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THE CURSE OF ZEUS. Rami Khouzam, MD. The Statue of Zeus at Olympia. An enormous statue of the Greek father of gods, carved by the great sculptor Pheidias

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Rami Khouzam, MD

the statue of zeus at olympia
The Statue of Zeus at Olympia
  • An enormous statue of the Greek father of gods, carved by the great sculptor Pheidias
  • In his right hand a figure of Victory made from ivory and gold. In his left hand, his scepter inlaid with all metals, and an eagle perched on the sceptre
  • The sandals of the god are made of gold, as is his robe

Pausanias the Greek (2nd century AD)

7 wonders of the ancient world
7 Wonders of the Ancient World
  • Today, archaeological evidence reveals some of the mysteries that surrounded the history of the Wonders for centuries
  • For their builders, the Seven Wonders were a celebration of religion, mythology, art, power, and science
  • For us, they reflect the ability of humans to change the surrounding landscape by building massive yet beautiful structures, one of which ( the Pyramid) stood the test of time to this very day
index case
Index Case
  • 42-year-old white male
  • No significant past medical hx. except x possible marijuana
  • Was working on a ladder 12 feet high
  • Electrocuted with 440 volts
  • Contact burns to bilateral hands
  • Cardioversion done 5 times
Prior to arrival to the hospital:
  • SVT --> Cardioversion x 5
  • Hypotension --> Dopamine and Epinephrine drips
  • Intubated
  • Vitals on arrival:
    • Pulse: 101
    • BP: 71/46
    • RR: 24
PE (pertinent findings):
  • Neck in C-collar
  • Ears: some blood behind Lt. tympanic membrane
  • Chest: Bilateral crackles
  • Heart: S1S2 RRR Few extra-beats, No m,g,r
  • Upper extremities: 2nd & 3rd degree burns on the palmar aspects of both hands
  • K: 3.1, Cr: 1.1
  • WBCs: 27.8  10.5
  • AST/ALT: 63/54
  • ABGs: 7.25/43.8/213.7/18.6/99.1%
  • Lactic a: 4.2
  • UDS: + methamphetamine
Trop 1.38 2.87 1.81
  • CK 989 2190
  • CKMB 19.4 17.2
  • CKMB index 2.0 0.8
  • Myoglobin > 500 > 500
  • PCWP: 19
  • PA: 31/14
  • CVP: 15
  • CO: 16 / CI: 11
  • SVR: 335
  • MAP: 80
  • CXR:
  • Interstitial & alveolar pulmonary opacities centrally with relative sparing peripherally:
  • consistent with pulmonary edema
TTE on admission
  • Mild eccentric LVH
  • LV systolic function was moderately to severely decreased
  • EF: 25-30%
Day 3:
  • Levophed discontinued
  • Weaned off of the vent & extubated
  • Blood culture: MRSA
  • Day 8:
  • Discharged home on: pain meds & antibiotics
TTE (prior to d/c)
  • Normal left ventricular systolic function
  • EF: 65%
the hanging gardens of babylon
The Hanging Gardens of Babylon
  • A palace with legendary gardens built on the banks of the Euphrates river by King Nebuchadnezzar II
electrical injuries


Critical Care Medicine

Volume 30.Number 11.November 2002

Adults in workplace, children at home
  • Severity of injury depends on:
    • Intensity of electrical current (voltage of source and resistance of victim)
    • Pathway through victim’s body
    • Duration of the contact with the source
Immediate death may occur from:
  • 1) Current-induced ventricular fibrillation
  • 2) Asystole
  • 3) Respiratory arrest secondary to:
    • Paralysis of the central respiratory control system
    • Paralysis of the respiratory muscles
history overview
History Overview
  • Lightning was attributed to supernatural powers
  • Zeus ruler of the ancient Greek gods holding thunderbolts which he used as warning or punishment against who disobeyed him
Zeus, the youngest son of Cronus and Rhea, was the supreme ruler of Mount Olympus and of the Pantheon of gods who resided there
  • Being the supreme ruler he upheld law, justice and morals, and this made him the spiritual leader of both gods and men
  • Zeus was a celestial god, and originally worshiped as a weather god by the Greek tribes
He has always been associated as being a weather god, as his main attribute is the thunderbolt, he controlled thunder, lightning and rain
  • Theocritus wrote circa 265 BCE: "sometimes Zeus is clear, sometimes he rains”
  • He is also known to have caused thunderstorms
Discovery and widespread use of electricity in the mid-1800s took away the supernatural aura
  • 1st electrical fatality recorded in France in 1879
Thomas Alva Edison was both a scientist and an inventor
  • Born in 1847
  • When Edison was born, society still thought of electricity as a novelty, a fad. By the time he died, entire cities were lit by electricity
In his lifetime, Edison patented 1,093 inventions
  • The most famous of his inventions was an incandescent light bulb
  • He believed in hard work, sometimes working twenty hours a day. Edison was quoted as saying, "Genius is one percent inspiration and 99 percent perspiration"
In tribute to this important American, electric lights in the United States were dimmed for one minute on October 21, 1931, a few days after his death
Electrical injuries (excluding lightning) are responsible for > 500 deaths/year in the US
  • > 1/2 of them occur in the workplace.
  • 4th leading cause of work-related traumatic death
  • Electrocutions at home: > 200 deaths/year
Lightning responsible for 93 deaths/year in US
  • Morbidity 5-10 times higher than that due to other forms of electrical injury
  • Iatrogenic electrical injury in the ICU: defibrillators, pacemakers, electrosurgical devices
  • Story of CPR: how to treat electrocuted electrical linemen who were in VF
principles of electricity
Principles of Electricity
  • Electricity: flow of electrons (negatively charged outer particles of an atom) through a conductor
  • When the electrons flow away from this object through a conductor they create an electric current: amperes
Voltage: force that causes electrons to flow: volts
  • Anything that impedes the flow of electrons through a conductor creates resistance: ohms
Power lines range from:
    • Low: < 600 volts
    • Ultrahigh: > 1 million volts
  • Utility power lines with high voltages in sparsely populated areas
  • Through a succession of transformers voltage is gradually reduced
  • Most homes in US & Canada have a 120/240 V other countries (Europe, Asia..): 220 V
the temple of artemis at ephesus
The Temple of Artemis at Ephesus
  • A beautiful temple in Asia Minor erected in honor of the Greek goddess of hunting and wild nature
Electrical current exists in 2 forms:
  • 1) AC: (Alternating Current): when electrons flow back and forth through a conductor in a cyclic fashion
  • It is used in household and offices and is standardized to a frequency of 60 cycles/sec (60 Hz)
2) DC: (Direct Current): when electrons flow only in one direction
  • Used in certain medical equipment: defibrillators, pacemakers, electrical scalpels
  • AC is far more efficient and also more dangerous than DC (~ 3 times): tetanic muscle contractions that prolong the contact of victim with source
Issue of safety over efficiency: early days of electricity when Thomas Edison (who developed and popularized DC was fighting against George Westinghouse (who developed AC)
  • AC: first death penalty by electrocution
Lightning is a form of DC
  • Occurs when electrical difference between a thundercloud and the ground overcomes the insulating properties of the surrounding air
  • Current rises to a peak in about 2 µsec
  • Lasts for only 1-2 sec
Voltage >1,000,000 V
  • Currents of >200,000 A
  • Transformation of the electrical energy to heat generated temperatures as high as 50,000ºF
  • Extremely short duration prevents from melting
the mausoleum at halicarnassus
The Mausoleum at Halicarnassus
  • A fascinating tomb constructed for King Maussollos, Persian satrap of Caria
determinants of electrical injuries
Determinants of Electrical Injuries
  • Ohm’s law:
  • Current = Voltage/Resistance
  • Exposure of different parts of the body to the same voltage  different current  different degree of damage because resistance varies
The least resistance is found in nerves, blood, mucous membranes and muscles
  • The highest resistance is found in bones, fat and tendons
  • Skin’s resistance ranging between 40,000 and 100,000 Ω depending on thickness
  • Moisture of the skin; electrocution of a person in a bathtub or swimming pool
Moist mucus membranes: significant orofacial injury to infants and toddlers
  • Nerves and blood vessels are the best conductors: path of least resistance for current after it enters the body
  • Duration of the contact: shock caused by AC will produce bigger injury than shock caused by DC of the same amperage
Pathway of the current through the body:
    • Vertical pathway parallel to the axis of the body is the most dangerous. It involves all the vital organs; central nervous system, heart, respiratory muscles, in pregnant women the uterus and fetus
    • Horizontal pathway from hand to hand: the heart, respiratory muscles and spinal cord
    • Pathway through the lower part of the body: local damage
the colossus of rhodes
The Colossus of Rhodes
  • A colossus of Helios the sun-god, erected by the Greeks near the harbor of a Mediterranean Island
electrical injury to specific tissues organs
Electrical Injury to Specific Tissues & Organs
  • Cardiovascular System:
  • Pathophysiology:
  • Direct necrosis of the myocardium
  • Cardiac dysrhythmias
Focal or diffuse
  • Widespread, discrete, patchy contraction band necrosis involving the myocardium, nodal tissue, conduction pathways and coronary arteries
A current > 50-100 mA with hand-to-hand or hand-to-foot transmission  ventricular fibrillation
  • High-voltage current (AC or DC)  ventricular asystole
  • Lightning  cardiac standstill
  • Sinus rhythm may spontaneously return
Cardiac dysrhythmias reported in survivors of electrical injuries pathogenesis is rather unclear, multifactorial
Possible mechanisms:
    • 1) Arrythmogenic foci due to myocardial
  • necrosis (esp. SA Node injury)
    • 2) Alterations in the Na+ - K+ adenosine triphosphatase concentration
    • 3) Changes in the permeability of myocyte membranes
    • 4) Anoxic injury (respiratory arrest precedes the injury to the heart)
Large arteries not acutely affected because their rapid flow:dissipate heat. Medial necrosis: aneurysm formation and rupture
  • Smaller vessels acutely affected d.t. coagulation necrosis  compartment syndrome
Clinical Manifestations
  • Cardiac standstill, ventricular fibrillation: most serious
  • Sinus tachycardia, nonspecific ST- and T-wave changes: much better prognosis
  • Conduction defects, various degrees of heart blocks, BBB and QT interval
Supraventricular tachycardias and atrial fibrillation: usually do not cause significant hemodynamic compromise
  • On echocardiogram: some depression of the right & left ejection fractions
Cutaneous Injuries & Burns
  • Extensive flash and flame burns
  • Hemodynamic, autonomic, cardiopulmonary, renal, metabolic and neuroendocrine responses
Nervous System
  • Loss of conciousness, confusion & impaired recall
  • Peripheral motor & sensory nerves  motor & sensory deficits
  • Seizures, visual disturbances & deafness
  • Hemiplegia, quadriplegia, spinal cord injury
  • Transient paralysis, autonomic instability  hypertension, peripheral vasospasm due to lightning from massive release of catecholamines
Respiratory System
  • Direct injury to the respiratory control center  cessation of respiration or suffocation secondary to tetanic contractions of the respiratory muscles
  • Acute respiratory dysfunction syndrome secondary to ischemia, aggressive fluid resuscitation, ventilator-associated pneumonia
Other Systems
  • Kidneys susceptible to anoxic/ischemic injury
  • Release of myoglobin & creatinine phosphokinase  renal tubular damage  renal failure
  • Fractures
  • Transient autonomic disturbances  fixed pupils may be perceived as severe brain injury or even death
  • Temporary sensorineural hearing loss
the lighthouse of alexandria
The Lighthouse of Alexandria
  • A lighthouse built by the Ptolemies on the island of Pharos off the coast of their capital city
management of electrical injuries
Management of Electrical Injuries
  • Overall fluid management should be judicious unless: SIADH
Patient Monitoring
  • Most severe cardiac complications present acutely
  • Very unlikely for a patient to develop a serious or life-threatening dysrhythmia hours or days later
  • Asymptomatic normal ECG do not need cardiac monitoring
Preexisting heart disease: monitor such patients for 24 hrs after the injury
  • Criteria for cardiac monitoring:
    • Exposure to high voltage
    • Loss of consciousness
    • Abnormal ECG at admission
Type of cardiac monitoring: (controversial)
    • Continuous telemetry
    • Serial ECGs
    • Serial measurement of cardiac enzymes
  • Prognostic value of CK-MB, noninvasive and invasive imaging studies (echocardiography, thallium studies & angiography): rather poor and inconsistent
  • Muscles injured by an electrical current can contain up to 25% CK-MB fraction (as opposed to the normal 2-3%)
  • No information regarding changes in troponin
  • “One ounce of prevention is worth a pound of treatment”
the great pyramid of giza
The Great Pyramid of Giza
  • A gigantic stone structure near the ancient city of Memphis, serving as a tomb for the Egyptian Pharaoh Khufu

“Man fears Time, yet Time fears the Pyramids”

Arab proverb