. Prospective serial assessment
of memory function and affective status is needed to establish the frequency of decline. Since the
subjective experience of poor memory may arise from other cognitive or emotional factors such as
distractibility or fatigue, these should also be assessed.(23) The lack of obvious correspondence
between neuropsychologic deficits and in-jury variables or other individual differences highlights
the need for thorough evaluation.
The studies cited in Table 1 describe a variety of emotional problems, ranging from anxiety to
marital break-down to major depression, and illustrate several main features of late psychologic
sequelae: they are variable in severity and duration, they are difficult to predict from injury
parameters, and their etiology is not readily inferred. For example, such reported difficulties as
sleep disturbance, memory deficit, depression, sexual dysfunction, and chronic pain, as well as
weakness, dizziness, and confusion may arise from neurologic injury, psychologic reaction, or
from the subtle interrelationship between the two.
Among EI studies, single-case reports involved high-voltage exposure while the remaining
samples were heterogeneous for volt-age level. HEIDI: Beck Depression Inventory; CT: computed
tomography; EEG: electroencephalogram; MMPI, Minnesota Multiphasic Personality Inventory
(Hs, D, and Hy are clinical scales); NA, not assessed; PNBD, persistent neurobehavioral disorder
(organic brain syndrome); PTSD, post-traumatic stress disorder.