Environmental Advanced

Lightning strike with multiple casualties at outdoor festival

Adult · 24yr · male

Patient Information

Dispatch: You are called to the main stage area at the Fremantle Sunset Festival. Witnesses report a lightning strike near the crowd — multiple people are down. One adult male is unresponsive on the ground.
Patient: Darren Kowalski — 24yr (80kg)
Incident History: Pt was standing near the main stage barriers when lightning struck approximately 3 metres away. Pt was thrown backwards and is now unresponsive on the ground. At least 2 other bystanders nearby are also injured.
Emergency Contact: Nicole Kowalski (Wife) — 0412 774 339

Initial Rapid Assessment

Response: Pain
Airway: Patent. No visible airway obstruction. No stridor. Jaw relaxed. Mouth clear.
Breathing: Shallow and irregular. Reduced rate. Laboured effort. No audible wheeze or crackles. Chest rises bilaterally but minimally.
Circulation: Weak and irregular radial pulse palpable. Skin: pale, cool and clammy. No active external haemorrhage visible. Entry/exit burn marks noted on right hand and left foot.
Disability: GCS 8 (E2V2M4). Not orientated to time, place or person. Pupils sluggish bilaterally.
Exposure: Entry wound: right palm — charred, circular burn approximately 1 cm. Exit wound: left foot dorsum — stellate burn pattern. Clothing partially scorched across right torso. No limb deformity apparent. No cervical spine tenderness on palpation.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	88% (RA)	Moderate	8	140	88/54	4s	8	4 4 SL	35.6	6.2 mmol/L	–
10 mins	96% (O2 NRB 15L)	Mild	14	118	102/66	3s	11	4 4 ++	35.8	6.2 mmol/L	6

History Taking

Treatment Response

Diagnosis

This patient is suffering from a direct lightning strike injury with associated loss of consciousness, haemodynamic instability, respiratory compromise, burn injuries (entry right hand, exit left foot), and cardiac arrhythmia (tachycardia with irregular rhythm consistent with post-lightning arrhythmia). Two additional walking-wounded casualties require triage.

Facilitator Triggers — if trainees miss a critical step

! (If trainees fail to triage the scene before focusing solely on Darren — after 2 minutes, a second bystander walks up distressed and says: 'My friend over there is also on the ground and not moving!' Facilitator directs trainees to the second casualty — a 28-year-old female who is conscious and alert with a singed arm and GCS 15. A third bystander has minor flash burns to arms only and is ambulatory. Trainees must allocate resources: Darren is urgent, female bystander Priority 2, third bystander Priority 3.)
! (If oxygen is not applied within 3 minutes, patient's SpO2 drops further to 84% RA and RR slows to 6 — facilitator cues: 'The patient's breathing is becoming more shallow and he looks cyanotic.')
! (If trainees do not assess for entry and exit wounds during Exposure, facilitator cues: 'You notice a distinctive burn mark on the patient's right hand — what do you think caused this?')
! (If trainees do not identify the irregular pulse as a potential arrhythmia and do not consider requesting ALS backup, facilitator cues: 'The patient's pulse feels irregular and you notice his colour has not improved despite oxygen — what do you want to do next?')
! (If trainees attempt to administer an out-of-scope medication for arrhythmia management, facilitator states: 'That medication is outside your scope of practice — what can you do within your scope right now?')
! (If BVM ventilation is not initiated despite RR of 8 and SpO2 of 88%, facilitator cues: 'The patient's breathing is inadequate — what intervention does this require?')
! (If c-spine is not considered given the mechanism of being thrown backwards, facilitator cues: 'The patient was thrown approximately one metre from the strike site — does this mechanism concern you regarding the cervical spine?')

Treatment Objectives

1 Ensure scene safety — confirm no live electrical source, no standing water in contact with source, no ongoing lightning risk before approaching any casualty.
2 Perform rapid scene triage — identify three casualties: Darren Kowalski (urgent — unresponsive, haemodynamic instability), 28-year-old female bystander (Priority 2 — conscious, singed arm, ambulatory), third bystander (Priority 3 — minor flash burns, ambulatory). Allocate EHS resources accordingly and call for additional EHS/ALS backup via CSP.
3 Approach Darren Kowalski — don appropriate PPE (gloves, eye protection).
4 Perform Primary Survey with c-spine consideration — mechanism of being thrown backwards warrants spinal precautions.
5 Assess airway: patent but unresponsive — insert appropriately sized Oropharyngeal Airway (OPA). Measure from centre of lips to angle of mandible.
6 Assess breathing: RR 8, shallow and irregular, SpO2 88% RA — initiate assisted BVM ventilation with high-flow oxygen at 15 L/min. Ventilate at 10–12 breaths/minute for an adult with inadequate spontaneous effort. Maintain gentle tidal volume with visible minimal chest rise.
7 Apply Non-Rebreather Mask at 10–15 L/min once spontaneous breathing improves sufficiently OR continue BVM ventilation while breathing remains inadequate. Target SpO2 94–98%.
8 Assess circulation: weak and irregular pulse — note irregularity as potential cardiac arrhythmia. Ensure ALS/Paramedic backup is requested urgently via CSP.
9 Assess disability: GCS 8 (E2V2M4) — perform BGL: 6.2 mmol/L (no hypoglycaemic intervention required). Note pupils sluggish bilaterally.
10 Exposure: identify and document entry wound right palm and exit wound left foot dorsum. Do not attempt to remove clothing adhered to burn sites.
11 Assess burn wounds: apply cool running water to burn sites for minimum 20 minutes at 15°C. Do not apply ice directly. Avoid hypothermia — monitor temperature (initial 35.6°C).
12 Apply warm blanket to non-burned areas to prevent further heat loss — patient is at risk of hypothermia (temp 35.6°C, cool/clammy skin). Use Ready-Heat Blanket if available, placed over a sheet — do not place directly on burned areas.
13 Position patient: supine with c-spine precautions given mechanism. Apply lanyard/headblocks as per Spinal Trauma CPG. If patient vomits, perform Lateral Trauma Position maintaining spinal alignment with 3-person technique.
14 Perform Vital Sign Survey: document all vitals at initial assessment and every 5 minutes (time-critical patient).
15 Perform Secondary/CNS Survey: assess head-to-toe for additional injuries (fractures from being thrown, TBI signs — note sluggish pupils). Document findings on ePCR.
16 Note bilateral leg weakness reported on regaining consciousness — document as potential neurological deficit and communicate to receiving facility.
17 Call CSP urgently for ALS Paramedic backup.
18 Reassess all three casualties at regular intervals. Update triage status as condition changes.
19 Prepare urgent ambulance via CSP for Darren Kowalski with IMISTAMBO handover of receiving ED. Communicate: lightning strike mechanism, entry/exit burns, initial LOC, cardiac arrhythmia, neurological deficit, current GCS and vitals.
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 · Primary Survey · Bag Valve Mask Ventilation · Oxygen Delivery · Lateral Trauma Position · Spinal Trauma · Secondary & CNS Survey · Direct Pressure and Trauma Bandages · Glasgow Coma Scale (GCS) · Blood Glucose Monitor · Tympanic Thermometer · Ready Heat Blanket

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