Successful management of pulmonary edema secondary to accidental electrocution in a young dog.

BACKGROUND: Human records describe pulmonary edema as a life-threatening complication of electric shock. Successful management requires prompt recognition and intensive care. However, in companion animals, electrocutions are rarely reported, even though domestic environments are full of electrical devices and there is always the possibility of accidental injury. Therefore, it is important for veterinarians to know more about this condition in order to achieve successful patient outcomes. CASE PRESENTATION: A 3-month-old male Labrador Retriever was presented with a history of transient loss of consciousness after chewing on a household electrical cord. On admission, the puppy showed an orthopneic position with moderate respiratory distress. Supplemental oxygen via nasal catheter was provided, but the patient showed marked worsening of respiratory status. Point-of-care ultrasound exams suggested neurogenic pulmonary edema due to electrical shock close to the central nervous system and increased B-lines without evidence of cardiac abnormalities. Mechanical ventilation of the patient was initiated using volume-controlled mode with a tidal volume of 9 to 15 ml/kg until reaching an end-tidal carbon dioxide ≤ 40 mm Hg, followed by a stepwise lung-recruitment maneuver in pressure-controlled mode with increases of the peak inspiratory pressure (15 to 20 cm H2O) and positive end-expiratory pressure (3 to 10 cm H2O) for 30 min, and return to volume-controlled mode with a tidal volume of 15 ml/kg until reaching a peripheral oxygen saturation ≥ 96%. Weaning from the ventilator was achieved in six hours, and the patient was discharged two days after admission without neurological or respiratory deficits. CONCLUSIONS: We present a rather unusual case of a neurogenic pulmonary edema subsequent to accidental electrocution in a dog. Timely diagnosis by ultrasound and mechanical ventilation settings are described. Our case highlights that pulmonary edema should be considered a potentially life-threatening complication of electrical shock in small animal emergency and critical care medicine.

Veno-arterial extracorporeal membrane oxygenation for electrical injury induced cardiogenic shock support: a case report.

BACKGROUND: High voltage electrical injury (HVEI) of more than 1000 V is a potentially devastating form of a multisystem injury associated with high morbidity and mortality. We present the first case of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a life saving device for treating a patient with severe cardiogenic shock after a high voltage electrical injury. CASE PRESENTATION: A 26-year-old male sustained HVEI while working with a concrete mixer pump that came in contact with a high voltage cable of 10,000 V. He was immediately disconnected from the mixer pump, underwent cardiopulmonary resuscitation and was transported to the nearest medical centre with severe cardiogenic shock with an ejection fraction (EF) of < 10%. Upon arrival, he was in critical condition, sedated and mechanically ventilated, haemodynamically unstable and supported by intravenous (IV) inotropes after a few events of ventricular fibrillation, with an electrical entry point on the left hand and an exit point located on his right leg. Blood pH was 6.8, PCO2 53 mmHg, PaO2 of 57 mmHg, lactate 8 mmol/L, and Troponin 38,000 ng/dl. The EF was 10% with global severe left ventricular dysfunction. During cardiopulmonary resuscitation (CPR), including cardiac massage and few electrical shocks, he was immediately connected to the VA-ECMO via open right femoral approach with distal arterial leg perfusion. He was treated with IV broad spectrum antibiotics, and high volume fluids to prevent rhabdomyolysis-induced acute kidney injury, total parenteral nutrition, topical silver sulfadiazine cream, and Granuflex for severe electrical burns. He was gradually weaned from inotropes over the next 3 days, during which his clinical condition and bloodwork improved tremendously. His EF gradually increased to 50% and he was weaned from the VA-ECMO, and underwent decannulation 86 h after initialization. He was discharged on day 27 without any sequelae. CONCLUSION: The VA-ECMO treatment can be a lifesaving device for treating severe cardiogenic shock caused by high voltage electrical injury, and should be considered while treating these "high-mortality risk" patients.

Protocols for documentation of electrical injuries for electrical safety inspectors and emergency medical practitioners.

BACKGROUND: Electric shocks are common, and victims report difficulty in finding practitioners with knowledge of the injury. Medical Practitioners, especially in private practice, report lack of knowledge of the injury and lack of expertise in assessing and treating the injury. The authors are often requested to suggest investigation protocols, assessment protocols, and treatment protocols, and to provide educational information. METHODS: The international body establishing electrical standards on the effects of current on the body (International Electrotechnical Commission, Maintenance Team 4 (MT4) of Technical Committee 64 (TC64)) have established protocols for the factors which require documentation and reporting of the injury. This article provides a narrative approach to using these protocols in accord with the standards (IEC 60479). The level of evidence is Level III (US/Canada classification). TYPE: This article collects together and collates physical and medical aspects of investigating electric shocks, and summarizes those of importance, and which are potentially forgotten. The thoroughness of initial assessment is emphasized. SUBSTANCE: Summaries are set out to guide first attenders and emergency medical personnel as to findings and observations which must be recorded for later comprehensive medicolegal reporting and which are often overlooked. CONCLUSION: Wider teaching in the nature of electric shocks will enhance assessment of victims and thorough recording of pertinent information and thus will enhance later medicolegal reporting. Many such factors are initially overlooked and lead to inadequate reporting for forensic purposes.

Bilateral impending macular holes after a high-voltage electrical shock injury and its surgical outcome: a case report.

INTRODUCTION: A macular hole is a rare complication after high-voltage electrical shock injury and only a few cases have been reported to date. To the best of our knowledge, this is the first report of bilateral impending macular holes after high-voltage electrical shock. CASE PRESENTATION: We report a case of bilateral impending macular holes in a 39-year-old male Chinese patient who sustained a high-voltage electrical shock three months prior to presentation. Our patient complained of gradually diminished eyesight in both eyes, with visual acuity of 20/100 and 20/40 in his right and left eyes respectively. Our patient underwent pars plana vitrectomy accompanied by octafluoropropane gas and triamcinolone acetonide injections, and was discharged from our hospital with slightly improved vision. CONCLUSION: The visual outcome of impending macular holes caused by high-voltage electrical shock may be poor despite tissue residue at the fovea and surgical intervention aimed at aiding macular recovery. Surgery is, however, effective in the short term in restoring normal anatomical macular structure.

Bilateral maculopathy following electrical burn: case report / Maculopatia bilateral após queimadura elétrica: relato de caso

CONTEXT: Electrical burns are an important etiology in dealing with patients suffering from burns. In situations of extensive deep lesions of multiple organs and systems affecting young and economically active people, there is a need for expensive multidisciplinary treatment, with a high socioeconomic cost for the community. Among the permanent injuries that explain this high cost, eye injuries stand out, since they are widely disabling. Although rare, lesions of the posterior segment of the eye are associated with higher incidence of major sequelae, and thus deserve special attention for dissemination and discussion of the few cases observed. CASE REPORT: The authors report the case of a patient who suffered high-voltage electrical burns and presented bilateral maculopathy, which evolved with a need for a surgical approach to repair retinal detachment and permanent low visual acuity. CONCLUSION: This report highlights the rarity of the etiology of maculopathy and the need for campaigns for prevention not only of burns in general, but also especially of electrical burns. .

CONTEXTO: As queimaduras elétricas representam etiologia importante na abordagem de pacientes vítimas de queimaduras. Lesões extensas e profundas de múltiplos órgãos e sistemas e o acometimento de população jovem economicamente ativa apontam para a necessidade de tratamento multidisciplinar dispendioso, com alto custo socioeconômico para as comunidades. Dentre as lesões permanentes que justificam esse alto custo, as oculares têm local de destaque, porque são amplamente incapacitantes. Embora raras, as lesões do segmento posterior do olho estão associadas a maior incidência de sequelas importantes, merecendo atenção especial para divulgação e discussão dos poucos casos observados. RELATO DE CASO: Os autores relatam o caso de paciente vítima de queimadura elétrica com fio de alta voltagem que apresentou maculopatia bilateral, evoluindo com necessidade de abordagem cirúrgica para correção de descolamento de retina e baixa acuidade visual permanente. CONCLUSÃO: Este relato destaca a raridade da etiologia da maculopatia e a necessidade de campanhas de prevenção não só das queimaduras em geral, mas especialmente das queimaduras elétricas. .

Development and Characterization of an Engraftable Tissue-Cultured Skin Autograft: Alternative Treatment for Severe Electrical Injuries.

BACKGROUND/AIMS: Optimizing the treatment regimens of extensive or nonhealing defects is a constant challenge. Tissue-cultured skin autografts may be an alternative to mesh grafts and keratinocyte suspensions that are applied during surgical defect coverage. METHODS: Autologous epidermal and dermal cells were isolated, in vitro expanded and seeded on collagen-elastin scaffolds. The developed autograft was immunohistochemically and electron microscopically characterized. Subsequently, it was transplanted onto lesions of a severely burned patient. RESULTS: Comparability of the skin equivalent to healthy human skin could be shown due to the epidermal strata, differentiation, proliferation markers and development of characteristics of a functional basal lamina. Approximately 2 weeks after skin equivalent transplantation the emerging new skin correlated closely to the adjacent normal skin. CONCLUSION: The present study demonstrates the comparability of the developed organotypic skin equivalent to healthy human skin and its versatility for clinical applications.

Inner ear damage following electric current and lightning injury: a literature review.

Audiovestibular sequelae of electrical injury, due to lightning or electric current, are probably much more common than indicated in literature. The aim of the study was to review the impact of electrical injury on the cochleovestibular system. Studies were identified through Medline, Embase, CINAHL and eMedicine databases. Medical Subject Headings used were 'electrical injury', 'lightning', 'deafness' and 'vertigo'. All prospective and retrospective studies, case series and case reports of patients with cochlear or vestibular damage due to lightning or electrical current injury were included. Studies limited to external and middle ear injuries were excluded. Thirty-five articles met the inclusion criteria. Fifteen reported audiovestibular damage following electric current injury (domestic or industrial); a further 15 reported lightning injuries and five concerned pathophysiology and management. There were no histological studies of electrical current injury to the human audiovestibular system. The commonest acoustic insult after lightning injury is conductive hearing loss secondary to tympanic membrane rupture and the most frequent vestibular symptom is transient vertigo. Electrical current injuries predominantly cause pure sensorineural hearing loss and may significantly increase a patient's lifetime risk of vertigo. Theories for cochleovestibular damage in electrical injury include disruption of inner ear anatomy, electrical conductance, hypoxia, vascular effects and stress response hypothesis. The pathophysiology of cochleovestibular damage following electrical injury is unresolved. The mechanism of injury following lightning strike is likely to be quite different from that following domestic or industrial electrical injury. The formulation of an audiovestibular management protocol for patients who have suffered electrical injuries and systematic reporting of all such events is recommended.

Unwitnessed lithium ion disc battery ingestion: case report and review of best practice management of an increasing clinical concern.

OBJECTIVE: To describe a case of unwitnessed lithium ion disc battery ingestion, with a review of radiology findings and current best practice management. CASE REPORT: A three-year-old girl presented following ingestion of a foreign body, which her four-year-old brother claimed was a one pound coin. The patient was managed non-urgently and transferred for specialist ENT assessment 6 hours following the initial ingestion, with no evidence of airway compromise. A corroded battery was removed from the level of the cricopharyngeus after 8 hours, with an associated circumferential mucosal burn. CONCLUSION: There is increasing concern regarding the acknowledged rising incidence of lithium ion disc battery ingestion. The lack of a high index of suspicion and the inability to recognise subtleties on imaging may lead to suboptimal management with a higher degree of unnecessary immediate and delayed morbidity. The recently published American Academy of Pediatrics Guidelines may guide the approach to managing battery ingestions.

Carotid rupture following electrical injury: a report of two cases.

Electrical injuries often result in extensive tissue damage where vascular damage may occur and result in thrombosis and spontaneous rupture of blood vessels. Rupture of the brachial, radial, ulnar, internal mammary, and obturator arteries has been reported in the literature. The authors present two cases of carotid artery rupture following high-voltage electrical injuries. The first case is a 21-year-old man who was climbing a fence near a high-voltage power line when a gold chain he was wearing around his neck caught on the power line, resulting in a 10% circumferential electrical injury to his neck. He presented with visible arterial bleeding from the large neck wound and was taken to the operating room, where a 1-cm laceration to the carotid artery was repaired with a vein patch. On the second postoperative day, the patch dislodged, and a spontaneous rupture of the common carotid artery occurred. The damaged artery was subsequently ligated. The patient recovered with no neurological sequelae. The second case is a 43-year-old man who suffered a high-voltage injury while working on an electrical panel, resulting in a 50% TBSA full-thickness burn to the face, scalp, trunk, and extremities. Four weeks after admission, a latissimus dorsi myocutaneous free flap was used for coverage of exposed outer table of the skull. Intraoperatively, the carotid artery spontaneously ruptured proximal to where the dissection was being carried out. The patient recovered with no neurological sequelae. High-voltage electrical injury results in significant damage to blood vessels via a number of mechanisms. Rupture of a major vessel is a rare, life-threatening sequelae of electrical injury.

Does voltage predict return to work and neuropsychiatric sequelae following electrical burn injury?

Voltage has historically guided the acute management and long-term prognosis of physical morbidity in electrical injury patients; however, few large studies exist that include neuropsychiatric morbidity in final outcome analysis. This review compares high (>1000 V) to low (<1000 V) voltage injuries, focusing on return to work and neuropsychiatric sequelae following electrical burn injury. Patients with electrical injuries admitted to the University of North Carolina Jaycee Burn Center between 2000 and 2005 were prospectively entered into a trauma database, then retrospectively reviewed. Patients were divided into 4 cohorts: high voltage (>1000 V), low voltage (<1000 V), flash arc, and lightning. Demographics, hospital course, and follow-up were recorded to determine physical and neuropsychiatric morbidity. Differences among cohorts were tested for statistical significance. Over 5 years, 2548 patients were admitted to the burn center, including 115 patients with electrical injuries. There were 110 males and 5 females, with a mean age of 35 years (range, 0.75-65 years). The cause of the electrical injury was high voltage in 60 cases, low voltage in 25 cases, flash arc in 29 cases and lightning in 1 case. The mean total body surface area burn was 8% (range, 0%-52%). The etiology was work-related electrical injury in 85 patients. Mean follow-up period was 352 days with 13 (11%) patients lost to follow-up. Patients with high voltage injuries had significantly larger total body surface area burn, longer ICU stays, longer hospitalizations, and significantly higher rates of fasciotomy, amputation, nerve decompression and outpatient reconstruction, with 4 cases of renal failure and 2 deaths. In spite of these differences, high and low voltage groups experienced similar rates of neuropsychiatric sequelae, limited return to work and delays in return to work. Final impairment ratings for the high and low voltage groups were 17.5% and 5.3%, respectively. Electrical injuries often incur severe morbidity despite relatively small burn size and/or low voltage. When comparing high and low voltage injuries, similarities in endpoints such as neuropsychiatric sequelae, the need for late reconstruction, and failure to return to work challenge previous notions that voltage predicts outcome.

Adjunctive hyperbaric oxygen therapy contributes healing in electrical injury: a case report of high voltage electrical injury.

In electrical injuries, new treatment modalities and guidelines are needed for improving clinical outcome and the survival of damaged tissue. Although there is no published study about hyperbaric oxygen (HBO) therapy for electrical injury in the literature, it is indicated in conditions, which may contribute to the clinical presentation of electrical injury such as thermal burns, crush injuries, necrotizing soft tissue infections, problematic wounds and compromised skin grafts and flaps. An 11-year-old child with high voltage electrical injury treated with adjunctive hyperbaric oxygen for 90 minutes twice a day at 2,4 ATA for one week, then once a day for six days for a total of 20 sessions was presented to demonstrate the beneficial effects of hyperbaric oxygen therapy initiated before irreversible damage had taken place. Although hyperbaric oxygen therapy was initiated rather late, when the most effective window for intervention had already past, HBO was effective in fighting against necrosis, infection and tissue loss. Adjunctive HBO therapy is suggested for electrical injuries for its contribution to healing. In order to see the favourable effects of HBO, it is better to start the treatment within the first 24 hours following injury.

Pediatric electrical injuries: a review of 38 consecutive patients.

BACKGROUND/PURPOSE: The aim of this study was to explore the mechanisms, complications, morbidity, and mortality associated with electrical injuries in children. METHODS: The charts of pediatric patients who had been admitted to the authors' center with electrical burn injuries (EBI) between January 1993 and October 2002 were reviewed retrospectively. RESULTS: Of the 764 acute burn admissions over a 9-year period, 5% (38 patients) had EBI. Mean age was 9.6 +/- 4.4 years (range, 1 to 16 years). Seventy-six percent of the EBI patients were boys (M to F, 29:9), and the extent of the burn wounds ranged from 1% to 50% of total body surface area (TBSA; mean, 18.6% +/- 14.7%). High-voltage (HV) electricity accounted for 63% of the EBI (1 lightning), and 37% were caused by low-voltage (LV) current. In 19 children, serious high-voltage injuries occurred by direct contact with outlet electrical transfer wires with a metal from a balcony or with manual contact while climbing to the pole. A total of 153 surgical procedures were performed on the EBI patients, and 26% of the cases (10 of 38) required amputations. Patients who sustained HV electrical injuries had associated major complications. All of the patients underwent close cardiac monitoring, and none had cardiac complications. The average hospital stay was 23.8 +/- 14.2 (range, 2 to 48) days. One patient died of wound sepsis. CONCLUSIONS: Although not frequent, EBI remain a serious problem, particularly in adolescent boys, and short- and long-term morbidity are significant. HV injuries occur mainly in the adolescent population and require more aggressive care. Balcony injury is a specific etiology for EBI, and special consideration is required to prevent this type of injury in our country.

Experience of 14 years of emergency reconstruction of electrical injuries.

Although there have been great advances in the treatment of electrical injuries in the last 20 years, the extremity loss ratio in electrical injuries remains at an unacceptably high level. The primary cause is due to the progressive tissue necrosis which results in the continuous extension of necrosis in the wound, leading to loss of the whole injured extremity. This study reports attempts to break the dangerous tissue necrosis circle and save the form and function of damaged extremities. After 14 years of systematic experimental and clinical studies a successful comprehensive urgent reconstruction alternative (CURA) for electrical injuries is proposed. CURA includes: debriding the wound as early as possible after injury; preserving the vital tissue structures as much as possible, such as nerves, vessels, joints, tendons, bone, even though they have undergone devitalization or local necrosis; repairing these vital tissues during the first surgery if functional reconstruction requires it; protecting the wound bed by covering with tissue flaps of rich blood supply; improving flap survival through moist dressings supported by continuous irrigation beneath the flaps for a 24-72h period after surgery with measures to control local infection; and last, giving general systemic treatment with vasoactive agents and antibiotics. Four hundred and fifty nine wounds in 155 patients suffering from electrical injuries have been successfully treated with this technique between 1986 and 2000 and are reported in this paper. Satisfactory results were obtained with the extremity loss proportion reduced to less than 9% compared with 41.5% during the 10 years before 1984 in the same hospital. The authors suggest that CURA is an effective and workable method for treatment of electrical injuries.

Transient hypothalamic hypothyroidism and diabetes insipidus after electrical injury.

Transient or permanent diabetes insipidus (DI) due to damage in vasopressinergic neurons--which may be hereditary or caused by head injury, brain surgery, tumors, granulomatous disorders, infections, vascular disorders, autoimmunity, and idiopathic causes--is not rare. Hypothalamic hypothyroidism is due to decreased thyrotropin-releasing hormone secretion and is seen rarely. We report a case of transient hypothalamic hypothyroidism and transient DI due to electrical injury.

Radiofrequency electrocution (196 MHz).

Radiofrequency (RF) electrocutions are uncommon. A case of electrocution at 196 MHz is presented partly because there are no previous reports with frequencies as high as this, and partly to assist in safety standard setting. A 53-year-old technician received two brief exposures to both hands of 2A current at 196 MHz. He did not experience shock or burn. Progressively over the next days and months he developed joint pains in the hands, wrists and elbows, altered temperature and touch sensation and parasthesiae. Extensive investigation found no frank neurological abnormality, but there were changes in temperature perception in the palms and a difference in temperature between hands. His symptoms were partly alleviated with ultra-sound therapy, phenoxybenzamine and glyceryl trinitrate patches locally applied, but after several months he continues to have some symptoms. The biophysics and clinical aspects are discussed. It is postulated that there was mainly surface flow of current and the micro-vasculature was effected. Differences to 50 Hz electrocution are noted. Electrocution at 196 MHz, even in the absence of burns may cause long-term morbidity to which physicians should be alerted. Safety standards should consider protection from electrocution at these frequencies.

Injury by electrical forces: pathophysiology, manifestations, and therapy.

The pathogenesis and pathophysiologic features of electrical injury are more complex than once thought. The relative contributions of thermal and pure electrical damage depend on the duration of electric current passage, the orientation of the cells in the current path, their location, and other factors. If the contact time is brief, nonthermal mechanisms of cell damage will be most important and the damage is relatively restricted to the cell membrane. When contact time is much longer, however, heat damage predominates and the whole cell is affected directly. These parameters also determine the anatomic tissue distribution of injury. Damage by Joule heating is not known to be dependent on cell size, whereas larger cells are more vulnerable to membrane breakdown by electroporation. Cells do survive transient plasma membrane rupture under appropriate circumstances or if therapy is instituted quickly. If membrane permeabilization is the primary cellular pathologic condition, then injured tissue may be salvageable and the challenge for the future is to identify a technique to reseal the damaged membranes promptly. Present standards of care for electrical injury require a fully staffed and well-equipped intensive care unit, available operating suites, and the availability of the full range of medical specialists. Major teaching hospitals with burn centers may be the ideal setting for the treatment of an electrical trauma victim. After the initial resuscitation, efforts are directed primarily towards preventing additional tissue loss mediated through the compartment syndrome, compressive neuropathies, or the presence of necrotic tissue. Renal and cardiac failure caused by the release of intracellular muscle contents into the circulation must be prevented. Attention can then be directed towards maximizing tissue salvage and preventing late skeletal and neuromuscular complications. Reconstructive procedures that transfer healthy tissue from a distance are necessary to optimize the functional value of the remaining tissue. Finally, unless the patient is rehabilitated psychologically, the real benefit from other sophisticated care will not be fully realized. These goals are important throughout the acute care of the patient. In the future, new guidelines for treating electrical trauma will be based on a clearer understanding of the relevant pathophysiologic features. These strategies will rely on improved diagnostic imaging and on reversing the fundamental problem of cell membrane damage. Moreover, complex biochemical and organ system pathophysiologic interactions will require careful management. If successful, research efforts presently underway should improve the prognosis of victims after electrical trauma.

Eletricidade: efeitos sistêmicos e cardiovasculares / Eletricity: systemic and cardiovascular effects

Acidentes por eletricidade continuam sendo responsáveis por um número substancial de morbidade e mortalidade. As vítimas de choque elétrico apresentam um amplo espectro de complicaçöes, variando de uma sensaçäo transitória desagradável secundária a uma exposiçäo a corrente elétrica de baixa intensidade até morte súbita por eletrocussäo acidental. Esta revisäo descreve os mecanismos patogênicos responsáveis, complicaçöes sistêmicas e cardiovasculares, bem como a prevençäo, prognóstico e o tratamento das injúrias e arritmias cardácas.

Trauma eléctrico: fisiopatología y resucitación / Electric trauma: physiopathology and resuscitation

La atención del paciente que sufre una injuria eléctrica es generalmente poco conocida por el médico general, probablemente debido a su relativa poco frecuencia, excepto en centros especializados a tal fin o en instituciones en que este fenómeno traumático es más frecuente (ej.: trabajadores de red de distribución eléctrica). Se describe la epidemiología del trauma eléctrico, su atención inicial y forma de presentación en el terreno, como también los tipos de lesiones que pueden aparecer luego de la injuria, por lo general de manifestación tardía con posibles secuelas severas a largo plazo. El seguimiento atento de estos pacientes a corto y mediano plazo es la clave para prevenir daños mayores.

Emergency treatment and early fluid resuscitation following electrical injuries.

Injuries caused by high-tension electrical current are rare, but pathophysiologically unique with destructive effects. As a form of thermal trauma, electrical injuries represent a connection of skin burns and deep tissue destruction unpredictable in its depth which mostly resembles a crush injury. Emergency treatment measures begin with the separation from the electrical contact if any and prompt transport to the nearest institution with all means for cardiorespiratory resuscitation and complete recovery. Resuscitation of the patient after electric shock continues then with fluid replacement using special formula modified for such cases, correction of acidosis and myoglobinuria and finally with escharotomy and fasciotomy which is most often necessary.