Environmental Advanced

Lightning strike with multiple casualties at outdoor festival

Adult · 31yr · female

Patient Information

Dispatch: You are called to the main stage area at the Fremantle Winter Festival — reports of a lightning strike during a sudden storm. Multiple people down. Proceed to the northern end of the festival grounds.
Patient: Sarah Kowalski — 31yr (65kg)
Incident History: Pt is a 35YO female who was standing near a metal scaffolding structure during a lightning strike. Bystanders report she was thrown approximately 1.5 metres and lost consciousness briefly. Two other patients nearby — one ambulant and complaining of ringing in his ears, one male unconscious and not breathing.
Emergency Contact: David Kowalski (Husband) — 0412 774 391

Initial Rapid Assessment

Response: Voice
Airway: Patent. Nil visible obstruction. Nil stridor. Pt able to speak in short sentences.
Breathing: Rapid and shallow. Increased work of breathing. Accessory muscle use noted. RR 22. SpO2 89% on room air.
Circulation: Radial pulse present — rapid and irregular. Skin: pale, diaphoretic. Entry burn noted to right hand, exit burn to right foot. No catastrophic external haemorrhage.
Disability: GCS 12 (E3V4M5). Confused and disoriented to time and place. Pupils equal and reactive to light — 4mm bilaterally. Complains of chest pain and palpitations.
Exposure: Entry wound to right palm — full thickness burn approximately 2cm diameter. Exit wound to plantar surface right foot — similar appearance. Scattered superficial erythema to right forearm. No other obvious trauma on rapid survey.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	89% (RA)	Moderate	22	138	90/58	3s	12	4 4 ++	36.2	6.8 mmol/L	7
10 mins	97% (O2 NRB 15L)	Mild	18	118	102/64	2s	14	4 4 ++	36.2	6.8 mmol/L	5

History Taking

Treatment Response

Diagnosis

This patient is suffering from a direct/indirect lightning strike injury with suspected cardiac dysrhythmia (rapid irregular pulse consistent with a post-lightning arrhythmia), respiratory compromise, entry and exit burn wounds, and transient loss of consciousness. The scene also presents a multiple casualty incident requiring triage.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not perform a scene size-up and identify multiple casualties within the first 60 seconds — the conscious bystander approaches and grabs the officer's arm shouting 'My mate over there isn't breathing!' Direct trainees to articulate their triage decision before committing to primary patient.)
! (If the trainee does not call for backup/additional resources within the first 2 minutes — facilitator states: 'Your radio crackles. Supervisor asks for a status update. How many patients do you have and what resources are you requesting?')
! (If oxygen is not applied within 3 minutes — patient's SpO2 drops to 85% on room air and respiratory distress escalates to Severe. RR increases to 28.)
! (If the trainee does not note the irregular pulse or fails to consider cardiac arrhythmia — patient clutches her chest and says 'My heart feels like it's going crazy, it's jumping all over the place.' Pulse remains irregular and rapid at 138 bpm.)
! (If burn wounds are not identified and dressed — patient reports increasing pain to right hand rated 9/10 and asks 'Why does my hand feel like it's still on fire?')
! (If the trainee attempts to move the patient to assess the unconscious third casualty without delegating or calling additional crew — facilitator intervenes: 'You cannot leave your primary patient unattended. How are you managing multiple casualties?')
! (If c-spine precautions are not considered given the mechanism of being thrown 1.5 metres — facilitator prompts: 'The patient was thrown backwards. What does your trauma management principle tell you about mechanism of injury here?')

Treatment Objectives

1 Ensure scene safety — confirm scene is clear of live electrical source and no standing water in contact with any electrical source before approaching any patient.
2 Perform rapid scene size-up — identify three casualties: (1) Sarah Kowalski — conscious, confused, priority patient; (2) ambulant male — walking wounded, lowest priority; (3) unconscious male not breathing — highest priority. Call for immediate backup via CSP — request additional ambulance crews and Police/DFES if structural hazard (scaffolding) remains.
3 Don appropriate PPE including gloves.
4 Approach primary patient (Sarah Kowalski) — perform Primary Survey with c-spine consideration given mechanism of being thrown 1.5 metres.
5 Open, clear and maintain airway — patent, no intervention required at this time.
6 Assess breathing — RR 22, SpO2 89% RA, moderate respiratory distress.
7 Administer Oxygen via Non-Rebreather Mask at 10–15 L/min — titrate to SpO2 target 94–98%. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
8 Assess circulation — identify rapid and irregular pulse. Note this as a potential cardiac arrhythmia secondary to lightning strike. Identify entry burn (right palm) and exit burn (right foot). No catastrophic haemorrhage.
9 Assess disability — GCS 12, confusion, oriented to person only. Perform BGL — 6.8 mmol/L (normal, no hypoglycaemia treatment required).
10 Perform Exposure assessment — document entry and exit wounds, extent of burns to right hand and right foot.
11 Perform Vital Signs Survey — BP 90/58, HR 138 (irregular), RR 22, SpO2 89% RA, GCS 12.
12 Dress burn wounds — cool burn areas for a minimum of 20 minutes with clean water at approximately 15°C. Remove jewellery from right hand. Apply damp sterile dressings after cooling.
13 Position patient supine with c-spine consideration — given mechanism and altered GCS, maintain spinal precautions (lanyard around neck, instruct patient to keep head and neck still, apply head blocks once on stretcher).
14 Consider Methoxyflurane (Penthrox) 3 mL inhaled for pain management (chest pain 7/10, burn pain 6/10) — confirm patient is alert enough to self-administer and can follow instructions (GCS improving to 14 at 10 mins with oxygen).
15 Reassess vitals at 10 minutes — expect SpO2 improvement to 97% on O2, GCS improvement to 14, some reduction in HR with oxygen therapy.
16 Arrange urgent ambulance support via CSP — IMISTAMBO handover to receiving ED — communicate: lightning strike, suspected cardiac arrhythmia, burn injuries with entry and exit wounds, transient LOC, multiple casualty incident.
17 Delegate management of ambulant casualty (walking wounded male) to another crew member or event first aider if available.
18 Ensure unconscious non-breathing male casualty receives immediate CPR from additional crew — this is outside the scope of the primary patient officer to manage simultaneously.
19 Monitor patient persistently — record full observations every 5 minutes given time-critical status.
20 Scenario ends on arrival of ambulance and IMISTAMBO handover.
21 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Electrical injuries · Burn Trauma · Cardiac Dysrhythmia · Haemorrhage · Primary Survey · Oxygen Delivery · Penthrox Inhaler Administration · Direct Pressure and Trauma Bandages · Transient Loss of Consciousness (Fainting / Syncope)

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