Lightning injuries: Difference between revisions
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==Background== | ==Background== | ||
*Second most common storm-related injury | |||
*Approximately 30 million ground strikes per year | |||
* | |||
=== | ===Injury Mechanisms<ref name="gatewood">Gatewood M, Zane R. Lightning injuries. Emery Med Clin N Am. 2004; 22: 369-403</ref>=== | ||
* | *Direct strike = patient is hit directly by lightning current | ||
= | **Often fatal and may cause penetrating injuries<ref>Waes. O et al. "Thunderstruck": Penetrating Thoracic Injury From Lightning Strike. Annals of Emergency Medicine. 63(4). 2014. 457-458</ref> | ||
*Splash Injury = current "splashes" to the patient from another object which is struck first | |||
*Conduction = patient is in content with an object (e.g. metal fence) that is struck by lightning | |||
*Ground current = Also known as step voltage. Occurs when the current spreads out from the initial strike point and then travels through the patient's body | |||
*Blunt Trauma = Secondary injury pattern that results when the lightning causes a wave of force to propagate through the air to the patient or as a secondary object strikes the patient. | |||
==Prehospital== | ===Prehospital Care=== | ||
* | *'''Reverse triage''' = in lightning-related MCI cases, care should be delivered to patients in cardiac arrest first | ||
**Patients struck by lightning who are alive on EMS arrival will likely survive<ref name="gatewood" /> | |||
**Patients | *All patients should be transported, preferably to a burn center | ||
*Consider spinal precautions in all patients | |||
*All patients | |||
* | |||
==Clinical Features== | ==Clinical Features== | ||
*Injuries often involve multiple organ systems | *Injuries often involve multiple organ systems<ref>Cooper M. et al. Blumenthal R: ''Lightning Injuries''. Auerbach PS ed: ''Wilderness Medicine'', 6th ed. Philadelphia: Elsevier/Mosby; 2012</ref> | ||
===Cardiopulmonary=== | ===Cardiopulmonary=== | ||
*Both cardiac and respiratory arrest may be present without evidence of external injury | *Both cardiac and respiratory arrest may be present without evidence of external injury | ||
*Ventricular dysrhythmias, asystole, and [[QT prolongation]] most common | *Ventricular dysrhythmias, asystole, and [[QT prolongation]] most common | ||
*Although cardiac automaticity may spontaneously return, apnea may persist | *Although cardiac automaticity may spontaneously return, apnea may persist | ||
*Duration of apnea rather than cardiac arrest is the critical prognostic factor | **Duration of apnea rather than cardiac arrest is the critical prognostic factor | ||
*Myocardial infarction after lightning injury is unusual | *Myocardial infarction after lightning injury is unusual | ||
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===Vascular=== | ===Vascular=== | ||
*Vasomotor spasm may cause loss of | *Vasomotor spasm may cause loss of distal pulses, coolness of extremities, loss of sensation | ||
*''Keraunoparalysis'' - temporary paralysis due to sympathetic nervous system activation and vascular spasm | *''Keraunoparalysis'' - temporary paralysis due to sympathetic nervous system activation and vascular spasm | ||
**Resolves spontaneously | **Resolves spontaneously | ||
**Compartment syndrome is rarely the cause (skeletal muscle unaffected in strikes) | **Compartment syndrome is rarely the cause (skeletal muscle unaffected in strikes) | ||
===Ocular=== | ===Ocular=== | ||
*Cataracts may occur | *Cataracts may occur weeks to years after injury (must document careful eye exam in all patients) | ||
*Other injuries include vitreous hemorrhage, corneal abrasion, retinal detachment | *Other injuries include vitreous hemorrhage, corneal abrasion, retinal detachment | ||
===Auditory=== | ===Auditory=== | ||
*Blast effect producing [[Tympanic Membrane Rupture]] is relatively common | *Blast effect producing [[Tympanic Membrane Rupture]] is relatively common | ||
[[File:PerforationTympan.jpg| | |||
[[File:PerforationTympan.jpg|thumb|Perforated TM]] | |||
===Derm=== | ===Derm=== | ||
*Lichtenberg figures (ferning pattern) | *Lichtenberg figures (ferning pattern) - pathognomonic for lightning strike | ||
**Occur due to electron showering over the skin, not true burn; disappear within 24hr | **Occur due to electron showering over the skin, not true burn; disappear within 24hr | ||
*Flash burns | *Flash burns | ||
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*Contact burns | *Contact burns | ||
**Occur when metal close to the skin is heated from the lightning current | **Occur when metal close to the skin is heated from the lightning current | ||
[[File:Lightning injury (1).jpg|thumb]] | |||
===Neuro=== | ===Neuro=== | ||
*Keraunoparalysis - a neurologic and muscular "stunning" that can follow lightning strikes and usually resolves. It is thought of as a neurologic phenomenon but is a result of arterial vasospasm from catecholamine release. It will resolve within hours. | *Keraunoparalysis - a neurologic and muscular "stunning" that can follow lightning strikes and usually resolves spontaneously. It is thought of as a neurologic phenomenon but is a result of arterial vasospasm from catecholamine release. It will resolve within hours. | ||
**Limb weakness, sensory abnormalities, absent pulses, cold temperature extremities | **Limb weakness, sensory abnormalities, absent pulses, cold temperature extremities | ||
===Ortho=== | ===Ortho=== | ||
*[[Compartment Syndrome]] and [[rhabdomyolysis]] are | *[[Compartment Syndrome]] and [[rhabdomyolysis]] are unlikely due to short duration of lightning current | ||
=== | ===Special Populations=== | ||
*50% of pregnancies have fetal demise{{Citation needed|reason=Reliable source needed|date=February 2016}} | *50% of pregnancies have fetal demise{{Citation needed|reason=Reliable source needed|date=February 2016}} | ||
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==Evaluation== | ==Evaluation== | ||
Clinical diagnosis | *Clinical diagnosis | ||
===Work-Up=== | ===Work-Up=== | ||
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*[[ECG]] | *[[ECG]] | ||
*CT Brain(for patients with coma, altered mental status, confusion) | *CT Brain(for patients with coma, altered mental status, confusion) | ||
*Other imaging is directed toward visible or suspected injuries | *Other imaging and workup is directed toward visible or suspected injuries | ||
==Management== | ==Management== | ||
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<references/> | <references/> | ||
[[Category:Environmental]][[Category:EMS]] | [[Category:Environmental]] | ||
[[Category:EMS]] | |||
[[Category:Trauma]] | [[Category:Trauma]] | ||
Revision as of 00:02, 25 December 2016
Background
- Second most common storm-related injury
- Approximately 30 million ground strikes per year
Injury Mechanisms[1]
- Direct strike = patient is hit directly by lightning current
- Often fatal and may cause penetrating injuries[2]
- Splash Injury = current "splashes" to the patient from another object which is struck first
- Conduction = patient is in content with an object (e.g. metal fence) that is struck by lightning
- Ground current = Also known as step voltage. Occurs when the current spreads out from the initial strike point and then travels through the patient's body
- Blunt Trauma = Secondary injury pattern that results when the lightning causes a wave of force to propagate through the air to the patient or as a secondary object strikes the patient.
Prehospital Care
- Reverse triage = in lightning-related MCI cases, care should be delivered to patients in cardiac arrest first
- Patients struck by lightning who are alive on EMS arrival will likely survive[1]
- All patients should be transported, preferably to a burn center
- Consider spinal precautions in all patients
Clinical Features
- Injuries often involve multiple organ systems[3]
Cardiopulmonary
- Both cardiac and respiratory arrest may be present without evidence of external injury
- Ventricular dysrhythmias, asystole, and QT prolongation most common
- Although cardiac automaticity may spontaneously return, apnea may persist
- Duration of apnea rather than cardiac arrest is the critical prognostic factor
- Myocardial infarction after lightning injury is unusual
Neuro
- Symptoms are usually immediate and transient or delayed and permanent
- Seizure, LOC, confusion, amnesia, extremity paralysis
- Pupillary dilation or anisocoria may occur that is unrelated to brain injury
- Cannot neuroprognosticate anyone for 24hrs based on pupils[citation needed]
Vascular
- Vasomotor spasm may cause loss of distal pulses, coolness of extremities, loss of sensation
- Keraunoparalysis - temporary paralysis due to sympathetic nervous system activation and vascular spasm
- Resolves spontaneously
- Compartment syndrome is rarely the cause (skeletal muscle unaffected in strikes)
Ocular
- Cataracts may occur weeks to years after injury (must document careful eye exam in all patients)
- Other injuries include vitreous hemorrhage, corneal abrasion, retinal detachment
Auditory
- Blast effect producing Tympanic Membrane Rupture is relatively common
Derm
- Lichtenberg figures (ferning pattern) - pathognomonic for lightning strike
- Occur due to electron showering over the skin, not true burn; disappear within 24hr
- Flash burns
- Similar to those found in arc welders; appear as mild erythema, may involve cornea
- Punctate burns
- Look similar to cigarette burns; are full-thickness
- Contact burns
- Occur when metal close to the skin is heated from the lightning current
.jpg)
Neuro
- Keraunoparalysis - a neurologic and muscular "stunning" that can follow lightning strikes and usually resolves spontaneously. It is thought of as a neurologic phenomenon but is a result of arterial vasospasm from catecholamine release. It will resolve within hours.
- Limb weakness, sensory abnormalities, absent pulses, cold temperature extremities
Ortho
- Compartment Syndrome and rhabdomyolysis are unlikely due to short duration of lightning current
Special Populations
- 50% of pregnancies have fetal demise[citation needed]
Differential Diagnosis
Evaluation
- Clinical diagnosis
Work-Up
- CBC, chem, total CK, UA
- ECG
- CT Brain(for patients with coma, altered mental status, confusion)
- Other imaging and workup is directed toward visible or suspected injuries
Management
- Aggressive resuscitation
- Lightning-induced Cardiac Arrest has better prognosis than CAD-induced Cardiac Arrest
- Hypotension is not an expected finding (i.e. suggests traumatic blood loss)
- Maintain cervical spine precautions
Disposition
- Admit patients with persistent muscle pain or neuro, cardiac rhythm or vascular abnormalities
- Dishcarged patients require follow up to assess for delayed effects of lightning injury
See Also
References
- ↑ 1.0 1.1 Gatewood M, Zane R. Lightning injuries. Emery Med Clin N Am. 2004; 22: 369-403
- ↑ Waes. O et al. "Thunderstruck": Penetrating Thoracic Injury From Lightning Strike. Annals of Emergency Medicine. 63(4). 2014. 457-458
- ↑ Cooper M. et al. Blumenthal R: Lightning Injuries. Auerbach PS ed: Wilderness Medicine, 6th ed. Philadelphia: Elsevier/Mosby; 2012