Originalien
Med Klin Intensivmed Notfmed 2016 · 111:708–714
DOI 10.1007/s00063-015-0107-y
Received: 29 July 2015
Revised: 18 August 2015
Accepted: 21 September 2015
Published online: 23 October 2015
© Springer-Verlag Berlin Heidelberg 2015
Redaktion
M. Buerke, Siegen
Background
Electrical injuries can be classified by the
underlying voltage as low-voltage (< 1000
alternating current or < 1500 direct cur-
rent) and high-voltage (≥ 1000 alternat-
ing current or ≥ 1500 direct current) in-
juries [13, 30]. Additional groups of “flash
burns” (in which there is no electrical cur-
rent flow through the body of the patient)
and lightning burns are used at times
[13, 17, 21].
High-voltage injuries are common-
ly work-related injuries in young men,
whereas low-voltage injuries mainly occur
in a domestic environment. Most of all,
children and women are affected by these
more frequent low-voltage accidents [4].
The injuries caused by electrical accidents
can for instance affect the cardiovascular,
respiratory, musculoskeletal and nervous
systems, kidneys, and the skin [1]. Relat-
ed mortality and morbidity are affected by
the magnitude of voltage, resistance of the
body, exposure to either direct current or
alternating current (AC), duration of ex-
posure, the pathway of the current inside
the body and the contact time [1, 12]. AC
may lead to a tetanized state of skeletal
muscle that detains the release from the
source of electricity [26].
Table 1  Patients characteristics
Collective group
Patients char- All patients
acteristics
(Mean ± SD) (n)
Age (yrs) 17.5 ± 17.0 (169)
Male (n) 102 (60 %)
Height (cm) 132 ± 40 (64)
Weight (kg) 48.0 ± 31.4 (43)
BMI (kg/m2) 21.4 ± 5.0 (36)
SD standard deviation, yrs years, m meter, kg kilogram, BMI Body mass index.
708 |  Medizinische Klinik – Intensivmedizin und Notfallmedizin 8 · 2016
C. Krämer · R. Pfister · T. Boekels · G. Michels
Department of Internal Medicine III, University of Cologne, Cologne, Germany
Cardiac monitoring always
required after electrical injuries?
Besides the thermic damages of the
body, diffuse destruction of the cell mem-
brane and secondary detriments of the
microcirculation, cardiac arrhythmias
that are caused by the electrophysiolog-
ical impact of the current are a dreaded
complication. Electricity that transverse
the myocardium is more likely to be fatal,
especially if it has a transthoracic (hand-
to-hand) pathway [25]. Besides the more
frequent change of polarity of the AC, the
point of the current impact at the cardiac
cycle also seems to be relevant. If the cur-
rent transverses the myocardium during a
vulnerable period, it may provoke ventric-
ular fibrillation—analogous to an R-on-T
phenomenon [14]. Cardiac arrest is more
often seen in high-voltage injuries [1].
Overall, electrical injury causes 0.54
deaths per 100,000 people/year and the
mortality ranges from 3–15 %, mainly
based on cardiac arrhythmia and arrest
[1, 3, 17, 18, 25]. These detrimental car-
diac complications usually happen in di-
rect temporal relation to the initial injury
[1]. The European Resuscitation Council
(ERC) recommends to monitor patients
in hospital who have a history of cardiore-
spiratory problems [25]. Besides the ERC
criteria, other risk factors should be men-
tioned. Important risk factors in victims
High-voltage
Children Adults All patients
(0–17 yrs) (≥ 18 yrs)
5.0 ± 4.3 (97) 34.3 ± 12.5 (72) 40.7 ± 19.4 (7)
54 (56 %) 48 (67 %) 5 (71 %)
120 ± 29 (43) 177 ± 10 (21) 180 ± 13 (2)
21.5 ± 15.4 (22) 75.8 ± 15.3 (21) 83.5 ± 14.8 (2)
17.5 ± 3.7 (15) 24.1 ± 3.8 (21) 25.8 ± 0.7 (2)
of electrical injuries are cardiopulmonary
arrest, transthoracic current, high-voltage
injury, pathological initial electrocardio-
gram (ECG)/ cardiac arrhythmias, loss of
consciousness, history of cardiovascular
diseases, symptomatic patients (palpita-
tions, chest pain, dyspnea, tetanic muscle
contraction, neurologic problems), preg-
nancy, abnormal laboratory (elevated
cardiac enzymes and/or troponin levels),
concomitant injuries, soft-tissue damage
and burns. Despite the guideline recom-
mendations unnecessary inpatient moni-
toring frequently happens due to the fear
of cardiac complications [23].
The aim of the study was to evaluate
cardiac complications of children and
adults emerging after low- and high-volt-
age electrical injury.
Methods
We evaluated medical records of patients
admitted because of electrical trauma
(identified by the ICD-10 code T 75.0 and
T 75.4) to the University Hospital of Co-
logne from January 2000 to January 2014.
The data were obtained from the electron-
ic health record system ORBIS (AGFA
Health Care, Bonn, Germany) and re-
viewed for the following details: age, sex,
Low-voltage
All patients Children Adults
(0–17 yrs) (≥ 18 yrs)
16.9 ± 16.7 (162) 5.0 ± 4.3 (97) 34.3 ± 12.5 (72)
96 (59 %) 54 (56 %) 48 (67 %)
131 ± 40 (61) 110 ± 30 (43) 177 ± 10 (21)
47.1 ± 31.0 (40) 21.5 ± 15.4 (22) 75.8 ± 15.3 (21)
21.3 ± 5.0 (33) 17.5 ± 3.7 (15) 24.1 ± 3.8 (21)
Table 2  Initial symptoms
Collective group High-voltage Low-voltage
All patients Children Adults All patients All patients Children Adults
(0–17 yrs) (≥ 18 yrs) (0–17 yrs) (≥ 18 yrs)
(n = 132) (n = 84) (n = 48) (n = 4) (n = 128) (n = 84) (n = 44)
Initial symptoms
Pain 94 (45 %) 65 (50 %) 29 (38 %) 3 (30 %) 91 (46 %) 65 (49 %) 26 (35 %)
Cardiac arrhythmia 16 (8 %) 10 (7 %) 6 (8 %) 2 (20 %) 14 (7 %) 10 (7 %) 4 (5 %)
Dyspnea 2 (1 %) 1 (1 %) 1 (1 %) – 2 (1 %) 1 (1 %) 1 (1 %)
Shivering 5 (2 %) 4 (3 %) 1 (1 %) – 5 (3 %) 4 (3 %) 1 (1 %)
Short absence 7 (3 %) 3 (2 %) 4 (5 %) – 7 (4 %) 3 (2 %) 4 (5 %)
Vertigo 3 (1 %) 1 (1 %) 2 (3 %) – 3 (2 %) 1 (1 %) 2 (3 %)
Paraesthesia 18 (9 %) 13 (10 %) 5 (6 %) – 18 (9 %) 13 (10 %) 5 (7 %)
Others 25 (12 %) 15 (11 %) 10 (13 %) 4 (40 %) 24 (12 %) 18 (13 %) 9 (12 %)
None 38 (18 %) 19 (15 %) 19 (25 %) 1 (10 %) 37 (19 %) 19 (14 %) 18 (24 %)
yrs years.

Table 3  Cardiac monitoring results and length of inpatient stay

Collective Group High-voltage Low-voltage
[%] [%]
All patients Children Adults All patients All patients Children Adults
(0–17 yrs) (≥ 18 yrs) (0–17 yrs) (≥ 18 yrs)
(n = 129) (n = 72) (n = 52) (n = 7) (n = 122) (n = 72) (n = 50)
Electrocardiogram recordings
Normal 109 (85 %) 67 (93 %) 37 (71 %) 5 (71 %) 104 (85 %) 67 (93 %) 37 (74 %)
Abnormal 20 (16 %) 5 (7 %) 15 (29 %) 2 (29 %) 18 (15 %) 5 (7 %) 13 (26 %)
Cardiac arrest 1 (1 %) 0 1 (2 %) 1 (14 %) 0 0 0
 Sinus tachycardia 6 (5 %) 1 (1 %) 5 (10 %) 1 (14 %) 5 (4 %) 1 (1 %) 4 (8 %)
 Sinus arrhythmia 3 (2 %) 2 (3 %) 1 (2 %) 0 3 (2 %) 2 (3 %) 1 (2 %)
 ST segment changes 6 (5 %) 2 (3 %) 4 (8 %) 0 6 (5 %) 2 (3 %) 4 (8 %)
 PAC 3 (2 %) 1 (1 %) 2 (4 %) 0 3 (2 %) 1 (1 %) 2 (4 %)
 PVC 1 (1 %) 1 (1 %) 0 0 1 (1 %) 1 (1 %) 0
 AV-block I° 1 (1 %) 0 1 (2 %) 0 1 (1 %) 0 1 (2 %)
 Delta wave 1 (1 %) 0 1 (2 %) 0 1 (1 %) 0 1 (2 %)
yrs years, PAC premature atrial contraction, PVC premature ventricular contraction, AV atrio-ventricular.

Table 4  Length of inpatient stay and total costs

Collective group High-voltage Low-voltage
[%] [%]
All patients Children Adults All patients All patients Children Adults
(0–17 yrs) (≥ 18 yrs) (0–17 years) (≥ 18 years)
Length of inpatient stay (days)
ICU/IMC 0.77 ± 0.79 0.78 ± 0.71 0.73 ± 0.89 1.71 ± 2.36 0.72 ± 0.63 0.78 ± 0.71 0.63 ± 0.49
General ward 0.71 ± 6.46 0.12 ± 0.45 1.28 ± 9.02 16.40 ± 32.29 0.10 ± 0.48 0.12 ± 0.45 0.08 ± 0.52
Total length of stay 1.50 ± 5.86 1.13 ± 0.58 1.99 ± 8.97 13.57 ± 27.59 0.96 ± 0.63 1.12 ± 0.58 0.74 ± 0.64
Total costs (€) Collective High-voltage Low-voltage – Low-voltage – –
Group [%] [%] [%]
All patients All patients All patients p-Valuea Children Adults (n = 40) p-Valuea
(n = 122) (n = 4) (n = 118) (n = 78)
723 ± 328 1246 ± 985 703 ± 266 0.255 735 ± 293 638 ± 191 0.024
IMC intermediate care unit, ICU intensive care unit.
aUnpaired T-test.

Medizinische Klinik – Intensivmedizin und Notfallmedizin 8 · 2016  | 709


height, weight, body mass index, occupa-
tion, body location of electricity entrance,
voltage of electricity, initial symptoms,
date of admission, admission ward, spe-
cialty consultations, laboratory param-
eters, ECG recordings and the length of
hospital stay.
A standard descriptive analysis was
performed. We used unpaired t-tests for
parametric variables and Mann–Whitney
U-test for nonparametric variables to per-
form pair wise comparisons for the total
costs. All reported p-values are two-sid-
ed and p-values < 0.05 were considered
to be statistically significant. All analyses
were performed using SPSS version 22.0®
(SPSS, Inc., USA).
Results
A total of 258 patients from January 2000
to January 2014 were admitted to the Uni-
versity Hospital of Cologne because of
electrical trauma. In the analysis, the data
of 169 patients could be included, because
in 89 cases the medical records were not
complete.
Patient demographics and
characteristics of electrical injuries
Patients were aged 1–73 years, with a me-
dian of 17.5 ± 17 years. A total of 60 % of
the patients were male. The anthropomet-
ric data of the patients divided into chil-
dren (0–17 years) and adults (≥ 18 years)
are shown in .  Table 1. In all, 4 % (n = 7)
of the injuries were high-voltage inju-
ries and 96 % (n = 162) were low-voltage
trauma. Most of the accidents occurred
at home (65 %) and at work (19.5 %). The
cases were unevenly distributed through-
out the study period, but there is an in-
creasing trend from 2006 (. Fig. 1). Dur-
ing the course of the year, the highest rates
of electrical injuries were found in Janu-
ary, June, and November (. Fig. 2).
Location of the current entry
and initial symptoms
In the majority of cases, the entry wound
was located at the hands (high-voltage
group: 57 %; low-voltage group: 77 %).
The locations of the entry wounds for the
high- and low-voltage group are shown
710 |  Medizinische Klinik – Intensivmedizin und Notfallmedizin 8 · 2016
Abstract · Zusammenfassung
Med Klin Intensivmed Notfmed 2016 · 111:708–714  DOI 10.1007/s00063-015-0107-y
© Springer-Verlag Berlin Heidelberg 2015
C. Krämer · R. Pfister · T. Boekels · G. Michels
Cardiac monitoring always required after electrical injuries?
Abstract
Background.  Controversy still exists regard-
ing inpatient monitoring of patients exposed
to electrical injuries.
Materials and methods.  In a monocentric
retrospective study, we evaluated the med-
ical records of 169 patients admitted to the
University Hospital of Cologne from January
2000 to January 2014 because of electrical
trauma. The electrocardiogram (ECG) data of
40 patients were missing.
Results.  Patients in our collective were pre-
dominantly young men (60 %) with an aver-
age age of 17.5 ± 17 years (1 year to 73 years).
The electrical trauma occurred occupation-
al (20 %), domestic (65 %), and during leisure
time (15 %). In the high-voltage (≥ 1000 V)
group (n = 7; 71 % male; 40.0 ± 19.4 years)
one death was reported, related to an open
intracranial injury and cardiac arrest. Of the
EKG-Monitoring nach Stromunfällen immer notwendig?
Zusammenfassung
Hintergrund.  Bezüglich der kardiologischen,
stationären Überwachung von Patienten
nach Stromunfällen existieren weiterhin kon-
troverse Meinungen.
Material und Methoden.  In einer monozen-
trischen retrospektiven Studie erfolgte die
Auswertung der Elektrokardiogramme (EKGs)
von 169 Patienten, welche im Zeitraum von
Januar 2000 bis Januar 2014 aufgrund eines
elektrischen Stromschlages in das Universi-
tätsklinikum Köln aufgenommen wurden. Die
EKGs von vierzig Patienten fehlten.
Ergebnisse.  Das Durchschnittsalter der
überwiegend männlichen (60 %) Patienten
betrug 17,5 ± 17 Jahre (1 bis 73 Jahre). Die
Unfälle ereigneten sich bei der Arbeit (20 %),
bei der Hausarbeit (65 %) und während des
Spielens zu Hause (15 %). In der Gruppe der
Hochspannungsunfälle (≥ 1000 V; n = 7; 71 %
männlich; 40,0 ± 19,4 Jahre) trat ein Todesfall
aufgrund eines offenen Schädel-Hirn-Trau-
mas und Herzstillstandes auf. Fünf der sechs
in .   Fig. 3. Most of the patients’ initial
symptoms were pain (45 %). Other initial
symptoms were paresthesia (9 %), cardi-
ac arrhythmia (8 %), short absence (3 %),
shivering (2 %), dyspnea (1 %), and verti-
go (1 %) (. Table 2).
six surviving patients five showed normal EC-
Gs and one a sinus tachycardia. In the low-
voltage (< 1000 V) group (n = 162, 56 % male;
5.0 ± 4.3 years) the ECG findings were as fol-
lows: 104 normal, 5 sinus tachycardia, 3 sinus
arrhythmia, 6 ST segment changes, 3 prema-
ture atrial contraction, 1 premature ventricu-
lar contraction, 1 atrio-ventricular (AV)-Block
and 1 delta wave. In all, one patient showed a
self-limiting supraventricular tachycardia.
Conclusion.  Asymptomatic and stable pa-
tients without any risk factors and with a nor-
mal initial ECG need no inpatient cardiac
monitoring after an electrical injury.
Keywords
Electrical injury · Low-voltage injury ·
High-voltage injury · Cardiac monitoring ·
Cardiac arrhythmia
überlebenden Patienten zeigten normale
EKGs und ein Patient eine Sinustachykardie.
In der Niederspannungsgruppe (< 1000 V;
n = 162, 56 % männlich; 5,0 ± 4,3 Jahre) zeig-
ten sich folgende EKG-Befunde: 104 Nor-
malbefunde, 5 Sinustachykardien, 3 Sinusar-
rhythmien, 6 ST-Streckenveränderungen, 3
supraventrikuläre Extrasystolen (SVES), 1 ven-
trikuläre Extrasystole (VES), 1 atrio-ventriku-
lärer (AV)-Block und 1 Deltawelle. Ein Patient
präsentierte eine selbstlimitierende supra-
ventrikuläre Tachykardie (SVT).
Schlussfolgerung.  Bei asymptomatischen,
stabilen Patienten ohne jegliche Risikofakto-
ren und mit einem normalen initialen EKG ist
keine stationäre kardiale Überwachung not-
wendig.
Schlüsselwörter
Stromunfall · Niederspannungsunfall ·
Hochspannungsunfall · Kardiologisches
Monitoring · Kardiale Arrhythmien
Admission ward and
specialty consultations
Most of the patients were admitted to the
pediatric cardiology (38 %) and general
pediatric department (23 %). Other de-
partments were the emergency depart-
ment (22 %), the general internal medi-
 30
Collective group
Children
25 Adults
20
Cases
15
10
5 high-voltage accidents stayed a mean of
0 a low-voltage injury stayed at the hospital
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Fig. 1 8 Distribution of electrical injuries from 2000–2013
cine intermediate (IMC)/intensive care
unit (ICU) (6 %), the cardiovascular IMC/
ICU (4 %), and the anesthesiological ICU
(1 %). The most frequent specialty depart-
ments consulted were cardiology (22 %),
trauma surgery (13 %), ophthalmology
(2 %), psychiatry (2 %), and general inter-
nal medicine (1 %).
Laboratory parameters
In all, 40 of the patients showed elevat-
ed serum creatine kinase values. Elevat-
ed cardiac enzymes were found in 31 pa-
tients (muscle-brain type creatine ki-
nase; CK-MB) and elevated levels for
troponin T in 25 cases. In the high-volt-
age group the mean laboratory parame-
ters were as follows: 170.5 ± 64.5 U/l (se-
rum creatine kinase; CK), 13.7 ± 6.6 U/l
(CK-MB) and 0.002 ± 0.002 µg/l (tropo-
nin T). In the low-tension group, the pa-
tients showed CK, CK-MB, and troponin
T values of 169 ± 97 U/l, 20.9 ± 12.6 U/l and
0.001 ± 0.003 µg/l, respectively.
ECG recording results
ECGs of 129 patients were available for re-
view. In all, 109 of these ECGs were nor-
mal, 20 abnormal. The abnormal EC-
Gs consisted of one cardiac arrest, six si-
nus tachycardia, three sinus arrhythmia,
six ST segment changes, three premature
atrial contraction (PAC), one premature
ventricular contraction (PVC), one atrio-
ventricular (AV)-block, and one delta
wave (.  Table 3), including two patients
with combined ECG changes (ST seg-
ment changes in combination with sinus
arrhythmia or sinus tachycardia). In the
high-voltage group five patients showed
normal ECGs. Cardiac arrest and sinus
tachycardia were found in one patient
each (. Table 3). In the low-voltage group
122 ECGs were available. A total of 104 of
these patients showed normal ECGs. The
abnormal ECGs (18) contained 5 sinus
tachycardia, 3 sinus arrhythmia, 6 ST seg-
ment changes, 3 PAC, 1 PVC, 1 first-degree
AV block and 1 delta wave (. Table 3), in-
cluding 2 patients with combined ECG
changes (ST segment changes in com-
bination with sinus arrhythmia or sinus
tachycardia).
Stratified into children and adults, the
ECG findings of the low-voltage group
were as follows: 67 of the children had
normal ECGs, the abnormal ECGs (5)
consisted of 1 sinus tachycardia, 2 sinus
arrhythmia, 2 ST segment changes, 1 PAC
and 1 PVC (.  Table 3), including 2 chil-
dren with combined ECG changes (ST
segment changes in combination with si-
nus arrhythmia or sinus tachycardia). One
of the children developed a secondary,
self-limiting sinus tachycardia, another
children single PAC at night after an ini-
tial normal ECG.
Medizinische Klinik – Intensivmedizin und Notfallmedizin 8 · 2016  | 711
Regarding the adults, 37 patients had
normal ECGs. The 13 abnormal ECGs
included 4 sinus tachycardia, 1 sinus ar-
rhythmia, 4 ST segment changes, 2 PAC,
1 first-degree AV block and 1 delta wave
(. Table 3). One of the patient developed
the sinus tachycardia at night.
Length of hospital stay
and total costs
The mean length-of-stay at the collec-
tive group was 1.5 ± 5.9 days. Patients with
13.6 ± 27.6 days, patients with low-voltage
1.0 ± 0.6 days (.  Table 4). Children with
for 1.12 ± 0.58 days, adults on average for
0.74 ± 0.64 days. The total costs based on
the Diagnosis Related Group (DRG) re-
muneration (including all discounts and
surcharges) of the collective group were
723 ± 328 €. No difference was found be-
tween the total costs of the high-voltage
group (1246 ± 985  €) and the low-volt-
age group (703 ± 266 €; p = 0.255). In the
low-voltage group, total costs of treat-
ment differed between children and adults
(735 ± 293  € vs. 638 ± 191  €; p = 0.024;
.  Table 4), which resulted from a differ-
ent length of stay.
Discussion
The present study showed an increasing
number of patients taken to the Hospital
of Cologne after electrical accidents from
2006 to 2013. Accordingly, Sun et al. [28]
noted an increasing trend from 2005, with
an annual rate of 18.1 %.
In this study, one patient died after a high-
voltage accident because of traumatic brain in-
jury. The resulting mortality rate of 0.62 % was
lower compared with those described in pre-
vious studies. Authors present various mortal-
ity rates of electric injuries ranging from 2 %
in Iran [22] to 9.1 % in Turkey [2]. In the high-
voltage groups the reported mortality rates
are up to 15–17 % [17, 19]. We could only in-
clude the data of the patients that were admit-
ted to our hospital. No information is provid-
ed about patients after electrical accidents who
did not reach the hospital. For that reason the
actual number of electrical incidents as well as
the number of electrical accidents with lethal
consequence may be even higher.
 Originalien

20
Collective group
Low voltage children
18 Low voltage adults
High voltage
16

14

12
Cases

10

0
January February March April May June July August September October November December

Fig. 2 8 Distribution of electrical injuries in the course of the year

Children and adolescents accounted for

8%
almost 20 %. The high percentage of chil-
14% 5%
dren (57 %) in this study could be respon-
2%
sible for the lack of differences by sex as
1%
the typical work-related injuries are not
5%
relevant in young ages. Children are in-
3% volved in electrical injuries that mostly oc-
cur in the course of playing at home. This
57% is supported by the fact that the percent-
29% 77% age of men at the present adult group is
even higher than in the collective group.
The high proportion of children is in ac-
cordance with the survey of Searle et al.
[23]. A total of 43 % of the 268 patients ad-
Hand Whole body
Hand mitted to their department after electric
Arm Unknown
Head accidents have been children aged 0–17
Head No note years. Also the percentage of 39 % female
Unknown
a b Trunk patients was similar to our findings.
The incidence of cardiac arrhythmia
Fig. 3 8 Body location of the entry wound at the high (a), and low-voltage (b) group after electrical accidents described in the
literature ranges from 15 to 40 % [5, 29].
Most of the cardiac arrhythmias that oc-
Compared with most of the recent scribed the percentage of men with 84– curred could be seen at the initial ECG.
studies, the percentage of women was 90 %. In the study of Sun et al. [28] the This is in accordance with most of the re-
fairly high with 40 % in the present sur- subjects were predominantly young men cent studies, where authors stated that the
vey. Akkas et al. [1] and Sun et al. [28] de- that injured in work-related incidents. cardiac arrhythmias can usually be record-

712 |  Medizinische Klinik – Intensivmedizin und Notfallmedizin 8 · 2016


Electrical injury
Monitoring of vital functions
Case history and physical
examination
ECG and laboratory
Admission with ECG monitoring
for 24 hours
Discharge or hospital stay
a b
Fig. 4 8 Management of patients after electrical injury before (a), and after the study (b). *Risk fac-
tors: high-voltage injury, loss of consciousness, history of cardiovascular diseases, pregnancy, abnor-
mal laboratory (elevated cardiac enzymes and/or troponin levels), transthoracic current, concomitant
injuries, soft-tissue damage and burns
ed directly after the injury [1, 16]. Our data
revealed initial abnormal ECGs in 15.5 %
of the patients, which may have existed
before the injury. These findings are in ac-
cordance to recent studies in the way that
the information about abnormal ECGs in
patients after electric injuries is ranging
from 3 to 37 % [4, 9, 27]. At their review
about electrical injury and the frequen-
cy of cardiac complications, Arrowsmith
et al. [4] evaluated ECG data of 104 pa-
tients admitted during a 5-year period. In
all, 3 % of the ECGs were abnormal as they
showed self-limiting atrial and ventricu-
lar ectopic beats and an atrial fibrillation
that was medicated with digoxin. The EC-
Gs did not show severe arrhythmias and
it was discernable that cardiac complica-
tions were more frequent in those who
had a loss of consciousness at the time of
injury or who suffered a high-voltage ac-
cident. At a collective of 134 high-risk pa-
tients monitored after an electrical inju-
ry, 11 % had abnormal initial ECGs. None
of the patients developed potential late ar-
rhythmia [7]. Similar findings of abnor-
mal ECG revealed a study of Sigmund et
al. [24] where the authors examined the
ECGs of 320 patients after low-voltage
electrical accidents. They found unspe-
ed on 11 patients showing abnormal ECGs,
Electrical injury
especially consisting of sinus tachycardia.
Furthermore, they showed significant re-
Disturbed state of the Yes lationships between mortality and tachy-
(emergency ward or intermediate care/intensive care unit)
vital functions?
cardia. Overall, it seems difficult to com-
No pare the findings of the ECG analysis as
Case history and physical there is no coherent definition of unspe-
examination, laboratory
cific ECG changes or abnormalities.
Concerning the necessity of ECG
Admission
Yes monitoring after electrical injuries not on-
*Risk factors?
ly primary arrhythmias but also second-
No ary arrhythmias, even arising after a nor-
Yes mal initial ECG, are appreciable. In the
Symptomatic?
context of the present study, one adult pa-
No
tient showed a tachycardia at night after a
Yes
Abnormal ECG? normal initial ECG that was successfully
(12-lead ECG and rhythm strip)
treated with beta-blocker. There are sev-
No eral studies that examined the occurrence
Discharge of secondary arrhythmias after electrical
injuries so far. Blackwell et al. [9] moni-
tored 196 patients after electrical inju-
ry and none of these 196 patients showed
delayed arrhythmias. As a result of their
study the authors developed a new algo-
rithm for the treatment of patients after
electrical injury. The management proto-
cific ECG changes in 13 % and abnormal col recommends no ECG monitoring of
ECGs in 11 % of their patients. Even a to- asymptomatic patients with normal ini-
tal of 36 % ECG abnormalities was report- tial ECG after a low-voltage injury. Pa-
ed in a study of Solem et al. [27], including tients with significant symptoms or ECG
the data of 64 patients after electrical inju- changes should be monitored for at least
ries. Similar values were found by Black- 6 h. Besides these studies, there are occa-
well and Haylar [9]. sional case reports describing cardiac ar-
Referred to the children with low-volt- rhythmias arising hours or days after the
age accidents, 6.9 % of the initial ECGs accident [6, 20].
showed abnormalities. This is lower than Referred to the children at the present
a current study of Searle et al. [23] ana- study, secondary arrhythmias were found
lyzing secondary data of survivors of elec- in two cases, including a self-limiting si-
trical accidents to determine the frequen- nus tachycardia and single PAC at night.
cy of cardiac arrhythmia. The study re- None of the children developed fatal car-
vealed mild cardiac arrhythmias—includ- diac arrhythmias. On the contrary, no sec-
ing sinus tachycardia, sinus bradycardia, ondary arrhythmias were found by Bailey
and isolated extra beats—in 28.7 % of the at al. [8] and Gokdemir et al. [15] at their
children. An antiarrhythmic therapy was studies, including 141 and 36 children, re-
not necessary. Also abnormal ECGs were spectively. Accordingly, none of the 38
shown in a retrospective study of Claudet children, monitored at a study of Celik
et al. [11]. Of the 48 children, 8 showed et al. [10] at least for 24 h after electrical
abnormal ECGs, such as sinus tachycar- accidents, developed cardiac abnormali-
dia, incomplete right bundle branch block ties. However, three of the children’s EC-
(RBBBs) and V1negative T-waves. The Gs showed nonspecific temporary ST seg-
ECGs normalized within 12 h and no de- ment changes. The CK and CK-MB values
layed arrhythmias occurred. Contrary to were elevated in all of the 31 determined
our study, the authors defined incomplete cases. Overall, four of these patients sus-
RBBBs as abnormal ECGs. This could be a tained low-voltage injuries.
reason for their higher rate (16.7 %) of ab-
normal ECGs. Gokdemir et al. [15] report-
Medizinische Klinik – Intensivmedizin und Notfallmedizin 8 · 2016  | 713
 Originalien
Limitations
The present study has some limitations.
First, the data were evaluated retrospec-
tively. For that reason no pre-ECGs were
available and no information is given
about arrhythmias existing before the in-
jury. Second, the number of patients is in-
sufficient in relation to the incidence of
cardiac arrhythmias in order to derive
general recommendations for ECG mon-
itoring after electrical injuries. Thus, the
present study has to be seen in addition to
previous findings. One final limitation is
that the present study is monocentric and
therefore only data of the patients that
were admitted to our hospital could be
included. Furthermore, no information is
given about patients who died before the
arrival of the emergency ambulance. That
is why the actual number of electrical ac-
cidents cannot be stated.
Conclusion for clinical practice
55Asymptomatic and stable patients
without any risk factors and with a
normal initial ECG need no inpatient
cardiac monitoring after electrical in-
jury.
55Victims of electrical injury with unsta-
ble vital functions and/or risk factors
and/or clinical symptoms and/or an
abnormal ECG should be admitted to
an emergency ward or an intermedi-
ate care/ intensive care unit (. Fig. 4).
Corresponding address
PD Dr. G. Michels
Department of Internal Medicine III,
University of Cologne
Kerpener-Str. 62, 50937 Cologne
guido.michels@uk-koeln.de
Compliance with
Ethics Guidelines
Conflict of Interest.  C. Krämer, R. Pfister, T. Boekels,
and G. Michels state that there are no conflicts of
interest.
The study was approved by the institutional ethic
committee. No informed consent was necessary as
the retrospective data were obtained within the stan-
dard diagnostic flow chart (. Fig. 4) in all patients
with electrical injuries.
714 |  Medizinische Klinik – Intensivmedizin und Notfallmedizin 8 · 2016
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