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Approach to the Critical Patient
Immediate priorities
High risk lightning presentation
Immediate collapse
Transient respiratory arrest with secondary hypoxic cardiac arrest
Ventricular fibrillation or asystole
Reverse triage for multiple victims
Apneic or pulseless patients prioritized first
Prolonged resuscitation reasonable with lightning
Trauma plus medical dual pathway
Concomitant blunt trauma from blast or fall
Concomitant burns and dysrhythmia risk
Airway and breathing
Intubation triggers
Persistent apnea
Refractory hypoxemia
GCS 8 or less
Severe agitation interfering with care
Ventilation targets
SpO2 94 to 98 percent
End tidal CO2 35 to 45 mmHg
Cervical spine precautions
High energy mechanism
Altered mental status
Circulation and rhythm
Immediate monitoring
Continuous ECG monitoring
Defibrillator pads in place for unstable presentation
Shock evaluation
Hemorrhagic shock from trauma
Neurogenic shock from spinal cord injury
Cardiogenic shock from dysrhythmia or myocardial dysfunction
Vascular access
Two large bore IV lines
Intraosseous access if no IV within 90 seconds
Temperature and environment
Hypothermia risk
Wet clothing removal
Active rewarming for core temperature under 35 C
Hyperthermia risk
Active cooling for temperature 40 C or higher
Key decision points
Need for resuscitation bay
Cardiac arrest or peri arrest
Any rhythm instability
Any hypotension with altered mental status
Severe neurologic deficit
Focal deficit
Seizure
Persistent altered mental status
Significant burns
TBSA 10 percent or higher
Full thickness burn concern
Circumferential extremity burn
Observation versus admission
Telemetry need
Abnormal ECG
Chest pain
Syncope
Cardiac arrest
Significant burn
Significant rhabdomyolysis risk
Trauma imaging pathway
High risk fall
Head strike with symptoms
Spine pain or neurologic deficit
PITFALLS
Common misses
Tympanic membrane rupture
Otalgia
Hearing loss
Delayed cataract and retinal injury
Visual changes after discharge
Rhabdomyolysis without large burns
Dark urine
Muscle pain
Keraunoparalysis misread as spinal cord injury
Transient weakness and sensory loss
Cool pulseless appearing limb with recovery over hours
History
Focused lightning history
Exposure context
Mechanism category
Direct strike
Side flash
Ground current
Contact injury
Upward streamer
Location and environment
Open field
Water exposure
Shelter type
Time since strike
Witnessed collapse
Estimated downtime
Cardiorespiratory symptoms
Loss of consciousness
Duration
Post event confusion
Chest pain
Exertional similarity
Pleuritic component
Palpitations
Onset after strike
Associated syncope
Dyspnea
Persistent apnea episode history
Aspiration concern
Neurologic symptoms
Headache
Thunderclap pattern
Persistent vomiting
Weakness or numbness
Symmetry
Ascending pattern
Seizure
Witnessed tonic clonic activity
Postictal phase
Memory gaps
Retrograde amnesia
Anterograde amnesia
Injury pattern clues
Fall or blast trauma
Height
Impact sites
Burns and skin findings
Painful burn areas
Clothing damage
Ear and eye symptoms
Hearing loss
Tinnitus
Vision loss
Photophobia
Risk modifiers
Comorbidities
Cardiac disease
Heart failure
Coronary disease
Channelopathy history
Neurologic disease
Seizure disorder
Prior stroke
Kidney disease
Baseline creatinine history
Medications
QT prolonging agents
Antipsychotics
Macrolides
Anticoagulants
DOAC use
Warfarin use
Pregnancy status
Gestational age
Abdominal pain or vaginal bleeding
Physical Exam
Primary survey findings
Vital signs and perfusion
Hemodynamic instability
SBP under 90 mmHg
Tachycardia with poor perfusion
Respiratory compromise
RR over 30
SpO2 under 90 percent on room air
Cardiac and lung exam
Dysrhythmia signs
Irregular pulse
Bradycardia with hypotension
Heart failure signs
Crackles
Elevated JVP
Neurologic status
GCS
Trend over time
Sedation confounders
Focal deficits
Cranial nerves
Motor asymmetry
Sensory level
Spinal cord signs
Hyperreflexia
Priapism
Bladder retention
Secondary survey focus
Skin and burn pattern
Lichtenberg figures
Fern like erythema
Self limited hours to days
Thermal burns
Entry or exit like focal burns
Contact points at metal objects
Circumferential burn concern
Distal pain
Distal paresthesia
Delayed cap refill
Musculoskeletal and compartments
Long bone injury
Deformity
Point tenderness
Compartment syndrome
Pain out of proportion
Pain with passive stretch
Tense compartments
Ear exam
Tympanic membrane integrity
Perforation
Hemotympanum
Eye exam
Visual acuity
Baseline comparison
New deficit
Pupils
Anisocoria
Afferent defect
Corneal findings
Abrasion
Foreign body
PITFALLS
Keraunoparalysis
Transient limb weakness
Rapid onset after strike
Resolution within hours
Peripheral vasospasm findings
Cool mottled extremity
Weak pulses with later normalization
Differential Diagnosis
Life threats to exclude
Cardiac arrest and dysrhythmia
Ventricular fibrillation
ICD 10 I49.01
Ventricular tachycardia
ICD 10 I47.20
Complete heart block
ICD 10 I44.2
Intracranial injury from fall or blast
Intracranial hemorrhage
ICD 10 I62.9
Concussion
ICD 10 S06.0X0A
Spine injury
Cervical fracture
ICD 10 S12.9XXA
Spinal cord injury
ICD 10 S14.109A
Thoracic trauma
Pneumothorax
ICD 10 J93.9
Pulmonary contusion
ICD 10 S27.329A
Rhabdomyolysis and AKI
Rhabdomyolysis
ICD 10 M62.82
Acute kidney failure
ICD 10 N17.9
Burn injury
Burn unspecified body region
ICD 10 T30.0
Effects of lightning
ICD 10 T75.0XXA
Mimics and associated conditions
Electrical injury not lightning
Electric current exposure
ICD 10 W86.XXXA
Heat illness at outdoor event
Heat exhaustion
ICD 10 T67.5XXA
Hypothermia after storm exposure
Hypothermia
ICD 10 T68.XXXA
Acute coronary syndrome
NSTEMI
ICD 10 I21.4
Stroke
Acute ischemic stroke
ICD 10 I63.9
Laboratory Tests
Core labs for moderate to severe presentations
Metabolic and renal
Electrolytes and creatinine
Potassium mmol/l for hyperkalemia risk
Creatinine trend for AKI
Bicarbonate
Metabolic acidosis from shock or rhabdomyolysis
Glucose
Hypoglycemia mimic for altered mental status
Muscle injury and hemolysis
Creatine kinase
Rhabdomyolysis screening
Serial trend every 6 to 8 hours when elevated
AST and ALT
Muscle injury contribution to transaminitis
Cardiac injury
High sensitivity troponin
Chest pain or abnormal ECG
Rising pattern for myocardial injury
Hematology and coagulation
Complete blood count
Trauma bleeding concern
Leukocytosis nonspecific stress marker
INR and aPTT
Anticoagulant use
Major trauma pathway
Urine testing
Urinalysis
Heme positive with few RBC as myoglobin clue
Specific gravity for hydration status
Urine myoglobin
Supportive for rhabdomyolysis when available
Point of care and targeted tests
Blood gas and lactate
Venous or arterial blood gas
pH and PaCO2 mmHg for ventilatory failure
Severe acidosis trigger for escalation
Lactate
Shock marker
Trend response to resuscitation
Pregnancy testing
hCG
Any patient with pregnancy potential
Guides fetal monitoring pathway
Interpretation pitfalls
Cardiac biomarkers
Troponin elevation mechanisms
Demand ischemia from arrest
Direct myocardial injury
Single normal troponin
Limited early sensitivity after immediate event
Urine heme
Heme positive with no RBC
Myoglobin possibility
Hemolysis possibility
Diagnostic Tests
Scoring Systems
Triage and severity tools
Trauma activation criteria
Hypotension
GCS under 13
High risk mechanism fall or blast
Burn size estimation
Rule of nines adult
Lund and Browder chart pediatrics
Rhabdomyolysis risk stratification
CK over 5000 IU per l high AKI risk
Rising creatinine high AKI risk
ECG based risk grouping
Low risk ECG
Normal sinus rhythm
No ischemic changes
High risk ECG
Dysrhythmia
Conduction block
ST segment changes
MRI
Neuro axis evaluation
Brain MRI indications
Persistent focal deficit with normal CT
Persistent altered mental status with unclear cause
Spine MRI indications
Objective myelopathy signs
Persistent sensory level
Suspected ligamentous injury with normal CT
Limitations
Unstable patient incompatibility
Time delay in resuscitation setting
CT
Head and spine imaging
CT head noncontrast
Head trauma with symptoms
New seizure
Persistent altered mental status
CT cervical spine
Neck pain
Neurologic deficit
High risk mechanism with unreliable exam
Chest and abdomen imaging
CT chest abdomen pelvis trauma protocol
High energy fall
Abdominal tenderness
Thoracic trauma signs
CT angiography indications
Suspected major vascular injury from blast trauma
Limb ischemia not consistent with keraunoparalysis
CT pearls
Normal CT head
Does not exclude delayed neurologic sequelae
Normal CT spine
Does not exclude spinal cord concussion or ligamentous injury
Ultrasound
POCUS applications
eFAST
Free fluid assessment in unstable trauma
Pneumothorax assessment
Cardiac ultrasound
Pericardial effusion assessment in arrest
Global systolic function assessment in shock
Vascular ultrasound
Arterial flow assessment when limb ischemia suspected
DVT assessment when prolonged immobilization
Ultrasound limitations
Operator dependence
Quality variability
Documentation requirements
Negative eFAST
Does not exclude retroperitoneal bleeding
Disposition
Level of care criteria
ICU indications
Cardiac arrest
Post ROSC care
Targeted temperature management consideration per local protocol
Unstable dysrhythmia
Recurrent ventricular arrhythmia
Bradycardia with hypotension
Respiratory failure
Persistent apnea episodes
Mechanical ventilation
Severe rhabdomyolysis
Hyperkalemia mmol/l elevation
Rising creatinine with oliguria
Telemetry admission indications
Abnormal ECG
ST changes
QT prolongation
Conduction block
Chest pain
Troponin elevation
Ongoing symptoms
Syncope
Unexplained collapse
Significant burns
TBSA 10 percent or higher
Full thickness concern
Observation unit criteria
Normal initial ECG
Brief monitoring period per local protocol
Repeat ECG if symptoms evolve
Mild symptoms only
Normal neurologic exam
No significant trauma
Discharge criteria
Safe discharge conditions
Normal ECG
No dysrhythmia on monitoring
No concerning symptoms
Normal neurologic exam
Resolution of transient symptoms
Reliable follow up
No significant trauma
Imaging negative when indicated
Pain controlled with oral meds
Low rhabdomyolysis concern
CK not rising
Normal renal function trend
Treatment
Cardiac arrest and dysrhythmias
Resuscitation pathway
ACLS per current AHA guidance
Early defibrillation for VF or pulseless VT
High quality CPR with minimal interruptions
Respiratory arrest focus
Assisted ventilation to prevent secondary hypoxic arrest
Early airway placement when feasible
Post ROSC bundle
SpO2 94 to 98 percent
PaCO2 35 to 45 mmHg
MAP 65 mmHg or higher
Unstable bradycardia
Atropine
Atropine IV 1 mg
Repeat every 3 to 5 minutes
Maximum 3 mg
Transcutaneous pacing
Symptomatic bradycardia refractory to atropine
Sedation if time and perfusion allow
Epinephrine infusion
Epinephrine IV infusion 2 to 10 microg per minute
Titrate to perfusion targets
Continuous ECG monitoring
Narrow complex tachycardia
Adenosine
Adenosine IV 6 mg rapid push
Second dose 12 mg rapid push
Avoid in irregular wide complex rhythm
Ventricular dysrhythmia
Amiodarone for VF or pulseless VT refractory to shocks
Amiodarone IV 300 mg
Additional dose 150 mg
Follow with infusion per ACLS protocol
Magnesium for torsades
Magnesium sulfate IV 2 g
Repeat dosing per recurrence
QT prolongation correction strategy
Rhabdomyolysis and kidney protection
Fluid strategy
Isotonic crystalloid
Normal saline IV bolus 10 to 20 ml per kg for hypovolemia
Maintenance infusion guided by urine output
Urine output targets
Adults 1 to 2 ml per kg per hour
Pediatrics 1 to 2 ml per kg per hour
Electrolyte management
Hyperkalemia protocol if potassium elevation mmol/l
Calcium gluconate IV 3 g
Repeat for persistent ECG changes
Continuous ECG monitoring
Insulin regular IV 10 units
Dextrose IV 25 g
Glucose recheck every 30 to 60 minutes
Salbutamol inhaled 10 to 20 mg nebulized
Tachycardia monitoring
Additive to insulin effect
Hypocalcemia
Avoid routine calcium replacement in rhabdomyolysis unless symptomatic
Calcium replacement for seizures or arrhythmia
Compartment syndrome mitigation
Limb elevation at heart level
Avoid excessive elevation with ischemia concern
Frequent neurovascular checks
Surgical consultation triggers
Progressive pain with passive stretch
Diminishing pulses not due to vasospasm
Burns and wound care
Burn care basics
Cooling and cleaning
Cool running water for superficial thermal burns
Avoid ice application
Dressings
Nonadherent dressing for partial thickness burns
Moist wound environment
Tetanus prophylaxis
Tdap if not up to date
TIG for unknown or incomplete vaccination with dirty wound
Burn center referral triggers
Full thickness burn
Any size
High risk functional areas
Hands feet face genitalia major joints
Specialized care requirement
Functional outcome risk
Circumferential extremity burn
Escharotomy consideration
Distal ischemia risk
Infection prevention
Systemic antibiotics
Not routine for uncomplicated burns
Indicated for cellulitis or invasive infection signs
Pain control and sedation
Analgesia options
Acetaminophen
Acetaminophen PO 1000 mg
Maximum 4000 mg per 24 hours
Lower maximum in liver disease
Ibuprofen
Ibuprofen PO 400 mg
Repeat every 6 hours
Avoid in significant AKI risk
Fentanyl
Fentanyl IV 25 microg
Repeat every 5 to 10 minutes
Titrate to pain control
Morphine
Morphine IV 2 mg
Repeat every 5 to 10 minutes
Avoid in hypotension
Agitation and procedures
Ketamine
Ketamine IV 0.2 mg per kg
Repeat dosing for analgesia
Airway monitoring
Midazolam
Midazolam IV 1 mg
Repeat every 2 to 3 minutes
Respiratory depression monitoring
Eye and ear injury management
Eye care
Irrigation for debris exposure
Normal saline until symptom relief
Fluorescein exam for abrasion
Ophthalmology consultation triggers
Decreased visual acuity
Hyphema
Suspected globe injury
Delayed complications counseling
Cataract risk
Retinal injury risk
Ear care
Tympanic membrane rupture
Keep ear dry
Avoid otic drops unless prescribed
ENT referral triggers
Vertigo
Facial weakness
Persistent hearing loss
Special Populations
Pregnancy
Maternal and fetal priorities
Maternal stabilization first
ABCs prioritized
Left lateral tilt for hypotension reduction
Fetal assessment
Viable gestation fetal monitoring per local protocol
Obstetrics consultation
Rh status consideration
Rh immunoglobulin for trauma with Rh negative status per local protocol
Imaging considerations
CT when maternal life threat
Do not delay indicated imaging
Shielding when feasible
MRI use
Preferred for neuro axis when stable
Avoid gadolinium unless essential
Geriatric
Higher complication risk
Baseline cardiac disease
Lower threshold for telemetry
Lower threshold for troponin testing
Anticoagulant use
Lower threshold for CT head
Bleeding risk assessment
Medication adjustments
Opioid sensitivity
Lower initial dosing
Delirium monitoring
Pediatrics
Weight based resuscitation
Fluids
Isotonic crystalloid 10 to 20 ml per kg bolus
Reassess after each bolus
Analgesia dosing
Acetaminophen PO 15 mg per kg
Ibuprofen PO 10 mg per kg
Telemetry thresholds
Lower threshold for monitoring
Unwitnessed event
Any syncope
Nonaccidental trauma consideration
History mismatch
Suspicious injuries
Background
Epidemiology
Lightning injury patterns
Seasonal clustering
Warm weather peak
Outdoor activity association
Mechanism distribution
Ground current common mechanism
Direct strike less common but higher severity
Mortality drivers
Immediate cardiopulmonary arrest
Secondary trauma injuries
Pathophysiology
Electrical energy effects
Depolarization
Cardiac conduction disruption
Respiratory center disruption
Blast and barotrauma
Tympanic membrane rupture
Blunt trauma from shock wave
Thermal effects
Superficial flash burns
Deep tissue injury possible without large surface burn
Keraunoparalysis mechanism
Autonomic mediated vasospasm
Transient limb ischemia appearance
Rapid recovery typical
Therapeutic Considerations
Resuscitation principles
Early ventilation emphasis
Respiratory arrest primary event in some cases
Prevent secondary hypoxic arrest
Dysrhythmia readiness
Early defibrillation availability
Continuous monitoring for delayed arrhythmia
Rhabdomyolysis prevention
Early fluids
Reduce myoglobin nephrotoxicity
Maintain renal perfusion
Hyperkalemia anticipation
ECG monitoring
Repeat electrolytes with rising CK
Patient Discharge Instructions
copy discharge instructions
Lightning injury discharge guidance
Wound care
Keep dressings clean and dry
Daily gentle cleaning with soap and water for minor burns
Hydration
Increased oral fluids unless restricted by clinician
Monitor urine color for darkening
Activity
Avoid strenuous exercise for 48 to 72 hours
Gradual return if no symptoms
Return to ED now for red flags
Chest pain
Palpitations
Fainting
Shortness of breath
New weakness or numbness
Severe headache
Seizure
Confusion worsening
Decreasing urine output
Dark cola colored urine
Increasing burn pain redness swelling or pus
Vision changes
Hearing loss or drainage from ear
Follow up
Primary care within 48 to 72 hours
Ophthalmology referral if any vision symptoms
ENT referral if hearing symptoms persist
References
Clinical guidelines and evidence sources
Core guidelines
American Heart Association Guidelines for CPR and ECC 2025
Adult advanced life support section
Defibrillation and medication algorithms
American Heart Association Focused Update on ACLS 2023
Updated evidence for cardiac arrest interventions
Applies to lightning arrest resuscitation framework
Wilderness Medical Society Practice Guidelines for prevention and treatment of lightning injuries 2014 update
Reverse triage recommendation
Telemetry and organ system based management recommendations
Emergency medicine resources
ACEP wilderness medicine lightning injury review
ED evaluation emphasis on ATLS and ACLS framework
Admission for persistent neurologic cardiac or vascular abnormalities
Annals of Emergency Medicine review of electrical shock and lightning strike
Aggressive resuscitation recommendation
Cardiopulmonary arrest focus
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.