A Man Collapsed in Golf Court

1. HKCEM College Tutorial A Man Collapsed in Golf Court author Dr. Lau chuleung, terry Oct., 2013

2. Golfer collapsed at golf court while playing golf • Issue(s) identified? • Confusion • Hypertension • Tachycardia • One sided weakness • Outdoor activity • DDx? • Hypertensive emergency • CNS – CVA, ICH • Intoxication • Heat illness • Psychi – psychosis, malingering, conversion • HI • Spinal cord injury • Epilepsy • M/38 • Severe headache, left sided weakness, generalized pain, Left hearing impairment • Confused (E4 V4 M6) • Ask questions repeatedly • Amnesia • BP 210/110mmHg • Pulse 124 bpm • T - 37.3 ºC • RR 18/min, SpO2 99%RA

3. What are your immediate management? • Manage in Resuscitation Room • Stabilized ABC • Oxygen • Intravenous access +/- fluid • Monitoring – cardiac monitor, BP/P/GCS/SpO2 • Get further History from witness, ambulance crew or other informant • P/E…

4. Physical Examination • Damage clothing • Scalp wound • Skin lesion

5. What condition is in your mind? • LIGHTNING strike! • Delivers a massive electrical pulse over a fraction of a millisecond • Tell-tale clues include • Casualty (or multiple casualties) found outdoors √ • Exploded clothing √ • Cutaneous burns (linear, punctate or feathery) √ • Tympanic membrane rupture

6. Mechanisms of Injury • Direct Strike • Contact • Side flash • Ground current • Upward streamer

7. Mechanisms of Injury • Blunt trauma - Thrown by massive skeletal muscle contraction • Flashover effect- Current passes over and around casualty's body but not through it • Clothes and shoes are torn apart • Only superficial skin wounds • Blast barotrauma - Explosion of air around the lightning channel • Injury to hollow viscus • Fractures by a blast wave • Blast penetrating injury - Lightning strike–induced explosion of nearby structure in which shrapnel causes penetrating injuries to patient

8. Lightning VsHigh-voltage Electricity

9. Lightning VsHigh-voltage Electricity • ANYMORE? • Unlike generated electricity that is voltage driven, lightning is a “current” phenomenon. • Generated electricity points of contact are on the upper limbs, hands and wrists, while lightning mostly hits the head, neck and shoulders • Lightning limits less likely to cause internal burns than generated electricity

10. Lightning Injury - Effects • Lightning electricity will travel the path of least resistance. • The order of least to greatest resistance: nerve < blood < muscle < skin < fat < bone • Primarily an injury to the nervous system • Tissue damage of lightning is mediated thermally and electrically • Associated with massive catecholamine release EYE ENT

11. Lightning Injury - Skin • Entrance / Exit wound • Scalp, feet • Singed or scorched hair • Burns • Wounds / bruising – blunt / penetrating injury

12. Lichtenberg figure • Pathognomonic - Arborescentburn of lightning • Transient dermatologic phenomena • within 1hour of strike • Gradually fades within 24–36h • Non-painful, non-pruritic • Blanch with pressure • Leave no residual scar • No histologic change or damage • Treatment is not required

13. Lightning seldom causes substantial burns • Linear • Sweat or water accumulate • Sweat vaporizes into steam when lightning travels over the skin (also known as “flashover”). • Punctate • Multiple, small cigarette-like burns • Few millimeters to 1 cm in diameter • Current passing out from the underlying deep tissue • “tip-toe” sign • Water droplets on the skin (from sweat or rain) becoming superheated and turning to steam from the energy of a lightning strike • Feathering (Lichtenberg figure) • Thermal burns • Objects being heated up - metal coins, necklaces, watch, zipper

14. Lightning Injury - Cadiovascular • Massive DC “countershock”  simultaneously depolarizes the entire myocardium  Asystole • Other complications • Transient hypertension • Arrhythmia– VF, VT, AF, PVC • ECG changes - ST elevation, prolongation of QT interval • Myocardial injury • Takotsubo cardiomyopathy - “transient left ventricular apical ballooning syndrome” • CHF • Extremities may appear cool, blue, or pulseless due to transient vasospasm • Most of these findings resolve within 3 days

15. Lightning Injury – Neurological Symptoms • Problems coding new information and accessing old information • Problems multitasking • Slower reaction time • Distractibility • Irritability and personality change • Inattentiveness or forgetfulness • Intense headaches • Chronic pain from nerve injury • Ringing in the ears and dizziness or balance problems • Difficulty sleeping, sometimes sleeping excessively at first and later only two or three hours at a time

16. Lightning Injury – Neurological Cx • Keraunoparalysis - ‘‘lightning paraplegia’’ • Temporary state of sensory loss, motor paralysis, and pallor of the extremities caused by acute neurologic injury in combination with significant catecholamine release • Recovery occurs within hours • Cerebral salt wasting syndrome • Spinal cord injury • Guillain-Barre´ syndrome

17. Cherington Classification (Neurological Injury) • Category I - transient neurological symptoms • Category II - neurological complications are prolonged or permanent • Category III - delayed neurological conditions reported weeks or months after the initial injury • Category IV - lightning linked complications

18. Lightning Injury – ENT • Acoustic effects - damage to middle and inner ear • TM rupture (50%) • Centralaudiovestibular system problems • Hemorrhagic and purulent effusions of middle ear and mastoid air cells • Rupture of Reissner membrane • Degeneration of striavascularis and organ of Corti • Edema of intracanalicular portion of facial nerve • Microfractures of otic capsule • Inner ear hemorrhage

19. Lightning Injury – EYE • Mechanisms • Passage of current through the lens • Blunt and blast trauma • Vasoconstriction • Heat • Iridocyclitis • Cataracts, often bilateral • 2 days to 4 yr after injury • Retinal damage, macular oedema, haemorrhage, papilloedema and optic neuritis

20. Lightning Injury – Gastrointestinal • Paralytic ileus • Gastric dilatation • Stress ulcer • Gastrointestinal bleeding • Gastrointestinal perforation

21. Lightning Injury – Musculoskeletal • Dislocation • Fractures • Physealinjury • Compartment syndrome • Rhabdomyolysis

22. Lightning Injuries by Body System

23. Lightning Injury – Scene Safety & Pre-hospital Mx • Ensuring scene safety is paramount • Rescuers are at risk if thunderstorms are in the area • Environmental Signs of Direct Lightning Strike • Damage to nearby trees - splitting or removal of bark • Arc marks on the walls or nearby structures • Soil may show fulgurite formation (Pictures on the right) • Bore or tube-like structures formed in sand or rock by lightning • Ground - fern pattern (Picture A)

24. Lightning Injury – Scene Safety & Pre-hospital Mx • Victims  safe to touch? • YES! will not retain electrical charge • Reverse Triage • If a group of persons is struck by lightning, direct attention to those with no signs of life • Rapidly focus on providing ventilatory support to unconscious victims or those in cardiopulmonary arrest • Prevents primary cardiac arrest from degenerating into hypoxia-induced secondary cardiac arrest • Victims who show some return of consciousness or who have spontaneous breathing are already on the way to recovery

25. Lightning Injury – Scene Safety & Pre-hospital Mx • Spine immobilization for: • Cardiopulmonary arrest (suspected trauma) • Significant mechanical trauma • Suspected loss of consciousness at any time • Cover superficial burns with sterile saline dressings. • Immobilize injured extremities. • Rapid extrication to decrease risk for repeat lightning strikes

26. Lightning Injury – ED Management • Initial resuscitation is the primary goal of medical care • Fluid resuscitation, particularly if hypotension and/or rhabdomyolysis are present • Search for sources of bleeding secondary to blunt trauma • Evaluation for secondary injuries • Wound care, ATT, pain control

27. Lightning Injury – History • If a witness is available: • Was there a storm? • Was there lightning? • Did the witness actually see the lightning strike the victim? • Where was the deceased at the time of the strike (e.g., under a tree, on an open golf course)? • What was the activity of the deceased before death? • A meticulous description of the lightning event must be given. • Was any attempted resuscitation applied? • How many people were involved? • Were there any survivors? If so, where are they? • Medical history - any cardiac problems?

28. Lightning Injury – Immediate Effects • If not suffer cardiac arrest at the time of the incident • Muscle soreness • Headache, nausea, stomach upset and other post-concussion types of symptoms • Mild confusion, memory slowness or mental clouding • Dizziness, balance problems • Pulmonary injuries • Neurologic signs • Seizures • Deafness • Blindness • Contusion from shock wave • Tympanic membrane rupture

29. Lightning Injury – P/E • Awake patient should be assessed for orientation and short-term memory • Continuing confusion or a deteriorating level of consciousness mandates CT Brain • Skin - entry / exit wounds, burns (size, shape, distribution, severity) • CNS & peripheral neurology • Keraunoparalysis • Spinal cord injury • Vascular thrombosis • Abdominal examination • Absent bowel sounds - ileus • Signs of contusion to the liver, bowel, or spleen • Musculoskeletal - fracture / dislocation • ENT – Tympanic membrane rupture (50%) • EYE

30. Lightning – Investigations & Imaging • Blood – electrolytes, RFT, cardiac markers, muscle enzymes • Urine - Myoglobinuria • Cervical spine imaging • Cranial burns, contusions, LOC, or change in mentation • Any suspicion of a fall or being thrown • CXR – barotrauma, blunt / penetrating injury • ECG, ECHO • Other studies to rule out fractures, dislocations, and other bony injuries may be obtained as clinically indicated • CT brain – persistent confusion, injury • MRI – spinal cord injury

31. Lightning Injury - Disposal • Asymptomatic patients with normal ECG could be discharged after a brief period of observation • Observation up to 24 hours has been suggested for patients with pre-existing heart disease • Admission – high risk indicators • Referral (late sequelae)

32. Lightning Injury – Late Sequelae • EYE • Cataract • Neuropsychiatric • Personality changes/self-isolation • Irritability and embarrassment • Can't remember people, job responsibilities and key information • Difficulty carrying on a conversation • Depression • Chronic pain and headaches • Skin • Granuloma annulare • Squamous cell carcinoma

33. Lightning Injury - Prevention • Precautions can reduce a person's risk for lightning injury: • Seek shelter when a thunderstorm is approaching. “When thunder roars, go indoors” • Avoid tall structures - isolated trees, flag poles • Stay away from open fields, open structures or vehicles, or contact with conducive material, such as computers and telephones. • Figure: Warnings at Great Wall in China • Avoid being near or in water

34. Lightning Injury - "30-30 Rule" • Thunder travels about 1/3 kilometer per second. • To determine the distance between where the lightning strike hit and your position • Count the number of seconds between the lightning flash and the thunder, and divide by 3 • If within 30 seconds, then the storm is within 10 kilometers  “Strike danger zone” • Individuals should wait 30 minutes after hearing the last thunderclap before resuming outdoor activity • Establish an appropriate buffer zone

35. Lightning Injury - Prevention • Group persons • Split up but still be within sight of each other - 6 meters apart • Survival of one person whose heart or breathing has stopped as a result of a strike depends on prompt action by companions • Walk in short steps • "step voltage" - the voltage difference between the feet • The higher the distance the higher the voltage in the event of a strike • Assume the Lightning Position

36. Lightning Injury - Pregnancy • High rate of fetal or neonatal death (~50%) • Even where maternal survival occurs • Fetus is likely at higher risk than the mother because it is surrounded by highly conductive amniotic fluid. • Lightning strikes have been reported to cause uterine rupture and induction of labor • Pregnant women greater than 20 weeks’ gestation who have been struck by lightning should be evacuated to a hospital for lightning- associated injury screening and fetal monitoring.

37. Lightning – Pitfalls • Any person found with linear burns, mental status changes, ruptured tympanic membrane, and clothes exploded off should be treated as a victim of lightning strike. • Carry out CPR even if the casualty appears dead • Pupils may be fixed and dilated as a result of muscular paresis - they do not necessarily represent brain death • Cardiopulmonary resuscitation should be performed over a longer period of time • Better prognosis than those with cardiopulmonary arrest secondary to other type of injury • Absent peripheral pulses could be due to vasospasm

38. Lightning Injury - References • Burns 2013;39(2):e8-12 • Burns 2013;38(3):e9-12 • WILDERNESS & ENVIRONMENTAL MEDICINE 2012;23:260–9 • Ann Emerg Med. 2012;59(4):335, 340 • Auerbach: Wilderness Medicine, 6th ed. (2011) • ACLS (2010) • Core Manual (2010) • Journal of the Neurological Sciences 2009;276:199–201 • Clinical & Experimental Dermatology. 2009;34(7):e485-6 • Burns 2008;34(5):585–94 • Burns 2008;34(5):722–6 • Burns 2005;31(8):1045-9