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

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.

Electrical burn-induced vocal cord injury: insights from a case report and literature review

We report a rare case of vocal cord injury from an electrical burn, managed successfully with conservative, non-invasive treatment. This unique case illustrates potential complications of electrical trauma and underscores the need for vigilance and consideration of conservative management approaches.

Neurotrophic keratitis caused by lightning injury: a case report

BACKGROUND

This study aimed to report a case of neurotrophic keratitis caused by lightning.

CASE PRESENTATION

A 38-year-old man was hit by lightning and suffered eye injury. He eventually developed neurotrophic keratitis.

RESULTS

The patient's injury history and burn site were analyzed, and it was judged that lightning directly damaged his cornea, eventually resulting in neurotrophic keratitis. Fortunately, the patient's vision improved after treatment.

CONCLUSION

Lightning can cause eye damage, and the clinical manifestations are diverse. Lightning currents cause corneal nerve loss, resulting in neurotrophic keratitis. To maintain corneal integrity and prevent disease progression, early assessment and appropriate treatment are necessary.

Predictors of mortality following electrical and lightning injuries in Malawi: A decade of experience

INTRODUCTION

Electrical injuries can be devastating, and data is lacking in low-resource settings. We aimed to identify predictors of mortality following electrical and lightning injuries (ELI) in Malawi.

METHODS

We performed a retrospective observational study of patients presenting with ELI and burn injuries at a tertiary hospital in Malawi from 2011 to 2020. Outcomes were compared and predictors of mortality were modeled.

RESULTS

A total of 382 ELI and 6371 burn patients were included. The mean ages for ELI and burn groups were 24 ± 14 and 11 ± 14 years, respectively (p < 0.01). Most patients were injured at home (91% in the burn group versus 51% in the ELI group, p < 0.01). The crude mortality rate in the ELI group was 28%, compared to 12% in the burn group (p < 0.01). On multivariate logistic regression, predictors of mortality included ELI (odds ratio [OR] 13.3, 95% confidence interval [CI] 7.2-24.5) and total body surface area burned (OR 1.1, 95% CI 1.1-1.1). Predicted mortality for ELI has increased over time (p = 0.05).

CONCLUSIONS

ELI confers more than 13 times higher odds of mortality than burn injuries in Malawi, with mortality risk increasing over time. More efforts are needed to prevent electrical hazards and implement timely interventions for patients with ELI.

Prehospital mass casualty incident triage simulation builds knowledge and confidence in medical trainees

Background

Mass casualty incident (MCI) triage simulation is an increasingly useful tool for teaching triage systems to medical students, trainees, and hospital staff. MCI simulation in the prehospital setting has not yet been studied in this population.

Objectives/Aims

We aimed to assess the effectiveness of a prehospital MCI simulation in medical students, residents, and fellows. Our primary outcome was knowledge of the components of the triage algorithms used in MCI response. Our secondary outcome was each participant's confidence level if required to assist with or lead a MCI response.

Methods

This was an observational study with pre-post surveys. We recruited 30 medical students, 14 emergency medicine (EM) residents, and four pediatric EM fellows to fill out a survey before and after a 3-h simulation session practicing the START and JumpSTART algorithms on two prehospital MCI scenarios.

Results

Overall, all groups demonstrated significant improvement in knowledge of triage colors, information needed to assign a triage color, pediatric airway management during a MCI, and indications for breaths-first CPR. They also demonstrated significant increase in confidence both in assisting with and in leading a MCI response.

Conclusions

Simulated practice triaging patients in prehospital MCI scenarios improves knowledge of triage algorithms and increases confidence in assisting with or leading a MCI response in medical trainees.

Rain may improve survival from direct lightning strikes to the human head

There is evidence that humans can survive a direct lightning strike to the head. Our question is: could water (rain) on the skin contribute to an increase in the survival rate? We measure the influence of rain during high-energy direct lightning strikes on a realistic three-compartment human head phantom. We find a lower number of perforations and eroded areas near the lightning strike impact points on the head phantom when rain was applied compared to no rain. Current amplitudes in the brain were lower with rain compared to no rain before a fully formed flashover. We conclude that rain on the scalp potentially contributes to the survival rate of 70-90% due to: (1) lower current exposition in the brain before a fully formed flashover, and (2) reduced mechanical and thermal damage.

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.

Herz-Kreislauf-Stillstand im alpinen Gelände

Die Anzahl von Touristen und Freizeitsportlern in Bergregionen nimmt zu. Im Verhältnis dazu steigt auch die Zahl an Notfallsituationen wie Herz-Kreislauf-Stillstand. Wiederbelebungsmaßnahmen in diesen Umgebungsbedingungen sind anspruchsvoll. Eine besondere Bedeutung in diesem Rahmen hat die prolongierte kardiopulmonale Reanimation.

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.

The various pathological manifestations of a lightning strike exemplified in a single four-fatality incident - A case report and review of a literature

The lightning strike is one of leading cases of weather-related death worldwide. We present an unusual case of four fatality-lightning strike with various pathological manifestations. All victims died from a single lightning strike in the mountains that also caused injury to 156 other people. All victims had mechanical damage and rock damage that are typical for lightning strikes in the mountainside. Another lesions indicative of lightning strike and electrical damage were, among others: burnt and torn clothes (all cases) current marks (Cases 1, 2 and 3) and Lichtenberg figures along with flashover marks on Case 1. In the review we described the pathophysiological mechanisms of lightning-induced lesions and injuries and epidemiological trends of lightning-strike deaths. Our study exemplifies various manifestations of lightning strikes on forensic examination and underlines the necessity to take lightning strike into consideration when investigating open-air deaths of unclear origin.

Electrocution Stigmas in Organ Damage: The Pathological Marks

BACKGROUND

Diagnostic criteria for electrocution related death are still a challenge in forensic pathology and it seems that the electrical mark is the only reliable evidence.

METHODS

A comparison of histological and morphological findings of skin and internal organs from an autopsy series of electrocution deaths with those mostly reported in literature as representative for electrocution.

RESULTS

The morphological changes of heart, brain and other main internal organs are still unspecific. Organ's damage observed in electrocution deaths shows a wide variability, not reliable for a certain diagnosis of electrocution. The electrical mark is still the golden standard for diagnosis of electrocution.

CONCLUSIONS

In electrocution related deaths, pathological findings of the main internal organs are not enough evidence to support with certainty a post-mortem diagnosis that a victim suffered an electrical damage. Although the organ histological changes are undoubtedly the starting point for a better understanding of the fatal even, the diagnosis of death from electrical damage is still a dark and unsolved chapter. The electrical mark still represents a fundamental indicator above all in the medical-legal field, but the identification of pathognomonic elements and signs not limited to the skin alone could be a valid help in the future, especially in unclear cases.

Recommendations on the Appropriate Level of Medical Support at Ultramarathons

Participation in ultramarathons continues to grow, especially among older individuals and among younger runners who may have less running and wilderness experience than many past participants. While ultramarathons tend to have relatively few serious medical issues, adverse medical incidents do occur. These factors make it increasingly important that appropriate safety precautions and medical support are defined and implemented at these events to enhance the safety of participants, spectators, and volunteers. This document establishes the minimum recommended level of medical support that should be available at ultramarathons based on current knowledge and the experience of the authors. It offers a balance that is intended to avoid excessive stress on the local medical system while also precluding undue burden on events to provide medical support beyond that which is practical. We propose a three-level classification system to define the extent of medical services, personnel, systems, supplies, and equipment in place and recommend the level of medical support based on event size, distance/duration, remoteness, and environmental conditions that may be encountered during the event. This document also outlines the recommended education and training of medical providers and discusses other medical and logistical considerations related to the provision of medical support at ultramarathons. We suggest that ultramarathon organizers review and adopt these recommendations to enhance safety and reduce the risk of adverse events to participants.

Secondary maternal-fetal consequences to electrical injury: A literature review

Electrical injuries can occur in pregnant women but currently their incidence is not completely known. Notwithstanding, those represent clinical important events such maternal and fetal death, which can be avoided if properly managed. The objective of this paper is to describe the results of electrical injury (high and low voltage), in pregnant women in scientific reports. A systematic search was performed with keywords "electrical injuries", "lightning injuries", "lightning strike", "pregnant women" and "pregnancy", using the databases: MedLine, Scielo, Lilacs, Clinical key, Web of Science, Scopus, Springer, Science Direct, Embase and Medic Latina. Filters like language, time, design and availability of text were not used. Descriptive analyses were carried out for variables such as maternal-fetal consequences, voltage and type of exposure, based on the reports identified. From the total 74 cases identified, 71.1% survived after the exposition. From the total live-births 28.6% did not show any alteration, 7.1% presented maceration and burns, while 64.3% had another outcome. Electric injury leads to fetal compromise and death in exposed pregnant women, mainly in the first hours after the injury. However, monitoring should be continued for the risk of complications such as placenta abruption, oligohydramnios and fetal distress. It is possible an underreporting of these events.

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.

Research Gaps in Wilderness Medicine

INTRODUCTION

Wilderness medicine involves the treatment of individuals in remote, austere environments. Given the high potential for injuries as well as the unique treatment modalities required in wilderness medicine, evidence-based clinical practice guidelines are necessary to provide optimal care. In this study, we identify evidence gaps from low-quality recommendations in wilderness medicine clinical practice guidelines and identify new/ongoing research addressing them.

METHODS

We included relevant clinical practice guidelines from the Wilderness Medical Society and obtained all 1C or 2C level recommendations. Patient/Problem/Population, intervention, comparison, outcome (PICO) questions were created to address each recommendation. Using 24 search strings, we extracted titles, clinical trial registry number, and recruitment status for 8899 articles. We categorized the articles by trial design to infer the effect they may have on future recommendations.

RESULTS

Twelve clinical practice guidelines met inclusion criteria. From these we located 275 low-quality recommendations and used them to create 275 PICO questions. Thirty-three articles were relevant to the PICO questions. Heat-related illness had the highest number of relevant articles (n=9), but acute pain and altitude sickness had the most randomized clinical trials (n=6).

CONCLUSION

Overall, few studies were being conducted to address research gaps in wilderness medicine. Heat-related illness had the most new or ongoing research, whereas no studies were being conducted to address gaps in eye injuries, basic wound management, or spine immobilization. Animals, cadavers, and mannequin research are useful in cases in which human evidence is difficult to obtain. Establishing research priorities is recommended for addressing research gaps identified by guideline panels.

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.