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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 104-106

Transient cardiomyopathy after the indoor lightning strike


Department of Pediatrics, Pramukhswami Medical College, Bhaikaka University, Karamsad, Gujarat, India

Date of Submission25-Dec-2021
Date of Decision11-Mar-2022
Date of Acceptance18-Mar-2022
Date of Web Publication12-May-2022

Correspondence Address:
Dr. Krutika Rahul Tandon
Department of Pediatrics, Pramukhswami Medical College, Bhaikaka University, Karamsad - 388 325, Anand, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcc.jpcc_100_21

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  Abstract 


Lightning injury can also affect young child by indoor penetration of lightning strike and in spite of cardiac involvement good supportive intensive care may change the outcome. Herein we report one case of lightning with cardiac complication admitted in our pediatric intensive care unit.

Keywords: Burns, cardiac complications, thunder, transient cardiomyopathy


How to cite this article:
Tandon RK, Tandon KR, Gohil A, Vani P, Mori S. Transient cardiomyopathy after the indoor lightning strike. J Pediatr Crit Care 2022;9:104-6

How to cite this URL:
Tandon RK, Tandon KR, Gohil A, Vani P, Mori S. Transient cardiomyopathy after the indoor lightning strike. J Pediatr Crit Care [serial online] 2022 [cited 2022 Dec 6];9:104-6. Available from: http://www.jpcc.org.in/text.asp?2022/9/3/104/345089




  Introduction Top


Lightning strike is a natural calamity that risks various medical complications and mortality. Lightning usually occurs during outdoor activities rather than indoors. Individuals engaging in outdoor activities are more prone to strikes by lightning. Indoor strikes by lightning have also been reported through windows or doors or exposed electric wire.[1],[2],[3] The most common and immediate cause of death from a lightning strike is due to cardiopulmonary arrest. The known cardiac complications include myocardial infarction, arrhythmia, and cardiac contusion. We describe a female child who developed transient ischemic electrocardiogram (ECG) changes and transient cardiomyopathy after a lightning strike, successfully managed in intensive care unit (ICU) with no long-term morbidity.


  Case Report Top


A 2-year 8-month-old female child was brought to emergency department (ED) with a history of lightning injury on the same day of admission in the morning. She had lightning burns due to thunder while she was playing inside her Kaccha house in a village. Other family members remain unaffected. She remained unconscious for 10 min. Hence, parents took the child to a government hospital where the child regained consciousness. Subsequently, the patient was referred to our hospital due to the unavailability of burn care facilities as she had lightning burns on the chest. When the child was received in an ED, she had a heart rate (HR) of 180/min, respiratory rate (RR) of 70/min, blood pressure of 92/60 mmg, oxygen saturation on room air by pulse oximeter of 96%, capillary refilling time of 3–4 s, pulse volume low and cold peripheries. As per vitals, the patient was in compensatory shock. In general examination, there were superficial burns on the abdomen, thorax, and neck region. Systemic examination did not reveal much. The patient was in shock, so electively intubated after shifting to pediatric ICU (PICU), put on ventilator support (Pressure assist control mode) with initial setting of PIP-12, PEEP-5, FiO2 50%, RR-25 (iTime-0.55) and on inotropes (inj dobutamine 10 microgram/kg/min). Other supportive case provided including antibiotics (inj ceftriaxone) after sending blood culture. The surgical reference was done for superficial burn for regular care as well as dressing [Figure 1]. Blood investigations were sent. An ECG and 2D echocardiography were also ordered. ECG showed tachycardia with T-wave inverted in V2-V4 with intermittent delta wave seen in lead aVF [Figure 2]. Echo showed left ventricular ejection fraction (LVEF) of 30%–35% with right ventricular (RV) dysfunction. Arterial blood gas showed metabolic acidosis with pH 7.20: HCO3-14 and base excess-11, PaO2-111, PCO2-31, and lactate-2.6. Hence, diagnosis of cardiogenic shock due to lightning was kept. On day one of admission creatine phosphokinase (CPK) and Troponin-I (as unavailability of CPKMB) was also done which were 1826 U/L and 6.767 ng/ml, respectively, suggesting definite myocardial ischemic injury. The next day even more profound features of cardiogenic shock with a decrease in urine output and rise in creatinine level were observed (day 1 creatinine was 0.43 mg/dL raised to 1.02 mg/dL on day 2). Hence, 2nd inotropes were added as inj adrenaline 0.2 μg/kg/min and dobutamine inj tapered to 5 μg/kg/min. Digoxin syrup was added as per creatinine clearance at maintenance dose with caution. Other treatment modalities continued including ventilator support with restricted intravenous fluids. Antibiotics were upgraded (inj meropenem and inj teicoplanin) on day 2 in view of worsening shock after sending blood culture and wound culture with renal dose adjustment as the patient developed a high-grade fever also with a high inflammatory marker value (C-reactive protein-52.8 and procalcitonin-33.70). As hemoglobin was low on the 3rd day of admission, calculated dose of packed cell volume was also given. Improvement started on day 4 of admission in the form of a decrease in the requirement of inotropes (inj adrenaline was continued from 0.3 μg/kg/min to 0.1 μg/kg/min and dobutamine stopped), feed tolerance through Ryle's tube, and good urine output. Furthermore, LVEF also improved from 30%–35% to 40%–45% on repeating 2D echo by cardiologist. The patient was extubated on the 5th day of admission and shifted to the pediatric ward with close monitoring. On the 6th day, the antibiotic was stopped as well as inotrope as blood and wound culture came negative. On the 7th day, the patient was taking orally well. Her HR was settling to 100–110/min with normal rhythm with RR of 30/min maintaining oxygen saturation on room air. The patient was discharged on the 11th day with good left ventricular ejection function and RV function on repeat echocardiography. The last CPK was 227 U/L.
Figure 1: Burns on chest and abdomen

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Figure 2: Electrocardiogram. The electrocardiogram showed normal sinus rhythm with a heart rate of 180/min with intermittent delta (arrow) wave seen in lead aVF with T-wave inversion in V2–V4

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  Discussion Top


Lightning occurs when the large potential difference between cloud and ground, measured in millions of volts, is broken down. Upon attachment, this potential difference disappears as an enormous current flow impulsively for a short time.[1] Victims of lightning strikes have a high mortality rate of 10%–30%. The overall fatality rate is about 0.25 per million population per year in India, and the peak months are June–September.[2] The various methods of lightning-induced injuries are contact injury of the victim with a conducting element, direct strike, ground current when lightning traverses from the striking point through the ground and into the victim, and blast injury.[3] Lightning victims can be classified into four major categories. The first category, immediate and transient symptoms, includes amnesia, headache, and loss of consciousness. The second category, immediate and permanent or prolonged, consists of derangements of the cardiovascular and nervous system such as cardiac arrest, hypoxic-ischemic encephalopathy, and intracranial hemorrhage. The third category includes delayed neurological syndromes such as motor neuron disease and movement disorders, which can occur within days, months, or years. The fourth category includes the traumatic injury complex secondary to falls, blunt trauma, or blast injuries related to lightning.[3] The deadliest complication of lightning is cardiac arrest. One case described, succumbed due to lightning without external injury had cardiac contusion as a cause.[4] Another case was reported in one journal having ECG changes like in our patient.[5] Cardiac etiology of pediatric cardiac arrest is present in approximately 8%, and in those patients, ventricular fibrillation (VF) or pulseless ventricular tachycardia may be present.[3] A massive direct current shock increased autonomic stimulation with an associated catecholaminergic surge has additive effects on the HR and rhythm. Research has shown that ventricular arrhythmias, including ventricular tachycardia and VF, are much more common than initially thought.[6] Acute myocardial infarction or ischemia due to a lightning strike is rare. Infarction may develop because of direct tissue damage or lightning-induced vasospasm as in our index case.[7] Hence, it is recommended that direct hits patients be monitored continuously in ICU. Cardiac dysfunction including severe biventricular failure, like in our patient echocardiography usually reversible within 2 weeks.[8]

In one of the cases discussed in the article, the patient was having ST changes in ECG after the lightning strike, but 2D echocardiography was normal. The patient succumbs to death due to other organ dysfunction.[9] Hence, even though the results of cardiac injury may be reversible, respiratory arrest as a result of damage to the respiratory center in the brainstem may occur. Hypoxia/anoxia may then also contribute to myocardial depression. The prognosis of patients who experience cardiopulmonary arrest and/or brain damage from hypoxia is relatively poor. As extremely high voltages with brief exposure are involved, a clinical pattern of signs and symptoms differs from a simple electrical accident. Therefore, challenging for the attending medical team its management.[10] As published earlier rhythm problems in PICU are mostly due to central lines or artifacts or electrolytes disturbances, and one require to confirm whether it is stable or unstable for better outcome.[11] However, one should consider lightning when kids are found lying unconscious either indoors or outdoors during the rainy season. Adults and children are to be educated about the dangers of lightning. This case illustrates that lightning injuries are also an in-door occurrence, with some authors suggesting almost one-third of these events penetrate inside houses. Good supportive management is also of utmost importance with cardiac involvement for a better outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's legal guardian has given the consent for images and other clinical information to be reported in the journal. The patient's legal guardian understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Biswas S, Karim ME, Chowdhury JA, Sarkar PK, Begum M, Sarkar MM, et al. Lightning injury in indoor setting – A case report. J Dhaka Med Coll 2015;24:79-81.  Back to cited text no. 1
    
2.
Kreci A, Vyshka G, Sinamati A. Lightning injuries in an in-door setting: A case report and review of the literature. J Environ Pollut Hum Health 2013;1:16-20.  Back to cited text no. 2
    
3.
Apanga PA, Azumah JA, Yiranbon JB. A rare manifestation of burns after lightning strike in rural Ghana: A case report. J Med Case Rep 2017;11:200.  Back to cited text no. 3
    
4.
Sumangala CN, Kumar MP. Lightning death: A case report. J Indian Acad Forensic Med 2015;37:93-5.  Back to cited text no. 4
    
5.
McIntyre WF, Simpson CS, Redfearn DP, Abdollah H, Baranchuk A. The lightning heart: A case report and brief review of the cardiovascular complications of lightning injury. Indian Pacing Electrophysiol J 2010;10:429-34.  Back to cited text no. 5
    
6.
Christophides T, Khan S, Ahmad M, Fayed H, Bogle R. Cardiac effects of lightning strikes. Arrhythm Electrophysiol Rev 2017;6:114-7.  Back to cited text no. 6
    
7.
Rotariu EL, Manole MD. Cardiac arrest secondary to lightning strike: Case report and review of the literature. Pediatr Emerg Care 2020;36:e18-20.  Back to cited text no. 7
    
8.
Singh O, Singh J. Lightning fatalities over India: 1979-2011. Meteorol Appl 2015;22:770-8.  Back to cited text no. 8
    
9.
Akın A, Bilici M, Demir F, Gözü Pirinççioğlu A, Yıldırım A. ST-segment elevation following lightning strike: Case report and review of the literature. Turk J Pediatr 2015;57:186-8.  Back to cited text no. 9
    
10.
Lichtenberg R, Dries D, Ward K, Marshall W, Scanlon P. Cardiovascular effects of lightning strikes. J Am Coll Cardiol 1993;21:531-6.  Back to cited text no. 10
    
11.
Kukreti V, Shamim M. Cardiac arrhythmias in pediatric intensive care unit. J Crit Care 2014;1:54.  Back to cited text no. 11
    


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