Lightning injuries: Difference between revisions

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==Background==
==Background==
There are 5 major means of injury from a lightning strike (direct, splash, contact, ground current, blunt trauma)<ref name="
*Second most common storm-related injury
gatewood">Gatewood M, Zane R. Lightning injuries. Emery Med Clin N Am. 2004; 22: 369-403</ref>
*Approximately 30 million ground strikes per year
===Direct Strike===
*Most often a fatal injury and occurs when the patient is hit with the lightning current.
*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===
===Injury Mechanisms<ref name="gatewood">Gatewood M, Zane R. Lightning injuries. Emery Med Clin N Am. 2004; 22: 369-403</ref>===
*Occurs when the current "splashes" to the patient from another object which was struck first
*Direct effect of electrical current on body
===Contact===
*Electrical to thermal conversion of energy causing superficial and deep burns
*Occurs when the patient is in content with an object that is struck by lightning
*Direct strike = patient is hit directly by lightning current
===Ground 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>
*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
*Splash Injury = current "splashes" to the patient from another object which is struck first
===Blunt Trauma===
*Conduction = patient is in contact with an object (e.g. metal fence, tree) that is struck by lightning
*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.
*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==
===Prehospital Care===
*Emphasis is on early scene safety to prevent bystander and rescuer injury
*'''Reverse triage''' = in lightning-related MCI cases, care should be delivered to patients in [[cardiac arrest|cardiac]] and respiratory 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 struck by lightning who are alive on EMS arrival will likely survive<ref name="gatewood" />
**Patients with lightning injuries who are in cardiac arrest should be treated FIRST.''' ("Resuscitate the Dead")'''
*All patients should be transported, preferably to a burn center
**If the patient does not suffer an immediate cardiac or respiratory arrest they have a good chance of survival<ref name="gatewood"></ref>
*Consider spinal precautions in all patients
*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 [[Burns|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 Features==
==Clinical Features==
*Injuries often involve multiple organ systems in patients who survive<ref>Cooper M. et al. Blumenthal R: ''Lightning Injuries''. Auerbach PS ed: ''Wilderness Medicine'', 6th ed. Philadelphia: Elsevier/Mosby; 2012</ref>
[[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 arrest|cardiac]] and [[respiratory failure|respiratory arrest]] may be present without evidence of external injury
*Ventricular dysrhythmias, asystole, and QT prolongation most common
*[[Ventricular dysrhythmias]], [[asystole]], and [[QT prolongation]] most common
*Although cardiac automaticity may spontaneously return, apnea may persist
*Although cardiac automaticity may spontaneously return, apnea may persist
*Duration of apnea rather than cardiac arrest is the critical prognostic factor
**Duration of apnea rather than cardiac arrest is the critical prognostic factor
*Myocardial infarction after lightning injury is unusual
*[[Myocardial infarction]] after lightning injury is unusual


===Neuro===
===Neuro===
*Symptoms are usually immediate and transient or delayed and permanent
*Symptoms are usually immediate and transient or delayed and permanent
*[[Seizure]], LOC, confusion, amnesia, extremity paralysis
*[[Seizure]], [[syncope|LOC]], [[confusion]], amnesia, extremity [[weakness|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
*Cannot neuroprognosticate anyone for 24hrs based on pupils{{Citation needed|reason=Reliable source needed|date=February 2016}}
**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 pulse, coolness of extremities, loss of sensation
*Vasomotor spasm may cause loss of distal pulses, coolness of extremities, [[numbness|loss of sensation]]
*''Keraunoparalysis'' - temporary paralysis due to sympathetic nervous system activation and vascular spasm
*Keraunoparalysis - see above
**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 patients)
*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
*Other injuries include [[vitreous hemorrhage]], [[corneal abrasion]], [[retinal detachment]]
 
===Auditory===
===Auditory===
*Blast effect producing [[Tympanic Membrane Rupture]] is relatively common
*Blast effect producing [[Tympanic Membrane Rupture]] is relatively common
[[File:PerforationTympan.jpg|150px|Perforated TM]]


===Derm===
===Derm===
*Lichtenberg figures (ferning pattern)
*Lichtenberg figures (ferning pattern) - pathognomonic for lightning strike
**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
[[File:Lightning injury (1).jpg|150px]]
*Flash [[burns]]
**Occur due to electron showering over the skin, not true burn; disappear within 24hr
*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
*Punctate burns
*Punctate burns
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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
===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===
===Ortho===
*[[Compartment Syndrome]] and [[rhabdomyolysis]] are less likely as lightning duration much less than electrocution injury
*[[Compartment Syndrome]] and [[rhabdomyolysis]] are unlikely due to short duration of lightning current
*Associated with [[posterior shoulder dislocation]]


===Pregnancy===
===Special Populations===
*50% of pregnancies have fetal demise{{Citation needed|reason=Reliable source needed|date=February 2016}}
*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==
Clinical diagnosis, based on H&P
===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


===Work-Up===
===Diagnosis===
*CBC, chem, total CK, UA
*Clinical diagnosis
*ECG
 
*CT Brain(for patients with coma, altered mental status, confusion)
{{Burn thickness chart}}
*Other imaging is directed toward visible or suspected injuries


==Management==
==Management==
*Reverse triage - prolonged on-scene CPR and ACLS protocol is indicated even if there are no initial signs of life
*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)
**Maintain cervical spine precautions
**[[therapeutic hypothermia|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
*Discharged patients require follow up to assess for delayed effects of lightning injury


==See Also==
==See Also==
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<references/>
<references/>


[[Category:Environmental]][[Category:EMS]]
[[Category:Environmental]]
[[Category:EMS]]
[[Category:Trauma]]
[[Category:Trauma]]

Latest revision as of 19:20, 15 November 2023

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 and respiratory 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

Superficial second degree burn from lightning injury.
Lichtenberg figure.
Patterned charring along the contact points of a metallic locket due to lightning strike.
Lightning-induced cataract.
Perforated TM

Injuries often involve multiple organ systems[3]

Cardiopulmonary

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

Auditory

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

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

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

Burn Thickness Chart[6]

Thickness Deepest Skin Structure Involved Pain & Sensation Appearance Expected Course Image
Superficial (first-degree)
  • Epidermis
  • Painful
  • Dry, erythema (no blisters)
  • Blanching (intact cap refill)
  • Heals without scarring, 5-10 days

Sunburn.jpg

Superficial Partial (second-degree)
  • Superficial dermis (papillary region)
  • Painful
  • Wet, pale pink, blisters
  • Blanching (intact cap refill)
  • Heals without scarring, <3 weeks

Hand2ndburn.jpg Scaldburn.jpg

Deep Partial (second-degree)
  • Deep dermis (reticular region)
  • Decreased sensation
  • Pale white-yellow, blisters
  • Does not blanch (absent cap refill)
  • Heals in 3-8 weeks
  • Likely to scar if healing >3 weeks
  • May require skin-graft if does not heal within 3 weeks

Major-2nd-degree-burn.jpg

Full (third-degree)
  • Hypodermis (subcutaneous tissue)
  • Decreased sensation
  • White, leathery
  • Does not blanch (absent cap refill)
  • Heals by contracture, >8 weeks
  • Almost always requires skin grafting

8-day-old-3rd-degree-burn.jpg

Fourth-degree
  • Underlying fat, muscle and bone
  • Decreased sensation
  • Black; charred with eschar
  • Does not blanch (absent cap refill)
  • Does not heal
  • Frequently requires amputation

Ожог кисть.jpg

Management

  • Reverse triage - prolonged on-scene CPR and ACLS protocol is indicated even if there are no initial signs of life
  • 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
  • Discharged patients require follow up 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
  4. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361158/
  5. ↑ Galster K et al. Lightning Strike in Pregnancy With Fetal Injury. Wilderness and Environmental Medicine. June 2016. Volume 27, Issue 2, Pages 287–290.
  6. ↑ Haines E, et al. Optimizing emergency management to reduce morbidity and mortality in pediatric burn patients. Pediatric Emergency Medicine Practice. 12(5):1-23. EB Medicine.
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