Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – basic life support, cervical immobilization, and transfer to ED

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ACUTE
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all patients
1st line – 

basic life support, cervical immobilization, and transfer to ED

Prior to determining the patient's cardiorespiratory status, the rescuer must first ensure that the danger of further shock has been removed to allow for a safe environment for resuscitation.[20]​​

Patients with electrical injuries require immediate airway, breathing, and circulation assessment. They should be treated as a multitrauma patient with cervical immobilization at least until the full extent of their injuries has been quantified.[19]​​

Except for cases of sudden cardiac arrest, lightning strikes generally do not result in immediate injuries that pose a threat to a person's life. This implies that patients who do not experience cardiac arrest when emergency responders arrive are unlikely to die within the next hour. Therefore, priority should be given to administering resuscitation and medical intervention to those who are presumed to be dead initially.[30]

Most patients will have no sequelae from low-voltage electrical injury in the nonindustrial setting and may be discharged following normal ECG and physical examination.

Patients with loss of consciousness, persistent ECG changes, and significant secondary injuries should be admitted to the hospital.[23] Standard supportive care is required.[19]​​

Plus – ACLS protocols

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ACUTE
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all patients
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with cardiac arrhythmias
Plus – 

ACLS protocols

Treatment recommended for ALL patients in selected patient group

Prior to determining the patient's cardiorespiratory status, the rescuer must first ensure that the danger of further shock has been removed to allow for a safe environment for assessment.[20]​​

Patients with life-threatening arrhythmias should be treated appropriately with standard ACLS protocols.[31][32]​

Patients who are at high risk, such as those with ECG changes, loss of consciousness, and/or high-voltage injuries, will still be advised to undergo 24-hour monitoring.[33]

Patients with ECG changes should be monitored for a minimum of 6 hours after injury. If the ECG is still abnormal, patients should be admitted for ongoing monitoring.[34]

Plus – consider targeted temperature control

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ACUTE
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all patients
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with cardiac arrest
Plus – 

consider targeted temperature control

Treatment recommended for ALL patients in selected patient group

In patients with cardiac arrest and secondary anoxic brain injury, targeted temperature control should be considered.[35][36]

Guidelines recommend that comatose adult patients with return of spontaneous circulation receive targeted temperature control by selecting and maintaining a constant temperature between 89.6°F and 99.5°F (32°C and 37.5°C) for at least 24 hours.[31][32]​​[37]​​​​​ 

Plus – dressing and intravenous fluid

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ACUTE
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all patients
|
with cutaneous burns
Plus – 

dressing and intravenous fluid

Treatment recommended for ALL patients in selected patient group

Cutaneous burns should be placed under cool or lukewarm running water when possible, preferably for 20 minutes.[38] Plain or mild soap can be used to cleanse minor burn wounds.

Wounds can then be covered with simple, clean dressings, not necessarily sterile. Cling film can be used as a temporary dressing which is cheap, widely available, and allows subsequent re-examination through the dressing.

Early discussion with the local burns team is required to decide if emergency surgery or transfer is required.

Intravenous fluid should be given, but there are no clear guidelines on the amount, as the "rule of nines" does not incorporate the underlying tissue damage in electrical injury.[39]​​

Fluid resuscitation is guided by blood pressure, pulse rate, urine output, level of consciousness, and central venous pressure monitoring if appropriate.

Consider – immunization

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ACUTE
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all patients
|
with cutaneous burns
Consider – 

immunization

Treatment recommended for SOME patients in selected patient group

Tetanus immunization history should be checked, with vaccination and tetanus immunoglobulin considered if the patient is not immune.​[40]

Plus – appropriate management of fractures, dislocations, and compartment syndrome

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ACUTE
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all patients
|
with extremity trauma
Plus – 

appropriate management of fractures, dislocations, and compartment syndrome

Treatment recommended for ALL patients in selected patient group

Fractures and dislocations should be appropriately managed.

The limb should be assessed for compartment syndrome, and early surgical intervention with fasciotomy/escharotomy or amputation of a nonviable extremity performed.[29][41]​​ See Compartment syndrome of extremities (Management).

Plus – intravenous fluid to maintain urine output >1 mL/kg/hour

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ACUTE
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all patients
|
with rhabdomyolysis
Plus – 

intravenous fluid to maintain urine output >1 mL/kg/hour

Treatment recommended for ALL patients in selected patient group

If rhabdomyolysis is present, intravenous fluids should be given at a rate that ensures a urine output of at least 1 mL/kg/hour.

Use of mannitol and alkalization of the urine is controversial.[42] High volumes of fluid (up to 10 L/day) are the mainstay of treatment, with the amount of fluid administered depending on the severity.[26][43]

Definitive management for cases of severe rhabdomyolysis might require renal replacement therapy.[26]​​

Plus – appropriate management of head and spinal injuries

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ACUTE
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all patients
|
with neurologic injuries
Plus – 

appropriate management of head and spinal injuries

Treatment recommended for ALL patients in selected patient group

Head and spinal injuries should have appropriate neurologic care.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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