ORIGINAL ARTICLE Fatal Lightning Strikes in Malaysia A Review of 27 Fatalities O. P. Murty, MBBS, MD, Chong Kah Kian, MBBS, Mohammed Husrul Ari Husin, MBBS, Ranjeev Kumar a/l Nanta Kumar, MBBS, and Wan Yuhana W. Mohammed Yusuf, MBBS Abstract: Lightning strike is a natural phenomenon with potentially devas- tating effects and represents one of the important causes of deaths from environmental phenomena. Almost every organ system may be affected as lightning current passes through the human body taking the shortest path- ways between the contact points. A 10 years retrospective study (1996 – 2005) was conducted at University Hospital Kuala Lumpur (20 cases) also including cases during last 3 years from Hospital Tengku Ampuan Rahimah, Klang (7 cases) from the autopsy reports at Forensic Pathology Units of these 2 hospitals. Both these hospitals are attached to University of Malaya. There were 27 fatal cases of lightning strike with male preponderance(92.59%) and male to female ratio of 12.5:1. Majority of victims of lightning strike were from the age group between 30 and 39 years old. Most of the victims were foreign workers. Indonesians workers contributed to 59.26% of overall cases. Majority of them were construction workers who attributed i.e.11 of 27 cases (40.74%). Most of the victims were brought in dead (37.04%). In majority of the cases the lightning incidence occurred in the evenings, with the frequency of 15 of 27 cases (62.5%). The month of December represented with the highest number of cases (5 cases of 23 cases); 2004 had the highest incidence of lightning strike which was 5 (19.23%). Lightning strike incidence oc- curred when victims had taken shelter (25.9%) under trees or shades. Lightning strike in open areas occurred in 10 of 27 cases (37.0%). Head and neck were the most commonly affected sites with the incidence of 77.78% and 74% respectively in all the victims. Only 29.63% of the cases presented with ear bleeding. Key Words: lightning injuries, lightning strike, fatal lightning, environmental accidents (Am J Forensic Med Pathol 2009;30: 246 –251) L ightning is one of the most common weather phenomena and accidental deaths due to lightning are reported off and on. Lightning is defined as a momentary, atmospheric, transient, high current electrical discharge whose path length is measured in kilo- meters from clouds to earth. 1 Lightning strikes the earth more than 100 times each second and 8 million times per day. 2 Lightning injuries are more commonly seen in, open, rural, or exposed envi- ronments rather than in the city, where high buildings have metal frames and lightning-protection devices. The power of lightning is awesome with an estimated 10,000 to 200,000 amperes (A) of current and 20 million to 1 billion volts. 2,3 Lightning can be categorized as cloud to ground, intracloud, or intercloud. Cloud-to-ground lightning is the most damaging and dangerous form of lightning. Often, cloud-to-ground lightning bolts strike the highest object, like the top of a building or the top of a tall tree. Intracloud lightning is the most common type of lightning. This occurs between oppositely charged centers within the same cloud. Intercloud lightning is less common and occurs between oppositely charged clouds. 4 Streak lightning is the most frequent type of lightning and accounts for human injuries. Another type, sheet lightning, travels within a cloud and gives the cloud the appearance of a white sheet. Several rare forms of lightning include ribbon and bead lightning. These are forms of ground discharge with a flash consisting of several strokes. Ribbon lightning occurs when the channel is blown perpendicular to the line of sight by the wind, displacing subse- quent strokes. Consequently, the flash appears as a ribbon of several strokes. In bead lightning, the main lightning flash breaks into luminous sections, or beads, as the light intensity of the channel decays. 2,5 During thunderstorm, people seek shelter under high risk places like under big and tall trees, inside small huts, or under metal roof, such as bus stops and canteens, because their top priority is to escape from rain. Lightning injuries are usually the result of 5 different mechanisms: direct strike, contact injury, side flash (splash), ground current (step voltage), and blunt trauma. 6–8 Direct strike injuries occur when lightning strikes a person directly. Contact injuries occur when a person touches an object that is part of the lightning current pathway. Side flash or splash injuries occur when lightning arcs from the object struck to a nearby object. 6,7 Ground current or step voltage injuries occur when the lightning current spreads peripherally through the ground from the site of the strike. Blunt injuries occur in 2 fashions. In the first, the victim’s muscu- lature contracts diffusely, causing the victim to be thrown up to a distance from the lightning strike. 6 The mode of death in lightning victims is mainly cardiac arrest. 2 Arterial vascular spasm commonly occurs and may lead to damage to the heart, gastrointestinal tract and brain. Respiratory arrest usually results from the transient paralysis of the medullary respiratory center and may lead to sudden death. 6,9 Lightning strikes can also cause damage to the central nervous system. 2 In most of the lightning victims, cut surface of the brain shows cerebral edema. Surviving patients may show either normal- ization of mental status or sequelae ranging from headaches and distractibility to persistent psychiatric disorder and dementia. 5,10 Cataracts, may occur immediately after injury or months later in patients who have lightning strike near the head. Corneal burns, intraocular hemorrhage or thrombosis, uveitis, retinal detachment, choroidoretinitis, iridocyclitis, hyphema, and orbital fractures may also occur. Nonreactive dilated pupils in a lightning strike victim may be a sign of direct eye involvement or autonomic dysfunction. 2 In lightning strike substantial ear damage and hearing loss are common. Tympanic membrane may rupture. Middle ear and mas- toid may show effusion with bleeding. The rupture of Reissner’s membrane, herniation of a portion of cerebellum into the internal auditory meatus, microfractures of the otic bones may occur in lightning victims. 2 Manuscript received February 1, 2007; accepted February 6, 2008. From the Forensic Pathology Unit, Department of Pathology, University of Malaya, Kuala Lumpur, Malaysia. Reprints: O. P. Murty, MBBS, MD, Department of Forensic Medicine and Toxicology, Rm 304, New Forensic Block, FMT, All India Institute of Forensic Medicine, New Delhi 110029, India. E-mail: dropmurty@yahoo.co.in; dromurty2008@gmail.com. Copyright © 2009 by Lippincott Williams & Wilkins ISSN: 0195-7910/09/3003-0246 DOI: 10.1097/PAF.0b013e31819d20a4 Am J Forensic Med Pathol • Volume 30, Number 3, September 2009 246 | www.amjforensicmedicine.com