Background
• Acts as direct current → asystole; heart’s intrinsic automaticity usually restarts in SR but CNS injury & concussion may cause respiratory arrest w/ secondary cardiac arrest
Approach
• Early & continuous cardiac monitoring for dysrhythmias
• Evaluate for concomitant trauma (fall, injury); maintain c-spine precautions
• Reverse triage in field: Lightning victims that appear dead should get CPR as pts can be pulseless w/ fixed, dilated pupils & still have good survivability
History
• Usually obvious, reported lightning strike near pt; often witnessed collapse
Findings
• TM rupture, transient vasospasm (cool ext), symp nervous system instability
• Various burn patterns
• Linear: Caused by steam production during flashover (charge passes over surface of body only) where sweat accumulates
• Punctate: Multiple cigarette-like burns
• Feathering: Not actual burns; electron showers make a ferning pattern on skin (Lichtenberg figures)
• Thermal: Usually from burnt clothing
• Ocular pathology: Corneal lesions, hyphema, vitreous hemorrhage, retinal detachment, cataracts develop long term
• Keraunoparalysis: Transient paralysis that can occur, likely 2/2 vasospasm, LE > UE, usually resolves in hours, still will need eval for true spinal cord pathology 2/2 trauma
Evaluation
• ECG, CBC, Chem 7, CK (rhabdomyolysis), UA (myoglobin), head CT if unresponsive
Treatment
• Resuscitate, eval for trauma, immobilize c-spine, continuous cardiac monitoring
• High-volume IV crystalloid (NS); same tx as electrical injury (10f)
• Urinary catheter placement: Target urine output 1–1.5 mL/kg/h (200–300 mL/h)
• If rhabdomyolysis (↑ CK, +UA dip), maintain high UOP until urine dip negative
• Treat wounds the same as thermal burns (10d), tetanus, wound care, etc.
• Splint injured extremities in best “position of fxn” to minimize contractures & edema
Disposition
• If asx & nl exam, can be discharged; good prognosis if survive in field
• ECG Δ, myoglobinuria, entry/exit burns, partial/full thickness burns: Admit to burn center
Pearl
• Lightning causes ∼50–300 deaths in US each year, 25–30% of lightning strike victims die, of those that survive ∼75% have permanent disability