Lightning Strike and Electric Shock Survivors, International

Prior to1989 no known support group existed for victims of lightning or electrical shock injury and their families. A lightning strike survivor of twenty years, Steve Marshburn, recognized the need both from his personal experience and after meeting two other survivors. With his wife and psychologist, he formed Lightning Strike and Electric Shock Survivors International. The organization has grown nearly one hundredfold from the thirteen who attended the first annual meeting. The support group serves people from around the world, has produced a number of publications, participated in research about these injuries and has become active in prevention activities. This paper will describe some of the factors that have led to such success for the organization.     

Neurorehabilitation of spinal cord injuries following lightning and electrical trauma

While spinal cord injuries caused by lightning strike or electrical shock are rare, their clinical manifestations pose unique challenges to the clinician who must anticipate the interaction of multiple system involvement with the altered physiology of spinal cord injury. Spinal cord damage may be secondary to the direct effects of electrical current passing through neural tissue producing immediate or delayed impairment. Alternatively, lightning strike and electrical shock may lead to spinal cord damage due to the secondary consequences of injury such as spinal fractures sustained after a fall. In addition to effects on the spinal cord, electrical trauma may result in injury to the brain, peripheral nervous system, musculoskeletal system, skin, and cardiovascular system. This article will review the neurorehabilitation approach to this rare and challenging group of patients.     

Mechanisms of electrode induced injury. Part 3: practical concepts and avoidance

This three part series of articles has discussed mechanisms of electrode related injuries from a theoretical viewpoint in Part 1 (Stecker et al. 2006) and from a clinical experience viewpoint in Part 2 (Patterson et al. 2007). The third and final part of the series discusses practical concepts for the end user to use to both understand the basic principles at work in the creation of electrode related injuries as well as to avoid electrode related injuries. To help accomplish this, an online presentation with animations and voiceover is used to supplement written explanations of these basic principles. Areas of interest include mechanical pressure points, adhesives in contact with skin, electrosurgical unit (ESU) radiofrequency concepts, magnetic resonance imaging (MRI) radiofrequency concepts, electrochemical concepts, and basic electrical safety concepts. The goal of this article series has been to heighten awareness of electrode related lesions in general and to help clinicians become better at injury avoidance. A list of electrode related injury avoidance fundamentals is presented. Finally, practical scenarios are presented to illustrate the applications of the concepts.     

Lightning stroke and neuropsychological impairment: cases and questions

OBJECTIVE—To objectify neuropsychological impairments in survivors of lightning stroke with lasting complaints about poor concentration and inability to divide their attention.
DESIGN—A series of six cases of lightning stroke were studied. All patients had lost consciousness and reported amnesia of varying length. Assessment took place between one and four years after injury, ensuring that their neurological state had stabilised. They were tested with a neuropsychological battery with an emphasis on attention and memory. Personality and emotional reaction to the accident were assessed with questionnaires and a lightning fear scale. Complaints were recorded by means of a trauma complaints list including 10 questions on symptoms of the post-traumatic stress disorder.
RESULTS—Patients reported fatigue and lack of energy as their main complaints. In addition, poor concentration, irritability, and emotional lability were mentioned often. Neuropsychological tests disclosed mild impairments in memory, attention, and visual reaction times. Two patients could be classified as depressed, and one of these also showed convincing signs of the post-traumatic stress disorder.
CONCLUSION—As the lasting complaints and impairments could not be explained, for all six cases, as resulting from head injury concomitant with lightning stroke, cerebral hypoxia or a post-traumatic stress syndrome, it is concluded that lightning stroke can result in subtle cognitive impairments. It is speculated that most complaints of these survivors are caused by a vegetative dysregulation, a disorder that has often been noted in the literature on the effects of electrical injury to the nervous system. Such a dysregulation might cause both the main complaint of fatigue and the mild cognitive impairments identified with the present test battery.

     

Neurological and neuropsychological consequences of electrical and lightning shock:review and theories of causation

Injuries from lightning and electrical injuries involve multiple systems of the body, however neurological symptoms are very widely reported. A disabling neuropsychological syndrome is also noted.This paper presents a comprehensive review of neurological and neuropsychological symptoms. Partial theories of causation for these injuries have been advanced, however, there is no convincing explanation for both delay in onset of symptoms and also the genesis of the neuropsychological syndrome. A theory of causation is proposed which satisfies both these constraints.This theory suggests circulating hormones such as cortisol, together with nitric oxide and oxidant free radicals from glutamatergic hyper-stimulation, act on tissues remote from the injury path including the hippocampus.This theory opens a research path to explore treat-ment options.     

Neurorehabilitation of cerebral disorders following lightning and electrical trauma

The most devastating casualties in lightning and electrical trauma patients are the result of lesions of the nervous system, and especially lesions of the brain. The brain injuries can be divided into three categories: global dysfunction; focal brain injuries; and behavioral-cognitive sequelae without gross physical signs. Lightning injuries are usually the result of outdoor sports and leisure activities. Most electrical trauma cases are the result of workplace accidents. Rehabilitation planning should begin early after the incident and often needs to be continued for a long time. The goal of the rehabilitation team is to maximize functional return in patients with deficits related to brain lesions. The neurorehabilitation team includes the neurorehabilitation physician, physical therapists, occupational therapists, psychologists, speech therapists, and case managers.     

Posttraumatic stress,functional impairment,and service utilization after injury: a public health approach

Each year in the United States approximately 2.5 million Americans incur injuries so severe that they require inpatient admissions to acute care medical settings. This article reviews the development of posttraumatic stress disorder (PTSD) and related comorbid medical conditions among injured trauma survivors. Between 10% and 40% of injured trauma survivors appear to develop PTSD in the weeks and months after their injury. The symptoms of PTSD are clearly linked to a broad spectrum of functional impairment and diminished well-being in injured patients. Although PTSD, depression, somatic amplification, and recurrent substance use are common disturbances after injury, it appears that few symptomatic trauma survivors receive formal mental health evaluation or treatment. Substantial perceived and structural barriers to accessing care exist for injured trauma survivors. The public health significance of these findings is discussed and implications for future intervention development are explored in the following chapters.     

Bilateral plexopathy following lightning injury

INTRODUCTION: The consequences of lightning injuries on the peripheral nervous system are widely unknown. CASE REPORT: We report on a 31 year-old woman who developed a bilateral brachial plexopathy 15 days after a lightning strike. The patient recovered progressively. CONCLUSION: Peripheral neuropathies due to lightning strikes are probably unrecognized in most of the cases, because occurrence may be delayed and only few patients were adequately investigated. Pathophysiological hypotheses are unclear and lean on experimental studies using electrical current.     

The duration of seeking help following traumatic brain injury: The persistence of nonneurological symptoms

Abstract

Traumatic brain injury is a major health problem. Studies have concluded that there is an incidence of 400,000 to 600,000 new injuries annually. However, little information is available on the duration of symptom complaints after injury and thus a lack of information on the prevalence of these complaints in the injured. This study surveyed the persistence of sympton complaints when patients sought help from a neuropsychology service as outpatients after traumatic brain injury. A retrospective review of patient records found that patients sought help an average of 7.3 years after injury. This can be extrapolated to mean that there are as many as 3 to 4.4 million survivors of brain injury with residual difficulties in the U.S. Patients whose injuries were at least 1 year old sought help an average of 9.9 years after injury. Overall, the most frequent complaints were cognitive, job/school, medical, and emotional problems. The implications and limitations of the survey are discussed.     

Diffuse electrical injury: comparison of physical and neuropsychological symptom presentation in males and females

OBJECTIVE: Electrical injuries can produce physical, neurological, and neuropsychological sequelae that exist even in the total absence of a theoretical current path that includes the brain. Diffuse electrical injury (DEI) is a rarely occurring class of electrical injury (EI) that can occur even after low-voltage contact. The objective of the study was to compare the occurrence rate of symptoms reported retrospectively by a female DEI group with a male DEI group. METHODS: A Web-based interactive survey was completed by survivors of low-voltage injuries (<1000 V) regarding symptoms present six months or more following electrical shock. Chi square analysis of the occurrence of 65 symptoms was performed. RESULTS: The only significant differences were that unexplained moodiness, dizziness, and short-term memory loss were reported more often by the male group, and the diagnosis of chronic pain was more common in the female group. For the majority of symptoms, no significant difference between the two groups was revealed. CONCLUSIONS: Results suggest that DEI may present with certain differences in men compared with women. The results also confirm previous reports that patients may present with broad symptomatology after low-voltage contact.     

Migraine: a genetic disease?

Several cases of motor neuron disease (MND) after electric injury have been reported in the last number of years, but the relationship between electric injury and MND remains controversial. Herein we report the case of a 60-year-old man who developed a MND following an electrical trauma. In the case presented here, the onset of disease at the site of lightning strike and the short interval of time between the electrical injury and the clinical onset of MND raise the possibility of considering electrical shock as a trigger factor for MND.     

The neurological complications of electrical injury: a nursing case management perspective

High-energy electrical injury, whether from lightning strike or electrical shock, occurs primarily in the workplace. Neurological dysfunction can be a devastating complication of electrical injury. A review of the literature was undertaken to develop a better understanding of the epidemiology, mechanisms of injury and neuropathology associated with this type of injury. The numerous challenges inherent in the management of these complex cases were illustrated by three case studies.     

RISK FACTORS FOR POST‐INJURY MENTAL HEALTH PROBLEMS

Serious nonfatal physical injuries and burns are common occurrences that can have substantial implications for personal, social, and occupational functioning. Such injuries are frequently associated with significant mental health issues, and compromised quality of life and well‐being. The purpose of this review is to summarize the current literature on physical, psychological, and social risk factors for mental health issues post‐injury and to contextualize findings using Engel's biopsychosocial framework. We distinguish between pre‐injury, injury‐related, and post‐injury risk factors for mental health problems. Female sex, history of mental health problems or trauma, type of injury, and level of pain are among the strong risk factors for mental health problems post‐injury. We highlight inconsistent findings in the literature, identify directions for future research, and explore the implications of the risk factors identified for treatment and prevention.     

Electrical injury and amyotrophic lateral sclerosis: a systematic review of the literature

Electrical injury may act as a potential precipitating or risk factor for amyotrophic lateral sclerosis (ALS). A systematic review of the literature was undertaken to assess the relationship between electrical injury and the development of ALS. Information for the review was obtained using five medical databases, and from manual searching of individual papers. Patients presenting with a neurological syndrome after electrical injury, including lightning, were included and classified into four categories: ALS; progressive upper motor neurone (UMN) syndrome; progressive lower motor neurone (LMN) syndrome; and non-progressive syndrome. Linear regression and chi2 testing were used for analysis of the data. 96 individuals, comprising 44 with ALS, 1 with a progressive UMN syndrome, 7 with a progressive LMN syndrome and 44 with a non-progressive syndrome, were identified from 31 papers with publication dates between 1906 and 2002. The median interval between electrical injury and disease onset was 2.25 years for all progressive syndromes and just over 1 week for the non-progressive syndrome. The more severe the shock (excluding lightning), the more likely individuals were to have a non-progressive motor syndrome. A non-progressive spinal cord syndrome is associated with more severe electrical injury. Overall, the evidence reviewed does not support a causal relationship between ALS and electric shock.     

Brain injury and emotion: An overview to a special issue on biopsychosocial approaches in neurorehabilitation

Survivors of acquired brain injury (ABI) are at risk of a range of neuropsychiatric and behavioural disorders. Emotional disturbance, with reactive elements of mood disorder, such as depression and anxiety, appear particularly common. Specific anxiety disorders, such as post-traumatic stress disorder (PTSD) have also been identified. Pain syndromes are also common-particularly in those who have suffered Traumatic Brain Injuries (TBI). Survivors of ABI are often atrisk of substance misuse and of irritability states. Their relationships may suffer from the stresses triggered by the aftermath of injury. Intimate, in particular, sexual relationships may be particularly affected. These effects are not, necessarily, only consequent of severe injuries, as mild TBI can also have, for some, significant neuropsychiatric effects. Assessment and management of such conditions are compromised by survivors of injury often having a limited insight into the sequelae of their injuries. Interventions for such disorders and forms of distress are increasingly available. This paper introduces the special issue of Neuropsychological Rehabilitation on biopsychosocial approaches in neurorehabilitation. A range of papers provide overviews for assessing and managing such neuropsychiatric, mood and behavioural (health and habit) disorders.     

Current Status and Future Prospects for Upper and Lower Extremity Motor System Neuroprostheses

This paper reviews the current state of the art and identifies the major challenges facing the future development and clinical application of neuroprostheses to provide limb movement. It gives insight into the current status of functional electrical stimulation (FES) for motor control, identifies problems, and proposes possible directions of development in cervical cord injury, thoracic spinal cord injury, and stroke. For upper extremity function, existing clinical applications are covered, major problems are identified, and possible future trends are highlighted. The discussion on lower extremity applications describes current and possible future solutions of the major impediments to the development of FES systems for individuals with paraplegia after spinal cord injury and surface and implantable setups for stroke survivors with hemiplegia. Particular attention is given to sensor issues and requirements for walking with FES after stroke.     

Neuropsychological and psychosocial consequences of minor head injury.

Twenty subjects with minor head injury were compared to an uninjured group at 1 and 12 months after injury on a battery of neuropsychological and psychosocial measures. The results indicate that single minor head injury in persons with no prior compromising condition is associated with mild but probably clinically non-significant difficulties at 1 month after injury. Disruptions of everyday activities, however, are extensive with other system injuries significantly contributing to these problems. Recent reports in the literature may represent overestimation of head injury related losses due to lack of control for the effects of pre-injury characteristics and other system injuries.     

Epidemiology of burn injuries: Highlighting cultural and socio-demographic aspects

Burns are devastating injuries that disproportionately affect people in developing countries, including children. In addition to a high mortality rate, survivors are burdened with life-long physical and emotional scars. The etiology and nature of burn injuries varies significantly by country, and this chapter explores the predominant causes and patterns of burn injury in both the developing and industrialized worlds. Gender differences play a significant role in the risk of burn injuries, across a spectrum with a predominance of women injured in fires from cooking and heating fuels in the developing world and industrial accidents primarily affecting men in developed nations. Children are particularly vulnerable to burn injuries, accounting for almost 50% of all burn patients in some studies. A majority of pediatric burns are scald injuries usually affecting very young children below the age of 5 years, and we discuss the behavioral patterns underlying this finding. Finally, the elderly form a rapidly increasing proportion of the population in many countries, and are often burdened with comorbidities that are likely to pose significant challenges in burn care.     

Autonomic nervous system dysfunction in lightning and electrical injuries

Autonomic nervous system (ANS) dysfunction is a serious complication of lightning and electrical trauma (L/ET). The ANS regulates the normal vegetative functioning of many organ systems. When ANS is compromised after lightning and electric trauma, patients are vulnerable to serious medical problems. Three conditions of ANS dysfunction of particular concern for L/ET patients are complex regional pain syndrome (CRPS), cardiovascular abnormalities, and keraunoparalysis (KP). The patient with CRPS presents with pain, hyperpathia, sweating, and edema hours to days after trauma. Neurorehabilitation is exceedingly important. A primary goal is to keep the affected extremity mobile and functional. Some patients benefit from sympathetic blockade. Cardiovascular abnormalities associated with lightning and electrical trauma can be life threatening. Care for these patients require a multidisciplinary team including a cardiologist. Keraunoparalysis is a frightening and distressing complication of lightning strikes. The syndrome consists of limb paralysis, sensory symptoms, pallor, coolness and absent pulses. Release of excessive catecholamines is said to be responsible for these findings. Fortunately, the condition is transient.