Severe
Injury
and Death
Associated
With
Home
Infant
Cardiorespiratory
Monitors
Murray
L. Katcher,
MD, PhD, Mary Melvin
Shapiro,
MA,
and Connie
Guist, RN, BSN
From the Department of Pediatrics, University of Wisconsin Center for Health Sciences and the State of Wisconsin Division of Health, Madison; and the Wisconsin Sudden Infant Death Syndrome Center, Department of Pediatrics, Medical College of Wisconsin,
Milwaukee
ABSTRACT. Five cases of electrical injury to young chil-dren caused by misuse of components of home cardiores-piratory monitors are reported. The injuries, which in-cluded one electrocution, occurred when partially or com-pletely disconnected electrode wires were inserted, by an older monitored child or preschool-aged sibling, into a live power cord or an uncovered wall outlet. Anticipatory guidance of home monitor users should emphasize poten-tial electrical injuries and appropriate injury-control be-haviors. Pediatrics 1986;78:775-779; apnea of infancy,
injury control, accident prevention, electrical burn, cardi-orespiratory monitors.
Infants with abnormal ventilatory patterns or altered chemical control of respiration are at risk for consequences that range from minor neurologic damage to death. These risks have led the American Academy of Pediatrics and others to recommend use of home electronic cardiorespiratory monitors and to publish guidelines for their use.”2 However, their presence in a home is not risk free.
We recently became aware of five cases of severe electrical injury, including one death, resulting from the misuse, by a young child, of electrode lead wires or the power cord from a home monitor. The pur-poses of this report are to alert the medical com-munity to this hazard and to suggest ways to pre-vent these injuries.
Received for publication April 9, 1986; accepted June 2, 1986. Reprint requests to (M.L.K.) Department of Pediatrics, Univer-sity of Wisconsin, Clinical Sciences Center, 600 Highland Aye, H6/446 Madison, WI 53792.
PEDIATRICS (ISSN 0031 4005). Copyright © 1986 by the
American Academy of Pediatrics.
MATERIAL AND METHODS
Sources of Data
A letter dated May 15, 1985, from the Vermont Infant Apnea Program to the Wisconsin Division of Health first informed us of the monitor-related electrocution of an infant (case 3), and the Wiscon-sin Sudden Infant Death Syndrome Center re-printed the notice in its newsletter.3 The newsletter was distributed throughout the state to monitor dealers, to families monitoring subsequent siblings of victims of sudden infant death syndrome (SIDS), to hospitals with infant apnea programs, and to other interested parties. This notification resulted in our being informed about two previously unre-ported cases from the Madison, Wisconsin, area (cases 1 and 2). A letter from the Food and Drug Administration, Center for Devices and Radiologic Health, dated June 21, 1985, informed us of two additional injuries (cases 4 and 5).
In an attempt to find other cases in Wisconsin, as well as to alert health professionals, a letter dated June 28, 1985, was sent by one ofus (M.L.K.) to all pediatricians, family practitioners, city and county public health agencies, and hospitals in Wis-consin. Newspaper articles in several Wisconsin cities informed consumers of potential danger.
The records of admissions related to electrical burns, involving individuals 18 years of age or younger for the period between January 1, 1970, and July 1, 1985, were reviewed for all four Madi-son, Wisconsin, hospitals (excluding the Veterans Administration Hospital), in a search for injuries related to cardiorespiratory monitors.
searched on July 1, 1985, for injuries to individuals
18 years of age or younger involving electric wire or wiring systems (product No. 0605) or medical mon-itoring systems (product No. 2476): (1) National Electronic Injury Surveillance System, injury sta-tistics reported by a representative sample of emer-gency rooms; (2) Death Certificate Data Base, deaths enumerated by International Classification of Diseases codes that have a high probability of being product related; (3) Reported Incidents Data Base, a listing of product-related injuries or deaths reported to US Consumer Product Safety Commis-sion through consumer complaints, news clippings, medical examiners and coroners, the American Trial Lawyers Association, Underwriters Labora-tory, Consumers Union, and government agencies; and (4) the data base of Accident Investigations. The search of the National Electronic Injury Sur-veillance System, the Death Certificate, and the Accident Investigations data bases covered the pe-nod of 1973 to July 1985; the search of the Reported Incidents Data Base covered the period of 1978 to July 1985.
RESULTS
Except for the five cases mentioned before, no additional cases were found from the review of local hospital records for more than 15 years, from the review of the four national US Consumer Product Safety Commission data bases, from our statewide request to report, or from a review of the medical literature. Recent communication with the Food and Drug Administration’s Center for Devices and Radiologic Health made us aware of a sixth case, not discussed in this report, in which a monitored child received full-thickness burns to the chest at the electrode sites. Further details of the injury scenario have been withheld (A. Thomas, Center for Devices and Radiologic Health, personal com-munication, 1986).
CASE REPORTS
Case I
This white boy was born after a 32-week gestation to a 19-year-old gravida 1 woman. After an initial period of respiratory distress syndrome, requiring mechanical yen-tilation, the infant remained in the neonatal intensive care unit for 71 days because of prolonged central apnea. He was discharged on a regimen of theophylline and a home cardiorespiratory monitor. The theophylline dose was gradually decreased, and at 8 months of age the child was taken off the monitor. Three weeks later he had an episode of cyanosis, considered to have been caused by obstructive apnea, and the home cardiorespiratory mon-itoring was resumed. At 24 months of age, a tonsillectomy
was performed, and his airway function improved mark-edly. The home monitoring was continued until 30 months of age.
At
18 months of age, he was out of his crib at approx-imately 3 PM and discovered a damaged electrode lead wire that had been left next to his monitor. Picking up the useless wire, he inserted one end of it into an electricwall outlet. Upon hearing a loud popping sound, his
mother ran from an adjacent room into the bedroom. She discovered an electrical fire and her unconscious son, who was having a convulsion. Finding no apparent pulse or respiration, the mother administered cardiopulmonary resuscitation for 1#{189}minutes. The emergency medical service was called, which transported the child to a pe-diatric intensive care unit, where he stayed for 1#{189}days. He was hospitalized for a total of three days, during which time he had minor arrhythmias. The deep second-degree burns he received involved an area from his thumb through his fourth finger; the burns healed without resid-ual damage.
Case 2
This second born of identical twin white boys was born at 30 weeks’ gestational age to a 24-year-old gravida 3, para 1, abortus 1 woman; his birth weight was 1,830 g. A paternal uncle was purported by the family to have died of SIDS, but the cause of death was unconfirmed by us. The child had a mild case of respiratory distress syn-drome; no ventilatory support was required. However, episodes of apnea and bradycardia developed, and he remained in the neonatal intensive care unit for approx-imately 10 weeks. He was discharged with a home cardi-orespiratory monitor because of continuing apnea and bradycardia; the monitor continues to be used at the time of this writing (36 months of age).
On the day of the electrical injury at 23 months of age, the child awoke at 7:30 AM with his electrode lead wire completely unfastened at both ends, that is, from the belt that held the electrodes in place and from the patient cable, which in turn was connected to the monitor. He crawled out of his bed, unplugged the monitor charging box from the wall outlet, and inserted both ends of the lead wire into the outlet. The power surge not only caused second-degree burns to his first three digits and to his thenar area but also threw him across the room. Both twins cried, causing their mother to enter the bedroom, where she discovered the plastic-coated wire still burning in the wall outlet. She shut off the power from a nearby fuse box and quickly immersed the burned hand in water. The child was subsequently taken to his physician and required ten days of outpatient burn management. His burns healed with no permanent damage.
Case 3
the parent left the room briefly, the infant’s 4-year-old sibling picked up the electric power cord that was still plugged into the wall outlet but which had previously been disconnected at the other end from the monitor. The older sibling then plugged the loose end of the electrode lead wire into the “live” electric power cord, thereby causing the infant’s death by electrocution.
Case 4
The 2#{189}-year-old sibling of an infant on a home cardi-orespiratory monitor picked up an unattached electrode lead wire and inserted the wire into a wall socket. The sibling received a second-degree burn to the left hand.
Case 5
A 2-year-old boy disconnected his monitor electrode lead wires from the patient cable. With his electrode lead wires still attached to his chest, he left his bedroom and entered a room in which a tape recorder was located. He unplugged the tape recorder from an extension cord con-nected to a wall outlet and then plugged the loose end of his wire into the “live” extension power cord. He suffered third-degree burns to his chest at the electrode site.
DISCUSSION
Medical electric monitoring equipment may cause electrical injuries through malfunction or im-proper grounding4 or electrolytic burns under skin
electrodes.5
However, the injuries and deathre-ported here were not caused in these ways. Rather, disconnected components of the cardiorespiratory monitors were misused. One pattern of misuse in-volved “live” power cords, and another involved electric wall outlets.
When correctly used, the electrode lead wires from the monitored child are plugged into the pa-tient cable, which in turn connects to the cardi-orespiratory monitor (Figure). In case 3, the elec-trode lead wires were mistakenly plugged into the power cord that was designed to connect the mon-itor to the electric wall outlet. The electric current flowed directly from the wall outlet, through the monitor power cord, to the electrodes affixed to the infant’s chest, bypassing the monitor. In case 5, the electrode lead wires were plugged by the monitored child into a “live” extension cord. The remaining three injuries (cases 1, 2, and 4) occurred when completely disconnected electrode lead wires were inserted into wall outlets.
Several types of factors seem to have contributed to the occurrence of these electrical injuries. First, electric power cords pose a risk. They are known to be attractive to young children and to have caused injury to them.6 Most notable are the very serious oral commissure burns that occur when a young child bites a cord or puts the end of a “live” cord
into his mouth.79 Some electrical burns and shocks could be avoided by eliminating exposure of the “live” end of a power cord. In addition, the power cord should never be disconnected from an electri-cal appliance (including the cardiorespiratory mon-itor) without also being unplugged from the wall outlet and put away. Perhaps cardiorespiratory monitors could be redesigned so that the power cord would remain permanently attached to the monitor. In general, the use of extension power cords in a home should be discouraged.
A second risk factor is the presence in the home
of a somewhat older (>9-month-old) child, whether it is the child being monitored or an older sibling. These children are physically capable of imitating their parents’ behavior, albeit incorrectly or map-propriately, such as plugging wires into cords and using wall outlets. Older siblings (described as “jeal-ous”) have in the past turned off their younger sibling’s apnea monitor.1#{176} Parents should caution their children, whether older siblings of monitored infants or older monitored children themselves, that no one except an adult may handle any of the monitor equipment.
A third risk factor is the presence of uncovered
wall outlets, although they have been discounted as frequent sources of electrical injuries to children.’1 In this series, they were implicated in three of the five injuries (cases 1, 2, and 4). These injured chil-dren ranged in age from 18 months to 30 months. Their injuries occurred when they inserted the corn-pletely disconnected electrode lead wires into the wall outlets. The risk of such injuries may be less-ened in several ways. First, accessibility to wall outlets can be reduced by the use of plastic plugs or caps for the outlets. Second, the power outlet serving the cardiorespiratory monitor should be fitted with a ground fault interrupter. Third, acces-sibility to the electrode lead wires can be minimized by keeping all unused lead wires locked up, by discarding old ones, and by disconnecting the lead wires from the monitored child rather than from the patient cable when the child is not actually being monitored. An attempt has recently been made to redesign cardiorespiratory monitor equip-rnent so that the ends of the electrode lead wires will not fit into wall outlets or into the end of power cords.
This pEcture shows the correct way to connect the infant tothe Monitor. The ELECTRODE LEADS are plugged into the PATIENT CABLE which in turn connects to the MONITOR. The MONITOR is
connected to the WALL SOCKETby the POWER CORD.
A.
POWER CORD
Dangerous
Situations
These pictures show situations inwhich accidents can occur. The ELECTRODE LEADSca be incorrectly plugged into:
A.the POWER CORD
B. aWALL SOO(ET
C.a household EXTENSION cORD, or other appliance cord
instead of being pluggedinto the PATIENT CABLE.
WALL SOCKET
C.
B.
..
,,
-
#{163}lsctrod.EXTENSIONCORD
Correct
Connections
Figure. Correct and dangerous connections of cardiorespiratory monitor lead wires. (Illustration courtesy of the Food and Drug Administration, Center for Devices and Radiologic Health, and may be reproduced without permission.)
Product Safety Commission data bases because they were not caused by monitor malfunction.
In the past, health professionals have been
con-cerned about the psychologic and social impacts of home monitoring,’#{176}”2’4 and guidelines for counsel-ing parents have emphasized these.2”5 Similar em-phasis should be placed on prevention of monitor-related injuries at the initial family orientation to the monitor. In addition, information such as that included in the Figure should accompany all cardi-orespiratory monitors at the time of purchase or rental to alert families to this danger.
SUMMARY
1. All electric power cords should be unplugged from the wall outlet and put away when not in use. (This warning applies to cardiorespiratory monitor power cords, to extension cords, and to other de-tachable electric appliance power cords.)
2. Electrode lead wires should be either com-pletely connected (to the monitored child and to the patient cable or cardiorespiratory monitor) or completely disconnected and put out of reach.
3. Older children, whether a sibling or the mon-itored child, should not be left unsupervised in the daytime when a child is wearing monitor equip-ment.
4. Children should be warned specifically not to handle any monitor components.
5. Children should be warned not to insert any object into wall outlets or electric cord sockets, and, when not in use, wall outlets should be covered with safety covers.
ACKNOWLEDGMENTS
We thank Nancy Kaufman, RN, for first making us
aware of this problem; Kathy Condit, RN, for informing us about cases 1 and 2; Joel Friedman for providing us with Consumer Product Safety Commission data; and Al Thomas in the Food and Drug Administration, Center for Devices and Radiologic Health, for making the illus-tration available to us. We acknowledge the personnel in the medical records departments of Madison General, Methodist, St Marys, and University of Wisconsin
Hos-pitals.
REFERENCES
1. American Academy of Pediatrics, Task Force on Prolonged Infantile Apnea: Prolonged infantile apnea: 1985. Pediatrics 1985;76:129-131
2. Wisconsin Apnea Task Force: Prolonged Infantile Apnea: Guidelines for Evaluation and Intervention. Madison,
Wis-consin Department of Public Instruction, bulletin No. 4066,
1983
3. Wisconsin Sudden Infant Death Syndrome Center: Wis Perspect 1985;4(2):15
4. Hull CJ: Electrical hazards in monitoring. list Anesthesiol Clin 1981;19:177-195
5. 0rpm JA: Unexpected burns under skin electrodes. Can Med Assoc J 1982;127:1106
6. Oeconomopoulos CT: Electrical burns in infancy and early
childhood. Am J Dis Child 1962;103:67-70
7. Thomson HG, Juckes AW, Farmer AW: Electric burns to the mouth in children. Plast Reconstr Surg 1965;35:466-477
8. Pitts W, Pickrell K, Quinn G, et al: Electrical burns of lips and mouth in infants and children. Plast Reconstr Surg 1969;44:471-479
9. Gifford GH, Marty AT, MacCollum DW: The management of electrical mouth burns in children. Pediatrics
1971;47:113-119
10. Wasserman AL: A prospective study of the impact of home monitoring on the family. Pediatrics 1984;74:323-329
11. Young TL, Reisinger KS: Wall socket electrical burns:
Rel-evance tohealth education? Pediatrics 1980;65:825-827
12. Bergman AB, Beckwith JB, Ray CG: The apnea monitor business. Pediatrics 1975;56:1-2
13. Black L, Hersher L, Steinschneider A: Impact of the apnea
monitor on family life. Pediatrics 1978;62:681-685
14. Cain LP, Kelly DH, Shannon DC: Parents’ perceptions of
the psychological and social impact of home monitoring. Pediatrics 1980;66:37-41
15. Barr A: At Home With a Monitor-A Guide for Parents. Chicago, National Sudden Infant Death Syndrome
