Med. Electron. BioL Engng. Vol. 1, pp. 133-134. Pergamon Press, 1963.
Printed in Great Britain
LETTER TO THE EDITOR
ELECTRICAL HAZARDS IN CARDIAC
DIAGNOSIS AND TREATMENT
RECENT reports of accidental electrocution of patients
during diagnosis or surgery have focussed attention on
the risk involved when multiple leads are connected to
the body. EDITOaIAL(Lancet, 1960) cites the case of a lung
surgery patient who received a lethal 325-V shock from
an ungrounded cardiac monitor, when a grounded dia-
thermy electrode completed the current path through the
myocardium. NOORDIJKet al. (1961) have since reported
two cases where connection of electrocardiograph leads to
patients during pacemaker stimulation produced ventri-
cular fibrillation. ZOLL and LINENrnAL (1960) have
warned of the danger of connecting other equipment to a
patient undergoing pacemaker stimulation.
BUaCrtELL (1961) has summarized some of these cases
in a recent report on the hazards involved in using cardiac
pacemakers.
We have experienced two instances c i electric shock
from a somewhat less obvious cause. The first occurred
d u r i n g the development of a simplified procedure for
coronary arteriography (HoPPs et aL, 1962). Electro-
:ardiograph leads were attached to the four limbs of a
dog. A catheter was inserted into the femoral artery, over
the arch of the aorta and down to the region o f the cor-
anary-bearing sinuses. In preparation for radio-opaque
~ontrast injection, the catheter was filled with saline.
When the primed catheter was connected to the grounded
Gidlund power syringe, the animal went into immediate
ventricular fibrillation.
Subsequent investigation showed defective grounding
of the multi-channel electrocardiograph monitor. With
the chassis of the instrument ungrounded, a 60 c/s poten-
tial of 100 V r.m.s, to ground was measured, using a high
impedance voltmeter. During the 'warm up' period
before the plate voltage relay closed, there was still a
potential of about 55 V to ground.
The saline column in the catheter was obviously the
conducting medium to ground. Its d.c. resistance mea-
sured 32 k t2, while a column of 50 per cent Hypaque
measured 27 k I).
When the electrocardiograph leads were attached to a
dog, with the saline- or Hypaque-fdled catheter grounded
to the metal syringe, the 100-V open-circuit value dropped
to 45 V. Substitution of a 260-k f~ resistor for the body
and catheter produced an equivalent voltage. The
steady-state current then approximated 175 ~tA while the
instantaneous value at the moment of connection was
390 ~A.
In another instance, a 26-year-old male was under-
going cardiac catheterization under general anaesthesia,
133
for suspected pulmonary stenosis. The presence of
stenosis was confirmed and a No. 8 Institutes of Health-
type catheter with blind tip and side holes was introduced
to the right ventricle for cine-angio studies of the right
ventricular outflow tract and pulmonary valve. The
catheter was filled with saline and connected to the
Gidlund power syringe. At the moment of connection
interference obscured the electrocardioscope trace.
Rigidity was soon evidenced and fluoroscopy showed the
characteristic movement of ventricular fibrillation. The
injection syringe was disconnected and the electro-
cardiogram showed active fibrillation. Open-chest
cardiac massage was followed by countershock defibrilla-
tion, and normal contractions ensued. The pulmonary
stenosis was corrected uneventfully 3 weeks later.
In this case investigation showed that the syringe
equipment was not grounded, and that an open-circuit
voltage of 79 V r.m.s, existed between the case and ground.
The instantaneous current was calculated to be 415 izA,
and the steady-state value 270 ~zA.
These voltages were leakage potentials, attributed to
the power transformers of the instruments, or to capaci-
tors on the primary side. They were high-impedance
potentials of limited current capacity. As such they offered
little shock danger to the operator, evoking no skin
sensation. Therein perhaps lies the danger, for we are
accustomed to think that a current which cannot be felt
is quite safe. However, the myocardium has a much
lower threshold of excitation. While the steady-state
values calculated in these two cases probably were sub-
threshold, the instantaneous value of approximately
400 ~tA (r.m.s.) certainly could elicit a response in the
vulnerable period of the cardiac cycle.
The conductivity of saline or Hypaque might not
appear to constitute a hazard to catheterization in the
presence of electrical equipment, yet in the above two
cases, the resistance of the catheter column was small
compared with that offered by the body tissues. With
the equipment described, the hazard was eliminated by
installing three-pin power connectors, ensuring effective
grounding of the chassis. Cardiac stimulators may
require additional measures to avoid leakage currents
in the 'off' position.
We have experienced another electrical hazard of a
somewhat different nature. During heart surgery under
hypothermia, the electrocardiogram was monitored from
small needle electrodes in all four limbs, to eliminate
contact difficulties. Following intermittent use of the
electrocautery equipment, high frequency burns were
evidenced at the limb leads. The electrocautery equipment
was not the unit normally used in this procedure, and
examination showed that the indifferent electrode was
134 LETTER TO THE EDITOR
not grounded to the chassis and system ground. The
high frequency current had then taken a route to ground
through the electrocardiograph leads which were unpro-
tected by r.f. chokes. Because the EKG amplifier was
equipped with automatic muting during elcctrocautery
or ventricular defibrillation, it gave no warning of the
r.f. current.
In this particular electrocautery unit, no provision had
been made by the manufacturer for grounding the in-
different electrode, and it was necessary to modify the
equipment.
Ground fault monitors are used commonly in Canada
and the United States to detect low impedance faults in
operating theatre electrical equipment. They give warning
of potential shock hazards to the operating staff but
usually are insensitive to impedance faults above 150 k ft.
These faults, singly or in combination, may give rise to
currents sufficiently high to excite the heart and induce
ventricular fibrillation. The only solution to the problem
appears to be to supplement the protection offered by the
fault detector with careful inspection and grounding of
all electrical equipment used in the theatre or examina-
tion room.
J. A. HoPPS and O. Z. Roy
Radio and Electrical Engineering Division, National Re-
search Council, Ottawa, Canada.
REFERENCES
BURCHELL,H. B. (1961) Hidden hazards of cardiac pace-
makers. Circulation 24, 161-163.
EDITORIAL (1960) Fatal shock from a cardiac monitor.
Lancet 1, 872.
HoPPS, J, A., RoY, O. Z., DON, C. and BOOSVAROS,G. A.
(1962) Single-shot coronary arteriography. Med. Elec-
tron. Biol. Engng. 1 (1) 75-78.
NOORDLIK, J. A., OEY, F. T. and TEBRA, W. (1961)
Myocardial electrodes and the danger of ventricular
fibrillation. Lancet l, 975-977.
ZOLL, P. M. and LINENTHAL, A. J. (1960) Long-term
electric pacemakers for Stokes-Adams disease. Circula-
tion 22, 341-345.