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Lightning Injury

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Lightning Injury Lightning Injury Sept 2014 Epidemiology 90% males; 20% toddlers, 25% adolescents, 20% workers Lightning mortality rate 10-30%, 75% survivors have residual disability Differ significantly from high voltage electrical injury: Injury patterns, Injury severity, Emergency treatment Lightning AC vs Lightning Duration: 0.3-2secs 10micro – 3millisecs Voltage: Up to 200,000 Billions Tissue damage: Deep Superficial Cardiac rhythm: VF (low V), asystole (high V) Asystole (also with DC) Renal/rhabdo Common Rare Fasciotomy Common Rare Blunt inj Yes Yes Cause of death VF, prolonged apnoea Asystole, prolonged apnoea, blunt inj blunt inj, deep tissue burns High voltage DC shock WET SKIN: DECREASES risk - helps current over OUTSIDE of body Type of Strike Determines nature and severity of injuries Ball lightning: moving floating ball; low energy; rarely fatal; assoc with neuro sequelae Direct strike: most serious injuries Contact injury: victim touching object Side flash: victim near object Ground current: lightning spread through ground; inj more severe if victim’s legs apart due to large potential difference between feet Blast injury: major organs, ear Flashover: less internal cardiac inj and muscle necrosis Assoc with shockwave which can cause hollow viscus inj, retinal detachment, TM perf Assessment Examination: do thorough MS, NS and skin exam; assess eyes and ears; if decr BP, search for results of trauma Skin: cutaneous findings in 90% lightning strikes; look for entry and exit points (rare in lightning); linear burns (along sweat lines), punctate burns (1-10mm, may be full thickness), feathering lesions (due to extravasation of blood into subC tissue; Lichtenberg figures, pathognomonic), thermal inj (clothing, belt buckles, only 5% are full thickness); in lightning burns are usually superficial and heal well ECG: do initial ECG; monitoring not indicated if asymptomatic and normal ECG (most severe cardiac complications present acutely; very unlikely delayed); less AF, but more asystole in lightning strike Indications for ECG monitoring (at least 12hrs): high voltage (>1000V)/abnormal ECG/LOC, seizures, paeds, prev cardiac disease, burns Bloods/urine: monitor for myoglobinuria; less deep tissue damage, myoglobinuria and renal failure in lightning strike; FBE, U&E, CK, LFT, Gluc, FWTU, ECG Imaging: for suspected injuries www.shakEM.co.nz 1 Lightning Injuries Immediate: cardiac arrest, chest and muscle pain, neuro deficits, contusions from shock waves, TM rupture Delayed: cutaneous burns, cataracts, myoglobinuria (rare) Cardiac: Asystole, arrhythmias, nonspecific ST-T changes, acute MI (rare), long QT Respiratory: Inhibition of the brainstem respiratory centers Vascular: spasm, vasoconstriction (compartment syndrome rare) Nervous: LOC, confusion, disorientation, amnesia, autonomic dysfunction (with loss of pupillary function), coagulation of brain substance, epidural and subdural hematomas, intraventricular hemorrhage, skull fractures, seizures, transient or permanent paralysis Skin: Feathering, linear bums, punctate bums, true thermal bums Musculoskeletal: Muscle necrosis (rare), dislocations (posterior shoulder), fractures Renal: Myoglobinuria (rare) Gastrointestinal: Gastric atony, ileus, perforations (uncommon) Ophthalmologic: Mydriasis, loss of light reflex, anisocoria, Horner's syndrome, cataracts Otologic: Tinnitus, hearing loss, ruptured tympanic membranes Keraunoparalysis: Lightning-induced limb paralysis extremely common. Flaccidity and complete loss of sensation. Peripheral pulses impalpable, limb mottled, pale, blue appearance. Mechanism unclear ?vasospasm Management Safety of rescuers (safe to approach in lightning); if mass casualties, give priority to cardiac arrest (reverse triage compared to normal) C: assume SC inj; spinal # may affect multiple vertebrae therefore image entire column A: airway may be difficult if airway burns; early ETT if extensive burns B: resp arrest may persist after ROSC, so ventilation needs to be supported C: aggressive prolonged CPR indicated (cardiac arrhythmias and prolonged resp arrest may be only clinical problem; often young and survive prolonged CPR with minimal probs; resus may be successful even when time to commencement of resus prolonged; but chance of recovery low after 20-30mins CPR); arrhythmias usually resolve spontaneously, but otherwise trt as per usual; give 20ml/kg IVF bolus then aim 1-2ml/kg/hr UO (or IVF as per Parkland formula = 2-4ml/kg/% + maintenance); consider alkalinisation of urine D: remove smouldering clothes; all require opthalmology review due to potential for delayed complications; dilated pupils are not sign of brain death Disposition Discharge if <240V, brief, no LOC / tetany / burn wounds, asymptomatic + normal exam and ECG (if minor wound / paraesthesia, do ECG and urine) Admit if : >600V / abnormal ECG or examination / horizontal transmission Neuro & ophthlamic followup Prognosis Lightning: leg burns mortality 30%; cranial burns mortality 37%; cardiac arrest mortality 76%; if survive initial strike (no immediate sequelae), v good prognosis unless significant 2Y injury; 25-50% survivial rate in arrhythmia if bystander CPR; overall mortality from lightening 34% (2/3 in 1 st hr from apnoea / arrhythmia) DC shocks have 3x morbidity / mortality After cardiac arrest may get return cardiac automaticity, but persistent resp paralysis - hypoxic brain injury CRITICAL PROGNOSTIC FACTOR = DURATION OF APNOEA (not duration of pulselessness) In pregnancy DC cardioversion safe; burns have adverse effect CTG & U/S required for all pregnant victims www.shakEM.co.nz 2 .
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