Lightning injuries

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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.
  • May cause penetrating injuries[2]

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[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

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

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

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

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

See Also

References

  1. 1.0 1.1 Gatewood M, Zane R. Lightning injuries. Emery Med Clin N Am. 2004; 22: 369-403
  2. Waes. O et al. "Thunderstruck": Penetrating Thoracic Injury From Lightning Strike. Annals of Emergency Medicine. 63(4). 2014. 457-458
  3. Cooper M. et al. Blumenthal R: Lightning Injuries. Auerbach PS ed: Wilderness Medicine, 6th ed. Philadelphia: Elsevier/Mosby; 2012