Patient Survives Direct Lightning Hit Thanks to EMS and Hospital

A 36-year-old male was standing on a baseball diamond, coaching his son’s team on a July afternoon, when he was struck by lightning. He immediately went into cardiac arrest. Lightning continued nearby combined with heavy rainfall.

Bystanders started CPR at once. EMS arrived directly at the diamond within seven minutes of the incident. The crew took over CPR after confirming pulselessness and apnea. The patient’s brother advised rescuers that he had opened the airway right after the patient went down, and CPR was started within one minute of the arrest. The patient was healthy and had no other medical problems.

The patient was ventilated with a bag-valve-mask (BVM) and promptly moved into the ambulance. A three-lead monitor assessment revealed asystole. Providers continued CPR and established an IV. One milligram of epinephrine was administered IV.

Oral tracheal intubation was attempted but was unsuccessful on the first two attempts due to edema around the epiglottis and other airway structures. On the third attempt, a bougie introducer was utilized to enter the airway past one vocal cord that was finally visualized. The endotracheal tube (ETT) was passed over the bougie introducer into the trachea. The esophageal detector device was negative and the initial end tidal carbon dioxide (ETCO2) reading was 40 mmHg. Breath sounds were equally present and no sounds were heard over the epigastrium.

Shortly afterward, the patient was noted to be in V-fib. He was defibrillated at 360 joules, monophasic. CPR was resumed.

Two minutes later, providers thought he was in an idioventricular rhythm without a pulse, and they continued CPR. On the next assessment two minutes later, the patient appeared to be in v-fib and was defibrillated again. CPR was restarted.

As the patient was being placed in spinal precautions to begin transport, a carotid pulse was noted at a rate of 100 bpm. A radial pulse was present and BP was 200/120 mmHg. The patient continued to be unresponsive, and there was neither spontaneous movement of his extremities nor response to painful stimuli.

Reassessment of the ETCO2 revealed a value of 32 mmHg. The patient was then given 80 mEq of sodium bicarbonate IV. The next ETCO2 reading was 80 mmHg. The crew increased the ventilation rate in response.

En route, the secondary survey, or detailed assessment, demonstrated the following findings: a partial-thickness (second-degree) burn was present on the right side of the scalp near the parietal region. A partial-thickness burn measuring 12 inches in height and three inches wide was noted over the sternum. A full-thickness (third-degree) burn was observed on the medial aspect of both ankles. The percentage of burns was estimated to be 25%. The rest of the survey was negative.

On arrival to the emergency department (ED), the physician estimated a Glasgow Coma Scale (GCS) of 3. The pulses remained intact and the patient continued to be unresponsive. At this point, BP was 207/106 mmHg. An arterial blood gas revealed a pH of 7.11 (normal 7.4), a bicarbonate level of 14 (normal 20 25) and a pCO2 of 59 (normal 40). Heart rate was approximately 100 throughout the ED stay. At the time of transport to the ICU, the BP was 163/94 mmHg.

The physical examination concurred with the EMS assessment with the exception of second-degree burns noted on right calf, the right posterior neck and bottom of both feet. A total of 25% body surface burn area was estimated. No evidence of any compartment syndrome was observed in the extremities or thorax. The pupils were equal and reactive. CT scans of the head, chest and abdomen were normal.

Outcome
After one night in the ICU, the patient was transferred to a regional burn center. While there, his burns began to heal but he experienced an episode of aspiration pneumonia after being extubated. This necessitated reintubation. He was treated with IV antibiotics and underwent a bronchoscopy to clear some of the infection and secretions. As his mental status improved and permitted more detailed assessment, concern developed that he had experienced significant anoxic encephalopathy (brain injury due to prolonged low levels of oxygen). He had no other acute complications.

Approximately two weeks after the lightning strike, the patient was transferred to a long-term-care hospital facility. He had finally been able to remain off the ventilator and the ETT, but his lower extremity strength was diminished and he was very unsteady — even just trying to sit up. Intensive rehabilitation continued at this hospital and, surprisingly, the patient improved dramatically. Minor derangements of his electrolytes were corrected.

One week after admission to the long-term-care facility, the patient was able to be moved to a specialty rehabilitation hospital. He continued to improve and, six weeks after the injury, the patient was discharged home to continue rehabilitation as an outpatient.

At the time of discharge, his attending physician noted that his burns were nearly completely healed. His functional capability permitted him to perform the activities of daily living with moderate independence. His upper and lower extremity strength was now normal and his gait was nearly normal. His cognitive functions were fairly intact, but it was felt that he still lacked insight and had short term memory deficits.

Throughout his hospitalizations, his BP remained elevated and it was determined that he required antihypertensive medicine on discharge as well as a mood stabilizer and an antidepressant.

He continued to improve in outpatient rehabilitation, For a prolonged time, he lived with his brother and wife, who provided the supervision that he needed as he completed his rehabilitation.

Ten months after the injury, the patient and his family appeared at an EMS case review featuring a formal presentation and discussion of his case. With his consent, media were also present. The patient walked into the room and shook hands with all, conversing without difficulty. More recently, the patient was able to attend his local high school’s twentieth class reunion. Most of the attendees knew about his brush with death and, as a result, it was an especially meaningful event.

Discussion
I selected this case for two reasons: First, we are in the summer season and it is now the peak of lightning risk. Hopefully, this serves as a reminder that we need to respect the power of this natural phenomenon; and second, this is one of my personal favorite cases.

Why?

Because this patient’s result was so amazingly positive despite the fact that he had almost no chance of survival. Even if he did survive such devastating injuries, it seemed very likely he would not have normal mental capacity to function successfully in society.

It’s also one of my favorites because it demonstrates the strengths of the trauma and EMS system coming together for the benefit of a critically injured individual. At every level, professionals coped with the challenges this patient suffered. From the immediate life-saving interventions started by friends and family at the dangerous scene and continued by EMS rescuers to the acute care hospitals and then to rehabilitation, no one gave up on this patient.

Hopefully, a stop at the oasis helps fortify us for the vast desert ahead.

Lightning
Data on lightning-related injuries is sketchy, probably because most near strikes go unreported, but here’s what we know:

  • Unlike electrical injuries from man made sources, lightning is a high energy, but very brief duration phenomenon.
  • Lightning strikes are more frequent in areas closer to the equator.
  • Certain U.S. geographic regions are more prone to lightning risk. These include the Rocky Mountain States, Florida, the Gulf Coast, East Coast and areas of the Midwest. Florida is said to have twice the number of casualties as any other state.
  • Most strikes hit to people engaged in outdoor activity, but strikes can also penetrate buildings.
  • Lightning tends to seek tall and/or isolated objects to strike.
  • Injuries due to strikes (or near strikes) are estimated to be 750 5,000 per year.
  • Lightning deaths are one of the top three causes of environmental deaths.
  • Annual U.S. mortality related to strikes is about 10 20% (40 60 total fatalities). However, this number is likely underestimated.
  • Lightning is a very high energy source but tends to have very brief contact with the skin, making skin and internal burns unusual.
  • Most common injuries involve the neurologic system, including cognitive deficits, numbness, tingling, weakness of extremities or mottling of the skin (keraunoparalysis) and a variety of other problems.
  • Blunt force injuries related to the strike are fairly common.
  • Cardiac arrest is the only known direct cause of death due to lightning strikes. Lightning acts as a massive defibrillator, often leading to asystole. This leads to respiratory arrest and anoxia. In some patients, however, the heart may spontaneously restore a normal rhythm.
  • Most importantly, lightning should be respected. By the time thunder is heard, lightning is also present whether or not it can be seen.

Lessons Learned
This was a very rare case for the reasons outlined above. The patient appeared to suffer a nearly direct strike. Patients generally do not survive these. Significant skin burns are rare in lightning strikes, but his patient had substantial burns. In survivors, substantial neurologic injuries requiring prolonged therapy is common.

The scene associated with a lightning strike is not safe. Rescuers need to appreciate that, in some situations, care may have to be delayed until the patient can be moved to a safe location.

The results in this case point out the importance of prompt, effective bystander CPR, which has been stressed in multiple studies. It is unlikely this patient would have survived without it.

The crew in this case worked very well as a team from initial contact to hospital arrival. Despite setbacks, they never gave up. They continued CPR and defibrillations when appropriate and came up with an alternative that helped them secure the airway — all in less-than-ideal circumstances. This was undoubtedly fundamental in the patient’s survival. These against-the-odds outcomes are why most of us went into EMS in the first place.

Resources

Cooper MA: “Myths, Miracles, and Mirages.” Seminars in Neurology. 15(4):358 361, 1995.

Cooper MA: “Lightning Injuries.” http://emedicine.medscape.com/article/770642-overview

For more on natural phenomena, read“When Lightning Strikes”here.

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