Reverse triage for lightning-strike MCI
Reverse triage is essential in lightning-strike induced mass casualty incident (MCI) since those who appear dead may be easily resuscitated with good survival rates, so should be attended to first.
Patients sufferring from lightning strike may initially have fixed and dilated pupils (autonomic dysfunction) and cold mottled extremities from vasospasm. Asystole occurs from direct depolarization of the myocardium but typically spontaneous ROSC is achieved. Respiratory arrest from medullary paralysis can take longer to resolve and patients may develop a secondary hypoxic arrest.
Tourniquet time < 2 h is considered safe
The general conclusion is that a tourniquet can be left in place for 2 h with little risk of permanent ischemic injury. However, the majority of the literature looks at pneumatic tourniquets in elective theatre cases with normovolemic patients. In hypovolemic trauma patients with non‐pneumatic tourniquets these figures may not be applicable.
There is very little data on the complication rate of clinically indicated pre‐hospital tourniquet application and therefore there is no safe tourniquet time. One study identified that 5.5% of 110 pre‐hospital tourniquet applications resulted in neurological complications, with an ischemic time between 109–187 min. None of these resulted in limb loss. The mean ischemic time for use of a tourniquet with no complications was 78 minutes.
From PHTLS 8th Ed...
Not all traumatic PTX require chest tube!
PTX < 35 mm on chest CT can be safely observed in both penetrating and blunt trauma if hemodynamically stable (failure rate 9%).
Observing pneumothoraces: The 35-millimeter rule is safe for both blunt and penetrating chest trauma. J Trauma Acute Care Sure. 2019 Apr; 86(4):557-564.
Alteplase may be considered in some patients with a presumed or confirmed pulmonary embolism.
Kearon C, Aki EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016;149:315-352.