Lightning injuries: Difference between revisions
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===Injury Mechanisms<ref name="gatewood">Gatewood M, Zane R. Lightning injuries. Emery Med Clin N Am. 2004; 22: 369-403</ref>=== | ===Injury Mechanisms<ref name="gatewood">Gatewood M, Zane R. Lightning injuries. Emery Med Clin N Am. 2004; 22: 369-403</ref>=== | ||
*Direct effect of electrical current on body | |||
*Electrical to thermal conversion of energy causing superficial and deep burns | |||
*Direct strike = patient is hit directly by lightning current | *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> | **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 | *Splash Injury = current "splashes" to the patient from another object which is struck first | ||
*Conduction = patient is in | *Conduction = patient is in contact with an object (e.g. metal fence, tree) 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 | *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 | ||
**Most common mechanism of injury | |||
*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. | *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. | ||
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==Clinical Features== | ==Clinical Features== | ||
[[File:PMC5253516 icrp a 1275646 f0001 c.png|thumb|Superficial second degree burn from lightning injury.]] | |||
[[File:PMC4763624 IJD-61-109-g002.png|thumb|Lichtenberg figure.]] | |||
[[File:PMC4891493 CCR3-4-618-g001.png|thumb|Patterned charring along the contact points of a metallic locket due to lightning strike.]] | |||
[[File:PMC3350295 CRIM.OPHMED2011-724395.003.png|thumb|Lightning-induced cataract.]] | |||
[[File:PerforationTympan.jpg|thumb|Perforated TM]] | |||
''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 | ||
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*[[Seizure]], LOC, confusion, amnesia, extremity paralysis | *[[Seizure]], LOC, confusion, amnesia, extremity paralysis | ||
*Pupillary dilation or anisocoria may occur that is unrelated to brain injury | *Pupillary dilation or anisocoria may occur that is unrelated to brain injury | ||
* | **Neuroprognostication should not be based on dilated pupils alone in setting of lightning strike<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361158/</ref> | ||
*Keraunoparalysis - neuromuscular "stunning" that usually resolves spontaneously within hours | |||
**Thought of as a neurologic phenomenon but actually result of arterial vasospasm from catecholamine release | |||
===Vascular=== | ===Vascular=== | ||
*Vasomotor spasm may cause loss of distal pulses, coolness of extremities, loss of sensation | *Vasomotor spasm may cause loss of distal pulses, coolness of extremities, loss of sensation | ||
* | *Keraunoparalysis - see above | ||
===Ocular=== | ===Ocular=== | ||
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===Auditory=== | ===Auditory=== | ||
*Blast effect producing [[Tympanic Membrane Rupture]] is relatively common | *Blast effect producing [[Tympanic Membrane Rupture]] is relatively common | ||
===Derm=== | ===Derm=== | ||
*Lichtenberg figures (ferning pattern) - pathognomonic for lightning strike | *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 leading to extravasation of RBC's, not a true burn; disappear within 24hr | ||
*Flash burns | *Flash burns | ||
**Similar to those found in arc welders; appear as mild erythema, may involve cornea | **Similar to those found in arc welders; appear as mild erythema, may involve cornea | ||
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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 | ||
===Ortho=== | ===Ortho=== | ||
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===Special Populations=== | ===Special Populations=== | ||
*50% of pregnancies have fetal demise | *50% of pregnancies have fetal demise, though literature is sparse<ref>Galster K et al. Lightning Strike in Pregnancy With Fetal Injury. Wilderness and Environmental Medicine. June 2016. Volume 27, Issue 2, Pages 287–290.</ref> | ||
**Third trimester appears to carry the greatest risk of adverse outcomes | |||
**Most surviving fetuses have no long term morbidity when carried to term | |||
**Any lightning strikes in pregnancy requires fetal monitoring, comprehensive testing in-hospital performed by Ob/Gyn | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*[[Blast injury]] | *[[Blast injury]] | ||
{{Burn DDX}} | |||
==Evaluation== | ==Evaluation== | ||
===Work-Up=== | ===Work-Up=== | ||
* | *Exposure: complete and thorough physical exam head to toe | ||
*[[ECG]] | *[[ECG]] | ||
*CT | *CBC | ||
*Chem | |||
*Total CK | |||
*[[UA]] - to evaluate for myoglobinuria | |||
*[[CT brain]] (for patients with [[coma]], [[altered mental status]], confusion) | |||
*Other imaging and workup is directed toward visible or suspected injuries | *Other imaging and workup is directed toward visible or suspected injuries | ||
===Diagnosis=== | |||
*Clinical diagnosis | |||
==Management== | ==Management== | ||
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**[[Hypotension]] is not an expected finding (i.e. suggests traumatic blood loss) | **[[Hypotension]] is not an expected finding (i.e. suggests traumatic blood loss) | ||
**Maintain cervical spine precautions | **Maintain cervical spine precautions | ||
**Targeted Temperature Management between 32 and 36 degrees Celsius shown to be neuroprotective in setting of hypoxic ischemic encephalopathy after cardiac arrest | |||
==Disposition== | ==Disposition== | ||
*Admit patients with persistent muscle pain or neuro, cardiac rhythm or vascular abnormalities | *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 | *Dishcarged patients require follow up to assess for delayed effects of lightning injury | ||
Revision as of 14:31, 15 June 2019
Background
- Second most common storm-related injury
- Approximately 30 million ground strikes per year
Injury Mechanisms[1]
- Direct effect of electrical current on body
- Electrical to thermal conversion of energy causing superficial and deep burns
- 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 contact with an object (e.g. metal fence, tree) 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
- Most common mechanism of injury
- 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
- Neuroprognostication should not be based on dilated pupils alone in setting of lightning strike[4]
- Keraunoparalysis - neuromuscular "stunning" that usually resolves spontaneously within hours
- Thought of as a neurologic phenomenon but actually result of arterial vasospasm from catecholamine release
Vascular
- Vasomotor spasm may cause loss of distal pulses, coolness of extremities, loss of sensation
- Keraunoparalysis - see above
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 leading to extravasation of RBC's, not a 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
Ortho
- Compartment Syndrome and rhabdomyolysis are unlikely due to short duration of lightning current
Special Populations
- 50% of pregnancies have fetal demise, though literature is sparse[5]
- Third trimester appears to carry the greatest risk of adverse outcomes
- Most surviving fetuses have no long term morbidity when carried to term
- Any lightning strikes in pregnancy requires fetal monitoring, comprehensive testing in-hospital performed by Ob/Gyn
Differential Diagnosis
Burns
- Smoke inhalation injury (airway compromise)
- Chemical injury
- Acrolein
- Hydrochloric acid
- Tuolene diisocyanate
- Nitrogen dioxide
- Systemic chemical injury
- Specific types of burns
- Associated toxicities
Evaluation
Work-Up
- Exposure: complete and thorough physical exam head to toe
- ECG
- CBC
- Chem
- Total CK
- UA - to evaluate for myoglobinuria
- CT brain (for patients with coma, altered mental status, confusion)
- Other imaging and workup is directed toward visible or suspected injuries
Diagnosis
- Clinical diagnosis
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
- Targeted Temperature Management between 32 and 36 degrees Celsius shown to be neuroprotective in setting of hypoxic ischemic encephalopathy after cardiac arrest
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
- ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361158/
- ↑ Galster K et al. Lightning Strike in Pregnancy With Fetal Injury. Wilderness and Environmental Medicine. June 2016. Volume 27, Issue 2, Pages 287–290.