Electrical injuries: pathophysiology and emergency management

Electrocution Due to Fractal Wood Burning: Two Case Reports and a Review of the Medical Literature

ABSTRACT

Fractal wood burning is a new technique of pyrography that passes an electrical current through a piece of wood resulting in decorative electrical burns. This practice has become increasingly popular with many walk-through tutorials of the process found online. This includes videos of how to build homemade devices fashioned from disassembled microwave oven transformers. There have been 31 reported deaths and many serious injuries due to fractal wood burning resulting in news headlines, warning statements, and an outright ban of the practice at certain woodworking events. The medical community has begun to recognize the danger of fractal wood burning with a few cases of severe burn injuries reported. We report 2 cases of electrocution from fractal wood burning accidents. The scene investigations were examined, including the similarities in the homemade microwave oven transformers that were used, as well as the autopsy findings. The pathophysiology of fractal wood burning and the creation of Lichtenberg figures is discussed as well as the high-voltage injury patterns seen in cases of fractal wood burning accidents. Other cases of electrical injury from fractal wood burning accidents reported in the news and medical literature were then examined in terms of demographics, burn pattern, cardiac findings, and whether a homemade wood burning device was involved.

An unusual case of high-voltage electrical injury involving fractal wood burning

A 26-year-old female was brought to the emergency department after an apparent electrocution. She was unresponsive, pulseless, and found to be in ventricular fibrillation upon arrival. The patient achieved return of spontaneous circulation after defibrillation. Further examination showed partial to full thickness burns to both hands, right chest wall, and buttocks. She was stabilized and then transferred to a regional burn center for additional care. Further history revealed the patient had learned how to create art with Lichtenberg figures using a high-voltage transformer extracted from a home microwave oven and a wooden canvas, a process called fractal wood burning. There are countless online video tutorials that describe how to replicate this process; however, the dangers of this practice are frequently omitted and have now become a growing public health concern. This article hopes to expand on the previous single publication, discuss the exceedingly high mortality rate, motivate emergency medicine providers and other clinicians to publish cases related to fractal wood burning-related injuries, and promote public awareness of this perilous practice.

Electrical Injury (a Literature Review)

The analysis of domestic and foreign literature sources showed that the problem of diagnosing and treating electrical injuries remained relevant as in the early 20th century. Over the past century, the mechanisms of the effects of electric current on organs and tissues have been well studied. However, the search for methods for diagnosing the volume of tissue damage has not been completed, and such methods are necessary, since they are designed to help determine the volume of surgical intervention. Many patients still require repeated surgical interventions to completely excise necrotic tissue. In most patients with severe electrical trauma, reconstructive surgery takes place in several stages. Today, most clinical data and practical recommendations are based on the opinions of individual experts and limited clinical studies.

Authors declare lack of the conflicts of interests.

Acute and long-term clinical, neuropsychological and return-to-work sequelae following electrical injury: a retrospective cohort study

OBJECTIVE

To determine acute and long-term clinical, neuropsychological, and return-to-work (RTW) effects of electrical injuries (EIs). This study aims to further contrast sequelae between low-voltage and high-voltage injuries (LVIs and HVIs). We hypothesise that all EIs will result in substantial adverse effects during both phases of management, with HVIs contributing to greater rates of sequelae.

DESIGN

Retrospective cohort study evaluating EI admissions between 1998 and 2015.

SETTING

Provincial burn centre and rehabilitation hospital specialising in EI management.

PARTICIPANTS

All EI admissions were reviewed for acute clinical outcomes (n=207). For long-term outcomes, rehabilitation patients, who were referred from the burn centre (n=63) or other burn units across the province (n=65), were screened for inclusion. Six patients were excluded due to pre-existing psychiatric conditions. This cohort (n=122) was assessed for long-term outcomes. Median time to first and last follow-up were 201 (68-766) and 980 (391-1409) days, respectively.

OUTCOME MEASURES

Acute and long-term clinical, neuropsychological and RTW sequelae.

RESULTS

Acute clinical complications included infections (14%) and amputations (13%). HVIs resulted in greater rates of these complications, including compartment syndrome (16% vs 4%, p=0.007) and rhabdomyolysis (12% vs 0%, p<0.001). Rates of acute neuropsychological sequelae were similar between voltage groups. Long-term outcomes were dominated by insomnia (68%), anxiety (62%), post-traumatic stress disorder (33%) and major depressive disorder (25%). Sleep difficulties (67%) were common following HVIs, while the LVI group most frequently experienced sleep difficulties (70%) and anxiety (70%). Ninety work-related EIs were available for RTW analysis. Sixty-one per cent returned to their preinjury employment and 19% were unable to return to any form of work. RTW rates were similar when compared between voltage groups.

CONCLUSIONS

This is the first investigation to determine acute and long-term patient outcomes post-EI as a continuum. Findings highlight substantial rates of neuropsychological and social sequelae, regardless of voltage. Specialised and individualised early interventions, including screening for mental health concerns, are imperative to improvingoutcomes of EI patients.

Thomas A. Swift's Electric Rifle Injuries to the Eye and Ocular Adnexa: The Management of Complex Trauma

PURPOSE

To report the ocular and adnexal injuries sustained by patients with Thomas A. Swift's electric rifles (TASER; TASER International, Scottsdale, AZ), review the literature, and discuss the management of this complex trauma.

DESIGN

Multicenter, retrospective case series and literature review.

PARTICIPANTS

Seventeen eyes of 16 patients (5 eyes of 5 patients treated at 3 institutions, and 12 eyes of 11 previously reported cases).

METHODS

The clinical data of 17 eyes were pooled. Spearman's correlation coefficient was used to assess the association between the extent of TASER injury and patient outcomes.

MAIN OUTCOME MEASURES

Extent of TASER injury (zone of injury, penetrating vs. perforating) and association with patient outcomes (visual acuity [VA] and retinal detachment [RD]).

RESULTS

In our cohort, 4 patients were transported by law enforcement and 1 was transferred from a community hospital. Four patients were taken to the operating room for TASER removal and globe repair; 1 patient underwent removal in the emergency room. Of 17 pooled cases, 12 (71%) involved open-globe injury. Of these, there was a high rate of zone 3 injuries (100%; n = 12) and a high incidence of RD (73%; 8 of 11, eviscerated eye excluded). Among patients with closed-globe injury (n = 5), 1 patient demonstrated exudative RD and 1 patient demonstrated retinal dialysis with RD. Of 10 patients with RD, 1 (10%) achieved resolution with monitoring (exudative RD); 1 (10%) underwent cryopexy and pneumatic retinopexy; 3 (30%) underwent vitrectomy, and 5 (50%) with poor prognosis did not undergo vitreoretinal surgery. In the 3 patients who underwent vitrectomy, all 3 (100%) demonstrated redetachment resulting from proliferative vitreoretinopathy and required additional surgery. Visual acuity on presentation was significantly correlated with final VA (ρ = 0.783; P = 0.02). Men (94%) were more likely than women (6%) to sustain TASER trauma. Median age was 26 years. There was a 50% rate of loss to follow-up.

CONCLUSIONS

Thomas A. Swift's electric rifle injuries to the eyes or ocular adnexa represent complex trauma. Zone 3 injuries are common. The visual prognosis is guarded, and eyes may require multiple surgeries to preserve vision. Patients are at high risk for loss to follow-up by way of incarceration.

Neurotological findings after electrical injury at the workplace

OBJECTIVES/HYPOTHESIS

Neurotological findings secondary to electrical injuries have rarely been reported in the world literature. We attempt to characterize the neurotological findings following electrical injury and to determine the role head injury and loss of consciousness play in this population's clinical presentation.

STUDY DESIGN

Retrospective cohort study.

METHODS

A database containing 3,438 patients with work-related injuries was scanned for individuals who sustained and survived electrical injuries at work. Detailed analysis of the frequencies of presenting features and test results was performed. A comparative analysis was made between the subsets of patients with and without loss of consciousness and/or head injury.

RESULTS

A cohort of 42 patients was identified. All patients had multiple symptoms. Dizziness was a significant complaint in all workers with electrical injuries. Other common complaints included tinnitus and imbalance. Characterization of these symptoms is provided in detail according to statistical frequency. In this cohort, 25 workers had a concomitant head injury and 17 workers had an associated loss of consciousness. There was no statistically significant difference when clinical presentation, examination, and balance testing results were compared between the subsets.

CONCLUSIONS

Frequency and characterization of symptoms following electrical injury are provided. Dizziness is the most common presenting neurotological feature. Loss of consciousness and/or associated head injury do not affect the clinical presentation in this particular population.

LEVEL OF EVIDENCE

2b. Laryngoscope, 127:2126-2131, 2017.

Lightning-strike Injury

Although lightning-strike injury is uncommon, it is the cause of death in more people in the United States annu ally than any other natural disaster. Consequently, the emergency medicine specialist and intensivist should be familiar with the special problems of a lightning-strike victim. Lightning is a massive electrical discharge that results from a complex sequence of atmospheric events. When this massive electrical discharge strikes a human being, it causes predictable cardiac and neurological in juries. Synchronous myocardial contraction occurs at the moment of impact and is followed by a variable period of asystole. Prolonged asystole may cause isch emia and ventricular fibrillation. Alternatively, ventric ular fibrillation may occur primarily if the electrical discharge strikes during the vulnerable period of the cardiac cycle. Unconsciousness, depression of respira tory efforts, and seizures are also immediate conse quences of lightning strike. Respiratory arrest is pre sumed to be a consequence of inhibition of the medullary respiratory center. Retrograde and antegrade amnesia, confusion, disorientation, and vasomotor insta bility with transient paralysis of usually the lower ex tremities are commonly seen in lightning-strike victims. Other complications occur more variably, but should be carefully sought by the responsible clinician. These in clude burns at the exit and entrance sites of the light ning strike, eye injuries (e.g., cataracts, corneal lesions, intraocular bleeding), and rupture of the tympanic membrane. Besides describing the pathophysiology of these and other consequences of lightning strike, a com prehensive approach to the initial and long-term man agement of the lightning-strike victim is discussed.

Ophthalmic injuries from a TASER

The TASER (TASER International) is an energy-conducting weapon, that is becoming more frequently used by law enforcement officials to subdue combative individuals. Though generally regarded as a safe alternative, the use of such weapons has been reported to cause serious injuries. We describe a case in which ocular injuries were sustained by impalement with a TASER dart. Emergency physicians should be aware of the potential for serious ophthalmic injuries from TASERs and how such injuries should be managed.

Neuropsychological Dysfunction in Severe Accidental Electrical Shock: Two Case Reports

There has been a relative absence of studies that have longitudinally examined the neuropsychological profiles of women who have sustained severe accidental electrical shocks. A case is reported of a college-educated woman who received an estimated 120-V electrical shock. Neuropsychological assessments conducted at 2 months, and at 1 and 2 years postinjury, revealed a diversity of deficits indicative of diffuse, mild to moderate neurocognitive dysfunction, as well as symptomatology consistent with depression and posttraumatic stress disorder. For comparison, a second case of a man who received a 69,000-Velectrical injury is also presented. Although only minimal neurocognitive deficits were observed in this individual, he exhibited a similar psychological profile. The results of this study are discussed in light of the contrasting neurocognitive findings but consistent psychological presentations across the two cases.

Lightning injuries

Lightning is persistently one of the leading causes of death caused by environmental or natural disaster. To understand the pathophysiology and treatment of lightning injuries one must first discount the innumerable myths, superstitions, and misconceptions surrounding lightning. The fundamental difference between high voltage electrical injury and lightning is the duration of exposure to current. Reverse triage should be instituted in lightning strike victims because victims in cardiopulmonary arrest might gain the greatest benefit from resuscitation efforts, although there is no good evidence suggesting that lightning strike victims might benefit from longer than usual resuscitation times. Many of the injuries suffered by lightning strike victims are unique to lightning, and long-term sequelae should be anticipated and addressed in the lightning victim.

Electric injury, part I: treatment priorities, subtle diagnostic factors, and burns

Patients with electric injury present a significant challenge. Possible mechanisms of injury include electrical disruption of cardiac rhythm and breathing, burns of several types, and inhalation of gases from fires. Mechanical trauma may come from electric arc blast, explosion of gases, falls, and strong muscle contractions. Additionally, the patient may have multiple co-existent injuries, comorbidities, an abnormal mental status, and a severely disrupted acid-base balance. These factors can make diagnosis and treatment difficult. In addition, electric injury can cause a number of slowly developing and subtle sequelae that may be difficult, if not impossible, to diagnose on initial examination.

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.

Do children need to be monitored after electric shocks?

OBJECTIVE

To determine whether cardiac monitoring is required in children sustaining electric shock at Australian household voltage.

METHODOLOGY

Records of patients admitted via the Emergency Department of Princess Margaret Hospital for Children, Perth, Australia, for the period 1968-96 were retrospectively reviewed. The initial ECG findings of patients with an electric shock were recorded, and the development of any arrhythmia.

RESULTS

Forty-four patients were identified, 40 of whom had sustained a household electrical injury. One patient had an abnormal ECG on admission, none developed an arrhythmia and all survived.

CONCLUSIONS

Routine cardiac monitoring is not required after exposure to Australian household electricity supply if the child is asymptomatic and has a normal ECG on presentation.

Eleven-year-old male with high-voltage electrical injury and premature ventricular contractions

We present a case of a boy with potential high-voltage electrical injury. The patient sustained electrical injuries after his kite became entangled in a high-power electrical line. He presented to the emergency department with minor external electrical burns and frequent premature ventricular contractions (PVCs). The patient's clinical course is outlined. A discussion of the epidemiology of high-voltage electrical injury in children and the clinical management of electrical-injury-induced cardiac complications is provided. Although cardiac abnormalities are found in a significant proportion of high-voltage electrical injuries, the vast majority are evident within 12 h, resolve spontaneously within a few days, and cause little or no long-term sequelae. A small proportion of normal children have clinically benign PVCs.

Lightning injury of the tympanic membrane

A number of cases of otologic injuries by lighting strikes have been described in the otolaryngological literature. The mechanism of these injuries remains uncertain. We report 3 cases of lightning injury that presented to us. Analysis of these cases suggests that the mechanism of injury is direct conduction of electricity from the scalp to the soft tissues of the external auditory canal to the tympanic membrane. The conduits of the electrical surge are the subcutaneous blood vessels, smaller vessels being damaged more than larger vessels. Since the tympanic membrane central vessels are smaller than the canal vessels, the central area of the tympanic membrane would be most vulnerable, and this is seen clinically. A review of the literature supports this proposed mechanism of injury.

Electric shock, Part III: Deliberately applied electric shocks and the treatment of electric injuries

Earlier parts of this series have discussed the physics, pathophysiology, and nature of electric injury. This part will discuss deliberately applied electric shocks and the treatment of electric injuries. Electric shocks are deliberately applied to persons during electroshock therapy and with stun guns, shock batons, and electric cattle prods. Electric injuries, whether a complication of deliberate electric shock or due to accidental injury, should be treated to preserve cardiac and respiratory function and to prevent further tissue damage. Safe extrication at the scene, rapid triage, and emergency medical treatment are discussed.

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.

Cardiovascular effects of lightning strikes

OBJECTIVES

The purpose of this study was to investigate the effects of lightning strikes on the cardiovascular system.

BACKGROUND

A lightning strike can attack its victims in one of three ways: direct hit, splash or ground strike. The cardiovascular system can be affected directly by mechanical or electrical trauma during a direct hit or can be indirectly affected through effects on the total body with extensive catecholamine release or autonomic stimulation. Reported effects include hypertension, tachycardia, nonspecific electrocardiographic (ECG) changes including prolongation of the corrected QT (QTc) interval, transient T wave inversion and myocardial necrosis with creatine kinase-MB (CK-MB) fraction release.

METHODS

Nineteen victims from five separate lightning strikes were studied over a 2-month period. Each patient was evaluated by serial ECG, CK-MB determinations and echocardiography.

RESULTS

The early (0 to 72 h) effects of lightning were demonstrated on the ECG by ST segment elevation consistent with acute current of injury, prolonged QTc interval with direct hits and nonspecific ST and T wave changes. On echocardiography, segmental or global ventricular dysfunction was seen, and pericardial effusion was also detected. During the intermediate (3- to 14-day) period, new and often marked ECG changes consistent with pericarditis or ischemia were seen. No new echocardiographic changes were detected, however, and the early abnormalities including severe left ventricular dysfunction with cardiogenic shock have reversed. The late (1 to 12 months) period revealed only one patient with long-term sequelae (recurrent pericarditis that persisted for 5 months).

CONCLUSIONS

Unless both entrance and exit sites are limited to the lower limbs, direct and splash lightning strikes cause myocardial damage as assessed by abnormal serum enzyme determinations or abnormal echocardiographic findings. Only direct hits resulted in echocardiographic abnormalities or a prolonged QTc interval. The degree of myocardial injury can be severe with left and right ventricular ejection fraction < 15% and can be reversible.

Electrocution in Western Australia, 1976-1990

OBJECTIVE

To describe the epidemiology of electrical fatalities in Western Australia between 1976 and 1990.

DATA SOURCES

Data for the study were gathered from hospital records, autopsy reports and findings from State Energy Commission and coronal investigations.

DATA EXTRACTION

Information that was abstracted included age, sex, occupation, voltage, history of incident and autopsy findings.

DATA SYNTHESIS

There were 104 victims. Death occurred most frequently in young men exposed to low voltage current during summer, and nearly half the fatalities occurred in the workplace. Water was present in up to 52% of fatalities. Without exception, all victims developed a lethal arrhythmia at the time of exposure to the electric shock, which usually resulted in death at the scene.

CONCLUSION

When a victim is exposed to a fatal electric shock, the lethal arrhythmia occurs at the time of electrocution and is just as likely to occur at home as in the workplace. Electrical fatalities can be prevented largely by the use of residual current devices.

Household electric shocks: who should be monitored?

OBJECTIVE

To decide who should be monitored after exposure to household 240 volt 50 Hz alternating current electric shocks.

DESIGN AND SETTING

Records of patients admitted to the Intensive Care Unit of Royal Perth Hospital for the period 1978-1987 were retrospectively reviewed. A literature review was also performed to compare previous findings with our own (Medline search; keywords--electrical injury, arrhythmia).

RESULTS

There were 20 patients in the series, and all patients survived the electric shock. Of the 18 who presented with no cardiovascular symptoms or electrocardiographic abnormalities, none developed arrhythmias while being monitored in the Intensive Care Unit.

CONCLUSION

Routine cardiac monitoring is not required after electric shock with household alternating current if the patient is asymptomatic and has a normal electrocardiogram on presentation.

Lightning injury with lung bleeding in a tracheotomized patient

A 68-year-old man, who had undergone laryngectomy six months earlier, was struck by lightning and developed pulmonary hemorrhage. This was attributed to pulmonary barotrauma due to a lightning blast via his tracheostoma.

Lightning strikes

Lightning strike is a natural phenomenon with potentially devastating effects. The physics of lightning strike and the physiology of lightning injury are discussed. Three cases are reported and the clinical features are described. Aspects of the management of such patients are discussed with particular emphasis on assessment and resuscitation in the Emergency Department.

Electrical injury of the eye

A 17-year-old male suffered superficial and deep facial burns after coming into contact with a high tension electrical cable with his head and right side of the face. The right eye sustained severe thermal coagulative injuries and subsequently was enucleated. Histopathological examination showed that the retinal neuropile was relatively intact although the retinal and choroidal circulations were severely compromised. The left eye was less affected but a dense cataract developed and required lensectomy. Visual acuity remained poor in the left eye due to retinal atrophy, retinal vascular attenuation and optic nerve degeneration. Electroretinographic tests and pseudo-random binary stimulus visually evoked responses were useful in predicting the visual outcome.

Electrical shock in pregnancy: a case report

Electrical shock in pregnancy is associated with significant perinatal morbidity and mortality. A case of such an electrical shock in pregnancy is reported. A review of the literature follows. The severity of maternal injury does not correlate with the injury sustained by the fetus. Close fetal surveillance following electrical injury is necessary.

Electronic gun (Taser) injuries

The Taser is an electrical weapon used for immobilization. Two hundred eighteen patients who were shot by police with a Taser for violent or criminal behavior were compared to 22 similar patients shot by police with .38 Specials. The long-term morbidity rate was significantly different for "tasered" victims (0%) and for those with bullet wounds (50%) (P less than .05). The mortality rate was also significantly different between "tasered" victims (1.4%), and gunshot wound victims (50%) (P less than .05). Possible complications associated with Taser wounds included contusions, abrasions, and lacerations (38%); mild rhabdomyolysis (1%); and testicular torsion (0.5%). Although 48% of "tasered" patients required hospitalization, all but one was for a preexisting injury or toxic or psychiatric problem. We conclude that Tasers are relatively safe when compared to shooting with more conventional weapons.

Abortion caused by electrical current

A case of electrical accident in a pregnant woman at 9 weeks of gestation is described. No fetal heart activity was noted immediately after the injury, and spontaneous abortion occurred two days later.

Abdominal visceral perforation secondary to electrical injury: case report and review of the literature

A patient with a vesico-enteric fistula was successfully treated with resection of the small intestine and dome of the bladder and drainage of the intervening abscess. A search of the literature reveals this to be a very unusual complication of high-voltage electrical injury.

Cardiopulmonary arrest secondary to lightning injury in a pregnant woman

A young woman who was seven months pregnant was struck by lightning, resulting in cardiopulmonary arrest. Bystander CPR was begun at the scene. Vital signs were restored by the time the rescue squad arrived. The patient was comatose on arrival in the emergency department and fetal death was apparent. The patient's neurological status improved markedly, with a small residual motor deficit.

The Taser weapon: a new emergency medicine problem

The Taser is an electrical law enforcement and self-defense weapon that is being used with increasing frequency. The weapon is described and its effects and ballistic and electrical considerations are reviewed. Clinical aspects of Taser injury, including weapon-fired barb injury, barb removal methods, injury secondary to electrical current, ventricular fibrillation, possible interactions with implanted pacemakers, and injuries secondary to weapon-induced falls, are discussed. Taser injuries are a new and increasingly frequent emergency medicine problem.

Lightning injuries

The physical properties of lightning are given, including a description of the different observed lightning forms. The wide variety of effects of lightning on humans is reviewed. In the prehospital care of those struck by lightning, emphasis is upon immediate resuscitation of those who appear unresponsive. Recommendations for emergency department evaluation, treatment, and disposition are given. Guidelines to prevent humans from being struck by lightning are discussed.