Arrhythmias and laboratory abnormalities after an electrical accident: a single-center, retrospective study of 333 cases.

BACKGROUND: Even though electrical injuries are common in the emergency room, guidelines, consensus, and general recommendations for the management of these patients do not exist in Europe. Documented cases of delayed arrhythmias are rare and their connection with electrical injury has not been fully confirmed. We also use cardio-specific markers for the risk stratification of myocardial injury, but there is no significant study referring to their utility in this clinical situation. These reasons led us to retrospectively analyze all cases of electrical injuries over 23 years to determine the prevalence of cardiac arrhythmias (mainly malignant arrhythmias and delayed arrhythmias). METHODS: We retrospectively searched all patients admitted to the University Hospital in Pilsen, CZ, with a diagnosis of electric injury (ICD diagnostic code T754) from 1997 to 2020. The hospital´s information system was used to research the injury; data were drawn from patient medical records. RESULTS: We identified 333 cases of electrical injury in our hospital. Men accounted for about two-thirds, and women one-third. Children accounted for about one-third of cases. Most were low-voltage injuries (< 1000 V, 91.6%). All participants had an initial ECG, and 77.5% of patients had continuous ECG monitoring, usually lasting 24 h. Cardiac arrhythmias were noticed in 39 patients (11.7%). The most frequent arrhythmias were: ventricular fibrillation, sinus tachycardia, bradycardia and arrhythmia, atrial fibrillation, and supraventricular tachycardia. The ECG showed cardiac conduction abnormalities in 28 patients (8.1%), and ten patients (3%) had supraventricular or ventricular extrasystoles. In ten cases (3%), we found changes in ST segments and T waves on the initial ECG. Thirty-one patients (9.3%) suffered a loss of consciousness and 50 patients (15.02%) reported paresthesia. The most frequent ion disbalances were hypokalemia (18%) and hypocalcemia (3.3%). Patients with an ion disbalance had significantly more arrhythmias and newly diagnosed cardiac conduction abnormalities. Troponin levels (cTnI or hs-cTnT) were measured in 258 cases (77.48%) and found to be elevated above the 99th percentile in 19 cases (5.7%). Almost one-third of patients had burns of various degrees of seriousness, and 41 patients (12.3%) had concomitant traumatic injuries. Eleven patients underwent pre-hospital resuscitation, three died in the hospital, and another died as result of intracranial hemorrhage. CONCLUSION: All malignant arrhythmias occurred immediately after the electrical injury, delayed life-threatening arrhythmias were not observed, and no predictive factors of malignant arrhythmias were found. While elevations of cardiac troponins were observed sporadically, they did not appear helpful for risk stratification. In patients with arrhythmias, ion disbalance may be more critical. We concluded that asymptomatic, uninjured adult and pediatric patients with normal initial ECG findings do not need continuous ECG monitoring and may be discharged home. Recommendations for high-risk patients and patients with mild ECG abnormalities at admission are less obvious.

[Electrical Accidents]. / Stromunfälle.

Electrical Accidents Abstract: When persons seek medical help after an electrical injury, physicians have to inquire on the type (AC/DC) and strength of current (>1000V is considered "high voltage") as well as the exact circumstances (loss of consciousness, falls) of the accident. In the advent of high-voltage accidents, loss of consciousness, arrhythmias, abnormal ECG or elevated troponin levels, in-hospital rhythm monitoring is warranted. In all other cases, the type of extra cardiac injury primarily directs the management. Superficial skin marks may disguise more extensive thermal injuries of inner organs.

[Criteria for assessing the severity of the lesion and the outcome of the electric injury, depending on the parameters of the current and its pathways]. / Kriterii otsenki tyazhesti porazheniya i iskhoda elektrotravmy v zavisimosti ot parametrov toka i putei ego prokhozhdeniya.

The purpose of the work is to establish the relationship between the magnitudes of the electric current and clinical and physiological manifestations (outcome) on the basis of data from special literature. When performing forensic medical examinations, questions are often raised about the possibility of saving the life of an injured person in the provision of timely medical care, as well as the possibility of taking active actions after causing damages. The totality of the above information will enable to answer these questions reasonably. Besides, the data summarized in the article are necessary when planning experimental work in the study of electropathology and when conducting biomedical tests.

[Case studies in expert review of electrical injury]. / Vozmozhnost' resheniya situatsionnykh zadach v ramkakh ekspertizy elektrotravmy.

Electrical injury is quite rare in forensic practice, and situational examinations for this type of injury are even rarer. A case of an electrical injury is presented where the circumstances of the death and the conditions of injury were not obvious. As part of the commissioned examination, a repeated review of the accident scene and an examination of the alleged injuring object were conducted, which facilitated reconstruction of conditions and circumstances of the electric injury.

Patients with low-voltage electric shock referred to an Emergency Department. / Pasienter med strømgjennomgang fra lavspenning henvist til et akuttmottak.

BACKGROUND: Patients exposed to electricity are often referred to the Emergency Department, but guidelines differ as to how they should be managed. In this article, we describe patients with low-voltage electric shock in the Emergency Department at St Olav's Hospital, Trondheim University Hospital. MATERIAL AND METHOD: Retrospective data from patients referred to the Emergency Department following low-voltage electric shock (< 1,000 V) in the period 1.1.2012-31.12.2017 (N = 210) were included. RESULTS: The median age was 26 years and 186/210 (89 %) were men. Out of the 210 patients, 165 (79 %) had symptoms following electric shock. Localised pain and chest discomfort occurred in 84/165 (51 %) and 57/165 (35 %) of patients respectively. ECG findings were normal in 168/209 (80 %), and no patients had arrhythmias requiring treatment or elevated troponin T or creatine kinase. No patients had serious complications or died. INTERPRETATION: Low-voltage electric shock did not cause serious arrhythmias or elevated levels of troponin T or creatine kinase. It should be possible to manage asymptomatic patients with normal findings on clinical examination and ECG in a prehospital setting without reducing patient safety.

Pediatric electrical injuries in the emergency department: an evidence-based review.

Electrical injuries in pediatric patients are uncommon but can be life-threatening and require efficient and effective identification and management. Injury severity is based on the characteristics of the electricity, the duration of contact with the electrical source, and the current's pathway through the body. This issue discusses the specific threats posed by high-voltage, low-voltage, and lightning injuries. The various presentations are described, including burns, arrhythmias, respiratory arrest, cardiac arrest, blunt trauma from falls or blast events, rhabdomyolysis, tympanic membrane rupture, and altered mental status, among others. The most current literature is reviewed, and an evidence-based approach is provided for the diagnosis and management of electrical injuries in pediatric patients presenting to the emergency department.

ECG monitoring in high voltage electric injury patients presenting with normal ECG: Time to revisit practice?

Advanced Trauma Life Support (ATLS) recommends prolonged ECG monitoring of patients with high risk factors post electric injuries, for detecting and treating potentially life threatening arrhythmias. We hereby present our experience of high voltage electric injuries (HVEI) patients with high risk factors, managed at a level 1 Trauma Centre. Seven patients of high voltage electric injuries with significant burns (BSA > 10% of 2nd degree and above) were admitted over a year (Jan 1, 2019 to Dec 31, 2019), age ranging from 11 to 51 (median 25 yrs). Six out of seven patients (85.7%) were males. Mode of injury was recreational in one, workplace related in one and accidental in five (71.4%). Six patients had entry wounds in extremities, and three underwent emergency limb saving surgery (all escharotomies). Three patients underwent eventual amputation of injured extremity. Serum creatine kinase was monitored in all and multisystem involvement was seen in three patients; one patient (referred) required haemodialysis due to renal failure. There was no mortality. In all cases, 24 h continuous ECG monitoring was carried out as per ATLS and ERC (European Resuscitation Council) guidelines. There was no episode of paroxysmal or persistent rhythm disturbance in our patients during in-hospital stay or follow up. Review of pertinent literature suggests similar experiences of other authors. HVEI is a rare injury and most centres have reported on their experience with small number of patients as in our study. Currently, continuous ECG monitoring post HVEI seems to be the safe practice for patients with cardiac co-morbidities. Further studies are required to find other subsets of HVEI patients likely to benefit from ECG monitoring, and the clinical significance of 'delayed arrhythmias' post HVEI.

Advances in forensic diagnosis of electric shock death in the absence of typical electrical marks.

Electrical injury is a relatively uncommon but potentially devastating form of multi-system injury with high morbidity and mortality. In common electric injury cases, it is usually difficult to find characteristic changes of electric injury in major organs by using routine histopathological test methods unless there are landmark traces of electric injury, known as electric marks. How to determine electric shock death, especially in the absence of typical electrical marks on the body surface in some cases (which account for about two-thirds of electric injury cases), remains a challenging problem in forensic practice. Our summary shows that many current related studies have focused their efforts to find characteristic histopathological changes in major organs of the body caused by electric injury. Based on the results obtained through comparison of the literature, we find that it may be more urgent and important to find the optimal autopsy or sampling sites in cases with no typical electric marks, knowing that these sites may often reflect the most significant histopathological changes of electric injury, for instance anatomy and sampling of the anterior wrist and the medial malleolus in cases involving the hand-to-foot electric circuit pathway. In this article, we make a summary of advances in identification methods of electric injury, hoping that it could provide some new insights for further research in this field.

Morphological cardiac changes in electrocution deaths: A literature review.

Electrical injury may lead to damage to the conducting tissue, myocardial changes and even sudden cardiac death. Victims of low-voltage electrocution may have no electric marks, burns or other signs typical of electrical injuries. In these cases, the absence of other specific findings could make the identification of the cause of death very difficult. A broad spectrum of cardiac changes in cases of electrocution has been described in the literature, including the break-up of myocardial fibres, cardiomyolysis, haemorrhagic areas, the separation of myofibres and alternating hypercontracted-hyperdistended myocytes. All the described alterations, however, cannot be exclusively attributed to electrocution, since no specific morphological cardiac findings have so far been identified in electrocution. However, a few histological patterns recur, and their knowledge may be important for the forensic pathologist. This literature review describes the main pathological patterns observed in cases of fatal electrocution based on a literature search carried out up to September 2019 in the databases PubMed and Scopus. The search criteria included the keywords for cardiac lesions and electrocution. On the grounds of the literature data, a list of major and minor diagnostic markers for the passage of the electrical current through the heart tissue was created.

Determination of metallization with energy-dispersive X-ray fluorescent spectrometry in experimental electric injury.

We investigated the application of energy-dispersive X-ray fluorescent spectrometry (EDX) analysis to the detection of aluminum (Al), tin (Sn) and zinc (Zn) as the electric conductor in experimental electrical injury. Experimental electrical injury was caused by exposure to alternating current at 100 V for 10 s. The peaks of Al, Sn, and Zn were detected by EDX in formalin-fixed skin samples of each current exposure group. Histological examination revealed blister formation in all samples of each current exposure group. EDX analysis technique can be applied to detect Al, Sn, and Zn as the electric conductor, and is useful in the diagnosis of electrocution.

Fatal Direct Current Electrocution in a Welder.

Direct current (DC) electrocution is exceedingly rare, especially in the context of workplace accidents and exposure, where electrical fatality is almost exclusively associated with alternating current (AC). The DC electrocution requires a much higher voltage to cause significant injury and death, and therefore is generally considered safer than AC. Here, we present a case of DC electrocution where a welder accidentally electrocuted himself while repairing a metal plate inside a silo. The decedent had complained of feeling shocks in his arm while welding twice before being electrocuted. Autopsy revealed minimal trauma, along with a classic targetoid electrical burn and punctate lesions likely to be electrical burns. Correlation of the history obtained at the scene and the examination performed at autopsy aided the identification of this rare cause of death.

A Pilot Study on the Diagnosis of Fatal Electrocution by the Detection of Myocardial Microhemorrhages.

In electrocutions, death may be caused by alterations in the heart conduction system provoking ventricular fibrillation. This study aims to identify histological cardiac markers of high- and low-voltage electrocution. Two groups of decedents were evaluated: group A included 14 fatalities caused by high- or low-voltage electrocution and group B (control) included 14 fatalities due to other traumatic or disease causes. Myocardial sampling with microscopic examination was performed on all the hearts using the hematoxylin and eosin and Masson's trichrome stains to investigate morphological characteristics that could indicate the damage caused by high- and low-voltage electrocutions. Interstitial myocardial hemorrhagic infiltration was the only differentiating finding, which was shown only in high-voltage electrocution. This pathological finding has not been previously reported, and it may be specific to high-voltage electrocution deaths. Further studies are warranted.

Pediatric electrical injury in Turkey: Five year retrospective hospital-based study.

BACKGROUND: We aimed to evaluate children who presented with electrical injury to the emergency department. We tried to reveal the complications of these patients and the measures to be taken in this regard. METHODS: Medical records of pediatric patients who were admitted with electrical injury to emergency department between January 2007 and January 2012 were retrospectively reviewed. An information form was completed about demographic data, clinical features, exposure place, electrical current type, clinical course, duration of hospitalization, electrocardiography, echocardiography and other systems findings. RESULTS: Children who were the most exposed to electrical injury were children 4 years and under. While low-voltage current exposure was more common in younger ages, high-voltage current exposure was more common in older ages. Most of our patients (%72) were exposed to low voltage. Patients who exposed to high-voltage electricity had significantly higher levels of CPK, CK-MB, LDH, AST, and ALT compared to patients who were exposed to low voltage electricity. None of the patients have died. CONCLUSION: Young children are often exposed to electric shock at home. Increasing precautions to be taken at home reduces electrical shock injuries. Children and especially families should be educated in this regard.

Joint Shock/Death Risk Prediction Model for Patients Considering Implantable Cardioverter-Defibrillators.

BACKGROUND: The risk of death or appropriate therapy varies widely among recipients of implantable cardioverter-defibrillators (ICDs). The goals of this study were to develop a risk prediction tool that jointly considers future outcome probabilities of ICD shock and death. METHODS AND RESULTS: We performed a secondary analysis of patients receiving ICDs as part of the SCD-HeFT trial (Sudden Cardiac Death in Heart Failure Trial). We applied an illness-death regression model to jointly model both ICD shocks and death under the semi-competing risks framework, which predicts for each patient their probability of having received ICD shocks, dying, or both at any given point in time. Among 803 ICD recipients (mean age, 60 years; 23% women) followed for a median of 41.1 months, 430 (53.5%) patients completed the study without dying or receiving an ICD shock, 206 (25.7%) received at least 1 shock but survived, 113 (14.1%) died before experiencing a shock, and 54 (6.7%) received at least 1 shock and subsequently died. Predicted outcome probabilities based on baseline demographic and clinical variables reveal substantial heterogeneity in joint shock and death risks, both between patients at each time point and for each single patient across time. Overall, predictive performance for ICD shock and death individually was adequate, based on area under the curve at 5 years of 0.65 for shocks and of 0.79 for death. CONCLUSIONS: Our analysis of outcomes after ICD implantation provides an alternative predictive model for individual risk of death or ICD shocks. If validated, this may provide a useful tool for individualized counseling regarding likely outcomes after device implantation, while also informing the design of further studies to focus the clinical effectiveness and cost-effectiveness of ICD therapy. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00000609.

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.

High Impedance Electrical Accidents: Importance of Source and Subject Impedance.

In most cases, the diagnosis of an electrical injury or electrocution is straightforward. However, there is a necessity for much closer analysis in many cases. There exist sophisticated electrical safety standards that predict outcomes for shocks of various currents applied to different parts of the body. Unfortunately, the actual current is almost never known in an accident investigation. A common source of errors is the assumption that the source (including the return) has zero impedance. Another surprisingly common problem is the erroneous assumption that the body current is equal to the source current capability. METHODS: We used the following methodology for analyzing such cases: (1) Determine body pathway, (2) Estimate body pathway impedance, (3) Determine source voltage, (4) Determine source impedance, (5) Calculate delivered current using total pathway impedance, and (6) Ignore available current as it is largely confounding in most cases. RESULTS: We analyzed 6 difficult cases using the above methodology. This includes 2 subtle situations involving pairs of matched case-control subjects where a subject was electrocuted while his work partner was not. CONCLUSIONS: Careful calculations of the amplitude and duration of the shock is required for understanding the limits and potential causation of such electrical injury. This requires the determination of both the source and body pathway impedance. Available current is usually irrelevant and overemphasized.

Points & Pearls: Electrical injuries in the emergency department: an evidence-based review

Electrical injuries can be caused by exposure to current from low-voltage and high-voltage sources as well as lightning strikes, and the circumstances of the exposure will dictate management strategies. Human tissues have varying resistance characteristics and susceptibility to damage, so injuries may be thermal, electrical, and/or mechanical, potentially causing burns, thrombosis, tetany, falls, and blast injury. This issue reviews the types of trauma seen with electrical injury and how body systems can be affected by occult or delayed effects, and the optimal evidence-based resuscitation and management strategies associated with each. [Points & Pearls is a digest of Emergency Medicine Practice.]