Approximately a third of all lightning strikes are fatal. We report an unusual case of lightning affecting a mother and her two children aged 6 and 1½ years. The six year old child was brought in deep coma and his BP was unrecordable. There was a full thickness linear burn around his waist, and a silver chain (which was the point of entry of the electricity) was found to be embedded within. He had a star shaped exit wound over the occiput, and large lacerated and charred wounds around the groin, the pubis, and the gluteal region; he also had extensive superficial burns. Routine blood counts, urea, creatinine, electrolyte levels, and ECG were all normal.

The BP normalised following administra-tion of IV fluids, plasma and dopamine. The chain was removed and the area was sutured. Twenty four hours after admission an emergency laparotomy was done for suspected peritonitis. He was found to have two small perforations, one each in the terminal ileum and the descending colon. Both perforations were closed. The wounds in the inguinal region underwent debridement and secondary suturing. He recovered uneventfully and 3 years later shows no late effects of lightning.

The mother was brought in a confused state, and had left hemiparesis, filigree burns, and a macular burn of the left retina. She recovered completely, but developed a posterior capsular cataract of the left eye 5 months later. Her 1½ year old child was brought dead to the hospital. The gold chain around his neck was deeply embedded into the muscles and had a deep lacerated wound around the neck exposing the muscles.

In this report, two of the three victims of the lightning strike suffered from deep full thickness burns at the site of the metal chains they were wearing, embedding the chains deep into the tissues. To the best of our knowledge, only two similar cases have been reported earlier(1,2). Visceral perforation following lightning strike is extremely rare. In our case, the child sustained perforation of the terminal ileum and descending colon which could be explained very well by the mechanism of the blast effect of lightning(3).

Lightning usually causes death by injuring the medullary centers of the brain, leading to cardiac asystole or respiratory arrest. Prompt life support measures contribute to successful resuscitation in many patients. Apneic patients need prompt and prolonged respiratory support as recovery has been reported even after four hours(4). Patients struck by lightning frequently have cardiac asystole which responds to a manual blow to the chest or spontaneously resolves after several minutes of cardiac massage and mouth to mouth resuscitation. Attention should be paid to possible fractures and spinal cord injuries incurred at the time of the accident.

Hospital management includes aggressive treatment of hypovolemic shock. This is common after a lightning strike due to rapid loss of fluid into areas of tissue damage and from surface burns. This child responded rapidly to measures to combat hypovolemic shock and had no manifestations of cardiac injury.

Fluid replacement principles used in the treatment of crush injury should be followed, as there may be extensive muscle injury after a lightning strike. Ringer Lactate should be administered to maintain a urine output greater than 50 ml/h. Furosemide or mannitol is recom-mended along with alkalinisation of the urine if myoglobinuria persists even after establish-ment of adequate urine flow. Patients should be on ECG monitor for at least 24 hours, as significant arrhythmias may occur. The electri-cal burns are managed just like other burns.

Patients who remain comatose should undergo monitoring of intracranial pressure, and should receive prompt treatment for cerebral edema. The mother suffered from a confusional state and hemiparesis, which responded to measures to control cerebral edema. Neurological complications of lightning include hypoxic encephalopathy, cerebral edema, permanent neurological damage, seizure disorder and loss of vision. Patients with spinal cord lesions are likely to have permanent sequelae and paralysis.

During a severe thunderstorm refuge near hilltops, riverbanks, hedges, telephone poles and trees should be avoided. The safest shelter is a closed house, while a closed automobile, cave, ditch or even lying on the ground curled up with hands close together is relatively secure. Presence of a helmet proved to be life saving for an athlete who sustained lightning strike to his head(5)

Sheela S.R.,
Mary Margaret Kattakkayam,
Borappa K,
Samaritan Hospital,
Kizhakkambalam 683 562,
Ernakulam District,
Kerala, India.