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Abstract:Thunderstorms and lightning are uncommon in the Arabian Gulf. Lightning is a giant spark ofelectricity in the atmosphere or between atmosphere and ground. Most frequently fatalities afterthe lightning injury are due to direct lightning strike and cardiorespiratory arrest. It is essentialthat acute care physicians as well as paramedical personnel are aware of lightning injury and itsmanagement. This is a case of a field worker who was struck by lightning while working, whichled to a cardiorespiratory arrest.A young male was brought to the emergency room with a history of having been struck bylightning while he was at work in the desert on a roadside project in a thunderstorm. Thelightning injury was witnessed by his colleagues and they started immediate basic life supportwhen they found him unconscious without a pulse. He was intubated, ventilated and started onvasopressors in the nearest primary health centre. He was then transferred to an intensive careunit. He was weaned off vasopressors and ventilation by day four and was extubated thentransferred to the ward and subsequently discharged home.Awareness of the danger posed by lightning injury is essential. Early life support is important forbetter outcome of lightning induced cardiorespiratory arrest.Keywords: lightning injury; cardiorespiratory arrest basic and advanced cardiac life supportIntroductionLightning injuries are the third most common cause of weather-related casualties in the UnitedStates1 but rare in the Middle East. These injuries occur as a result of direct strike, contact injury,side splash, ground current, or an upward streamer. It is commonly associated with a mild tosevere burn and cardiorespiratory arrest is the frequent cause of death. Twenty per cent oflightning strike patients die at the scene.2 The majority of deaths are due to cardiac arrest.3 Toimprove the outcome, it is essential to provide immediate basic or advanced life support to thesepatients at the scene. This is a case of lightning injury which resulted in cardiorespiratory arrestat the scene and immediate life support lead to a positive outcome.Case reportA 24 year old male patient was brought to the emergency department with a history of havingbeen struck by lightning while he was working on a road project in the desert during athunderstorm. One of his co-workers witnessed the lightning strike and found him unconsciouswithout any pulse or breathing. He immediately started basic life support and then transportedthe patient to the nearest primary health center within five minutes away. In the primary healthcentre, he was unconscious, hypotensive with palpable pulse. He was intubated and started ondopamine 7 mcg/kg/minute and transferred to the tertiary care hospital.On arrival at the hospital, his heart rate (HR) was 122 beats/minute with no arrhythmia, oxygensaturation was 99 per cent on the ventilator with fraction inspired oxygen (Fio2) of 0.4, andblood pressure was 113/56 mm Hg. He was localizing to pain with pupils equal and reacting tolight. He had 25 per cent superficial to deep burns, on his shoulders, arm and upper chest. Hiselectrocardiogram (ECG) was normal but he had a rupture of the right tympanic membrane. Hewas then transferred to the surgical intensive care unit (SICU).In SICU he was connected to a ventilator, started on daily required intravenous fluid, anti-ulcerprophylaxis and flamazine ointment and given local dressing for his burn. His ECG was normal,but his cardiac biomarkers and lactate levels were elevated (Figure 1). He remainedhemodynamically stable with the same dose of dopamine. On day two after a sedation vacation,he was able to obey simple commands and capable of moving all his limbs. He was weaned offdopamine by day three and weaned from the ventilator and extubated by day four. He was ontramadol and paracetamol for analgesia and a high caloric/high protein diet. He was transferredto the burns unit on day seven and discharged home on day ten. After a year, burns on hissternum were keloid and he underwent excision under anesthesia.DiscussionThunderstorm and lightning injuries are rare events in the Arabian desert. Cardiorespiratoryarrest is the immediate cause of death in lightning injury patients. Awareness of lightninginjuries and the early need for basic or advanced life support will improve morbidity andmortality of these patients. There is insufficient evidence on lightning injury andcardiorespiratory arrest.Lightning injuries as well as fatalities are reduced in United States of America (USA) but remaina public health concern in the developing countries. In USA the lightning fatalities have droppedto less than 0.3 per million population, but has remained high in Africa and South AsiancountriesCommonly ligthning strikes young males and they are 5.5 times more at risk of lightning injury.In the USA, two thirds of lightning victims were enjoying water related leisure activities whenlightning struck whereas in Africa and South Asian countries, lightning fatalities are high amongthe manual agriculture field workersRisk of lightning injury is increased when individuals are unaware that open areas are unsafeduring a thunderstorm and a failure to understand that lightning poses a real danger. It is acommon belief that nothing attracts lightning but isolation, height and narrowness of objects arerisk factors for being struck by lightning. Two factors relevant to humans include cell phone/iPod use which puts the user at risk of lightning injury as these electronic devices distract theattention of the user during thunderstorms. Landline phone users are also at risk of lightninginjury as the hard wires to these devices act as a conduit for the lightning charge to enter and exitfrom the structures. Manual labourers working in open fields or individuals playing golf duringa thunderstorm are also at risk of lightning injury.Lightning injuries are classified into minor, moderate and severe. Loss of tympanic membraneintegrity and amnesia are minor injuries. Motor weakness, seizures and coma are consideredmoderate injuries whereas severe lightning injuries can cause cardiorespiratory arrest andhypoxic brain injury.Lightning causes mild to moderate burns, as the contact period is brief. It can cause tympanicmembrane rupture due to barotrauma. Cardiorespiratory arrest can be primary due to thelightning injury and usually these patients die. Secondary cardiorespiratory arrest, followinglighting injury can also occur due to paralysis of respiratory centers in the brain, causing hypoxiaand cardiac arrest. This can occur even if the heart regains spontaneous circulation but the patientremains apneic. Lighting injuries rarely can cause severe stunned myocardium.Lightning injury can be diagnosed by the history of being struck by lightning. Occasionally,there can be a triad of arboreal burns, Lichtenberg figures; and a disheveled appearance of thepatient. Patients may be confused or amnestic. Severe lightning injury patients may present withcardiorespiratory arrest. All patients with a history of a lightning injury should be evaluated fortympanic membrane integrity. Ophthalmological examination should also discover visual acuityand early cataract.Severe lightning injury patients should be evaluated for any electrolyte abnormality, completeblood count and cardiac biomarker levels. All these patients should have 12 lead ECG andcontinuous ECG monitoring. Radiological evaluation depends on the severity of the injuries andpatient presentation. If the patient is hypotensive, presence of secondary injuries should beevaluated.Lightning injuries should be differentiated from high voltage electrical injuries. In high voltageelectrical injuries, commonly there will be entry and exist wounds, marked muscle injury,rhabdomyolysis and renal impairment or failure; there will be no tympanic membrane injury.In the management of lightning injuries airway control is necessary including, breathingassistance, restoration of circulation, evaluation of disabilities and calculation of burn surfacearea.Cardiorespiratory resuscitation must be started as early as possible, preferably at the scene of thelightning. As the risk of secondary cardiac arrest is high, resuscitation should be continued untilthe airway is secured and ventilation is assisted.11 Prevention is the best means of safety againstlightning injuries. Optimal prevention is dictated by the proverb “when thunder roars, goindoors!”During a thunderstorm one should move away from towers/tall buildings, avoid shelter under atree, avoid open fields, hill or ridge tops. Additionally, one should avoid water, wet items, metalobjects and if camping in an open area, set up camp in a low area or in a valley. If indoors, stayoff corded phones, do not touch electric instruments, avoid plumbing, do not wash hands, takeshower or wash dishes and do not lie on concrete floors or lean against concrete walls.Lightning may result in permanent disabilities due to cataract, neuropathies, deafness andsympathetic instability. Reported mortality in lightning injury is 0-32 per cent. Prognoses ispoor if the patient has leg burns, cranial burns and or cardiopulmonary arrest.ConclusionCardiorespiratory arrest is an immediate cause of death in lightning injury patients. Lightninginjuries are common in males and 25 per cent of these injuries occur while working outsideduring a thunderstorm. The primary risk factor for a lightning injury is being unaware of thedanger of lightning injuries. Cardiorespiratory arrest in lightning injury patients could beprimarily due to a massive lightning injury or secondary due to paralysis of respiratory centers.Earlier cardiopulmonary resuscitation is the key for a better outcome. Prevention of lightninginjuries can be dictated by the proverb “when thunder roars, go indoors!”.
