A Shocking Threat: Clinical Review on Lightning Injuries and Treatment Protocols
Aug 22, 2024
2024/8/22
This study dives deep into the rare yet severe consequences of lightning injuries. These injuries, though infrequent, are significant due to their unpredictable nature and potential for high morbidity and mortality rates.
1. The article establishes the various mechanisms by which lightning strikes can harm victims, ranging from ground strikes to side flashes and even direct hits.
2. Emphasis is placed on the importance of rapid and accurate diagnosis, especially considering the internal injuries often overshadow superficial damage.
3. A comprehensive treatment protocol is proposed, focusing on managing the cardiovascular and neurological consequences of strikes, which are often the most critical.
4. The study further advocates for improved awareness among medical professionals regarding the nuances of treating lightning injuries, highlighting the specificities such as reverse triage in multi-casualty situations.
5. Lightning injuries are notably distinct from other high-voltage injuries due to their mechanism and pattern of damage, particularly the risk of delayed or persistent neurological sequelae.
Cited from: A Shocking Injury: A Clinical Review of Lightning Injuries Highlighting Pitfalls and a Treatment Protocol
Author: J Jensen, J Thurman, A Vincent
DOI: https://doi.org/10.1016/j.injury.2022.08.024
Introduction
Lightning injuries, though rare, pose a significant threat due to their often unpredictable and fatal outcomes. This paper systematically reviews existing evidence on the epidemiology, clinical presentation, treatment, and sequelae of these injuries, offering a detailed guide for medical professionals. Given the lack of comprehensive systematic reviews on this topic, the authors provide a much-needed framework for addressing the consequences of lightning strikes, especially in prehospital and ICU settings.
Method
The study employed a systematic review method, screening multiple databases such as PubMed, MEDLINE, and Embase to collect and analyze guidelines, reviews, and existing case reports on lightning injuries. A total of 536 articles were initially screened, eventually narrowed down to 56 that were deemed relevant. The authors graded these articles using the Levels of Evidence 2 Table and the SANRA (Scale for the quality assessment of narrative review articles) tool. Each article’s clinical relevance was discussed to ensure a comprehensive understanding of lightning injuries and their implications for emergency treatment protocols.
Result
1. Mechanisms of Lightning Injuries
Lightning injuries can result from seven distinct mechanisms, including direct strikes, side flashes, ground strikes, upward streams, blast injuries, contact injuries, and phone electrocution. The review reveals that ground strikes are the most common, making up 50% of lightning-related injuries. This mechanism involves the current traveling from the ground into the victim’s body, often causing internal damage that may not manifest externally. Side flashes, where lightning strikes a nearby object and jumps to the victim, account for 30-50% of injuries.
The study highlights that the severity of lightning injuries depends heavily on the pathway of the current through the body. For instance, when the current passes through the heart or brain, it can cause fatal cardiovascular or neurological damage. Statistical data gathered from case reports shows that approximately 10-30% of lightning strike victims succumb to their injuries, making these mechanisms vital in understanding the risks involved.
Among less frequent but equally severe mechanisms is the direct strike, which occurs in 3-5% of cases but has the highest mortality rate. Contact injuries, caused when the victim is in contact with an object struck by lightning, contribute to 1-2% of cases. This thorough analysis of mechanisms emphasizes the variability of lightning injuries and the need for specialized diagnosis and treatment.
2. Clinical Presentation and Diagnosis
The review discusses in detail the challenges associated with diagnosing lightning strike injuries. One of the key findings is that these injuries do not always present with clear external signs. For instance, in many cases, burns may be superficial or absent altogether, but internal injuries such as cardiovascular damage or nerve trauma may still exist. This presents a challenge for emergency healthcare providers, who must be trained to recognize subtle signs like Lichtenberg figures—branch-like patterns on the skin caused by electrical discharge.
Lichtenberg figures, as noted in the study, are not burns but rather transient skin markings that disappear after 24 hours. Their presence can serve as a critical diagnostic clue that the patient has sustained a lightning injury. In terms of cardiovascular injuries, the review mentions that patients may present with abnormal ECG readings, such as QT prolongation or T-wave inversion. Monitoring of heart function is essential in lightning victims, as the review found a 5-10% occurrence of serious cardiac issues, such as arrhythmias or myocardial infarctions.
Finally, the neurological symptoms are highly variable, ranging from temporary paralysis (keraunoparalysis) to more severe and long-lasting issues such as memory loss, confusion, or even permanent disability. The review indicates that up to 85% of lightning strike survivors experience neurological damage, and 70-75% of them may face long-term disabilities. This calls for careful assessment and prolonged monitoring of patients, even if initial examinations appear normal.
3. Treatment Protocol
Based on the comprehensive review of clinical cases and existing guidelines, the authors propose an evidence-based treatment protocol for lightning injuries. A key recommendation from the review is the importance of reverse triage in multi-casualty incidents involving lightning strikes. Reverse triage focuses on treating patients who appear dead first, as they may still be revivable after a lightning strike due to delayed onset of fatal injuries. Cardiovascular and respiratory assessments are also prioritized, with immediate resuscitation efforts recommended.
In terms of hospital care, the study advocates for continuous ECG monitoring and neurological assessments in all lightning strike patients. Even if the patient’s initial presentation seems stable, delayed complications are common, and these can include sudden arrhythmias or neurological deterioration. The review stresses that all patients should be kept under observation for at least 24 hours, as some critical conditions might only become apparent over time. Blood tests and urinalysis are also recommended to check for signs of myoglobinuria and rhabdomyolysis, which can lead to acute renal failure in some cases.
The review emphasizes the importance of prolonged resuscitation efforts, even for patients who are unresponsive after traditional resuscitation techniques. Studies cited in the review show that patients who undergo resuscitation for 30 minutes or more still have a high chance of survival, especially in cases where lightning-induced asystole or respiratory failure is reversible with appropriate intervention.
Conclusion
This review provides an in-depth analysis of lightning injuries, highlighting the importance of timely diagnosis and evidence-based treatment protocols. Prolonged resuscitation and close monitoring are key factors in improving outcomes. The proposed treatment protocol could significantly improve the care of lightning strike victims, both in prehospital and hospital settings.
