CASE PRESENTATION
We present a 28 year-old male heavy smoker, without any known chronic
illnesses, who worked as an exterminator using pesticides in a palm
plantation. He was electrocuted by touching a high voltage exposed
electric wire, from an electric poll. He reported pain and new
pigmentation in his right hand and left foot. However, he denied losing
consciousness, incontinence, chest pain or palpitation. He didn’t seek
medical care. Six hours later he returned to work and suddenly collapsed
with cardiac arrest. Resuscitation was immediately initiated by his
coworker. A few minutes later, a local nurse from a nearby settlement
placed an automated external defibrillator (AED). The AED indicated
ventricular fibrillation and 3 DC shocks (200J) were delivered
successfully, with return of spontaneous circulation immediately after.
In the ambulance, the patient was breathing heavily with six breaths per
minutes and low oxygen saturation. 300mg Ketamin and 20mg Etomidate were
given intravenously in order to initiate mechanical respiratory support.
Three attempts of performing intubation failed.
At the local hospital he was somnolent, with pinpoint pupils. Arterial
blood pressure was 113/60 mmHg, pulse was rhythmic and rapid. Burns were
noticed on his right palm and left foot. Sinus tachycardia, (110-120
beat/min), Right axis deviation, long QT interval (QTc = 550 msec) and
Inverted T wave (on leads III, aVF) were noticed on performed ECGs. No
ST changes were seen (Figure 1). Creatinine phosphokinase was high 840
mg/dl. Troponin was not measured.
A short echocardiogram, performed by a senior cardiologist, indicated
good global systolic function, with 55% estimated left ventricular
ejection fracture. No significant valvular disturbance, nor pericardial
effusion or regional wall motion abnormality were noticed. A full body
CT scan was performed without any significant pathological findings. No
enzymatic evidence of myocardial infarction was found.
Mechanical ventilation initiated in the ICU, after sedation with
intravenous Propofol and Fentanyl. Mild Hypothermia established for 24
hours, with target temperature of 34⸰c. A day after he
was able to breath without oxygen support and could recount the initial
events. No serious neurological deficits were noticed. He was treated
mainly with respiratory physiotherapy, and was discharged a few days
later, fully functioning.
In the following months, the patient complained of anxiety, insomnia,
urine incontinence and palpitations. He denied syncope or near syncope.
He was examined by neurologist and performed an Electroencephalogram
(EEG) with no pathological finding. The patient was follow up by
cardiologist in ambulatory clinic. Electrocardiogram and Echocardiogram
which performed two months later revealed no difference compared to
previous findings. 24 hour ECG monitoring (Holter) indicated a few
isolated ventricular premature beats.