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Scanning electron microscopy with energy-dispersive x-ray (SEM/EDX) analysis is an investigation whose potential has become increasingly important in the field of forensic research and diagnosis. We present the procedure to perform a well-carried-out SEM/EDX analysis on corpses affected by different types of injuries, such as blunt force trauma, ligature strangulation, electrocution, sharp force trauma, gunshot wounds, and intoxication. After the areas of forensic interest have been macroscopically identified, the sampling can be performed in 2 different ways: apposition of the double-sided graphite tape on the damaged area or performing the excision of a biological sample. In both cases, a proper negative control sample is required. In all cases, SEM/EDX analysis can detect exogenous microtraces consistent with the types of injuries involved. In blunt force trauma, microparticles of different nature deriving from the contact of the blunt instrument with the victim may be observed; in sharp force trauma, metal microtraces (Fe, Cr, Al, Ti) can be identified. In ligature strangulation, exogenous microtraces may be found in the cutaneous furrow. In electrocution, it allows to identify the pathognomonic metal pattern (Cu, Zn, Fe) of the "electric mark." In gunshot wounds, the main applications regards the detection of metal particles (Pb, Ba, Sb) of gunshot residues. Finally, in the analysis of intoxicants, it may identify traces of toxic substances. Thus, the authors conclude that SEM/EDX analysis can provide essential information to assist in the medicolegal investigation of death.

Background: Electric shocks are common, and victims report difficulty in finding practitioners with knowledge of the injury. Medical Practitioners, especially in private practice, report lack of knowledge of the injury and lack of expertise in assessing and treating the injury. The authors are often requested to suggest investigation protocols, assessment protocols, and treatment protocols, and to provide educational information. Methods: The international body establishing electrical standards on the effects of current on the body (International Electrotechnical Commission, Maintenance Team 4 (MT4) of Technical Committee 64 (TC64)) have established protocols for the factors which require documentation and reporting of the injury. This article provides a narrative approach to using these protocols in accord with the standards (IEC 60479). The level of evidence is Level III (US/Canada classification). Type: This article collects together and collates physical and medical aspects of investigating electric shocks, and summarizes those of importance, and which are potentially forgotten. The thoroughness of initial assessment is emphasized. Substance: Summaries are set out to guide first attenders and emergency medical personnel as to findings and observations which must be recorded for later comprehensive medicolegal reporting and which are often overlooked. Conclusion: Wider teaching in the nature of electric shocks will enhance assessment of victims and thorough recording of pertinent information and thus will enhance later medicolegal reporting. Many such factors are initially overlooked and lead to inadequate reporting for forensic purposes.

OBJECTIVE: An electrical injury (EI) is an emergency that causes high morbidity and mortality each year. The aim of this study was to define the epidemiological, clinical, and laboratory factors that might predict severe patients and cardiac arrest in pediatric EI cases. METHODS: All of the patients' medical files were reviewed retrospectively through a 2-year period for the demographic, clinical, and laboratory findings. The patients were classified into the severe injury group or the mild injury group. The SPSS (Chicago, Ill) software was used to analyze the data. RESULTS: Among the 38 patients, 18 patients (47.4%) were in the mild group, and 20 patients (52.6%) were in the severe group. Low-voltage injuries were observed in 35 (92.1%) of the patients. Most of the severe patients were injured with low voltage (75%) and in household settings (85%). Plug and sockets were the most observed source of the injuries in all of the patients, whereas water-related injuries were most prevalent in the severe group. The source of injury was different in the mild and severe groups (P = 0.009). In the severe group, 13 patients (34.2%) were resuscitated after cardiopulmonary arrest. In the multivariate analysis of the demographic data, the most predictive parameters for cardiac arrest and the clinical severity in EIs are the factors of electrical cables and water. CONCLUSIONS: Electrical injuries are a significant concern in the pediatric population. Our results showed that low voltage and household electricity could cause morbidity and mortality. Language: en

CASE A 43-year-old man suffered household electric shock from 220 V alternating current when he accidently touched a live wire with his left hand. Subsequently, he was diagnosed to have osteonecrosis of the left femoral head and underwent total hip arthroplasty. CONCLUSION We suggest that the electric current could have thrombosed the terminal subsynovial vessels of the femoral head, leading to osteonecrosis. To the best of authors' knowledge, only 2 cases of osteonecrosis of the hip after electric shock have been reported in the literature. A literature review of the delayed consequences of electric shock injuries pertaining to orthopaedics is also presented.

The aim of this study was to investigate the epidemiological characteristics of low-voltage electrocution deaths in Guangdong, China. Three thousand three hundred seventy autopsy reports from the Department of Forensic Pathology, Zhongshan School of Medicine, Sun Yat-Sen University, over a period of 10 years (2001-2010) were reviewed, of which 71 low-voltage electrocution cases were identified. The descriptive statistical analyses were carried out with the application of SPSS 19.0 software. Electrocution accounted for 2.11% of all autopsied cases. The age range was 3 to 57 years with a mean age of 31.77 ± 11.0 years. The average age of male victims was 33.08 ± 10.77 years, and that of female victims was 22.63 ± 11.06 years. The majority of the victims (87.33%) were male. Among the circumstances leading to electrocution, most of them occurred in factory and in the street. Considering the contact details, deaths were caused most frequently by touching electrical wires (n = 27, 38.02%), followed by touching charged machine (n = 20, 28.17%). There were no suicide and homicide cases. Of all electrocution cases, 50.70% occurred during the summer period from June through August. The upper extremity was the most frequently involved contact site (59.72%). No electrical burn marks were present in 14 cases (19.72%). Our results indicated that most deaths from electrocution occur more often in factories, in summer seasons, and to young male workers, which can help in the development of a differentiated strategy for the prevention of electrocution, while taking into consideration sex, age, occupation, and season of the year.

Implantable cardioverter defibrillators (ICDs) save lives in patients at risk for sudden death attributable to ventricular arrhythmias, pacemakers (PMs) have been improving symptoms in patients with bradyarrhythmias for decades, and, more recently, cardiac resynchronization devices have improved mortality, morbidity, and quality of life for patients with heart failure.1 However, these devices can also be life-changing for the patients receiving them. The need for long-term follow-up, concerns regarding malfunction, and lifestyle restrictions all affect patients with any implanted device. For patients with ICDs, receiving shocks, both appropriate and inappropriate, can impact quality of life (QOL). Lead or device malfunction can result in unnecessary shocks, and recalls can cause anxiety. Shocks at the end of life can be particularly devastating. However, with careful attention by the healthcare team, both shocks and their impact can be reduced. In addition to shocks, restrictions imposed by the ICD can also impact QOL. The possibility of syncopal arrhythmias and loss of control attributable to shocks, as well, has led to concerns regarding the safety of driving and of sports participation for some individuals, a further burden. Remote monitoring increases the ease of follow-up for patients and physicians and may improve timeliness of management. However, a consequence of remote follow-up has been a decrease in the amount of time electrophysiologists may spend face-to-face with patients, emphasizing the importance of communication between electrophysiologist and primary cardiologist. This article will review ways in which electrophysiologists, general cardiologists, and patients can work together to minimize the burdens that can accompany these devices, often weighing issues of patient QOL, safety, and autonomy. Studies of overall QOL for patients with ICDs have shown mixed results. Some studies have found no significant differences in overall QOL between ICD patients and other cardiac patients,2,3 PM patients, or the general population. …

We present the case of a 12-year-old girl with abnormal extrapyramidal movements associated with basal ganglia lesions after electrical injury. After her injury, our patient initially did well and recovered from acute cardiovascular and hemodynamic instability, and the results of her neurological examination, head computed tomography scan, and electroencephalogram were normal on discharge from hospital. Two weeks after discharge, she developed extrapyramidal movements, and head magnetic resonance imaging showed areas of bilateral, symmetrical enhanced associated with signal intensity in the basal ganglia, hypoxic encephalopathy, and cerebral edema that may have occurred secondary to the cardiopulmonary arrest that she suffered immediately after her accident. The symptoms disappeared after low dose levodopa was instituted and have not recurred during the 15 months of treatment. Injury and death from electric current, although rare, are not uncommon and occur mostly as a result of accidental contact with a live wire. This is the first case report documenting the use of levodopa for extrapyramidal movements secondary to high-tension electrocution.

Poisoning, hanging, and burning are the usual methods adopted by people to commit suicide. Suicide by electrocution and that too high voltage is one of the rarest methods adopted for the purpose. We report the case of a young man who committed suicide by climbing up a 25-ft-high electric pole. The deceased was a regular alcoholic and was under severe depression for a long time because of his personal problems. He survived for more than 2 days after the incident. His serum urea and creatinine levels were elevated, so were the creatine kinase total and creatine kinase-MB level. The method adopted and the findings make this case a rare scientific report. Moreover, to the best of our knowledge, this is the first reported case in an English scientific literature of a high-voltage suicidal electrocution with multiple exit wounds. The circumstances surrounding the manner of electrocution and the features of electric injuries are presented and discussed.

Electrical injuries in swimming pools are an important pediatric public health concern. We sought to (1) improve our understanding of the clinical presentation and outcomes following and (2) describe the epidemiology of swimming pool electrical injuries in the United States. We reviewed 4 cases of pediatric (

Death due to accidental electrocution occurs frequently. The aim of this study was to investigate alterations in cardiac connexin 43 (Cx43), angiotensin II (Ang II), endothelin 1 (ET-1), and type III collagen associated with fatal electrocution.Twenty-four Sprague-Dawley rats were divided into control, fatal electrocution (220 V, 50 Hz, 60 seconds), and electrical injury (220 V, 50 Hz, 60 seconds) groups. Animals were deeply anesthetized with sodium pentobarbital before each treatment, with the anode connected to the left foreleg and the cathode to the right hindleg, followed by cervical dislocation. Control animals received cervical dislocation alone. Immunohistochemical analysis was performed to evaluate the cardiac protein expression of Cx43, Ang II, ET-1, and type III collagen. Sections were analyzed by digital image analysis.The expression of Cx43 was significantly reduced after fatal electrocution, with the integrated optical density also lower when compared with control (P < 0.05). Expression of both Ang II and ET-1 was significantly increased after fatal electrocution, supported by integrated optical density when compared with control (P < 0.05). But no significant difference was found in type III collagen expression between the fatal electrocution group and the control group.In summary, cardiac protein expression of Cx43, Ang II, and ET-1 was found to be significantly altered with fatal electrocution, suggesting that these 3 proteins may be important underlying mechanisms of death during fatal electrocution. The current findings indicate that such alterations would be reflected in abnormal cardiac function and a possible cause of sudden death.

OBJECTIVE: Conducted electrical weapons (CEWs) such as the TASER are often used by law enforcement (LE) personnel during suspect apprehension. Previous studies have reported an excellent safety profile and few adverse outcomes with CEW use in adults. We analyzed the safety and injury profile of CEWs when used during LE apprehension of children and adolescents, a potentially vulnerable population. METHODS: Consecutive CEW uses by LE officers against criminal suspects were tracked at 10 LE agencies and entered into a database as part of an ongoing multicenter injury surveillance program. All CEW uses against minors younger than 18 years were retrieved for analysis. Primary outcomes included the incidence and type of mild, moderate, and severe CEW-related injury, as assessed by physician reviewers in each case. Ultimate outcomes, suspect demographics, and circumstances surrounding LE involvement are reported secondarily. RESULTS: Of 2026 consecutive CEW uses, 100 (4.9%) were uses against minor suspects. Suspects ranged from 13 to 17 years, with a mean age of 16.1 (SD, 0.99) years (median, 16 years). There were no significant (moderate or severe) injuries reported (0%; 97.5% confidence interval, 0.0%-3.6%). Twenty suspects (20%; 95% confidence interval, 12.7%-29.1%) were noted to sustain 34 mild injuries. The majority of these injuries (67.6%) were expected superficial punctures from CEW probes. Other mild injuries included superficial abrasions and contusions in 7 cases (7%). CONCLUSIONS: None of the minor suspects studied sustained significant injury, and only 20% reported minor injuries, mostly from the expected probe puncture sites. These data suggest that adolescents are not at a substantially higher risk than adults for serious injuries after CEW use. Language: en

Voltage has historically guided the acute management and long-term prognosis of physical morbidity in electrical injury patients; however, few large studies exist that include neuropsychiatric morbidity in final outcome analysis. This review compares high (1000 V) to low (1000 V) voltage injuries, focusing on return to work and neuropsychiatric sequelae following electrical burn injury. Patients with electrical injuries admitted to the University of North Carolina Jaycee Burn Center between 2000 and 2005 were prospectively entered into a trauma database, then retrospectively reviewed. Patients were divided into 4 cohorts: high voltage (1000 V), low voltage (1000 V), flash arc, and lightning. Demographics, hospital course, and follow-up were recorded to determine physical and neuropsychiatric morbidity. Differences among cohorts were tested for statistical significance. Over 5 years, 2548 patients were admitted to the burn center, including 115 patients with electrical injuries. There were 110 males and 5 females, with a mean age of 35 years (range, 0.75-65 years). The cause of the electrical injury was high voltage in 60 cases, low voltage in 25 cases, flash arc in 29 cases and lightning in 1 case. The mean total body surface area burn was 8% (range, 0%-52%). The etiology was work-related electrical injury in 85 patients. Mean follow-up period was 352 days with 13 (11%) patients lost to follow-up. Patients with high voltage injuries had significantly larger total body surface area burn, longer ICU stays, longer hospitalizations, and significantly higher rates of fasciotomy, amputation, nerve decompression and outpatient reconstruction, with 4 cases of renal failure and 2 deaths. In spite of these differences, high and low voltage groups experienced similar rates of neuropsychiatric sequelae, limited return to work and delays in return to work. Final impairment ratings for the high and low voltage groups were 17.5% and 5.3%, respectively. Electrical injuries often incur severe morbidity despite relatively small burn size and/or low voltage. When comparing high and low voltage injuries, similarities in endpoints such as neuropsychiatric sequelae, the need for late reconstruction, and failure to return to work challenge previous notions that voltage predicts outcome.

INTRODUCTION:: Controversy persists over the safety of conducted electrical weapons (CEWs), which are increasingly used by law enforcement agencies around the world. The purpose of this study was to examine injury patterns and physiologic conditions after CEW use under real life conditions. METHODS:: A retrospective, cohort design was used, examining all CEW uses by one police department during a 6-year period. Data were collected from use-of-force forms and medical records and included conditions surrounding the use of force, medical histories, and data from emergency department evaluations and hospital admissions. RESULTS:: Of 1,101 individuals subjected to (Taser M26 and X26) CEW use during the study period, 92.6% were male, the average body mass index was 26.2, and the age range was 9 to 73 years. Of the 886 (80.5%) with medical records, 46.8% had a psychiatric history and 72.9% had a substance abuse history. Emergency department (ED) evaluations occurred for 295 (26.8%) incidents. Of chief complaints, 41.7% were trauma related, 26.8% were for altered mental status, and 21.7% were for psychiatric evaluation. On presentation, 17.6% had a pulse >120, 1.7% were febrile, and 30.9% were altered; 1.4% met criteria associated with "excited delirium." When laboratory workup occurred, 70.6% had positive urine toxicology and 44.8% had positive alcohol levels. Troponin I was positive for one patient. Other laboratory abnormalities were rare, although extensive evaluations were infrequently done. Admission occurred in 24.4% of ED presentations (6.5% of all subjects); of discharge diagnoses for these patients, 59.7% were psychiatric, 22.2% were for unrelated trauma, 11.1% were for restraint-related trauma, and 6.9% were for unrelated medical diagnoses. No patients died. CONCLUSIONS:: Significant injuries related to 6 years of law enforcement CEW use in one city were rare. A large percentage of those subjected to CEW use had diagnoses of substance abuse and/or psychiatric conditions. Most admissions after CEW use were unrelated to law enforcement restraint. Language: en

BACKGROUND: High-pressure blast injuries to the hand due to vole captive bolt devices are serious injuries that are to a great extent unknown to emergency care operators and trauma surgeons. There is no study on the functional outcome of these patients. METHODS: We assessed the functional outcome of patients with injuries inflicted by vole captive bolt devices. Therefore, a protocol consisting of a physical examination and an assessment of static muscle power (grip and pinch strength) was performed. To capture the subjective experience of patients regarding their injury related disability and impairment, the DASH follow-up questionnaire was used. Based on clinical/radiologic findings and outcome, a classification of this unique subgroup of blast injuries was developed. RESULTS: The functional outcome of 34 patients suffering hand injuries due to captive bolt devices between 2004 and 2007 was assessed. A significant reduction of static muscle testing parameters compared with the uninjured hand was revealed. Fourteen patients lost a digit. Average time lost from work was 5.4 weeks. CONCLUSION: Vole captive bolt device-related hand injuries are followed by deterioration of hand function. The present observations alarmed national authorities. The manufacturers were required to take engineering and teaching measures to rule out handling errors that were identified as leading cause of injury. Language: en

Heart injury due to electric shock is currently diagnosed based on electrocardiogram (ECG) changes or elevated levels of myocardial enzymes or both. However, the rate at which ECG detects abnormalities is very low; thus, the estimated rate of the diagnosis of myocardial damage due to electric shock is lower than the actual rate. The method of nuclear medicine study of the heart is superior with regard to evaluating transient ischemia, such as angina pectoris, in patients whose ECG and myocardial enzyme levels are normal. Therefore, we attempted to diagnose transient myocardial damage in electric shock patients by using nuclear medicine study of the heart.

Background: Data from our previous studies indicate that Taser X26 stun devices can acutely alter cardiac function in swine. We hypothesized that most transcardiac discharge vectors would capture ventricular rhythm, but that other vectors, not traversing the heart, would fail to capture the ventricular rhythm. Methods: Using an Institutional Animal Care and Use Committee (IACUC) approved protocol, four Yorkshire pigs (25–36 kg) were anesthetized, paralyzed with succinylcholine (2 mg/kg), and then exposed to 10 second discharges from a police-issue Taser X26. For most discharges, the barbed darts were pushed manually into the skin to their full depth (12 mm) and were arranged in either transcardiac (such that a straight line connecting the darts would cross the region of the heart) or non-transcardiac vectors. A total of 11 different vectors and 22 discharge conditions were studied. For each vector, by simply rotating the cartridge 180-degrees in the gun, the primary current-emitting dart was changed and the direction of current flow during the discharge was reversed without physically moving the darts. Echocardiography and electrocardiograms (ECGs) were performed before, during, and after all discharges. p values < 0.05 were considered significant. Results: ECGs were unreadable during the discharges because of electrical interference, but echocardiography images clearly demonstrated that ventricular rhythm was captured immediately in 52.5% (31 of 59) of the discharges on the ventral surface of the animal. In each of these cases, capture of the ventricular rhythm with rapid ventricular contractions consistent with ventricular tachycardia (VT) or flutter was seen throughout the discharge. A total of 27 discharges were administered with transcardiac vectors and ventricular capture occurred in 23 of these discharges (85.2% capture rate). A total of 32 non-transcardiac discharges were administered ventrally and capture was seen in only eight of these (25% capture rate). Ventricular fibrillation (VF) was seen with two vectors, both of which were transcardiac. In the remaining animals, VT occurred postdischarge until sinus rhythm was regained spontaneously. Conclusions: For most transcardiac vectors, Taser X26 caused immediate ventricular rhythm capture. This usually reverted spontaneously to sinus rhythm but potentially fatal VF was seen with two vectors. For some non-transcardiac vectors, capture was also seen but with a significantly (p < 0.0001) decreased incidence.

Deep brain stimulators (DBS) may be affected by electromagnetic interference (EMI). Little research has been conducted regarding this phenomenon, although supportive background information and a literature review offer implications of EMI for persons who have this device. The warning information on Medtronic's Web site that is specific to the DBS device indicates that theft detectors and security screening devices may cause the stimulation to turn on or off and may cause some patients to experience a momentary increase in perceived stimulation. This information supports the rationale for practitioners to recommend that patients with DBS turn off their device when anticipating exposure to EMI. EMI with DBS does not appear to present an immediate safety issue even though it may cause device malfunction and a resulting temporary interruption in therapeutic benefit for persons who have the device. However, the absence of sound research on the effects of EMI on DBS does not permit the exclusion of EMI as a potential health concern. Meanwhile, healthcare professionals who care for patients with DBS should routinely educate them about potential interactions and appropriate accommodations.

We report a case with bilateral intumescent electric cataracts, outcomes of cataract surgery with a new technique, and a histopathologic study of the anterior capsule followed by a review of the literature on electric cataracts. The patient had bilateral cataract extraction and posterior chamber intraocular lens implantation, achieving a visual acuity of 20/20. Hematoxylin and eosin staining of the anterior capsule revealed significant scar tissue formation consisting of fibroblast proliferation and hyaloid production over the basement membrane of the anterior capsule. Electric injuries can cause bilateral intumescent cataracts; the outcomes after cataract surgery are excellent provided the fundus and optic nerve examinations are normal. Scar formation over the anterior capsule may disturb lens nutrition, leading to cataract formation.

Esselman PC, Thombs BD, Magyar-Russell G, Fauerbach JA: Burn rehabilitation: State of the science. Am J Phys Med Rehabil 2006;85:383–413.

Two cases of suicidal electrocution are presented: one using a household lamp, the other using a homemade electrocution machine. The mechanisms of death and the histologic changes in electrocution are discussed.

The passage of electric current through the human body causes variable harm, ranging from loss of consciousness to death caused by paralysis of the bulbar nerve centers. This report describes a fatal case caused by an illegal fishing practice involving stunning fish with electric shocks produced by an electric generator carried through the water inside the carcass of an old refrigerator to keep it afloat. This occurrence is unusual because of the circumstances giving rise to the use of electric current and the cause of death, which resulted from the combination of the electric current produced by the generator and the saltwater, bringing about death by drowning.

A case of atypical autoerotic death is described. An 18-year-old white man clad in two brassieres was found dead in his bedroom by his brother. Two wet green terry cloths were under the brassiere cups, connected to the house current via two metal washers and a bifid electrical cord. Literature depicting nude women was found near the victim. Autopsy revealed second-degree and third-degree burns of the mammary regions. Death was attributed to accidental self-electrocution. The authors will discuss typical and atypical forms of autoerotic death.

Electrical injury is a relatively infrequent but potentially devastating form of multisystem injury with high morbidity and mortality. Most electrical injuries in adults occur in the work-place, whereas children are exposed primarily at home. In nature, electrical injury occurs due to lightning, which also carries the highest mortality. The severity of the injury depends on the intensity of the electrical current (determined by the voltage of the source and the resistance of the victim), the pathway it follows through the victim's body, and the duration of the contact with the source of the current. Immediate death may occur either from current-induced ventricular fibrillation or asystole or from respiratory arrest secondary to paralysis of the central respiratory control system or due to paralysis of the respiratory muscles. Presence of severe burns (common in high-voltage electrical injury), myocardial necrosis, the level of central nervous system injury, and the secondary multiple system organ failure determine the subsequent morbidity and long-term prognosis. There is no specific therapy for electrical injury, and the management is symptomatic. Although advances in the intensive care unit, and especially in burn care, have improved the outcome, prevention remains the best way to minimize the prevalence and severity of electrical injury.

Although peripheral-nerve injury has been described as clearly related to electrical injury, that electrical injury is usually associated with third- and often fourth-degree burns. The report presented here describes three cases of low-voltage electrical injury with associated peripheral-nerve symptoms but without clinically significant cutaneous burns. The symptoms and clinical findings resembled peripheral-nerve compression. The presence of these symptoms and findings in the upper- and lower-extremities and the presence of bilateral involvement suggest a systemic electrical injury that resembles a peripheral neuropathy. Symptoms were relieved by the decompression of nerves at multiple sites in each extremity. Perineurial fibrosis was identified at the time of nerve decompression. It is proposed that the electrical injury causes maximal heat production at areas of minimal limb cross-sectional area. In these areas, the peripheral nerve is in close proximity to bone and fibrous tissue. This results in perineurial fibrosis and symptoms of a compressive peripheral neuropathy.

Fatalities caused by electrocution often lack specific morphologic evidence. Investigation of the death scene along with technical inspection of the electrical apparatus may help in clarifying the cause and manner of death. Cutaneous current marks may be the only sign of low voltage associated fatalities. The authors report a case of an electrician who committed suicide by electrocution using a time switch after oral ingestion of diazepam. Electrodes (coins) were fixed with adhesive tape at the height of the heart to the front and back of the left side of the chest. Autopsy revealed a blackish linear mark on the pleura parietalis of the inner side of the thoracic cavity, connecting the cutaneous current marks. Current-related and heat-related changes, such as hypercontraction bands of the intercostal muscles and coagulative changes of the perineurium of peripheral nerves, were found at histologic examination. Taking into consideration that the body had been under the influence of low-voltage current for 7 days, the morphologic alteration on the pleura parietalis was in accordance with an internal current mark, indicating the main route of current flow through the body. To the authors' knowledge, such a current-related phenomenon has not been reported to occur on an inner body surface before.

The National Fire Protection Association regulates electrical codes in health care facilities. Because the discontinuation of flammable anesthetic use, isolated power systems (IPSs) have not been required in dry locations. The National Fire Protection Association delegates responsibility of designating dry and wet locations to health care facilities. Our hospital has designated our operating rooms as dry locations, and they have neither IPSs nor ground fault circuit interrupters. We describe a macroshock electrical injury to a nurse when she plugged in equipment to an extension cord. Designating the operating room as a wet location and installing an IPS would have prevented her injury. Language: en

There is little published information concerning the epidemiology of injuries in the construction industry involving cranes other than for electrical injury from power line contact. For the 11-year period of 1984 through 1994, the US Occupational Safety and Health Administration (OSHA) investigated 502 deaths in 479 incidents involving cranes in the construction industry. Electrocution was the largest category, with 198 deaths (39%) reported. Other major categories were assembly/dismantling (58 deaths, 12%), boom buckling (41 deaths, 8%), crane upset/overturn (37 deaths, 7%), and rigging failure (36 deaths, 7%). The majority of the deaths during assembly/dismantling involved removal of the boom pins from lattice boom cranes. Only 34% of the construction firms employing the fatally injured workers had ever been inspected by OSHA. OSHA cited the employer for safety violations in 436 deaths (83%). Additional worker training, increased OSHA inspections, and crane inspection programs could prevent many crane-related deaths.

Data from the Census of Fatal Occupational Injuries surveillance system from 1992 through 1996 were analyzed to allow a better understanding of exposures to harmful substances or environments that resulted in agricultural work fatalities. There were 357 fatalities as a result of these exposures in the agriculture production and agriculture services sectors, representing 10% of all work-related deaths that occurred in these industry sectors during this period. Contact with electric current represented 52.9% of these fatalities. Agricultural services reported 87 electrocutions, 50 of which occurred among tree trimmers. The events most likely to result in fatalities were contact with overhead power lines (26.3%) and drowning (17.1%). The overall fatality rate was 2.1 deaths per 100,000 workers. The development of appropriate hazard-awareness training for workers, such as that for electrical and drowning-related hazards, may help prevent future deaths in these industry sectors.

Individuals exposed to an electrical injury develop a variety of complications, several of which are recognized years after the initial electrical shock. Alteration in gastrointestinal and nervous system function has been described in these patients, yet the frequency and character of these abnormalities are poorly understood. We reviewed records of 40 individuals with a history of electrical injury to identify evidence of delayed onset of complications.Forty consecutive patients with electrical shock injuries were monitored for up to 5 yr after their traumatic event using a comprehensive systems review. Of the eight patients who described an alteration in their gastrointestinal and neurological functions, four agreed to undergo further testing. Investigations included a flexible sigmoidoscopy, anorectal manometry, stool evaluation, serological and biochemical serum analysis, and a psychological examination.Each of the four patients described an increase in stool frequency and urgency. Anorectal manometry detected a reduction in threshold to rectal balloon distention and an abnormal anal sphincter control. Bowel function improved with meselamine. Psychiatric symptoms involving memory and concentration were observed in varying degrees.To our knowledge, these induced physiological and psychological changes after exposure to electrical shock injury have not yet previously been described. Our findings should encourage further clinical investigations to better anticipate, diagnose, and manage these and other as yet unrecognized delayed complications of electrical shock injury.

Electrocution is one of the rarest modes of suicide. In this case, one school going adolescent committed suicide by electrocution using bare electric wire. This is a rare case of suicidal death by applying live wires around the wrists, simulating the act of judicial electrocution. He positioned himself on armed chair and placed the nude wire loops from a cable around both wrists and switched on the current by plugging in to nearest socket by foot. There were linear electric contact wounds completely encircling around the both wrists. In addition to these linear electric burns all around wrists, there were electrical burns over both hands. This death highlights the need of supervision and close watch on children for self-destructing activities and behavior. This case also highlights unusual method adopted by adolescent to end his life.

Electrical injury may cause central nervous system (CNS) complications and peripheral nerve disorders. Delayed neurologic complications are rarely reported. A case of delayed reversible motor neuronopathy caused by low-voltage electrical injury is reported due to its rarity. A 22-year-old female received an electric shock of 110 volts while pushing up a metal gate during a rainy morning on April 16, 2005. She initially suffered loss of consciousness for several hours, and then became quadriplegic, from which she completely recovered 10 days later. After return to work for 1 month, she developed weakness and numbness of bilateral upper limbs. Nerve conduction velocity study and bilateral median nerve somatosensory evoked potential were normal. Magnetic resonance imaging of the brain and cervical spine were also normal. Electromyography showed mild denervation, reduced interference and polyphasia over the upper arms, suggestive of anterior horn cell lesion. After rest and rehabilitation for 2 weeks, the patient completely recovered her muscle power over proximal upper limbs and partially over the distal upper limbs. Follow-up at the outpatient clinic 4 months later showed total recovery of muscle power. Low-voltage electrical current can cause acute transient quadriplegia and delayed motor neuronopathy. The mechanism of this patient's recovery from electric shock, followed by deterioration 1 month later, and then recovery after rest is unclear. We considered whether the mechanism of weakness after electric injury, with initial recovery followed later by the development of weakness, might be due to overuse, just like in post-poliomyelitis syndrome. This needs further investigation.

Objective: This study explored the relationship of neuropsychological complaints to accident- and injury-related characteristics, affective state, and work status in a group of electrical injury (EI) patients. Methods: Sixty-three EI patients and 22 electricians with no history of electrical shock completed the Neuropsychological Symptom Checklist and the Beck Depression Inventory as part of an extensive neuropsychological evaluation. Results: The EI group endorsed significantly more physical, cognitive, and emotional symptoms than did the controls. Symptom complaints were not related to injury parameters or litigation status. Only the time interval between injury and assessment accounted for differences in symptom presentation, with patients in the postacute stages of recovery showing the most cognitive and emotional complaints. Conclusion: The neuropsychological syndrome of electrical injury survival includes physical, cognitive, and emotional complaints. Considering that most electrically injured patients are treated within the acute medical setting, greater attention needs to be directed early in the course of treatment toward addressing neuropsychologic and psychiatric issues.

A perforator flap completely spares the underlying muscle, so the muscle tissue can now be used as a second flap for the reconstruction of another defect after the harvest of the overlying perforator flap as long as sufficient nutritive branches to the muscle remain. The authors describe here the creation of 2 independent free flaps from a single donor site, the latissimus dorsi musculocutaneous unit. The 2 flaps, thoracodorsal artery perforator and its corresponding muscle flap, were created and transferred to 2 distinct defects. Using this technique, we could avoid creation of double donor sites and so minimize the donor morbidity to that associated with the traditional single musculocutaneous flap. This technique was employed by us for treating 2 patients who presented with 2 separate defects.

Rupture of a flexor tendon in the nonrheumatoid population is rare. Localizing the level of the tendon rupture can be a difficult task. We describe an individual who presented with the sudden inability to flex the index finger of the hand, which had been subjected to a severe electrical injury. Physical exam demonstrated lack of index finger flexion at the distal joint. The patient denied any pain or history of recent trauma. Preoperative magnetic resonance imaging (MRI) successfully located the proximal and distal ends of the ruptured flexor digitorum profundus tendon in the forearm. MRI allows for accurate preoperative assessment of tendon position and degree of retraction, thereby facilitating surgical planning and approach. Accurate localization of tendon pathology preoperatively minimizes unnecessary dissection, shortens the operative procedure, and clarifies operative planning.

Background Converting enzyme inhibitor (CEI) therapy, but not angiotensin II subtype I receptor blockade, has been shown to attenuate left ventricular remodeling in the dog after transmyocardial direct current (DC) shock. The purpose of this study was to address the importance of preservation of bradykinin to the antiremodeling effect of CEI treatment in this model. Methods and Results Twenty-four hours after DC shock, adult mongrel dogs were assigned to one of three groups: a control group; a group treated with ramipril 10 mg BID; and a group treated with ramipril 10 mg BID along with a continuous subcutaneous infusion of HOE 140, a bradykinin antagonist. To assess change in left and right ventricular structure, a magnetic resonance imaging (MRI) study was performed 4 weeks after DC shock and compared with a baseline MRI study performed before DC shock. The increase in left ventricular mass (mean±SEM) in the control group was similar to that observed in the CEI–HOE 140 group (+0.73±0.19 versus +0.75±0.18 g/kg, P =NS), but both were greater than the change in mass in the ramipril group (−0.48±0.13 g/kg, P =.004 and P =.0005, respectively). No significant change occurred in left ventricular volume or right ventricular structure in any group. Mean arterial pressure was reduced by ramipril compared with the control group (−8±2 versus +7±2 mm Hg, P =.03), and this effect was not blunted by the addition of HOE 140 (−7±3 mm Hg). Conclusions Prevention by ramipril of the early increase in left ventricular mass in the DC shock model appears to be related to the preservation of bradykinin.

The case of a patient with thoracic intervertebral disc prolapse, cord compression, and delayed paraplegia with recovery secondary to high-tension electrical current is presented. The unusual entry wound in the neck, makes this a rare event that to our knowledge has not been previously described in the literature. Magnetic resonance imaging allowed noninvasive and early diagnosis, and in the future probably will reveal the true incidence of cord compression in electrical injury victims.

BACKGROUND Patients with acute coronary artery thrombosis often develop primary malignant ventricular arrhythmias (MVA) early after coronary occlusion. In contrast, acute ischemia induced by nonthrombotic balloon occlusion during routine coronary angioplasty rarely elicits such arrhythmias. This study was designed to assess the role of intracoronary thrombosis in arrhythmogenesis during acute ischemia. METHODS AND RESULTS We compared the incidence of MVA associated with acute left anterior descending coronary artery (LAD) thrombosis elicited in open-chest anesthetized dogs by electrical injury (n = 10) or intracoronary stent (n = 9) versus LAD balloon occlusion (n = 15). Compared with animals subjected to balloon occlusion, those with thrombotic occlusion had a significantly greater incidence of MVA, defined as nonsustained ventricular tachycardia (total duration > 10 seconds), sustained ventricular tachycardia, or ventricular fibrillation developing within the first 30 minutes of occlusion. In the combined thrombosis groups, MVA developed in 11 of 19 animals (58%) (6 of 10 dogs with electrical injury and 5 of 9 stent animals). In contrast, MVA occurred in only 1 of 15 animals (7%) subjected to balloon occlusion. This striking and significant difference in arrhythmias occurred despite the fact that radioactive microsphere perfusion analysis documented that the extent of left ventricular myocardium rendered ischemic was equal in all groups (percent of left ventricular myocardium with occlusion flow < or = 50% of baseline: electrical injury, 25.2 +/- 5.3%; stent, 27.1 +/- 3.6%; balloon, 34.3 +/- 11.6%; P = NS). Furthermore, there were no differences between the animals with thrombosis or balloon occlusion with respect to changes in echocardiographic parameters of left ventricular function, aortic pressure, or heart rate after occlusion. CONCLUSIONS These data provide evidence that despite equal magnitudes of jeopardized myocardial mass, acute ischemia induced by thrombotic coronary occlusion results in a greater incidence of MVA than does nonthrombotic balloon occlusion. These findings suggest that the process of intracoronary thrombosis itself exerts arrhythmogenic effects above and beyond the impact of ischemia on myocardium induced by coronary occlusion.

The diagnosis of low-voltage electrocution is aided by the presence of electrical burns. When the victim is immersed in water, however, the cooling effect of the water prevents heating of the tissues and eliminates the usual entry and exit points. Cases are described here in which electrical shock and water immersion combined to bring about fatal results. Although electrical shock was instrumental in bringing about these deaths, the actual cause of death in two of the cases was not electrocution, but drowning. The cases demonstrate the need for thorough site investigation, which will assist the pathologist at autopsy and also serve the community by preventing similar deaths at the same death scene.

Bone marrow embolism in electrocution was first described in the literature by Rappaport et al (Am J Pathol. 1951;27(3):407-433) in 1951. Two case studies demonstrating this phenomenon are reported here, one involving high-voltage exposure with associated skeletal injuries and the other involving domestic current and without evidence of skeletal injury. Both cases demonstrated bone marrow embolism on histologic examination of the lungs. The purposes of this article are to reiterate the existence of this unusual phenomenon and to consider possible pathogenetic mechanisms.

Whilst posterior shoulder dislocation is rare, it remains a frequently missed diagnosis. In all patients with a history of seizure, electrocution or similar trauma, where external rotation of the shoulder is limited, we recommend that an axillary or modified axillary view be added to the standard two radiographic shoulder views as routine protocol, to avoid missing a posterior dislocation.

We investigated the ocular damage resulting from operation of a solid blade pole-mounted in-line electrical switch at between 16 and 17 kV with current loads between 38 A and 340 A. Spectroradiometric data for the electric arcs produced as the switch was opened were obtained over the waveband 200 to 1500 nm. The eyes of adult pigmented rabbits were exposed to the arc flash at a distance of 2 m. The ocular tissues were assessed clinically and histologically up to 48 h postexposure. Threshold damage was clinically detectable only in eyes exposed to a 340 A arc. We conclude that at the normal current loads on a 17-kV electric power transmission line, the principal oculovisual hazards are due to molten metal fulminated from the switch by the arc, and after-images due to the bright visible light flash. At a working distance of 2 m, the ultraviolet ocular hazard is negligible. Adequate eye protection is provided by clear polycarbonate safety lenses.

BACKGROUND This study was designed to determine whether arterial reocclusion after thrombolysis can be prevented by lipoprotein-associated coagulation inhibitor (LACI), a physiological inhibitor of tissue factor-induced coagulation mediated by the extrinsic pathway. METHODS AND RESULTS Thrombosis was induced in femoral arteries of anesthetized dogs with the use of anodal current to elicit extensive vascular injury and formation of platelet-rich thrombi in one artery and with thrombogenic copper wire to elicit fibrin-rich thrombi without appreciable vascular injury in the contralateral artery. Recanalization of both vessels was induced with t-PA (1.7 mg/kg i.v. over 1 hour) and verified with Doppler flow probes. Reocclusion occurred within 2 hours in seven of seven arteries with electrical injury-induced thrombosis and in four of seven arteries with copper wire-induced thrombosis in the absence of LACI. In dogs given infusions of recombinant DNA-produced LACI (225 micrograms/kg over 15 minutes, followed by 4 micrograms/kg/min i.v.) after completion of the infusion of t-PA, no reocclusion occurred during the 2-hour interval of observation in any of the five arteries subjected to electrical injury (p less than 0.001), and cyclic partial occlusions were nearly abolished (0.4 +/- 0.4/hr in LACI-treated dogs compared with 13.7 +/- 5.5/hr in saline-treated dogs, p less than 0.0001). In contrast, reocclusion occurred in two of five arteries with indwelling copper wires, and cyclic partial occlusions were unaffected despite LACI. LACI prolonged the partial thromboplastin time modestly (1.7 +/- 0.2 x baseline) but did not affect platelet counts or aggregation assessed ex vivo. CONCLUSIONS Inhibition of the extrinsic pathway of coagulation with LACI prevents thrombotic arterial reocclusion after thrombolysis in vessels subjected to extensive vascular injury. Our results demonstrate that activation of the extrinsic pathway plays a critical role in thrombotic reocclusion and that LACI provides a highly targeted approach to facilitate sustained recanalization without directly inhibiting platelets.

Bilateral legs damaged by high-voltage electrical injury were treated by amputation and a free thin rectus abdominis myocutaneous flap with reduced muscle. Damaged arteries at 2 months after injury showed disappearance of endothelium, and a decreased number and morphological changes in smooth-muscle cells. Injured nerves and muscles showed early regenerating processes after total degeneration, and no progressive muscular necrosis. These results suggest that severe degeneration of the neurovascular bundle and muscle is unavoidable in high-voltage electrical injuries of the extremities. Therefore, early amputation, sequential debridement, late coverage by a flap, and prolonged rehabilitation are required in this injury.

High-voltage electrical trauma frequently results in extensive and scattered destruction of skeletal muscle along the current path. The damage is commonly believed to be mediated by heating. Recent experimental and theoretical evidence suggests, however, that the rhabdomyolysis and secondary myoglobin release that occur also can result from electroporation, a purely nonthermal mechanism. Based on the results of a computer simulation of a typical high-voltage electric shock, we have postulated that electroporation contributes substantially to skeletal muscle damage and could be the primary mechanism of damage in some cases of electrical injury. In this study, we determined the threshold field strength and exposure duration required to produce rhabdomyolysis by the electroporation mechanism. The change in the electrical impedance of intact skeletal muscle tissue following the application of short-duration, high-intensity electric field pulses is used as an indicator of membrane damage. Our experiments show that a decrease in impedance magnitude occurs following electric field pulses that exceed threshold values of 60 V/cm magnitude and 1-ms duration. The field strength, pulse duration, and number of pulses are factors that determine the extent of damage. The effect does not depend on excitation-contraction coupling. Electron micrographs confirm structural defects created in the membranes by the applied electric field pulses, and these represent the first clear demonstration of rhabdomyolysis in intact muscle due to electroporation. These results provide compelling evidence in support of our postulate.

Multiple defibrillations by the automatic implantable cardioverter/defibrillator (AICD) have been reported to result in localized epicardial damage. No data exist, however, regarding whether this damage can be detected in the clinical setting or whether it interferes with the detection of true myocardial infarction. Forty-nine patients who received defibrillations by patch electrodes were studied prospectively. We attempted to document the presence of myocardial injury with the following three commonly used modalities for the detection of myocardial infarction: serial electrocardiographic changes, serial creatine phosphokinase (CPK) and CPK-MB release, and technetium 99m pyrophosphate scanning. Fifteen patients received defibrillations by AICD patches at the time of AICD generator replacement. Nine patients received defibrillations at the time of new AICD lead placement. The average total energy delivered was 85 +/- 29 J. None of these patients had detectable myocardial injury. Ten patients had defibrillations by the AICD patches at the time of bypass operation. One patient in this group developed acute myocardial infarction in the inferior wall after posterior descending coronary bypass operation, as detected by electrocardiogram, 99mTc pyrophosphate scanning, and CPK-MB analysis. Fifteen patients were evaluated for spontaneous AICD discharges. Thirteen had a maximum of five consecutive shocks, and cumulative energy delivered was not greater than 330 J. None of these patients had detectable injury. Two patients had CPK-MB release of 15.3% and 7.5%, respectively. One of these patients had a positive 99mTc pyrophosphate scan. These two patients received 12 and 17 rapid and consecutive AICD discharges, respectively, with cumulative delivered energy of 360 and 510 J, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Injury and death from electric current although rare, are not uncommon. In majority of the fatalities, death usually results from accidental contact with a live wire, both in industrial and domestic circumstances. The entry wound is usually in the hand or foot, with the exit wound being in the opposite hand or foot touching the earth (or the ground). Rarely, due to a unique position of the body and circumstances, they may be seen on head, face, neck, mouth, lips, body trunk, etc. However, here we present a unique site of electrocution, the eye, which has probably never been reported before. This case was also accidental in nature. Language: en