Biomarkers in Cardiology Research

Biomarkers in Cardiology Research

30th Annual Emergencies in Medicine Conference, March 4 - 8, 2012, Hyatt Escala Lodge, Park City, UT

Martin Möckel, M.D., PhD and Julia Searle, M.D. Charité – Universitätsmedizin Berlin

Department of Cardiology and Emergency Medicine UnitBerlin, Germany

Shock to the Heart!Electric Current and Cardiac Injury


30th Annual Emergencies in Medicine Conference, March 4 - 8, 2012, Hyatt Escala Lodge, Park City, UT

None

Disclosures


Electrical injuriesGermany: • ~ 4000 severe electrical injuries/year, 50-60 lethal• Majority are domestic accidents,

mainly due to human failure• ~80 % low voltage (3% lethal), •~ 20 % high voltage (30% lethal) • Men > women • 20% in children under the age of 7 years

In the U.S.: •> 500 deaths per year, ~50% workplace accidents (4th leading cause of work-related traumatic death•>200 deaths at home /year – mainly malfunction of devices and misuse•>2000 cases of burns in children requiring treatment


Scientific evidence: Case Reports3 Case ReportsJensen, P. J., et al. "Electrical injury causing ventricular arrhythmias." Br.Heart J. 57.3 (1987): 279-83.

Severe, ongoing ventricular arrhythmia after electrical injury

but

in all patients onset of arrhythmia with a delay of 8-12 hours after the accident

•43-year old electrician, 3000V current from one hand to the other

12 hours after the incident: Patient collapses playing football

Further episodes after 6 days and 6 months


Scientific evidence: Case Reports

• 43-year old woman with electrical injury (380V), electrical current from hand to hand, 8 hours after the incident, the patient experiences dizziness and palpitations, from then on further daily attacks over the next two months.

• 34-year old man, electrical current from left hand to right shoulder. After 12 hours chest pain and palpitations. From then on regular ventricular arrhythmias with declining frequency over 2 years.


Scientific evidence: Clinical trials

• 48 patients after high voltage accidents (>1000V)

• No serious cardiac arrhythmias in any patient with normal ECG on admission (during the first 24 hours after admission)


Scientific Evidence: Clinical trials

Arrowsmith et al. 1997 (Swansea, UK)

• retrospective review of 145 patients with electrical injury within 5 years (88% low voltage accidents)

• 72% with 12-lead ECG, of these 73% with 24-hour cardiac monitoring

• 4 patients with arrhythmias:

• in 3 patients occasional ectopic beats, settled within 24 hours

• in 1 patient atrial fibrillation after high voltage accident, settled after digoxin medication

In all 4 patients ECG changes were present at admission

Initial unconsciousness and high voltage increased risk for arrhythmia

Conclusion: In patients with a normal ECG at admission and no history of loss of conciousness, cardiac arrhythmias are not to be expected

Arrowsmith, J., R. P. Usgaocar, and W. A. Dickson. "Electrical injury and the frequency of cardiac complications." Burns 23.7-8 (1997): 576-78.


Scientific Evidence: Clinical trialsBailey et al. 2007 (Quebec, Canada)

• 134 patients from 21 Emergency Departments over a 4-year period with previously identified theoretical risk factors of significant electrical injury

•transthoracic current

•tetany

•loss of consciousness

•voltage source > or =1000 V (n=13)

11% (n=15) patients with abnormal initial ECGs

No patient developed potentially lethal late arrhythmia during the 24 hours of cardiac monitoring

Asymptomatic patients with transthoracic current/and or do not require cardiac monitoring, whilst patients with high voltage accidents and patients with initial consciousness (sign of arrhythmia) should be monitored

Bailey, B., P. Gaudreault, and R. L. Thivierge. "Cardiac monitoring of high-risk patients after an electrical injury: a prospective multicentre study." Emerg.Med.J. 24.5 (2007): 348-52.


Scientific Evidence: Clinical trials

Proposal by Blackwell et al. after 3 year prospective audit of 212 presentations to the ED with low voltage electrical injury

Implementation of a new management protocol which led to a massive reduction of hospital admissions

Blackwell N, Hayllar J. A three year prospective audit of 212 presentations to the emergency department after electrical injury with a management protocol. Postgrad Med J, 2002


Guidelines


Study Hypothesis

Patients after electrical injury

without significant concomitant injuries

without significant ECG changes

without concomitant injuries requiring hospital admission

will not develop further, specifically cardiac complications and are allowed to be discharged from the Emergency Department


Study Design

All patients of all ages with a main hospital diagnosis

ICD-10- Code T 75.4 (Electrocution)

admitted to the Charité University Hospital Berlin, Campus Virchow Klinikum between January 2001 and December 2008

Patient chart review:

Type of current and severity of electrical injury

Complications and concomitant injuries at admission

Cardiac monitoring

In-hospital complications

In-hospital-Outcome

268 patients in an eight-year period


Patients with electrical injuries wereyoung and of male gender

Median age: 23 years (25th percentile 6 years/ 75th percentile 35 years)

29%

71%

Minimum Age 10 monthsMaximum Age 92 years

29%

71%


30% of our patients were children under the age of 7 years


Most electricals accidents occured in the domestic environment

63%

37%


Current sources

• 81% human failure

• 10% faulty electrical device


50% of our patients made their own way to the ED

6 %

24 %


Severity of electrical injuries• 94.4% low voltage accidents, 3% high voltage (>500 V)

• Entry of electrical current in 94% arm/hand, exit of current in 84% not available

Burns:

I° burns: 2%

II° burns:7%

III° burns: 0.7% (n=2)

IV° burns: 0.4% (n=1)


Severity of electrical injuries3% (n=8) high voltage accidents (>500 V), n=6 of them work-related

• 3 patients with burns (1 x I°, 2 x II°), 2 patients with electrical marks (entry and exit)

•2 patients initially unconscious

•3 patients with serious injuries (head trauma, keratitis photoelectrica, fractures of spine and rib + pneumothorax)

•ECG at admission:

•2 patients with tachycardia, 1 patient with bradycardia

•2 patients with unspecified ST deviations

• Laboratory at admission:

•3 patients with CK-elevation (1 patients + CK-MB elevation), after 6-12 hours 2 patients with CK-elevation, no CK-MB elevation

All patients were monitored overnightBiomarkers in Cardiology Research

No patient experienced cardiac arrhythmias during the monitoring period except for one patient with a nocturnal sinus bradycardia


Findings on admission• 1% (n=2) of our patients had initially been unconscious

ECG at admission:

•1% (n=3) with singular supraventricular extrasystolies

•1% (n=3) with singular ventricular extrasystoles

•1% (n=3) with first degree AV-Block

Laboratory values at admission:

• CK increase in 19 % of patients (tested in 78% of patients)

• Myoglobin increase in 2 % (n=5) patients (tested in 78% of patients)

• Troponin increase in 2 patients (tested in 78% of patients)

CK increase associated with concomitant injuries

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In-hospital findings

Subsequent ECG (available in 61% of patients):

• n=1 new incomplete right bundle branch block (RBBB)

•n=1 new incomplete RBBB plus singular supraventricular extrasystoles

• n=1 new incomplete RBBB plus singular supraventricular extrasystoles plus Couplets

Subsequent laboratory values:

• CK increase in 7 % of patients (tested in 38% of patients)

• Myoglobin increase in 1 patient (tested in 38% of patients)

• Troponin increase in 1 patient (tested in 38% of patients)

http://www.whereismydoctor.com/images/guides/Image/ECG_0.jpg

http://www.visualphotos.com/photo/1x4249396/vial_of_blood_sample_700-00167340.jpg


Case Report I: A typical case with mild ECG abnormalities

25 year old, male electricianElectrical injury with a non-insulated power cable (4th electrical injury of his life)No loss of consciousness, no concomitant injuries, no electric markNo symptoms and complaints at presentation to the EDAll laboratory values within normal range (including troponin and CK)ECG: unspecific ST-elevation in II, III, V2-V6, new incomplete right bundle branch block in follow-up ECG 6h after admission


Case Report I

ECG at atmission (I,II,III, aVR, aVL, aVF)


Case Report I

ECG at admission (V1-V6)


Case Report I

ECG 6 hours after admission (I,II,III, aVR, aVL, aVF)


Case Report I

ECG 6 hours after admission (V1-V6)

New incomplete RBBB

Outcome:The patient spent one night at an intensive care unit with continuous cardiac monitoring and was discharged without arrhythmias or complications.


Case Report II: A severe case

33 year old, male patientDomestic electrical injury while repairing a toaster which was purchased on a flee market.

Patient is found unconscious, at arrival of emergency physician at his home very low ventricular fibrillation, almost asystole.

Electric mark on index finger and thumb, right hand. After successful resuscitation, the patient is transferred to the ICU.


Case Report II: A severe case

ECG at admission

Outcome:The patient initially develops multi-organ failure, but no cardiac complications or further arrhythmias. After 2 weeks he is discharged with a mild neurologic deficit.


Case Report III: An unusual case

15 year old, male patient is admitted to the Emergency Department and reports an “electrical injury” with consecutive syncope.He reports to have fallen against an electrical fence in an animal park and to subsequently having fainted.Extensive medical history with (amongst others) transposition of the great vessels (TGV), switch surgery and known ventricular arrhythmias with intermittent couplets

Outcome:Hospital admission for observation and monitoring. Sinus bradycardia at night (45 bpm) but no ventricular arrhythmias. Multiple PVB and couplets in 24h ECG, probably not related to electrical injury.


Case Report IV: Biomarker abnormalities

40 year old, male patient with a domestic electrical injury while repairing a washing machine, voltage unknown (220 or 380 V)

No initial unconsciousness, no symptoms or complaints at presentation.

Troponin at admission elevated to 0.21 µg/L and mild ST-elevations V2-V6 in the initial ECG.


Case Report IV

Outcome:ECG and troponin back to normal after 6 hours. No cardiac arrhythmias in 24h cardiac monitoring, patient is discharged on the next day.

ECG at admission


Case Report V: Burns IV°

18 months old girlManaged to get hold of an electric cable from her cot and to rip the cable out of the wall, the girl is found crying with cable in hand.3rd and 4th degree burns on right hand, electric marks on 3 fingers. No ECG/cardiac abnormalities at presentation.

Outcome:Hospital admission, initially with 24h continuous monitoring. Later during hospital course debridement and skin transplantation.No cardiac arrhythmias throughout hospital stay


Conclusion:

This is one of the few larger scale studies evaluating the occurrence of late arrhythmias after electrical injury.

In our cohort, consisting of all 268 patients who were admitted to the Charité Berlin, CVK, Germany, with an electrical injury over an 8 year period,

NO patient experienced major cardiac arrhythmias during the continuous monitoring.


Conclusion:

Unless concomitant injuries or other diseases warrant hospital admission,

it seems to be safe to discharge patients

24-hour Monitoring after Electrical Injury– Sense or Nonsense?

J. Searle, A. Slagman, W. Maass, M. MockelCharité - Universitätsmedizin Berlin, Department of Cardiology CVK and Emergency Medicine CVK,CCM, Berlin, Germany

Introduction:For fear of late arrhythmias, it has become current practice to admit patients after survived electrical injury to intensive care or observation units for continuous cardiac monitoring. Yet, evidence for the necessity of this costly measure has never been established. So far, reports on late cardiac arrhythmias after electrical injury originate from case reports (e.g. Jensen et al. 1987), whereas clinical studies never found a relationship between the two. Yet, all trials so far, investigated low patient numbers (Purdue et al. 1986, 48 pts.; Arrowsmith et al. 1997, 145 pts.; Bailey et al. 2007, 120 pts.).

Methods:A retrospective case note review was performed of all patients who were admitted to the Charité Campus Virchow Klinikum (CVK), a University hospital in Berlin, Germany after electrical injury. For this, the hospital information system was screened for patients with a main hospital diagnosis ICD-code T75.4 (electrical injury). Thus, 268 patients who were admitted to between 2001 and 2008 with electrical injury were identified.

Hypothesis:Patients, who present to the Emergency Department after survived electrical injurywithout life-threatening arrhythmias or significant ECG-changes at presentation and

without concomitant injuries or diseases or injurieswill not develop electrical injury-related cardiac complications

and therefore do not require hospital admission and continuous cardiac monitoring.

Results II: Causes for electrical injuriesMost electrical accident occur in the domestic environment rather than being work-related (Figure 1). This is reflected by the distribution of causes as shown in figure 2.

Results I: Patient characteristicsA total of 268 patients with electrical injury were enrolledMedian Age 23 years (25th %ile 6 years / 75th %ile 35 years), min. 1 year, max. 92 years. 30% of patients were children at an age < 7 years (figure 1).The majority of patients were male (figure 2)

Results IV: 94% of the accidents occured with low voltage. Severe injuries were rare in our cohort as is represented by the mode of arrival (figure 5) and the skin alterations caused by the electric current (figure 6); 2% of patients had I° burns, 7% had 2° burns, and only 2 and 1 patients had III° and IV° burns respectively.

Results V: OutcomeAll 268 patients were admitted to an intensive care or observation unit and had 24 hours continuous cardiac monitoring. The only abnormality was a sinus bradycardia of 45bpm during the first night of hospitalization.

Case Report I: A typical case with mild ECG abnormalities25 year old, male electricianElectrical injury with a non-insulated power cable(4 th electrical injury of his life)No loss of consciousness, no concomitant injuries, no electric markNo symptoms and complaints at presentation to the EDAll laboratory values within normal range (including troponin and CK)ECG: unspecific ST-elevation in II, III, V2-V6, new incomplete right bundle branch block in follow-up ECG 6h after admission

Results III: Cardiac diagnostics at presentation and during the hospital stayOnly two patients were initially unconsciousA total of 9 patients had an abnormal ECG at presentation • singular supraventricular extrasystoles (n=3)• singular ventricular extrasystoles (=3)• AV-block I° (n=3).A follow-up ECG was performed in 61% of the patients, 3 patients showed abnormalities:• new incomplete right bundle branch block (n=1)• new RBBB and singular supraventricular ES (n=1)• new RBBB and singular ventricular ES (n=1)CK was measured in 78% and was elevated in 19% of these patients.Troponin was measured in 78% and was elevated in 2 of these patients.Myoglobin was measured in 78% and elevated in 5 patients.

Outcome:The patient spends one night at an intensive care unit with continuous cardiac monitoring and is discharged without arrhythmias or complications.

Case Report II: An unusual case15 year old, male patient is admitted to the Emergency Department and reports an “electrical injury” with consecutive syncope.He says he fell against an electrical fence in an animal park and subsequently fainted.Extensive medical history with (amongst others) transposition of the great vessels (TGV), switch surgery, known ventricular arrhythmias with couplets

Case Report III: Burns IV°18 months old girlManaged to get hold of an electric cable from her cot and to rip the cable out of the wall, the girl is found crying with cable in hand.3rd and 4th degree burns on right hand, electric marks on 3 fingers. No ECG/cardiac abnormalities at presentation.

Index ECG ,case report I Follow-up ECG, case report I

Case Report VI: A severe case33 year old, male patientDomestic electrical injury while repairing a toaster which was purchased on a flee market. Patient is unconscious, at arrival of emergency physician at his home very low ventricular fibrillation, almost asystole. Electric mark on index finger and thumb, right hand. After successful resuscitation, the patient is transferred to the ICU.

Outcome:The patient initially develops multi-organ failure, but no cardiac complications or further arrhythmias. After 2 weeks he is discharged with a mild neurologic deficit.

Outcome:Hospital admission for observation and monitoring. Sinus bradycardia at night (45 bpm) but no ventricular arrhythmias. Multiple VES and couplets in 24h ECG, probably not related to electrical injury.

Outcome:Hospital admission, initially with 24h continuous monitoring Debridement and skin transplantation.No cardiac arrhythmias throughout hospital stay

Case Report IV: Biomarker abnormalities40 year old, male patient with a domestic electrical injury while repairing a washing machine, voltage unknown (220 or 380 V)No initial unconsciousness, no symptoms or complaints at presentation. Troponin at admission elevated to 0.21 µg/L and mild ST-elevations V2-V6 in the initial ECG.

Outcome:ECG and troponin are back to normal after 6 hours. No cardiac arrhythmias in 24h cardiac monitoring, patient is discharged on the next day.

Index ECG ,case report IV

Conclusion: This is the first larger scale study evaluating the occurrence of late arrhythmias after electrical injury. In our cohort, consisting of all 268 patients who were admitted to the Charité Berlin, CVK, Germany, with an electrical injury over an 8 year

period, NO patient experienced major cardiac arrhythmias during the continuous monitoring. Unless concomitant injuries or other diseases warrant hospital admission, it seems to be safe to discharge patients after initial assessment.

ESC Congress, Paris, August 2011, Postersession 7, 31/08/2011, Poster Zone C

Figure 3: cause of electrical injuries Figure 4: Distribution of specific causes Figure 1: Age distribution Figure 5: Mode of arrival at the hospital Figure 6: Skin alterations caued by electric´current

Index ECG , case report VI Index ECG, case report VI

Figure 2: Gender distribution


Thank you for your attention!


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Biomarkers in Cardiology Research