Lightning injuries: prevention and on-site treatment in mountains and remote areas

Lightning Strike Injuries

Lightning is a common environmental hazard, and is a significant cause of global injury and death. Care and evaluation should follow general trauma guidelines, but several unique aspects of lightning injuries necessitate deviations from standard care that can improve survival and overall outcomes. When evaluating lightning strike patients, some common injury patterns are pathognomonic for lightning strikes and easy to recognize, while others are subtle and require heightened awareness. While most lightning-related injuries resolve spontaneously, some may have significant long-term symptoms. Anticipatory guidance and specialty referral may be needed for appropriate follow-up, evaluation, and treatment.

Termination of Cardiopulmonary Resuscitation in Mountain Rescue: A Scoping Review and ICAR MedCom 2023 Recommendations

Lugnet, Viktor, Miles McDonough, Les Gordon, Mercedes Galindez, Nicolas Mena Reyes, Alison Sheets, Ken Zafren, and Peter Paal. Termination of cardiopulmonary resuscitation in mountain rescue: a scoping review and ICAR MedCom 2023 recommendations. High Alt Med Biol. 24:274-286, 2023. Background: In 2012, the International Commission for Mountain Emergency Medicine (ICAR MedCom) published recommendations for termination of cardiopulmonary resuscitation (CPR) in mountain rescue. New developments have necessitated an update. This is the 2023 update for termination of CPR in mountain rescue. Methods: For this scoping review, we searched the PubMed and Cochrane libraries, updated the recommendations, and obtained consensus approval within the writing group and the ICAR MedCom. Results: We screened a total of 9,102 articles, of which 120 articles met the inclusion criteria. We developed 17 recommendations graded according to the strength of recommendation and level of evidence. Conclusions: Most of the recommendations from 2012 are still valid. We made minor changes regarding the safety of rescuers and responses to primary or traumatic cardiac arrest. The criteria for termination of CPR remain unchanged. The principal changes include updated recommendations for mechanical chest compression, point of care ultrasound (POCUS), extracorporeal life support (ECLS) for hypothermia, the effects of water temperature in drowning, and the use of burial times in avalanche rescue.

Lichtenberg Figures: How a Cutaneous Sign Can Solve Suspicious Death Cases

Lightning is a natural weather phenomenon that occurs most commonly during the summer months in the afternoon or early evening. Lightning strikes can cause accidental deaths. In developed countries, lightning fatalities occur almost exclusively outdoors. Deaths from lightning may be in remote places with no witnesses. Forensic pathologists may not be able to reach the scene of death because it is too hazardous or inaccessible. Bodies may have neither evidence of skin burns nor torn areas on their clothes. The presumption of accidental death may be difficult to prove. We present 3 cases in which neither the examination of the death scene nor the examination of the bodies by those who attested to the death were performed. The bodies were transported to the morgue for a forensic autopsy because the deaths were considered suspicious. Physicians who attest to death in open spaces during weather that could produce lightning should actively search for Lichtenberg figures, which are considered irrefutable proof of fatal lightning in such settings. They should also photograph them and submit them as evidence. Nevertheless, physicians should keep in mind that Lichtenberg figures are not considered pathognomonic of lightning because some skin manifestations may mimic them.

A shocking injury: A clinical review of lightning injuries highlighting pitfalls and a treatment protocol

INTRODUCTION

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.

A 9-year retrospective review of lightning deaths from the Eastern Anatolian Region of Turkey

In this study, deaths from lightning strikes in Eastern Turkey revealed distinct patterns in lifestyle and physical injury. Farmers, sailors, and those engaged in outdoor sports are all at risk of being struck by lightning. Death from a lightning strike is associated with cardiovascular and central nervous system damage. This study examines cases of autopsies that were performed on bodies that had suffered a lightning strike, including sociodemographic data, burns on the body, injured regions, histopathological findings, and causes of death. This retrospective evaluation included 17 cases. The cases comprised 88.2% males and 11.8% females, with a mean age of 41.5 years. The person's occupation was farmer in 29.4% of the cases and shepherd in 70.6%. Their deaths occurred most frequently in the summer months. Deaths associated with lightning strikes are more frequent in east of Turkey than in other regions, as agriculture and livestock are common sources of income. The majority of the victims among the cases were males working outside because of their occupations. Histopathologically, subarachnoid fresh bleeding was seen in five cases, subpleural fresh bleeding in the lungs in five cases, and interlobular rupture in the lungs in three cases. Deaths associated with lightning strikes have been correlated with a low level of education in this subject. This study is the largest case study of deaths associated with lightning strikes in Turkey.

Cases of Lightning Strikes during Mountain-Sports Activities: An Analysis of Emergencies from the Swiss Alps

Background: Lightning strikes are a risk during mountain-sport activities. Yet little is known about the prevalence of injuries related to lightning strikes during mountain hiking, backcountry skiing, or high-altitude mountaineering. This study therefore examined the occurrence and characteristics of lightning-strike-related emergencies during mountain-sport activities in the Swiss Alps. Methods: We analyzed 11,221 alpine emergencies during mountain hiking, 4687 during high-altitude mountaineering, and 3044 during backcountry skiing in the observational period from 2009 to 2020. Identified cases were analyzed in detail regarding age, sex, the time of occurrence, altitude, location, the severity of the injury as quantified by its NACA Score (National Advisory Committee for Aeronautics Score), and injury pattern. Results: We found no cases related to backcountry skiing. Eight cases of lightning strikes during mountain hiking (four female and four male) were identified. The mean age was 32.5 ± 17.5 years, the mean NACA Score was 2.5 ± 1.9, and the mean altitude was 1883.8 ± 425.7 m. None of these cases were fatal, and only one victim was seriously injured. Fifteen cases were identified during high-altitude mountaineering (four female and 11 male). The mean age was 38.7 ± 5.2 years, the mean NACA Score was 3.1 ± 2.5, and the mean altitude was 3486.4 ± 614.3 m. Two lightning strikes were fatal. In these two cases, rope partners were injured by a lightning strike (NACA Score = 4). Most cases were on relatively exposed terrain, such as the Matterhorn Hörnligrat or the Eiger Mittellegigrat. Discussion: The typical victims were 30–40-year-old men. It is possible that the lightning strikes are a consequence of a lower risk aversion among these alpinists, which is be supported by the fact that most of the events occurred on famous mountains such as the Matterhorn or Eiger. Furthermore, since most of the locations were on relatively exposed terrain where one could not quickly find shelter, we recommend careful tour planning with serious consultation of the weather forecast and the likelihood of thunderstorms before climbing exposed sections to prevent emergencies related to lightning strikes.

Phosphate Coatings: EIS and SEM Applied to Evaluate the Corrosion Behavior of Steel in Fire Extinguishing Solution

Phosphate coatings are one of the most important methods in preventing metal corrosion, especially iron alloys. The high interest in this method for industrial applications is mainly due to the low costs associated with the phosphating solution component and technological process. Considering this aspect and the advantages offered to the materials (corrosion resistance, good adhesion, wear resistance), this study evaluates the potential of using the phosphate coating method in health and safety applications. Therefore, the deposition of a layer of zinc phosphate on the steel surface used in the manufacture of components for personal protective equipment was approached. Firefighters, during rescue/evacuation operations, use protective equipment for fall arrest, whose accessories (hooks, carabiners) are made of steel. Due to the low corrosion resistance property of carbon steel, these accessories must be replaced frequently. This paper aims to analyze the possibility of improving the corrosion resistance of carbon steel in a fire extinguishing solution. Accordingly, the electrochemical behavior of two different types of coatings was studied by electrochemical impedance spectroscopy (EIS) and scanning electron microscope (SEM). In the literature, different corrosion evaluating methods or systems have been considered, and up until now, there has been no previous study to have approached the corrosive behavior of C45, phosphate C45, and painted phosphate C45 immersed in fire extinguishing solution.

Determination of Death in Mountain Rescue: Recommendations of the International Commission for Mountain Emergency Medicine (ICAR MedCom)

Determination of death requires specific knowledge, training, and experience in most cases. It can be particularly difficult when external conditions, such as objective hazards in mountains, prevent close physical examination of an apparently lifeless person, or when examination cannot be accomplished by an authorized person. Guidelines exist, but proper use can be difficult. In addition to the absence of vital signs, definitive signs of death must be present. Recognition of definitive signs of death can be problematic due to the variability in time course and the possibility of mimics. Only clear criteria such as decapitation or detruncation should be used to determine death from a distance or by laypersons who are not medically trained. To present criteria that allow for accurate determination of death in mountain rescue situations, the International Commission for Mountain Emergency Medicine convened a panel of mountain rescue doctors and a forensic pathologist. These recommendations are based on a nonsystematic review of the literature including articles on determination of death and related topics.

Evaluation of the Corrosion Resistance of Phosphate Coatings Deposited on the Surface of the Carbon Steel Used for Carabiners Manufacturing

This study aims to evaluate the corrosion resistance of carbon steel, used for carabiners manufacturing, coated with three different types of phosphate layer. The phosphate layers have been obtained by phosphate conversion coating with three different types of phosphate solutions: zinc-based solution, zinc-iron-based phosphate solution, and manganese-based phosphate solution. Additionally, the test was performed on zinc phosphate samples impregnated with molybdenum bisulfate-based oil and zinc phosphate samples further coated with a layer of elastomer-based paint. Considering the areas where the carabiners are used (civil engineering, navigation, oil industry, rescue operations, etc.), the corrosive environments studied are rainwater, Black Sea water, and fire extinguishing solution. The structure of the deposited layers was studied by scanning electron microscopy, while the interface structure between the alloy and corrosive environment was analyzed by electrochemical impedance spectroscopy. According to this study, the corrosion resistance of zinc-based phosphate coated samples and zinc/iron-based phosphate coated samples is higher than that of the studied carbon steel samples, despite the corrosion environment. Also, the most aggressive corrosion environment was the fire extinguishing solution.

Lightning accidents in the Austrian alps - a 10-year retrospective nationwide analysis

Background

Lightning strikes are rare but potentially lethal. The risk for suffering a lightning strike in a mountain environment is unknown. The aim of this nationwide study was to analyse all lightning accidents in the Austrian Alps from 2005 to 2015, to assess the circumstances of the accident, the injury pattern as well as the outcome.

Methods

From 2005 to 2015, data from the national Austrian Alpine Police database as well as the Clinical Information System of Innsbruck Medical University Hospital were searched for the keywords lightning injury, lightning strike, lightning as well as ICD-10 Code T75.0. Additionally, the archive data of Innsbruck Medical University Hospital was searched manually.

Results

The Austrian Alpine Police database, containing 109.168 patients for the years 2005–2015, was screened for lightning accidents. Sixty-four patients had been hit by lightning in the Austrian Alps, 54 were male. Four persons died on scene; survival rate was 93.8%. Two deceased persons were hunters, who were killed by the same lightning strike. Sixty-three patients suffered a lightning strike while doing a recreational activity, mostly hiking (n = 55), a few hunting and only one doing occupational timberwork. Sixty-three patients suffered a lightning strike between June and August with nearly half (46.9%) of the accidents happening on a Saturday or Sunday, and mainly (95.3%) between 12:00 and 22:00 h.

Discussion

Persons who perform recreational outdoor and occupational activities in an alpine environment during summer and after noon incur a higher risk of sustaining a lightning strike. The primary risk group includes young male mountaineers and hunters. The mortality rate was low.

Trial registration

The study was approved by the Ethics Committee of the Medical University of Innsbruck (AN4757 315/4.4) and retrospectively registered with Clinical Trials NCT03405467, January 19, 2018.

Management of Multi-Casualty Incidents in Mountain Rescue: Evidence-Based Guidelines of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM)

Blancher, Marc, François Albasini, Fidel Elsensohn, Ken Zafren, Natalie Hölzl, Kyle McLaughlin, Albert R. Wheeler III, Steven Roy, Hermann Brugger, Mike Greene, and Peter Paal. Management of multi-casualty incidents in mountain rescue: Evidence-based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). High Alt Med Biol. 19:131–140, 2018.

Introduction: Multi-Casualty Incidents (MCI) occur in mountain areas. Little is known about the incidence and character of such events, and the kind of rescue response. Therefore, the International Commission for Mountain Emergency Medicine (ICAR MEDCOM) set out to provide recommendations for the management of MCI in mountain areas.

Materials and Methods: Details of MCI occurring in mountain areas related to mountaineering activities and involving organized mountain rescue were collected. A literature search using (1) PubMed, (2) national mountain rescue registries, and (3) lay press articles on the internet was performed. The results were analyzed with respect to specific aspects of mountain rescue.

Results: We identified 198 MCIs that have occurred in mountain areas since 1956: 137 avalanches, 38 ski lift accidents, and 23 other events, including lightning injuries, landslides, volcanic eruptions, lost groups of people, and water-related accidents.

Discussion: General knowledge on MCI management is required. Due to specific aspects of triage and management, the approach to MCIs may differ between those in mountain areas and those in urban settings.

Conclusions: Mountain rescue teams should be prepared to manage MCIs. Knowledge should be reviewed and training performed regularly. Cooperation between terrestrial rescue services, avalanche safety authorities, and helicopter crews is critical to successful management of MCIs in mountain areas.

Neurologic complications of acute environmental injuries

Environmental injuries can result in serious neurologic morbidity. This chapter reviews neurologic complications of thermal burns, smoke inhalation, lightning strikes, electric injury, near drowning, decompression illness, as well as heat stroke and accidental hypothermia. Knowing the pathophysiology and clinical presentation of such injuries is essential to proper management of primary and secondary medical complications. This chapter highlights the most frequently encountered neurologic injuries secondary to common environmental hazards, divided into the topics: injuries related to fire, electricity, water, and the extremes of temperature.

The Infectious and Noninfectious Dermatological Consequences of Flooding: A Field Manual for the Responding Provider

Meteorological data show that disastrous floods are increasingly frequent and more severe in recent years, perhaps due to climatic changes such as global warming. During and after a flood disaster, traumatic injuries, communicable diseases, chemical exposures, malnutrition, decreased access to care, and even mental health disorders dramatically increase, and many of these have dermatological manifestations. Numerous case reports document typical and atypical cutaneous infections, percutaneous trauma, immersion injuries, noninfectious contact exposures, exposure to wildlife, and exacerbation of underlying skin diseases after such disasters as the 2004 Asian tsunami, Hurricane Katrina in 2005, and the 2010 Pakistan floods. This review attempts to provide a basic field manual of sorts to providers who are engaged in care after a flooding event, with particular focus on the infectious consequences. Bacterial pathogens such as Staphylococcus and Streptococcus are still common causes of skin infections after floods, with atypical bacteria also greatly increased. Vibrio vulnificus is classically associated with exposure to saltwater or brackish water. It may present as necrotizing fasciitis with hemorrhagic bullae, and treatment consists of doxycycline or a quinolone, plus a third-generation cephalosporin and surgical debridement. Atypical mycobacterial infections typically produce indolent cutaneous infections, possibly showing sporotrichoid spread. A unique nontuberculous infection called spam has recently been identified in Satowan Pacific Islanders; combination antibiotic therapy is recommended. Aeromonas infection is typically associated with freshwater exposure and, like Vibrio infections, immunocompromised or cirrhotic patients are at highest risk for severe disease, such as necrotizing fasciitis and sepsis. Various antibiotics can be used to treat Aeromonas infections. Melioidosis is seen mainly in Southeast Asia and Australia, particularly in rice farmers, and can remain latent for many years before presenting as the host's immunocompetence wanes. It can present with a variety of skin findings or as a nonspecific febrile illness, and preferred treatment consists of ceftazidime or a carbapenem with trimethoprim/sulfamethoxazole (TMP/SMX) for 2 weeks, then continuing TMP/SMX for at least 3 months. Leptospirosis is a waterborne zoonosis that is often prevalent after heavy rains or flooding. Different forms exist, including Fort Bragg fever, which produces a distinctive erythematous papular rash on the shins. Doxycycline is often sufficient; however, volume and potassium repletion may be necessary if renal involvement exists. Chromobacterium violaceum infection may occur after open skin is exposed to stagnant or muddy water. Cultured colonies produce a unique violacein pigment, and treatment typically consists of a carbapenem. Both typical and atypical fungal infections are increased in the flooding disaster scenario, such as dermatophytosis, chromoblastomycosis, blastomycosis, and mucormycosis. Appropriate antifungals should be used. In addition, land inundated with water expands the habitat for parasites and/or vectors, thus increased vigilance for regional parasitic infections is necessary after a flood. Lastly, noninfectious consequences of a flooding disaster are also common and include miliaria, immersion foot syndromes, irritant and allergic contact dermatitis, traumatic wounds and animal bites, and arthropod assault, as well as exacerbation of existing skin conditions such as atopic dermatitis, psoriasis, and alopecia areata due to increased stress or nonavailability of daily medications.

Wilderness Medical Society practice guidelines for the prevention and treatment of lightning injuries: 2014 update

To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the treatment and prevention of lightning injuries. These guidelines include a review of the epidemiology of lightning and recommendations for the prevention of lightning strikes, along with treatment recommendations organized by organ system. Recommendations are graded on the basis of the quality of supporting evidence according to criteria put forth by the American College of Chest Physicians. This is an updated version of the original WMS Practice Guidelines for Prevention and Treatment of Lightning Injuries published in Wilderness & Environmental Medicine 2012;23(3):260-269.

Neurologic emergencies in sports

PURPOSE OF REVIEW

Sports neurology is an emerging area of subspecialty. Neurologists and non-neurologists evaluating and managing individuals participating in sports will encounter emergencies that directly or indirectly involve the nervous system. Since the primary specialty of sports medicine physicians and other practitioners involved in the delivery of medical care to athletes in emergency situations varies significantly, experience in recognition and management of neurologic emergencies in sports will vary as well. This article provides a review of information and elements essential to neurologic emergencies in sports for the practicing neurologist, although content may be of benefit to readers of varying background and expertise.

RECENT FINDINGS

Both common neurologic emergencies and less common but noteworthy neurologic emergencies are reviewed in this article. Issues that are fairly unique to sports participation are highlighted in this review. General concepts and principles related to treatment of neurologic emergencies that are often encountered unrelated to sports (eg, recognition and treatment of status epilepticus, increased intracranial pressure) are discussed but are not the focus of this article. Neurologic emergencies can involve any region of the nervous system (eg, brain, spine/spinal cord, peripheral nerves, muscles). In addition to neurologic emergencies that represent direct sports-related neurologic complications, indirect (systemic and generalized) sports-related emergencies with significant neurologic consequences can occur and are also discussed in this article.

SUMMARY

Neurologists and others involved in the care of athletes should consider neurologic emergencies in sports when planning and providing medical care.

Lesions along the upper motor neuronal pathway with locked-in features after lightning strike and cardiac arrest: a case-review analysis

OBJECTIVE

This study describes a case of lesions of the upper motor neuronal pathway with locked-in features after lightning strike and cardiac arrest.

DESIGN

A case-review analysis.

METHODS

In a 29-year-old male who was hit by a lightning strike during farming activities, cardiopulmonary resuscitation was provided first by co-workers and continued with success by the medical rescue service. After conducting advanced life support under monitoring and therapeutic hypothermia, quadriplegia with facial diplegia was recognized. A review was undertaken detailing the clinical course.

RESULTS

MR imaging presented signs consistent with hypoxia-induced damage and diffusion-weighted MR images revealed pronounced damages along the upper motor neuronal pathway. A reactive electroencephalogram pattern, sustained eye movement and the patient communicating via eye-blinking were interpreted as locked-in features. Two weeks after admission the patient was transferred to a neurological rehabilitation centre for further professional care.

CONCLUSION

Direct damage of the upper motor neuron pathway due to the current of the lightning should be considered, albeit the relative contribution of hypoxia-induced damage cannot be separated.

Fatalities Among Iranian High-altitude Outdoor Enthusiasts: Causes and Mechanisms

Purpose

This study was performed to determine the possible causes and mechanisms of fatalities among Iranian mountaineers during climbing.

Methods

By contacting several sources, deceased mountaineers were identified. Data about the causes and mechanism of death was retrospectively obtained using a standard questionnaire for each case.

Results

A total of 29 deaths were identified from March 2006 to June 2010. Deceased subjects had a mean age of 39 years (SD: 12.8, Range: 20-67). Falling was the most common accident leading to death of outdoor enthusiasts (n = 14, 48%). Asphyxia (n = 6, 24%) was the most common cause of death among the subjects, followed by heart attack, internal bleeding, cerebral hemorrhage and hypothermia (17%, 17%, 17% and 10%, respectively).

Conclusions

Our findings suggest that education of medical service providers of the climbing groups on facing victims in high altitude areas, where they have limited resources, can be particularly helpful. In addition, a national program to educate mountaineers might help to reduce fatalities.

Injuries, sequelae, and treatment of lightning-induced injuries: 10 years of experience at a swiss trauma center

Principals. Lightning is one of the most powerful and spectacular natural phenomena. Lightning strikes to humans are uncommon but can cause devastating injuries. We analyzed lightning-related admissions to our emergency department from January 2000 to December 2010 to review and highlight the main features of lightning-related injuries. Methods. All data were collected prospectively and entered in the emergency department' database (Qualicare Switzerland) and retrospectively analyzed. Results. Nine patients with lightning-related injuries presented to our emergency department. Four were female, and five were male. The most common site of injury was the nervous system (6 out of 9 patients) followed by the cardiovascular system (5 out of 9 patients). The third most common injuries occurred to the skin (3 out of 9 patients). Four of the patients had to be hospitalized for further observation. Conclusion. Reports of lightning strikes and related injuries are scarce. The establishment of an international register would therefore benefit the understanding of their injury patterns and facilitate specific treatment.

Evaluation of injury and fatality risk in rock and ice climbing

Rock and ice climbing are widely considered to be 'high-risk' sporting activities that are associated with a high incidence of severe injury and even death, compared with more mainstream sports. However, objective scientific data to support this perception are questionable. Accordingly, >400 sport-specific injury studies were analysed and compared by quantifying the injury incidence and objectively grading the injury severity (using the National Advisory Committee for Aeronautics score) per 1000 hours of sporting participation. Fatalities were also analysed. The analysis revealed that fatalities occurred in all sports, but it was not always clear whether the sport itself or pre-existing health conditions contributed or caused the deaths. Bouldering (ropeless climbing to low heights), sport climbing (mostly bolt protected lead climbing with little objective danger) and indoor climbing (climbing indoors on artificial rock structures), showed a small injury rate, minor injury severity and few fatalities. As more objective/external dangers exist for alpine and ice climbing, the injury rate, injury severity and fatality were all higher. Overall, climbing sports had a lower injury incidence and severity score than many popular sports, including basketball, sailing or soccer; indoor climbing ranked the lowest in terms of injuries of all sports assessed. Nevertheless, a fatality risk remains, especially in alpine and ice climbing. In the absence of a standard definition for a 'high-risk' sport, categorizing climbing as a high-risk sport was found to be either subjective or dependent on the definition used. In conclusion, this analysis showed that retrospective data on sport-specific injuries and fatalities are not reported in a standardized manner. To improve preventative injury measures for climbing sports, it is recommended that a standardized, robust and comprehensive sport-specific scoring model should be developed to report and fully evaluate the injury risk, severity of injuries and fatality risk in climbing sports.

[Advanced cardiopulmonary resuscitation under special circumstances: part 2]

Based on the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR), guidelines were published for managing basic and advanced life-saving procedures in the event of cardiac arrest. The fact that special circumstances for cardiac arrest must be considered resulted in a separate chapter. This two-part article reviews essential information as well as necessary modifications of the standard advanced life support algorithm in cases of electrolyte disorders, hyperthermia and hypothermia, cardiac arrest in pregnancy, trauma, electrical emergencies and cardiac surgery. Part 1 has already dealt with life-threatening drowning, asthma, anaphylaxis and poisoning.

Lightning injury: a review

Lightning is an uncommon but potentially devastating cause of injury in patients presenting to burn centers. These injuries feature unusual symptoms, high mortality, and significant long-term morbidity. This paper will review the epidemiology, physics, clinical presentation, management principles, and prevention of lightning injuries.

Notfallmedizinische Versorgung von Blitz- und Stromschlagverletzungen

The pattern of injuries following electrical accidents and the treatment by emergency teams differ depending on whether exposure was to a low-voltage or high-voltage power source or to a lightning bolt. Tissue damage results from the direct effect of current on cell membranes and from conversion of electrical energy into heat. Depending on the magnitude of electrical energy and the duration of exposure, cardiac dysrhythmia, damage to nerve tissue, extensive burns and shock may occur. Multi-system injury is frequently observed, either directly related to electrical shock or secondary to concurrent trauma. Extrication of victims from the energy field must be performed under strict observance of self-protection measures for the rescuers. In high-voltage incidents the rescuers must wait at a distance until the power supply has been turned off and demonstrably grounded. Analgesia, anxiolysis and administration of crystalloid fluids are needed, especially for injuries from high-voltage power sources. Severe burns of the face and neck call for early intubation and ventilation. Monitoring is performed with pulsoximetry, blood pressure measurement and ECG, giving highest priority to the unconscious patient with cardiac and respiratory arrest. Cardio-pulmonary resuscitation (CPR) follows the international guidelines for resuscitation and may be effective after delayed onset and even after prolonged resuscitation attempts.