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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 265-267

Atrial fibrillation following low voltage electrical injury


1 Department of Medicine, Medical College, IPGMER and SSKM Hospitals, Kolkata, West Bengal, India
2 Department of Nephrology, IPGMER and SSKM Hospitals, Kolkata, West Bengal, India
3 Department of Medicine, ESI-PGIMSR and ESIC Medical College, Joka, Kolkata, West Bengal, India
4 Department of Dermatology, Venereology and Leprosy, IPGMER and SSKM Hospitals, Kolkata, West Bengal, India

Date of Web Publication12-Jun-2015

Correspondence Address:
Dr. Amlan Kanti Biswas
C/o, Hirendra Nath Kundu, 37 Number North Sreerampur, Garia, Kolkata - 700 084, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.158712

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  Abstract 

This is a case report of occurrence of paroxysmal atrial fibrillation (AF) in a previously healthy 50-year-old man after suffering from a nonfatal electrical injury. The patient developed palpitation and sustained nonfatal electrical burn in his right hand after coming in contact with 440 voltage alternating current. His electrocardiogram done at the emergency revealed AF. However he was hemodynamically stable and hence put under conservative therapy. He reverted back to sinus rhythm within 24 h of admission and continued to remain so. Although ventricular arrhythmia is common after electrical injury, AF has been rarely reported in literature.

Keywords: Arrhythmia, atrial fibrillation, electrical injury


How to cite this article:
Biswas AK, Banerjee A, Ghosh A, Bala S, Sengupta RS. Atrial fibrillation following low voltage electrical injury. CHRISMED J Health Res 2015;2:265-7

How to cite this URL:
Biswas AK, Banerjee A, Ghosh A, Bala S, Sengupta RS. Atrial fibrillation following low voltage electrical injury. CHRISMED J Health Res [serial online] 2015 [cited 2020 Aug 14];2:265-7. Available from: http://www.cjhr.org/text.asp?2015/2/3/265/158712


  Introduction Top


Electrical injury may produce a variety of bodily manifestations ranging from simple skin breach to severe burn. Not only skin, soft tissues and muscles, the heart can bear the brunt in various ways. Injury to the heart can occur in the form of arrhythmias ranging from supraventricular or ventricular ectopics to various forms of atrioventricular (AV) blocks as well as ventricular tachycardia and ventricular fibrillation resulting in sudden cardiac death. [1] Few authors even reported myocardial ischemic changes as well as myocardial infarction. [2] However atrial fibrillation (AF) is a rare occurrence following such catastrophe and even rarer after a low voltage alternating current injury. Here we report a case of AF initiated after a low voltage alternating current injury.


  Case Report Top


The patient is a 50-year-old male factory worker. While operating an electric driven machine he received an electric shock from alternating current of 440 V. He was previously healthy and had no cardiac problem. He was a nonsmoker and neither had any kind of addiction. He was not on any medications, nor did he have any significant medical history.

He presented at the emergency with complaint of palpitation and had grade 1 burn injury in the right hand [Figure 1]. He was conscious and hemodynamically stable. His blood pressure was 130/80 mmHg in left hand supine and pulse rate was more than 120 beats/min irregularly irregular in nature. Other vitals were normal. His systemic examination including cardiovascular and neurologic did not contribute anything new except for a variable first heart sound.
Figure 1: Electric burn injury over palmar aspect of right hand

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Electrocardiogram (ECG) revealed that patient was having AF [Figure 2]. Routine hemogram was normal and other reports were as follows: Serum Urea - 20 mg/dl, serum creatinine - 1.0 mg/dl, serum Na + - 139 mmol/l, serum K + - 3.9 mmol/l. His creatine phosphokinase (CPK) and CPK myocardial band levels were 830 IU/l and 15 IU/l respectively. Qualitative troponin-T assay was negative.
Figure 2: Image showing atrial fibrillation immediately after electric injury

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The patient was admitted to the ward and was treated conservatively. Proper care of the burn wound was taken by our surgery team. As the patient was young without any known organic heart disease, no history of hypertension, diabetes and was heamodynamically stable at the time of presentation, rate control was preferred over rythm control and the patient was given sustained release metoprolol in a dose of 50 mg orally once daily. Considering the thromboembolic risk the patient was assessed according to the "CHADS 2 visual analog scale (VAS)" score which was "0" to our patient and that is why the patient was not given any anticoagulation or antiplatelet.

The patient recovered from palpitation the very next day. On examination the pulse rate was 66 beats/min and was found to be regular. Repeat ECG showed that he had reverted back to sinus rhythm [Figure 3]. Other investigations including patient's transthoracic echocardiography and thyroid profile were normal. Metoprolol was stopped after 72 h as the patient remained in sinus rhythm. The patient was discharged after another 72 h with only medications for burn injury. He was reviewed once again after 7 days with fresh ECG and he continued to remain in sinus rhythm.
Figure 3: Image showing recovered sinus rhythm

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  Discussion Top


In our patient AF developed soon after electrocution and returned to sinus rhythm within 24 h. He was electrocuted by 440 V alternating current.

Electrical injury has been found to cause arrhythmia, myocardial ischaemia, left ventricular dysfunction, transient hypertension and even myocardial infarction and cardiac rupture. [1],[2],[3] Arrhythmias commonly found are premature ventricular ectopics, ventricular tachycardia, ventricular fibrillation, bundle branch blocks and AV blocks. [3],[4] Studies have shown that incidence of arrhythmia following electrical injury ranges from 10% to 36%. But incidence of AF following electric injury is very rare. In a study involving 182 cases of electric injury over a period of 20 years, only two cases of AF were reported and one of them required cardioversion. [2],[5]

The mechanism of occurrence of arrhythmia following electrocution is not clear. It is possible that because of difference in electrical resistance, current preferentially travel along blood vessels and nerve and makes them more vulnerable to injury. For this same reason cardiac myocytes are also similarly susceptible. Myocardial necrosis occurs following electrical injury, resulting in subsequent fibrosis, which is presumed to be the cause of the arrhythmogenic foci. [5] Altered Na + /K + pump activity along with increase in intracardiac potassium concentration have also been observed. [6] Arrhythmias may occur immediately or a few days following electrical injury. Though most commonly they are found on the 1 st day of the injury but the delayed ones are more fatal. [6],[7] Increased cardiac Na + /K + pump activity and increased concentration of serum potassium following electrical injury may be other causes of arrhythmia.

Most of the reported cases of AF occurred after electrical injury from a high voltage current source predominantly more than 10,000 V but in our case it occurred after a low voltage electric current of about 440 V. [8]

For management of AF the three main goals are considered-Rate control, rhythm control and anticoagulation to prevent thromboembolism. The 2006 AHA/ACC/ESC guideline recommended that there is no mortality advantage to a management strategy aimed at maintaining sinus rhythm. [9] Rhythm control is reserved for patient who remain symptomatic despite efforts to optimise ventricular response to AF and therefore approach to AF has evolved to focus largely on rate control and anticoagulation. [9],[10],[11],[12] So our patient was put on metoprolol and with that he responded well. Regarding anticoagulation CHADS 2 VAS score was used. As the patient was 50-year-old male without any history of diabetes, hypertension, no prior stroke, no peripheral vascular disease or coronary artery disease his score was found to be "0" and was not put on any anticoagulation or antiplatelet.


  Conclusion Top


We want to report this case to show that AF can occur even from a low voltage electrical injury.

 
  References Top

1.
DiVincenti FC, Moncrief JA, Pruitt BA Jr. Electrical injuries: A review of 65 cases. J Trauma 1969;9:497-507.  Back to cited text no. 1
[PUBMED]    
2.
Butler ED, Gant TD. Electrical injuries, with special reference to the upper extremities. A review of 182 cases. Am J Surg 1977;134:95-101.  Back to cited text no. 2
[PUBMED]    
3.
Solem L, Fischer RP, Strate RG. The natural history of electrical injury. J Trauma 1977;17:487-92.  Back to cited text no. 3
[PUBMED]    
4.
Wander GS, Bansal RK, Anand IS, Arora S, Khurana SB, Chawla LS. Atrial fibrillation following electrical injury. Jpn Heart J 1992;33:131-4.  Back to cited text no. 4
    
5.
Bøggild H, Freund L, Bagger JP. Persistent atrial fibrillation following electrical injury. Occup Med (Lond) 1995;45:49-50.  Back to cited text no. 5
    
6.
Jensen PJ, Thomsen PE, Bagger JP, Nørgaard A, Baandrup U. Electrical injury causing ventricular arrhythmias. Br Heart J 1987;57:279-83.  Back to cited text no. 6
    
7.
Arrowsmith J, Usgaocar RP, Dickson WA. Electrical injury and the frequency of cardiac complications. Burns 1997;23:576-8.  Back to cited text no. 7
    
8.
Akdemir R, Gunduz H, Erbilen E, Ozer I, Albayrak S, Unlu H, et al. Atrial fibrillation after electrical shock: A case report and review. Emerg Med J 2004;21:744-6.  Back to cited text no. 8
    
9.
Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol 2011;57:e101-98.  Back to cited text no. 9
    
10.
Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002;347:1834-40.  Back to cited text no. 10
    
11.
Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002;347:1825-33.  Back to cited text no. 11
    
12.
Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial fibrillation - Pharmacological Intervention in Atrial Fibrillation (PIAF): A randomised trial. Lancet 2000;356:1789-94.  Back to cited text no. 12
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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