Lightning injuries: Difference between revisions
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==Background== | ==Background== | ||
* | There are 5 major means of injury from a lightning strike (direct, splash, contact, ground current, blunt trauma)<ref name= | ||
** | gatewood">Gatewood M, Zane R. Lightning injuries. Emery Med Clin N Am. 2004; 22: 369-403</ref> | ||
*[[ | ===Direct Strike=== | ||
*Keraunoparalysis | *Most often a fatal injury and occurs when the patient is hit with the lightning current. | ||
* | ===Splash Injury=== | ||
* | *Occurs when the current "splashes" to the patient from another object which was struck first | ||
===Contact=== | |||
*Occurs when the patient is in content with an object that is struck by lightning | |||
===Ground Current=== | |||
*This is also known as step voltage and occurs when the current spreads out from the initial strike point and then travels through the patient's body | |||
===Blunt Trauma=== | |||
*This is a secondary injury 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== | |||
*Emphasis is on early scene safety to prevent bystander and rescuer injury | |||
*Patients with lightning injuries who appear to be dead should be treated FIRST at the scene.''' ("Resuscitate the Dead")''' | |||
**If the patient does not suffer an immediate cardiac or respiratory arrest they have a good chance of survival<ref name="gateway"></ref> | |||
*Emphasize early bystander CPR | |||
*[[ACLS (Main)]] - Initial cardiac, respiratory monitoring and rhythm analysis for defibrillation. | |||
*Fixed and dilated pupils do not indicate brain death. This can result from from Keraunoparalysis | |||
*All patients require transport and [[Burns|burn patients]] should go to a Burn Center. | |||
*Spinal precautions should be applied to all victims since the strike can produce violent muscle contractions even if there is not fall history. | |||
==Affected Systems== | ==Affected Systems== | ||
*Injuries often involve multiple organ systems in patients who survive<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 | ||
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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 | ||
===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. | |||
**Limb weakness, sensory abnormalities, absent pulses, cold temperature extremities | |||
===Ortho=== | |||
*[[Compartment Syndrome]] and [[rhabdo]] are also common depending on the trajectory of the current | |||
==Work-Up== | ==Work-Up== | ||
*CBC, chem, total CK, UA | *CBC, chem, total CK, UA | ||
*ECG | *ECG | ||
*CT (for coma, AMS, confusion) | *CT Brain(for patients with coma, AMS, confusion) | ||
*Other imaging is directed toward visible or suspected injuries | |||
==Treatment== | ==Treatment== | ||
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*[[Electrical Injuries]] | *[[Electrical Injuries]] | ||
== | ==Sources== | ||
<references/> | |||
[[Category:Environ]] | [[Category:Environ]][[Category:EMS]] | ||
[[Category:Trauma]] | [[Category:Trauma]] | ||
Revision as of 21:19, 2 April 2015
Background
There are 5 major means of injury from a lightning strike (direct, splash, contact, ground current, blunt trauma)[1]
Direct Strike
- Most often a fatal injury and occurs when the patient is hit with the lightning current.
Splash Injury
- Occurs when the current "splashes" to the patient from another object which was struck first
Contact
- Occurs when the patient is in content with an object that is struck by lightning
Ground Current
- This is also known as step voltage and occurs when the current spreads out from the initial strike point and then travels through the patient's body
Blunt Trauma
- This is a secondary injury 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
- Emphasis is on early scene safety to prevent bystander and rescuer injury
- Patients with lightning injuries who appear to be dead should be treated FIRST at the scene. ("Resuscitate the Dead")
- If the patient does not suffer an immediate cardiac or respiratory arrest they have a good chance of survival[2]
- Emphasize early bystander CPR
- ACLS (Main) - Initial cardiac, respiratory monitoring and rhythm analysis for defibrillation.
- Fixed and dilated pupils do not indicate brain death. This can result from from Keraunoparalysis
- All patients require transport and burn patients should go to a Burn Center.
- Spinal precautions should be applied to all victims since the strike can produce violent muscle contractions even if there is not fall history.
Affected Systems
- Injuries often involve multiple organ systems in patients who survive[3]
Cardiopulmonary
- Both cardiac and respiratory arrest may be present without evidence of external injury
- 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
Vascular
- Vasomotor spasm may cause loss of pulse, 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 wks-yrs after injury (must document careful eye exam in all pts)
- 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 w/in 24hr
- Flash burns
- Similar to those found in arc welders; appear as mild erythema, may involve cornea
- Punctate burns
- Look similar to ciagarette burns; are full-thickness
- Contact burns
- Occur when metal close to the skin is heated from the lightning current
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.
- Limb weakness, sensory abnormalities, absent pulses, cold temperature extremities
Ortho
- Compartment Syndrome and rhabdo are also common depending on the trajectory of the current
Work-Up
- CBC, chem, total CK, UA
- ECG
- CT Brain(for patients with coma, AMS, confusion)
- Other imaging is directed toward visible or suspected injuries
Treatment
- 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)
Disposition
- Admit pts w/ persistent muscle pain or neuro, cardiac rhythm or vascular abnormalities
- Dishcarged pts require f/u to assess for delayed effects of lightning injury