Unusual Resucitation situations: Environmental Emergencies
Researchers report that 90% of lightning-strike victims survive, but up to 70% have a significant disability resulting from the strike.
When an environmental emergency progresses to respiratory and/or cardiac arrest, standard treatment is less likely to succeed. This article reviews assessment and treatment for unusual resuscitation situations resulting from the environmental emergencies of lightning injury, drowning and severe hypothermia.
Lightning Injuries
Lightning is wildly unpredictable in where it strikes and the severity of injuries it causes. It is the second leading weather-related cause of fatalities in the United States. An average of 67 fatalities per year are reported, but many researchers believe deaths and injuries are underreported because lightning is often not recognized as the cause of death or injury.
The energy of a lightning strike super- heats the surrounding air to as much as 50,000º F in a few millionths of a second. A lightning bolt can generate between 100 million and one billion volts of electricity. Lightning’s electrical energy can disrupt the body’s electrical communication pathways, especially in the heart and brain. The superheated air at the strike location is at extremely high pressure, creating a shock wave that expands outward for 10 m before becoming an ordinary sound wave. It can cause blunt trauma to the patient from the concussive force.
According to lightning injury expert MaryAnn Cooper, MD, lightning injuries range from trivial to fatal and are categorized as either immediate or delayed. Immediate injuries like cardiac arrest are instantaneous and unpredictable. The prognosis for patients with severe injuries is poor. Delayed injuries, which are a result of neurological insult to the brain after lightning strike, might not present until hours or days later.
Cardiopulmonary arrest is the only immediate cause of death for lightning-strike victims. The electrical effect of lightning sends the heart into ventricular standstill, or asystole, and paralyzes the brain’s respiratory center, incapacitating them and putting the patient into respiratory and cardiac arrest.
Respiratory arrest persists longer than cardiac arrest. Heart automaticity, the heart’s own electrical system, reorganizes contractions quickly. At this point, the heart is pumping but is not being supplied with oxygen.
As respiratory arrest continues, the heart becomes hypoxic, leading to arrhythmias and, ultimately, the return of cardiac arrest. Immediate basic and advanced cardiac life support skills can prevent hypoxia-related cardiac arrest.
Before we discuss assessment and treatment of lightning-related cardiac arrest, it is important to dispel myths about lightning strikes that may perpetuate improper actions that delay treatment and put rescuers at risk.
A common myth says, “If it is not raining, I am safe.” In fact, lightning can strike 10–15 miles from the storm, with clear blue sky overhead.
Lightning can also strike the same place twice. If an area or object was hit once, there is a chance it will be hit again.
Another myth that causes considerable delays in treatment is that lightning-strike victims carry an electrical charge. In fact, it is safe to immediately touch the patient and provide treatment.
Evacuating the patient is your highest priority. According to Ron Holle of the National Severe Storms Laboratory, “It is relatively unusual for victims to have major fractures that would cause paralysis or major bleeding complications unless they have suffered a fall or been thrown a distance. As a result, rescuers need to choose whether evacuation from high-risk areas to an area of lesser risk is warranted, and they should not be afraid to move the victim rapidly if necessary. Rescuers are cautioned to minimize their exposure to lightning as much as possible.”
An open garage or picnic shelter is not sufficient shelter. Rapidly move the patient to a fully enclosed structure or a vehicle with closed windows. Although spinal cord injuries from lightning strikes are rare, provide spinal stabilization for any patient who is unconscious, has fallen from a height or was thrown by the lightning strike.
