ELECTRICAL INJURIES

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THE CURSE OF ZEUS
Rami Khouzam, MD
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The Statue of Zeus at Olympia

• An enormous statue of the Greek father of gods,
  carved by the great sculptor Pheidias
• In his right hand a figure of Victory made from
  ivory and gold. In his left hand, his scepter
  inlaid with all metals, and an eagle perched on
  the sceptre
• The sandals of the god are made of gold, as is
  his robe
• Pausanias the Greek (2nd century AD)

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7 Wonders of the Ancient World

• Today, archaeological evidence reveals some of
  the mysteries that surrounded the history of the
  Wonders for centuries
• For their builders, the Seven Wonders were a
  celebration of religion, mythology, art, power,
  and science
• For us, they reflect the ability of humans to
  change the surrounding landscape by building
  massive yet beautiful structures, one of which (
  the Pyramid) stood the test of time to this very
  day

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Index Case

• 42-year-old white male
• No significant past medical hx. except x possible
  marijuana
• Was working on a ladder 12 feet high
• Electrocuted with 440 volts
• Contact burns to bilateral hands
• Cardioversion done 5 times

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• Prior to arrival to the hospital
• SVT -- Cardioversion x 5
• Hypotension -- Dopamine and Epinephrine drips
• Intubated
• Vitals on arrival
• Pulse 101
• BP 71/46
• RR 24

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• PE (pertinent findings)
• Neck in C-collar
• Ears some blood behind Lt. tympanic membrane
• Chest Bilateral crackles
• Heart S1S2 RRR Few extra-beats, No m,g,r
• Upper extremities 2nd 3rd degree burns on the
  palmar aspects of both hands

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• Labs
• K 3.1, Cr 1.1
• WBCs 27.8 ? 10.5
• AST/ALT 63/54
• ABGs 7.25/43.8/213.7/18.6/99.1
• Lactic a 4.2
• UDS methamphetamine

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• Trop 1.38 2.87 1.81
• CK 989 2190
• CKMB 19.4 17.2
• CKMB index 2.0 0.8
• Myoglobin 500 500

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• Swan-Ganz
• PCWP 19
• PA 31/14
• CVP 15
• CO 16 / CI 11
• SVR 335
• MAP 80
• CXR
• Interstitial alveolar pulmonary opacities
  centrally with relative sparing peripherally
• consistent with pulmonary edema

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• TTE on admission
• Mild eccentric LVH
• LV systolic function was moderately to severely
  decreased
• EF 25-30

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• Day 3
• Levophed discontinued
• Weaned off of the vent extubated
• Blood culture MRSA
• Day 8
• Discharged home on pain meds antibiotics

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• TTE (prior to d/c)
• Normal left ventricular systolic function
• EF 65

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The Hanging Gardens of Babylon

• A palace with legendary gardens built on the
  banks of the Euphrates river by King
  Nebuchadnezzar II

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ELECTRICAL INJURIES

• Critical Care Medicine
• Volume 30.Number 11.November 2002

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• Adults in workplace, children at home
• Severity of injury depends on
• Intensity of electrical current (voltage of
  source and resistance of victim)
• Pathway through victims body
• Duration of the contact with the source

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• Immediate death may occur from
• 1) Current-induced ventricular fibrillation
• 2) Asystole
• 3) Respiratory arrest secondary to
• Paralysis of the central respiratory control
  system
• Paralysis of the respiratory muscles

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History Overview

• Lightning was attributed to supernatural powers
• Zeus ruler of the ancient Greek gods holding
  thunderbolts which he used as warning or
  punishment against who disobeyed him

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• Zeus, the youngest son of Cronus and Rhea, was
  the supreme ruler of Mount Olympus and of the
  Pantheon of gods who resided there
• Being the supreme ruler he upheld law, justice
  and morals, and this made him the spiritual
  leader of both gods and men
• Zeus was a celestial god, and originally
  worshiped as a weather god by the Greek tribes

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• He has always been associated as being a weather
  god, as his main attribute is the thunderbolt, he
  controlled thunder, lightning and rain
• Theocritus wrote circa 265 BCE "sometimes Zeus
  is clear, sometimes he rains
• He is also known to have caused thunderstorms

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• Discovery and widespread use of electricity in
  the mid-1800s took away the supernatural aura
• 1st electrical fatality recorded in France in 1879

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• Thomas Alva Edison was both a scientist and an
  inventor
• Born in 1847
• When Edison was born, society still thought of
  electricity as a novelty, a fad. By the time he
  died, entire cities were lit by electricity

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• In his lifetime, Edison patented 1,093 inventions
• The most famous of his inventions was an
  incandescent light bulb
• He believed in hard work, sometimes working
  twenty hours a day. Edison was quoted as saying,
  "Genius is one percent inspiration and 99 percent
  perspiration"

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• In tribute to this important American, electric
  lights in the United States were dimmed for one
  minute on October 21, 1931, a few days after his
  death

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• Electrical injuries (excluding lightning) are
  responsible for 500 deaths/year in the US
• 1/2 of them occur in the workplace.
• 4th leading cause of work-related traumatic death
• Electrocutions at home 200 deaths/year

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• Lightning responsible for 93 deaths/year in US
• Morbidity 5-10 times higher than that due to
  other forms of electrical injury
• Iatrogenic electrical injury in the ICU
  defibrillators, pacemakers, electrosurgical
  devices
• Story of CPR how to treat electrocuted
  electrical linemen who were in VF

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Principles of Electricity

• Electricity flow of electrons (negatively
  charged outer particles of an atom) through a
  conductor
• When the electrons flow away from this object
  through a conductor they create an electric
  current amperes

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• Voltage force that causes electrons to flow
  volts
• Anything that impedes the flow of electrons
  through a conductor creates resistance ohms

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• Power lines range from
• Low
• Ultrahigh 1 million volts
• Utility power lines with high voltages in
  sparsely populated areas
• Through a succession of transformers voltage is
  gradually reduced
• Most homes in US Canada have a 120/240 V other
  countries (Europe, Asia..) 220 V

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The Temple of Artemis at Ephesus

• A beautiful temple in Asia Minor erected in honor
  of the Greek goddess of hunting and wild nature

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Pathophysiologic effects of Different Intensities
of Electrical Current
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• Electrical current exists in 2 forms
• 1) AC (Alternating Current) when electrons flow
  back and forth through a conductor in a cyclic
  fashion
• It is used in household and offices and is
  standardized to a frequency of 60 cycles/sec (60
  Hz)

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• 2) DC (Direct Current) when electrons flow only
  in one direction
• Used in certain medical equipment
  defibrillators, pacemakers, electrical scalpels
• AC is far more efficient and also more dangerous
  than DC ( 3 times) tetanic muscle contractions
  that prolong the contact of victim with source

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• Issue of safety over efficiency early days of
  electricity when Thomas Edison (who developed and
  popularized DC was fighting against George
  Westinghouse (who developed AC)
• AC first death penalty by electrocution

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• Lightning is a form of DC
• Occurs when electrical difference between a
  thundercloud and the ground overcomes the
  insulating properties of the surrounding air
• Current rises to a peak in about 2 µsec
• Lasts for only 1-2 sec

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• Voltage 1,000,000 V
• Currents of 200,000 A
• Transformation of the electrical energy to heat
  generated temperatures as high as 50,000ºF
• Extremely short duration prevents from melting

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The Mausoleum at Halicarnassus

• A fascinating tomb constructed for King
  Maussollos, Persian satrap of Caria

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Determinants of Electrical Injuries

• Ohms law
• Current Voltage/Resistance
• Exposure of different parts of the body to the
  same voltage ? different current ? different
  degree of damage because resistance varies

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• The least resistance is found in nerves, blood,
  mucous membranes and muscles
• The highest resistance is found in bones, fat and
  tendons
• Skins resistance ranging between 40,000 and
  100,000 O depending on thickness
• Moisture of the skin electrocution of a person
  in a bathtub or swimming pool

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• Moist mucus membranes significant orofacial
  injury to infants and toddlers
• Nerves and blood vessels are the best conductors
  path of least resistance for current after it
  enters the body
• Duration of the contact shock caused by AC will
  produce bigger injury than shock caused by DC of
  the same amperage

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• Pathway of the current through the body
• Vertical pathway parallel to the axis of the body
  is the most dangerous. It involves all the vital
  organs central nervous system, heart,
  respiratory muscles, in pregnant women the uterus
  and fetus
• Horizontal pathway from hand to hand the heart,
  respiratory muscles and spinal cord
• Pathway through the lower part of the body local
  damage

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The Colossus of Rhodes

• A colossus of Helios the sun-god, erected by the
  Greeks near the harbor of a Mediterranean Island

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Electrical Injury to Specific Tissues Organs

• Cardiovascular System
• Pathophysiology
• Direct necrosis of the myocardium
• Cardiac dysrhythmias

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• Focal or diffuse
• Widespread, discrete, patchy contraction band
  necrosis involving the myocardium, nodal tissue,
  conduction pathways and coronary arteries

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• A current 50-100 mA with hand-to-hand or
  hand-to-foot transmission ? ventricular
  fibrillation
• High-voltage current (AC or DC) ? ventricular
  asystole
• Lightning ? cardiac standstill
• Sinus rhythm may spontaneously return

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• Cardiac dysrhythmias reported in survivors of
  electrical injuries pathogenesis is rather
  unclear, multifactorial

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• Possible mechanisms
• 1) Arrythmogenic foci due to myocardial
• necrosis (esp. SA Node injury)
• 2) Alterations in the Na - K adenosine
  triphosphatase concentration
• 3) Changes in the permeability of myocyte
  membranes
• 4) Anoxic injury (respiratory arrest precedes the
  injury to the heart)

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• Large arteries not acutely affected because their
  rapid flow?dissipate heat. Medial necrosis
  aneurysm formation and rupture
• Smaller vessels acutely affected d.t. coagulation
  necrosis ? compartment syndrome

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• Clinical Manifestations
• Cardiac standstill, ventricular fibrillation
  most serious
• Sinus tachycardia, nonspecific ST- and T-wave
  changes much better prognosis
• Conduction defects, various degrees of heart
  blocks, BBB and ?QT interval

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• Supraventricular tachycardias and atrial
  fibrillation usually do not cause significant
  hemodynamic compromise
• On echocardiogram some depression of the right
  left ejection fractions

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• Cutaneous Injuries Burns
• Extensive flash and flame burns
• Hemodynamic, autonomic, cardiopulmonary, renal,
  metabolic and neuroendocrine responses

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• Nervous System
• Loss of conciousness, confusion impaired recall
• Peripheral motor sensory nerves ? motor
  sensory deficits
• Seizures, visual disturbances deafness
• Hemiplegia, quadriplegia, spinal cord injury
• Transient paralysis, autonomic instability ?
  hypertension, peripheral vasospasm due to
  lightning from massive release of catecholamines

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• Respiratory System
• Direct injury to the respiratory control center ?
  cessation of respiration or suffocation secondary
  to tetanic contractions of the respiratory
  muscles
• Acute respiratory dysfunction syndrome secondary
  to ischemia, aggressive fluid resuscitation,
  ventilator-associated pneumonia

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• Other Systems
• Kidneys susceptible to anoxic/ischemic injury
• Release of myoglobin creatinine phosphokinase ?
  renal tubular damage ? renal failure
• Fractures
• Transient autonomic disturbances ? fixed pupils
  may be perceived as severe brain injury or even
  death
• Temporary sensorineural hearing loss

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The Lighthouse of Alexandria

• A lighthouse built by the Ptolemies on the island
  of Pharos off the coast of their capital city

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Management of Electrical Injuries

• Overall fluid management should be judicious
  unless SIADH

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• Patient Monitoring
• Most severe cardiac complications present acutely
• Very unlikely for a patient to develop a serious
  or life-threatening dysrhythmia hours or days
  later
• Asymptomatic normal ECG do not need cardiac
  monitoring

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• Preexisting heart disease monitor such patients
  for 24 hrs after the injury
• Criteria for cardiac monitoring
• Exposure to high voltage
• Loss of consciousness
• Abnormal ECG at admission

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• Type of cardiac monitoring (controversial)
• Continuous telemetry
• Serial ECGs
• Serial measurement of cardiac enzymes
• Prognostic value of CK-MB, noninvasive and
  invasive imaging studies (echocardiography,
  thallium studies angiography) rather poor and
  inconsistent
• Muscles injured by an electrical current can
  contain up to 25 CK-MB fraction (as opposed to
  the normal 2-3)
• No information regarding changes in troponin

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Prophylaxis...

• One ounce of prevention is worth a pound of
  treatment

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The Great Pyramid of Giza

• A gigantic stone structure near the ancient city
  of Memphis, serving as a tomb for the Egyptian
  Pharaoh Khufu
• Man fears Time, yet Time fears the Pyramids
• Arab proverb

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"Genius is one percent inspiration and 99 percent
perspiration."