Survival after prolonged cardiopulmonary resuscitation in cardiac arrest due to electric shock

Dhiraj R Jadhav, Lakshmi Vijaya, Joseph Alexis, Vinay Pandit

Department Of Emergency Medicine, JIPMER, Puducherry, India

Keywords:Electric injury Pediatric arrest Prolonged CPR

ABSTRACT

1. Introduction

Electric shock can be lethal if immediate medical help is not obtained.As time interval increases from time of arrest to beginning of CPR, the outcome will be poor. Death may occur due to respiratory arrest secondary to paralysis of respiratory centre or respiratory muscles. Ventricular fibrillation can also occur if current pass through the myocardium. Timely done CPR and other medical interventions can be savior[1]. when arrested patient is in pediatric age group, will pose unique challenges to emergency physician. This case highlights importance of early CPR and team efforts in successful outcome of arrested pediatric patients.

2. Case report

Two year old male child brought with alleged history of electric shock at around 7:30 p.m. at home, while playing child has held open ends of electric cable in left hand and became unresponsive.Within 15 min child was brought to emergency department. On examination child was not responsive and carotid pulse was not palpable. The patient was taking agonal gasp breathing. As per Pediatric Advanced Life Support protocol CPR was started and cardiac monitors were connected, it showed ventricular fibrillation,so defibrillation was done and CPR was continued. The left femoral intravenous access was established. The patients received injection adrenaline 1 mg IV every 3-5 min and injection Amiodarone 5 mg/kg bolus 50 mg followed by 25 mg infusion because of recurrent ventricular tachycardia despite defibrillation. Intravenous 20 mL/kg bolus of normal saline was also started and CPR was continued till 8:55 p.m. ROSC was achieved after 70 min of CPR.The endotracheal intubation was done and confirmed the position with ETCO2. arterial blood gases was obtained and showing pH 6.6,bicarbonates 8, lactate 8, K 4.1, Na 151. Patient also received sodium bicarbonate infusion. Infusion of nor-adrenaline 0.2 mic/kg/min was started. The Patient was shifted to Pediatric ICU. In ICU patient was kept on ventilator support and diagnosed with electrocution induced myoglobinuria and acute kideny injury which was treated with dialysis. Patient also developed right femoral Deep Vein Thrombosis for which anticoagulation was given. After stabilization and weaning from ventilator support patient was found to have cortical blindness and deafness.

3. Discussion

Electrical injuries are relatively uncommon but potentially multisystem injury with high morbidity and mortality and may be fatal. The adults primarily get electrical injuries at workplace, which are usually due to high voltage while children usually get them at home because of low voltage current[2].

In developing countries like India due to lack of awareness, non standard equipment and availability of cheap alternatives leads to increasing electrocution and electrical fatalities[3].

Patient should be immediately transported to Emergency Department without delay and CPR should be started in case of unresponsive patient. Airway management is utmost important in case of electric burns around neck and face. Early tracheal intubation is needed in these cases because extensive soft-tissue edema may develop and lead to airway obstruction. Respiratory muscle paralysis may be present for several hours and needs prolonged ventilator support[4]. Vigorous fluid therapy is required to maintain good urine output and to enhance the excretion of myoglobin, potassium and other products of tissue damage[5]. Resuscitative attempts are highly successful in lightning victims than in patients with cardiac arrest from other causes, same can be true for arrest due to electric shock[6].

Acute neurologic symptoms after electrical injury have a better prognosis. The initial electrical injury might result in a transient neurapraxia like the situation[7]. Neurologic symptoms are believed to arise from hemorrhage, cerebral edema, or chromatolysis[8]. Our patient developed blindness and deafness which improved over a period of two months. Every passing minute will cause neuronal loss and worse outcome so early CPR is the key for better outcome of arrested victim.

One case was reported to achieve restoration of spontaneous circulation after cardiac arrest due to electric shock after 40 min of CPR[9]. In our case restoration of spontaneous circulation was achieved after 70 min of CPR. It is probably the longest CPR needed

to achieve restoration of spontaneous circulation in cardiac arrest due to electric shock.

In conclusion, early defibrillation and timely done resuscitation and team efforts may give better chance of survival to victim arrested due to electric shock. Prolonged CPR may have favourable outcome in cardiac arrest due to electric injuries as in our patient. Thus we suggest team resuscitation and prolonged CPR for patients in cardiac arrest due to electric shock.

We also suggest better preventive measures, safety norms and education of parents may be helpful in avoiding such a fatal incidences.

Conflict of interest statement

The authors report no conflict of interest.