A Unique Case of Delirium Resulting From Electrical Accident-Induced Spinal Trauma

Abstract

Sir: We would like to report a unique case of onset of delirium associated with electrical injury and spinal trauma in an adult. Reviewing the literature on psychiatric complications of electrical injury, we found no report of a relationship between adult-onset delirium and electrical injury. Case report. Mr. A, a 25-year-old man, was admitted to our hospital in 2006 after having suffered an electrical injury with loss of consciousness and falling on his back from a height of 6 m. He received an electrical shock (25,000 V) for 12 to 15 seconds. On admission, the patient was extremely agitated and his consciousness was very confused. No motor activity deficits were present. His cardiac and biochemical examinations revealed no abnormalities. Chronic drug use history was absent. A burn of approximately 1 × 1 cm was identified on the right thumb, and an 8 × 10 cm burn was exhibited on the left leg below knee. The head computed tomography also exhibited no abnormalities. His lumbar vertebral tomography revealed third lumbar vertebra burst fracture. On day 2 after electrical injury, when sedation was discontinued, he began experiencing severe acute confusion, in which he screamed and manifested difficulty staying asleep. He felt extremely irritable. His thought process was not logical and fluctuated during the course of the day. The patient underwent psychiatric consultation and was diagnosed as having delirium (based on his history and clinical findings). His acute confusion was not controlled with heavy-sedation–inducing administration of haloperidol 2 mg/mL (10 drops orally) twice daily for 7 weeks. Owing to resistant irritability, quetiapine tablets 25 mg twice daily were administered additionally. After 3 weeks on treatment with haloperidol and quetiapine, the patient has remained better. Although Baqain et al.1 stated that an electrical current can produce nerve lesions, the mechanisms involved in the pathogenesis of neurologic damage after electrical trauma are unknown. Many patients with high-voltage electrical trauma suffer a bony displacement due to electrostatic repulsion, and a vertebral fracture may be evaluated. In our patient, however, we thought that the fracture was due to the fall. Bergman and Coletti2 defined delirium (acute confusion) as diffuse impairment of higher cortical function characterized by a sudden onset of disordered cognition, dysfunction of the reticular activation system, and disturbed psychomotor behavior. Disturbance develops during a short period (usually hours to days) and tends to fluctuate during the course of the day, as it did in our patient. Bergman and Coletti2 stated that decline in cho-linergic activity may play a major role in the development of delirium. Treatment with anticholinergic drugs, opioids, anti-parkinsonism agents, histamine-2 receptor blockers, cardiovascular agents, antibiotics, anticonvulsants, anti-inflammatory agents, or oral hypoglycemic agents may reveal acute confusion, especially in elderly people. However, our patient was young and exhibited the clinical symptoms preoperatively; thus, drug or surgical etiology cannot explain his condition. The patient was diagnosed as having delirium according to clinical findings. We thought that the pathway followed by the electrical current might have caused an acute decline in cholinergic system function and was responsible for the neurologic damage. Finally, the diagnosis of delirium after electrical injuries is based on the patient's history and clinical findings. Ghaemi et al.3 reported parasomnias, Pliskin et al.4 reported narcolepsy and posttraumatic depression, and Khanna et al.5 reported mania associated with electrical injury, but none of these reported delirium. The most interesting part of this case was that although the high-voltage electricity entered his body from his right thumb and came out from his left leg under his knee, he showed a unique case of delirium associated with his head.