Morning Report: 3/23/2012

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.