systemic manifestation of electrocution

1. Systemic manifestation of
Electrocution: How much do we
know?
Ajay Dhiman
Moderator: Dr Amulya Rattan

2. Demographics
• Mostly young men at work and smallchildren
• Youngchildren: electrical cords and outlets (low-voltage)
• Older children: power lines (high-voltage) from climbing trees and
power poles
• Deaths:3-7timeshigherinhighvoltage
• Burns unit admissions:3-5%
Shih JG , Shahrokhi S, Jeschke MG Review of adult electrical burn injury outcomes worldwide: An analysis of low- voltage versus high-voltage
electrical injury. J Burn Care Res. 2017 ; 38(1): e293–e298

3. Factors affecting extent
of injury
• Current – amount and type (AC or DC)
• Potential difference (Voltage)
• Resistance (Ohms)
• Duration of event
• Route of current

4. Type of current
P Saukko and B. Knight (2004)
Alternating current more dangerous than direct current
• More likely to cause cardiac arrhythmias
• Tetanic spasm of muscles of hand, preventing victim from
releasing grasp
• Four to six times more likely to cause death
Saukko P, Knight B (2004) Knight’s forensic pathology 3rd edn. Arnold,London, pp 326-338

5. Amount of current
• Amperage of the current is the most important factor in
electrocution
• Relative to both potential difference as well as resistance
V=I x R
Therefore,
I α V
I α 1
R

7. Voltage
• DM Fatovich (1992)
 Most deathsoccurbetween110Vand380V
• Z Peng and C Shikui (1995)
 Electrocution rarewhenvoltagelessthan 80V
• B Marc et al. (2000)
 Deaths mayoccur at low voltageif humidity reducesresistanceor if
contactifprolonged
Marc B., Baudry F., Douceron H., Ghaith A., Wepierre J.L. and Garnier M. (2000) Suicide by electrocution with low voltage current. J. Forensic
Sci. 45, 216–22.

9. Resistance
AC Koumbourlis (2002)
Body tissues have variable resistance between 500 Ω and
1,000 Ω
 Bones,fat andtendon havehighresistance
 Nerves,blood, mucousmembraneandmuscleshavelow
resistance
koumbourlis AC. Electrical injuries. Crit Care Med. 2002;30(11 Suppl):S424-S430

10. •Exposureof different parts of body to samevoltagewill produce
different amperages.
–Skinhasmoderate resistancevariable basedon thickness and
dampness.
•Dryskincanhaveup to 100,000Ω
•Water or sweatsoakedskinmayhave1,000Ω

11. Duration of event
• Deaths have been reported with as low as 24 V when contact
is maintained for long times

12. Route of Current
LM Al-Alouisi (2010)
• Passage of current through heart or brain increases mortality
• Current passes from point of contact to nearest earthed point
• Most common route being hand to foot or hand to hand
Al-Alousi LM (2010) Homicide by electrocution. Med Sci Law 30: 239-246

13. Mechanisms of electricity-induced injury
• Electrical energy causing direct tissue damage, altering cell
membrane resting potential, and eliciting muscle tetany.
• Conversion of electrical energy into thermal energy, causing
massive tissue destruction and coagulative necrosis.
• Mechanical injury with direct trauma resulting from falls or
violent muscle contraction
Shih JG , Shahrokhi S, Jeschke MG Review of adult electrical burn injury outcomes worldwide: An analysis of low- voltage versus high-voltage electrical
injury. J Burn Care Res. 2017 ; 38(1): e293–e298

14. Specific organeffects
• Cardiac
• Renal
• Musculoskeletal
• GIT
• CNS/ Peripheral NervousSystem
• EYESandENT
• Cutaneous burns

15. Cardiac
Main cause of death fromelectrocution
• Arrhythmia –15%,within first few hours
• Acute cardiac injury cancause asystole and death (DC) or
ventricular fibrillation (AC)
• VFmain cause of death
• Also: AF,1st / 2nd AVblock, BBBs,
• Coronaryspasm
• Myocardial rupture from coagulation necrosis

16. 1 Electrical cardiac
injuries: current
concepts and
management
2017 Clinical review Arrhythmias and Myocardial tissue
injuries
2 Electric Shock–
Induced Coronary
Artery Thrombosis
2019 Case report •A 32-year-old man, 6000-V
electric shock.
•exertional angina
•stress echocardiography: positive
result for ischemia.
•cardiac catheterization: showed
severe coronary artery disease, as
well as an occluded left anterior
descending coronary artery (LAD)
and an occluded circumflex artery

17. Renal
• Rhabdomyolysis :- 10% of survivors
results from massive muscle destruction
• Intracellular contents released:
 myoglobin
 creatinine kinase (CK)
 lactate dehydrogenase
 potassium

18. AKI
• Most significant complication
• Due to myoglobin-induced renal vasoconstriction with
resultant ischaemia
• Myoglobin cast formation in the distal convoluted tubule
causing obstruction
• Nephrotoxic effects of myoglobin on the epithelial cells of the
proximal convoluted tubule
R. Vanholder, M.S. Sever, E. Erek, N. Lameire, Rhabdomyolysis, J. Am. Soc. Nephrol. 11 (8) (2010) 1553–1561.

19. 1 High-voltage
electrical injury
complicated by
compartment
syndrome and
acute kidney
injury
2018 Case
Report
Rhabdomyolysis is common sequela of
electrical burns and may result in severe and
permanent metabolic and renal impairment
2 Acute Renal
Failure Following
Electrocution
2010 Case
Report
•Acute renal failure: not a common fatal
complication
• Myoglobin, released into the bloodstream
due to rhabdomyolysis following electrical
injury to the muscles, is often blamed as the
offending agent

20. Musculoskeletal
• Electrothermal damage: progressive muscle devitalization
from vascular thrombosis
• Subsequently, edema around necrotic muscles within their
unyielding fascial sheath results in progressive obliteration of
microcirculation, giving rise to compartment syndrome
Vascular
thrombosis
Edema around
necrotic muscle
Obliteration of
microcirculation

21. • Full extent of myonecros is not apparent at first and extend
due to ongoing ischemia
• Unfortunately, amputation is often an inevitable consequence
of electrical burns
• Tarim A, Ezer A. Electrical burn is still a major risk factor for amputations. Burns. 2013;39(2):354-357.

22. 1 Electrical burn is still a
major risk factor for
amputations
2013 Original
article
amputation rate was higher in
electrically burn patients.
Patients were mostly males and
adults.
2 A Rare Case of Triceps
Brachii Injury After
Electrocution
2017 Case report an uncommon case of
intramuscular tear associated
with insertional distal tendon
injury occurred in a man
survived to high-voltage electric
discharge.
3 Humeral Neck Fracture
After Electrocution
2015 Case report a very rare case of proximal
humeral fracture after
electrocution due to violent
muscle contractions, associated
with partial-thickness burns of
the left hand

23. GIT
• First case: 1927 by Simonin
• Reported perforation of the small intestine
Marques EG , Junior Periera GA, Neto BFM , Freitas RA . Visceral injury in electrical shock trauma: proposed guideline for the
management of abdominal electrocution and literature review Article in International Journal of Burns and Trauma.
Int J Burn Trauma 2014;4(1):1-6

24. • Abdominal visceral perforation: direct consequence of the
electric current rather than a complication
• Usually occurs in conjunction with overlying abdominal wall
involvement
• Amount of heat generated lead to vaporization of tissues
• If peritoneum involved, visceral perforation may present
immediately

25. • In literature the rare gastrointestinal complications:
recognized late (18th -21st day)
Singh A P , Mathur V, Tanger R , Gupta A K. Low Voltage Electric Current Causing Ileal Perforation: A Rare Injury. APSP J Case Rep.
2016 May-Jun; 7(2): 17
Hajong R, Tongper D, Khariong PDS, Mibang N. Jejunal perforation following electric burns-a case report. IOSR J Den Med Sci.
2013;7:24-25
Colon NC, Schlegel C, Chung DH. Herndon DN (ed): “Total burn care”. WB Saunders; New York: 2012. Surgical management of
complications of burn injury

26. 1 Electrocution Causing
Descending Colon Perforation
2017 Case report A 40 year old male
sustained electric burn.
3 days later, complaints of
abdominal pain and
progressive abdominal
distension
2 Low Voltage Electric Current
Causing Ileal Perforation
2016 Case report 8-year old male presented
after 10 days of sustaining
electric burn over left
forearm, chest, and
abdominal wall with
perforation diagnosed at 10th
day
3 Electric Current Causing
Sigmoid Perforation
2015 Case report 31 year-old male, electrician
(by occupation) presented in
emergency department
within 6 hours of history of
high tension electric current
burn on left hand, arm, with
severe abdominal pain
diagnosed as perforation

27. CNS and Peripheral nerve injuries
50%have impairment (withhigh-voltage)
• Transient loss of consciousness
• Quadriplegia, hemiplegia,paresthesia
• Respiratory depression
• Memory disturbances / agitation / confusion
• Coma
• Seizure

28. • Sensory / motor findings from peripheral nerve damage often
“patchy”, canget complex regional pain syndrome (CRPS)
• Findingscommonly delayed from days to months post-injury
(high voltage)

29. Acute Stroke due to Electrocution: Uncommon or Unrecognized?
(Case report 2016)
38-year-old white male grabbed a “live” electrical wire.
On examination
• Complete amnesia of the inciting event.
• Alert but disoriented
• Most of the responses were limited to either head nodding or a few words associated with
paraphasia.
Discussion
• Acute stroke due to electrocution is uncommon and has been described in only nine cases
• Paucity of knowledge regarding the pathophysiology, clinical features, treatment, and
outcomes of stroke due to electrocution
• Direct electrical stimulation of cerebral vessels can cause vasospasm

30. Acute Ischemic Stroke Associated with Low-voltage Electrical Injury
A Case Report (2015)
A man aged 79 years worked as a television mechanic was found unconscious at work
place
O/E:
• Left facial paralysis and left hemiplegia
• Deep tendon reflexes were brisk
• Plantar response was extensor on the left
Possible mechanism:
• Thermal injury, electroporation and vascular injury

31. Electrical injury to the brain (Case report 2012)
37-year-old had touched live electricity cables with his left hand
Complaints:
• patient had global numbness and clumsiness of his left arm
• numbness of the left side of his face
O/E:
• Reduced sense of touch of the entire left arm and left side of his face
• Clumsiness of the left arm
• Elevated tendon reflex of the left knee were found on neurological exam
Discussion
• Peripheral nerves, ipsilateral to the side of shock, and the contralateral upper white
matter tracts are damaged, suggesting that this whole nerve tract has been injured.
• Proposed mechanisms of injury:
 thermal injury
 Electroporation of neurons which is a destructive hyperpermeability of cell
membranes caused by an electrical current
 Direct electro-conformational denaturation of proteins.

32. Eyeinjuries
EYE INJURIES
• Cataracts –develop months/yearslater
• Hyphaema,vitreous hemorrhage, optic nerve injury
Saffle JR, Crandall A. Cataracts a long term complication of electrical injury. J Trauma. 2015 Jan;25(1):17e21.
Stephen V, John SR, Chakraborty A, Chakrabarti M. Bilateral cataract following electrical injury. Kerala J Ophthalmol. 2006;18(3):252e254.

33. Bilateral cataract post-electrocution: A case report (2017)
Case
• a 45 year old patient victim of a work accident by high voltage electrification
• two years later: low visual acuity with bilateral leukocoria
Ophthalmologic examination
• Limited visual acuity to light perception
• Total cataract bilateral
• Fundus not visible.
• Two-dimensional ultrasound: normal posterior segment
pathogenesis
• scar tissue formation by proliferation of fibroblasts on the basement membrane of
the anterior capsule
•decreased capsular permeability
•disruption of lens metabolism due to circulatory disorder
• the participation of a uveal inflammatory reaction

34. ENTinjuries
EARINJURIES
• Tympanic membrane rupture –common
• Hearing loss –immediate/delayed
• Tinnitus, vertigo, facialnerve injury
Barber B, Côté DW, Liu R. Electric shock ear torture: a rare cause of tympanic membrane perforation and mixed
hearing loss. J Otolaryngol Head Neck Surg. 2011;40(3):E22-E25.

35. Bilateral hearing loss following electrocution: A case report (2005)
57-year-old woman suffered a domestic electrocution
Complaints : deafness and tinnitus
O/E: with pure tone audiometry
tinnitus and sensorineural hearing
Exact pathophysiology unknown,
likely to be a combination of brain, vestibulocochlear nerve and cochlear injury
Post-mortem examinations
Possible mechanism of cochlear injury (rupture of Reissner’s membrane, loss of spiral
ganglion cells, degeneration of the stria vascularis and organ of Corti) due to electrocution

36. Cutaneousinjuries
• Entry and exitwounds
• Degreeof external injury cannot determine extent of internal
injury
• Kissingburn –at flexor creases,associatedwith extensive
underlying tissuedamage

37. • Entry and exitwounds
Cutaneousinjuries

38. • Kissing burn – at flexor creases, associated with extensive underlying
tissue damage
Cutaneous injuries

39. System Presentation
Skin Cutaneous burns
Cardiac Arrhythmias, cardiacarrest
Respiratory Respiratory arrest due to muscletetany or central nervous
system causes
Neurologic Lossof consciousness, transient paralysis or paraesthesia,
peripheral neuropathy, spinal cord injury
Musculoskeletal Fractures or dislocations secondary to muscle spasmor
falls, muscle necrosis,compartment syndrome
Renal Myoglobinuria leading to renal failure
Other Cataracts, deafness
‘
SPresentations of electricalinjuries of multi
Tablefrom: Electricalinjuries:Areview for the EmergencyClinician: EmergencyMedicinePractice,
Oct 2009

40. Amar Priyanshu Aryan Inderjeet khursheed Ravikumar Ramlal
Age 11 12 25 26 40 45 51
Low/high
voltage
High High High High High High High
Injury
arrival time
22hrs 6hrs 3 hrs 1hr20 min 9 days 7.5 hrs 2hrs
% BSA 6 13 14 5 12 4 11
Place of
occurence
Home Home Home Workplace Workplace Workplace Workplace
Concomitan
t
mechanical
trauma /fall
No No History of
fall
No History of
fall
No History of
fall
Primary
survey Normal Normal
Hypotensio
n Normal
Hypotensio
n Normal Normal
Initial ECG Normal Normal Normal Normal Normal Normal Normal
Follow up
ECG Normal Normal Normal Normal Normal Normal Normal
Entry point LEFT HAND Right hand LEFT ARM Left
shoulder
LEFT ARM B/L HANDS RT ARM
AND LEFT
HAND
Exit point Anterior
abdominal
wall over left
hypogastrium
LEFT FOOT Left feet B/L THIGHS B/L FOOT
Our Experience

41. Myoglobinu
ria No No No No Yes No No
Acute
kidney
injury
No Yes Yes No Yes No No
CK MB 88.5 600 5410 83.34 859 96 406
Amputation
s No Below elbow Above Elbow No
Below
elbow No No
Systemic
involvement
Pneumo
peritone
um
without
peritoni
sm
No
Jejunal and
sigmoid colon
perforation
(PAD 6)
No
Fundus
ulcers with
Hematemes
is(PAD 14)
No No
Secondary
complicatio
ns
No Yes
Myonecrosis of
the wound
Nodular scabies
at stump site
Acute kidney
injury
Yes
Surgical Site
infection
Myonecrosis
Anemia
Hypoalbunemia
Pneumonia
Graft failure
Septic artritis
Parestheisias
Acute kidney
injury
No Yes
Surgical Site
infection
Myonecrosi
s Anemia
Hypoalbune
mia AKI
with
multiple
dialysis
No No
Hospital stay2 days 6 days 45 days 2 days 9 days 1 day 3 days
Final
outcome
Discharg
e Discharge Expired Discharge Discharge Discharge Discharge

42. Thank you