Morning Report: 3/23/2012 - The Original Kings of County

Thank you to Dr. Backster for today’s Morning Report with some clinical pearls on lightning injuries:

Lighting strikes

Neg charged lightning: more common, occurs within the storm

Pos charged lightning: stronger, longer exposure, & can occur miles from the storm

Mechanisms of injury from lightning: electrical (direct or splash), heat/thermal burns, shock wave/blunt trauma

Neurologic: Electricity damages neurons directly—necrosis, hematomas. Chronic generalized HA that can last months. Extremity pain and paresthesias that can last months &may have delayed presentation– Chronic autonomic dystrophy or reflex sympathetic dystrophy. 2/3 LE paralysis, 1/3 UE paralysis. Mottled skin with decreased sensation due to sympathetic dysfuction, will often resolve within hours. Neurologic dysfuction may affect eyes, so fixed/dilated pupils cannot be used reliably as indicators of severe brain injury. Repiratory center may be paralyzed leading to arrest.

Trauma: Pay careful attention to anything dripping out of the ear. Pulmonary contusion possible. Remember C-spine, battle sign eval etc, as falls likely.

Cardiac: asystole with spontaneous return of activity s a hallmark, but any other type of dysrhythmia is possible. EKG may be delayed in showing ischemic changes up to 1 wk, while other changes may be transient and resolve within a wk.

Burn classification: 1 Linear/Flash burns—1-2^nd degree caused by heat/steam on skin, most often found axilla, underbreast, groin. 2 Puncate—discrete circular burns mm-cm diameter, full thickness resemble cigarette burns. Due to current passing directly through skin. 3 Lichtenberg figures (not true burn as no damage) ferning flowery pattern that looks like a burn on skin. 4 Thermal—2^nd-3^rd degree burns, often at sites of metal touching skin, clothes. 5 Combination of above types.

Classifications

Minor injuries: HA, amnesia, transient neurologic dysfunction, TM rupture.

Can consider for discharge after observation, should get neuro f/up.

Moderate injuries: neurologic manifestations (lethargy, coma, concussion, extremity paralysis, seizure, Horner syndrome), cardiogenic dysfunction (sympathetic instability, asystole with spont return of rhythm), TM rupture highly likely, 1^st-2^nd degree burns. Cataracts (develop days later).

Long term sequelea possible– neuropathies, sympathetic disorders.

Severe injuries: cardiorespiratory arrest, anoxic brain injury.

While heart often has spont return of activity, respiratory center often does not.

Poor prognosis.

Management: ABCDs, note pulses all extremities, cont cardiac monitoring, burn mgmt., easy fluid resuscitation as there is a risk of cerebral edema. If hypotensive, consider more blunt force injuries/internal hemorrhage & long bone fx.

Summary of what to look for: Blunt trauma, tympanic rupture, asystole (with spont return of activity), respiratory arrest, burns (Lichtenberg), neuro dysfunction.

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital