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Lightning Does Strike Twice: A Fulminology Primer for Nurse Practitioners
CONTINUING EDUCATION
Lightning Does Strike Twice: A Fulminology Primer for Nurse Practitioners Nancy Prahm, MSN, RN, Bernadette M. Longo, PhD, APHN-BC, Kimberly Baxter, MSN, FNP-BC, and Timothy J. Brown, PhD
ABSTRACT Lightning strikes cause more fatalities in the United States than floods, tornadoes, or hurricanes, although 90% of victims survive. Lightning strikes can cause diverse and major health consequences for every organ system, resulting in cardiovascular, neurological, and mental health sequelae. Misinformation and a lack of understanding about lightning and the associated health risks are commonplace. Therefore, nurse practitioners have the opportunity to apply evidence-based knowledge in the care of lightning-strike victims, as well as educate all their patients on preventive measures. Keywords: environmental health, lightning injuries, neurologic manifestations, safety Ó 2013 Elsevier, Inc. All rights reserved. Nancy Prahm, MSN, RN, is an emergency room nurse at Renown South Meadows in Reno, NV. Bernadette M. Longo, PhD, RN, CNL, APHN-BC, is an associate professor in the Orvis School of Nursing at the University of Nevada in Reno and can be reached at [email protected]. Kimberly Baxter, MSN, RN, FNP-BC, is an assistant professor and director of undergraduate nursing education in the Orvis School of Nursing. Timothy J. Brown, PhD, is a research professor in atmospheric sciences at the Desert Research Institute in Reno, NV.
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ightning is known to strike outdoor workers or enthusiasts such as golfers, hikers, hunters, and fisherman, but injuries can also occur to those engaged in more mundane indoor activities. One third of lightning injuries occur indoors.1,2
Injuries can result from lightning current following the pathways of a building’s plumbing, electrical, and telephone lines. Case reports describe injuries to victims who were simply using sinks, showers, toilets, telephones, electrical appliances, or even riding in
This CE learning activity is designed to augment the knowledge, skills, and attitudes of nurse practitioners and assist in their understanding of the care required for patients struck by lightning. At the conclusion of this activity, the participant will be able to: A. Contrast misinformation and scientific evidence about lightning risks and prevention B. Describe adverse physiological and psychological effects from lightning strikes C. Identify proper follow-up/management of a lightning strike victim The authors, reviewers, editors, and nurse planners all report no financial relationships that would pose a conflict of interest. The authors do not present any off-label or non-FDA-approved recommendations for treatment. This activity has been awarded 1.0 contact hours for nurses and advanced practice nurses and 0.5 contact hours of pharmacology credit. The activity is valid for CE credit until October 1, 2015. Readers may receive the 1.0 CE credit free by reading the article and answering each question online at www.npjournal.org, or they may mail the test answers and evaluation, along with a processing fee check for $10 made out to Elsevier, to PO Box 786, East Amherst, NY 14051. Required minimum passing score is 70%. This educational activity is provided by Nurse Practitioner AlternativesÔ. NPAÔ is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Accreditation does not imply endorsement by NPA, JNP, Elsevier, or ANCC of recommendations or any commercial products displayed or discussed in conjunction with the educational activity.
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motor vehicles or planes.3,4 Most victims of lightning survive but experience residual effects. Nurse practitioners may see patients after lightning strikes with or without ongoing sequelae. This article discusses the physical properties of lightning and its health risk, epidemiology, and pathophysiology, as well as recommendations for tertiary care for the unique patient population of strike victims. VIGNETTE
In July during a hike along the Tahoe Rim Trail in the Sierra Nevada Mountains, 2 teenagers were struck by lightning. A visible thunderstorm was building nearby, and the group estimated about 15 minutes before rain arrived. Teenagers Shawn and Carmel ran ahead hoping to seek shelter. Suddenly, a lightning bolt struck a boulder a meter away from them. Shawn was indirectly hit and suffered immediate cardiac arrest. Responding quickly, his mother and 3 other hikers performed successful cardiopulmonary resuscitation (CPR) with quick return of pulse but weak agonal breathing. Shawn’s mother saw that his necklace had melted and burned the skin on his neck and the front of his shirt was charred. The lightning also injured Carmel, who was running next to Shawn. A second lightning bolt had traveled through the ground and entered her body indirectly. Carmel complained of a roaring sound in her left ear and could not stand or move her legs. She experienced temporary lower extremity numbness and paralysis and also had unusual skin lesions on her back. The victims were flown by helicopter to the nearest trauma center. Shawn was first evaluated in the emergency department and then admitted to intensive care, unresponsive and with ventilator-dependent respiratory failure. After several months in the critical and acute care units, he was moved to a specialty area for extensive rehabilitation. Shawn improved physically to some extent but suffered long-term physical and neuropsychological dysfunction. Carmel was noted to have an unusual erythemic skin lesion, known as a Litchtenberg figure, on her back. A left tympanic membrane defect was noted. She was admitted for serial neurologic exams and monitoring. She continued to improve and was discharged home after an overnight stay. Her legs remained slightly numb but had full strength and mobility. Her 480
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skin lesions were faintly visible and disappeared after several days. Carmel complained of decreased hearing and ringing in the left ear. She was discharged with minor injuries and expected to recover fully. WHAT IS LIGHTNING?
Lightning flashes occur worldwide on average 1.4 billion times a year, with an average frequency of 44 flashes per second, but not all reach the earth’s surface.5 Thunderstorm lightning is caused by an electrical charge separation as a result of collisions of ice crystals and graupel (small, soft hail). Turbulence within a storm causes collisions between ice crystals and graupel, and the collisions break the attractive force within the graupel’s atoms. The collision frees some positive nuclei for transfer to ice crystals. Consequently, some ice crystals become positively charged, and some graupel becomes negatively charged. The thunderstorm’s updraft carries the positive ice crystals into the upper regions of the storm, where they repel each other and spread out. The negatively charged graupel particles settle into the cloud’s lower region, where they repel each other and spread out. Moreover, the cloud’s negatively charged region repels electrons on the ground’s surface, making the surface area beneath the cloud positively charged (Figure 1). This positive area travels with the thunderstorm as it moves. The charge separations established by the collisions are critical to the development of lightning flashes, both near and within clouds, from cloud-to-cloud, and from cloud-to-ground.5-7 A single lightning strike from cloud to ground represents a sequence of 3 events: the stepped leader, the upward streamer, and the flashing bolt. As the charge-separation process continues, the negative charge in the storm steadily increases, as does the ground’s positive charge. The attractive force between the 2 regions also increases, and this force becomes so strong that it ignites a stepped leader into the cloud. The stepped leader is a stream of electrons that functions as a pathfinder as it zigzags toward the ground. From the ground, an upward streamer of positive nuclei rushes to meet the leader. The instant they connect, a path for the bolt is complete, and a flash of a billion trillion electrons explodes across the sky.6,8 In an average home in the United States, electricity has up to 240 volts and up to 200 amps and Volume 9, Issue 8, September 2013
Figure 1. Charge Separation Within a Thunderstorm That Leads to Lightning
Image courtesy of the National Oceanic and Atmospheric Administration and the Department of Commerce.
performs at an average temperature of 68 F. Domestic electricity has sufficient power to electrocute and kill. In comparison, a single flashing bolt of lightning carries 100 million volts, 200,000 amps, and reaches a peak temperature of 50,000 F.9,10 The extreme heat within the lightning channel expands outward into cooler air faster than sound travels. This pulse produces a shockwave that we perceive as sound called thunder.11 EPIDEMIOLOGY
Surprisingly, lightning is the deadliest of common natural hazards. Lightning killed 9,207 persons in the US during 1940-2011. By comparison, 7,478 persons died in floods, 7,374 in tornadoes, and 3,318 in hurricanes.12 However, there is low case fatality for lightning injuries. Ninety percent of victims survive, but not without residual impairments; 74% of survivors suffer from permanent injuries and long-term physical and mental health consequences.13,14 www.npjournal.org
The highest density of lightning strike locations is also where the highest mortality occurs. In a geographic comparison, lightning strike locations (Figure 2) correlate strongly with lightning deaths (Figure 3). The Southeastern states have both the most strikes and deaths. Florida ranks first in both categories with Texas following closely.14 Lightning occurs less frequently in the Northern and Western states, with fewer deaths as well.15,16 Thunderstorms and lightning strikes occur primarily in the late spring and summer.14-16 In the Northern hemisphere lightning strike frequency increases rapidly in May and June, reaching maximum occurrences in July and then slowly decreasing in August and September.8,17 Lightning strikes can occur at anytime, but the temporal occurrence begins to rapidly increase around 10 AM, reaching a maximum around 4 PM.8,18 Morbidity is at least 300 or more nonlethal injuries per year.8,9 However, these data are underreported The Journal for Nurse Practitioners - JNP
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Figure 2. Distribution of Lightning Strikes in North America (flashes/km2/yr)
Image courtesy of the National Space Science and Technology Center’s Lightning Team Satellite Data.
because some victims do not seek treatment and there are no formal means of reporting for providers. The mechanism of injury depends on the passage of lightning energy through the victim’s body. This passage of electric current can cause variable degrees of tissue or organ injury, from trivial to a system failure that results in immediate death (Table 1). PATHOPHYSIOLOGY
Lightning strikes can cause diverse and major health consequences for every organ system, especially the cardiovascular and neurological systems. Lightninginduced cardiac injuries and cardiopulmonary arrest are the main causes of death.20 Cardiac arrest can be primary or secondary from hypoxia because CPR Figure 3. Lightning Deaths in the United States from 1959 to 2007
Image courtesy of the National Weather Service. 482
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was not promptly initiated. Acute injuries include ventricular fibrillation, electrocardiogram (ECG) changes, and myocardial necrosis. Survivors of cardiac arrest may suffer from long-term problems, including atrial fibrillation, premature ventricular contractions, prolonged QT interval, pericarditis, cardiomyopathy, and ischemia.14,20,21 Vascular injuries may result in vasodilation, vasomotor instability, and vasospasm. Significant and serious health consequences include a wide range of neurologic injuries. Electrical current from a lightning strike can cause acute and chronic damage to the central, autonomic, and peripheral nervous systems because of their extreme sensitivity.22 Direct strikes to the head can cause damage to the central nervous system, including subdural hematomas, hemorrhage, coagulation, dural tears, petechiae, skull fractures, and injury to the neurons in the pons and medulla that control ventilation.14,22 Victims may require surgical interventions or mechanical ventilation, depending on the location and severity of the insult. Lightning strikes harm the autonomic nervous system causing dizziness, hypertension, impotence, and gastrointestinal problems. Injury to the peripheral nervous system affects both myelin sheaths and axons resulting in pain, tingling, numbness, paresthesias, movement disorders, and paralysis of the extremities known as keraunoparalysis.14,22 These injuries can be acute with rapid improvement and resolution but may persist and linger and can be permanent. Blunt force trauma from lightning occurs in 2 ways. First, lightning current provokes violent muscular contractions, which result in chaotic body movements, throwing the body into the air and subsequently onto the ground. The second mechanism results from the lightning shockwave, which contains a tremendous amount of energy and is capable of hurling a victim 10 meters or more through the air into objects (rocks, trees) and the ground. In the case of mountaineers, victims are often thrown off cliffs or down steep ridges. This intense energy passing through the body can contuse soft organs and tissues, leading to pulmonary contusions, pneumothorax, sheared arteries and veins, ocular injuries, and perforated tympanic Volume 9, Issue 8, September 2013
Table 1. Lightning-Strike Pathways and Prevalence6,14,20 Pathway of lightning
Prevalence of injuries
Direct Strike
3%-5%
The lightning strikes the victim before hitting the ground or another ground-based object. Direct strikes usually occur outside in open, flat areas and are most likely to kill a victim.
Slide Flash
30%
The lightning strike hits an object (eg, a tree) and then jumps from the object to the victim. A side flash can also occur between 2 persons standing near each other.
Ground Current
40%-50%
After a lightning strikes the ground or a ground-based object, the charge spreads outward along the surface. The spreading charge will pass through any living thing in its way. Ground currents cause more casualties than the other pathways.
Conduction
1%-2%
A victim is touching an electric conductor (eg, metal fence, flag pole, bleachers, telephone) at the same time it is struck by lightning.
Upward Streamers
20%-25%
Persons in a positively charged ground area are in danger of having an upward streamer pass through them to complete the lightning channel path.
Description
membranes. The shockwave can also fracture the skull, ribs, extremities, and the spine.8,23,24 Lightning energy entering and exiting the eye or ear produces trauma. Ocular injuries primarily include cataracts, which usually occur quickly but can develop in months or even years after the strike. Case reports include other immediate ocular injuries, including retinal detachment, bleeding, optic nerve damage, corneal lesions, and iritis. A ruptured tympanic membrane is the most common ear injury. Other otologic insults include hearing loss, tinnitus, vertigo and the development of chronic otitis media.23 Lightning can cause first, second, or third degree burns at the entry and exit wound sites. Second-degree burns appear yellow or white with redness and clear blisters. Third degree burns appear stiff and whitebrown.25 A characteristic skin pattern called Lichtenberg figures (aka lightning flowers) may occur in victims caused by current-induced injury to capillaries beneath the skin or from the shockwave produced by the lightning discharge. Lichtenberg figures are reddish and fernlike and last hours to days or even months.23 Common with other traumas, being struck by lightning causes psychological stress. If mental health assessments and rapid treatment are missed during the immediate post-strike period, the victim is at risk for developing posttraumatic stress disorder (PTSD). Lightning can also cause debilitating neuropsychological injuries that mimic traumatic brain injury. Survivors of lightning injuries have described seizurelike activity, headaches, chronic pain, personality www.npjournal.org
changes, depression, anxiety, short-term memory loss, sleep disturbance, and increased irritability.14,22 Continuation of these neuropsychological or PTSD symptoms can cause impairment of the person’s social life and ability to perform activities of daily living. Several case reports have noted PTSD and mood disorders that are often unrecognized or undertreated by their health care providers.26 CASE EXEMPLAR
Carmel, a 14-year-old white, non-Hispanic female, was brought in by her mother for complaints of hearing problems, increased headaches, fearful behavior, insomnia, and emotional outbursts at school and home. She avoids going outside and will not walk to or from school. Carmel was always an “A” student with good citizenship, but over the past month she fell behind in class assignments and received detention twice for talking back to her teachers. She was also increasingly defiant at home and refused to do chores or visit her ailing friend in the rehabilitation hospital. Instead of studying and going to bed at an acceptable time, she stayed up late playing music and using social media. Past medical history and family history were negative for chronic illness, depression, anxiety, conduct, or mood disorders. Symptoms began 2 weeks ago after she was struck by lightning. Physical Examination
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Vital Signs: Blood pressure 110/60, respiratory rate 18, heart rate 112, temperature 98.2 F Skin: Scattered open and closed comedones on forehead, chin, and nose; no evidence of burns or residual Lichtenberg figures HEENT: PERRL; visual acuity intact; right tympanic membrane (TM) intact; left TM dull and retracted with small flap noted upper left margin; no erythema or discharge; whispered words at 2 feet and Weber test reveal hearing loss in left ear Heart: regular rhythm; normal S1, S2; no murmurs, rub, or gallop Lungs: breathing unlabored, symmetrical chest expansion; resonate to percussion breath sounds clear bilaterally Neuromuscular: no atrophy, weakness, or tremors; gait smooth and coordinated; negative Romberg; sensation and strength equal bilaterally; DTRs 2 þ and equal; cranial nerves, II-XII grossly intact aside from hearing defect 12-point Review of Systems: Positive for hearing loss, sleep onset and maintenance insomnia, headaches, anxiety, depression, and hypervigilance Menstruation: menarche age 12; LMP 10 days ago, near regular 24-day cycles; abstinent Social: denies tobacco, alcohol, or illicit drug use; attends 10th grade Health promotion: vaccinations up-to-date; runs cross-country and track; lacto-ovo vegetarian Medication: multiple vitamins, occasional acetaminophen for headaches Diagnosis:
1. Acute stress disorder (ICD-9 308.3) secondary to lightning strike manifested by anxiety, sleep onset and maintenance insomnia, irritability, avoidance, and labile behavior 2. Persistent posttraumatic perforation of left tympanic membrane (ICD-9 384.2) 3. Hearing loss (ICD-9 389) 4. Paresthesia (ICD-9 782.0) resolved 5. First degree burn (ICD-9 940) Litchenberg figure resolved Plan
1. Immediate treatment includes further assess for intensity of depression and suicidal/impulsivity 484
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risk in patient and any family-based issues; explain the co-morbid mental health implications from the lightning event; recognize the insight necessary for further care; review and support positive stress coping skills; consider antidepressant medication trial; order diagnostic tests: CMP, CBC, UA, TSH; refer to psychology for acute stress counseling and therapy to prevent PTSD; and encourage mother/patient to work with school counselor. 2. Refer to ear/nose/throat (ENT) clinician for evaluation of TM perforation and audiology exam. 3. Return to clinic after completion of diagnostic tests, psychological evaluation, and ENT evaluation or sooner if symptoms worsen. RECOMMENDATIONS FOR TERTIARY CARE
The primary care nurse practitioner (NP) will rarely deal with acute lightning injuries. Instead, the NP will deal with the long-term cardiac problems, neuropsychological problems, and chronic pain related to the initial injury. No evidence-based therapy for lightning strike injuries exists; therefore, the NP should provide ongoing monitoring with a focus on symptom management. Careful follow up is necessary to ensure problem resolution or stability in patients with lightningassociated cardiovascular injuries (ie, episodes of chest pain, syncope, lightheadedness, shortness of breath, hypotension, or hypertension). A physical exam will identify heart rate and blood pressure abnormalities, as well as adventitious lung sounds, rhythm disturbances, abnormal S3 and S4 heart sounds, and pericardial rubs. A 12-lead ECG is important to follow up on any initial and ongoing abnormalities. If lightning initially caused myocardial injury and caused systolic or diastolic dysfunction, a follow-up ECG and echocardiogram can be useful to exclude cardiomyopathy. Neurological injuries can result in functional problems with memory, concentration, or problem solving or behavioral problems with emotional lability, sleep dysfunction, aggressive behavior, or depression. The NP can refer the patient and family to a lightning support network. Sleep evaluation by nocturnal polysomnography, neurocognitive and pharmacologic Volume 9, Issue 8, September 2013
Table 2. Myths vs Facts About Lightning Safety4,19,23 Myths
Facts
If you see storm clouds in the distance but see no lightning, hear no thunder, and have no clouds or rain near, you are safe.
Lightning can travel for miles through clear skies over land or water before striking the earth or you.
If you are caught outside in a storm and lightning strikes near you, you are safe because it will not strike twice in the same place.
Lightning may strike twice in the same place. After a bolt has struck the ground, an object, or a water surface, it is not unusual for more subsequent bolts to rapidly follow the first bolt’s path to the ground.
If caught outside and there is a taller object nearby (eg, tree, service tower), stand close to it. You will be safe because it will be struck rather than you.
Not necessarily. Even if the object is struck first, a side flash will likely jump from the object to you.
If caught outside in an open, flat area (eg, field, pasture) lie flat on the ground. You will be safe.
When lightning strikes near you and you are lying flat on the ground, you are perfectly positioned for the ground current to pass through you.
In a car you are safe because the tires are rubber insulators and thus prevent lightning form passing through the car to the ground.
Tires provide no protection. A vehicle that has a metal roof and sides is safe because it serves as a Faraday cage. It the vehicle lacks a metal roof or sides, it is not safe.
You are perfectly safe inside an enclosed structure, including a house.
Being safe inside a home during a thunderstorm depends on what you are doing. Do not touch or be too close to electrical appliances, plumbing fixtures, or other electrical conductors.
treatment of depression, and referral to psychology or psychiatry may be indicated. Long-term psychiatric problems may be best managed by neurocognitive, relaxation, and pharmacological therapies. Management of ongoing pain and paresthesias can be tremendously challenging for both the patient and provider. Nonsteroidal anti-inflammatory drugs are recognized as the primary pharmacological intervention for post-strike pain management.27 Useful adjuncts for long-term management may include tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, neuroleptics, and antiepileptic agents. Chronic pain may necessitate referral to a pain management specialist. SAFETY AND EDUCATION
NPs have an opportunity to educate their patients with evidence and dispel myths about the dangers of lightning strikes and prevention strategies. The inclusion of environmental safety screening and education has increased in NP practice by becoming part of the annual examination for all patients. Tables 2 and 3 provide easy-to-read information for distribution. No one can be completely safe from being struck by lightning, but avoidance strategies can reduce risks. www.npjournal.org
To be well informed about the dangers, everyone should know daily local weather forecasts, the local lightning climatology, lightning’s pathways to victims, harmful consequences, and the 30-second/30-minute rule of thumb. As a storm develops and lightning is first seen, observers should count until thunder occurs. If the count is 30, the storm (positively charged area) is within 6 miles, and the observer is in a high-risk lightning strike area. Once 30 minutes have passed since the last flash or thunder, it is safe to resume normal activities.6,9 Many people wait to seek cover until the rain begins, when actually the highest risk Table 3. Online Resources National Weather Service, Lightning Safety, http://www. lightningsafety.noaa.gov/index.htm National Lightning Safety Institute, http://www. lightningsafety.com/ Lightning Location Maps, http://www.weather.com/ maps/activity/golf/uslightningstrikes_large.html, http://www.intellicast.com/Storm/Severe/Lightning.aspx, http://weather.weatherbug.com/lightning.html? zcode¼z6286 Lightning Strike & Electric Shock Survivors International, Inc, http://www.lightning-strike.org/DesktopDefault.aspx
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for lightning to strike is the temporal period of 30 minutes before and after the rain. The action to avoid a lightning strike depends on the surroundings. The most protective place is inside a structure that has 4 walls, a roof, and a floor but also has electrical power, water, and sewer services. People must not use or even touch any appliance or fixture connected to these services during a storm. In addition, they must keep the doors and windows closed. The next best protective place is inside a vehicle with a roof, sides, front, and back constructed of metal. Again, it is advisable not to use or touch any electrical power controls or metal surfaces and to keep the doors and windows closed.6,9 Two thirds of lightning injuries occur outdoors.1,2 Getting inside a protective structure or vehicle as soon as possible is highly advisable. If not possible, people should keep a distance from taller objects and objects that conduct electricity. Next, they should get into a crouch on the balls of the feet with feet touching together, arms around knees, and hands over ears. If the skin tingles or hair stands up, they should stay in a crouch—do not lie down.6,9 At this point, they should use the 30-30 rule of thumb. When lightning is not followed by thunder within 30 seconds, leave the area. If lightning occurs while leaving, followed by thunder within 30 seconds, they should resume the crouched position and move to a safe place by leapfrogging. Alternatively, people can crouch and stand up only momentarily to relieve cramps and then return to the crouched position. People can use this up-and-down technique for 30 minutes. When 30 minutes have passed without thunder and lightning, they should seek a safe place. CONCLUSION
Although 90% of lightning-struck victims avoid death, the residual effects can be chronic and severely debilitating, with neurological, cardiovascular, and psychological sequelae. The primary reason people become victims is that they are uninformed or misinformed about the dangers of lightning and evidencebased avoidance behaviors. NPs can properly care for victims of lightning strikes and also educate their patients about this natural phenomenon. Together, the 486
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National Weather Service, NPs, educators, and news outlets can improve the understanding of lightning and prevent injuries and death. References 1. Elsom D. Deaths and injuries caused by lightning in the United Kingdom: analyses of two databases. Atmospheric Research. 2000;56(5):325-334. 2. Mistovich J, Krost W, Limmer D. Beyond the basics: lightning-strike injuries. EMS Magazine. 2008;37(3):82-89. 3. National Weather Service. Lightning safety: survivor stories. http://www. lightningsafety.noaa.gov/survivors.htm. Accessed April 23, 2013. 4. National Weather Service. Lightning safety: recent lightning headlines. http:// www.lightningsafety.noaa.gov/in_news.htm. Accessed April 23, 2013. 5. Christian H, Blakeslee R, Christian H, et al. Global frequency and distribution of lightning as observed from space by the Optical Transient Detector. J Geophysical Research Atmosp. 2003;108(D1):ACL 4-1eACL4-15,16. 6. National Weather Service. Lightning safety: how thunderstorms develop. http://www.lightningsafety.noaa.gov/overview.htm. Accessed May 1, 2013. 7. National Weather Service. Lightning safety: understanding lightning: thunderstorm electrification. http://www.lightningsafety.noaa.gov/science_ electrication.htm. Accessed March 5, 2013. 8. Gatewood M, Zane R. Lightning injuries. Emerg Med Clin North Am. 2004;22(2):369-403. 9. National Weather Service. Lightning safety: understanding lightning. http:// www.lightningsafety.noaa.gov/science.htm. Accessed March 5, 2013. 10. Lederer W, Cerchiari E, Paradis N. Cardiac arrest: the science and practice of resuscitation. In: Paradis NA, Halperin HR, Kern KB, et al., eds. Electrical Injuries. Cambridge, UK: Cambridge University Press; 2007:1140. 11. Jain SK, Singh VP. Lightning paths in sky share similarities with channel networks on Earth. EOS, Transactions American Geophysical Union. 2004;85(26):249-256. 12. National Weather Safety. Weather fatalities. http://www.nws.noaa.gov/om/ hazstats/resources//weather_fatalities.pdf. Accessed March 1, 2013. 13. National Lightning Safety Institute. Information for lightning strike victims. Section 4.3. http://www.lightningsafety.com/nlsi_pls/lstrike.html. Accessed March 10, 2013. 14. Adekoya N, Nolte K. Struck-by-lightning deaths in the United States. J Environ Health. 2005;67(9):45-50,58. 15. Insurance Institute for Business & Home Safety. Protect your home: evaluate your risk. http://www.disastersafety.org/lightning/protect-your-home/. Accessed March 8, 2013. 16. National Weather Safety. Lightning facts & figures. www.srh.noaa.gov/mlb/? n¼lightning_stats. Accessed March 20, 2013. 17. Orville R, Huffines G. Cloud-to-ground lightning in the United States: NLDN results in the first decade, 1989-98. http://www.physics.nmt.edu/wrsonnenf/ phys535/pubs/2001_NLDNFirstDecadeResultsProbabilityMaps.pdf. Accessed July 9, 2013. 18. Holle R. Diurnal variations of NLDN cloud-to-ground lightning in the United States. American Meteorological Society Annual Meeting, Austin, Texas, January 2013. 19. National Weather Service. Lightning safety: lightning safety myths and truths. www.lightningsafety.noaa.gov/myths.htm. Accessed March 4, 2013. 20. Ruiz FJR, Laiglesia FJR, Escolar AL, et al. Cardiac injury after indirect lightning strike. Rev Esp Cardiol. 2002;55(07):768-770. 21. Auerbauch P. Lightning injuries in the wilderness. Wilderness Medicine. 5th ed. St Louis: Mosby Elsevier; 2007:91. 22. Mistovich J. Lightning strike injuries. http://www.ems1.com/ems-products/ ambulances/articles/439502-lightning-strike-injuries/. Accessed April 5, 2013. 23. Hark W. The human effects of lightning strikes and recommendations for storm chasers. http://www.harkphoto.com/light.html. Accessed March 4, 2013. 24. Figgis P, Alaverez G. Delayed esophageal perforation following lightning strike: a case report and review of the literature. J Med Case Rep. 2012;6(1):244. 25. Tintinalli J, Stapczynski J, Ma OJ, Cline D. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2010:1374-1386. 26. Primeau M, Engelstatter G, Bares K. Behavioral consequences of lightning and electrical injury. Semin Neurol. 1995;15(3):279-285. 27. Cooper M. Lightning injuries. http://emedicine.medscape.com/article/770642overview#a0101. Accessed June 6, 2013. 1555-4155/13/$ see front matter © 2013 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2013.06.006
Volume 9, Issue 8, September 2013
Lightning Does Strike Twice: A Fulminology Primer for Nurse Practitioners Nancy Prahm, MSN, RN, Bernadette M. Longo, PhD, APHN-BC, Kimberly Baxter, MSN, FNP-BC, and Timothy J. Brown, PhD
ABSTRACT Lightning strikes cause more fatalities in the United States than floods, tornadoes, or hurricanes, although 90% of victims survive. Lightning strikes can cause diverse and major health consequences for every organ system, resulting in cardiovascular, neurological, and mental health sequelae. Misinformation and a lack of understanding about lightning and the associated health risks are commonplace. Therefore, nurse practitioners have the opportunity to apply evidence-based knowledge in the care of lightning-strike victims, as well as educate all their patients on preventive measures. Keywords: environmental health, lightning injuries, neurologic manifestations, safety Ó 2013 Elsevier, Inc. All rights reserved. Nancy Prahm, MSN, RN, is an emergency room nurse at Renown South Meadows in Reno, NV. Bernadette M. Longo, PhD, RN, CNL, APHN-BC, is an associate professor in the Orvis School of Nursing at the University of Nevada in Reno and can be reached at [email protected]. Kimberly Baxter, MSN, RN, FNP-BC, is an assistant professor and director of undergraduate nursing education in the Orvis School of Nursing. Timothy J. Brown, PhD, is a research professor in atmospheric sciences at the Desert Research Institute in Reno, NV.
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ightning is known to strike outdoor workers or enthusiasts such as golfers, hikers, hunters, and fisherman, but injuries can also occur to those engaged in more mundane indoor activities. One third of lightning injuries occur indoors.1,2
Injuries can result from lightning current following the pathways of a building’s plumbing, electrical, and telephone lines. Case reports describe injuries to victims who were simply using sinks, showers, toilets, telephones, electrical appliances, or even riding in
This CE learning activity is designed to augment the knowledge, skills, and attitudes of nurse practitioners and assist in their understanding of the care required for patients struck by lightning. At the conclusion of this activity, the participant will be able to: A. Contrast misinformation and scientific evidence about lightning risks and prevention B. Describe adverse physiological and psychological effects from lightning strikes C. Identify proper follow-up/management of a lightning strike victim The authors, reviewers, editors, and nurse planners all report no financial relationships that would pose a conflict of interest. The authors do not present any off-label or non-FDA-approved recommendations for treatment. This activity has been awarded 1.0 contact hours for nurses and advanced practice nurses and 0.5 contact hours of pharmacology credit. The activity is valid for CE credit until October 1, 2015. Readers may receive the 1.0 CE credit free by reading the article and answering each question online at www.npjournal.org, or they may mail the test answers and evaluation, along with a processing fee check for $10 made out to Elsevier, to PO Box 786, East Amherst, NY 14051. Required minimum passing score is 70%. This educational activity is provided by Nurse Practitioner AlternativesÔ. NPAÔ is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Accreditation does not imply endorsement by NPA, JNP, Elsevier, or ANCC of recommendations or any commercial products displayed or discussed in conjunction with the educational activity.
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motor vehicles or planes.3,4 Most victims of lightning survive but experience residual effects. Nurse practitioners may see patients after lightning strikes with or without ongoing sequelae. This article discusses the physical properties of lightning and its health risk, epidemiology, and pathophysiology, as well as recommendations for tertiary care for the unique patient population of strike victims. VIGNETTE
In July during a hike along the Tahoe Rim Trail in the Sierra Nevada Mountains, 2 teenagers were struck by lightning. A visible thunderstorm was building nearby, and the group estimated about 15 minutes before rain arrived. Teenagers Shawn and Carmel ran ahead hoping to seek shelter. Suddenly, a lightning bolt struck a boulder a meter away from them. Shawn was indirectly hit and suffered immediate cardiac arrest. Responding quickly, his mother and 3 other hikers performed successful cardiopulmonary resuscitation (CPR) with quick return of pulse but weak agonal breathing. Shawn’s mother saw that his necklace had melted and burned the skin on his neck and the front of his shirt was charred. The lightning also injured Carmel, who was running next to Shawn. A second lightning bolt had traveled through the ground and entered her body indirectly. Carmel complained of a roaring sound in her left ear and could not stand or move her legs. She experienced temporary lower extremity numbness and paralysis and also had unusual skin lesions on her back. The victims were flown by helicopter to the nearest trauma center. Shawn was first evaluated in the emergency department and then admitted to intensive care, unresponsive and with ventilator-dependent respiratory failure. After several months in the critical and acute care units, he was moved to a specialty area for extensive rehabilitation. Shawn improved physically to some extent but suffered long-term physical and neuropsychological dysfunction. Carmel was noted to have an unusual erythemic skin lesion, known as a Litchtenberg figure, on her back. A left tympanic membrane defect was noted. She was admitted for serial neurologic exams and monitoring. She continued to improve and was discharged home after an overnight stay. Her legs remained slightly numb but had full strength and mobility. Her 480
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skin lesions were faintly visible and disappeared after several days. Carmel complained of decreased hearing and ringing in the left ear. She was discharged with minor injuries and expected to recover fully. WHAT IS LIGHTNING?
Lightning flashes occur worldwide on average 1.4 billion times a year, with an average frequency of 44 flashes per second, but not all reach the earth’s surface.5 Thunderstorm lightning is caused by an electrical charge separation as a result of collisions of ice crystals and graupel (small, soft hail). Turbulence within a storm causes collisions between ice crystals and graupel, and the collisions break the attractive force within the graupel’s atoms. The collision frees some positive nuclei for transfer to ice crystals. Consequently, some ice crystals become positively charged, and some graupel becomes negatively charged. The thunderstorm’s updraft carries the positive ice crystals into the upper regions of the storm, where they repel each other and spread out. The negatively charged graupel particles settle into the cloud’s lower region, where they repel each other and spread out. Moreover, the cloud’s negatively charged region repels electrons on the ground’s surface, making the surface area beneath the cloud positively charged (Figure 1). This positive area travels with the thunderstorm as it moves. The charge separations established by the collisions are critical to the development of lightning flashes, both near and within clouds, from cloud-to-cloud, and from cloud-to-ground.5-7 A single lightning strike from cloud to ground represents a sequence of 3 events: the stepped leader, the upward streamer, and the flashing bolt. As the charge-separation process continues, the negative charge in the storm steadily increases, as does the ground’s positive charge. The attractive force between the 2 regions also increases, and this force becomes so strong that it ignites a stepped leader into the cloud. The stepped leader is a stream of electrons that functions as a pathfinder as it zigzags toward the ground. From the ground, an upward streamer of positive nuclei rushes to meet the leader. The instant they connect, a path for the bolt is complete, and a flash of a billion trillion electrons explodes across the sky.6,8 In an average home in the United States, electricity has up to 240 volts and up to 200 amps and Volume 9, Issue 8, September 2013
Figure 1. Charge Separation Within a Thunderstorm That Leads to Lightning
Image courtesy of the National Oceanic and Atmospheric Administration and the Department of Commerce.
performs at an average temperature of 68 F. Domestic electricity has sufficient power to electrocute and kill. In comparison, a single flashing bolt of lightning carries 100 million volts, 200,000 amps, and reaches a peak temperature of 50,000 F.9,10 The extreme heat within the lightning channel expands outward into cooler air faster than sound travels. This pulse produces a shockwave that we perceive as sound called thunder.11 EPIDEMIOLOGY
Surprisingly, lightning is the deadliest of common natural hazards. Lightning killed 9,207 persons in the US during 1940-2011. By comparison, 7,478 persons died in floods, 7,374 in tornadoes, and 3,318 in hurricanes.12 However, there is low case fatality for lightning injuries. Ninety percent of victims survive, but not without residual impairments; 74% of survivors suffer from permanent injuries and long-term physical and mental health consequences.13,14 www.npjournal.org
The highest density of lightning strike locations is also where the highest mortality occurs. In a geographic comparison, lightning strike locations (Figure 2) correlate strongly with lightning deaths (Figure 3). The Southeastern states have both the most strikes and deaths. Florida ranks first in both categories with Texas following closely.14 Lightning occurs less frequently in the Northern and Western states, with fewer deaths as well.15,16 Thunderstorms and lightning strikes occur primarily in the late spring and summer.14-16 In the Northern hemisphere lightning strike frequency increases rapidly in May and June, reaching maximum occurrences in July and then slowly decreasing in August and September.8,17 Lightning strikes can occur at anytime, but the temporal occurrence begins to rapidly increase around 10 AM, reaching a maximum around 4 PM.8,18 Morbidity is at least 300 or more nonlethal injuries per year.8,9 However, these data are underreported The Journal for Nurse Practitioners - JNP
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Figure 2. Distribution of Lightning Strikes in North America (flashes/km2/yr)
Image courtesy of the National Space Science and Technology Center’s Lightning Team Satellite Data.
because some victims do not seek treatment and there are no formal means of reporting for providers. The mechanism of injury depends on the passage of lightning energy through the victim’s body. This passage of electric current can cause variable degrees of tissue or organ injury, from trivial to a system failure that results in immediate death (Table 1). PATHOPHYSIOLOGY
Lightning strikes can cause diverse and major health consequences for every organ system, especially the cardiovascular and neurological systems. Lightninginduced cardiac injuries and cardiopulmonary arrest are the main causes of death.20 Cardiac arrest can be primary or secondary from hypoxia because CPR Figure 3. Lightning Deaths in the United States from 1959 to 2007
Image courtesy of the National Weather Service. 482
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was not promptly initiated. Acute injuries include ventricular fibrillation, electrocardiogram (ECG) changes, and myocardial necrosis. Survivors of cardiac arrest may suffer from long-term problems, including atrial fibrillation, premature ventricular contractions, prolonged QT interval, pericarditis, cardiomyopathy, and ischemia.14,20,21 Vascular injuries may result in vasodilation, vasomotor instability, and vasospasm. Significant and serious health consequences include a wide range of neurologic injuries. Electrical current from a lightning strike can cause acute and chronic damage to the central, autonomic, and peripheral nervous systems because of their extreme sensitivity.22 Direct strikes to the head can cause damage to the central nervous system, including subdural hematomas, hemorrhage, coagulation, dural tears, petechiae, skull fractures, and injury to the neurons in the pons and medulla that control ventilation.14,22 Victims may require surgical interventions or mechanical ventilation, depending on the location and severity of the insult. Lightning strikes harm the autonomic nervous system causing dizziness, hypertension, impotence, and gastrointestinal problems. Injury to the peripheral nervous system affects both myelin sheaths and axons resulting in pain, tingling, numbness, paresthesias, movement disorders, and paralysis of the extremities known as keraunoparalysis.14,22 These injuries can be acute with rapid improvement and resolution but may persist and linger and can be permanent. Blunt force trauma from lightning occurs in 2 ways. First, lightning current provokes violent muscular contractions, which result in chaotic body movements, throwing the body into the air and subsequently onto the ground. The second mechanism results from the lightning shockwave, which contains a tremendous amount of energy and is capable of hurling a victim 10 meters or more through the air into objects (rocks, trees) and the ground. In the case of mountaineers, victims are often thrown off cliffs or down steep ridges. This intense energy passing through the body can contuse soft organs and tissues, leading to pulmonary contusions, pneumothorax, sheared arteries and veins, ocular injuries, and perforated tympanic Volume 9, Issue 8, September 2013
Table 1. Lightning-Strike Pathways and Prevalence6,14,20 Pathway of lightning
Prevalence of injuries
Direct Strike
3%-5%
The lightning strikes the victim before hitting the ground or another ground-based object. Direct strikes usually occur outside in open, flat areas and are most likely to kill a victim.
Slide Flash
30%
The lightning strike hits an object (eg, a tree) and then jumps from the object to the victim. A side flash can also occur between 2 persons standing near each other.
Ground Current
40%-50%
After a lightning strikes the ground or a ground-based object, the charge spreads outward along the surface. The spreading charge will pass through any living thing in its way. Ground currents cause more casualties than the other pathways.
Conduction
1%-2%
A victim is touching an electric conductor (eg, metal fence, flag pole, bleachers, telephone) at the same time it is struck by lightning.
Upward Streamers
20%-25%
Persons in a positively charged ground area are in danger of having an upward streamer pass through them to complete the lightning channel path.
Description
membranes. The shockwave can also fracture the skull, ribs, extremities, and the spine.8,23,24 Lightning energy entering and exiting the eye or ear produces trauma. Ocular injuries primarily include cataracts, which usually occur quickly but can develop in months or even years after the strike. Case reports include other immediate ocular injuries, including retinal detachment, bleeding, optic nerve damage, corneal lesions, and iritis. A ruptured tympanic membrane is the most common ear injury. Other otologic insults include hearing loss, tinnitus, vertigo and the development of chronic otitis media.23 Lightning can cause first, second, or third degree burns at the entry and exit wound sites. Second-degree burns appear yellow or white with redness and clear blisters. Third degree burns appear stiff and whitebrown.25 A characteristic skin pattern called Lichtenberg figures (aka lightning flowers) may occur in victims caused by current-induced injury to capillaries beneath the skin or from the shockwave produced by the lightning discharge. Lichtenberg figures are reddish and fernlike and last hours to days or even months.23 Common with other traumas, being struck by lightning causes psychological stress. If mental health assessments and rapid treatment are missed during the immediate post-strike period, the victim is at risk for developing posttraumatic stress disorder (PTSD). Lightning can also cause debilitating neuropsychological injuries that mimic traumatic brain injury. Survivors of lightning injuries have described seizurelike activity, headaches, chronic pain, personality www.npjournal.org
changes, depression, anxiety, short-term memory loss, sleep disturbance, and increased irritability.14,22 Continuation of these neuropsychological or PTSD symptoms can cause impairment of the person’s social life and ability to perform activities of daily living. Several case reports have noted PTSD and mood disorders that are often unrecognized or undertreated by their health care providers.26 CASE EXEMPLAR
Carmel, a 14-year-old white, non-Hispanic female, was brought in by her mother for complaints of hearing problems, increased headaches, fearful behavior, insomnia, and emotional outbursts at school and home. She avoids going outside and will not walk to or from school. Carmel was always an “A” student with good citizenship, but over the past month she fell behind in class assignments and received detention twice for talking back to her teachers. She was also increasingly defiant at home and refused to do chores or visit her ailing friend in the rehabilitation hospital. Instead of studying and going to bed at an acceptable time, she stayed up late playing music and using social media. Past medical history and family history were negative for chronic illness, depression, anxiety, conduct, or mood disorders. Symptoms began 2 weeks ago after she was struck by lightning. Physical Examination
General: Appears anxious, tearful at times, poor eye contact, restricted affect, disheveled grooming, slight body odor The Journal for Nurse Practitioners - JNP
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Vital Signs: Blood pressure 110/60, respiratory rate 18, heart rate 112, temperature 98.2 F Skin: Scattered open and closed comedones on forehead, chin, and nose; no evidence of burns or residual Lichtenberg figures HEENT: PERRL; visual acuity intact; right tympanic membrane (TM) intact; left TM dull and retracted with small flap noted upper left margin; no erythema or discharge; whispered words at 2 feet and Weber test reveal hearing loss in left ear Heart: regular rhythm; normal S1, S2; no murmurs, rub, or gallop Lungs: breathing unlabored, symmetrical chest expansion; resonate to percussion breath sounds clear bilaterally Neuromuscular: no atrophy, weakness, or tremors; gait smooth and coordinated; negative Romberg; sensation and strength equal bilaterally; DTRs 2 þ and equal; cranial nerves, II-XII grossly intact aside from hearing defect 12-point Review of Systems: Positive for hearing loss, sleep onset and maintenance insomnia, headaches, anxiety, depression, and hypervigilance Menstruation: menarche age 12; LMP 10 days ago, near regular 24-day cycles; abstinent Social: denies tobacco, alcohol, or illicit drug use; attends 10th grade Health promotion: vaccinations up-to-date; runs cross-country and track; lacto-ovo vegetarian Medication: multiple vitamins, occasional acetaminophen for headaches Diagnosis:
1. Acute stress disorder (ICD-9 308.3) secondary to lightning strike manifested by anxiety, sleep onset and maintenance insomnia, irritability, avoidance, and labile behavior 2. Persistent posttraumatic perforation of left tympanic membrane (ICD-9 384.2) 3. Hearing loss (ICD-9 389) 4. Paresthesia (ICD-9 782.0) resolved 5. First degree burn (ICD-9 940) Litchenberg figure resolved Plan
1. Immediate treatment includes further assess for intensity of depression and suicidal/impulsivity 484
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risk in patient and any family-based issues; explain the co-morbid mental health implications from the lightning event; recognize the insight necessary for further care; review and support positive stress coping skills; consider antidepressant medication trial; order diagnostic tests: CMP, CBC, UA, TSH; refer to psychology for acute stress counseling and therapy to prevent PTSD; and encourage mother/patient to work with school counselor. 2. Refer to ear/nose/throat (ENT) clinician for evaluation of TM perforation and audiology exam. 3. Return to clinic after completion of diagnostic tests, psychological evaluation, and ENT evaluation or sooner if symptoms worsen. RECOMMENDATIONS FOR TERTIARY CARE
The primary care nurse practitioner (NP) will rarely deal with acute lightning injuries. Instead, the NP will deal with the long-term cardiac problems, neuropsychological problems, and chronic pain related to the initial injury. No evidence-based therapy for lightning strike injuries exists; therefore, the NP should provide ongoing monitoring with a focus on symptom management. Careful follow up is necessary to ensure problem resolution or stability in patients with lightningassociated cardiovascular injuries (ie, episodes of chest pain, syncope, lightheadedness, shortness of breath, hypotension, or hypertension). A physical exam will identify heart rate and blood pressure abnormalities, as well as adventitious lung sounds, rhythm disturbances, abnormal S3 and S4 heart sounds, and pericardial rubs. A 12-lead ECG is important to follow up on any initial and ongoing abnormalities. If lightning initially caused myocardial injury and caused systolic or diastolic dysfunction, a follow-up ECG and echocardiogram can be useful to exclude cardiomyopathy. Neurological injuries can result in functional problems with memory, concentration, or problem solving or behavioral problems with emotional lability, sleep dysfunction, aggressive behavior, or depression. The NP can refer the patient and family to a lightning support network. Sleep evaluation by nocturnal polysomnography, neurocognitive and pharmacologic Volume 9, Issue 8, September 2013
Table 2. Myths vs Facts About Lightning Safety4,19,23 Myths
Facts
If you see storm clouds in the distance but see no lightning, hear no thunder, and have no clouds or rain near, you are safe.
Lightning can travel for miles through clear skies over land or water before striking the earth or you.
If you are caught outside in a storm and lightning strikes near you, you are safe because it will not strike twice in the same place.
Lightning may strike twice in the same place. After a bolt has struck the ground, an object, or a water surface, it is not unusual for more subsequent bolts to rapidly follow the first bolt’s path to the ground.
If caught outside and there is a taller object nearby (eg, tree, service tower), stand close to it. You will be safe because it will be struck rather than you.
Not necessarily. Even if the object is struck first, a side flash will likely jump from the object to you.
If caught outside in an open, flat area (eg, field, pasture) lie flat on the ground. You will be safe.
When lightning strikes near you and you are lying flat on the ground, you are perfectly positioned for the ground current to pass through you.
In a car you are safe because the tires are rubber insulators and thus prevent lightning form passing through the car to the ground.
Tires provide no protection. A vehicle that has a metal roof and sides is safe because it serves as a Faraday cage. It the vehicle lacks a metal roof or sides, it is not safe.
You are perfectly safe inside an enclosed structure, including a house.
Being safe inside a home during a thunderstorm depends on what you are doing. Do not touch or be too close to electrical appliances, plumbing fixtures, or other electrical conductors.
treatment of depression, and referral to psychology or psychiatry may be indicated. Long-term psychiatric problems may be best managed by neurocognitive, relaxation, and pharmacological therapies. Management of ongoing pain and paresthesias can be tremendously challenging for both the patient and provider. Nonsteroidal anti-inflammatory drugs are recognized as the primary pharmacological intervention for post-strike pain management.27 Useful adjuncts for long-term management may include tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, neuroleptics, and antiepileptic agents. Chronic pain may necessitate referral to a pain management specialist. SAFETY AND EDUCATION
NPs have an opportunity to educate their patients with evidence and dispel myths about the dangers of lightning strikes and prevention strategies. The inclusion of environmental safety screening and education has increased in NP practice by becoming part of the annual examination for all patients. Tables 2 and 3 provide easy-to-read information for distribution. No one can be completely safe from being struck by lightning, but avoidance strategies can reduce risks. www.npjournal.org
To be well informed about the dangers, everyone should know daily local weather forecasts, the local lightning climatology, lightning’s pathways to victims, harmful consequences, and the 30-second/30-minute rule of thumb. As a storm develops and lightning is first seen, observers should count until thunder occurs. If the count is 30, the storm (positively charged area) is within 6 miles, and the observer is in a high-risk lightning strike area. Once 30 minutes have passed since the last flash or thunder, it is safe to resume normal activities.6,9 Many people wait to seek cover until the rain begins, when actually the highest risk Table 3. Online Resources National Weather Service, Lightning Safety, http://www. lightningsafety.noaa.gov/index.htm National Lightning Safety Institute, http://www. lightningsafety.com/ Lightning Location Maps, http://www.weather.com/ maps/activity/golf/uslightningstrikes_large.html, http://www.intellicast.com/Storm/Severe/Lightning.aspx, http://weather.weatherbug.com/lightning.html? zcode¼z6286 Lightning Strike & Electric Shock Survivors International, Inc, http://www.lightning-strike.org/DesktopDefault.aspx
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for lightning to strike is the temporal period of 30 minutes before and after the rain. The action to avoid a lightning strike depends on the surroundings. The most protective place is inside a structure that has 4 walls, a roof, and a floor but also has electrical power, water, and sewer services. People must not use or even touch any appliance or fixture connected to these services during a storm. In addition, they must keep the doors and windows closed. The next best protective place is inside a vehicle with a roof, sides, front, and back constructed of metal. Again, it is advisable not to use or touch any electrical power controls or metal surfaces and to keep the doors and windows closed.6,9 Two thirds of lightning injuries occur outdoors.1,2 Getting inside a protective structure or vehicle as soon as possible is highly advisable. If not possible, people should keep a distance from taller objects and objects that conduct electricity. Next, they should get into a crouch on the balls of the feet with feet touching together, arms around knees, and hands over ears. If the skin tingles or hair stands up, they should stay in a crouch—do not lie down.6,9 At this point, they should use the 30-30 rule of thumb. When lightning is not followed by thunder within 30 seconds, leave the area. If lightning occurs while leaving, followed by thunder within 30 seconds, they should resume the crouched position and move to a safe place by leapfrogging. Alternatively, people can crouch and stand up only momentarily to relieve cramps and then return to the crouched position. People can use this up-and-down technique for 30 minutes. When 30 minutes have passed without thunder and lightning, they should seek a safe place. CONCLUSION
Although 90% of lightning-struck victims avoid death, the residual effects can be chronic and severely debilitating, with neurological, cardiovascular, and psychological sequelae. The primary reason people become victims is that they are uninformed or misinformed about the dangers of lightning and evidencebased avoidance behaviors. NPs can properly care for victims of lightning strikes and also educate their patients about this natural phenomenon. Together, the 486
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National Weather Service, NPs, educators, and news outlets can improve the understanding of lightning and prevent injuries and death. References 1. Elsom D. Deaths and injuries caused by lightning in the United Kingdom: analyses of two databases. Atmospheric Research. 2000;56(5):325-334. 2. Mistovich J, Krost W, Limmer D. Beyond the basics: lightning-strike injuries. EMS Magazine. 2008;37(3):82-89. 3. National Weather Service. Lightning safety: survivor stories. http://www. lightningsafety.noaa.gov/survivors.htm. Accessed April 23, 2013. 4. National Weather Service. Lightning safety: recent lightning headlines. http:// www.lightningsafety.noaa.gov/in_news.htm. Accessed April 23, 2013. 5. Christian H, Blakeslee R, Christian H, et al. Global frequency and distribution of lightning as observed from space by the Optical Transient Detector. J Geophysical Research Atmosp. 2003;108(D1):ACL 4-1eACL4-15,16. 6. National Weather Service. Lightning safety: how thunderstorms develop. http://www.lightningsafety.noaa.gov/overview.htm. Accessed May 1, 2013. 7. National Weather Service. Lightning safety: understanding lightning: thunderstorm electrification. http://www.lightningsafety.noaa.gov/science_ electrication.htm. Accessed March 5, 2013. 8. Gatewood M, Zane R. Lightning injuries. Emerg Med Clin North Am. 2004;22(2):369-403. 9. National Weather Service. Lightning safety: understanding lightning. http:// www.lightningsafety.noaa.gov/science.htm. Accessed March 5, 2013. 10. Lederer W, Cerchiari E, Paradis N. Cardiac arrest: the science and practice of resuscitation. In: Paradis NA, Halperin HR, Kern KB, et al., eds. Electrical Injuries. Cambridge, UK: Cambridge University Press; 2007:1140. 11. Jain SK, Singh VP. Lightning paths in sky share similarities with channel networks on Earth. EOS, Transactions American Geophysical Union. 2004;85(26):249-256. 12. National Weather Safety. Weather fatalities. http://www.nws.noaa.gov/om/ hazstats/resources//weather_fatalities.pdf. Accessed March 1, 2013. 13. National Lightning Safety Institute. Information for lightning strike victims. Section 4.3. http://www.lightningsafety.com/nlsi_pls/lstrike.html. Accessed March 10, 2013. 14. Adekoya N, Nolte K. Struck-by-lightning deaths in the United States. J Environ Health. 2005;67(9):45-50,58. 15. Insurance Institute for Business & Home Safety. Protect your home: evaluate your risk. http://www.disastersafety.org/lightning/protect-your-home/. Accessed March 8, 2013. 16. National Weather Safety. Lightning facts & figures. www.srh.noaa.gov/mlb/? n¼lightning_stats. Accessed March 20, 2013. 17. Orville R, Huffines G. Cloud-to-ground lightning in the United States: NLDN results in the first decade, 1989-98. http://www.physics.nmt.edu/wrsonnenf/ phys535/pubs/2001_NLDNFirstDecadeResultsProbabilityMaps.pdf. Accessed July 9, 2013. 18. Holle R. Diurnal variations of NLDN cloud-to-ground lightning in the United States. American Meteorological Society Annual Meeting, Austin, Texas, January 2013. 19. National Weather Service. Lightning safety: lightning safety myths and truths. www.lightningsafety.noaa.gov/myths.htm. Accessed March 4, 2013. 20. Ruiz FJR, Laiglesia FJR, Escolar AL, et al. Cardiac injury after indirect lightning strike. Rev Esp Cardiol. 2002;55(07):768-770. 21. Auerbauch P. Lightning injuries in the wilderness. Wilderness Medicine. 5th ed. St Louis: Mosby Elsevier; 2007:91. 22. Mistovich J. Lightning strike injuries. http://www.ems1.com/ems-products/ ambulances/articles/439502-lightning-strike-injuries/. Accessed April 5, 2013. 23. Hark W. The human effects of lightning strikes and recommendations for storm chasers. http://www.harkphoto.com/light.html. Accessed March 4, 2013. 24. Figgis P, Alaverez G. Delayed esophageal perforation following lightning strike: a case report and review of the literature. J Med Case Rep. 2012;6(1):244. 25. Tintinalli J, Stapczynski J, Ma OJ, Cline D. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2010:1374-1386. 26. Primeau M, Engelstatter G, Bares K. Behavioral consequences of lightning and electrical injury. Semin Neurol. 1995;15(3):279-285. 27. Cooper M. Lightning injuries. http://emedicine.medscape.com/article/770642overview#a0101. Accessed June 6, 2013. 1555-4155/13/$ see front matter © 2013 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2013.06.006
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