[Massive organ injuries resulting from resuscitation measures]

Intra-Abdominal Hemorrhage following Cardiopulmonary Resuscitation: A Report of Two Cases

Cardiopulmonary resuscitation (CPR) represents an emergency procedure, consisting of chest compressions and artificial ventilation. Two rare cases of intra-abdominal bleeding following cardiac compressions are reported. The first case was a 29-year-old female with massive pulmonary embolism (PE). Following CPR due to cardiac arrest, she showed signs of intra-abdominal bleeding. A liver laceration was found and sutured. The patient passed away, due to massive PE. The second patient was a 62-year-old female, suffering from cardiac arrest due to drowning at sea. CPR was performed in situ. At presentation to the emergency department she showed signs of intra-abdominal bleeding. The origin of the hemorrhage was found to be vessels of the lesser curvature of the stomach, which were ligated. Regarding the first patient PE has already been described as a cause for liver lacerations in CPR due to stasis and liver enlargement. The second case is the first report of gastric vessel injury without gastric rupture/laceration and pneumoperitoneum. Complications of CPR should not represent a drawback to performing cardiac compressions. Parenchymatic injuries have been related to inappropriate technique of chest compressions during basic life support. Therefore, it is of utmost importance for the providers to refresh their knowledge of performing CPR.

Liver laceration related to cardiopulmonary resuscitation

Cardiopulmonary resuscitation (CPR) is recognized as a medical procedure performed to maintain vital functions of a person whose cardiac and respiratory functions have stopped. Chest compression is the most essential component of CPR and it is performed on the lower half of the sternum. During CPR, many complications may occur because of chest compressions, especially chest injuries including sternum and rib fractures. Rarely tracheal injury, rupture of the stomach, or liver or spleen injury may also occur as complications. In this study, we present two cases of liver injury caused by resuscitation. With this article, we want to emphasize the importance of making correct chest compressions.

Frequent and rare complications of resuscitation attempts

INTRODUCTION

Resuscitation attempts require invasive iatrogenic manipulations on the patient. On the one hand, these measures are essential for survival, but on the other hand can damage the patient and thus contain a significant violation risk of both medical and forensic relevance for the patient and the physician. We differentiate between frequent and rare resuscitation-related injuries. Factors of influence are duration and intensity of the resuscitation attempts, sex and age of the patient as well as an anticoagulant medication.

MATERIALS AND METHODS

Review of current literature and report on autopsy cases from our institute (approximately 1,000 autopsies per year).

RESULTS

Frequent findings are lesions of tracheal structures and bony chest fractures. Rare injuries are lesions of pleura, pericardium, myocardium and other internal organs as well as vessels, intubation-related damages of neural and cartilaginous structures in the larynx and perforations of abdominal organs such as liver, stomach and spleen.

CONCLUSION

We differentiate between frequent and rare complications. The risk of iatrogenic CPR-related trauma is even present with adequate execution of CPR measures and should not question the employment of proven medical techniques.

Children of persons with Alzheimer disease: what does the future hold?

Children of persons with Alzheimer disease (AD), as a group, face an increased risk of developing AD. Many of them, throughout their adult lives, seek input on how to reduce their chances of one day suffering their parent's fate. We examine the state of knowledge with respect to risk and protective factors for AD and recommend a research agenda with special emphasis on AD offspring.

Middle-aged children of Alzheimer parents, a pilot study: stable neurocognitive performance at 20-year follow-up

The objective of this pilot study on a convenience sample of 25 offspring of Alzheimer patients (mean age 61.5 +/- 8.8 years; range, 50-82) was the early detection of neurocognitive decline. This preliminary report appears to be the first one dealing with 20-year follow-up of neurocognitive data of Alzheimer's disease (AD) children. Digit symbol (Wechsler Adult Intelligence Scale) was the only of 11 neurocognitive measures with a significant decline. And that decline between first and last testing (mean = 19.98 +/- 0.30 years) was on raw scores, not scaled scores. Neither parents' age at onset of AD nor autopsy confirmation or offspring APOE-e4 status influenced neurocognitive results. More robust data than currently available are needed to confirm the findings of this first pilot study and to determine both the trajectory of neurocognitive decline in AD and the risks of developing AD faced by children whose parent had the disease.

Memory for new information as a cognitive marker of liability to Alzheimer's disease in a high risk group: a research note

BACKGROUND

The development of Alzheimer's disease (AD) is often insidious and there is evidence that pre-morbid neuropsychological deficits exist.

OBJECTIVES

To examine aspects of neuropsychological performance as cognitive markers in a group at high risk of developing AD.

METHODS

Memory for novel information and verbal fluency were examined in 33 unaffected biological siblings of patients who fulfilled criteria for probable AD, and 22 controls who reported no family history of dementia.

RESULTS

Comparisons between siblings and controls revealed significant differences on overall memory performance. This was also the case when siblings were grouped according to whether or not they possessed the apoE epsilon 4 allele. There were no significant differences between siblings and controls on verbal fluency measures.

CONCLUSIONS

Detailed measures of memory performance may be clinically useful in groups at a high risk of developing AD. However, further longitudinal research in such high-risk groups is needed before conclusions can be made with confidence.

Cognitive impairment in elderly who are not yet demented

Patients with neuropathological changes of Alzheimer disease may not be demented during initial evaluation of memory disturbance. Understanding current issues regarding the patient with incipient degenerative dementia should help identify those at greatest risk for progression and may help delay onset of symptoms.

Cognitive deficits in asymptomatic first-degree relatives of Alzheimer's disease patients

The present study was designed to determine whether neuropsychological deficits exist in asymptomatic first-degree relatives of Alzheimer's disease (AD) patients. The neuropsychological performances of 20 first-degree asymptomatic relatives of NINCDS-ADRDA diagnosed AD patients were compared to 20 normal controls without family history of AD. Cognitive functions assessed included intelligence, memory, overall brain function, verbal learning, and language and constructional abilities. Significant statistical differences were found between the groups across several cognitive areas indicating lower functioning in the first-degree relatives of AD patients. Fifty percent of the first-degree subjects but only 20% of controls showed a pattern of significant neuropsychological deficit. The results demonstrate neuropsychological deficits in asymptomatic first-degree relatives of AD patients, suggesting that preclinical markers for AD may be present long before the clinical manifestation of the disease.

Cognitive function and prediction of dementia in old age

Longitudinal changes in cognitive functioning were examined for a sample of aging twins, some of whom developed dementia while others did not. Individuals who were judged to be demented at a mean age of eighty-five years had achieved lower scores on most tests twenty years prior to diagnosis, and experienced greater declines in vocabulary and forward digit span over time, than those surviving to a comparable age without dementia. These trends were observed for individuals with mild, as well as moderate-to-severe, dementia and were unrelated to physical health status or premorbid activity patterns. It is suggested that dementing illness may develop very slowly, and that the likelihood of exhibiting clinically significant dementia may vary with premorbid intellectual level.

[Genesis of atraumatic liver hemorrhages]

Hepatic hemorrhages are not unusual after sharp or blunt abdominal traumata. They are of particular interest when deadly hepatic hemorrhages are under discussion as the single or contributory cause of death in forensic investigations, for instance after reanimation or acts of violence. The test results in rabbits demonstrate that artificial and specific enzyme-assimilation conditions can cause atraumatic hepatic hemorrhages in only a few days. With and without concomitant injuries, liver bleeding may have an atraumatic genesis. An additional human case report shows the possibility of confusion with atraumatic rhexis hemorrhage in the liver.

[2-stage rupture of the liver as a complication of external heart massage]

A delayed rupture of the liver after resuscitation is reported. In the case of a 27-year-old woman, pulmonary embolism was followed by asystolia, which was remedied by external cardiac massage. This procedure caused ruptures of the liver, which first led to the formation of a subcapsular hematoma and 5 1/2 hours later, due to a secondary rupture of the capsule, led to internal bleeding and death. Degenerative changes of the parenchyma cells in the vicinity of the rupture were recognized, as well as fibrin separations on the detached Glisson's capsule, as signs of a survival period of several hours. Histological investigation of the lungs revealed a hepatocellular embolism and--in the absence of rib or sternum fractures--fat and bone-marrow embolisms. The morphological findings are discussed with reference to pertinent reports in the literature.