THE CURSE OF ZEUS

1. THE CURSE OF ZEUS Rami Khouzam, MD

2. The Statue of Zeus at Olympia • An enormous statue of the Greek father of gods, carved by the great sculptor Pheidias • In his right hand a figure of Victory made from ivory and gold. In his left hand, his scepter inlaid with all metals, and an eagle perched on the sceptre • The sandals of the god are made of gold, as is his robe Pausanias the Greek (2nd century AD)

3. 7 Wonders of the Ancient World • Today, archaeological evidence reveals some of the mysteries that surrounded the history of the Wonders for centuries • For their builders, the Seven Wonders were a celebration of religion, mythology, art, power, and science • For us, they reflect the ability of humans to change the surrounding landscape by building massive yet beautiful structures, one of which ( the Pyramid) stood the test of time to this very day

4. Index Case • 42-year-old white male • No significant past medical hx. except x possible marijuana • Was working on a ladder 12 feet high • Electrocuted with 440 volts • Contact burns to bilateral hands • Cardioversion done 5 times

5. Prior to arrival to the hospital: • SVT --> Cardioversion x 5 • Hypotension --> Dopamine and Epinephrine drips • Intubated • Vitals on arrival: • Pulse: 101 • BP: 71/46 • RR: 24

6. PE (pertinent findings): • Neck in C-collar • Ears: some blood behind Lt. tympanic membrane • Chest: Bilateral crackles • Heart: S1S2 RRR Few extra-beats, No m,g,r • Upper extremities: 2nd & 3rd degree burns on the palmar aspects of both hands

7. Labs: • K: 3.1, Cr: 1.1 • WBCs: 27.8  10.5 • AST/ALT: 63/54 • ABGs: 7.25/43.8/213.7/18.6/99.1% • Lactic a: 4.2 • UDS: + methamphetamine

8. Trop 1.38 2.87 1.81 • CK 989 2190 • CKMB 19.4 17.2 • CKMB index 2.0 0.8 • Myoglobin > 500 > 500

9. Swan-Ganz: • PCWP: 19 • PA: 31/14 • CVP: 15 • CO: 16 / CI: 11 • SVR: 335 • MAP: 80 • CXR: • Interstitial & alveolar pulmonary opacities centrally with relative sparing peripherally: • consistent with pulmonary edema

12. TTE on admission • Mild eccentric LVH • LV systolic function was moderately to severely decreased • EF: 25-30%

13. Day 3: • Levophed discontinued • Weaned off of the vent & extubated • Blood culture: MRSA • Day 8: • Discharged home on: pain meds & antibiotics

14. TTE (prior to d/c) • Normal left ventricular systolic function • EF: 65%

15. The Hanging Gardens of Babylon • A palace with legendary gardens built on the banks of the Euphrates river by King Nebuchadnezzar II

16. ELECTRICAL INJURIES Critical Care Medicine Volume 30.Number 11.November 2002

17. Adults in workplace, children at home • Severity of injury depends on: • Intensity of electrical current (voltage of source and resistance of victim) • Pathway through victim’s body • Duration of the contact with the source

18. Immediate death may occur from: • 1) Current-induced ventricular fibrillation • 2) Asystole • 3) Respiratory arrest secondary to: • Paralysis of the central respiratory control system • Paralysis of the respiratory muscles

19. History Overview • Lightning was attributed to supernatural powers • Zeus ruler of the ancient Greek gods holding thunderbolts which he used as warning or punishment against who disobeyed him

20. Zeus, the youngest son of Cronus and Rhea, was the supreme ruler of Mount Olympus and of the Pantheon of gods who resided there • Being the supreme ruler he upheld law, justice and morals, and this made him the spiritual leader of both gods and men • Zeus was a celestial god, and originally worshiped as a weather god by the Greek tribes

21. He has always been associated as being a weather god, as his main attribute is the thunderbolt, he controlled thunder, lightning and rain • Theocritus wrote circa 265 BCE: "sometimes Zeus is clear, sometimes he rains” • He is also known to have caused thunderstorms

22. Discovery and widespread use of electricity in the mid-1800s took away the supernatural aura • 1st electrical fatality recorded in France in 1879

23. Thomas Alva Edison was both a scientist and an inventor • Born in 1847 • When Edison was born, society still thought of electricity as a novelty, a fad. By the time he died, entire cities were lit by electricity

24. In his lifetime, Edison patented 1,093 inventions • The most famous of his inventions was an incandescent light bulb • He believed in hard work, sometimes working twenty hours a day. Edison was quoted as saying, "Genius is one percent inspiration and 99 percent perspiration"

25. In tribute to this important American, electric lights in the United States were dimmed for one minute on October 21, 1931, a few days after his death

26. Electrical injuries (excluding lightning) are responsible for > 500 deaths/year in the US • > 1/2 of them occur in the workplace. • 4th leading cause of work-related traumatic death • Electrocutions at home: > 200 deaths/year

27. Lightning responsible for 93 deaths/year in US • Morbidity 5-10 times higher than that due to other forms of electrical injury • Iatrogenic electrical injury in the ICU: defibrillators, pacemakers, electrosurgical devices • Story of CPR: how to treat electrocuted electrical linemen who were in VF

28. Principles of Electricity • Electricity: flow of electrons (negatively charged outer particles of an atom) through a conductor • When the electrons flow away from this object through a conductor they create an electric current: amperes

29. Voltage: force that causes electrons to flow: volts • Anything that impedes the flow of electrons through a conductor creates resistance: ohms

30. Power lines range from: • Low: < 600 volts • Ultrahigh: > 1 million volts • Utility power lines with high voltages in sparsely populated areas • Through a succession of transformers voltage is gradually reduced • Most homes in US & Canada have a 120/240 V other countries (Europe, Asia..): 220 V

31. The Temple of Artemis at Ephesus • A beautiful temple in Asia Minor erected in honor of the Greek goddess of hunting and wild nature

32. Pathophysiologic effects of Different Intensities of Electrical Current

34. Electrical current exists in 2 forms: • 1) AC: (Alternating Current): when electrons flow back and forth through a conductor in a cyclic fashion • It is used in household and offices and is standardized to a frequency of 60 cycles/sec (60 Hz)

35. 2) DC: (Direct Current): when electrons flow only in one direction • Used in certain medical equipment: defibrillators, pacemakers, electrical scalpels • AC is far more efficient and also more dangerous than DC (~ 3 times): tetanic muscle contractions that prolong the contact of victim with source

36. Issue of safety over efficiency: early days of electricity when Thomas Edison (who developed and popularized DC was fighting against George Westinghouse (who developed AC) • AC: first death penalty by electrocution

37. Lightning is a form of DC • Occurs when electrical difference between a thundercloud and the ground overcomes the insulating properties of the surrounding air • Current rises to a peak in about 2 µsec • Lasts for only 1-2 sec

38. Voltage >1,000,000 V • Currents of >200,000 A • Transformation of the electrical energy to heat generated temperatures as high as 50,000ºF • Extremely short duration prevents from melting

40. The Mausoleum at Halicarnassus • A fascinating tomb constructed for King Maussollos, Persian satrap of Caria

41. Determinants of Electrical Injuries • Ohm’s law: • Current = Voltage/Resistance • Exposure of different parts of the body to the same voltage  different current  different degree of damage because resistance varies

42. The least resistance is found in nerves, blood, mucous membranes and muscles • The highest resistance is found in bones, fat and tendons • Skin’s resistance ranging between 40,000 and 100,000 Ω depending on thickness • Moisture of the skin; electrocution of a person in a bathtub or swimming pool

43. Moist mucus membranes: significant orofacial injury to infants and toddlers • Nerves and blood vessels are the best conductors: path of least resistance for current after it enters the body • Duration of the contact: shock caused by AC will produce bigger injury than shock caused by DC of the same amperage

44. Pathway of the current through the body: • Vertical pathway parallel to the axis of the body is the most dangerous. It involves all the vital organs; central nervous system, heart, respiratory muscles, in pregnant women the uterus and fetus • Horizontal pathway from hand to hand: the heart, respiratory muscles and spinal cord • Pathway through the lower part of the body: local damage

45. The Colossus of Rhodes • A colossus of Helios the sun-god, erected by the Greeks near the harbor of a Mediterranean Island

46. Electrical Injury to Specific Tissues & Organs • Cardiovascular System: • Pathophysiology: • Direct necrosis of the myocardium • Cardiac dysrhythmias

47. Focal or diffuse • Widespread, discrete, patchy contraction band necrosis involving the myocardium, nodal tissue, conduction pathways and coronary arteries

48. A current > 50-100 mA with hand-to-hand or hand-to-foot transmission  ventricular fibrillation • High-voltage current (AC or DC)  ventricular asystole • Lightning  cardiac standstill • Sinus rhythm may spontaneously return

49. Cardiac dysrhythmias reported in survivors of electrical injuries pathogenesis is rather unclear, multifactorial

50. Possible mechanisms: • 1) Arrythmogenic foci due to myocardial • necrosis (esp. SA Node injury) • 2) Alterations in the Na+ - K+ adenosine triphosphatase concentration • 3) Changes in the permeability of myocyte membranes • 4) Anoxic injury (respiratory arrest precedes the injury to the heart)