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 34c. 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.