How to manage an elderly patient with a history of exposure to lightning?

From the Guidelines

Managing an elderly patient with lightning exposure requires immediate medical attention and a systematic approach, prioritizing vital function stabilization, thorough injury assessment, and consideration of underlying conditions and potential complications, as outlined in the most recent guidelines 1. The primary goal is to ensure scene safety and call emergency services promptly.

• Assess and stabilize vital functions, checking for cardiac arrest and initiating CPR if needed, as lightning can cause cardiac and respiratory arrest, with the primary cause of death in victims of lightning strike being cardiac arrest, which may be associated with primary VF or asystole 1.
• Monitor cardiac rhythm continuously, as arrhythmias are common.
• Perform a thorough secondary survey for injuries, including burns, fractures, and neurological deficits.
• Lightning burns are typically superficial and require standard burn care with cleaning, debridement if necessary, and appropriate dressings.
• Administer pain medication, such as acetaminophen or NSAIDs for mild pain, or opioids for severe pain, considering a multimodal analgesic approach to avoid side effects of opioid use in the elderly 1.
• Elderly patients may have underlying conditions that complicate recovery, so carefully review their medication list and medical history.
• Neurological complications like confusion, memory problems, or seizures should be treated appropriately—consider anticonvulsants like levetiracetam (500-1000mg twice daily) if seizures occur.
• Maintain adequate hydration and monitor renal function, as myoglobinuria from muscle damage can cause kidney injury.
• Long-term follow-up is essential, as some effects of lightning injury may be delayed or persistent, particularly neurological and psychological sequelae.
• Rehabilitation services may be necessary depending on the extent of injuries, and early involvement of palliative care teams and shared decision making can improve communication, outcomes, and quality of life 1.

From the Research

Management of Elderly Patient with History of Exposure to Lightning

To manage an elderly patient with a history of exposure to lightning, several factors should be considered:

• The patient's overall health and any pre-existing medical conditions should be taken into account when assessing the severity of the lightning injury 2.
• The risk of cardiac, muscular, and sensory disturbances, as well as keraunographic skin markings, should be evaluated, as these are common sequelae of lightning injuries 3, 4.
• A thorough evaluation, including hospitalization if warranted, is necessary to rule out any secondary injuries that may require expedient care 2.
• In the absence of a cardiac arrest or serious secondary injury, care for the lightning strike victim is generally supportive in nature 2.
• Prolonged cardiopulmonary resuscitation may be necessary in some cases, and on-the-spot advanced life support, hypothermia, and a moderate rehydration policy may contribute to a successful resuscitation 5.

Long-term Complications

• The majority of patients who survive lightning injuries do not suffer from long-term complications, and the overall outcome is more favorable than generally reported 3.
• However, some patients may experience residual neurologic, ocular, oto-vestibular, or psychological deficits, and these should be assessed and managed accordingly 3, 4.
• It is essential to note that lightning injuries can cause permanent sequelae and disability, and patients should be monitored and treated accordingly 6.