Lightning injuries: Difference between revisions
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*Emphasis is on early scene safety to prevent bystander and rescuer injury | *Emphasis is on early scene safety to prevent bystander and rescuer injury | ||
*Triage is the reverse of triage for [[Mass_casualty_incident_triage|Mass Casualty Incidents]] with focus on the patients in cardiac arrest first. | *Triage is the reverse of triage for [[Mass_casualty_incident_triage|Mass Casualty Incidents]] with focus on the patients in cardiac arrest first. | ||
*Patients with lightning injuries who | **Patients with lightning injuries who are in cardiac arrest should be treated FIRST.''' ("Resuscitate the Dead")''' | ||
**If the patient does not suffer an immediate cardiac or respiratory arrest they have a good chance of survival<ref name="gatewood"></ref> | **If the patient does not suffer an immediate cardiac or respiratory arrest they have a good chance of survival<ref name="gatewood"></ref> | ||
*Emphasize early bystander CPR | *Emphasize early bystander CPR | ||
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===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 | ||
*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=== | ===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=== | ===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=== | ===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=== | ===Auditory=== | ||
*Blast effect producing [[Tympanic Membrane Rupture]] is relatively common | |||
===Derm=== | ===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=== | ===Neuro=== | ||
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==Diagnosis== | ==Diagnosis== | ||
Clinical diagnosis, based on H&P. | |||
===Work-Up=== | ===Work-Up=== | ||
*CBC, chem, total CK, UA | *CBC, chem, total CK, UA | ||
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*Aggressive resuscitation | *Aggressive resuscitation | ||
**Lightning-induced [[Cardiac Arrest]] has better prognosis than CAD-induced [[Cardiac Arrest]] | **Lightning-induced [[Cardiac Arrest]] has better prognosis than CAD-induced [[Cardiac Arrest]] | ||
*[[Hypotension]] is not an expected finding (i.e. suggests traumatic blood loss) | **[[Hypotension]] is not an expected finding (i.e. suggests traumatic blood loss) | ||
==Disposition== | ==Disposition== | ||
Revision as of 06:59, 20 June 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
- Triage is the reverse of triage for Mass Casualty Incidents with focus on the patients in cardiac arrest first.
- Patients with lightning injuries who are in cardiac arrest should be treated FIRST. ("Resuscitate the Dead")
- If the patient does not suffer an immediate cardiac or respiratory arrest they have a good chance of survival[1]
- 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.
Clinical Presentation
- Injuries often involve multiple organ systems in patients who survive[2]
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
Differential Diagnosis
Diagnosis
Clinical diagnosis, based on H&P.
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