Its Shocking


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Lightning Emergencies
Shore EMS Conference 2010

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  • 90% of lightning strike victims survive and 10% die.
  • Contrary to popular belief wearing jewelry or having a metal plate does not increase the risk of being struck by lightning and it does not act as a lightning rod unless the height in increased. Only a object in the middle of a flat surface is at increased risk.
  • Lichtenberg figures appearing on people are sometimes called lightning flowers, and they are thought to be caused by the rupture of small capillaries under the skin due to the passage of the lightning current or the shock wave from the lightning discharge as it flashes over the skin. A lightning strike can also create a large Lichtenberg Figure in grass surrounding the point struck.
  • CNS, ANS, PNS – SENSITVE TO ELECTRICAL DISTURBANCESConfusion, amnesia, paralysis, and loss of consciousness are a result of the direct passage of current through the brain.
  • ANS-sympathetically mediated pain syndromes
  • Uveitis is swelling and irritation of the uvea, the middle layer ofthe eye.
  • Fixed and dilated pupils are typically a result of transient autonomic disturbances, not serious head injuries.
  • Blood work should include complete blood cell (CBC) count, creatinekinase (CK) with isoenzymes, routine urinalysis, and urine or serum myoglobin levels. Screening for myoglobin should be performed on the initial evaluation and admission to the hospital, but results are unlikely to be positive except in the most severe lightning strikesCK, myocardial muscle CK isoenzyme (CK-MB) or troponins, and urinalysis usually can detect deep tissue damage or cardiac injury.
  • Its Shocking

    1. 1. It’s Shocking Pre Hospital Management of Lightning Strikes and the Injuries they Cause<br />Brian D. King, AS, NREMT-P<br />
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    12. 12. Lightning Results from an Electrical Charge<br />
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    16. 16. Lightning <br />Measured as cosmic direct current <br />Current can range from 100 million to 2 billion volts<br />Amps as high as 200,000<br />Temp as high as 15,000 – 60,000°F<br />Duration 1/100th to 1/1000th of a second <br />Minimal internal & external burn <br />
    17. 17. Lightning & Thunder<br />Lightning strike suddenly heats the air around the lightning which causes a rapid expansion of air which then creates an explosive effect.<br />Since the strike is of such short duration the air cools rapidly and an implosion occurs which causes thunder. <br />Injuries: <br />Anything from blunt to penetrating trauma <br />Hearing loss<br />
    18. 18. Mechanism of Lightning Injuires<br />Ground Flash: <br />Lightning stokes a distance away from the victim & spreads out across the ground. The ground becomes energized eventually striking the patient. <br />Side Flash: <br />Lightning strikes an object and splashes or jumps to the patient <br />Upward Leader Strike:<br /> Results from positive ground current moving upward without contact with the downward stroke. <br />Direct Strike: <br />Patient is the point of contact for the strike <br />Contact Strike:<br />Patient being in contact with the object that is struck <br />
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    22. 22. Things to Consider: <br />Lightning can strike as much as 10-12 miles away. <br />If you can hear thunder, you can be struck by lightning. <br />Lightning can travel the length of a football field <br />With conduit it can travel up to 5 miles. <br />
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    24. 24. Case Study<br />“A walk on the beach”<br />
    25. 25. The Story <br />56 YOM & Wife walking home from town on the beach<br />Storm approaching from down the coast with increasing winds, thunder and lightning. <br />Start to run for cover running toward the house over a sand dune between fencing. <br />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<br />
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    27. 27. Airway:<br />Patent and self maintained<br />Breathing: <br />Slightly rapid with a regular rhythm. <br />Circulation: <br />Regular at radial<br />Skin is a normal color and dry condition<br />GCS: <br />14<br />
    28. 28. Vital Signs <br />RR:<br />22 <br />HR:<br />98 <br />BP: <br />158/62<br />SpO2: <br />97% with a non-rebreather<br />
    29. 29. Pre Hospital Treatment <br />Fully immobilized on a long board, with a rigid C-Collar and CIDs. <br />BLS transport to the Emergency Department<br />
    30. 30. In the ED<br />EKG & 12 Lead <br />Labs <br />Discharged <br />
    31. 31. The Next Day <br />A large bruise on the left lateral side extending from the upper chest to the lower abdomen<br />“Red dots” noted on the the scalp<br />
    32. 32. What Happened?<br />
    33. 33. Lightning Strikes<br />Lightning flashes 8 million times a day <br />Most lightning strikes are benign <br />600 Lightning strike injuries a year<br />70 Lightning strike related deaths a year<br />Odds of being struck by lighting: <br />1/6250<br />
    34. 34. Who’s most at risk?<br />Males five time more likely to be struck <br />Adults 16-35<br />Children <16<br />
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    36. 36. Is he more likely to be struck by lightning?<br />
    37. 37. What about her?<br />
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    41. 41. Jewelry will not increase the risk of being struck by lightning <br />May act as a conductor and cause a burn due to the extreme heat <br />Having a metal plate does not increase the risk of being struck <br />
    42. 42. When & Where<br />When<br />May-September <br />Highest Incidence June – August<br />Where<br />1/3 Working<br />1/3 Recreational Activities / Sports <br />1/3 Other<br />
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    45. 45. The Other 1/3<br />Don’t assume that a patient will be found outside <br />Lightning can transmit through plumbing fixtures or hardwired electrical devices <br />Computers <br />Phones<br />Video Games<br />
    46. 46. Thunderstorms & iPodsNot a Good Idea<br />NEJM-Volume 357:198-199 July 12,2007 Number 2<br />
    47. 47. 37 YOM, jogging in during a thunderstorm. <br />Adjacent tree was struck by lightning.<br />Witnesses reported that he was thrown approximately 8 ft from the tree<br />Brought to the ED: <br />Second degree burns on anterior chest & left leg. <br />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. <br />Both of tympanic membranes were ruptured. <br />Mandibular fracture<br />
    48. 48. ASSESSMENT<br />
    49. 49. Dispatch <br />More than likely the incident will not be dispatched as a lightning strike. <br />The patient may be inside. <br />You need to put the puzzle pieces together and be a detective. <br />
    50. 50. Things to think about: <br />90% of strikes involve one patient. <br />Most common cause of death is cardiac dysrhythmia<br />If patient not in cardiac or respiratory arrest patient is likely to survive <br />More on this latter<br />
    51. 51. Assessment <br />Head to toe assessment <br />The general stuff!<br />Assessment of perfusion<br />Beware of arterial spasm <br />
    52. 52. Injuries<br />
    53. 53. Burns<br />Usually not apparent <br />Look for a white area different from the patient’s normal skin color <br />Generally superficial burns<br />Due to short duration of contact with electrical current caused by the energy flashing over the body<br />Internal & External burns are possible<br />
    54. 54. Burns <br />Linear Burns<br />Punctuate Burns<br />Cigarette style burns <br />Feathering or pathognomonic fernlike patterns<br />Thermal Burns <br />
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    60. 60. Lichtenberg Figures<br />Also known as ferning pattern <br />
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    62. 62. Trauma<br />Pretty much anything!<br />Why?<br />
    63. 63. Neurological <br />Sensitive to electrical disturbances!<br />LOC<br />Seizures <br />Confusion<br />Paraplegia, quadriplegia<br />Hemiplegia, aphasia <br />Retrograde amnesia<br />Seizures<br />
    64. 64. Chronic Neurological Problems <br />CNS/Brain<br />Cognitive changes, sleep disturbances, seizures, distractibility, headaches, nausea<br />ANS: <br />Regulations of BP & Cardiac response<br />(+ tilt test, dizziness & HTN)<br />Impotence, GI problems<br />PNS: <br />Chronic Pain, sensory problems <br />
    65. 65. Cardiac Complications<br />Sensitive to electrical disturbances <br />Blood Pressure Changes<br />Transient HTN <br />Hypotension<br />Dysrhythmias<br />The “fibs” <br />PVC’s<br />Transient asystole<br />
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    67. 67. Respiratory Complications<br />Difficulty Breathing <br />Apnea<br />Hypoxia <br />
    68. 68. Occular Complications<br />Hyphema<br />Retinal detachment<br />Optic Nerve injury<br />Iritis<br />
    69. 69. Pupilary Changes<br />Fixed & Dilated <br />What would we think?<br />
    70. 70. Otologic Complications<br />Hearing loss<br />Ruptured tympanic membrane<br />
    71. 71. What are these problems being caused by?<br />Electrical Injury<br />Blunt trauma<br />Baro Trauma <br />Pressure Changes <br />
    72. 72. Head Injury <br />Basilar Skull fracture<br />
    73. 73. Treatment<br />
    74. 74. BLS<br />ABC’s <br />C-Spine precautions <br />Vitals<br />O2 PRN<br />Blood Sugar for AMS <br />
    75. 75. Paramedic <br />Same as BLS<br />EKG<br />12 Lead <br />Blood Sugar <br />IV<br />Blood Draw<br />
    76. 76. Mass Casualty Lightning Incidents<br />They do happen! <br />Do we use the standard triage method?<br />
    77. 77. Mass Casualty Lightning Incidents<br />If the patient did not arrest initially, it is likely they will survive. <br />Attend to patient’s in arrest FIRST!<br />This is the opposite of regular triage! <br />
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    79. 79. CLOSING THOUGHTS:<br />
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    82. 82. E-Mail:<br />Questions?<br />