Neurological Aspects of Lightning and Electrical Injuries
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This document discusses the neurological aspects of lightning and electrical injuries. It summarizes Cherington's classification of immediate transient symptoms, immediate prolonged symptoms, and delayed neurological syndromes. It then covers clinical presentations involving the central nervous system, cranial nerves, autonomic functions, spinal cord, peripheral nerves, and neuropsychological symptoms. The pathophysiology includes direct electrical damage, thermal damage, tissue separation, ischemic changes, and circulating neurohumoral actions. Treatment involves antidepressants, anti-neuropathic drugs, and potential agents targeting nitric oxide, glutamate, cortisol and antioxidants.
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Introduction
Definition of head injury
Risk factors
Causes
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Clinical manifestations
Complications
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Medical management
Surgical management
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Preventions.
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1) Head trauma can cause permanent injury, with motor vehicle crashes and falls being common causes. Approximately 30% of those with moderate head trauma will have another significant concurrent injury.
2) Primary brain injury results directly from trauma and causes bleeding, tearing and shearing of brain tissue. Secondary brain injury can occur later and includes hypoxia, swelling and increased pressure inside the skull.
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2) Primary brain injury occurs at the time of impact and includes injuries to the brainstem, hemispheres, and axons. Secondary brain injury can happen later and is often preventable, being caused by hypoxia, hypotension, increased intracranial pressure, fever, or low cerebral perfusion pressure.
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Head injury
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The document discusses head injuries, including injuries to the scalp, skull, and brain. Over 1 million people in the US receive treatment for head injuries annually, with 230,000 hospitalized, 80,000 suffering permanent disabilities, and 50,000 dying. Head injuries can cause damage through primary injury at impact and secondary injury from brain swelling or bleeding in the following hours and days. Treatment depends on the severity and type of injury, and may include surgery, monitoring of intracranial pressure, and supportive care measures. The most effective prevention is through safety measures like wearing seatbelts and helmets.
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- 1. Neurological Aspects of Lightning & Electrical Injuries Ade Wijaya, MD – December 2018
- 2. Cherington's classification • Immediate and transient symptoms (e.g., kearaunoparalysis, lichtenberg figures) • Immediate and prolonged symptoms (e.g., hypoxic encephalopathy, intracranial (IC) bleeding, cerebral infarction (especially parieto-occipital), cerebellar syndromes, spinal cord injury (some of which Cherington notes to be permanent), chronic epilepsy, peripheral nerve lesions (e.g., neuropathy, myopathy, neuromuscular junction disorders, polyneuropathy)). • Delayed neurological syndromes. Motor neuron disease following days, months, and even years. • Secondary symptoms (perhaps due to blast). IC haemorrhage, barotrauma, ruptured tympanic membrane. (Cherington, 1995, 2003)
- 4. Clinical Presentation Central syndromes • Cerebral haemorrhage - those consequences following bleeding within the cerebral structures • Cerebral infarction • Central encephalopathy, including hypoxic encephalopathy, that is, alteration in neuronal function due to loss or diminution of oxygen supply • Convulsions • Movement disorders, including Parkinsonism and other disorders of normal movement derived from central causes, whether added movements, modulation of normal movement, attenuation of normal movement, or loss of control of normal movement Cerebellar syndromes
- 5. Clinical Presentation Cranial nerve and related disorders • Specific cranial nerve involvement, including speech and articulation disorders • Ocular neurology • Cochleo-vestibular neural disorders • Synaesthesia Autonomic syndromes • Complex regional pain syndromes (CRPS) including Causalgia and reflex sympathetic dystrophy (RSD) • Postural hypotension – and other disturbances of autonomic function • Cerebral salt wasting – this may be endocrinological in origin, however also mediated by neural influence on the hypothalamus and pituitary gland.
- 6. Clinical Presentation Spinal cord disorders • Transverse myelopathy • Amyotrophic lateral sclerosis (ALS), and other motor neurone disorders - the loss of function of neural pathways controlling movement, in this case involving specific neurones in the anterior horn of the spinal cord. The generic “motor neurone disorder” includes more specific disorders such as ALS • Spinal origin dystonia Paralyses • Keraunoparalysis (a transient syndrome, lasting a small number of hours. It is seen in a limb in the line of current passage, and is thought to be due to vascular spasm to the region. The limb becomes cold, blanched, numb, and pulseless, and is confused with a compartment syndrome) • Paraplegia and quadriplegia
- 7. Clinical Presentation Peripheral nerve disorders • Specific peripheral nerve involvement • Myopathy • Myoclonus • Weakness syndrome and fatiguability Sensory abnormalities Neuropsychological Symptoms
- 8. Pathophysiology • Direct electrical damage • Thermal damage • Tissue separation - by force or by electrostatic effects • Ischemic changes • Circulating neurohumoural actions
- 9. Pathophysiology of Delayed Syndrome • Chronic ischaemia • DNA / protein alteration that affect vascular endothelial cells, leading to decreased blood supply to the central nervous system (Ghosh et al., 1995a). Farrell and Starr (1968)
- 10. Pathology • Focal petechial haemorrhages – especially in the cerebrum and medulla, and also in the anterior horn grey matter of the spinal cord. He says these are more common after AC shocks, and also large vascular tears are seen after lightning injury. • Chromatolysis – especially in pyramidal cells of the medullary nuclei, in anterior horn cells, and the Purkinje cells of the cerebellum. These changes are said to be patchy and sharply demarcated. • “Curious” dilatation of perivascular spaces, which he suggests are due to gas release, being seen largely in legal electrocution. • Tortuosity and fragmentation of the axons of peripheral nerves with breakdown of Schwann sheaths. Infiltration of the epineurium is seen with endothelial cells. • Spiral-like changes in muscle fibres. • In severe injury, the “entire brain and parts of the cord may be swollen softened and even diffluent.”
- 11. Treatment • Antidepresants • Anti neuropathic pain • Potential agents: - Nitric oxide antagonists, glutamate antagonists, cortisol antagonists, and antioxidants. Andrews CJ, Reisner AD. Neurological and neuropsychological consequences of electrical and lightning shock: review and theories of causation. Neural regeneration research. 2017 May;12(5):677.
- 12. Summary • Lightning and electrical injuries often cause neurological symptoms • Immediate vs delayed symptoms • From CNS to PNS symptoms REFERENCE: Andrews CJ, Reisner AD. Neurological and neuropsychological consequences of electrical and lightning shock: review and theories of causation. Neural regeneration research. 2017 May;12(5):677.