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AFTER YOUR softball game is canceled because of a thunderstorm, you start putting your equipment in your car. Suddenly you see a flash of lightning in the next field and hear someone shout that a player is down. Hurrying to help, you find Pete Dunn, 33, lying on the field unconscious. You keep his back and neck as straight as possible and help his teammates carefully move him to the shelter of a nearby concession stand, out of the storm.

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What's the situation?

Checking his ABCs (airway, breathing, and circulation), you find that Mr. Dunn is unresponsive and not breathing. His uniform is shredded and torn in several places around his right arm. One of his teammates has called 911.


What's your assessment?

Lightning strike-whether direct or indirect through the ground or a tree-can cause severe injuries. Cardiac arrest is the most common cause of death related to lightning strike. Respiratory arrest may persist even after a cardiac rhythm has been established.


Because lightning usually passes over the body's surface, rather than through the body, even in a direct hit, tissue damage and elevated levels of potassium, creatine kinase, and myoglobin are relatively rare. Burns, if present, are usually mild and superficial.


What must you do immediately?

Use a jaw-thrust maneuver to open Mr. Dunn's airway and deliver two rescue breaths. You see no signs of spontaneous circulation, so you start chest compressions. After a minute, you assess for signs of spontaneous breathing or circulation. Finding none, you continue with CPR.


The paramedics arrive and attach a portable monitor-defibrillator to Mr. Dunn. After determining that he's in ventricular fibrillation, they deliver two rapid defibrillations. Mr. Dunn's heart responds with sinus bradycardia followed by sinus tachycardia. He has a carotid pulse, but still isn't attempting to breathe, so the paramedics intubate and manually ventilate him. They also establish an I.V. access, draw blood for lab work, and start an infusion of 0.9% sodium chloride solution. Mr. Dunn is taken to the local hospital.


When continuous ECG monitoring is started in the ED, it reveals sinus tachycardia. A 12-lead ECG rules out cardiac conduction defects. Mr. Dunn is having vascular spasms caused by the lightning strike, so the staff uses a Doppler ultrasound to identify peripheral pulses. Mr. Dunn's BP is 148/86, but he's still not breathing spontaneously, so he's put on mechanical ventilation. The ED physician notes that the only burn injury is a superficial burn in a fernlike pattern on Mr. Dunn's right arm. He slows the I.V. infusion to prevent cerebral edema, which may accompany lightning strike. He examines Mr. Dunn's ears and finds blood behind both tympanic membranes, which were ruptured by high-pressure shock waves from the thunderclap. The physician orders a computed tomography scan of the brain, which rules out basilar skull fractures and intracerebral bleeding.


Mr. Dunn is transferred to the surgical ICU for ventilator support and ECG monitoring for delayed cardiac arrhythmias. Because eye injuries are common in lightning strike victims, the ED physician orders an ophthalmology consult.


What should be done later?

As Mr. Dunn regains consciousness, he begins to breathe spontaneously and to assist the ventilator. He's weaned from the ventilator, but the ECG monitoring continues: Conduction disturbances such as a prolonged QT interval may not be evident until the second day.


A neuropsychologist will evaluate Mr. Dunn for long-term neurologic damage, including peripheral injury and associated pain, and psychological dysfunction, which isn't related to the severity of the injury.


After 3 days, Mr. Dunn is discharged home. He'll be followed by the neuropsychologist for several months to watch for lightning-associated neurologic injuries.