Cardiac abnormalities demonstrated postmortem in four cases of accidental electrocution and their potential significance relative to nonfatal electrical injuries of the heart

Myositis "Diaphragm Cramp" as a Potential Cause of Respiratory Arrests in Infants. Comment on Salfi, N.C.M. et al. Fatal Deterioration of a Respiratory Syncytial Virus Infection in an Infant with Abnormal Muscularization of Intra-Acinar Pulmonary Arteries: Autopsy and Histological Findings. Diagnostics 2024, 14, 601

This Letter to the Editor provides additional information regarding the tragic case of a 6-month-old in Italy with respiratory syncytial virus who deteriorated and died unexpectedly from rapid respiratory insufficiency [...].

A statistical study of postmortem heart weight in Chinese adults

INTRODUCTION

Objective assessment of cardiac hypertrophy in forensic pathology practice is of great significance for forensic pathologists, for whom reference values for normal heart weights are needed. Developed regions such as Europe, the United States, and Japan recalculate the weight of human organs at regular intervals, but in China, there has been no systematic calculation of the weights of human organs since 2006.

AIMS

To statistically analyse the heart weight of Chinese adults postmortem and obtain a reference range.

MATERIALS AND METHODS

4170 adult autopsy reports were collected from 12 forensic departments in 10 provinces in China. The causes of death were classified by sex, and heart weight and the heart weight/body height ratio reference values were further calculated according to different body mass index and body heights. Finally, the cutoff value of cardiac hypertrophy in Chinese adults was calculated.

RESULTS

In the group of non-cardiovascular disease causes of death, the cardiac weight of the electric death group was higher, while the heart weight of the prolonged bed-rest group was significantly reduced. After the electric death and prolonged bed-rest groups were excluded, heart weight, the heart weight/body height ratio, and cutoff values for cardiac hypertrophy were further classified and analysed according to body mass index. The mean reference values for heart weight in men and women with normal weight status were 325.82 ± 41.60 g and 286.39 ± 44.84 g, and the heart weight/body height ratios were 1.95 ± 0.23 in men and 1.82 ± 0.27, respectively. The cutoff values for cardiac hypertrophy were 387.35 g for men and 346.80 g for women.

CONCLUSION

The heart weight reference values of both sexes in this study were significantly higher than those in 2006, which is considered related to the development of China's economy and the improvement of people's living standards. This study also suggests the need for a new round of statistical surveys and updated data on the weight of other organs.

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.

Electrical cardiac injuries: current concepts and management

Electrical injuries are a commonly encountered hazard in both the home and workplace. However, clinicians are often uncomfortable when faced with the patient who presents with an electric shock due to sparse literature and lack of systematic recommendations on this topic. Electrical injuries can range from minor skin burns to life threatening internal organ damage. A thorough clinical assessment to ascertain the path of current through the body and possible internal injury is essential. The main concern in an apparently stable individual after an electric shock is the potential for delayed occurrence of cardiac arrhythmias which will require monitoring in the intensive care setting. While it may be reasonable to discharge home from the emergency room selected patients with low voltage injuries, absence of syncope and a normal ECG, others may require monitoring for at least 24 h. Public education and increasing workplace as well as home safety measures are key steps in prevention. The present review summarizes current knowledge in pathophysiology, manifestations and management of electrical injuries, with specific focus on cardiac effects.

A method to establish a mouse model of bone marrow microenvironment injury

A normal bone marrow microenvironment plays a very important role in the normal functioning of hematopoietic stem cells. Once disturbed, this microenvironment can become favorable for the occurrence of blood disorders, cancers, and other diseases. Therefore, further studies on the bone marrow microenvironment should be performed to reveal regulatory and stem cell fate determination mechanisms and promote the development of bone marrow transplantation, tissue repair and regenerative medicine, and other fields. A small animal model for further research is also urgently needed. In this study, an electric shock device was designed to elicit a femur bone marrow microenvironment injury in mice. A wire was inserted into the distal femur but not into the proximal femur, and the bone marrow microenvironment was evidently damaged by application of 100 ± 10 V for 1.5 ± 0.5 min ; mortality, however, was low in the mice. Gross observation, hematoxylin and eosin staining, immunohistochemistry, bright-field microscopy, and micro-CT scanning were also conducted. A large number of new blood capillaries and sinusoids appeared in the injured distal femur after 2 weeks. The capillaries in the injured femur disappeared after 4 weeks, and mature blood vessels were scattered throughout the injured area. Red blood cells disappeared, and the cellular structure and trabecular bone were better than those observed 2 weeks previously. Thus, we developed a simply operated, accurate, reliable, and easily controlled small animal model as a good technical platform to examine angiogenesis and segmentation damage in the bone marrow microenvironment.

Electrical Injury-Induced Complete Atrioventricular Block: Is Permanent Pacemaker Required?

A considerable percentage of electrical injuries occur as a result of work activities. Electrical injury can lead to various cardiovascular disorders: acute myocardial necrosis, myocardial ischemia, heart failure, arrhythmias, hemorrhagic pericarditis, acute hypertension with peripheral vasospasm, and anomalous, nonspecific ECG alterations. Ventricular fibrillation is the most common arrhythmia resulting from electrical injury and is the leading cause of death in electrical (especially low voltage alternating current) injury cases. Asystole, premature ventricular contractions, ventricular tachycardia, conduction disorders (various degrees of heart blocks, bundle-brunch blocks), supraventricular tachycardia, and atrial fibrillation are the other arrhythmic complications of electrical injury. Complete atrioventricular block has rarely been reported and permanent pacemaker was required for the treatment in some of these cases. Herein, we present a case of reversible complete atrioventricular block due to low voltage electrical injury in a young electrical technician.

Development of ST Elevation Myocardial Infarction and Atrial Fibrillation after an Electrical Injury

Electrical energy is a type of energy that is commonly used in daily life. Ventricular premature beats, ventricular tachycardia, ventricular fibrillation, atrial tachycardia, atrial fibrillation, bundle branch blocks, and AV block are arrhythmic complications that are encountered in case of electric shocks. Myocardial infarction is one of the rarely seen complications of electric shocks yet it has fatal outcomes. Coronary arteries were detected to be normal in most of the patients who had myocardial infarction following an electric shock. So, etiology of myocardial infarction is thought to be unrelated to coronary atherosclerosis in these cases. Coronary artery vasospasm is thought to be the primary etiological cause. In our case report, we presented a patient who developed ST elevation MI with atrial fibrillation after an electric shock.

Electrocution induced symptomatic bradycardia necessitating pacemaker implantation

Electrical or electrocution injury is a common accidental occurrence and mostly workplace related. Fatal arrhythmias, skin injury and sudden death may ensue. However, it is rare for electrocution to result in permanent low rate sinus bradycardia, incompatible with an active lifestyle. The probable mechanisms for this pathological sinus bradycardia are sinus node dysfunction and autonomic dysfunction with vagal predominance. We describe a young patient who suffered a non fatal electrocution with resultant low rate sinus bradycardia and its successful treatment with a dual chamber rate responsive pacemaker.

Lesions along the upper motor neuronal pathway with locked-in features after lightning strike and cardiac arrest: a case-review analysis

OBJECTIVE

This study describes a case of lesions of the upper motor neuronal pathway with locked-in features after lightning strike and cardiac arrest.

DESIGN

A case-review analysis.

METHODS

In a 29-year-old male who was hit by a lightning strike during farming activities, cardiopulmonary resuscitation was provided first by co-workers and continued with success by the medical rescue service. After conducting advanced life support under monitoring and therapeutic hypothermia, quadriplegia with facial diplegia was recognized. A review was undertaken detailing the clinical course.

RESULTS

MR imaging presented signs consistent with hypoxia-induced damage and diffusion-weighted MR images revealed pronounced damages along the upper motor neuronal pathway. A reactive electroencephalogram pattern, sustained eye movement and the patient communicating via eye-blinking were interpreted as locked-in features. Two weeks after admission the patient was transferred to a neurological rehabilitation centre for further professional care.

CONCLUSION

Direct damage of the upper motor neuron pathway due to the current of the lightning should be considered, albeit the relative contribution of hypoxia-induced damage cannot be separated.

Accidental Electric Shock during Pregnancy: Reflection on a Case

Objectives Data on fetal effects following accidental electric shock during pregnancy are scarce. We report on a case of accidental maternal electric shock associated with benign fetal arrhythmia in a woman at 28 weeks' gestation. Study Design Case report. Results Although electrocution involving low-voltage, low-frequency current has been associated with fatal cardiac arrhythmias and conduction abnormalities, two protective parameters in the present case likely reduced the fetal injury: the dry skin at the site of current entry and the hand-to-hand pathway of current flow. Conclusion Because the pathophysiology of electric injury is altered during pregnancy, assessment of fetal well-being should be prompted no matter how trivial an incident may appear.

Connexin 43, angiotensin II, endothelin 1, and type III collagen alterations in heart of rats having undergone fatal electrocution

Death due to accidental electrocution occurs frequently. The aim of this study was to investigate alterations in cardiac connexin 43 (Cx43), angiotensin II (Ang II), endothelin 1 (ET-1), and type III collagen associated with fatal electrocution.Twenty-four Sprague-Dawley rats were divided into control, fatal electrocution (220 V, 50 Hz, 60 seconds), and electrical injury (220 V, 50 Hz, 60 seconds) groups. Animals were deeply anesthetized with sodium pentobarbital before each treatment, with the anode connected to the left foreleg and the cathode to the right hindleg, followed by cervical dislocation. Control animals received cervical dislocation alone. Immunohistochemical analysis was performed to evaluate the cardiac protein expression of Cx43, Ang II, ET-1, and type III collagen. Sections were analyzed by digital image analysis.The expression of Cx43 was significantly reduced after fatal electrocution, with the integrated optical density also lower when compared with control (P < 0.05). Expression of both Ang II and ET-1 was significantly increased after fatal electrocution, supported by integrated optical density when compared with control (P < 0.05). But no significant difference was found in type III collagen expression between the fatal electrocution group and the control group.In summary, cardiac protein expression of Cx43, Ang II, and ET-1 was found to be significantly altered with fatal electrocution, suggesting that these 3 proteins may be important underlying mechanisms of death during fatal electrocution. The current findings indicate that such alterations would be reflected in abnormal cardiac function and a possible cause of sudden death.

Essentials of low-power electrocution: established and speculated mechanisms

Even though electrocution has been recognized--and studied--for over a century, there remain several common misconceptions among medical professional as well as lay persons. This review focuses on "low-power" electrocutions rather than on the "high-power" electrocutions such as from lightning and power lines. Low-power electrocution induces ventricular fibrillation (VF). We review the 3 established mechanisms for electrocution: (1) shock on cardiac T-wave, (2) direct induction of VF, and (3) long-term high-rate cardiac capture reducing the VF threshold until VF is induced. There are several electrocution myths addressed, including the concept--often taught in medical school--that direct current causes asystole instead of VF and that electrical exposure can lead to a delayed cardiac arrest by inducing a subclinical ventricular tachycardia (VT). Other misunderstandings are also discussed.

Low-voltage direct-current stimulation is safe and promotes angiogenesis in rabbits with myocardial infarction

This study evaluates safety and efficacy of low-voltage direct-current (DC) electrical stimulation of angiogenesis in rabbits with myocardial infarction (MI). Thirty Japanese rabbits were divided into treatment and control groups, and MI was induced by ligation of the left circumflex (LCX) artery. Two platinum electrodes were placed directly on the epicardium on either side of LCX artery. Low-voltage DC stimulation (4.0 V/cm, 30 min/day) was performed in the treatment group immediately after surgery until fourth week post-operatively. Cardio-electrophysiological, respiratory, hematological, blood biochemical, histopathological, immunohistochemical parameters, as well as capillary density at the marginal zone of myocardial infarct were compared between treatment and control groups. Capillary density in the treatment group (63.1 ± 2.2) was significantly higher (P < 0.01) than that in controls (45.4 ± 3.9). Overall mortality was 6.7%, and the prevalences of pneumothorax and intraoperative arrhythmia were 3.3 and 6.7%, respectively. Transient hypotension, anemia, leukocytosis, hypoxemia, and a slight increase in myocardial enzymes levels were observed in both groups. Regarding electrical stimulation, no adverse reactions except a minor infiltration of inflammatory cells and mild degeneration were observed in the myocardium. It was, therefore, concluded that low-voltage DC stimulation in the MI rabbits was not only safe but also effective in promoting angiogenesis in the myocardium.

Two cases in which myocardial injury could be only evaluated by nuclear medicine studies on electric shock patients whose electrocardiogram and myocardial enzyme levels were normal

Heart injury due to electric shock is currently diagnosed based on electrocardiogram (ECG) changes or elevated levels of myocardial enzymes or both. However, the rate at which ECG detects abnormalities is very low; thus, the estimated rate of the diagnosis of myocardial damage due to electric shock is lower than the actual rate. The method of nuclear medicine study of the heart is superior with regard to evaluating transient ischemia, such as angina pectoris, in patients whose ECG and myocardial enzyme levels are normal. Therefore, we attempted to diagnose transient myocardial damage in electric shock patients by using nuclear medicine study of the heart.

A case of acute myocardial infarction due to indirect lightning strike

Lightning strike is a natural phenomenon with potentially devastating effects and represents one of the leading causes of cardiac arrest and death from environmental phenomena. Almost every organ system may be impaired as lightning passes through the human body preferring the pathways that the lowest resistance between the contact points. Lightning can also have widespread effects on the cardiovascular system, producing extensive catecholamine release or autonomic stimulation. The victim may develop hypertension, tachycardia, nonspecific electrocardiographic changes (including prolongation of the QT interval and transient T-wave inversion), and myocardial necrosis with release of creatine phosphokinase-MB fraction. We present the case of a 13-year-old boy with acute myocardial infarction secondary to an indirect lightning strike.

Severe stunned myocardium after lightning strike

OBJECTIVE

To report the development of myocardial stunning and severe heart failure after lightning strike with total recovery of function.

DESIGN

Case report.

SETTING

Coronary care unit at Medica Sur Clinic, Mexico.

PATIENT

A 42-yr-old woman who was hit by lightning developed rapid and progressive hemodynamic deterioration manifested by cardiogenic shock that required invasive monitoring. Twenty-four hours after the strike, intravenous levosimendan and intra-aortic balloon pump were initiated because the patient demonstrated no significant response to management with conventional inotropic agents. Two days later, echocardiographic signs of systolic and diastolic dysfunction improved markedly. Dual-isotope-imaging myocardial perfusion testing with technetium-99m-sestamibi and thallium-201, performed 9 days after admission, showed normal perfusion and normal left ventricular systolic function. The patient exhibited complete recovery of function. The exact mechanism of abnormal contractility in the absence of direct electrofulguration is unknown but may be explained by release of oxygen free radicals, proteolysis of the contractile apparatus, and cytosolic overload of intracellular calcium, followed by reduced myofilament sensitivity to calcium. These abnormalities are consistent with stunned myocardium.

CONCLUSIONS

Lightning strike may cause serious contractile dysfunction in the absence of irreversible myocardial injury, but the exact mechanism of this phenomenon remains unknown. We propose that lighting strike can cause myocardial stunning resulting in severe but reversible left ventricular dysfunction. The patient's recovery was facilitated by support treatment including administration of levosimendan, which increases the intracellular sensitivity to calcium, a mechanism disturbed in patients with myocardial stunning.

Electric shock: Cardiac effects relative to non fatal injuries and post-mortem findings in fatal cases

The documented cardiovascular effects of an electrical shock include acute myocardial necrosis, myocardial ischemia with or without necrosis, heart failure, arrhythmias, haemorrhagic pericarditis, acute hypertension with peripheral vasospasm and anomalous, non specific ECG alterations. Studies documenting the development of acute left ventricular failure and pulmonary oedema sustain that the observed ECG changes are secondary to myocardial injury. The cause of death of victims of instantly fatal electrical accidents is ventricular fibrillation, but it is not clear if this fibrillation is due to purely electrophysiological changes or to identifiable structural abnormalities in the heart. Little is known about the morphological changes in the heart, as differing anatomical alterations are described. Data from such studies may aid in a more accurate comprehension of clinical and morphological alterations of the heart and in the development of therapeutic strategies that could counterbalance such effects.

A case of takotsubo-shaped hypokinesis of the left ventricle caused by a lightning strike

A 62-year-old woman was struck by lightning while on a mountain and fortunately did not suffer burns or unconsciousness. She stayed at a mountain lodge overnight and was taken to our hospital by helicopter the next day. Upon admission, electrocardiography showed ST segment elevation indicating acute lateral myocardial infarction, and echocardiography showed takotsubo-shaped hypokinesis of the left ventricle indicating an apical aneurysm. Her serum escaped enzyme levels were increased, as is typical in cases of myocardial infarction, however, she did not complain of cardiac symptoms. Coronary arteriography performed 4 days after admission showed a normal coronary artery while left ventriculography showed apical akinesia. An echocardiogram obtained 2 days later showed resolution of the LV wall motion abnormality. This is the first reported case of takotsubo cardiomyopathy caused by lightning. Takotsubo-shaped hypokinesis is not described as a complication of lightning-induced cardiac injury and its pathogenesis remains controversial.

Cardiac pathology in death from electrocution

To better characterize the morphologic changes in electrocution, morphologic changes in the hearts of 21 subjects, who died instantaneously of electrocution, were compared to the hearts of decedents with different types of death. Sixteen myocardial samples per heart were processed for histological examination, and sections were prepared with a variety of specific stains. The frequency, location and extent of myocellular segmentation (stretching and/or rupture) of intercalated discs and associated changes of myocardial bundles and single myocells [myofibre break-up (MFB)] were recorded, quantitatively analysed and statistically evaluated. The frequency of MFB was maximal in cases of electrocution (90%). The findings show that MFB is an ante-mortem change and may be a distinct finding in electrocution.

Permanent myocardial dysfunction caused by high-voltage electrical injury--a case report

Electrical injury, particularly alternating current, may lead to disease of conducting tissue or to myocardial damage, or even may cause sudden death. In the present case, the authors report a 22-year-old man who sustained extensive upper extremity trauma from a high-voltage electrical injury and manifested clinical signs of left ventricular heart failure.

Prevalence of potential risk factors in victims of electrocution

OBJECTIVE

To identify risk factors of fatal arrhythmia following electrical shock, by comparing the prevalence of transthoracic current, tetany, decreased skin resistance because of wet extremities, skin burns and heart disease in victims of electrocution with instant as opposed to delayed death.

DESIGN

Retrospective case-control study, based on the charts from the coroner's office.

RESULTS

A total of 124 deaths from electrocution occurred between 1987 and 1992. One victim presumably died from delayed arrhythmia and was excluded from the study. Twenty victims had decreased skin resistance because of wet extremities and five had tetany. Autopsy revealed coronary heart disease in 21 cases, and burns in 109; 10 did not have any skin lesion. There was no difference in risk factors between those who died instantly presumably from arrhythmia (n=114) and those who died later from other causes (n=9).

CONCLUSION

No differences in risk factors were found between victims who died immediately from arrhythmia following electrical shock and those died later from other causes.

[Management of technology in intensive care]

The lives of hospitalized patients depend on diagnostic-therapeutic procedures and on the care provided by the health team. It also depends on the quality and availability of factors such as: physical structure and material and human and financial resources. The need to optimize these resources and re-establish patients' health has brought about the Intensive Care Units (ICU), whose design must consider the physical environment and clinical equipment which are indispensable in health care. Aiming at identifying the level of knowledge of health professionals as to technical and operational information in equipment manuals and the perception of the interviewed professionals in relation to the adequacy of the physical and electrical installations of such units, we conducted a descriptive study in an ICU of a public hospital in Salvador, Brazil. The results show that such installations were considered to be unsuitable for the safe development of activities and that most of the health team members did not know the technical or operational specifications in the equipment manuals.

Electrical and lightning injuries

Electricity and lightning can cause injury in a variety of ways, some of which may remain hidden from the unsuspecting physician until it is too late. Prompt and, if necessary, prolonged resuscitation are of proven benefit. Particular attention must be paid to the patient who suffers high-voltage injury, and deep electrothermal burns on damage to vital organs should be excluded. Uncommonly late sequelae are seen, and such patients require appropriate care.

Contraction bands in visceral and vascular smooth muscle

Smooth muscle contraction bands (SMCBs) have been described in the gastrointestinal tract, subsequent to acute ischemia, and in the coronary arteries of animals and individuals with a sudden death; in these circumstances SMCBs have been postulated to serve as a premortem marker, and suggested as diagnostically useful. The present investigation was undertaken to determine whether the presence of SMCBs could be correlated with a premortem clinical condition. Retrospectively, the routinely prepared histological sections from 76 autopsy and 93 surgical cases were screened semiquantitatively for the presence of SMCBs. The autopsy sections examined included the gastrointestinal tract, the prostate, and the coronary arteries, as well as all other smooth muscle-containing tissues; the surgical specimens included: coronary artery endarterectomies; saphenous vein bypass grafts; temporal artery biopsies; prostatic curettings; colectomies; varicose veins; leiomyomas of uterus, bowel, and skin; and, leiomyosarcomas. The clinical and pathology reports were reviewed for patient demographics, major clinical diagnoses, presence of shock, details of any resuscitation attempts, time interval to postmortem, and the cause of death. SMCBs were evident in 100% of the gastrointestinal and prostate, and in 96% of the coronary artery autopsy sections examined. All surgical specimens were positive for SMCBs, the exceptions being leiomyomas (positive in 13 of 22; 60%) and leiomyosarcomas (4 of 5; 80%); SMCBs in surgical specimens were less prominent when compared with those observed in autopsy tissue. No correlation was found between the presence of SMCBs and any clinical or demographic parameter assessed, because of the virtual universal occurrence of the SMCBs. The presence of less distinct SMCBs in surgical specimens may very well be artifactual, akin to myocardial and skeletal muscle contraction bands. The observation that SMCBs at autopsy are virtually ubiquitous suggests that they are best considered an agonal phenomenon, and a nonspecific pathological finding.

Electrical injury to the heart may cause long-term damage to conducting tissue: a hypothesis and review of the literature

Electrical injury, particularly alternating current, may lead to disease of conducting tissue, myocardial damage or may cause sudden cardiac death. Subtle abnormalities, particularly of sinus node function, may pose diagnostic difficulties and may not present for many years. The long-term follow-up of patients, perhaps as part of a registry, will help to define the clinical spectrum of cardiac presentations of electrical injury.

External cardioversion-related cardiac damage

Significant iatrogenic injury of the heart is an uncommon occurrence. Described is a unique case of electrical cardioversion injury of the heart. A 58-year-old man underwent orthotopic cardiac transplant for end-stage ischemic heart disease. Five months posttransplantation, he experienced severe acute rejection and developed progressive heart failure and atrial flutter, which were not responsive to medical treatment. The patient required external electrocardioversions, which were unsuccessful despite progressively increased voltage. He died of heart failure approximately two weeks after admission. Postmortem examination revealed the sequelae of acute and chronic heart failure, patchy myocardial fibrosis (healing rejection), ongoing mild to moderate acute rejection, and marked subepicardial wedge-shaped necrosis in the left ventricular free wall. The microscopic age of these areas was consistent with their occurrence at the time of attempted cardioversions, approximately seven days before death. Pathologists should be aware of this iatrogenic injury (and its morphologic pattern), so that it is not confused with ischemic or other forms of myocardial damage.

Electrical injuries: current concepts

Electrical injuries are often dramatic accidents and are potentially fatal. The systemic involvement which characterizes many of these injuries, requires familiarity with the broad spectrum of clinical manifestations and possible complications. While many victims of electrocution are killed before help can be provided, survivors may suffer severe injuries that need proper treatment. The pathophysiological aspects of electrical injuries and therapeutic principles are therefore discussed in this review as well as preventive measures.

Electrical shock and lightning strike

Cardiac arrest from electrical shock or lightning strike is associated with significant mortality and requires modification and extension of standard advanced life support measures to achieve successful resuscitation. Patients who experience electrical shock or lightning strike may sustain cardiac and respiratory arrest secondary to the direct effects of current. However, the majority of victims have associated multisystem involvement, including neurologic complications, cutaneous burns, and associated blunt trauma. As a result, a combination of advanced cardiac life support measures and advanced trauma life support techniques is indicated. Victims with cardiac arrest from electrical shock or lightning strike require prompt, aggressive resuscitation using standard methods for airway control, ventilation, and chest compressions, as well as usual measures for defibrillation and cardiac pharmacotherapy. Unique considerations include vigorous fluid resuscitation and spinal immobilization for victims of electrical shock and reversal of normal multiple casualty triage priorities when managing several lightning strike victims. Because the majority of victims are relatively young and seldom have significant underlying cardiac disease, the chance for successful resuscitation may be greater for patients who experience sudden death from electrical shock or lightning strike than for those with other causes of cardiac arrest, even among patients with initial rhythms traditionally unresponsive to therapy. Although numerous specialized aspects are required for the successful management of victims of electrical shock and lightning strike, the following article focuses on the unique considerations necessary for immediate care of cardiac arrest victims, with emphasis on the underlying mechanisms of sudden death and currently recommended guidelines for resuscitation.