The correct answer is:

Fluid restriction is recommended if the patient is normotensive.

Educational Objective:

Discuss fluid resuscitation in an individual following a lightning strike.

Key Point:

Fluid restriction, rather than resuscitation, is recommended if the patient is normotensive or hypertensive so as to decrease the person's risk of cerebral edema.

Explanation:

Any person whose condition is unstable after being struck by lightning (unstable vital signs, unconsciousness, disorientation) requires intravenous access. If the person is hypotensive, then fluid resuscitation with normal saline or Ringer lactate solution may be indicated but with caution, since cerebral edema may develop.

Peripheral pulses are often absent due to arterial vasospasm and are not a sign of hypovolemia or compartment syndrome. Generally, the spasms resolve after several hours and pulses return on their own. 

The need for fasciotomies is rare in persons struck by lightning, whereas they are very commonly required in patients who have come in contact with high-voltage wires. Fasciotomy may be needed when peripheral pulses remain absent PLUS compartment pressures become elevated over time (sometimes triggered by overhydration!).

Myoglobinuria is rarely caused by lightning injury alone. When it occurs, it is usually transient, so that mannitol-induced diuresis, alkalinization, and aggressive fluid loading are rarely necessary (however, they tend to be necessary in patients who came in contact with high-voltage wires).

Prophylactic antibiotics are indicated only if open fractures or cranial fractures that violate the dura are present.

Feathering marks are pathognomonic of lightning strikes but are actually rarely present. In lightning injuries, deep burns occur in fewer than 5% of persons struck by lightning. More common are 4 types of superficial burns or skin changes that mimic burns but do not really reflect burn injury. These are:

• Linear
• Punctate
• Feathering
• Thermal burns

"Feathering burns" are not true burns, because there is no damage to the skin per se. They are caused by electron showers induced by the lightning strike that make a fern-like pattern on the skin. These are only transient findings and require no therapy.

Overall, persons injured due to a lightning strike can appear impressively injured, yet, in the absence of obvious blunt trauma or extensive burns, the mainstay of therapy is observation with monitoring. Many severe-appearing symptoms (in the absence of blunt skeletal trauma) resolve on their own.

In this patient who was struck by lightning, note the pathognomonic punctate lesions seen in Figure 2 on her leg secondary to vaporized sweat or water particles.

Figure 2.

References:

Cooper MQ, et al. Lightning-related injuries and safety (chapter 5). In: Auerbach PS, et al. Wilderness Medicine. 7th ed., 2017:71-117.