Other than a few cracked ribs: An interesting case of post-cardio pulmonary resuscitation complication.

Dear Editor,

Since the development of cardiopulmonary resuscitation (CPR), unintended complications have been reported and described in the medical literature. The more common ones are related to closed chest compression.[1] There are also reports of uncommon complications that have been directly attributed to CPR such as solid organ injuries, damage to great vessels, and embolic phenomena. These rare complications are as life-threatening as the cause of the arrest itself and should therefore be considered in post-CPR care.

We have presented a case of a 48-year-old female with a history of cirrhotic liver disease from alcohol abuse, who was admitted to intensive care unit (ICU) for multiple episodes of hematemesis. She received blood products and underwent endoscopic banding for varices. On her third day of hospitalization, she was intubated for hypoxia and was treated for aspiration pneumonia. However, despite adequate antibiotic treatment, the patient failed daily spontaneous breathing trials. On the eleventh day of hospitalization, a bronchoscopy was done and blood clots were noted mainly in the right main stem bronchus causing atelectasis. The clots were then removed and, immediately after the procedure, the patient became hypoxic and went into pulseless electrical activity (PEA). Return of spontaneous circulation was achieved after 1 cycle of CPR. Work-up ruled out other etiological causes of the arrest (electrolyte abnormalities, acute coronary syndrome, and PE).

Two hours from the arrest, her hemoglobin dropped and serial monitoring showed a decreasing trend with no obvious external sources and a negative gastric lavage. Her platelet count was at baseline 60-80 K and international normalized ratio (INR) was 2.8. She once again received blood products and vitamin K, which increased her hemoglobin only to drop again at a nadir of 5.6 g/dl. It was also noted that her abdomen was getting distended rather fast. An intraperitoneal source of bleeding was high in the differentials. After stabilization, she was immediately sent for imaging and angiogram. Computed tomography (CT)-scan with contrast of the abdomen showed intraperitoneal IV-contrast extravasation and right perihepatic and subhepatic space consistent with hemoperitoneum. The angiogram showed extravasation from the right inferior phrenic artery. Correspondingly, a diagnostic paracentesis also revealed grossly bloody tap with a fluid hematocrit of 4%. The culprit vessel was successfully embolized [Figure 1], and the patient's hemoglobin remained stable. After resolving her other medical issues, the patient survived and was eventually discharged.

Figure 1

IR Superior Mesenteric Artery Angiography: Red arrow indicates extravasation from a branch of the right inferior phrenic artery

Abdominal injuries accounts for about 30% of post-CPR-related injuries. In autopsied patients, Krischer et al.,[2] noted that liver injuries were considerably frequent (2.1%). In some case reports, rarer injuries directly related to CPR were laceration of the great vessels, cardiac rupture, retinal hemorrhages, and pleural injuries.[3] For this particular patient, it was likely the trauma from CPR would interact with her coagulopathic state and ascites from cirrhosis. Therefore, in the right clinical setting, complications attributable to CPR itself should be considered in patients who are clinically deteriorating.