Rhabdomyolysis due to pulsed electric fields

Pearls and Pitfalls of Pulsed Field Ablation

Pulsed field ablation (PFA) was recently rediscovered as an emerging treatment modality for the ablation of cardiac arrhythmias. Ultra-short high voltage pulses are leading to irreversible electroporation of cardiac cells subsequently resulting in cell death. Current literature of PFA for pulmonary vein isolation (PVI) consistently reported excellent acute and long-term efficacy along with a very low adverse event rate. The undeniable benefit of the novel ablation technique is that cardiac cells are more susceptible to electrical fields whereas surrounding structures such as the pulmonary veins, the phrenic nerve or the esophagus are not, or if at all, minimally affected, which results in a favorable safety profile that is expected to be superior to the current standard of care without compromising efficacy. Nevertheless, the exact mechanisms of electroporation are not yet entirely understood on a cellular basis and pulsed electrical field protocols of different manufactures are not comparable among one another and require their own validation for each indication. Importantly, randomized controlled trials and comparative data to current standard of care modalities, such as radiofrequency- or cryoballoon ablation, are still missing. This review focuses on the "pearls" and "pitfalls" of PFA, a technology that has the potential to become the future leading energy source for PVI and beyond.

Study of clinical pattern of limb loss in electrical burn injuries

INTRODUCTION

Electrical burn injuries are devastating and cause not only loss of life but also severe disabilities in the form of limb loss. Increase in urbanization, industrialization and overcrowding has led to an increase in electric injuries.

MATERIAL AND METHODS

The study was prospective in nature evaluating electric burns and studied the pattern of limb loss for a duration of 18 months from October 2016 to March 2018. Parameters recorded were demographic data, clinical data regarding the electrical injuries, complications, and outcomes.

RESULTS

Male patients made up 85.3% of cases. Mean TBSA was 24.76 ± 19.18%. Mean age was 27.59 ± 13.73 years. Pediatric patients made up 17%. High voltage burns constituted 68.2 %. Electric contact burn was the most common type making up 49.5% of cases. The most common cause was occupational (38.9%). A fasciotomy was required in 22% of cases with an amputation rate of 38% (209 out of 550). There were 190 major amputations and 106 minor amputations. Overall, the right upper limb amputations were twice as common as the left. The ratio of upper limb: lower limb amputation was 4:1. Fifty patients (23.9%) required revision amputation. The age group 11 to 30 years made up 55.5% of amputations. There was no statistical difference in amputation rates between males (31.31%) and females (41.97%). In patients with TBSA less than 25% amputation rate was 47.77% as compared to patients with more than 25% TBSA, 19.47% (p<0.001). Most amputations occurred due to electric contact burns (74.16%). In the high voltage group, 46.1% underwent amputation vs low voltage group -20.6% (p<0.001). Overall mortality rate was 12.7%. Three hundred patients (55%) had low level of awareness regarding consequences of electric injury. Thirty one percent had medium level of awareness and only 14 % had high level of awareness. There was a significant correlation between education level and awareness in adult patients (p<0.001). Seventy percent of persons with occupational injuries used only footwear and no other protective equipment.

CONCLUSION

Increasing public awareness, safety measures at workplaces are measures that will help reducing electrical burns which reduce limb and life loss.

A model for acute kidney injury in severe burn patients

INTRODUCTION

In patients with severe burns, morbidity and mortality are high. One factor related to poor prognosis is acute kidney injury. According to the AKIN criteria, acute kidney injury has 3 stages based on urine output, serum creatinine level, and renal replacement therapy. In this study, we aimed to create a decision tree for estimating risk of acute kidney injury in patients with severe burn injuries.

METHODS

We retrospectively evaluated 437 adult patients with ≥20% total burn surface area injury who were treated at the Baskent University Ankara and Konya Burn Centers from January 2000 to March 2020. Patients who had high-voltage burn and previous history of kidney disease were excluded. Patient demographics, medical history, mechanism of injury, presence of inhalation injury, depth of burn, laboratory values, presence of oliguria, need for renal replacement therapy, central venous pressure, and prognosis were evaluated. These data were used in a "decision tree method" to create the Baskent University model to estimate risk of acute kidney injury in severe burn patients.

RESULTS

Our model provided an accuracy of 71.09% for risk estimation. Of 172 patients, 78 (45%) had different degrees of acute kidney injury, with 26 of these (15.1%) receiving renal replacement therapy. Our model showed that total burn surface area was the most important factor for estimation of acute kidney injury occurrence. Other important factors included serum creatinine value, burn injury severity score, hemoglobin value, neutrophil-to-lymphocyte ratio, and platelet count.

CONCLUSION

The Baskent University model for acute kidney injury may be helpful to determine risk of acute kidney injury in burn patients. This determination would allow appropriate treatment to be given to high-risk patients in the early period, reducing the incidence of acute kidney injury.

Photopolymerizable Hydrogel-Encapsulated Fibromodulin-Reprogrammed Cells for Muscle Regeneration

A central challenge in tissue engineering is obtaining a suitable cell type with a capable delivery vehicle to replace or repair damaged or diseased tissues with tissue mimics. Notably, for skeletal muscle tissue engineering, given the inadequate availability and regenerative capability of endogenous myogenic progenitor cells as well as the tumorigenic risks presented by the currently available pluri- and multipotent stem cells, seeking a safe regenerative cell source is urgently demanded. To conquer this problem, we previously established a novel reprogramming technology that can generate multipotent cells from dermal fibroblasts using a single protein, fibromodulin (FMOD). The yield FMOD-reprogrammed (FReP) cells exhibit exceeding myogenic capability without tumorigenic risk, making them a promising and safe cell source for skeletal muscle establishment. In addition to using the optimal cell for implantation, it is equally essential to maintain cellular localization and retention in the recipient tissue environment for critical-sized muscle tissue establishment. In this study, we demonstrate that the photopolymerizable methacrylated glycol chitosan (MeGC)/type I collagen (ColI)-hydrogel provides a desirable microenvironment for encapsulated FReP cell survival, spreading, extension, and formation of myotubes in the hydrogel three-dimensionally in vitro, without undesired osteogenic, chondrogenic, or tenogenic differentiation. Furthermore, gene profiling revealed a paired box 7 (PAX7) → myogenic factor 5 (MYF5) → myogenic determination 1 (MYOD1) → myogenin (MYOG) → myosin cassette elevation in the encapsulated FReP cells during myogenic differentiation, which is similar to that of the predominant driver of endogenous skeletal muscle regeneration, satellite cells. These findings constitute the evidence that the FReP cell-MeGC/ColI-hydrogel construct is a promising tissue engineering mimic for skeletal muscle generation in vitro, and thus possesses the extraordinary potential for further in vivo validation.

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.

Measurement and analysis of partial lightning currents in a head phantom

Direct lightning strikes to the human head can lead to various effects, ranging from burnings to death. The biological and physical mechanisms of a direct lightning strike in the human head are not well understood. The aim of this paper is to design an experimental setup to measure the spatial and temporal current distribution during a direct lightning strike to physical head phantoms to establish normative values for personal lightning protection equipment design and testing. We created head phantoms made of agarose, replicating the geometric and dielectric properties of scalp, skull, and intracranial volume. The bases of the three compartments were galvanically contacted via copper electrodes to measure the current per compartment. We used pulse generators to apply aperiodic voltage and current signals that modelled lightning components. Our experiments indicated that the scalp compartment was exposed to the current with a fraction of 80–90%. The brain and skull compartments were exposed between 6–13% and 3–6% of the total measured current respectively. In case of a flashover, most of the current (98–99%) flowed through the discharge channel. Unlike previous theoretical estimates and measurements in technical setups, we observed considerably longer times for the flashover to build up. In our experiments, the time to build up a fully formed flashover varied from approximately 30–700 μs. The observed current patterns in cases without and with flashover provided information on regions of possible damage in the human head. Consequently, we identified the phenomenon of a flashover as a potential mechanism for humans to survive a lightning strike. Our measured current distributions and amplitudes formed the base for normative values, which can be used in later experimental investigations regarding the possibilities of individual lightning protection equipment for humans.

Volume Resuscitation in Patients With High-Voltage Electrical Injuries

Volume resuscitation of patients with high-voltage electrical injuries (>1000 V) is a more complex challenge than standard burn resuscitation. High voltages penetrate deep tissues. These deep injuries are not accounted for in resuscitation formulae dependent on percentage of cutaneous burn. Myonecrosis occurring from direct electrical injury and secondary compartment syndromes can result in rhabdomyolysis, compromising renal function and urine output. Urine output is the primary end point, with a goal of 1 mL/kg/h for adult patients with high-voltage electrical injuries. As such, secondary resuscitation end points of laboratory values, such as lactate, base deficit, hemoglobin, and creatinine, as well as hemodynamic monitoring, such as mean arterial pressure and thermodilution techniques, can become crucial in guiding optimum administration of resuscitation fluids. Mannitol and bicarbonates are available but have limited support in the literature. High-voltage electrical injury patients often develop acute kidney injury requiring dialysis and have increased risks of chronic kidney disease and mortality. Continuous venovenous hemofiltration is a well-supported adjunct to clear the myoglobin load that hemodialysis cannot from circulation.

The Feasibility of Enhancing Susceptibility of Glioblastoma Cells to IRE Using a Calcium Adjuvant

Irreversible electroporation (IRE) is a cellular ablation method used to treat a variety of cancers. IRE works by exposing tissues to pulsed electric fields which cause cell membrane disruption. Cells exposed to lower energies become temporarily permeable while greater energy exposure results in cell death. For IRE to be used safely in the brain, methods are needed to extend the area of ablation without increasing applied voltage, and thus, thermal damage. We present evidence that IRE used with adjuvant calcium (5 mM CaCl₂) results in a nearly twofold increase in ablation area in vitro compared to IRE alone. Adjuvant 5 mM CaCl₂ induces death in cells reversibly electroporated by IRE, thereby lowering the electric field thresholds required for cell death to nearly half that of IRE alone. The calcium-induced death response of reversibly electroporated cells is confirmed by electrochemotherapy pulses which also induced cell death with calcium but not without. These findings, combined with our numerical modeling, suggest the ability to ablate up to 3.2× larger volumes of tissue in vivo when combining IRE and calcium. The ability to ablate a larger volume with lowered energies would improve the efficacy and safety of IRE therapy.

The occurrence of single and multiple organ dysfunction in pediatric electrical versus other thermal burns

BACKGROUND

Multiple organ failure (MOF) is a major contributor to morbidity and mortality in burned children. While various complications induced by electrical injuries have been described, the incidence and severity of single organ failure (SOF) and MOF associated with this type of injury are unknown. The study was undertaken to compare the incidence and severity of SOF and MOF as well as other complications between electrically and thermally burned children.

PATIENTS AND METHODS

Between 2001 and 2016, 288 pediatric patients with electrical burns (EB; n = 96) or thermal burns (CTR; n = 192) were analyzed in this study. Demographic data; length of hospitalization; and number and type of operations, amputations, and complications were statistically analyzed. Incidence of SOF and MOF was assessed using the DENVER2 classification in an additive mixed model over time. Compound scores and organ-specific scores for lung, heart, kidney, and liver were analyzed. Serum cytokine expression profiles of both groups were also compared over time. Significance was accepted at p < 0.05.

RESULTS

Both groups were comparable in age (CTR, 11 ± 5 years, vs EB, 11 ± 5 years), percent total body surface area burned (CTR, 33% ± 25%, vs EB, 32 ± 25%), and length of hospitalization (CTR, 18 ± 26 days, vs EB, 18 ± 21 days). The percentage of high-voltage injury in the EB group was 64%. The incidence of MOF was lower in the EB group (2 of 96 [2.1%]) than the CTR group (20 of 192 [10.4%]; p < 0.05). The incidence of single organ failure was comparable between groups. Incidence of pulmonary failure was comparable in both groups, but incidence of inhalation injury was significantly higher in the CTR group (p < 0.0001). Patients in the EB group had more amputations (p < 0.001), major amputations (p = 0.001), and combined major amputations (p < 0.01). Mortality was comparable between the groups. Serum cytokine expression profiles were also comparable between the groups.

CONCLUSIONS

In pediatric patients, electrical injury is associated with a lower incidence of MOF than other thermal burns. Early and radical debridement of nonviable tissue is crucial to improve outcomes in the electrical burn patient population.

LEVEL OF EVIDENCE

Retrospective chart review, level III.

Mathematical Modeling of Irreversible Electroporation for Treatment Planning

Irreversible Electroporation (IRE) is a new drug-free method to ablate undesirable tissue of particular use in cancer therapy. IRE achieves cell death within the targeted tissue through a series of electric pulses that elevate the transmembrane potentials to an extent that permanently damages the lipid bilayers throughout the treated region. Although the IRE procedure is easy to perform, treatment planning is complicated by the fact that the electric field distribution within the tissue, the greatest single factor controlling the extents of IRE, depends non-trivially on the electrode configuration, pulse parameters and any tissue heterogeneities. To address this difficulty, we instruct on how to properly model IRE and discuss the benefit of modeling in designing treatment protocols. The necessary theoretical basis is introduced and discussed through the detailed analysis of two classic dual-electrode configurations from electrochemotherapy: coaxial disk electrodes and parallel needle electrodes. Dimensionless figures for these cases are also provided that allow cell constants, treated areas, and the details of heating to be determined for a wide range of conditions, for uniform tissues, simply by plugging in the appropriate physical property values and pulse parameters such as electrode spacing, size, and pulse amplitude. Complexities, such as heterogeneous tissues and changes in conductivity due to electroporation, are also discussed. The synthesis of these details can be used directly by surgeons in treatment planning. Irreversible electroporation is a promising new technique to treat cancer in a targeted manner without the use of drugs; however, it does require a detailed understanding of how electric currents flow within biological tissues. By providing the understanding and tools necessary to design an IRE protocol, this study seeks to facilitate the translation of this new and exciting cancer therapy into clinical practice.

Horizontal gene transfer from macrophages to ischemic muscles upon delivery of naked DNA with Pluronic block copolymers

Intramuscular administration of plasmid DNA (pDNA) with non-ionic Pluronic block copolymers increases gene expression in injected muscles and lymphoid organs. We studied the role of immune cells in muscle transfection upon inflammation. Local inflammation in murine hind limb ischemia model (MHLIM) drastically increased DNA, RNA and expressed protein levels in ischemic muscles injected with pDNA/Pluronic. The systemic inflammation (MHLIM or peritonitis) also increased expression of pDNA/Pluronic in the muscles. When pDNA/Pluronic was injected in ischemic muscles the reporter gene, Green Fluorescent Protein (GFP) co-localized with desmin(+) muscle fibers and CD11b(+) macrophages (MØs), suggesting transfection of MØs along with the muscle cells. P85 enhanced (∼ 4 orders) transfection of MØs with pDNA in vitro. Moreover, adoptively transferred MØs were shown to pass the transgene to inflamed muscle cells in MHLIM. Using a co-culture of myotubes (MTs) and transfected MØs expressing a reporter gene under constitutive (cmv-luciferase) or muscle specific (desmin-luciferase) promoter we demonstrated that P85 enhances horizontal gene transfer from MØ to MTs. Therefore, MØs can play an important role in muscle transfection with pDNA/Pluronic during inflammation, with both inflammation and Pluronic contributing to the increased gene expression. pDNA/Pluronic has potential for therapeutic gene delivery in muscle pathologies that involve inflammation.

A fatal case of electrocution with unique forensic radiological postmortem findings

PURPOSE

Documentation of forensic radiological observations in postmortem imaging of electrical injuries is not common yet and is less prevalent compared to other forms of burn injuries. However, electrical injuries have high morbidity and mortality. The objective of this case report was the visualization and evaluation of unique electrocution-related injuries by postmortem contrast and non-contrast enhanced imaging compared to a forensic autopsy.

METHODS

Forensic imaging included whole-body postmortem computed tomography (PMCT), PMCT-angiography (PMCTA), postmortem magnetic resonance tomography (PMMR), and PMMR-angiography (PMMRA). Initial external inspection and subsequent autopsy were performed.

RESULTS

Imaging results revealed intestinal mucosal pathologies, particularly of the gastric vascular integrity and remarkable rhabdomyolysis of the striated muscles of the extremities. Furthermore, PMCT and PMCTA revealed a hepatic lesion with perihepatic free fluid. The results from external inspection and autopsy correlated to the well-known pathologies of electrocution in the course of a high-voltage incident.

CONCLUSION

Postmortem imaging visualized electrocution-related injuries and aided substantially in the medico-legal investigation. These findings, particularly of the rhabdomyolysis in magnetic resonance tomography, may support the future image interpretation of cases with electrical injuries-in the living and the deceased.

Application of increased temperature from an exogenous source to enhance gene electrotransfer

The presence of increased temperature for gene electrotransfer has largely been considered negative. Many reports have published on the lack of heat from electrotransfer conditions to demonstrate that their effects are from the electrical pulses and not from a rise in temperature. Our hypothesis was to use low levels of maintained heat from an exogenous source to aid in gene electrotransfer. The goal was to increase gene expression and/or reduce electric field. In our study we evaluated high and low electric field conditions from 90 V to 45 V which had been preheated to 40 °C, 43 °C, or 45 °C. Control groups of non-heated as well as DNA only were included for comparison in all experiments. Luciferase gene expression, viability, and percent cell distribution were measured. Our results indicated a 2-4 fold increase in gene expression that is temperature and field dependent. In addition levels of gene expression can be increased without significant decreases in cell death and in the case of high electric fields no additional cell death. Finally, in all conditions percent cell distribution was increased from the application of heat. From these results, we conclude that various methods may be employed depending on the end user's desired goals. Electric field can be reduced 20-30% while maintaining or slightly increasing gene expression and increasing viability or overall gene expression and percent cell distribution can be increased with low viability.

Modeling cellular lysis in skeletal muscle due to electric shock

High-voltage electrical trauma frequently results in injury patterns that cannot be completely attributed to Joule heating. An electrical-injury model describing cellular lysis damage caused by supraphysiological electric fields is introduced, and used to evaluate the effects of high-voltage electric shock on the skeletal muscle of a human upper limb in a configuration that simulates hand-to-hand contact. A novel multiresolution admittance method, capable of efficiently handling large computational models while maintaining excellent accuracy, was used to perform the numerical computations. Values for the computed current through the arm and the upper limb impedance are reported.

Frequency-dependent interaction of ultrashort E-fields with nociceptor membranes and proteins

We examined the influence of ultrashort pulses (USP) on sensory neurons. Single and high frequency bursts of 12 ns E-fields were presented to rat skin nociceptors that expressed distinct combinations of voltage-sensitive proteins. A single E-field pulse produced action potentials in all nociceptor subtypes at a critical threshold (E(c) ) of 403 V/cm. When configured into high frequency bursts, USP charge integrated to reduce the action potential threshold in a frequency and burst duration-dependent manner with E(c) as low as 16 V/cm (4000 Hz, 25 ms burst). There was no evidence of electroporation at field intensities near the E(c) for nociceptor activation. USP bursts activated a late, persistent Ca(++) flux that was identified as a dantrolene-sensitive Ca(++) -induced Ca(++) release (CICR). Influx of Ca(++) into the cell was required for the CICR and resulted in a reduction of the single pulse E(c) by about 50%.

Effects of varying pulse parameters on ion homeostasis, cellular integrity, and force following electroporation of rat muscle in vivo

Electroporation is a technique used in vitro, ex vivo, and in vivo to permeabilize cell membranes. The effect on the tissue describes a continuum ranging from mild perturbations to massive tissue damage. Thus care should be taken when choosing pulses for a given application. Here the effects of electroporation paradigms ranging from severe to very gentle permeabilization were investigated on soleus, mainly composed of slow-twitch fibers, and extensor digitorum longus (EDL) and tibialis anterior (TA), almost exclusively composed of fast-twitch fibers. Five key physiological parameters were studied: force, muscle Na(+), K(+), and Ca(2+) content, and plasma lactate dehydrogenase activity. Four-week-old Wistar rats were anesthetized, and the lower part of the hind leg was electroporated. Blood samples were collected from the tail vein, and at the times indicated animals were killed and TA, EDL, and soleus muscles were collected for analysis of force and ion contents. Muscles were given eight high-voltage pulses of 100-mus duration (8HV) at varying field intensity, one short high-voltage pulse combined with one long low-voltage pulse (HVLV), or eight medium-voltage pulses of 20-ms duration (8MV). Intensity of the electrical field strength was determinant for the degree of changes observed in the muscle. Field strengths below 300 V/cm did not give rise to measurable changes, whereas 8HV pulses at high field intensities (1,200 V/cm) caused severe and long-lasting damage to the muscle. Interestingly, the damage was more pronounced in EDL and TA compared with soleus, possibly because of the difference in fiber type composition. HVLV only caused temporary changes, with force and ion content being normalized by 4 h, suggesting that this pulse combination may be useful for the introduction of ions and molecules (e.g., DNA) into muscle cells.

Towards solid tumor treatment by irreversible electroporation: intrinsic redistribution of fields and currents in tissue

Local and drug-free tissue treatment by irreversible electroporation (IRE) involves the creation of aqueous pores in a cell's plasma membrane (PM) and leads to non-thermal cell death by necrosis. To investigate explicit pore-based effects we use two-dimensional system models with different spatial scales. The first is a multicellular system model (spatial scale 100 mum) that has irregularly shaped cells, and quantitatively describes dynamic (creation and destruction, evolution in pore size) pore behavior at the PM. The second is a tissue model (spatial scale 200 mm) that is constructed from a unit cell and uses the asymptotic (fixed pore size) electroporation model. Both system models show that significant redistribution of fields and currents occurs through transient PM pores. Pore histograms for the multicellular model demonstrate the simultaneous presence of small and large pores during IRE pulses. The associated significant increase of PM permeability may prove to be essential to understanding how cell death by necrosis occurs. The averaged tissue conductivity in both models increases during IRE pulses because of electroporation. This leads to greater electrical dissipation (heating) and, thus, to larger temperature increases than suggested by tissue models with passive and static electrical properties.

Na+-K+ pump stimulation improves contractility in damaged muscle fibers

Skeletal muscles have a high content of Na+-K+-ATPase, an enzyme that is identical to the Na+-K+ pump, a transport system mediating active extrusion of Na+ from the cells and accumulation of K+ in the cells. The major function of the Na+-K+ pumps is to maintain the concentration gradients for Na+ and K+ across the plasma membrane. This generates the resting membrane potential, allowing the propagation of action potentials, excitation-contraction coupling and force development. Muscles exposed to (1) high extracellular K+ or (2) low extracellular Na+ show a considerable loss of force. A similar force decline is elicited by (3) increasing Na+ permeability or (4) decreasing K+ permeability. Under all of these four conditions, stimulation of the Na+-K+ pumps can restore contractility. Following exposure to electroporation or fatiguing stimulation, muscle cell membranes develop leaks to Na+ and K+ and a partially reversible loss of force. The restoration of force is abolished by blocking the Na+-K+ pumps and markedly improved by stimulating the Na+-K+ pumps with beta 2-agonists, calcitonin gene-related peptide, or dbcAMP. These observations indicate that the Na+-K+ pumps are important for the functional compensation of the commonly occurring loss of muscle cell integrity. Stimulation of the Na+-K+ pumps with beta 2-agonists or other agents may be of therapeutic value in the treatment of muscle cell damage induced by electrical shocks, prolonged exercise, burns, or bruises.

Microdosimetry for conventional and supra-electroporation in cells with organelles

Conventional electroporation (EP) by 0.1 to 1 kV/cm pulses longer than 100 micros, and supra-electroporation by 10 to 300 kV/cm pulses shorter than 1 micros cause different cellular effects. Conventional EP delivers DNA, proteins, small drugs, and fluorescent indicators across the plasma membrane (PM) and causes moderate levels of phosphatidylserine (PS) translocation at the PM. We hypothesize that supra-EP is central to intracellular effects such as apoptosis induction and higher levels of PS translocation. Our cell system model has 20,000 interconnected local models for small areas of the PM and organelle membranes, small regions of aqueous media, appropriate resting potentials, and the asymptotic EP model. Conventional EP primarily affects the PM, but with a hint of endoplasmic reticulum involvement. Supra-EP can involve all of a cell's membrane at the largest fields. Conventional EP fields tend to go around cells, but supra-EP fields go through cells, extensively penetrating organelles.

Cell Injury by Electric Forces

The molecular architecture of biological systems is heavily influenced by the highly polar interactions of water. Thus, macromolecules such as proteins that are highly water soluble must be electrically polar. Energy generation methods needed to support cell metabolic processes depend on compartmentalizing mobile ions and thus require electrical ion transport barriers such as membranes. One consequence of these biological design constraints is vulnerability to injury by electrical forces. Supraphysiological electric forces cause damage to cells and tissues by disrupting cell membranes and altering the conformation of biomolecules. In addition, prolonged passage of electrical current leads to damage by thermal mechanisms. This review will focus on the non-thermal effects.

Notfallmedizinische Versorgung von Blitz- und Stromschlagverletzungen

The pattern of injuries following electrical accidents and the treatment by emergency teams differ depending on whether exposure was to a low-voltage or high-voltage power source or to a lightning bolt. Tissue damage results from the direct effect of current on cell membranes and from conversion of electrical energy into heat. Depending on the magnitude of electrical energy and the duration of exposure, cardiac dysrhythmia, damage to nerve tissue, extensive burns and shock may occur. Multi-system injury is frequently observed, either directly related to electrical shock or secondary to concurrent trauma. Extrication of victims from the energy field must be performed under strict observance of self-protection measures for the rescuers. In high-voltage incidents the rescuers must wait at a distance until the power supply has been turned off and demonstrably grounded. Analgesia, anxiolysis and administration of crystalloid fluids are needed, especially for injuries from high-voltage power sources. Severe burns of the face and neck call for early intubation and ventilation. Monitoring is performed with pulsoximetry, blood pressure measurement and ECG, giving highest priority to the unconscious patient with cardiac and respiratory arrest. Cardio-pulmonary resuscitation (CPR) follows the international guidelines for resuscitation and may be effective after delayed onset and even after prolonged resuscitation attempts.

Role of Na+,K+ pumps in restoring contractility following loss of cell membrane integrity in rat skeletal muscle

BACKGROUND AND AIM

In skeletal muscles, electrical shocks may elicit acute loss of force, possibly related to increased plasma membrane permeability, induced by electroporation (EP). We explore the role of the Na(+),K(+) pumps in force recovery after EP.

METHODS

Isolated rat soleus or extensor digitorum longus (EDL) muscles were exposed to EP paradigms in the range 100-800 V cm(-1), and changes in tetanic force, Na(+),K(+) contents, membrane potential, (14)C-sucrose space and the release of the intracellular enzyme lactic acid dehydrogenase (LDH) were characterized. The effects of Na(+),K(+) pump stimulation or inhibition were followed.

RESULTS

Electroporation caused voltage-dependent loss of force, followed by varying rates and degrees of recovery. EP induced a reversible loss of K(+) and gain of Na(+), which was not suppressed by tetrodotoxin, but associated with increased (14)C-sucrose space and release of LDH. In soleus, EP at 500 V cm(-1) induced complete loss of force, followed by a spontaneous, partial recovery. Stimulation of active Na(+),K(+) transport by adrenaline, the beta(2)-agonist salbutamol, calcitonin gene-related peptide (CGRP) and dibutyryl cyclic AMP increased initial rate of force recovery by 183-433% and steady-state force level by 104-143%. These effects were blocked by ouabain (10(-3) m), which also completely suppressed spontaneous force recovery. EP caused rapid and marked depolarization, followed by a repolarization, which was accelerated by salbutamol. Also in EDL, EP caused complete loss of force, followed by a spontaneous partial recovery, which was markedly stimulated by salbutamol.

CONCLUSION

Electroporation induces reversible depolarization, partial rundown of Na(+),K(+) gradients, cell membrane leakage and loss of force. This may explain the paralysis elicited by electrical shocks. Na(+),K(+) pump stimulation promotes restoration of contractility, possibly via its electrogenic action. The major new information is that the Na(+),K(+) pumps are sufficient to compensate a simple mechanical leakage. This may be important for force recovery in leaky muscle fibres.

In vivo DNA gene electro-transfer: a systematic analysis of different electrical parameters

BACKGROUND

Intramuscular plasmid injection followed by electroporation is an efficient method for gene therapy or vaccination. Several protocols have been described that give good transduction levels with several reporter genes.

METHODS

In this work we have explored the efficiency of gene delivery upon variation of the different electrical parameters such as pulse length frequency and voltage monitoring both on short- and long-term protein production.

RESULTS

Having defined the best performing parameters, we have designed a short electric treatment that gives good levels of plasmid-encoded protein in different species such as mice, rabbits and monkeys.

A dynamic study of the thermal components in electrical injury mechanism for better understanding and management of electric trauma: an animal model

The thermal effects of acute electric trauma to living cells show some variation patterns and kinetics for different body components (muscle, bone, blood-vein and skin). Thermal energy transfer is random with no preferred directions, but electrical energy transfer is vectorial in the direction of the current. In the present study, a total 50 white male Wistar Albino rats, body weight 250-300 g, have been used to study electrical injury mechanism with subsequent change in muscle perfusion at different post-traumatic stages. The muscle temperature was found to increase with a sudden jump from 35.3+/-1.2 to 75.2+/-7.6 degrees C. The bone temperature increased from 35.2+/-1.4 to 45.8+/-1.2 degrees C and decayed slowly within 600+/-90 s. The venous blood curves show a similar pattern to that of muscle with a sudden jump of temperature from 36.4+/-.9 to 40.5+/-3.1 degrees C. The core temperature showed a flat pattern with a slight increase from 36.1+/-0.8 to 37.3+/-0.6 degrees C and the peak temperature was found after 70+/-10 s. From the scintigraphic study, muscle perfusion was found to be a minimum 72 h after electric shock. The right hind limbs of all the rats (ground) exhibited more intense histopathological damages (electric burns) than the left fore limb (source).

Crush injury and rhabdomyolysis

Crush injuries resulting in traumatic rhabdomyolysis are an important cause of acute renal failure. Ischemia reperfusion is the main mechanism of muscle injury. Intravascular volume depletion and renal hypoperfusion, combined with myoglobinuria, result in renal dysfunction. The infusion of intravenous fluids before extrication or soon after injury may lessen the severity of the crush syndrome. Serum CK levels can be used to screen patients with crush injuries to determine injury severity. Once intravascular volume has been stabilized, and the presence of urine flow has been confirmed, a forced mannitol-alkaline diuresis for prophylaxis against hyperkalemia and acute renal failure should be instituted. If an extremity compartment syndrome is suspected, one should have a low threshold for checking the intracompartmental pressures. Further studies are needed to demonstrate if any treatment regimen is truly superior to early, aggressive crystalloid infusion.

Electroporation: theory and methods, perspectives for drug delivery, gene therapy and research

Electroporation designates the use of short high-voltage pulses to overcome the barrier of the cell membrane. By applying an external electric field, which just surpasses the capacitance of the cell membrane, transient and reversible breakdown of the membrane can be induced. This transient, permeabilized state can be used to load cells with a variety of different molecules, either through simple diffusion in the case of small molecules, or through electrophoretically driven processes allowing passage through the destabilized membrane--as is the case for DNA transfer. Initially developed for gene transfer, electroporation is now in use for delivery of a large variety of molecules: From ions to drugs, dyes, tracers, antibodies, and oligonucleotides to RNA and DNA. Electroporation has proven useful both in vitro, in vivo and in patients, where drug delivery to malignant tumours has been performed. Whereas initial electroporation procedures caused considerable cell damage, developments over the past decades have led to sophistication of equipment and optimization of protocols. The electroporation procedures used in many laboratories could be optimized with limited effort. This review (i) outlines the theory of electroporation, (ii) discusses factors of importance for optimization of electroporation protocols for mammalian cells, (iii) addresses particular concerns when using electroporation in vivo, e.g. effects on blood flow and considerations regarding choice of electrodes, (iv) describes DNA electrotransfer with emphasis on use in the in vivo setting, and (v) sums up data on safety and efficacy of electroporation used to enhance delivery of chemotherapy to tumours in cancer patients.

Direct observation of poloxamer 188 insertion into lipid monolayers

P188, a triblock copolymer of the form poly(ethylene oxide)-poly(propylene oxide)-poly(ethylene oxide) helps seal electroporated cell membranes, arresting the leakage of intracellular materials from the damaged cells. To explore the nature of the interaction between P188 and cell membranes, we have constructed a model system that assesses the ability of P188 to insert into lipid monolayers. Using concurrent Langmuir isotherm and fluorescence microscopy measurements, we find that P188 changes the phase behavior and morphology of the monolayers. P188 inserts into both dipalmitoylphosphatidlycholine and dipalmitoylphosphatidylglycerol monolayers at surface pressures equal to and lower than approximately 22 mN/m at 30 degrees C; this pressure corresponds to the maximal surface pressure attained by P188 on a pure water subphase. Similar results for the two phospholipids indicate that P188 insertion is not influenced by headgroup electrostatics. Because the equivalent surface pressure of a normal bilayer is on the order of 30 mN/m, the lack of P188 insertion above 22 mN/m further suggests the poloxamer selectively adsorbs into damaged portions of electroporated membranes, thereby localizing its effect. P188 is also found to be "squeezed out" of the monolayers at high surface pressures, suggesting a mechanism for the cell to be rid of the poloxamer when the membrane is restored.

Biophysical injury mechanisms in electrical shock trauma

Electrical shock trauma tends to produce a very complex pattern of injury, mainly because of the multiple modes of frequency-dependent tissue-field interactions. Historically, Joule heating was thought to be the only cause of electrical injuries to tissue by commercial-frequency electrical shocks. In the last 15 years, biomedical engineering research has improved the understanding of the underlying biophysical injury mechanisms. Besides thermal burns secondary to Joule heating, permeabilization of cell membranes and direct electroconformational denaturation of macromolecules such as proteins have also been identified as tissue-damage mechanisms. This review summarizes the physics of tissue injury caused by contact with commercial-frequency power lines, as well as exposure to lightning and radio frequency (RF), microwave, and ionizing radiation. In addition, we describe the anatomic patterns of the resultant tissue injury from these modes of electromagnetic exposures.

Electroporation-facilitated delivery of plasmid DNA in skeletal muscle: plasmid dependence of muscle damage and effect of poloxamer 188

Electroporation has been reported to facilitate naked DNA gene transfer in skeletal muscle, but has also been implicated in the pathogenesis of electrical injuries. To assess the effects of electroporation on gene transfer, mouse quadriceps muscles were injected with the luciferase reporter plasmid VR1255 and electroporated with caliper electrodes. Intramuscular luciferase expression was increased 10- to 70-fold by electroporation, depending on the DNA dose and injection volume used. In the absence of plasmid DNA injection, electroporation of quadriceps muscles resulted in rapid elevations in serum creatine phosphokinase activity, but did not elicit visible muscle damage. However, in muscles injected with plasmid DNA and electroporated, visible lesions consistently developed in the areas proximal to electrode placement when field strengths optimal for gene transfer (300 volts/cm) were applied. The development of muscle lesions was independent of plasmid transgene expression and required the presence of plasmid in the muscle during electroporation. Co-injection of poloxamer 188 (pluronic F68) with VR1255 substantially reduced elevations in serum creatine phosphokinase activity following electroporation, but did not inhibit the development of muscle lesions. In non-electroporated muscles, co-injection of poloxamer 188 increased luciferase expression threefold. Poloxamer 188 may thus constitute a useful excipient for intramuscular delivery of naked DNA.

Nonlinear cell response to strong electric fields

The response of living cells to externally applied electric fields is of widespread interest. In particular, the intensification of electric fields across cell membranes is believed to be responsible, through membrane rupture and reversible membrane breakdown processes, for certain types of tissue damage in electrical trauma cases which cannot be attributed to Joule heating. Large elongated cells such as skeletal muscle fibres are particularly vulnerable to such damage. Previous theoretical studies of field intensification across cell membranes in such cells have assumed the membrane current to be linear in the applied field (Ohmic membrane conductivity) and were limited to sinusoidal applied fields. In this paper, we investigate a simple model of a long cylindrical cell, corresponding to nerve or skeletal muscle cells. Employing the electroquasistatic approximation, a system of coupled first-order differential equations for the membrane electric field is derived which incorporates arbitrary time dependence in the external field and nonlinear membrane response (non-Ohmic conductivity). The behaviour of this model is investigated for a variety of applied fields in both the linear and highly nonlinear regimes. We find that peak membrane fields predicted by the nonlinear model are approximately twice as intense, for low-frequency electrical trauma conditions, as those of the linear theory.

Kinetics of sealing for transient electropores in isolated mammalian skeletal muscle cells

Permeabilization of the plasma membrane by electrical forces (electroporation) can be either transient or stable. Although the exact molecular mechanics have not yet been described, electroporation is believed to initiate primarily in the lipid bilayer. To better understand the kinetics of membrane permeabilization, we sought to determine the time constants for spontaneous transient pore sealing. By using isolated rat flexor digitorum brevis skeletal muscle cells and a two-compartment diffusion model, we found that pore sealing times (tau p) after transient electroporation were approximately 9 min. tau p was not significantly dependent on the imposed transmembrane potential. We also determined the transmembrane potential (delta Vm) thresholds necessary for transient and stable electroporation in the skeletal muscle cells. delta VmS ranging between 340 mV and 480 mV caused a transient influx of magnesium, indicating the existence of spontaneously sealing pores. An imposed delta Vm of 540 mV or greater led to complete equilibration of the intracellular and extracellular magnesium concentrations. This finding suggests that stable pores are created by the larger imposed transmembrane potentials. These results may be useful for understanding nerve and skeletal muscle injury after an electrical shock and for developing optimal strategies for accomplishing transient electroporation, particularly for gene transfection and cell transformation.

A combination of poloxamers increases gene expression of plasmid DNA in skeletal muscle

Intramuscular administration of plasmid DNA is a promising strategy to express therapeutic genes, however, it is limited by a relatively low level of gene expression. We report here that a non-ionic carrier, SP1017, composed of two amphiphilic block copolymers, pluronics L61 and F127, also known as poloxamers, significantly increases intramuscular expression of plasmid DNA. Two reporter genes, luciferase and beta-galactosidase, and one therapeutic gene, erythropoietin, were injected intramuscularly with and without SP1017 into C57Bl/6 and Balb/C mice and Sprague-Dawley rats. SP1017 increased gene expression by about 10-fold and maintained higher gene expression compared with naked DNA. Comparison of SP1017 with polyvinyl pyrrolidone (PVP) showed that SP1017 exhibited a significantly higher efficacy and its optimal dose was 500-fold lower. Experiments with beta-galactosidase using X-gal staining suggested that SP1017 considerably increased plasmid DNA diffusion through the tissue. SP1017 also improved expression of the erythropoietin gene leading to an increase in its systemic level and hematocrits. Previous toxicity studies have suggested that SP1017 has over a 1000-fold safety margin. Poloxamers used in SP1017 are listed in the US Pharmacopeia as inactive excipients and are widely used in a variety of clinical applications. We believe that the described system constitutes a simple and efficient gene transfer method to achieve local or systemic production of therapeutic proteins.

The effect of lethal electrical shock on postmortem serum myoglobin concentrations

Postmortem serum myoglobin concentrations in blood from the femoral vein (peripheral withdrawal) and the heart (central withdrawal) of nine electrical fatalities were compared with those of 74 individuals who had died of other causes. Independent of the cause of death or topographical site, serum myoglobin concentrations rose dramatically with the passage of postmortem time (maximum concentrations in the control group: 975,100 micrograms/l). In 59% of the total sample (electrical fatalities plus controls), serum myoglobin concentrations were higher in the central blood, in the other 41% the concentrations were higher in the peripheral blood. The differences in concentrations between the peripheral and the central withdrawal area correlated with neither the postmortem interval nor the cause of death. Up to the second day postmortem there was a statistically significant difference in serum myoglobin concentrations between electrical fatalities and controls. The individual values within each group, however, varied widely and overlapped between groups. Controls who had also suffered muscle injury (polytrauma, myocardial infarction) did not have significantly higher serum myoglobin concentrations than controls without muscle injury. Myoglobin concentrations appear to be greatly influenced by the extent and duration of the muscle cramps induced by the electrical current. Correct interpretation of serum myoglobin concentrations depends on the knowledge of events surrounding the lethal electrical shock. Postmortem determination of serum myoglobin concentrations alone is, therefore, not sufficient to establish intravital exposure to electrical current and can aid the diagnosis only in special cases.

Pharmaceutical therapies for sealing of permeabilized cell membranes in electrical injuries

Several years ago, we proposed that loss of cell membrane structural integrity by electroporation is a substantial cause of tissue necrosis in victims of electrical trauma. Specifically, this involves the permeabilization of the lipid bilayer by thermal and electrical forces. We further suggested that certain mild surfactants in low concentration could induce sealing of permeabilized lipid bilayers and salvage of cells that had not been extensively heat-damaged. Successful restoration of membrane transport properties using the surfactant poloxamer 188 was reported in 1992. The purpose of this study is to further examine the response of electroporated rat skeletal muscle membranes to poloxamer 188 (P188) therapy by direct assay of membrane transport properties. Experimental evidence accumulated to date suggests that P188 is effective in sealing permeabilized cell membranes both in vitro and in vivo.

A histological analysis of a high voltage electric current injury to an upper limb

The mechanisms and patterns of high voltage electric current injury to living tissues are not fully understood. Most available data is derived from animal experimentation using voltages that are considerably lower that those encountered by human victims during electrocution accidents. This work aims to contribute human tissue histological data by analyzing the pattern of tissue damage after a real life unfortunate high voltage electrocution accident.

Efficient and regulated erythropoietin production by naked DNA injection and muscle electroporation

We show that an electric treatment in the form of high-frequency, low-voltage electric pulses can increase more than 100-fold the production and secretion of a recombinant protein from mouse skeletal muscle. Therapeutical erythopoietin (EPO) levels were achieved in mice with a single injection of as little as 1 microgram of plasmid DNA, and the increase in hematocrit after EPO production was stable and long-lasting. Pharmacological regulation through a tetracycline-inducible promoter allowed regulation of serum EPO and hematocrit levels. Tissue damage after stimulation was transient. The method described thus provides a potentially safe and low-cost treatment for serum protein deficiencies.

A practical assessment of transdermal drug delivery by skin electroporation

Transdermal drug delivery has many potential advantages, but the skin's poorly-permeable stratum corneum blocks delivery of most drugs at therapeutic levels. Short high-voltage pulses have been used to electroporate the skin's lipid bilayer barriers and thereby deliver compounds at rates increased by as much as four orders of magnitude. Evidence that the observed flux enhancement is due to physical alteration of the skin by electroporation, as opposed to only providing an iontophoretic driving force, is supported by a number of different transport, electrical and microscopy studies. Practical applications of electroporation's unique effects on skin are motivated by large flux increases for many different compounds, rapidly responsive delivery profiles, and efficient use of skin area and electrical charge. Greater enhancement can be achieved by combining skin electroporation with iontophoresis, ultrasound, and macromolecules. Sensation due to electroporation can be avoided by using appropriate electrical protocols and electrode design. To develop skin electroporation as a successful transdermal drug delivery technology, the strong set of existing in vitro mechanistic studies must be supplemented with studies addressing in vivo/clinical issues and device design.

Extensive pectoral muscle necrosis after defibrillation: nonthermal skeletal muscle damage caused by electroporation

A 37-year-old Italian male developed a myocardial infarct with subsequent ventricular fibrillation. He was defibrillated seven times with up to 360 Joules. Thirteen days later the patient died of recurrent myocardial infarct due to thrombotic occlusion of the left circumflex coronary artery. At autopsy, necrosis of the right pectoralis muscle was observed. Electroporation is the pathogenetic mechanism of skeletal muscle damage due to multiple defibrillations with high energy levels.