European Heart Journal (2018) 39, 1459–1465 CLINICAL REVIEW

doi:10.1093/eurheartj/ehx142 Clinical update

Electrical cardiac injuries: current concepts

and management
Victor Waldmann1,2,3, Kumar Narayanan2,4, Nicolas Combes5, Daniel Jost6,
Xavier Jouven1,2,3, and Eloi Marijon1,2,3*

Downloaded from https://academic.oup.com/eurheartj/article/39/16/1459/3746021 by guest on 01 May 2021

1
Cardiology Department, European Georges Pompidou Hospital, 20 rue Leblanc, 75015 Paris, France; 2Paris Cardiovascular Research Center (Inserm Unit 970), European
Georges Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France; 3Paris Descartes University, 12 rue de l’école de médecine, 75006 Paris, France; 4Cardiology Department,
Maxcure Hospitals, Telangana, Hyderabad 500081, India; 5Cardiology Department, Clinique Pasteur, 45 avenue de Lombez, 31300 Toulouse, France; and 6Brigade de Sapeurs
Pompiers de Paris, 1 Place Jules Renard, 75017 Paris, France

Received 1 November 2016; editorial decision 20 February 2017; accepted 11 April 2017; online publish-ahead-of-print 20 April 2017

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

... relating to management in both the seriously injured as well as the ap-
Introduction ..
.. parently healthy patient are discussed.
Electrical injuries, depending on a wide range of factors, are very ..
..
heterogeneous, ranging from benign small skin burns to extensive ..
..
injuries of internal organs, which could be life-threatening.1,2 .. Pathophysiology
Although clinical situations involving electrical mishaps are not un- ..
common, physicians are often uncomfortable dealing with these cases
.. Electricity is the flow of electrons through a potential gradient be-
..
due to the absence of systematic evidence-based recommendations .. tween two physical points, such as the two terminals of a battery,
on this phenomenon. A better understanding of electrical injuries
.. from high to low concentration, and is measured in Amperes (I). This
..
may be also particularly helpful to eventually prevent a large majority .. potential difference, expressed in voltage (V), represents the force
.. driving the electrons. Anything that impedes the flow of electrons
of accidents, essentially through public educational sessions, but im- ..
provement in physicians’ awareness is also essential to improve opti- .. through a conductor creates resistance, which is measured in ohms
..
mal management of this common but relatively unfamiliar situation. .. (R).3 The Ohm’s law [I = V/R] expresses the relationship among
This review attempts to synthesize existing information on this im- .. those factors, while Joule’s law [W (Joules) = R  I2  T] provides
..
portant but relatively neglected scenario and summarizes the main .. the thermal energy produced as a result of the relative current flow.
types of electrical injuries and their respective pathophysiology. .. Electric shock is the set of pathophysiological events resulting
..
Specifically, effects on the heart are outlined and practical issues . from the action of an electric current on the human body. Lightning is

* Corresponding author. Tel: þ33662833848, Fax: þ33156092664, Email: eloi_marijon@yahoo.fr

Published on behalf of the European Society of Cardiology. All rights reserved. V
C The Author 2017. For permissions, please email: journals.permissions@oup.com.
1460 V. Waldmann et al.

Downloaded from https://academic.oup.com/eurheartj/article/39/16/1459/3746021 by guest on 01 May 2021

Figure 1 Examples of current path through the body during an electric shock (from ‘Elektroschutz in 132 Bildern’, with the kind permission of Dr
EH Jellinek).

.. path through the body, and finally the magnitude of energy delivered.
..
.. Alternating current is considered more dangerous as it causes tetanic
.. muscle contraction with the resultant risk that the victim may be un-
..
.. able to release the electrical energy source. The current flow gener-
.. ally tends to occur from the entry point in contact with the electrical
..
.. source to the exit point, which most of the time is in contact with the
..
.. ground (where small skin surface burns are frequently seen), through
.. tissues of least resistance such as neurovascular axes (Figures 1 and 2).
..
.. The effects of increasing current intensities on the body are shown in
.. Table 1. It is traditionally said that it is the intensity of the current (I)
..
.. that kills and the amount of energy (W) that burns. First, it is often
.. thought that the magnitude of electrical hazard is proportional to
..
.. voltage, but in fact it depends on the intensity (I in Amperes), which is
.. linked both to voltage and resistance. Thus, even a low voltage shock
..
.. can be fatal, in case of decreased resistance, with ventricular fibrilla-
.. tion threshold of 50–100 mA for example (Table 1). Secondly, while
Figure 2 Entry/exit point skin burns photographs (courtesy of ..
Dr E Kras, Centre Hospitalier de Martigues, Martigues, France). .. even very short contact can trigger a cardiac arrest, burn lesion sever-
.. ity on the other hand is determined by the Joule’s law, where the dur-
..
.. ation of exposure plays an important role.
.. However, voltage is often the only variable known with certainty
..
the most extreme form, whereas the term ‘electrocution’ is used in .. after exposure to electricity and so is the most used marker for cate-
the setting of electrical injuries that result in death. Electrical injuries
.. gorizing electrical shocks (low-voltage electrical shocks are less than
..
involve both direct and indirect mechanisms. The direct damages are .. 1000 V and high-voltage are 1000 V or more, Table 2).5,6 While the-
caused by contact with electrical energy or electricity arc (an arc is a
..
.. oretically, 220 V outlets (as seen in Europe) are more dangerous than
flow of electrons through a gas, such as air) to a victim at ground .. 110 V (US), because the current intensity is doubled, in practice,
..
potential (supplying an alternative path to ground). It results from .. when the voltages are relatively close, the main determinant of elec-
both the direct effects of current on cell membranes, cellular de- .. trical injury severity remains the resistance (Ohm’s law [I = V/R]).
..
polarization and electroporation (defined as the creation of pores in .. The human body has an average internal resistance of about 500
cell membranes),4 as well as from the conversion of electric energy .. Ohms; however significant variations are present in different tissues.
..
into heat energy as current passes through body tissues. Indirect inju- .. Skin, bone, and fat have a higher resistance to electricity, usually pro-
ries may be linked to secondary mechanical trauma due to falls; or .. voking increases in temperature and coagulation, whereas nerves and
..
burns due to flash from the heat generated by an electrical arc or .. blood vessels present relatively low resistance, conducting electricity
flame from the ignition of clothing or other combustible materials. .. readily.7 The skin has a wide range of resistance to electricity and
..
Factors that determine the nature and severity of electrical trauma .. plays the crucial role of ‘gatekeeper’ when the body is exposed to
include voltage, resistance to current flow, type of current (direct or
.. electricity. Dry skin, whose resistance varies from one individual to
..
alternating), duration of contact with the current source, current . another but is often between 40 000 and 100 000 ohms, may suffer
Electrical cardiac injuries 1461

..
Table 1 Estimated effects of 60 Hz alternative cur-
.. In the Unites States, approximately 4400 victims are significantly
.. injured by electrical hazards and 400 people die of exposure to elec-
rents (A for Ampere) ..
.. tricity annually.1 Approximately ten percent of these are estimated
Current Effect .. to be cases of lightning strike (data from the U.S. Bureau of Labour
Intensity (I)
..
................................................................................................. .. Statistics). Although decreasing, electrocution still represents the sev-
.. enth cause of occupational fatalities, mainly in the construction indus-
1 mA Tingling, barely perceptible ..
16 mA Maximum current a person can grasp and ‘let go’
.. try and high voltage power line men.11 Patients surviving electrical
.. shock represent 3–6% of approximately 100 000 patients admitted
20 mA Muscle tetanization ..
.. to specialized burn units annually.6
20–50 mA Paralysis of respiratory muscles, respiratory arrest ..
50–100 mA Ventricular fibrillation threshold ..
..
2A Cardiac standstill and internal organ damage .. Cardiovascular effects
15–30 A Common household circuit breakers ..
..

Downloaded from https://academic.oup.com/eurheartj/article/39/16/1459/3746021 by guest on 01 May 2021

.. When the chest is situated along the path that connects the entrance
.. and exit points, the heart is often affected because the electric cur-
..
.. rent actually follows vascular axes, which present the lowest resist-
.. ance (along with nerves). Horizontal (hand to hand) as well as
..
Table 2 Main current origins with associated voltage .. vertical current passages (hand to foot or head to foot) can thus lead
.. to cardiac injury.12 The two major cardiac complications of electrical
Voltage (volts) Current’s origin ..
................................................................................................. .. shock are arrhythmias and myocardial tissue injuries.
..
High Voltage ..
45 000–400 000 High voltage line .. Arrhythmias
..
25 000 Rail network .. Arrhythmias are the most common cardiac complication of electric
1500 Overhead line
.. injury.13–15 The relative small size of the majority of studies do not
..
Low Voltage .. allows to provide reliable estimates of incidences; while some of
960 Mines
.. them have reported rates varying widely from a few percentage
..
750 Third rail subway conductor .. points to almost 40%, a recent larger study has recorded significant
380 Workshops
.. arrhythmias in only 3% of monitored patients.16 The most frequent
..
110/220 Domestic (USA/Europe) .. arrhythmias are sinus tachycardia and premature ventricular contrac-
.. tions, but atrial fibrillation and ventricular tachycardia or fibrillation
..
.. have been reported (Figure 3, Panels A and B).17,18 While exposure to
.. high-voltage (like lightning) or direct current will most likely cause
..
extensive superficial tissue damage from current exposure, but limit .. ventricular asystole, even low-voltage alternating current can cause
..
conduction of potentially life-threatening current to deeper, crucial .. sudden cardiac death by ventricular fibrillation. In a canine model,
structures.8 Skin resistance to current can be reduced substantially .. ventricular fibrillation occurred nine times more often with alternat-
..
by moisture, thereby converting what ordinarily might be a minor .. ing current than with direct current shocks.19 The frequency of
low-voltage injury with superficial tissue damage into a life-
.. 50–60 cycles per second (Hertz), used in most household and com-
..
threatening shock, by allowing more current to pass to deeper struc- .. mercial sources of electricity, increases the likelihood of heart expos-
.. ure to the current during its vulnerable period, a kind of ‘R-on-T
tures, resulting in more extensive injury to internal organs. ..
.. phenomenon’, triggering fibrillation.20 Most arrhythmias occur soon
.. after the electrical shock, but delayed ventricular arrhythmias have
..
Epidemiology .. been also reported. Jensen et al.21 identified delayed arrhythmias
.. 8–12 h after the accident in three cases: one received 3000 V direct
..
Although electricity is a relatively recent invention, humans have al- .. current whereas the other two cases were domestic injuries and
ways been exposed to electrical injuries caused by lightning. The dis- .. received 380 and 220 V shocks. In all these cases, the electrical cur-
..
covery and widespread use of electricity in the mid-1800s made .. rent passed through the thorax (arm to arm shocks). One had recur-
electrical injuries a common problem at work or at home, with the ..
.. rent ventricular fibrillation, one had ventricular tachycardia, and one
first electrical fatality recorded in 1879 in a French carpenter, caused .. had ventricular parasystole. The mechanism behind electrically
by an alternating current of 250 V from a dynamo.9
..
.. induced cardiac arrhythmias is not entirely understood but biopsies
The exact number of electrical accidents remains challenging to .. reported arrhythmogenic foci in patchy myocardial fibrosis with
estimate precisely, because a variable proportion of them do not
..
.. increased numbers of Naþ and Kþ pumps, potentially associated
end in medical consultation or hospitalization. The age distribution of .. with transient and localized changes in sodium and potassium trans-
..
patients who are electrocuted is bimodal; the first peak occurring .. port as well as concentrations with resultant changes in membrane
in children younger than 6 years of age, mainly in household acci- .. potential. As a consequence, arrhythmias can be triggered by these
..
dents (‘finger in the socket’),10 and the second occurs in adolescence .. areas of repolarization heterogeneity, with possible abnormal
and in young adulthood, involving more frequently high voltage .. enhanced automaticity or afterdepolarization and triggered activity
..
currents. . several hours after the injury.22 Furthermore, if necrotic areas/scars
1462
persist, this substrate can favour the occurrence of re-entry arrhyth-
mias remotely.
Myocardial injuries
Heart muscle damage can result from the direct effects of electric
current (electrothermal conversion and electroporation), but several
other mechanisms have been described. Myocardial infarction by cor-
onary spasm or thrombosis, myocardial contusion by cardiopulmon-
ary resuscitation with subsequent haematoma formation in small
coronary arteries, extensive catecholamine release mediated injuries
and coronary blood flow reduction secondary to generalized severe
hypotension compromising myocardial perfusion have all been pro-
posed (Figure 4).23–25
The diagnosis can be challenging, because chest pain is frequently
absent, and the injury may manifest only as non-specific changes in
the electrocardiogram (ECG, in particular ST segment and T wave
abnormalities or transient QT prolongation, Figure 3, panel A). In case
of coronary artery damage or spasm, classic clinical symptoms or
ECG patterns of myocardial infarction can be present, including ST
segment elevation or appearance of Q waves.23 The right coronary
artery seems more vulnerable in this setting, due to its relative prox-
imity to the chest surface.26 A coronary angiography must thus be
performed if there is any doubt as to the possibility of underlying cor-
onary artery disease, although myocardial infarction with normal cor-
onary angiogram has also been described.24 Anecdotally, transient
Figure 3 12-D ECG and continuous Holter monitoring showing a huge transient QT interval prolongation (Panel A) immediately after a high volt-
age electrical shock, associated with sinus tachycardia and premature ventricular extra-beats (Panel B) some hours later. Cardiac magnetic resonance
imaging showing extensive subepicardial delayed enhancement of both ventricles, consistent with non-ischaemic myocardial fibrosis (arrows), in a pa-
tient after a high voltage electric shock (3000 V, Panel C, courtesy of Dr JF Paul, Institut Mutualiste Montsouris, Paris, France, and Dr NT To, Centre
Chirurgical Marie Lannelongue, Le Plessis-Robinson, France).
V. Waldmann et al.
... Brugada patterns in ECG have been reported in patients after an
..
.. electric shock.27,28 Furthermore, although creatine kinase–MB sub-
.. fraction elevations are frequent in these patients, their significance in
..
.. this context is unknown due to the oft-associated peripheral muscle
.. necrosis, while the specificity of troponins has not been evaluated suf-
..
.. ficiently in this setting. Abnormalities on echocardiography or cardiac
..
.. MRI (such as hypokinesia or fibrosis, Figure 3, Panel C) can indicate
.. myocardial damage, but heart failure with reduced ventricular ejec-
..
.. tion fraction is rarely reported.29 Although cardiac function usually
.. returns to normal, cardiac abnormalities may sometimes persist.30,31
..
..
.. Other complications
..
.. Conduction disturbances, like sinus bradycardia or standstill, bundle-
Downloaded from https://academic.oup.com/eurheartj/article/39/16/1459/3746021 by guest on 01 May 2021
.. branch blocks or various degrees of atrioventricular blocks can occur
..
.. following electrical shocks.32 Indeed, electrical injuries seem to have a
..
.. predilection for the sinoatrial and atrioventricular nodes.26 The rea-
.. son for this vulnerability remains unclear. It has been hypothesized
..
.. that the sinoatrial and atrioventricular node ion channels are the easi-
.. est to disrupt and that ischaemia and infarction in the right coronary
..
.. artery distribution (running closest to the chest surface and supplying
..
.. both nodes) make the nodes more vulnerable to electrical cur-
... rent.1,26 Interestingly, conduction pathway injuries secondary to an
.. electric shock underlie the development of ablative techniques since
..
.. the description of the first fulguration, in 1979, where an external
.. shock had accidentally induced a total atrioventricular block due to
Electrical cardiac injuries 1463

Downloaded from https://academic.oup.com/eurheartj/article/39/16/1459/3746021 by guest on 01 May 2021

Figure 4 Mechanisms involved in electrical myocardial injuries.

..
the propagation of the electric current to an endocavitary electrode .. Extensive cutaneous burns are a common complication and can
positioned on the His bundle.33 .. cause dehydration, infection, or multiple organ failure. Because the
..
Due to its high water content, the vascular bed is an excellent con- .. resistance of the skin may be markedly altered by moisture, electric
ductor. Vascular damages are usually associated with high voltage .. current may be transmitted to deeper tissues before it causes signifi-
..
electric shock and preferentially affect small vessels. Large arteries .. cant damage to the skin. Thus, in contrast to burns caused by fires,
are not acutely affected because their rapid flow allows them to dissi- .. the severity of the skin burns cannot be used to assess the degree of
..
pate the heat produced by the electric current. However, they are .. internal injury in an electrical accident.37
susceptible to medial necrosis, with aneurysm formation and rupture
.. A respiratory arrest can occur immediately following electrical
..
at a later point of time. Vascular dissection can also be responsible .. shock from inhibition of the medullary respiratory centre in the brain
for secondary haemorrhage. Arterial intimal damage in smaller ves-
.. or prolonged paralysis or tetanic contraction of the diaphragm or
..
sels can be immediate or delayed up to several weeks, and may result .. other respiratory muscles. Parenchymal lung damage is really rare
.. but thermal burns of the airways or inhalation of toxic fumes and hot
in partial or complete thrombosis and occlusion, resulting in necro- ..
sis.34 Lastly, vascular injuries in the extremities are very likely to cause .. debris may occur.2
.. Electrical shock can damage the central and peripheral nervous
compartment syndromes that further compromise the circulation. ..
Other cardiac manifestations reported include haemorrhagic peri- .. system, with various non-specific clinical findings.38,39 Such patients
..
carditis, transient arterial hypertension and transient autonomic .. may have fixed and dilated pupils (due to reversible autonomic dys-
dysfunction.35 .. function); characteristics that should not lead to termination of resus-
..
.. citation efforts.40
Pathologic findings .. Bone has the highest electrical resistance and experiences the
..
Histologically, the main features are non-specific: widespread areas of .. most severe electrothermal injuries, which can result in osteonecro-
band necrosis, predominating along the conduction system, and focal
.. sis. Violent muscular contractions or injury due to falls can cause frac-
..
degeneration of smooth muscle fibres with apparent contracture .. tures or luxations.41 Oedema formation and tissue necrosis may lead
within the tunica media of both large and small coronary arteries.26
.. to the compartment syndrome and rhabdomyolysis.42
..
Chronic myocardial abnormalities such as fibromuscular dysplasia or .. Among other organ systems that may incur significant damage due
.. to electrical injury, the kidneys are of particular importance.
fatty infiltration have also been observed at autopsy, suggesting prior ..
unrecognized cardiomyopathy which could enhance vulnerability to .. Although direct injury from electric current is unusual, the kidneys
.. are very susceptible to anoxic/ischaemic injury that accompanies se-
cardiac arrest, with the electrical injury acting as trigger. ..
Furthermore, myofibre break-up has been proposed as the most spe- .. vere electrical injury, and muscle necrosis may cause myoglobin re-
.. lease leading to renal failure by tubular precipitation.43
cific finding on microscopic heart examinations.36 ..
..
..
..
Extracardiac injuries .. Management
..
..
Electrical energy is capable of damaging most organs, depending on .. General rules
current intensity and pathway, which could lead to a life-threatening
.. Before attempting to provide medical care, turning off the current
..
clinical state. . source to prevent a further accident/injury should be the first step.
1464
..
Next, the management is mainly symptomatic. Immediate resuscita- ..
tion of young victims in cardiac arrest from electrocution can result ..
..
in long-term survival and successful complete recovery has been re- ..
ported even after prolonged life support.44 Thus a prompt, aggres- ..
..
sive, and prolonged resuscitation attempt is warranted in witnessed ..
accidents.45 ..
..
Any victim of a severe electrical accident should be assumed to ..
have a spinal cord injury and should be managed with proper head
..
..
and neck immobilization. Entry and exit points have to be looked for ..
to evaluate the current pathway and thus estimate potentially dam-
..
..
aged organs, but they are sometimes not discernible, in particular ..
..
when the skin is wet with a lowered resistance. In case of extensive ..
burns, the patient must be admitted in a specialized burns unit ..
..
with dedicated surgical care such as skin graft or fasciotomy. Even
when low blood pressure is not present, intravenous hydration is
usually desirable to compensate for increased fluid requirements
due to fluid extravasation into third space compartment and fluid
losses and to prevent renal shut down secondary to myoglobin
precipitation.46
Cardiac monitoring
Figure 5 proposes a practical algorithm based on recommendations
and an analysis of the literature.2,6,44
In an apparently healthy patient, without extensive burns or other
life-threatening injury, the key issue is assessment of the risk of occur-
rence of serious cardiac arrhythmias, which requires ECG monitoring
in an intensive care unit. Although only small numbers of observa-
tional studies have specifically addressed this point, there is general
consensus that in case of low-voltage injuries and absence of history
of loss of consciousness or initial cardiac arrest, as well as a normal
ECG at admission, the risk of significant arrhythmias is quite low.47–50
Some authors however, suggest to monitor patients with prior
known heart disease, as a precaution, although a higher risk has not
Figure 5 Practical algorithm for apparently healthy patient management after electric accident.
*Despite the limited level of scientific evidence, it appears reasonable to systematically offer a cardiac monitoring (at least 24-h) to patients with significant
troponin elevation, given its high cardiac specificity.
V. Waldmann et al.
been demonstrated.44 Similar results have also been reported in
paediatric patient series,51–53 mostly in children up to 6 years, with-
out major differences in injury type or prognosis reported by age;
and with high-voltage injuries,37,54,55 though in the latter situation,
larger studies are necessary to be able to discharge such patients
home from the emergency room with a reasonable degree of confi-
dence. Thus, it is crucial to obtain an initial ECG on all patients with
an electrical injury, regardless of the voltage involved. Overall, the
duration of cardiac monitoring is not well established, with insufficient
evidence to formulate guidelines, but most authors recommend
monitoring for at least 24 h after the injury or after resolution of ar-
rhythmias.2 Indeed, as already discussed, transient repolarization
changes and premature contractions can potentially trigger arrhyth-
Downloaded from https://academic.oup.com/eurheartj/article/39/16/1459/3746021 by guest on 01 May 2021
.. mias even several hours after the injury.21
.. Concerning the helpfulness of cardiac enzymes for myocardial in-
..
.. jury evaluation or for rhythm risk stratification, data indicate that cre-
.. atine kinase-MB is an unreliable marker, with inadequate sensibility
..
.. and potential confounding by peripheral skeletal muscle injury.30,56–58
.. No significant study exists regarding the utility of troponin in these
..
.. clinical situations. Nevertheless, the widespread availability of tropo-
.. nin level measurement in the emergency departments and its greater
..
.. cardiac specificity represents a potential promising tool in the future
.. to aid decisions regarding patient management. Although there is a
..
.. need for further studies and no clear recommendation can be estab-
..
.. lished at this time due to the absence of sufficient evidence, it seems
.. reasonable to monitor patients with a significant troponin rise, re-
..
.. flecting myocardial damage with possible arrhythmias susceptibility,
.. and to investigate them with at least an echocardiogram.
..
.. Patients implanted with cardiac electronic devices are exposed to
.. specific hazards. An electric shock, similar to an external cardiover-
..
.. sion, may damage system integrity and therefore pacemakers and de-
.. fibrillators should be interrogated in the event of an electric
..
. injury.59,60 The electric noise can potentially lead to device inhibition
Electrical cardiac injuries 1465

..
in pacemaker-dependent patients, asynchronous pacing, and inappro- .. transmitted, resulting most often in harmless accidents. Information
priate therapies in patients with defibrillators. However, it has been .. campaigns are crucial to foster a better understanding of the risks
..
reported that ‘noise reversion’ algorithms could avoid inappropriate .. involved as well as the right approach to adopt in such cases.
device shock during electrical accident,61 and that in fact, sudden ..
..
death could be prevented by appropriate termination of ventricular ..
fibrillation initiated due to the electrical event, in patients carrying an .. Conclusions
..
implantable cardioverter defibrillator (ICD).62 Although mostly ..
necessary, internal ICD shocks represent a potential source of .. Depending on a wide range of factors, although electrical injuries are
.. most of the time benign,16 they could be life-threatening in case of ex-
therapeutic electrical cardiac injuries,63 with troponin elevations and ..
fibrosis adjacent to defibrillation leads reported, while external cardi-
.. tensive burns or internal organ damage. The main risk in the appar-
.. ently healthy patient is sudden death due to cardiac arrhythmias,70
oversion does not seem to cause significant heart damage.64 ..
In the pregnant patient, electrical or lightning injury carries the add-
.. requiring at the minimum assessment by a doctor with physical exam-
.. ination and ECG. Discharge to home from the emergency room
itional risk of complications to the pregnancy or the foetus. Foetal in- ..

Downloaded from https://academic.oup.com/eurheartj/article/39/16/1459/3746021 by guest on 01 May 2021

.. could be allowed in case of low-voltage electric shock in the absence
jury and death have been described following minor electrical injuries .. of ECG abnormality, but cardiac monitoring in intensive care unit for
to pregnant women, however, the causal relationship has been ques- ..
.. at least 24 h is recommended in other patients. The second main car-
tioned. In view of the small number of cases described, the real risks ..
are unknown.65–68 Spontaneous abortion following electrical accident .. diac complication is myocardial injury, where the diagnosis could be
.. challenging but most of the time reversible, with studies needed to
has been reported with frequency ranging widely from 6–73%. ..
Considering this poor and inhomogeneous medical literature, a watch- .. assess the potential role of troponin measurement for patient man-
.. agement. Finally, considering that electrical injuries are often avoid-
ful attitude with hospitalization for foetal cardiac monitoring seems ..
reasonable. .. able, preventive measures should be emphasized and it seems that
.. the best way to manage electrical injuries can still be summarized by
Finally, an individualized management strategy for long term follow- ..
up needs to be implemented, depending on initial clinical findings (ar-
.. the old saying: ‘One ounce of prevention is worth a pound of cure’.
.. Public education regarding electrical safety and safe use according to
rhythmias, myocardial damage. . .). Physical examination, ECG, and if ..
necessary Holter-ECG, echocardiography, or occasionally cardiac MRI
.. specifications of electric equipment at home and at work are the best
.. means of eliminating mortality and minimizing the morbidity of elec-
could be required depending on the specific scenario. ..
.. trical injuries.71
..
.. Conflict of interest: none declared.
Prevention ..
..
.. References
Ultimately, the best ‘treatment’ for electrical injuries remains preven- ..
tion. Concerted efforts are essential for preventing work-related acci-
.. 1. Spies C, Trohman RG. Narrative review: electrocution and life-threatening elec-
.. trical injuries. Ann Intern Med 2006;145:531–537.
dents in exposed occupations and home accidents involving children. .. 2. Koumbourlis AC. Electrical injuries. Crit Care Med 2002;30:S424–S430.
.. 3. Fish R. Electric shock, Part I: Physics and pathophysiology. J Emerg Med
Many recommendations exist for prevention of occupational injuries. ..
The first goal is to avoid hazardous contact with electricity by imple- .. 4. 1993;11:309–312.
.. Block TA, Aarsvold JN, Matthews KL, Mintzer RA, River LP, Capelli-Schellpfeffer
menting workplace safety instructions with respect to equipment .. M, Wollmann RL, Tripathi S, Chen CT, Lee RC. The 1995 Lindberg Award.
safety guidelines, periodic checks of electrical installations, de- .. Nonthermally mediated muscle injury and necrosis in electrical trauma. J Burn
.. Care Rehabil 1995;16:581–588.
energizing power lines before beginning work, following required .. 5. Bingham H. Electrical burns. Clin Plast Surg 1986;13:75–85.
clearance distance from power sources and training in hazard recogni- .. 6. Arnoldo B, Klein M, Gibran NS. Practice guidelines for the management of elec-
..
tion. Secondly, in case of an accident, the amount of electrical current .. 7. trical injuries. J Burn Care Res 2006;27:439–447.

passing through the body has to be minimized as far as possible by .. Cooper MA. Emergent care of lightning and electrical injuries. Semin Neurol
.. 1995;15:268–278.
measures to enhance resistance (both to the current source and to .. 8. Jain S, Bandi V. Electrical and lightning injuries. Crit Care Clin 1999;15:319–331.
the ground). Examples include using flame retardant protective cloth-
.. 9. Jex-Blake AJ. The Goulstonian Lectures on death by electric currents and by
.. lightning: delivered before the Royal College of Physicians of London. Br Med J
ing, non-conductive ladders or insulating blankets, and by automatic ..
power outage mechanisms (circuit breakers, fuses, and security re-
.. 10. 1913;1:425–430.
.. Baker MD, Chiaviello C. Household electrical injuries in children. Epidemiology
sidual current devices). Finally, standardized response measures and .. and identification of avoidable hazards. Am J Dis Child 1960 1989;143:59–62.
.. 11. Janicak CA. Occupational fatalities due to electrocutions in the construction in-
optimized incident management by training and availability of resusci- .. dustry. J Safety Res 2008;39:617–621.
tative equipment as well as other preventive measures are important .. 12. Chandra NC, Siu CO, Munster AM. Clinical predictors of myocardial damage
..
(mock drills, cardiopulmonary resuscitation training, proximity warn- .. 13. after high voltage electrical injury. Crit Care Med 1990;18:293–297.
Weber H, Schmitz L, Dische R, Rahlf G. Percutaneous intracardiac direct-
ing devices, widespread availability of defibrillators in public places).69 ..
.. current shocks in dogs: arrhythmogenic potential and pathological changes. Eur
For domestic cases, electrical installations must comply with mod- .. Heart J 1986;7:528–537.
ern safety standards. Education in general and especially education .. 14. Fineschi V, Donato SD, Mondillo S, Turillazzi E. Electric shock: cardiac effects
.. relative to non fatal injuries and post-mortem findings in fatal cases. Int J Cardiol
and supervision of young children are also indispensable.10 Utilization ..
of socket cover, removal of bare wiring and avoidance of using elec- .. 15. 2006;111:6–11.
Arnoldo BD, Purdue GF, Kowalske K, Helm PA, Burris A, Hunt JL. Electrical inju-
..
trical appliances with wet skin are essential preventive steps. The pro- .. ries: a 20-year review. J Burn Care Rehabil 2004;25:479–484.

tection currently offered by many modern electrical facilities (like

.. 16. Pawlik AM, Lampart A, Stephan FP, Bingisser R, Ummenhofer W, Nickel CH.
.. Outcomes of electrical injuries in the emergency department: a 10-year retro-
circuit breakers) limits the exposure time and the intensity of current . spective study. Eur J Emerg Med 2015;23:448–454.
1465a V. Waldmann et al.

17. Solem L, Fischer RP, Strate RG. The natural history of electrical injury. J Trauma .. 45. Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ,
1977;17:487–492. .. Jeejeebhoy FM, Gabrielli A. Part 12: cardiac arrest in special situations: 2010
18. Dixon GF. The evaluation and management of electrical injuries. Crit Care Med
.. American Heart Association Guidelines for Cardiopulmonary Resuscitation and
..
1983;11:384–387. .. Emergency Cardiovascular Care. Circulation 2010;122:S829–S861.
19. Lown B, Neuman J, Amarasingham R, Berkovits BV. Comparison of alternating .. 46. Okafor UV. Lightning injuries and acute renal failure: a review. Ren Fail
current with direct electroshock across the closed chest. Am J Cardiol .. 2005;27:129–134.
1962;10:223–233. .. 47. Cunningham PA. The need for cardiac monitoring after electrical injury. Med J
20. Kugelberg J. Electrical induction of ventricular fibrillation in the human heart. A .. Aust 1991;154:765–766.
study of excitability levels with alternating current of different frequencies. Scand .. 48. Fish RM. Electric injury, part III: cardiac monitoring indications, the pregnant
J Thorac Cardiovasc Surg 1976;10:237–240.
.. patient, and lightning. J Emerg Med 2000;18:181–187.
..
21. Jensen PJ, Thomsen PE, Bagger JP, Nørgaard A, Baandrup U. Electrical injury .. 49. Petroni T, Moubarak G, Varenne O, Weber S, Duboc D. Do we need to system-
causing ventricular arrhythmias. Br Heart J 1987;57:279–283. .. atically hospitalize electrocuted patients in ICU?. Int J Cardiol 2011;152:410–411.
22. Opie LH, Nathan D, Lubbe WF. Biochemical aspects of arrhythmogenesis and .. 50. Akkaş M, Hocagil H, Ay D, Erbil B, Kunt MM, Ozmen MM. Cardiac moni-
ventricular fibrillation. Am J Cardiol 1979;43:131–148. .. toring in patients with electrocution injury. Ulus Travma Acil Cerrahi Derg
23. Kinney TJ. Myocardial infarction following electrical injury. Ann Emerg Med .. 2012;18:301–305.
1982;11:622–625. .. 51. Bailey B, Gaudreault P, Thivierge RL, Turgeon JP. Cardiac monitoring of children
24. Ku CS, Lin SL, Hsu TL, Wang SP, Chang MS. Myocardial damage associated with .. with household electrical injuries. Ann Emerg Med 1995;25:612–617.
..

Downloaded from https://academic.oup.com/eurheartj/article/39/16/1459/3746021 by guest on 01 May 2021

electrical injury. Am Heart J 1989;118:621–624. .. 52. Bailey B, Gaudreault P, Thivierge RL. Experience with guidelines for cardiac
25. Vianello F. A man in the thunderstorm: coronary injuries and electric shock. .. monitoring after electrical injury in children. Am J Emerg Med 2000;18:671–675.
Cardiology 1997;88:486. .. 53. Zubair M, Besner GE. Pediatric electrical burns: management strategies. Burns
26. James TN, Riddick L, Embry JH. Cardiac abnormalities demonstrated postmor- .. 1997;23:413–420.
tem in four cases of accidental electrocution and their potential significance rela- .. 54. Purdue GF, Hunt JL. Electrocardiographic monitoring after electrical injury:
tive to nonfatal electrical injuries of the heart. Am Heart J 1990;120:143–157. .. necessity or luxury. J Trauma 1986;26:166–167.
27. Rangaraj R, Moorthy N, Patil SS, Manjunath C. Brugada-type electrocardiographic .. 55. Arrowsmith J, Usgaocar RP, Dickson WA. Electrical injury and the frequency of
pattern induced by electrocution. Indian Pacing Electrophysiol J 2009;9:56–59.
.. cardiac complications. Burns 1997;23:576–578.
..
28. Wang JG, McIntyre WF, Kong W, Baranchuk A. Electrocution-induced Brugada .. 56. Housinger TA, Green L, Shahangian S, Saffle JR, Warden GD. A prospective
phenocopy. Int J Cardiol 2012;160:e35–e37. .. study of myocardial damage in electrical injuries. J Trauma 1985;25:122–124.
29. Iino H, Chikamori T, Hatano T, Morishima T, Hida S, Yanagisawa H, Usui Y, .. 57. McBride JW, Labrosse KR, McCoy HG, Ahrenholz DH, Solem LD, Goldenberg
Kamada T, Watanabe K, Yamashina A. High-tension electrical injury to the heart .. IF. Is serum creatine kinase-MB in electrically injured patients predictive of myo-
as assessed by radionuclide imaging. Ann Nucl Med 2002;16:557–561. .. cardial injury?. JAMA 1986;255:764–768.
30. Guinard JP, Chiolero R, Buchser E, Delaloye-Bischof A, Payot M, Grbic A, Krupp .. 58. Ahrenholz DH, Schubert W, Solem LD. Creatine kinase as a prognostic indicator
S, Freeman J. Myocardial injury after electrical burns: short and long term study.
.. in electrical injury. Surgery 1988;104:741–747.
..
Scand J Plast Reconstr Surg Hand Surg 1987;21:301–302. .. 59. Waller C, Callies F, Langenfeld H. Adverse effects of direct current cardioversion
31. McGill MP, Kamp TJ, Rahko PS. High-voltage injury resulting in permanent right .. on cardiac pacemakers and electrodes Is external cardioversion contraindicated
heart dysfunction. Chest 1999;115:586–587. .. in patients with permanent pacing systems?. Europace 2004;6:165–168.
32. Robinson NM, Chamberlain DA. Electrical injury to the heart may cause long- .. 60. Manegold JC, Israel CW, Ehrlich JR, Duray G, Pajitnev D, Wegener FT, Hohnloser
term damage to conducting tissue: a hypothesis and review of the literature. Int J .. SH. External cardioversion of atrial fibrillation in patients with implanted pacemaker
Cardiol 1996;53:273–277. .. or cardioverter-defibrillator systems: a randomized comparison of monophasic and
33. Vedel J, Frank R, Fontaine G, Fournial JF, Grosgogeat Y. Permanent intra-hisian
.. biphasic shock energy application. Eur Heart J 2007;28:1731–1738.
..
atrioventricular block induced during right intraventricular exploration. Arch Mal .. 61. Saguner AM, Duru F. Implantable cardioverter defibrillator avoids shock during
Coeur Vaiss 1979;72:107–112. .. electrocution. Eur Heart J 2012;33:694.
34. Hunt JL, McManus WF, Haney WP, Pruitt BA. Vascular lesions in acute electric .. 62. Perret JN, Sanders TW, d’Autremont SB, Patrick HC. Ventricular fibrillation initi-
injuries. J Trauma 1974;14:461–473. .. ated by an electrocution injury and terminated by an implantable cardioverter-
35. Jost WH, Schönrock LM, Cherington M. Autonomic nervous system dysfunction .. defibrillator. J La State Med Soc 2009;161:343–347.
in lightning and electrical injuries. NeuroRehabilitation 2005;20:19–23. .. 63. Sham’a RA, Nery P, Sadek M, Yung D, Redpath C, Perrin M, Sarak B, Birnie D.
36. Fineschi V, Karch SB, D’Errico S, Pomara C, Riezzo I, Turillazzi E. Cardiac path-
.. Myocardial injury secondary to ICD shocks: insights from patients with lead frac-
ology in death from electrocution. Int J Legal Med 2006;120:79–82.
.. ture. Pacing Clin Electrophysiol 2014;37:237–241.
..
37. Hunt JL, Sato RM, Baxter CR. Acute electric burns. Current diagnostic and thera- .. 64. Lund M, French JK, Johnson RN, Williams BF, White HD. Serum troponins T and
peutic approaches to management. Arch Surg Chic Ill 1960 1980;115:434–438. .. I after elective cardioversion. Eur Heart J 2000;21:245–253.
38. Cherington M. Central nervous system complications of lightning and electrical .. 65. Leiberman JR, Mazor M, Molcho J, Haiam E, Maor E, Insler V. Electrical accidents
injuries. Semin Neurol 1995;15:233–240. .. during pregnancy. Obstet Gynecol 1986;67:861–863.
39. Wilbourn AJ. Peripheral nerve disorders in electrical and lightning injuries. Semin .. 66. Fatovich DM. Electric shock in pregnancy. J Emerg Med 1993;11:175–177.
Neurol 1995;15:241–255. .. 67. Einarson A, Bailey B, Inocencion G, Ormond K, Koren G. Accidental electric shock
40. Cherington M. Neurologic manifestations of lightning strikes. Neurology
.. in pregnancy: a prospective cohort study. Am J Obstet Gynecol 1997;176:678–681.
..
2003;60:182–185. .. 68. Sparic R, Malvasi A, Nejkovic L, Tinelli A. Electric shock in pregnancy: a review.
41. Butler ED, Gant TD. Electrical injuries, with special reference to the upper .. J Matern-Fetal Neonatal Med 2016;29:317–323.
extremities. A review of 182 cases. Am J Surg 1977;134:95–101. .. 69. Fordyce TA, Kelsh M, Lu ET, Sahl JD, Yager JW. Thermal burn and electrical inju-
42. Brumback RA, Feeback DL, Leech RW. Rhabdomyolysis following electrical in- .. ries among electric utility workers, 1995–2004. Burns 2007;33:209–220.
jury. Semin Neurol 1995;15:329–334. .. 70. Authors/Task Force Members, Priori SG, Blomström-Lundqvist C, Mazzanti A,
43. Rosen CL, Adler JN, Rabban JT, Sethi RK, Arkoff L, Blair JA, Sheridan R. Early .. Blom N, Borggrefe M, Camm J, Elliott PM, Fitzsimons D, Hatala R, Hindricks G,
predictors of myoglobinuria and acute renal failure following electrical injury.
.. Kirchhof P, Kjeldsen K, Kuck K-H, Hernandez-Madrid A, Nikolaou N, Norekvål
..
J Emerg Med 1999;17:783–789. .. TM, Spaulding C, Veldhuisen DJV. 2015 ESC Guidelines for the management of
44. Soar J, Perkins GD, Abbas G, Alfonzo A, Barelli A, Bierens JJLM, Brugger H, .. patients with ventricular arrhythmias and the prevention of sudden cardiac death:
Deakin CD, Dunning J, Georgiou M, Handley AJ, Lockey DJ, Paal P, Sandroni C, .. The Task Force for the Management of Patients with Ventricular Arrhythmias
Thies K-C, Zideman DA, Nolan JP. European Resuscitation Council Guidelines .. and the Prevention of Sudden Cardiac Death of the European Society of
for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: .. Cardiology (ESC). Endorsed by: Association for European Paediatric and
Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyper- .. Congenital Cardiology (AEPC). Eur Heart J 2015;36:2793–2867.
thermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution.
.. 71. Waldmann V, Narayanan K, Combes N, Marijon E. Electrical injury. BMJ
Resuscitation 2010;81:1400–1433.
.. 2017;357:j1418.