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Learning Station 3 Environmental Emergency 5 Par for the Course

1999 American Heart Association

We acknowledge outstanding contributions from Paul Berlin, MS, EMT-P, who provided initial drafts of the teaching support materials for this section.

Par for the Course

Playing golf on a local course, you take shelter during a brief thunderstorm. You see then hear a tremendous thunderclap one hole away. Aware of 3 friends playing there, you rush over, concerned that someone may have been hurt.

You see an alarming scene:

Three people are down Victim 1. Unconscious, not moving Victim 2. Sitting up, moaning, holding head Victim 3. Walking about, dazed, confused
Describe how you will approach this scene. What are your priorities? What is the concept of reverse triage here?

Reverse Triage
With multiple victims give highest priority to cardiac arrest patients Victims not in cardiac arrest have excellent chances of recovery Victim 1. Unresponsive person is pulseless and apneic Victim 2. Rapidly improving, making eye contact, wants to call home, thinks arm is broken Victim 3. Confused person, does not seem to understand you, cant hear, does not know what happened

Which victim do you approach? What are your actions?


Primary ABCD Survey

Airway? Breathing? Circulation? Defibrillation?

Incidence of Lightning Strike

Each year in the US: 1800 people struck by lightning 450 die Most common settings: Trees, camping, boating, golfing, using telephone

Lightning Facts

Primary cause of death is cardiac arrest secondary to VF or, more frequently, asystole Lightning acts as an instantaneous massive direct countershock Cardiac automaticity may restore organized cardiac activity

Secondary ABCD Survey

A: BVM breath sounds clear C: Pulses with CPR D: Dilated, unreactive pupils C: ECG: asystole C: Skin: mottled extremities C: Chest has fern pattern of mottling C: Small amount of blood from left ear


A, B, C, D CPR Prolonged CPR common Drugs and other therapies? Oxygen and ventilation for respiratory arrest May be all that is needed

ECG Changes

Patient has carotid pulse; BP 152/94 mm Hg Patient: still apneic; pupils dilated, unreactive



HEENT Chest Abdomen Extremities


Long-term Prognosis

Watch for Hearing loss Cataracts Burn scars Paresis Psychiatric illness



Lightning injuries differ from other high-voltage electrical injuries Consider lightning injuries as traumatic injuries follow C-spine precautions Burns are superficial, and only 25% die after being struck Triage priorities are different: Use reverse triage Good oxygenation and CPR are the key to resuscitation