What's Your Diagnosis? Pediatric Electrical Injuries in the ED

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got last Recognition and Management of Pediatric Travel-Associated Infectious Diseases in the Emergency Department right.

Case Presentation: Pediatric Electrical Injuries in the Emergency Department: An Evidence-Based Review

A 13-year-old girl who was struck by lightning while playing soccer is brought in by EMS…

The girl was playing soccer in an open field when a thunderstorm started. While trying to take shelter, lightning struck a tree approximately 2 feet away, and she was thrown several feet. An adult observed that she was unresponsive, so he called 911 and initiated CPR. When EMS arrived, an AED was placed and a shock was delivered, with subsequent return of spontaneous circulation. The patient was prepped for transport with a C-collar in place. During transport, her cardiac rhythm was sinus tachycardia, with a palpable pulse, and bag-valve mask ventilation was initiated for no spontaneous respirations.

Upon arrival to the ED, the girl is unresponsive. She has an intact airway but no spontaneous respirations. She has symmetric, clear breath sounds with bag-valve mask ventilation. Cardiac rhythm is sinus tachycardia with a palpable pulse, and her blood pressure is 130/90 mm Hg. She has a GCS score of 3. Her pupils are 4- to 5-mm and nonreactive. She has a Lichtenberg figure across her rib cage, an erythematous irregular patch on the dorsum of her right foot, and there is bloody drainage from her left ear.

How should you evaluate and manage this patient in the ED?

Case Conclusion

The patient had ROSC achieved by EMS after asystole, immediately following the event. She arrived to the ED as a full trauma activation. Two peripheral IVs were obtained. She was intubated due to prolonged respiratory muscle paralysis and a GCS score of 3. Post–cardiac arrest care was started per PALS recommendations. An ECG showed sinus tachycardia, which was consistent with the cardiac monitor on arrival. Blood work was ordered, including a CBC, glucose, electrolytes, BUN, creatinine, CK, urinalysis, and urine myoglobin, which were all reassuring. The girl’s urine pregnancy test was negative. A noncontrast CT of the head and cervical spine was obtained because of the GCS score and report that she was thrown a significant distance; these CT scans were negative. An E-FAST was negative. ENT was consulted for the tympanic membrane rupture, and the general surgery team was already present during the trauma activation and evaluated the patient’s burns. Once the patient was stabilized, she was transferred to the nearest burn center that accepted pediatric patients. The Lichtenberg figure resolved after a few hours, with no residual skin involvement at the site. The girl made a full recovery but did develop cataracts months later.