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Department of Emergency Medicine, Department of Emergency Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, GA, Nijmegen 6525, the Netherlands
Lightning strikes have high morbidity and mortality rates. Thousands of fatalities are estimated to be caused by lightning worldwide, with the number of injuries being 10 times greater. However, evidence of lightning injuries is restricted to case reports and series and nonsystematic reviews. In this clinical review, we systematically select, score, and present evidence regarding lightning injuries.
Material and methods
We performed a systematic search for reviews and guidelines in the PubMed, Embase (OvidSP), MEDLINE (OvidSP), and Web of Science databases. All publications were scored according to the Levels of Evidence 2 Table of the Oxford center for Evidence-Based Medicine. The reviews were also scored using the scale for the quality assessment of narrative review articles (SANRA) and guidelines from the Appraisal of Guidelines for Research & Evaluation (AGREE II).
Results
The search yielded 536 articles. Eventually, 56 articles were included, which consisted of 50 reviews, five guidelines and one overview. The available reviews and guidelines were graded as low to moderate evidence. Most damage from lightning injuries is cardiovascular and neurological, although an individual can experience complications with any of their vital functions. At the scene, initial treatment and resuscitation should focus on those who appear to be dead, which is called the reverse triage system. We proposed an evidence-based treatment protocol for lightning strike patients.
Conclusion
It is vital that every lightning strike patient is treated according to standard trauma guidelines, with a specific focus on the possible sequelae of lighting injuries. All emergency healthcare professionals should acknowledge the risks and particularities of treating lighting strike injuries to optimize the care and outcomes of these patients. Our evidence-based treatment protocol should help prehospital and in-hospital emergency healthcare practitioners to prevent therapeutic mismanagement among these patients.
]. Nevertheless, presentation at a healthcare facility seems rare. Retrospective studies of large hospitals have indicated that each year, approximately 1 in 35,000–40,000 patients is hospitalized due to lightning [
]. With the current data, it remains difficult to conclude anything regarding the exact number of lightning strike patients, who eventually present at the emergency department.
Why lightning injuries are underreported remains unknown. However, lightning can inflict serious damage on victims. Lightning can expose the body to over 1000,000 Vs and 10,000–200,000 As, which is classified as a high voltage injury [
]. The most critical difference from other high voltage injuries is the duration of exposure. A person's exposure to lightning is very short, typically lasting from 1/1000 s to 1/10 s [
]. Because of this short exposure period, only a small amount of energy is transferred internally, while the majority of the energy flows externally over the victim's body, which is also known as the “flashover” effect [
]. Due to the flashover effect, a person can actually survive a lightning strike. However, this effect also causes a much more serious injury pattern compared with other high voltage injuries, and lightning injuries have a 5–10 times higher estimated morbidity rate [
]. A blast wave causes injury through an explosion occurring in the air around the lightning channel. The electrical current often contributes to severe damage in patients, whereas severe injuries caused by blast waves or high temperature are rarer [
Lightning strikes the victim and the current passes through the body. Entry and exit wounds are often found.
2 Contact injury
Lightning strikes an object that is touched by the victim.
3 Side flash injury
Lightning strikes a nearby object (e.g., a tree) and flashes over to the victim.
4 Ground strike (most common)
Lightning strikes the ground and passes to the victim. The current enters the body through one leg and exits through the other.
5 Upward stream
Current flows through the body from the ground upwards.
6 Blast injury
Such injuries occur through a blast wave, through an explosion of nearby structures (which can cause penetrating injuries), or through the victim falling or being thrown.
7 Phone electrocution
A bolt of lightning that strikes a telephone line can cause an electrical surge to shoot through the wires and enter a handset. Nowadays, the odds of this are extremely small due to the use of wireless phones.
Which type of injury will occur in a lightning strike victim is determined by the type of mechanism, current (A), path of current flow across the body, duration of contact, and individual vulnerability [
]. Due to the many determinants, injuries vary significantly between individuals. Therefore, it is crucial to have a clear overview and sound understanding of these injuries. Considering the low documented incidence (some case reports and case series), assessing lighting strike patients and treating their injuries are challenging. The guidelines for treating lightning injuries remain poor and hardly any contain recommendations based on a systematic review of existing evidence. Therefore, the aim of this clinical review is to present the best available evidence regarding the epidemiology, clinical presentation, treatment, and sequalae of lightning injuries from the past 30 years as well as to highlight pitfalls in the approaches to these patients. Then, this clinical review provides an evidence-based treatment protocol, which could be of great use to all emergency healthcare professionals in the prehospital and in-hospital setting.
Materials and methods
Search strategy and study selection
We performed a systematic database search for reviews and guidelines in the PubMed, Embase (OvidSP), MEDLINE (OvidSP), and Web of Science databases. The search strategies are listed in Appendix A. Furthermore, a global search was performed on Google Scholar and UpToDate using the terms “lightning injuries,” “lightning injuries review,” and “medical aspects lightning injuries” to find additional articles. One author (RR) performed this screening. Articles with publication dates after January 1990 up to April 2022 were reviewed if written in Dutch, English, or German. Because of the many case reports and series, which varied significantly in injury presentation, the search was limited to reviews and guidelines. Articles were screened based on their title, abstract, and full-text and were discussed with a second author (ET). Articles were included if they contained relevant information regarding the epidemiology, clinical presentation, treatment, or sequalae of lightning injuries. Additional articles were screened for inclusion through cross-referencing the shortlisted articles.
Article quality assessment
The quality of the articles was assessed according to the Levels of Evidence 2 Table of the Oxford center for Evidence-Based Medicine (OCEBM) [
OCEBM Levels of Evidence Working Group*. “The Oxford Levels of Evidence 2”. Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653. * OCEBM Levels of Evidence Working Group = Jeremy Howick, Iain Chalmers (James Lind Library), Paul Glasziou, Trish Greenhalgh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, Hazel Thornton, Olive Goddard and Mary Hodgkinson (2011).
]. With the exception of two articles, all reviews were nonsystematic narrative reviews. These reviews could be considered level 5 evidence or even as nonevidence because of the lack of a systematic methodology. Only one set of included guidelines contained recommendations based on a systematic literature review (published in 2018), and therefore, it was scaled as level 1 evidence. Because of the low evidence quality of the articles, the recommendations in this articles should be used with caution. To provide a more detailed description of the quality of the included reviews and guidelines, reviews were also scored using the scale for the quality assessment of narrative review articles (SANRA) [
]. All scores, as well as the most critical characteristics of each article, are listed in Appendix B. When different articles presented conflicting information, their total included references and their quality scores were used as a tool to decide the quality of the information and their contribution to this review.
Results
In total, 536 articles were found through the systematic literature search. After duplicates were removed, 231 articles were screened. Eventually, 56 articles were included. Fig. 1 presents a PRISMA chart of the literature search.
For the sake of prevention, we wish to address some misconceptions about lightning as well as to provide safety tips, which we gleaned from the reviewed articles. Table 2 shows an overview of the misconceptions and safety tips. We feel that this is important to do because misconceptions could lead to inadequate risk mitigation before a lightning strike as well as inadequate treatment after one occurs.
A ball lightning is an actual phenomenon. It is described as a mixture of fire and lightning, which can move in any direction after a strike and suddenly disappears
Lightning injuries: prevention and on-site treatment in mountains and remote areas. official guidelines of the International Commission for Mountain Emergency Medicine and the Medical Commission of the International Mountaineering and Climbing Federation (ICAR and UIAA MEDCOM).
Lightning injuries: prevention and on-site treatment in mountains and remote areas. official guidelines of the International Commission for Mountain Emergency Medicine and the Medical Commission of the International Mountaineering and Climbing Federation (ICAR and UIAA MEDCOM).
The “30–30″ rule is recommended for safety. This rule states that you should seek shelter when the thunder is heard within 30 s of seeing a lightning strike and activity should not resume for 30 min after the last thunder is heard or the last lightning seen [
]. Most injuries occur outdoors where ground strikes or side flash injuries are most common. With ground strikes injuries the lightning strikes the ground and passes to the victim. The current enters the body through one leg and exits through the other. With side flash injuries the lighting strikes a nearby object and flashes over to the victim. About 50% of injuries are ground strike injuries, while side flash injuries contribute from 30% to ≤50% of total injuries. Direct strikes contribute from 3% to 5% of injuries and contact injuries only 1–2% [
]. With a direct strike the lightning hits the victim instantly, while with contact injuries the lightning strikes an object that is touched by the victim. Although direct strike injuries are uncommon, they have the highest mortality rates [
Lightning injuries: prevention and on-site treatment in mountains and remote areas. official guidelines of the International Commission for Mountain Emergency Medicine and the Medical Commission of the International Mountaineering and Climbing Federation (ICAR and UIAA MEDCOM).
]. Africa topped the list with mortality rates up to 84 deaths per million people per year, followed by countries in Asia and North and South America. Mortality rates in Europe were the lowest with an average of 0.1–0.4 deaths per million people per year. This discrepancy in mortality rates is due to the lack of lightning-safe facilities and fewer fully enclosed metal-topped vehicles, higher rates of labor-intensive agriculture, lack of awareness, and poor medical treatment in less developed countries [
Although clinical presentation in lightning strike victims varies greatly per individual, signs and symptoms of lightning strike victims are explained by the current following the path of least resistance. Nerves have the least resistance, followed by blood, muscles, skin, fat, and bones [
]; this may explain why neurological and cardiovascular damage are the most common and severe forms among these patients. In contrast to other high voltage injuries, burns are mostly not severe due to the short exposure time of patients [
Lightning injuries: prevention and on-site treatment in mountains and remote areas. official guidelines of the International Commission for Mountain Emergency Medicine and the Medical Commission of the International Mountaineering and Climbing Federation (ICAR and UIAA MEDCOM).
Management of multi-casualty incidents in mountain rescue: evidence-Based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM).
Return of spontaneous circulation (ROSC) is rather the rule then the exception, but respiratory arrest outlasts cardiac arrest. This states that apnea is the critical factor in mortality. So artificial respiration must be continued after ROSC [
Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency cardiac care committee and subcommittees, American Heart Association. Part IV. Special resuscitation situations.
Immediate and transient: loss of consciousness (75%); amnesia and headache (86%); paraesthesias (67%); muscle weakness (80%), and keraunoparalysis (67%). Keraunoparalysis is a temporary paralysis of the extremities (lower more common than upper) that are blue, mottled, cold, and pulseless [
Keraunoparalysis can mimic spinal cord injury or compartment syndrome. Diagnostic imaging should be performed if neurologic deficits persist despite resolution of pallor or pulselessness [
Full-thickness burns present as an entry wound, at the feet as an exit wound (also called “tip-toe sign”), or are caused via molten metal or a ball lightning [
Lightning injuries: prevention and on-site treatment in mountains and remote areas. official guidelines of the International Commission for Mountain Emergency Medicine and the Medical Commission of the International Mountaineering and Climbing Federation (ICAR and UIAA MEDCOM).
Given the highly variable clinical presentation of a lightning strike victim, treatment should follow standard trauma guidelines according to Advanced Trauma Life Support (ATLS) [
]. Additionally, it is crucial to present the risks and particularities in the treatment of these patients.
Diagnosis at scene
When diagnosis is unclear, critical clues pointing to lightning injuries are unexplained burns, specific sequelae such as Lichtenberg figures (Fig. 2), singed hair, torn clothes, molten metal, and tympanic membrane ruptures [
Apart from immediate cardiac arrest, lightning strike does not usually cause any immediately life-threatening injuries. This suggests that victims who are not in cardiac arrest upon arrival will most likely not die within the next 30–60 min [
Management of multi-casualty incidents in mountain rescue: evidence-Based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM).
Lightning injuries: prevention and on-site treatment in mountains and remote areas. official guidelines of the International Commission for Mountain Emergency Medicine and the Medical Commission of the International Mountaineering and Climbing Federation (ICAR and UIAA MEDCOM).
Management of multi-casualty incidents in mountain rescue: evidence-Based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM).
Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency cardiac care committee and subcommittees, American Heart Association. Part IV. Special resuscitation situations.
Initial assessment can proceed as usual. However, prehospital providers should keep in mind a few important aspects of the prehospital trauma care of a lightning strike patient:
-
Every patient should be treated as a polytrauma patient and undergo spinal immobilization at the scene [
Airway management is essential, because primary and secondary hypoxic cardiac arrest is a major cause of death in lightning strike patients. Management can include oral and nasal airway adjuncts, and bag-mask ventilation [
Lightning injuries: prevention and on-site treatment in mountains and remote areas. official guidelines of the International Commission for Mountain Emergency Medicine and the Medical Commission of the International Mountaineering and Climbing Federation (ICAR and UIAA MEDCOM).
Management of multi-casualty incidents in mountain rescue: evidence-Based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM).
Hemorrhage control and management of long-bone fractures is mostly not necessary in lightning strike patients, due to the low incidence of blunt injuries [
Lightning injuries: prevention and on-site treatment in mountains and remote areas. official guidelines of the International Commission for Mountain Emergency Medicine and the Medical Commission of the International Mountaineering and Climbing Federation (ICAR and UIAA MEDCOM).
Presentation of full-thickness burns are rare. However, a prehospital provider should always determine the severity and extent (total body surface area) of burns on a lightning strike patient. Aggressive fluid resuscitation should start immediately for patients with major burns [
]. Furthermore, all patients should have an ECG, blood test and urinalysis. One should look specifically for QT prolongation, T-wave inversion and ST alteration. Minimum laboratory examinations should include a complete blood count, myoglobin, electrolytes, blood urea nitrogen, creatinine, creatine phosphokinase, creatine kinase-MB, coagulation panel, troponin and urinalysis, including a test for myoglobin on fresh urine [
]. Lightning survivors with normal vital functions (i.e. heart rate, blood pressure and saturation), normal ECG, normal blood tests and normal urinalysis can safely be discharged after 12–24 h [
]. However, patients with high-risk findings should stay for at least 24 h and be closely monitored in either a Medium Care Unit (MCU) or Intensive Care Unit (ICU) [
]. High-risk findings are suspected direct strike, loss of consciousness, chest pain, dyspnea, cranial burns, leg burns, burns >10% of total body surface area (TBSA), persisting neurological damage, and pregnancy. In hospital, treatment should mainly focus on repeated and ongoing assessments, as the physical findings and mental state of lightning strike patients tend to change considerably over the first few hours. Alteration in mental state or new focal neurologic deficit indicates the need to obtain additional imaging studies, like CT. Lab studies that were abnormal upon admission should be repeated. Other laboratories are obtained based upon diagnosis. Hyponatremia may result in brain edema. As lightning strike patients are already at risk of developing cerebral edema, close monitoring of the serum sodium levels and immediate correction of electrolyte abnormalities are therefore necessary. Lightning strike patients with traumatic brain injury may have indications for intracranial pressure monitoring. Furthermore, it is important to monitor fluid status in the severely burned lightning strike patient. Clinical signs of volume status, such as blood pressure, capillary refill, heart rate, color and turgor of the skin should be closely monitored for the first 24 h [
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