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A Case of Lightening Strike
 

A Case of Lightening Strike

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    A Case of Lightening Strike A Case of Lightening Strike Presentation Transcript

    • Prof.P.VIJAYRAGHAVAN’S UNIT Dr.A.Vijayalakshmi. Final yr PG Stanley 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 examination
      • Pt . was unconscious
      • Pupils 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 examination
      • Cardiovascular 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%- 10.2gm
      • TC-8400 P78,L32
      • ESR 5/15
      • PLATELET -2.4 lakhs
      • RBS- 124 mg%
      • Urea- 32 ; Creatinine- 0.8
      • Na+ 138 ; K+ 4.2 ; Cl- 108 ; HCO3- 24
      • ECG- WNL
      • CXR - 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 WARD
      • Complete blood count, blood sugar, renal parameters, electrolytes, urine examination - normal
      • ECG -T wave inversion in LII, LIII, AVF ,v3-v6
      • CPK-67
      • CPK MB-16
      • Echocardiography
      • Normal LV function ,No RWMA.
    •  
      • DAY 4, 24 th 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 29 th -
      • ECG-repeated – normal sinus rhythm with no T wave changes
      • Patient 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 Injuries
      • Direct 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 Injuries
      • Ground 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 Injuries
      • These 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 damages the 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.
    • MANIFESTATIONS
      • Cardiopulmonary complications
        • Transient hypertension
        • Electrocardiographic changes
        • Myocardial injury(infarction)
        • Congestive heart failure
        • Dysrhythmia
        • Transient asystole
        • Atrial fibrillation
        • Ventricular fibrillation
        • Frequent premature ventricular contractions
        • Apnea
        • Hypoxemia
      • Neurologic/ psychiatric complications
        • Loss of consciousness
        • Confusion
        • Paraplegia, quadriplegia,Hemiplegia
        • Retrograde amnesia
        • Coma
        • Seizures
        • Intraventricular hemorrhage, Hematomas
        • Depression, anxiety, aphasia
        • Post 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 instability
        • Arterial spasm
        • Vasoconstriction, vasodilatation
        • Intra-abdominal complications
        • Gastric perforation
    •  
      • Laboratory Studies
      • complete blood cell count, RFT, electrolytes, creatinine kinase (CK) with isoenzymes
      • routine 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 Studies
      • Plain x-rays of the cervical spine and chest.
      • CT brain
      • MRI - 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.
    • TREATMENT
      • Medical Therapy
      • Typically, 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 MECHANISMS
      • Lightening 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 162-167 O.P. Murty
      • 2. An injury subjacent to lac ornament in a case of lightning Forensic Science International , In Press, Corrected Proof , Available online 26 November 2009 Ashesh Gunwantrao Wankhede, Vinod R. Agrawal, Dinesh R. Sariya
      • 3. The spinal cord in lightning injury: A report of two cases Journal of the Neurological Sciences , Volume 276, Issues 1-2 , 15 January 2009 , Pages 199-201 Sowmya Lakshminarayanan, Sudhanshu Chokroverty, Noam Eshkar, Raji Grewal
      • 4. Electrical and Lightning Injuries Small Animal Critical Care Medicine (First Edition) , 2009 , Pages 687-690 F.A. Mann
      • 5. Hair-raising event The New Scientist , Volume 203, Issue 2719 , 29 July 2009 , Page 65
      • 6. Lightning cooked dinner for early life The New Scientist , Volume 203, Issue 2717 , 15 July 2009 , Page 16 2005, Vol. 27, No. 2, Pages 129-134
      • 7.Lightning Injuries and Acute Renal Failure:
      • Renal failure 2005, Vol. 27, No. 2, Pages 129-134
    •