A Bolt From the Blue

   The call is for a person struck by lightning, but it's come more than 30 minutes after the storm ended, so the Attack One crew is hoping for some minor after-effect of a strike that occurred during the storm. But the incident site is ominous: a local golf course.

   They arrive to find bystanders doing chest compressions on a young woman in the grass about 50 yards outside the back door of the golf office. The smell is noticeable: a combination of ozone and the smell of a burned person. The bystanders are performing excellent compressions, so the crew has them continue as they set up the monitor/defibrillator and place the pads. As they do so, the paramedics notice a curious pattern of burns across the young lady's upper chest and neck and down her left arm. Her legs and head appear to be unburned. As they place a posterior pad, they also note burns on her upper back. Her clothing is singed, but not burned.

   The victim is soaking wet, so the rescuers dry her skin using some towels and place her rapidly on a dry backboard. The monitor notes ventricular fibrillation, so the defibrillator is charged and a single shock administered. The rhythm changes to a brief period of asystole, then develops into a sinus rhythm. Compressions are stopped, as the rhythm is generating a palpable carotid pulse.

   The crew applies high-flow oxygen and assists respirations with a bag-valve mask and oral airway. They want to move the girl quickly to the ambulance, so they do a rapid trauma and burn evaluation, identifying the burn areas noted before, some areas of obvious poor perfusion and delayed capillary refill, and some areas of skin that appear to be pink and warm. She has only palpable pulses in her legs and right arm.

   The bystanders describe what happened: The young lady was working at the golf club and, with everyone else, waited in the clubhouse as the thunderstorm raged. After the rain ended and the sky cleared, the workers were just walking out to check on the conditions of the course when a bolt of lightning appeared seemingly out of the blue and struck her. Fellow workers and golfers saw what happened, rushed to the girl and called 9-1-1 as they started chest compressions.

   As far as anyone knows, the girl is 16 years old and in good health. She was down only about 30 seconds without compressions. Her parents have been called and told to go to the hospital.

   The club manager is present and keeps nervously checking the skies to make sure no more lightning is coming. Bystanders are speaking quietly about the clear skies that were overhead as the bolt hit. The Attack One crew members secure an intravenous line in the girl's right arm, administer lidocaine, continue assisting ventilations, respectfully remove her wet clothing while covering her up, and apply dry dressings to the burns evolving over her torso and neck. She meets the criteria for a load-and-go transport, so the entire group assists in carrying her to the waiting transport vehicle.

   During transport, the girl begins to breathe on her own, starts moving her right arm and develops a rapid heart rate. Her burns develop into areas of stark white across her upper chest and back, but the right arm and both legs are pink and warm, with strong pulses. Her airway is stable with the rescue airway in place, and she can be bagged and oxygenated. The pulse oximeter begins to register an oxygen saturation. The patient starts to withdraw from painful stimuli. By the time she arrives at the hospital, she's received a liter bolus of saline.

   There she is turned over to the emergency department resuscitation team. The crew shares available history with the emergency staff, acknowledging it's minimal. The parents arrive soon after.

   The patient is stabilized in the ED, then prepared for transfer to the regional burn center. She has patches of full-thickness burns to her upper back and chest and left arm. The left arm also has poor pulses and no movement. In time, that arm needs surgery to restore blood flow, and the girl receives burn grafting on her back and chest. She has a complete cardiac and neurologic recovery (likely thanks at least in part to the rapid response of bystanders). The left arm requires long-term rehabilitation, but she eventually returns to school.

Case Discussion

   This is the "typical because it's atypical" case of an injury related to a lightning strike. Lightning strikes present with a wide variety of symptoms and clinical problems. Typical problems occur in the skin and cardiovascular and neurologic systems, as with this patient. Patient management will be guided by the ABCs of critical patient care. In the cardiac arrest situation, new guidelines stress early and uninterrupted compressions, with airway management performed around the need for ongoing cardiocerebral perfusion. Lightning-caused burns can appear innocuous on initial presentation, but may evolve to major and life-threatening problems hours to days later.

   The proverbial "bolt from the blue" is a cloud-to-ground lightning flash that typically extends from the front or back side of a thunderstorm cloud, then travels a distance of miles in clear air away from the storm cloud, and angles down and strikes the ground. Lightning flashes have been documented to travel more than 25 miles from thunderstorm clouds.

   Such distant flashes are dangerous, as they occur away from thunderstorms, where skies are clear. This is why many outdoor venues, sports organizers and schools develop policies of waiting 30 minutes or more after rain ends and the last lightning occurs before resuming organized outdoor activities.

Initial Assessment

A 16-year-old female struck by lightning, in cardiac arrest.

• Airway: Unstable.
• Breathing: Not breathing.
• Circulation: Patches of burns, mixed with pale skin.
• Disability: GCS of 3.
• Exposure of Other Major Problems: Combination of burn injuries and cardiac arrest.

Vital Signs

AMPLE Assessment

• Allergies: Unknown.
• Medications: None known.
• Past Medical History: Unknown.
• Last Intake: Around 1200, according to coworkers.
• Event: Lightning strike.

Customer Service Opportunity

   The management of lightning strike patients can be very challenging, and often disturbing to rescuers, bystanders and significant others. Prevention messages are ubiquitous, but there are still "clear air" lightning strikes that occur in front of or behind storms, as in this case. Lightning strikes can be situations where there are frequent bystander rescue actions--for instance, they often initiate CPR. The sight and smell of burn wounds can be very disturbing and may cause problems for bystanders.

   James J. Augustine, MD, FACEP, is medical advisor for the Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton. Contact him at jaugustine@emp.com.