Prof.P.VIJAYRAGHAVAN’S UNITDr.A.Vijayalakshmi.

Final yr PGStanley Medical College

A 50 years old male Mr.Gunalan was admitted with unconsciousness after being struck by Lightning on 21.11.2009.

He was working in the field on a rainy day in Tiruvallur district and was struck by lightning , became unconscious and was brought to the hospital.

There was no history of vomiting ,headache, seizures, blurring of vision.

No history of head injury.No history of chest pain, palpitation,

dyspnea.No history of abdominal pain, jaundice.No history of bowel and bladder

disturbances.

PAST HISTORY: No previous similar episodes Not a known case of seizure disorder, IHD,

T2DM, SHT, PT. No h/o head injury PERSONAL HISTORY: He is not a smoker, not consuming alcohol,

no history of extra marital affairs, not chewing tobacco, betel leaf and nuts.

General examinationPt . was unconsciousPupils equal both sides and reacting to light.Fundus was normal.Afebrile.No cyanosis, no clubbing, no pedal oedema,

no generalised lymphadenopathy.Pulse; 89/mt.BP 160/90 mm of Hg.

Systemic examinationCardiovascular system- S1, S2 normal. No murmur, added

sound.

Respiratory system- NVBS, no added sound.

Abdomen- Soft, no organomegaly.

CNS-Unconscious With GCS 8/15 E2V2M4.Higher functions could not be examined.Motor functions , Sensory, cerebellar

functions could not be examined.Plantar withdrawl reflex both sides.

Local examination

A linear laceration present in the right side of chest below the clavicle

A linear laceration present in the right inguinal region

Closer view of the inguinal lesion

Investigations Hb%- 10.2gmTC-8400 P78,L32ESR 5/15PLATELET -2.4 lakhsRBS- 124 mg%Urea- 32 ; Creatinine- 0.8Na+ 138 ; K+ 4.2 ; Cl- 108 ; HCO3- 24ECG- WNLCXR - NAD CT brain Normal study.

CT brain normal

Patient was treated in the IMCU for the first two days.

He regained consciousness but had difficulty in speaking and difficulty in sitting up in the bed. He was transferred to the ward from IMCU.

In the ward: DAY 3 23/11/2009 Patient was conscious, drowsy, responding to

commands. He started to move all 4 limbs but complained of severe pain all over the body.

O/E CVS, RS, Abdomen - normal CNS-Had memory deficit especially for recent

events.

INVESTIGATIONS DONE IN THE WARDComplete blood count, blood sugar, renal

parameters, electrolytes, urine examination - normal

ECG-T wave inversion in LII, LIII, AVF ,v3-v6CPK-67 CPK MB-16Echocardiography Normal LV function ,No RWMA.

DAY 4, 24th nov There was difficulty to sit and walk without

support.On examination. Conscious, oriented,Fundus was normal. CNS: tone- normal power- 4+/5 reflexes- retained plantar- B/L flexor no neck stiffness. no spinal tenderness.

MRI brain T2 weighted image showing multiple hyperintense lesions suggestive of infarction.

Bilateral hyperintense lesions

Neurologist opinion obtained. Multi infarct state. EEG Normal study.

Day 9 Nov 29th-ECG-repeated – normal sinus rhythm with no T wave changesPatient was discharged after 3 weeks without any residual disability.

FINAL DIAGNOSIS:

A CASE OF NONFATAL LIGHTNING STRIKE CAUSING SUPERFICIAL SKIN LACERATION , LOSS OF CONSCIOUSNESS , BILATERAL CEREBRAL INFARCTS WITHOUT RESIDUAL NEUROLOGICAL DEFICIT AND TRANSIENT ECG ABNORMALITY.

Lightening and its effects

Worldwide, lightning causes serious injuries in 1000-1500 individuals every year.

Only 20% of those struck die immediately. Persons struck are typically males aged 15-44

years. Most injuries occur between May

and September. The current in a lightning bolt is as high as

30,000 Amperes with 1,000,000 or more Volts. The short duration of about 1-100 milliseconds limits, but doesn’t prevent injury

Lightning-caused injuries fall into four main categories which depend on the actual path the electrical current of the lightning stroke takes as it flows through or over the victim on its way to ground:

Direct strike Splash Ground current Blunt trauma

DIRECT STRIKE InjuriesDirect strike injury occurs when the victim is hit

directly by the lightning bolt, or in direct contact with a metal object which is hit directly.

This type of injury occurs most often in people who are standing in the open or who are in contact with a metal object that is struck by the lightning stroke.

Most serious, since the victims are receiving the full strength of the current flow from the strike.

SPLASH Injuries Splash occurs when a lightning strike hits

an object and then jumps to near by people or objects on its way to ground.

This is the most common mechanism for lightning injury, and it is the reason that standing near any tall, grounded object (like a tree, light pole, sports bleachers, etc.) represents a greatly increased chance of injury during a thunderstorm.

GROUND CURRENT InjuriesGround current occurs when a lightning strike

hits the ground and is then transferred to a victim or victims nearby.

Less severe than those from direct strike or splash incidents, since the strength of the lightning current has been weakened by traveling through the ground

However, if the ground is wet or covered with standing water, the amount of weakening might be greatly reduced, increasing the danger of this form of injury.

BLUNT TRAUMA InjuriesThese are the injuries caused by the

explosive expansion and contraction of the air heated by the lightning stroke.

This type of injury is closely related to the victim’s actual distance from the lightning point of impact, and the energy dissipates as an inverse proportion to this distance.

This large flow of electrical current damagesthe human body through the sudden release of

electrical, thermal, and mechanical energy, and the injuries suffered from a

particular lightning strike may involve tissue damage from one or all of these mechanisms.

MANIFESTATIONSCardiopulmonary complications

Transient hypertensionElectrocardiographic changesMyocardial injury(infarction)Congestive heart failureDysrhythmiaTransient asystoleAtrial fibrillationVentricular fibrillationFrequent premature ventricular contractionsApneaHypoxemia

Neurologic/ psychiatric complications Loss of consciousnessConfusionParaplegia, quadriplegia,HemiplegiaRetrograde amnesiaComaSeizuresIntraventricular hemorrhage, HematomasDepression, anxiety, aphasiaPost traumatic stress disorder.Dementia Parkinsonism

Dermatologic complications – Cutaneous burns LICHTENBERG figures (arborescent, fern-like)

pathognomonic(present in this case)Ophthalmic complications

Cataracts Corneal lesions Vitreous hemorrhage Retinal detachment Optic nerve injury

Otologic complications Ruptured tympanic membrane Temporary hearing loss

Vascular complications Vasomotor instabilityArterial spasmVasoconstriction, vasodilatation

Intra-abdominal complications Gastric perforation

Laboratory Studiescomplete blood cell count, RFT, electrolytes,

creatinine kinase (CK) with isoenzymesroutine urinalysis, and urine or serum

myoglobin levels. Screening for myoglobin should be

performed on the initial evaluation and admission to the hospital, but results are unlikely to be positive except in the most severe lightning strikes.

Imaging StudiesPlain x-rays of the cervical spine and chest.CT brainMRI - may be helpful in cases of lightning injuries with

neurologic sequelae that persist beyond the first 24 hours.19

ECG -findings may be normal for the first 24-48 hours. Conduction abnormalities or evidence of subepicardial

ischemia is common in more severe strikes. EMG and EEG - are rarely helpful in the immediate

postinjury period.

TREATMENTMedical TherapyTypically, all lightning strike victims who do not

experience cardiac or respiratory arrest survive; Immediate attention should be directed to the

resuscitation of those patients in respiratory or cardiac arrest.18

Patients with dysrhythmia who typically have a poor prognosis (such as those with asystole) may recover.

The goal of this resuscitation is to oxygenate the brain and heart until spontaneous circulation is restored.

SAFETY MECHANISMSLightening rods and electrical charge dissipators

are used to prevent lightening damage and safely redirect lightening stroke.

Be aware lightening can occur on a day that seems devoid of clouds.

Lightening interfers with AM(amplitude modulation) radio signals much more than FM(frequency) signals.

And electronic devices affected by lightening strike.The safest place is inside a building and the

vehicles during lightening strike.

And if a person is injured by lightening they do not carry an electrical charge and can be safely handed to

apply First aid, before emergency service arrive.

Articles Lightning fatality with blast, flame, heat and current effects:

A macroscopic and microscopic view

Journal of Forensic and Legal Medicine, Volume 16, Issue 3, April 2009, Pages 162-167O.P. Murty

2. An injury subjacent to lac ornament in a case of lightningForensic Science International, In Press, Corrected Proof, Available online 26 November 2009Ashesh Gunwantrao Wankhede, Vinod R. Agrawal, Dinesh R. Sariya

3. The spinal cord in lightning injury: A report of two casesJournal of the Neurological Sciences, Volume 276, Issues 1-2, 15 January 2009, Pages 199-201Sowmya Lakshminarayanan, Sudhanshu Chokroverty, Noam Eshkar, Raji Grewal

4. Electrical and Lightning InjuriesSmall Animal Critical Care Medicine (First Edition), 2009, Pages 687-690F.A. Mann

5. Hair-raising eventThe New Scientist, Volume 203, Issue 2719, 29 July 2009, Page 65

6. Lightning cooked dinner for early lifeThe New Scientist, Volume 203, Issue 2717, 15 July 2009,Page 162005, Vol. 27, No. 2, Pages 129-134

7.Lightning Injuries and Acute Renal Failure: Renal failure 2005, Vol. 27, No. 2, Pages 129-134