Lightning injuries

Background

• Pts w/ lightning injury who appear to be dead should be treated FIRST at the scene
  • Have a reasonable chance of successful resuscitation
• Compartment syndrome and rhabdo are unusual
• Keraunoparalysis
  • Neurologic and muscular "stunning" that can follow lightning strikes and usually resolves
    • E.g. limb weakness, sensory abnormalities

Clinical Features

1. Cardiopulmonary
   1. Both cardiac and respiratory arrest may be present without evidence of external injury
      1. Although cardiac automaticity may spontaneously return, apnea may persist
         1. Duration of apnea rather than cardiac arrest is the critical prognostic factor
   2. Myocardial infarction after lightning injury is unusual
2. Neuro
   1. Symptoms are usually immediate and transient or delayed and permanent
      1. Seizure, LOC, confusion, amnesia, extremity paralysis
   2. Pupillary dilation or anisocoria may occur that is unrelated to brain injury
3. Vascular
   1. Vasomotor spasm may cause loss of pulse, coolness of extremities, loss of sensation
   2. Keraunoparalysis - temporary paralysis due to sympathetic nervous system activation and vascular spasm
      1. Resolves spontaneously
      2. Compartment syndrome is rarely the cause (skeletal muscle unaffected in strikes)
4. Ocular
   1. Ocular injuries are common
      1. Cataracts may occur wks-yrs after injury (must document careful eye exam in all pts)
      2. Other injuries include vitreous hemorrhage, corneal abrasion, retinal detachment
5. Auditory
   1. Blast effect producing TM rupture is relatively common
6. Derm
   1. Lichtenberg figures (ferning pattern)
      1. Pathognomonic for lightning strike
      2. Occur due to electron showering over the skin, not true burn; disappear w/in 24hr
   2. Flash burns
      1. Similar to those found in arc welders; appear as mild erythema, may involve cornea
   3. Punctate burns
      1. Look similar to ciagarette burns; are full-thickness
   4. Contact burns
      1. Occur when metal close to the skin is heated from the lightning current

Work-Up

• CBC, chem, total CK, UA
• ECG
• CT (for coma, AMS, confusion)

Treatment

• 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)

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

Source

Tintinalli