Lightning Emergencies Shore EMS Conference 2010

1. It’s Shocking Pre Hospital Management of Lightning Strikes and the Injuries they Cause Brian D. King, AS, NREMT-P

12. Lightning Results from an Electrical Charge

16. Lightning Measured as cosmic direct current Current can range from 100 million to 2 billion volts Amps as high as 200,000 Temp as high as 15,000 – 60,000°F Duration 1/100th to 1/1000th of a second Minimal internal & external burn

17. Lightning & Thunder Lightning strike suddenly heats the air around the lightning which causes a rapid expansion of air which then creates an explosive effect. Since the strike is of such short duration the air cools rapidly and an implosion occurs which causes thunder. Injuries: Anything from blunt to penetrating trauma Hearing loss

18. Mechanism of Lightning Injuires Ground Flash: Lightning stokes a distance away from the victim & spreads out across the ground. The ground becomes energized eventually striking the patient. Side Flash: Lightning strikes an object and splashes or jumps to the patient Upward Leader Strike: Results from positive ground current moving upward without contact with the downward stroke. Direct Strike: Patient is the point of contact for the strike Contact Strike: Patient being in contact with the object that is struck

22. Things to Consider: Lightning can strike as much as 10-12 miles away. If you can hear thunder, you can be struck by lightning. Lightning can travel the length of a football field With conduit it can travel up to 5 miles.

24. Case Study “A walk on the beach”

25. The Story 56 YOM & Wife walking home from town on the beach Storm approaching from down the coast with increasing winds, thunder and lightning. Start to run for cover running toward the house over a sand dune between fencing. Wife makes it across sand dune to safety and sees husband look back and then look forward and fell face first to the sand with a 2 minute loss of consciouness

27. Airway: Patent and self maintained Breathing: Slightly rapid with a regular rhythm. Circulation: Regular at radial Skin is a normal color and dry condition GCS: 14

28. Vital Signs RR: 22 HR: 98 BP: 158/62 SpO2: 97% with a non-rebreather

29. Pre Hospital Treatment Fully immobilized on a long board, with a rigid C-Collar and CIDs. BLS transport to the Emergency Department

30. In the ED EKG & 12 Lead Labs Discharged

31. The Next Day A large bruise on the left lateral side extending from the upper chest to the lower abdomen “Red dots” noted on the the scalp

32. What Happened?

33. Lightning Strikes Lightning flashes 8 million times a day Most lightning strikes are benign 600 Lightning strike injuries a year 70 Lightning strike related deaths a year Odds of being struck by lighting: 1/6250

34. Who’s most at risk? Males five time more likely to be struck Adults 16-35 Children <16

36. Is he more likely to be struck by lightning?

37. What about her?

41. Jewelry will not increase the risk of being struck by lightning May act as a conductor and cause a burn due to the extreme heat Having a metal plate does not increase the risk of being struck

42. When & Where When May-September Highest Incidence June – August Where 1/3 Working 1/3 Recreational Activities / Sports 1/3 Other

45. The Other 1/3 Don’t assume that a patient will be found outside Lightning can transmit through plumbing fixtures or hardwired electrical devices Computers Phones Video Games

46. Thunderstorms & iPodsNot a Good Idea NEJM-Volume 357:198-199 July 12,2007 Number 2

47. 37 YOM, jogging in during a thunderstorm. Adjacent tree was struck by lightning. Witnesses reported that he was thrown approximately 8 ft from the tree Brought to the ED: Second degree burns on anterior chest & left leg. Two linear burns extended along his anterior chestand neck to the sides of his face, terminating in substantialburns in the external auditory meatus bilaterally, correspondingto the positions of his earphones at the time of the lightningstrike. Both of tympanic membranes were ruptured. Mandibular fracture

48. ASSESSMENT

49. Dispatch More than likely the incident will not be dispatched as a lightning strike. The patient may be inside. You need to put the puzzle pieces together and be a detective.

50. Things to think about: 90% of strikes involve one patient. Most common cause of death is cardiac dysrhythmia If patient not in cardiac or respiratory arrest patient is likely to survive More on this latter

51. Assessment Head to toe assessment The general stuff! Assessment of perfusion Beware of arterial spasm

52. Injuries

53. Burns Usually not apparent Look for a white area different from the patient’s normal skin color Generally superficial burns Due to short duration of contact with electrical current caused by the energy flashing over the body Internal & External burns are possible

54. Burns Linear Burns Punctuate Burns Cigarette style burns Feathering or pathognomonic fernlike patterns Thermal Burns

55. WARNING: THE FOLLOWING VIDEO IS GRAPHIC

60. Lichtenberg Figures Also known as ferning pattern

62. Trauma Pretty much anything! Why?

63. Neurological Sensitive to electrical disturbances! LOC Seizures Confusion Paraplegia, quadriplegia Hemiplegia, aphasia Retrograde amnesia Seizures

64. Chronic Neurological Problems CNS/Brain Cognitive changes, sleep disturbances, seizures, distractibility, headaches, nausea ANS: Regulations of BP & Cardiac response (+ tilt test, dizziness & HTN) Impotence, GI problems PNS: Chronic Pain, sensory problems

65. Cardiac Complications Sensitive to electrical disturbances Blood Pressure Changes Transient HTN Hypotension Dysrhythmias The “fibs” PVC’s Transient asystole

67. Respiratory Complications Difficulty Breathing Apnea Hypoxia

68. Occular Complications Hyphema Retinal detachment Optic Nerve injury Iritis

69. Pupilary Changes Fixed & Dilated What would we think?

70. Otologic Complications Hearing loss Ruptured tympanic membrane

71. What are these problems being caused by? Electrical Injury Blunt trauma Baro Trauma Pressure Changes

72. Head Injury Basilar Skull fracture

73. Treatment

74. BLS ABC’s C-Spine precautions Vitals O2 PRN Blood Sugar for AMS

75. Paramedic Same as BLS EKG 12 Lead Blood Sugar IV Blood Draw

76. Mass Casualty Lightning Incidents They do happen! Do we use the standard triage method?

77. Mass Casualty Lightning Incidents If the patient did not arrest initially, it is likely they will survive. Attend to patient’s in arrest FIRST! This is the opposite of regular triage!

79. CLOSING THOUGHTS:

82. E-Mail: Brian11884@aol.com Questions?