Electrocution at a Construction Site: A Case Report

     EMS was called for a 35-year-old male who had been on an aluminum ladder at a construction site using a 115 volt, 60 Hz alternating current electric drill. At 9:26 a.m., he leaned against the wall and his chest came in contact with the (apparently defective) drill cord. The patient received an electrical shock that threw him off the ladder. He landed on his back on a concrete floor 10 feet below. Coworkers described a bright flash and then a loud crash. They called 9-1-1 at 9:28 a.m. Bystander CPR was not performed.

     The paramedics arrived at 9:31 and found the patient lying on electrical cords. After ensuring safety by shutting down the job-site's power, they evaluated the patient, who was in cardiopulmonary arrest with a rhythm of ventricular fibrillation. While maintaining spinal immobilization, consecutive defibrillation at 200, 300 and 360 J was administered at 9:32, resulting in a lethal rhythm felt to be asystole or fine ventricular fibrillation. An endotracheal tube was placed via the orotracheal route, chest compressions began, and IV access was established by 9:36 a.m. Radio contact was made with the receiving facility, and IV epinephrine (1 mg) and lidocaine (120 mg) were given. At 9:41, when repeat defibrillation at 360 J was ineffective, an additional dose of epinephrine (1 mg) was administered. Finally, the patient responded to a defibrillating shock of 360 J with a perfusing rhythm. At 9:43, the patient had a blood pressure of 180/P with a heart rate of 130, believed initially to be ventricular tachycardia.

     The patient was immobilized on a board with a cervical collar in place and transported at 9:57 a.m. On secondary examination en route, medics noted occipital scalp bleeding, burns to the chest and burns to the medial ankles. They also suctioned frothy pink sputum from the endotracheal tube (see Figure 1). On closer inspection, the patient's cardiac rhythm was thought to be sinus tachycardia. His condition remained unchanged, and the ambulance arrived (Code 3) at the emergency department at 10:04 a.m.

ED TREATMENT
     The mobile intensive care nurse (MICN), in communication with the medics, activated the trauma team prior to the patient's arrival. The team verified endotracheal tube placement. Breath sounds were rhonchorous, and the respiratory therapist suctioned additional pink, frothy sputum from the endotracheal tube. Concurrently, a second antecubital IV catheter was placed and blood samples were obtained for analysis. Pulses were easily palpated in all extremities, and there appeared to be good peripheral perfusion. Blood pressure was 154/94 with a pulse rate of 156. The patient was non-responsive to noxious stimuli and was assigned a Glasgow Coma score of 3T (intubated). Pupils were sluggishly reactive from 3 to 2 mm bilaterally.

     Secondary survey revealed a superficial scalp abrasion with hematoma. A 5 x 3 cm erythematous patch, believed to be the electrical entrance wound, was noted over the sternum (Figure 2). Bilateral ulcerated lesions (6 x 3 cm) surrounded by erythema and ecchymosis were present on the medial malleoli. These were assumed to be exit wounds (Figure 3).

     Chest radiography demonstrated pulmonary edema. A CAT scan of the head indicated mild diffuse cerebral edema, in addition to soft tissue swelling of the scalp. Cerebral edema may have resulted from anoxia, trauma or both. Electrocardiogram was markedly abnormal, with striking ST segment elevations across the precordial leads suggesting acute myocardial infarction (Figure 4 on page 192). On echocardiogram, a wall motion abnormality was found in the apex, notably the area of the myocardium directly beneath the sternal entrance wound. Numerous abnormalities were found in the blood and urinalysis that pointed toward rhabdomyolysis, as well as probable brain and cardiac injury.