Rami Khouzam, MD

The Statue of Zeus at Olympia

An enormous statue of the Greek father of gods, carved by the great sculptor Pheidias In his right hand a figure of Victory made from ivory and gold. In his left hand, his scepter inlaid with all metals, and an eagle perched on the sceptre The sandals of the god are made of gold, as is his robe
Pausanias the Greek (2nd century AD)

7 Wonders of the Ancient World

Today, archaeological evidence reveals some of the mysteries that surrounded the history of the Wonders for centuries For their builders, the Seven Wonders were a celebration of religion, mythology, art, power, and science For us, they reflect the ability of humans to change the surrounding landscape by building massive yet beautiful structures, one of which ( the Pyramid) stood the test of time to this very day

Index Case
42-year-old white male No significant past medical hx. except x possible marijuana Was working on a ladder 12 feet high

Electrocuted with 440 volts

Contact burns to bilateral hands

 Prior to arrival to the hospital:

SVT --> Cardioversion x 5 Hypotension --> Dopamine and Epinephrine drips Intubated Vitals on arrival:
Pulse: 101 BP: 71/46 RR: 24

PE (pertinent findings):
Neck in C-collar

Ears: some blood behind Lt. tympanic membrane

Chest: Bilateral crackles Heart: S1S2 RRR Few extra-beats, No m,g,r
Upper extremities: 2nd & 3rd degree burns on the palmar aspects of both hands

 Labs:

K: 3.1, Cr: 1.1 WBCs: 27.8 10.5 AST/ALT: 63/54 ABGs: 7.25/43.8/213.7/18.6/99.1% Lactic a: 4.2 UDS: + methamphetamine

Trop CK CKMB CKMB index Myoglobin

1.38 989 19.4 2.0 > 500

2.87

1.81 2190 17.2 0.8 > 500

Swan-Ganz: PCWP: 19 PA: 31/14 CVP: 15 CO: 16 / CI: 11 SVR: 335 MAP: 80

CXR: Interstitial & alveolar pulmonary opacities centrally with relative sparing peripherally: consistent with pulmonary edema

TTE on admission Mild eccentric LVH LV systolic function was moderately to severely decreased EF: 25-30%

Day 3: Levophed discontinued Weaned off of the vent & extubated Blood culture: MRSA Day 8: Discharged home on: pain meds & antibiotics

TTE (prior to d/c)

Normal left ventricular systolic function EF: 65%

The Hanging Gardens of Babylon

A palace with legendary gardens built on the banks of the Euphrates river by King Nebuchadnezzar II

ELECTRICAL INJURIES
Critical Care Medicine Volume 30.Number 11.November 2002

 Adults in workplace, children at home Severity of injury depends on:

Intensity of electrical current (voltage of source and resistance of victim) Pathway through victims body Duration of the contact with the source

Immediate death may occur from:

1) Current-induced ventricular fibrillation 2) Asystole 3) Respiratory arrest secondary to:
Paralysis of the central respiratory control system Paralysis of the respiratory muscles

History Overview
Lightning was attributed to supernatural powers Zeus ruler of the ancient Greek gods holding thunderbolts which he used as warning or punishment against who disobeyed him

 Zeus, the youngest son of Cronus and Rhea, was the supreme ruler of Mount Olympus and of the Pantheon of gods who resided there
Being the supreme ruler he upheld law, justice and morals, and this made him the spiritual leader of both gods and men

Zeus was a celestial god, and originally worshiped as a weather god by the Greek tribes

 He has always been associated as being a weather god, as his main attribute is the thunderbolt, he controlled thunder, lightning and rain
Theocritus wrote circa 265 BCE: "sometimes Zeus is clear, sometimes he rains

He is also known to have caused thunderstorms

 Discovery and widespread use of electricity in the mid1800s took away the supernatural aura 1st electrical fatality recorded in France in 1879

 Thomas Alva Edison was both a scientist and an inventor Born in 1847 When Edison was born, society still thought of electricity as a novelty, a fad. By the time he died, entire cities were lit by electricity

 In his lifetime, Edison patented 1,093 inventions The most famous of his inventions was an incandescent light bulb He believed in hard work, sometimes working twenty hours a day. Edison was quoted as saying, "Genius is one percent inspiration and 99 percent perspiration"

 In tribute to this important American, electric lights in the United States were dimmed for one minute on October 21, 1931, a few days after his death

 Electrical injuries (excluding lightning) are responsible for > 500 deaths/year in the US > 1/2 of them occur in the workplace. 4th leading cause of work-related traumatic death Electrocutions at home: > 200 deaths/year

 Lightning responsible for 93 deaths/year in US Morbidity 5-10 times higher than that due to other forms of electrical injury Iatrogenic electrical injury in the ICU: defibrillators, pacemakers, electrosurgical devices
Story of CPR: how to treat electrocuted electrical linemen who were in VF

Principles of Electricity
Electricity: flow of electrons (negatively charged outer particles of an atom) through a conductor When the electrons flow away from this object through a conductor they create an electric current: amperes

 Voltage: force that causes electrons to flow: volts Anything that impedes the flow of electrons through a conductor creates resistance: ohms

 Power lines range from:

Low: < 600 volts Ultrahigh: > 1 million volts

Utility power lines with high voltages in sparsely populated areas Through a succession of transformers voltage is gradually reduced Most homes in US & Canada have a 120/240 V other countries (Europe, Asia..): 220 V

The Temple of Artemis at Ephesus

A beautiful temple in Asia Minor erected in honor of the Greek goddess of hunting and wild nature

Pathophysiologic effects of Different Intensities of Electrical Current

 Electrical current exists in 2 forms:

1) AC: (Alternating Current): when electrons flow back and forth through a conductor in a cyclic fashion
It is used in household and offices and is standardized to a frequency of 60 cycles/sec (60 Hz)

2) DC: (Direct Current): when electrons flow only in one direction Used in certain medical equipment: defibrillators, pacemakers, electrical scalpels
AC is far more efficient and also more dangerous than DC (~ 3 times): tetanic muscle contractions that prolong the contact of victim with source

 Issue of safety over efficiency: early days of electricity when Thomas Edison (who developed and popularized DC was fighting against George Westinghouse (who developed AC) AC: first death penalty by electrocution

 Lightning is a form of DC

Occurs when electrical difference between a thundercloud and the ground overcomes the insulating properties of the surrounding air
Current rises to a peak in about 2 sec Lasts for only 1-2 sec

 Voltage >1,000,000 V
Currents of >200,000 A Transformation of the electrical energy to heat generated temperatures as high as 50,000F

Extremely short duration prevents from melting

The Mausoleum at Halicarnassus

A fascinating tomb constructed for King Maussollos, Persian satrap of Caria

Determinants of Electrical Injuries

Ohms law: Current = Voltage/Resistance
Exposure of different parts of the body to the same voltage different current different degree of damage because resistance varies

 The least resistance is found in nerves, blood, mucous membranes and muscles The highest resistance is found in bones, fat and tendons
Skins resistance ranging between 40,000 and 100,000 depending on thickness Moisture of the skin; electrocution of a person in a bathtub or swimming pool

 Moist mucus membranes: significant orofacial injury to infants and toddlers

Nerves and blood vessels are the best conductors: path of least resistance for current after it enters the body Duration of the contact: shock caused by AC will produce bigger injury than shock caused by DC of the same amperage

Pathway of the current through the body:

Vertical pathway parallel to the axis of the body is the most dangerous. It involves all the vital organs; central nervous system, heart, respiratory muscles, in pregnant women the uterus and fetus Horizontal pathway from hand to hand: the heart, respiratory muscles and spinal cord Pathway through the lower part of the body: local damage

The Colossus of Rhodes

A colossus of Helios the sungod, erected by the Greeks near the harbor of a Mediterranean Island

Electrical Injury to Specific Tissues & Organs

Cardiovascular System: Pathophysiology:
Direct necrosis of the myocardium

Cardiac dysrhythmias

 Focal or diffuse Widespread, discrete, patchy contraction band necrosis involving the myocardium, nodal tissue, conduction pathways and coronary arteries

 A current > 50-100 mA with hand-tohand or hand-to-foot transmission ventricular fibrillation

High-voltage current (AC or DC) ventricular asystole Lightning cardiac standstill Sinus rhythm may spontaneously return

 Cardiac dysrhythmias reported in survivors of electrical injuries pathogenesis is rather unclear, multifactorial

 Possible mechanisms:
1) Arrythmogenic foci due to myocardial necrosis (esp. SA Node injury) 2) Alterations in the Na+ - K+ adenosine triphosphatase concentration 3) Changes in the permeability of myocyte membranes 4) Anoxic injury (respiratory arrest precedes the injury to the heart)

 Large arteries not acutely affected because their rapid flow:dissipate heat. Medial necrosis: aneurysm formation and rupture Smaller vessels acutely affected d.t. coagulation necrosis compartment syndrome

Clinical Manifestations Cardiac standstill, ventricular fibrillation: most serious

Sinus tachycardia, nonspecific ST- and Twave changes: much better prognosis Conduction defects, various degrees of heart blocks, BBB and QT interval

 Supraventricular tachycardias and atrial fibrillation: usually do not cause significant hemodynamic compromise On echocardiogram: some depression of the right & left ejection fractions

Cutaneous Injuries & Burns Extensive flash and flame burns Hemodynamic, autonomic, cardiopulmonary, renal, metabolic and neuroendocrine responses

Nervous System
Loss of conciousness, confusion & impaired recall Peripheral motor & sensory nerves motor & sensory deficits Seizures, visual disturbances & deafness Hemiplegia, quadriplegia, spinal cord injury Transient paralysis, autonomic instability hypertension, peripheral vasospasm due to lightning from massive release of catecholamines

Respiratory System Direct injury to the respiratory control center cessation of respiration or suffocation secondary to tetanic contractions of the respiratory muscles
Acute respiratory dysfunction syndrome secondary to ischemia, aggressive fluid resuscitation, ventilator-associated pneumonia

Other Systems
Kidneys susceptible to anoxic/ischemic injury

Release of myoglobin & creatinine phosphokinase renal tubular damage renal failure
Fractures Transient autonomic disturbances fixed pupils may be perceived as severe brain injury or even death Temporary sensorineural hearing loss

The Lighthouse of Alexandria

A lighthouse built by the Ptolemies on the island of Pharos off the coast of their capital city

Management of Electrical Injuries

Overall fluid management should be judicious unless: SIADH

Patient Monitoring Most severe cardiac complications present acutely

Very unlikely for a patient to develop a serious or life-threatening dysrhythmia hours or days later

Asymptomatic normal ECG do not need cardiac monitoring

 Preexisting heart disease: monitor such patients for 24 hrs after the injury Criteria for cardiac monitoring:
Exposure to high voltage Loss of consciousness Abnormal ECG at admission

 Type of cardiac monitoring: (controversial) Continuous telemetry Serial ECGs Serial measurement of cardiac enzymes Prognostic value of CK-MB, noninvasive and invasive imaging studies (echocardiography, thallium studies & angiography): rather poor and inconsistent Muscles injured by an electrical current can contain up to 25% CK-MB fraction (as opposed to the normal 23%) No information regarding changes in troponin

Prophylaxis...

One ounce of prevention is worth a pound of treatment

The Great Pyramid of Giza

A gigantic stone structure near the ancient city of Memphis, serving as a tomb for the Egyptian Pharaoh Khufu Man fears Time, yet Time fears the Pyramids Arab proverb

"Genius is one percent inspiration and 99 percent perspiration."