Electrical injuries

[RUOkie]

Saw a very interesting pt today.

21 year old turned on a shop vac at work in April 2010. Apparently someone had plugged the extension cord into a non-grounded 220V outlet (by altering the plug). The vac blew up and he had an entrance wound on the 2nd and 3rd fingers of the R hand, and an exit wound just above the Left eye.

Since then he has had headaches, severe bruxism of the Left side of the jaw and intermittent R arm/shoulder pain.

He was fit with a TMJ oral prosthesis and lost to all follow up. Last week he broke a tooth on the prosthesis.

Sent to me by work comp case manager.

On PE: mild R facial droop. atrophy of the R masseter and mild sensory deficit in the R face. His strength in the RUE was 4+ to 5- with normal sensation.

I have set him up for a MRI of the brain, and am doing EMG next week with Facial N. studies and blink reflex. Also sent him back to the dentist for adjustment. I discussed BoTox to the L masseter to try to balance out the oral mechanics, but will wait until after the EMG for that. (I also would need to find an ENT to do that)

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[Ludicolo]

Nice.

Electrical injuries are fun – never know what to expect. Hope you set aside some extra time for the EMG. Please keep us updated.

Lots o’ questions: Stable or progressive symptoms? Unilateral headaches? Did he have any temporalis atrophy as well? Sensory loss in all trigeminal distributions? Vision problems? Hemifacial spasm?

Botox to the masseter (or temporalis) isn't a bad idea, and not technically difficult. Why have ENT to do it?

 

[RUOkie]

Nice.

Electrical injuries are fun – never know what to expect. Hope you set aside some extra time for the EMG. Please keep us updated.

Lots o’ questions: Stable or progressive symptoms? Unilateral headaches? Did he have any temporalis atrophy as well? Sensory loss in all trigeminal distributions? Vision problems? Hemifacial spasm?

Botox to the masseter (or temporalis) isn't a bad idea, and not technically difficult. Why have ENT to do it?

I sched 90min for the EMG.

Sx have been stable and constant since the injury. His headaches are bilateral but worse on the Left. He thinks the bruxism is the cause. The sensory loss is mild, and in all distributions. Temporalis looked pretty normal.

It is interesting, I noticed that his R eye seemed a little lower than his left. I asked him if he noticed any difference when he looked in the mirror, and he replied "no, but my mom thinks my face is uneven now"

I guess I was thinking ENT since I have never botoxed the masseter in 15 yrs of use of neurotoxins. I have needled it a few times during EMGs though, good thought, I know that it is an easy muscle to access. We'll see how the EMG goes next wk.

 

[neglect]

Electrical injuries are very variable and pretty uncommon. You won't meet many people with experience in them. I've only seen two cases, one with no injury, the other with entry right arm, exit left arm, high current. He had transient right arm dysfunction and profound median and ulnar dysfunction on the left that never went away.

I did do a NCV, which showed only low amplitudes diffusely (which is what you'd expect in a diffuse problem along the course of the nerve). The EMG was not impressive, although it sounds like you are sure to pick up some denervation in this guy. He was actually having symptoms with no signs in the legs, so I did an MRI spine out of interest, which was neg.

I didn't want to do anything further, but both the patient and the lawyer wished for another study after a year. The study was normal except some very mild chronic EMG findings in the clinically affected muscles. His degree of dysfunction on exam was much more impressive than the electrical studies.

These EMG/NCV's are an academic exercise. I doubt you'll find anything to do anything about.