LIGHTNING STRIKES

Although an ever present worry in the minds of climbers ("Premier de cordée...") and despite the frequentation of our massif rich in granitic peaks, lightning rarely strikes more than two people each year in the Mont-Blanc area.

MAIN CONSEQUENCES OF THE LIGHTNING STRIKE

One must differenciate between the direct consequences (effect of the strike) and the indirect results in the high mountain dangerous environment. Indeed, traumatic lesions due to a fall can always be found.

DIRECT CONSEQUENCES

• Burns: by arc or by flash if the ligthning stays in surface; in that case, the consequences are rarely severe. These burns must be differenciated from the deep and severe electrothermal burns by Joule effect when the electric current passes through the body. The current preferentially uses the pathways of least resistance, i.e. the vascular and nervous system.
• Neurological effects: Coma is not rare; it can be either superficial or profound. Amnesia of the accident is frequent. It is due to the bypassing of lightning through the encephalic structures. Keraunoparalysis, a peripheral lesion with vasomotor troubles, improves within 24 hours. After effects are frequent (hemiplegia, cortical atrophy, epilepsy, extrapyramidal syndrome, spinal and peripheral nervous lesions).
• Cardio-vascular lesions: Circulatory arrest happens by asystolia or ventricular fibrillation. A direct myocardic lesion by Joule effect, a myocardic contusion by the shock wave, a thrombosis of the coronary or peripheral arteries can also be seen. Late dysrhythmias necessitate cardiac moninoring for 24 or 48 hours. Hypovolemia may be caused by extensive oedema (Crush syndrome) or an associated traumatic lesion.
• Respiratory lesions: it can be a tetanization of the respiratory muscles for a short time, a direct lesion of nervous centres, a bronchial or pleural rupture, or a lesion of the alveolo-capillar membrane when the over-heated air explodes (blast).
• Neuro-sensory effects: ocular lesions due to retinal detachment and potential cataracts must be screened for. Auditory lesions including tympanic membrane rupture and balance impairments as a consequence of labyrinth damage can also occur.
• Muscular effects: extensive muscular breakdown with deep necrosis and rhabdomyolysis may occur allong the pathway of conduction.
• Renal effects: there are mainly three consequences: tubular pathology due to the muscle lysis (early fluid balance is vital); parenchymal lesions due to arterial thrombosis; traumatic lesions.
• Cutaneous lesions: burns of all severities, in particular at the points of lightning entry (restorative surgery is frequently required) and at points in contact with metal (climbing equipment, jewellery); fernlike patterns are classic (Lichtenberg bodies)

INDIRECT CONSEQUENCES

Prior to the strike: Panic in a stormy atmosphere is frequent. Simply sensing a buzz or the sight of "St Elmo's fire" can cause rash decision making and impulsive actions which lead to accidents.

During and after the strike: if the victim is not in a secure position, the shock could result in a fatal slip.

Consequently traumatic lesions must be searched for; especially the lesions of the head, the spine and the pelvic or shoulder girdles. Every person struck by lightning is suspected of having multiple trauma.

Finally, if the transport to the hospital is not immediate (storm always delays the rescue), hypothermia rapidly appears in these injured people.

MANAGEMENT

AT THE SCENE

Vital functions must be preserved. Depending on the environment, the manoeuvers are mainly: intubation, perfusion, sedation and immobilization. Hypothermia and associated traumatisms are always suspected. To prevent renal insufficiency a crystalloid perfusion is given as soon as possible to maintain fluid balance. This ideal theory is often challenged by the environment and difficult flying conditions. Most of the time, a rapid evacuation is the only solution.

AT THE HOSPITAL

1. Unharmed or slightly injured victim: worsening is always possible after a delay of several hours. Every victim must be watched over in an ICU for at least 24 hours. If the head has been hit, a regular ophtalmic examination is indicated to screen for cataract development.
   
2. Patient with severe lesions: the check-up must be complete to detect associated lesions (table 1). A saline drip ensures a urinary output of at least 1.5 ml/kg/h which must be maintained to prevent myoglobinuria developing. As far as the cardiac condition is concerned, severe conductive, excitability and ishaemic troubles should be ruled out. The use of anticoagulants is controversial because of the risk of haemorrage. Salvage surgery is indicated is some cases (fasciotomy, removal of necrotic tissue...).

CONCLUSION

Lightning rarely strikes alpinists; it's a chance because the overall mortality is around 50%. If the victim initially survives, prognosis is good if the evacuation is rapid. Indeed, the different lesions caused by the strike greatly reduce the organism capacities of adaptation to cold, altitude and mountainous environment.

Each victim must be suspected of having other injuries and should be watched over in an ICU for at least 24 hours.

The clinical presentation can be rich, but the symptomatic and preventive therapeutics of the different lesions (especially renal) usually give good results. After effects are essentially neurological and trophical; they can be disabling.

(c) DMTM CHAMONIX 1998

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