A 22 y.o. male was found unconscious. You notice something wrong with his shoe.
hint: the shoe is wet.
What is worng?
Our patient was struck by lightning.
Lightning occurs frequently all over the world. with 50 strikes estimated every second. 20% of lightning strikes hit the ground. In the US it is the second only to flooding in the number of deaths it causes. Two thirds of lightning strikes occur in June, July and August. In the US, Florida is the leader in lightning deaths.
The darker colors indicate more lightning deaths.
A bolt of lightning can exceed 10 million volts with a current of 30,000 to 110,000 amperes. Lightning causes different injuries than other high voltage exposures for two reasons. Lightning is a DC current and exposes the individual for only of 1/1,000 of a second. High voltage AC current (>1,000 volts)on the other hand, alternates in frequency at 50-60 Hz similar to the heart’s rhythm and often causes ventricular fibrillation and muscle tetany.
Only 5% of lightning injuries are direct strikes with many more being side splash, contact injury or ground current. Many lightning injuries are “flash over” where electrical current creates a brief ionized path of air around the body allowing much of the charge to travel just over the skin rather than through the body.
THE PRESENTATION
Lightning can cause injuries in a number of ways. Two examples of different effects of lightning follow.
1. Lee Trevino is a golfer who has been struck by lightning three times. In 1975 he was on the golf course in Oak Brook Illinois when lightning struck a body of water near him. The current traveled over the water through the ground to the tree he was standing under and threw him to the ground. He had a brief loss of consciousness and was thrown to the ground. He suffered a shoulder burns and a herniated disc.
the guidelines we now adhere to when it comes to avoiding lightning were not followed in this case. They sought refuge under a tall object, the object was near water and they had metal golf clubs and umbrellas which could attract a charge.
2. A platoon at Fort Bragg NC was in the field when the ground was hit by lightning. 100% of the soldiers hit had lower extremity paresthesia, 60% had tinnitus, 60% had brief loss of consciousness and 40% had CK elevation. All were monitored and recovered in 24 hrs.
THE EVALUATION OF LIGHTNING STRIKES
First, check airway, breathing and circulation. High risk individuals include: those with a direct strike, chest pain , dyspnea and those post arrest. These individuals require careful cardiac monitoring. Then complete a physical exam looking for:
Trauma -In a direct strike the current can cause burns, and muscle contraction resulting in falls. Burns can be the result of vaporization of metal jewelry or intense heating of wet skin. Blast injury occurs because there is rapid expansion of heated air. The shock wave of a lightning strike can cause ruptured eardrums. The heat produced can also cause cataracts by denaturing lens proteins. If the path of the current is through muscle; rhabdomyolysis can result.
lichtenberg figures
Neurologic findings-Lightning can disrupt the brain’s electrical activity briefly or cause the equivalent of a concussion. Victims often have amnesia for the event. Temporary paralysis can occur known as keraunoparalysis. AUtonomic dysfunction has also been reported.
Cardiac arrhythmias -Cardiopulmonary arrest can occur from depolarization of the myocardium. Spontaneous return of circulation may precede the resumption of breathing resulting in a second arrest from hypoxia( For this reason if multiple victims are found the patients in cardiac arrest should be the first ones treated. The myocardium can be stunned or ischemic after a lightning strike and cardiac monitoring is needed.
Our patient had no burns and was observed for six hours on a cardiac monitor. No arrhythmias developed. He had been walking in the rain with an umbrella. He was discharged from the ED.
FUN FACTS
Lightning can shock people indoors by travelling through plumbing or wiring to the ground. If people are near the conductive network it will jump to them. It is recommended that you do not flush a toilet during a thunderstorm.
Flashes of lightning called heat lightning are the result of high cirrus clouds in the troposphere scattering lightning’s light.
ball kughtning floats above the ground
Ball lightning can appear indoors and even pass through windows. It has been studied and was found to be superheated oxidizing silicon from soil. They consist of nanoparticles, Ball lightning is a floating orb of light hovering above the ground in a thunderstorm.
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