The Apparent Death In Electrocution

Background: Electrical injuries, though uncommon and largely preventable ,they usually have serious consequences including death .Objectives: To study the pattern of electric injuries, and recognize the factors that increase their mortality so that we can reduce it .Materials & Methods :A retrospective study of sever electrically injured cases in Babil Governorate during a period of 15 months, from January 2006 to March 2007 (included) was carried out. From the records of the burn wards of Hilla Teaching General Hospital and the autopsy records of Forensic Pathology Department of Babil Health Directorate, sever electrically injured victims were retrospectively studied according to the type of electric injury, the voltage, associated secondary traumatic injury and whether it is work related or not. .The age ,sex , location of entry and/or exit of the electric current and the emergency resuscitative measures applied in the Emergency Departments (EDs)were considered.Results:. The total number of electrically injured victims ( both hospitalized and non hospitalized ) were 33, 30(90.9%) cases due to contact with low voltage, 2(6.7%) due to high voltage and 1 (3.3%) due to lightning strike. Out of 28 cases for whom cardiopulmonary resuscitation was indicated, only in 14(50%) cases ,its application was recorded in the cards of Emergency Departments .Conclusions: The mortality rate following electrocution ,in Babil, was 93.93% which is too high in comparison with the international studies rate of 3-15%


Abstract:
Background: Electrical injuries, though uncommon and largely preventable ,they usually have serious consequences including death . Objectives: To study the pattern of electric injuries, and recognize the factors that increase their mortality so that we can reduce it . Materials & Methods :A retrospective study of sever electrically injured cases in Babil Governorate during a period of 15 months, from January 2006 to March 2007 (included) was carried out. From the records of the burn wards of Hilla Teaching General Hospital and the autopsy records of Forensic Pathology Department of Babil Health Directorate, sever electrically injured victims were retrospectively studied according to the type of electric injury, the voltage, associated secondary traumatic injury and whether it is work related or not. .The age ,sex , location of entry and/or exit of the electric current and the emergency resuscitative measures applied in the Emergency Departments (EDs)were considered . Results:. The total number of electrically injured victims ( both hospitalized and non hospitalized ) were 33, 30(90.9%) cases due to contact with low voltage, 2(6.7%) due to high voltage and 1 (3.3%) due to lightning strike. Out of 28 cases for whom cardiopulmonary resuscitation was indicated, only in 14(50%) cases ,its application was recorded in the cards of Emergency Departments . Conclusions: The mortality rate following electrocution ,in Babil, was 93.93% which is too high in comparison with the international studies rate of 3-15% . Key wards :Burns, ,Electric injuries ,Apparent death. Cardiopulmonary resuscitation .
Introduction: Patients with electric injury present a significant challenge . Possible mechanisms of injury include electrical disruption of cardiac rhythm and breathing , burns of several types, and inhalation of gases from fires. Mechanical trauma may come from electric arc blast, explosion of gases, falls, and strong muscle contractions 1 Contact with alternating current at 60 cycles per second (the frequency used in most US household and commercial sources of electricity) may cause tetanic skeletal muscle contractions, preventing self-release from the source of the electricity and thereby leading to prolonged exposure 2 . The extent of tissue damage in electric burns is not indicated by the extent of cutaneous injury; extensive internal damage can cause intravascular fluid losses and hypotension 3,4 . The heart is sensitive to electrical injury 5 , while the nervous system is highly sensitive 6 . Central nervous system involvement can present with amnesia ,loss of consciousness, confusion , anxiety , coma or injury to the respiratory center with resulting respiratory arrest 7,8 . Obstetric consultation should probably be obtained in all pregnant patients reporting electrical injury, regardless of any symptomatology at the time of presentation 9 . Both lightning and electrical trauma often cause multiple trauma, including injury to the spine 10 They should be treated as trauma patients ,with special attention given to cervical spine immobilization 11 . Deaths caused by electrical injury are usually VF(low voltage), a systole (high voltage),or respiratory arrest from interruption of the central respiratory center 5 . Material and Methods:The sever electrically injured patients who reached any hospital within Babil Health Directorate during a period of 15 months from Jan. 2006 to March 2007 were retrospectively studied. The sever electric injured cases involved the cases that required hospitalization or those who died following electric injuries .The data were obtained from the case files of burn wards ,and the autopsy records which also keep the ED cards of the referring health center or hospital. Data were analyzed by descriptive statistics. The patient characteristics regarding age, sex ,place of injury and whether work related or not, the mechanism of electric injury ,voltage ,entry and exit wounds of electric current ,any secondary traumatic injury , the description of the applied resuscitative measures, if any, also was considered. For those who died, the cause of death from the autopsy records was considered.

Results:
The total number of sever electrically injured victims in our study was 33,male to female ratio was 1.75 :1 .The hospitalized patients were 3(9.09%), 2 improved after surgical management (skin grafting in one , the other required upper limb amputation; in addition to skin grafting ), 1 died ;the cause of death was septicemia. The dead victims from the non hospitalized group were 30(90.91%)and represented those who reached the hospital or primary health center dead or apparently dead .Among dead victims following electric injuries -as shown in the table , children within 12 years of age were 10(32.258%),the remaining victims were adolescents and adults .None of the victims was 50 years or above. All the electrical injuries occurred at home ; none happened at a working place. In 18 (58.06%) cases ,the site of entry and/or exit wound(s) of the electric current were through the upper limbs . Viewing the ED cards indicated that 14 (50%) only obtained resuscitative measures on arrival, the time period of resuscitation was not pointed to in the records. 29(93.54%) of the electrically injured died due to contact with low voltage while one victim died following both lightning strike and high -voltage exposure (3.22%)for each . According to autopsy records, cardiopulmonary arrest was the primary cause of death in 90% of the dead victims and no secondary trauma contributed to the mortality of any victim was found. Discussion: Brain death is the absence of clinical brain function when the proximate cause is known and demonstrably irreversible 12 . Prior to diagnose brain death, conditions; like electric shock injury , and drugs that simulate brain death have to be excluded and drug levels measured to ensure that there is no reversible cause for coma .Moreover; metabolic and endocrine disturbances must have been excluded as the cause for the continuation of

Medical
unconsciousness . The assessment of brain stem functioning should be performed by 2 physicians of not less than 5 years registration and at least one of them should be a consultant 13 .
In our study ,we divided the victims into 3 groups according to the voltage of the power source or lightning bolt to which the victims were exposed. This division is important because treatment by emergency team differs for each group 3,14 . The 1 st group ; exposed to low voltage ,were 30, the 2 nd group ;exposed to high voltage was 1, the 3 rd group ; lightning strike ,also one victim .In our study ,non of the injuries was work related while the literature stated that electrical injuries are the 4 th leading cause of traumatic work related deaths 7 .Also the male to female ratio(1.75 :1) is less compared to other studies such as Nigerian burn center study 15 (4.8:1)while in Canadian burn care the ratio was 23.39: 1 16 ;the increased females rate of electric injuries in Babil was attributed to the shortage of the main electric power which, in turn , obliged their involvement in changing the source of electric power frequently at home particularly when the males are outdoors during the day time. Hanumadass ML and colleagues, in reviewing 113 cases of electrical burns during 10 years ,they found low-voltage electrical burns in 73 per cent. All 113 patients survived. They attributed this to early transfer of patients to the Burn Unit, aggressive fluid resuscitation, continuous haemodynamic and metabolic support, and early surgical intervention 17 . Children constituted 10( 32.25%) among the victims which is comparable with other studies 3 . The primary cause of death in 28 cases was cardiopulmonary arrest which is comparable to literature findings in the immediate death in persons who have sustained an electrical injury 18 . The mortality in our study was too high (93:93%) if compared to that of Nigerian's which was 12.5 % 15 . In the E.D ,the managing doctor should realize that electric injury may be a cause of coma ,apnea and fixed pupils 13 . Following electric or lightning injury ,irritation of the anterior chamber can cause miosis, Horner's syndrome or mydriasis can be mistaken as a fixedpupil which also may result from transient autonomic instability leading to early termination of resuscitation efforts 19 .
A few cases in our study were conveyed to the hospital late because some people believe that death following electrocution is irremediable .In spite of late arrival of the victim and the interval before the resuscitation attempt is prolonged, resuscitative efforts should be attempted for extended periods of time as it may be effective in reviving the victim 20 . Finding a normal pulsation in an electrically or lightning injured victim following a period of CPA(cardiopulmonary arrest) , even without application of resuscitative attempt, should not make us to believe that resuscitation is no longer required .The literature assures that in many cases intrinsic cardiac automaticity may spontaneously restore organized cardiac activity 21 . Aggressive persistent resuscitative efforts are indicated for all victims, especially those with spontaneous cardiac rhythms & prolonged apnea or coma 19 .
Ventilatory support may be required for several hours, but even in these cases , there is potential for full recovery 22 .Full support should be continued until cerebral function can be assessed 23 ..
A mortality of 93.9% resulting from low voltage injuries was found in our study while the literature states that ' in general, therapy for low-voltage and lightning injury is supportive and involves cardiac resuscitation for the more seriously injured and supportive care for the less severely injured 24 . An average of 2 cases loss monthly due to electric injury in Hilla Governorate was concluded . The mortality in our study was too high (93:93%) if compared to that of USA and Nigeria which were 3-15% and12.5 % respectively 25,15 .The high mortality could be contributed to either improperly attempted ,short -timed CPR or to non-resuscitating the victims with the belief that they were irremediable and dead ; shortage of familiarity with apparent death presentation among such cases . The latter was assured through noticing autopsy reports and ED cards which indicated that 14(50%) of the dead cases received no CPR .

Conclusions:
A mortality rate of 93.93% following electrocution ,in Babil, was too high compared to the range reported by the international studies. To prevent electrical accidents, the society should practice a conscious use of electricity and change the building codes that require a ground plug for all home outlets.
If someone faces an electrically injured victim, he must transfer him to the near-by hospital early, even if the victim appears dead. The clinicians should be familiarized with the tendency of electrocution victims to apparent death presentation which may be reversible if immediate and prolonged Cardiopulmonary resuscitation are started even if the victim reaches the hospital late or dead .
We recommend : 1 -Upgrading of ED of our hospitals through provision of advanced medical equipments required in performing CPR (Cardiopulmonary resuscitation ) ,in addition to ,improving the training of emergency teams .
2-International rules should be applied in signing death certificates by a medical committee after diagnosing brain death rather than clinical death only.