lightning strikes can be associated with multi - organ injuries leading to putative cutaneous , cardiological , renal and neuropsychological complications . however , due to the sporadic nature of lightning injuries , the body of literature and especially the management strategies on the subject are scarce . we report the clinical case and management of a lightning strike victim who presented with burns as well as cardiological and neurological complications . a 75-year - old female in good general health was struck by lightning as she was standing 3 metres away from a tree . on - site evaluation showed the patient in prone position ; her clothes and shoes were partially burned , still - smoking , and were removed immediately . she was hemodynamically stable ( bp 138/87  mmhg , hr 87 beats per minute ) and conscious . the patient was transferred to the emergency department for further evaluation , where thorough clinical examination by a plastic surgeon confirmed linear first and superficial second degree burns with some blisters on a line going from the left ear to the left toe , corresponding to about 6% of the total body surface area ( figures 1 , 2 and 3 ) . total body ct revealed no profound injuries with the exception of an old fracture of the second thoracic vertebra . the ecg depicted a right bundle branch block , with deep and symmetrical t - wave inversion in precordial and lateral leads and a prolonged qt interval ( 480  ms ) ( figure 4 ) . these ecg changes were associated with an elevation of troponine t levels ( peak : 403  ng / l ) . other laboratory investigations yielded normal blood count and no electrolyte abnormalities with the exception of a minimally elevated serum creatinine value of 89  mol / l . a transthoracic echocardiography revealed a reduced ejection fraction of the left ventricle at 40% with apical akinesia and preservation of the contractility of the basal segment . further cardiological evaluation by cardiac mri demonstrated apical hypokinesia with discrete left ventricular dysfunction without signs for myocarditis or myocardial infarction . overall , the cardiological status was compatible with a stress - induced cardiomyopathy of tako - tsubo . supportive measures were employed with the introduction of angiotensin - converting enzyme ( ace ) inhibitors and diuretics . the cardio - pulmonary function was monitored at the intermediate care unit for four days . superficial second degree burn on the patient s back , both buttocks and left calf with painful redness and blisters . longitudinal first degree burn on the medial surface of the left foot and second degree superficial burn on the left hallux with a painful blister . electrocardiogram showing a right bundle branch block , with deep and symmetrical t - wave inversion in precordial and lateral leads and a prolonged qt interval . in addition , the patient presented dysesthesia in the right l5 dermatome , diffuse allodynia on both legs and walking difficulties due to a sensation of numbness . lumbar mri confirmed the old fracture of the second thoracic vertebra and no signs of ligamentous instability . the neurological symptoms in both legs diminished ; however , the patient presented persistent radiculopathy in the l5 dermatome of the right leg and lumbar pain at the six weeks neurosurgical follow - up . the burn injuries were treated conservatively with daily showers and dressing changes with application of paraffin gauze dressing and topical hyaluronate . the wounds were completely healed by two weeks . at the six months follow - up , the patient had no residual scars on the burned skin . lightning injuries are rare but can be associated with high mortality and persistent long - term morbidity . six different energy transmission mechanisms from lightning strikes have been described : ( 1 ) ground strike , ( 2 ) contact voltage , ( 3 ) side flash , ( 4 ) wire - mediated lightning , ( 5 ) direct strike and ( 6 ) weak upward streamer . the most dangerous mechanism is a direct strike by the lightning , which usually causes lethal injuries . a flashover phenomenon happens when the lightning current does not break the skin resistance but passes directly over the skin dissipating into the ground . however , because the human skin has relatively high resistance to the passage of current , death does not usually result from injury to inner organs . in contrast , nervous and vascular tissues have the poorest resistance in the human body , which explains the frequent occurrence of neurological and cardiological complications . the full range of possible complications after lightning strikes highlights the importance of an interdisciplinary approach in the management of affected patients . the most frequent and important injuries are as follows : burns from a lightning strike are mostly superficial second degree burns and victims rarely suffer from extensive tissue destruction or large cutaneous burns . patients should be managed as any other burn victim , with early assessment of the indication for early excision and grafting versus conservative treatment . one described pathognomonic skin alteration seen in lightning injuries are the lichtenberg figures , where a physical phenomenon created by positive discharge over the skin provokes a transient reddish and ferning pattern on the skin [ 68 ] . she had no evidence for the presence of lichtenberg figures.cardiological manifestations may include direct necrosis to the myocardium and rhythm disturbances . cardiac arrest and ventricular fibrillation are the most serious cardiac complications and are usually fatal unless immediate resuscitative efforts are undertaken . to the best of our knowledge , this is one of the first reported cases of a tako - tsubo cardiomyopathy following a lightning strike . tako - tsubo cardiomyopathy , also known as stress - related cardiomyopathy , transient left ventricular apical ballooning syndrome or ampulla cardiomyopathy , is a transient wall motion abnormality of the left - ventricular apex caused by emotional or physical stress . ecg findings include a mimicking acute coronary syndrome , elevation of cardiac enzymes , absence of coronary lesion , balloon - like dilatation of the left ventricle and recovery of cardiac function within days to weeks . tako - tsubo cardiomyopathy is treated supportively in the acute phase . for hemodynamically unstable patients , patients with a tako - tsubo cardiomyopathy usually have a good prognosis with complete recovery in 96% of all cases . the differential diagnosis includes direct electrical injury , direct cardiac trauma , hypoxic injury and/or bystander myocarditis . the cardiological complication of our patient may be interpreted as a somatic manifestation of a post - traumatic stress disorder . ecg at the four weeks follow - up showed no persisting abnormalities.neurological manifestations following a lightning strike vary from transient benign symptoms to permanent disability . clinical findings may include a transient loss of consciousness , a transient amnesia , paresis or paresthaesia . keraunoparalysis , which is a temporary paralysis of the limbs , is pathognomonic of lightning injuries . our patient s neurological manifestations included dysesthesia and diffuse allodynia in both legs and walking difficulties . despite some clinical improvement , the patient presented persistent symptoms in the l5 dermatome of the right leg and lumbar pain at the 6 weeks follow-up.renal failure due to muscle necrosis and consecutive myoglobinuria is a possible finding in lightning strike victims . thus , the renal function has to be closely monitored at presentation and during hospitalisation , and volume substitution has to be consequent . our patient demonstrated a minimally elevated serum creatinine value , which normalised with hydration within 24  h of admission.lastly , acute and long - term psychological impairment should not be underestimated . the neuropsychological and cognitive deficits resemble those of a traumatic brain injury and a post - traumatic stress disorder . clinical features include fatigue , lack of energy , poor concentration , irritability and emotional instability . patients may demonstrate improvement over time . here , the importance of concerned physicians and a solid support network are to be emphasised . our patient was psychologically traumatised by the event ; however , she refused psychiatric evaluation.blunt trauma should be a major concern in lightning strike victims . patients may be injured from the explosive force of lightning or from a fall and can present missile injuries caused by pieces of wood or concrete due to explosive barotrauma , when air crossing lightning is rapidly heated and expands at supersonic speed . burns from a lightning strike are mostly superficial second degree burns and victims rarely suffer from extensive tissue destruction or large cutaneous burns . patients should be managed as any other burn victim , with early assessment of the indication for early excision and grafting versus conservative treatment . one described pathognomonic skin alteration seen in lightning injuries are the lichtenberg figures , where a physical phenomenon created by positive discharge over the skin provokes a transient reddish and ferning pattern on the skin [ 68 ] . cardiac arrest and ventricular fibrillation are the most serious cardiac complications and are usually fatal unless immediate resuscitative efforts are undertaken . to the best of our knowledge , this is one of the first reported cases of a tako - tsubo cardiomyopathy following a lightning strike . tako - tsubo cardiomyopathy , also known as stress - related cardiomyopathy , transient left ventricular apical ballooning syndrome or ampulla cardiomyopathy , is a transient wall motion abnormality of the left - ventricular apex caused by emotional or physical stress . ecg findings include a mimicking acute coronary syndrome , elevation of cardiac enzymes , absence of coronary lesion , balloon - like dilatation of the left ventricle and recovery of cardiac function within days to weeks . hemodynamically unstable patients , an intra - aortic balloon pump is required in addition to cardiopulmonary circulatory support . patients with a tako - tsubo cardiomyopathy usually have a good prognosis with complete recovery in 96% of all cases . the differential diagnosis includes direct electrical injury , direct cardiac trauma , hypoxic injury and/or bystander myocarditis . the cardiological complication of our patient may be interpreted as a somatic manifestation of a post - traumatic stress disorder . clinical findings may include a transient loss of consciousness , a transient amnesia , paresis or paresthaesia . keraunoparalysis , which is a temporary paralysis of the limbs , is pathognomonic of lightning injuries . our patient s neurological manifestations included dysesthesia and diffuse allodynia in both legs and walking difficulties . despite some clinical improvement , the patient presented persistent symptoms in the l5 dermatome of the right leg and lumbar pain at the 6 weeks follow - up . renal failure due to muscle necrosis and consecutive myoglobinuria is a possible finding in lightning strike victims . thus , the renal function has to be closely monitored at presentation and during hospitalisation , and volume substitution has to be consequent . our patient demonstrated a minimally elevated serum creatinine value , which normalised with hydration within 24  h of admission . the neuropsychological and cognitive deficits resemble those of a traumatic brain injury and a post - traumatic stress disorder . clinical features include fatigue , lack of energy , poor concentration , irritability and emotional instability . our patient was psychologically traumatised by the event ; however , she refused psychiatric evaluation . patients may be injured from the explosive force of lightning or from a fall and can present missile injuries caused by pieces of wood or concrete due to explosive barotrauma , when air crossing lightning is rapidly heated and expands at supersonic speed . our case underlines the fact that lightning strike victims are to be considered high - energy trauma patients and the entire panel of possible injuries should be evaluated . multiple manifestations to the skin , neurological , cardiological , musculoskeletal and the renal system may occur . a multi - disciplinary management is of paramount importance , and the psychological impact of a lightning strike needs to be assessed early .
abstractthe interdisciplinary management of patients with multiple organ injuries after lightning strike is of paramount importance . 
 cutaneous burns can be associated to other organ injuries requiring emergency and life - support treatment . 
 we report the case of a lightning strike victim who presented with burns as well as cardiologic and neurologic complications .