A 47-year-old man is brought to the emergency department after being injured by a lightning strike 10 minutes ago. He was playing tennis when a thunderstorm suddenly developed. He was struck by cloud-to-ground lightning and thrown several feet by the force of the bolt. Bystanders initiated chest compressions immediately. Emergency medical services arrived within 5 minutes and found the patient in cardiac arrest. On examination, his pupils are dilated and unresponsive to light. The electrical rhythm appears to be asystole. Which of the following is the most appropriate next step in management?

Question

A 47-year-old man is brought to the emergency department after being injured by a lightning strike 10 minutes ago.  He was playing tennis when a thunderstorm suddenly developed.  He was struck by cloud-to-ground lightning and thrown several feet by the force of the bolt.  Bystanders initiated chest compressions immediately.  Emergency medical services arrived within 5 minutes and found the patient in cardiac arrest.  On examination, his pupils are dilated and unresponsive to light.  The electrical rhythm appears to be asystole.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

Explanation: Lightning injuries are uncommon but can involve a number of organ systems, potentially leading to severe multisystem dysfunction and death. Characteristic features include thermal burns (superficial, partial, or full thickness), cardiac arrhythmias (eg, asystole, ventricular fibrillation), rhabdomyolysis with renal failure, and neurological dysfunction (loss of consciousness, temporary weakness/paralysis, autonomic dysfunction, respiratory depression). Excellent cardiopulmonary resuscitation (CPR) remains the most important component of basic and advanced cardiac life support (ACLS) for patients with asystole following lightning strike; every effort should be made not to interrupt CPR cycles. Chest compressions should be continued while administering vasopressors (eg, epinephrine) and identifying and treating reversible causes of cardiac arrest. Lightning injury can cause temporary autonomic dysfunction with fixed and dilated pupils; this finding should not preclude extended resuscitation efforts. Most victims of lightning injury are relatively young, have few clinical comorbidities, and may recover even following a prolonged period of asystole if they receive appropriate CPR (Choice E). (Choice A) Early defibrillation is indicated in patients with ventricular fibrillation (VF) and/or pulseless ventricular tachycardia (VT). It is ineffective in patients with asystole or pulseless electrical activity (PEA) and is contraindicated. (Choice C) Amiodarone has no role in the management of patients with asystole. It is occasionally used to treat stable patients with regular, wide complex tachycardia, and may be used for patients with pulseless VT or VF that is unresponsive to initial defibrillation. (Choice D) Atropine is considered first-line therapy for patients with symptomatic bradycardia. However, atropine is not recommended for the treatment of asystole or PEA. Educational objective: Lightning injury can cause cardiac arrest with asystole or ventricular fibrillation. It should be treated with prompt uninterrupted cardiopulmonary resuscitation and use of vasopressors (eg, epinephrine). Atropine is not recommended for the treatment of asystole or pulseless electrical activity. References: Lightning injuries (http://www.ncbi.nlm.nih.gov/pubmed/15163573) Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Case Science with Treatment Recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/20956249)

A 47-Year-Old Man Is Brought to the Emergency Department After