Emergency Medical Services (EMS) Agency

CASE OF THE MONTH – JANUARY 2020

Case Presentation:

Paramedics respond to an apartment complex where a 13-year-old male has collapsed.  He was on a rooftop deck with other tenants when he was suddenly jolted to the ground after lightning struck the metal support beam onto which he was holding.  He was thrown approximately 10 feet.  Bystanders attempted to help him regain consciousness by shaking his shoulders, but he remained unresponsive on EMS arrival.  Approximately 6 minutes has passed from the time of the lightning strike.

This patient is in cardiac arrest secondary to a lightning strike and should be treated in accordance with TP-1210-P, Cardiac Arrest in addition to TP-1221-P, Electrocution.  High quality CPR should be initiated immediately and the patient defibrillated early if there is a shockable rhythm.

Lightning strike patients are susceptible to several types of injury, with cardiac arrest being the most common cause of sudden death.  Cardiac arrest due to a lightning strike is typically due to ventricular fibrillation or asystole.  A lightning strike can result in a massive DC current suddenly depolarizing the entire myocardium, disrupting normal cardiac conduction pathways.  Following a lightning strike, casualties are also prone to chest muscle paralysis from the electrical current.  This can result in respiratory arrest which can lead to hypoxic cardiac arrest, even if normal electrical conduction activity of the heart recovers.

Therefore, this patient must be resuscitated immediately with high quality CPR, early defibrillation if in a shockable rhythm, and airway management.  If resuscitated early, most lightning strike casualties have a good prognosis.  If there are multiple victims following a lightning strike, patients in cardiac arrest should have the highest priority for treatment as patients are triaged.  This is sometimes referred to as ‘reverse triage’.  In a mass casualty incident (MCI) due to lightning strike, patients who are not in cardiac arrest typically will do well without any immediate treatment and those in cardiac arrest, though critical, have a high chance of survival with immediate intervention.

EMS initiates CPR.  Patient is 40 kg (longer than the length-based resuscitation tape, i.e. Broselow).  The patient is in ventricular fibrillation.  After two rounds of CPR with two defibrillations and one dose of Epinephrine (0.1mg/mL) 1mg, return of spontaneous circulation (ROSC) is achieved.  Following ROSC his vital signs are BP 98/52, HR 110, RR 8, SpO2 95%.

Lightning strike victims must also be assessed for trauma.  Sustaining a lightning strike and being “thrown” secondary to an electrocution can result in traumatic injury.   All lightning strike casualties should be assessed as if they sustained a high-energy blunt trauma.  In addition, any electrocution can result in burns requiring appropriate burn care if indicated (including removal of jewelry and clothing, volume resuscitation as indicated, and pain management).  Large cutaneous burns are less common in patients with lightning strike injury, but lightning strike patients may have sizeable thermal injury if they were wearing/in contact with metal objects or their clothing/surrounding objects ignited secondary to the lightning strike, resulting in secondary burns.

A complete trauma survey is performed on the patient.  Because the patient was thrown a distance and remains unconscious, spinal motion restriction (SMR) is maintained during movement of the patient.  On secondary trauma survey, a large feather-like skin lesion (click for image) is noted on the patient’s back in addition to small circular burn marks.  The patient’s updated vital signs are BP 115/72 HR 98 RR 12 SpO2 97%.  His distal upper extremities initially appeared pale, but have regained color.  Capillary refill is < 2 seconds.

Following a lightning strike, patients may have secondary blunt trauma and must be assessed.  Pressure waves can be generated from a lightning strike and result in tympanic membrane rupture or ocular injury much like a blast injury.

In addition, skin findings can include linear, punctate or thermal burns.  Linear burns are usually small in surface area and found in areas prone to sweating because they result from vaporization of water on the skin’s surface.  Punctate burns are also common and typically less than 1 cm in diameter.  Thermal burns occur from metal touching the victim’s skin (zippers, jewelry, ignited clothing).  Feathering marks, known as “Lichtenburg figures” are not truly burns, but due to extravasation of blood into the subcutaneous tissue.  They typically last for several hours and then disappear with no long term effects and do not require treatment.

Lightning strikes can also result in muscle injury.  Extremities may initially appear cool or pale due to transient vasospasm and patients may be unable to move muscle groups transiently.

Treatment for these findings are supportive.

The patient became transiently hypotensive after initial cardiac arrest resuscitation, but blood pressure improved to 100/74 after a Normal Saline 1L bolus was administered in accordance with TP-1210-P, Cardiac Arrest.  No obvious trauma was found but SMR was maintained based on mechanism of potential injury.  Given the patient was in cardiac arrest and ROSC was achieved, per Ref. No 510, Pediatric Patient Destination, the patient was transported to the nearest Pediatric Medical Center (PMC).  Note that even though he is longer than the length based resuscitation tape and received adult dosed medications, he should be transported to the PMC because he is a pediatric patient, not likely to need immediate cardiac catheterization.  CT imaging was obtained and no significant trauma was found.  The patient was admitted to the Pediatric ICU and made a full recovery with no long term neurological sequelae.

  • Cardiac arrest following lightning strikes must be recognized and resuscitated early with high quality CPR, defibrillation, and airway management.
  • Lightning strike victims must also be treated as blunt trauma patients and have full trauma surveys performed once immediate life threats are treated.
  • Burns may present after a lightning strike, though large surface area burns are rare.  If present they should be treated in accordance with standard burn protocols.

References

  1. Ritenour AE et al.  Lightning Injury:  A Review.  Burns.  2008; 34(5): 585-594.
  2. Houk et al.  Cardiac Arrest is Special Situations:  2010 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.  Circulation.  2010; 122: S829-S861

 

 

Author:   Denise Whitfield, MD, MBA