Gastric perforation after cardiopulmonary resuscitation: review of the literature

Catastrophic CPR-Related Injuries in Vascular Ehlers-Danlos Syndrome: A Case Report and Review

ABSTRACT

This article presents a case of severe CPR-related injuries leading to diagnosis of vascular Ehlers-Danlos syndrome. The subject is a 36-year-old female with a past medical history of a 10-mm aneurysm of the right internal carotid artery discovered on imaging 3 years prior to death. Major autopsy findings included subarachnoid hemorrhage in the base of the brain, bilateral hemothoraces, hemopericardium, laceration of the interatrial septum, laceration of the left pulmonary artery, and changes secondary to chronic alveolar hemorrhage in the lungs. The autopsy findings and subsequent unremarkable toxicology studies led to the suspicion of an underlying and clinically undiagnosed connective tissue disorder. Broad genetic exome testing revealed a mutation consistent with vascular Ehlers-Danlos syndrome. An overview of this disease, its diagnosis, and differential are further described herein, along with recommendations for forensic pathologists.

Gastric rupture caused by intragastric perforation of splenic artery aneurysm: a case report and literature review

BACKGROUND

The rupture of splenic artery pseudoaneurysm (SAP) is life-threatening disease, often caused by trauma and pancreatitis. SAPs often rupture into the abdominal cavity and rarely into the stomach.

CASE PRESENTATION

A 70-year-old male with no previous medical history was transported to our emergency center with transient loss of consciousness and tarry stools. After admission, the patient become hemodynamically unstable and his upper abdomen became markedly distended. Contrast-enhanced computed tomography performed on admission showed the presence of a splenic artery aneurysm (SAP) at the bottom of a gastric ulcer. Based on the clinical picture and evidence on explorative tests, we established a preliminary diagnosis of ruptured SAP bleeding into the stomach and performed emergency laparotomy. Intraoperative findings revealed the presence of a large intra-abdominal hematoma that had ruptured into the stomach. When we performed gastrotomy at the anterior wall of the stomach from the ruptured area, we found pulsatile bleeding from the exposed SAP; therefore, the SAP was ligated from inside of the stomach, with gauze packing into the ulcer. We temporarily closed the stomach wall and performed open abdomen management, as a damage control surgery (DCS) approach. On the third day of admission, total gastrectomy and splenectomy were performed, and reconstruction surgery was performed the next day. Histopathological studies of the stomach samples indicated the presence of moderately differentiated tubular adenocarcinoma. Since no malignant cells were found at the rupture site, we concluded that the gastric rupture was caused by increased internal pressure due to the intra-abdominal hematoma.

CONCLUSIONS

We successfully treated a patient with intragastric rupture of the SAP that was caused by gastric cancer invasion, accompanied by gastric rupture, by performing DCS. When treating gastric bleeding, such rare causes must be considered and appropriate diagnostic and therapeutic strategies should be designed according to the cause of bleeding.

Tension Pneumoperitoneum: A Rare Complication of Cardiopulmonary Resuscitation (CPR)

Tension pneumoperitoneum is a surgical emergency. Although rare, failure to diagnose and treat the condition may be lethal. Hence, being aware of this phenomenon, particularly in scenarios involving cardiopulmonary resuscitation (CPR), is important. Existing literature emphasises immediate abdominal needle decompression as the initial management followed by close monitoring and keeping a low threshold for surgical intervention as a definitive measure. We decided to write up this case report to raise awareness that a tension pneumoperitoneum can result as a complication of CPR, a well-known and widely practiced algorithm.

[A Giant Gastric Perforation Occurring in the Normal Mucosa during Endoscopy in a Patient with Advanced Gastric Cancer]

The incidence of giant gastric perforation occurring during upper gastrointestinal endoscopy is exceedingly rare. Gastric perforation can arise from excessive air insufflation and is more prevalent in elderly patients with atrophic gastritis. Although giant gastric mucosal lacerations during diagnostic endoscopy have occasionally been reported, there are few reports of giant gastric perforation. The authors experienced a giant gastric perforation occurring in the normal mucosa during endoscopy in an 81-year-old woman with advanced gastric cancer. The patient had reduced gastric extensibility due to the advanced gastric cancer surrounding the entire lower part of her stomach. During continuous air insufflation, only the upper part of the stomach became overdistended, resulting in mucosal rupture and perforation. In addition, old age and the presence of atrophic gastritis contributed to the increased risk of mucosal rupture. The patient was treated successfully with endoscopic clips. This paper reports this case with a review of the relevant literature.

Manner of death determination in a case of gastric mucosal tears

Gastric tears are rarely described in the forensic pathological literature, although they can lead to a fatal acute exsanguination. Such lesions can arise from several conditions leading to an increased intragastric pressure, such as Mallory Weiss syndrome, cardiopulmonary resuscitation, acute barotrauma and operative procedures, showing peculiar morphological features. We present a case of a 32-year-old drug addicted white woman found dead in a pool of blood in the house of her drug dealer, after taking a dose of intravenous heroin. At autopsy, abundant bloody gastric content and multiple and long gastric tears, extending from the cardias and fundus regions to the gastric corpus were observed; one of them involved the subserous region, resulting in a gastric wall rupture. The victim had no history of recent vomiting and of gastro-intestinal pathologies. Drugs and ethanol levels detected in the specimens of the victim were not consistent with lethal concentrations, thus the death was attributed to acute exsanguination. After reviewing the literature, it turned out that morphological aspects of the gastric tears, such as number, size and topographical distribution, observed at autopsy were atypical compared to those of typical gastric lacerations.

Fatal peritonitis due to gastric perforation in a male heroin addict: A case report and literature review

INTRODUCTION AND IMPORTANCE

Perforation of hollow organs, such as the stomach, within the abdomen can lead to the development of acute abdomen, a critical and potentially life-threatening condition. It is important to note that there is currently insufficient information available regarding the specific effects of heroin, an illegal substance commonly abused, in causing this particular complication.

CASE PRESENTATION

We present the case of a 32-year-old male who is addicted to heroin and was admitted to an addiction rehabilitation center with the aim of overcoming his addiction. After a few days of admission, the patient developed symptoms of abdominal pain, anorexia, and subsequent neurological manifestations, such as drowsiness, confusion, and a decreased level of consciousness. Tragically, the patient suffered a cardiorespiratory arrest upon arrival at the emergency room and despite efforts to resuscitate him, he unfortunately passed away.

CLINICAL DISCUSSION

During the autopsy of the aforementioned case, an observation was made of a perforation in the stomach, which ultimately led to the cause of death being identified as peritonitis. Acute peritonitis is recognized as one of the potential causes of acute abdomen, often resulting from the rupture of hollow organs within the abdominal region. It is characterized by inflammation of the serous membrane that lines the abdominal cavity.

CONCLUSIONS

Indeed, conducting original and coherent studies to investigate the potential effects of heroin on gastric perforation could prove to be highly valuable in facilitating the timely diagnosis and treatment of this fatal complication.

Effects of acupuncture on gastrointestinal diseases and its underlying mechanism: a literature review of animal studies

Acupuncture is a non-pharmacological traditional Chinese medical technique that has been used for various types of gastrointestinal (GI) diseases in Eastern medicine. However, the specific mechanisms underlying acupuncture treatment in the GI tract have not yet been elucidated. In this study, we searched the electronic databases PUBMED, EMBASE, and MEDLINE and identified 30 eligible studies that were summarized in this review. This review demonstrates that treatments, including both manual and electroacupuncture, have therapeutic mechanisms in diverse GI diseases. The underlying mechanisms are broadly divided into the following: changes in gene expression in the gastric mucosa or nuclei of the solitary tract, metabolic change induction, regulation of anti-inflammatory substances, vagal activity increase, change in functional connectivity between brain regions, and control of the number of neurons related to GI diseases. Although this study is limited in that it does not represent all types of GI diseases with different acupuncture methods, this study identified acupuncture as effective for GI diseases through various biological mechanisms. We hope that our study will reveal various mechanisms of acupuncture in GI diseases and play an important role in the therapy and treatment of GI diseases, thus advancing the field of study.

Pneumoperitoneum following cardiopulmonary resuscitation: An unusual case

Introduction and importance

High-quality cardiopulmonary resuscitation (CPR) is the foundation of cardiac arrest resuscitation. Pneumoperitoneum due to gastric perforation is a rare surgical complication of CPR that, if left untreated, can result in significant morbidity and mortality.

Case presentation

We present a 51-year-old male patient with sealed perforation who received an urgent but non-diagnostic exploratory laparotomy after initial esophageal intubation and resuscitation in cardiac arrest, despite significant evidence of surgical pneumoperitoneum.

Clinical discussion

It is unusual to experience spontaneous pneumoperitoneum after cardiopulmonary resuscitation. We should promote cardiopulmonary resuscitation training for both medical and non-medical personnel.

Conclusion

Early endotracheal intubation, avoidance of esophageal intubation, and quick insertion of an orogastric tube may reduce the risk of gastric perforation.

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Pneumoperitoneum due to gastric perforation is a rare surgical complication if left untreated, can result in morbidity and mortality.

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It is unusual to experience spontaneous pneumoperitoneum after cardiopulmonary resuscitation.

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We should promote cardiopulmonary resuscitation training for both medical and non-medical personnel.

Manual and Mechanical Induced Peri-Resuscitation Injuries-Post-Mortem and Clinical Findings

(1) Background: Injuries related to resuscitation are not usually systematically recorded and documented. By evaluating this data, conclusions could be drawn about the quality of the resuscitation, with the aim of improving patient care and safety. (2) Methods: We are planning to conduct a multicentric, retrospective 3-phased study consisting of (1) a worldwide literature review (scoping review), (2) an analysis of anatomical pathological findings from local institutions in North Rhine-Westphalia, Germany to assess the transferability of the review data to the German healthcare system, and (3) depending on the results, possibly establishing potential prospective indicators for resuscitation-related injuries as part of quality assurance measures. (3) Conclusions: From the comparison of literature and local data, the picture of resuscitation-related injuries will be focused on and quality indicators will be derived.

Upper gastrointestinal bleeding from a Mallory-Weiss tear associated with transesophageal echocardiography during successful cardiopulmonary resuscitation: A case report

BACKGROUND

In recent years, it has been recognized that transesophageal echocardiography (TEE) is of great value in resuscitation of cardiac arrest. However, its safety has rarely been reported.

CASE SUMMARY

We present a 59-year-old male patient scheduled to undergo cardiac surgery for rheumatic heart disease. Upper gastrointestinal bleeding from a Mallory-Weiss tear appeared following cardiopulmonary resuscitation, TEE, and percutaneous cardiopulmonary bypass resuscitation when he suffered from aesthesia-related cardiac arrest. Gastrointestinal injury was diagnosed promptly and treated effectively. However, the exact etiology of gastrointestinal injury was unclear; the interaction of closed-chest cardiac massage and the application of TEE may be involved as a most possible mechanism of injury.

CONCLUSION

Serious complications should be considered when TEE is used in patients with special pathophysiological conditions.

OUP accepted manuscript

Spontaneous pneumoperitoneum in a patient with a tracheostomy tube following cardiopulmonary resuscitation is exceedingly rare, with little experimental nor observational data to guide evidence-based management. We present the case of a 75-year-old woman with a tracheostomy tube who developed pneumoperitoneum following CPR. The patient experienced pulseless electrical activity arrest requiring nine rounds of chest compressions to return to spontaneous circulation. Computerized tomography demonstrated pneumothoraces, subcutaneous emphysema and extensive intraperitoneal, extraperitoneal and retroperitoneal free air without evidence of visceral perforation. The patient’s abdomen was distended without tenderness, guarding or rebound. She had a white blood cell count mildly elevated from her baseline levels. The management plan of serial abdominal exams without operative intervention was chosen given the absence of clinical and laboratory signs of peritonitis. This case highlights the importance of developing a standardized management algorithm for patients with pneumoperitoneum in the setting of tracheostomy tubes without evidence of perforation.

Endoscopic Insufflation–Induced Gastric Barotrauma during Percutaneous Endoscopic Gastrostomy: A Report of Three Patients and Review of Literature

Background We report three patients with endoscopic insufflation–induced gastric barotrauma (EIGB) during upper gastrointestinal endoscopy (UGIE) for percutaneous endoscopic gastrostomy (PEG). A definition and classification of EIGB is proposed.

Materials and Methods Records of patients undergoing UGIE over 7 years (April 2013–March 2020) were reviewed. Patients who developed new onset of bleeding or petechial spots in proximal stomach, in an area previously documented to be normal during the same endoscopic procedure, were studied.

Results New onset of bleeding or petechial spots in proximal stomach occurred in 3/286 (0.1%) patients undergoing PEG and in none of the 19,323 other UGIE procedures during the study period. All patients were men with median age 76 years (range 68–80 years), with no coagulopathy. Aspirin and apixaban were discontinued 1 week and 3 days prior to the procedure. Fresh blood was noted in the stomach at a median of 275 seconds (range 130–340) seconds after commencement of endoscopy. At retroflexion, multiple linear mucosal breaks of up to 3 cm, with oozing of blood, were noted in the proximal stomach along the lesser curvature, close to the gastroesophageal junction in two patients. In the third patient, multiple petechial spots were noticed in the fundus. The plan for PEG was abandoned and the stomach deflated by endoscopic suction. There was no subsequent hematemesis, melena, or drop in hemoglobin. One week later, repeat UGIE in the first two patients revealed multiple healing linear ulcers of 1 to 3 cm in the lesser curvature and PEG was performed.

Conclusion Overinsufflation over a short duration during UGIE may lead to EIGB. Early detection is key and in the absence gastric perforation, patients can be managed conservatively.

Two autopsy cases with injuries to the stomach following cardiopulmonary resuscitation

We herein report two autopsy cases with gastric injury associated with cardiopulmonary resuscitation (CPR). Case 1 was a 36-year-old woman who was found in cardiopulmonary arrest possibly caused by a fall from a height of 8 m. She received continuous manual chest compression with artificial ventilation while being transferred to the hospital. Autopsy revealed bruises on her left upper arm with a fracture to the left humerus and advanced pneumohemothorax that was associated with laceration of the left lung due to fracture of the dorsal left costa. Furthermore, complete rupture of the gastric wall (25 cm) was found without hemorrhage. Case 2 was an 85-year-old man found unconscious on the road. He had a history of oral anticoagulant administration, cognitive impairment, and gait disorder. He also received cardiac massage and manual artificial ventilation during CPR. Autopsy revealed severe head injury, possibly caused by a backward fall. His stomach was markedly dilated by air and a fresh intramural hematoma had extended into all layers of the stomach and adjacent omentum; however, injury of the abdominal wall was not evident. Histopathological investigation of the brain revealed advanced Alzheimer's disease and Lewy pathology, and the damaged neural tissue, which was positive for the amyloid precursor protein. We determined that the gastric injuries in both cases had been caused by CPR. We conclude that careful investigation is required for gastric injury cases to determine the etiology and correlation between gastric injury and cause of death when the victims receive CPR.

A case report of stomach perforation during automatic mechanical chest compression following pulseless electrical activity due to cibenzoline intoxication

Background

The current report describes a case of stomach perforation, a rare but serious complication, that occurred during cardiopulmonary resuscitation following severe cibenzoline intoxication.

Case Presentation

A woman aged in her 30s was brought into our hospital while receiving cardiopulmonary resuscitation for pulseless electrical activity. After starting extracorporeal membrane oxygenation (ECMO), her abdominal X‐ray examination revealed free air in her abdomen. She was diagnosed with internal gastric perforation. An emergency operation was carried out while the circulation was maintained using ECMO. As the patient’s blood cibenzoline concentration on admission was 3,868 ng/mL, she was diagnosed with cibenzoline intoxication caused by the self‐intake of twice the prescribed dose. She was successfully weaned off ECMO and discharged alive with full recovery.

Conclusion

We successfully treated a case of gastric perforation after pulseless electrical activity requiring ECMO support due to cibenzoline intoxication. Abdominal surgery can be carried out even if ECMO support is needed.

Complete gastroesophageal junction avulsion after near drowning: A case report and review of literature

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GE junction injuries are in pediatric population.

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These injuries are associated with high morbidity and mortality.

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A high index of suspicion and prompt recognition is needed.

Introduction

Gastroesophageal (GE) junction injuries are rare in the pediatric population. A complete GE junction separation in a child secondary to trauma has not reported in the literature yet.

Presentation of case

A 14-year-old boy presented with a complete GE junction avulsion after a near-drowning experience. He underwent immediate damage control surgery and delayed gastric pull-up esophageal reconstruction in 3-months. At the most recent clinic visit 5 months from the reconstruction, he can tolerate a regular diet without difficulty and is gaining weight and recovering well.

Conclusion

Complete GE junction injuries and avulsions are rare with limited data to guide management. These injuries are associated with mortality rates from 25% to 33%, therefore, high index of suspicion, prompt recognition and careful surgical planning is needed for favorable outcomes.

Gastric perforation following improper cardiopulmonary resuscitation in out-of-hospital cardiac arrest

Gastric perforation is a rare complication of cardiopulmonary resuscitation (CPR), mostly resulting from incorrect airway management. If left unrecognized, it is associated with high mortality and morbidity. We present a case of gastric perforation after improper CPR. A 56-year-old drunken male was sent to the emergency department due to coma after fall onto the ground. He was thought to have cardiac arrest at scene and was saved with CPR maneuver by his friends who has never been trained before. He was taken to the hospital by emergency medical service personnel and presented with abdominal distention and extensive pneumoperitoneum. Emergency laparotomy was performed which revealed gastric perforation at the lesser curvature of the stomach. The laceration was repaired without any difficulty and the patient was discharged home without any neurological deficit. The aim of this report is to remind the public and emergency physicians that gastric perforation should be suspected in patients with distended abdomen and pneumoperitoneum after CPR. Because the most common risk factor for CPR-related gastric perforation is the bystander-provided resuscitation, it is encouraged for the public to take formal CPR training.

Mallory-Weiss Tear After Cardiopulmonary Resuscitation in a Patient Suffering From Acute Myocardial Infarction

A report of a 79 year old male patient suffering from acute myocardial infarction with Mallory-Weiss tear after successful cardiopulmonary resuscitation(CPR) by emergency medical technician in the swimming pool is presented. Successful percutaneous coronary intervention(PCI) was done after appropriate transfusion. The patient survived and discharged without major complications after admitting 11days in the hospital. Importance of CPR in AMI patient is reiterated as complication such as Mallory-Weiss tear may arise.

Single Ventilation during Cardiopulmonary Resuscitation Results in Better Neurological Outcomes in a Porcine Model of Cardiac Arrest

PURPOSE

Recent basic life support (BLS) guidelines recommend a 30:2 compression-to-ventilation ratio (CV2) or chest compression-only cardiopulmonary resuscitation (CC); however, there are inevitable risks of interruption of high-quality cardiopulmonary resuscitation (CPR) in CV2 and hypoxemia in CC. In this study, we compared the short-term outcomes among CC, CV2, and 30:1 CV ratio (CV1).

MATERIALS AND METHODS

In total, 42 pigs were randomly assigned to CC, CV1, or CV2 groups. After induction of ventricular fibrillation (VF), we observed pigs for 2 minutes without any intervention. Thereafter, BLS was started according to the assigned method and performed for 8 minutes. Defibrillation was performed after BLS and repeated every 2 minutes, followed by rhythm analysis. Advanced cardiac life support, including continuous chest compression with ventilation every 6 seconds and intravenous injection of 1 mg epinephrine every 4 minutes, was performed until the return of spontaneous circulation (ROSC) or 22 minutes after VF induction. Hemodynamic parameters and arterial blood gas profiles were compared among groups. ROSC, 24-hour survival, and neurologic outcomes were evaluated at 24 hours.

RESULTS

The hemodynamic parameters during CPR did not differ among the study groups. Partial pressure of oxygen in arterial blood and arterial oxygen saturation were lowest in the CC group, compared to those in the other groups, during the BLS period (p=0.002 and p<0.001, respectively). The CV1 groups showed a significantly higher rate of favorable neurologic outcome (swine CPC 1 or 2) than the other groups (p=0.044).

CONCLUSION

CPR with CV1 could promote better neurologic outcome than CV2 and CC.

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.

Major traumatic complications after out-of-hospital cardiac arrest: Insights from the Parisian registry

AIM

Due to collapse and cardiopulmonary resuscitation (CPR) maneuvers, major traumatic injuries may complicate the course of resuscitation for out-of-hospital cardiac arrest patients (OHCA). Our goals were to assess the prevalence of these injuries, to describe their characteristics and to identify predictive factors.

METHODS

We conducted an observational study over a 9-year period (2007-2015) in a French cardiac arrest (CA) center. All non-traumatic OHCA patients admitted alive in the ICU were studied. Major injuries identified were ranked using a functional two-level scale of severity (life-threatening or consequential) and were classified as CPR-related injuries or collapse-related injuries, depending of the predominant mechanism. Factors associated with occurrence of a CPR-related injury and ICU survival were identified using multivariable logistic regression.

RESULTS

A major traumatic injury following OHCA was observed in 91/1310 patients (6.9%, 95%CI: 5.6, 8.3%), and was classified as a life-threatening injury in 36% of cases. The traumatic injury was considered as contributing to the death in 19 (21%) cases. Injuries were related to CPR maneuvers in 65 patients (5.0%, (95%CI: 3.8, 6.1%)). In multivariable analysis, age [OR 1.02; 95%CI (1.00, 1.04); p = 0.01], male gender [OR 0.53; 95%CI (0.31, 0.91); p = 0.02] and CA occurring at home [OR 0.54; 95%CI (0.31, 0.92); p = 0.02] were significantly associated with the occurrence of a CPR-related injury. CPR-related injuries were not associated with the ICU survival [OR 0.69; 95%CI (0.36, 1.33); p = 0.27].

CONCLUSIONS

Major traumatic injuries are common after cardiopulmonary resuscitation. Further studies are necessary to evaluate the interest of a systematic traumatic check-up in resuscitated OHCA patients in order to detect these injuries.

Tension pneumoperitoneum

A 35-year-old man stopped breathing after injecting a large dose of heroin. He subsequently received cardiopulmonary resuscitation from friends. He arrived to accident and emergency department with Glasgow Coma Scale of 13. On examination, he had distended and tense abdomen. CT Thorax, Abdomen, and Pelvis confirmed massive tension pneumoperitoneum. A 14 Fr intravenous cannula was inserted through the umbilicus to relieve the intra-abdominal pressure. An emergency laparotomy showed petechia along the anterior gastric wall, haematoma of lesser omentum but showed no evidence of gastrointestinal perforation or organ injury. Air leak test performed by insufflating air into the stomach via nasogastric tube and abdomen filled with normal saline showed no leak. On-table oesophagogastroduodenoscopy showed mild oesophagitis and petechia of cardiac gastric mucosa. He was treated with intravenous antibiotics and discharged on the fifth postoperative day with adequate analgesia.

Breaking your heart-A review on CPR-related injuries

Cardiopulmonary resuscitation (CPR) has been shown to increase survival after cardiac arrest, but is associated with the risk of acquired injuries to the patient. While traumatic chest wall injuries are most common, other injuries include upper airway, pulmonary and intra-abdominal injuries. This review discusses the risk factors and prevalence of CPR-related injuries.

Tension pneumoperitoneum after bystander cardiopulmonary resuscitation: A case report

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Abdominal visceral injuries following cardiopulmonary resuscitation are relatively infrequent.

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Tension pneumoperitoneum is a serious condition where free intraperitoneal air causes significant pressure decreasing venous return and cardiac output.

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Gastric perforation after CPR is identified on the lesser curvature, where the area has fewer mucosal folds and is fixed by the hepatogastric ligament.

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Veress needle desufflation can be an effective means of decompressing an abdomen under increased pressure from free intraperitoneal air.

Introduction

Abdominal visceral injuries after cardiopulmonary resuscitation (CPR) are infrequent though can be significant complications of CPR requiring invasive interventions. We present a case of a gastric perforation as a result of bystander CPR. This resulted in tension pneumoperitoneum necessitating abdominal decompression prior to laparotomy and repair.

Presentation of case

37-year-old female complained of abdominal pain and distension after return of spontaneous circulation from successful CPR following a drug overdose and cardiopulmonary arrest. Abdominal imaging showed significant amounts of free intraperitoneal air causing compression of the abdominal visceral organs. Patient underwent exploratory laparotomy. Prior to induction of general anesthesia with potential cardiovascular collapse from the tension pneumoperitoneum, the abdomen was decompressed with a spring-loaded insufflation (Veress) needle while the patient was awake. Upon exploration, there were two three-centimeter gastric perforations that were primarily repaired with omental patch. The patient had an uneventful recovery and discharged home on postoperative day four.

Conclusion

The Veress needle, usually used for insufflating the abdomen during laparoscopy, can also be an effective tool to decompress the abdomen when presented with tension pneumoperitoneum. Abdominal visceral injuries are rare following CPR but do occur and will likely require an invasive intervention. Surviving cardiac arrest as a young person and living without deficits outweighs the risk of a surgical correction for a visceral injury. While resuscitation measures are critical for survival, medical personnel need to be aware of potential complications from resuscitative efforts and potential management strategies.

Pneumoperitoneum after Cardiopulmonary Resuscitation: The Roles of Bystander-Provided BLS and Laryngeal Mask Airway

We present a case of post-resuscitative pneumoperitoneum following bystander cardiopulmonary resuscitation and artificial ventilation via a laryngeal mask airway. Artificial ventilation can result in gastric distention and contribute to subsequent gastric perforation. Among the various approaches to ventilating patients in respiratory failure, mouth-to-mouth and bag-valve-mask are much more likely to cause gastric inflation than ventilating with a laryngeal mask airway. Abdominal distention, haematemesis, and bloody gastric aspiration are common manifestations of post-resuscitative gastric perforation in which pneumoperitoneum is discovered in the majority of these patients by a roentgenogram of the chest after successful resuscitation. (Hong Kong j.emerg.med. 2015;22:126-129)

Stomach perforation post cardiopulmonary resuscitation-A case report

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Stomach perforation after cardiopulmonary resuscitation is rare.

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CPR performed by non-medical personnel is the main cause.

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Training of medical and non-medical persons in CPR is to be encouraged.

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Correct management of airway during CPR is important.

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High degree of vigilance is required in patients presenting after CPR.

Introduction

Stomach perforation after cardiopulmonary resuscitation is a rare finding. This is mainly caused by incorrect management of the airway during CPR performed by non-medical personnel.

Presentation of case

We report a case of 72 year old female who sustained a stomach perforation during prolonged CPR in an out of hospital arrest situation. This was diagnosed on a computed tomography scan of the abdomen requiring midline laparotomy and a primary repair of the stomach.

Discussion

The training of medical and non-medical persons in cardiopulmonary resuscitation is to be encouraged. However it should be emphasized that any technique which breaches the normal integrity of the body can itself lead to life-threatening complications.

Conclusion

A high degree of vigilance is required in patients presenting after a cardiac arrest and CPR.

On-Scene Rescue Breathing Resulting in Gastric Perforation and Massive Pneumoperitoneum

Rescue breathing performed too vigorously or by untrained individuals may cause gastric distension and perforation. A 26-year-old woman is presented who developed acute abdominal pain and distension after receiving rescue breathing following a heroin overdose. Massive pneumoperitoneum was seen on chest x-ray, and on subsequent laparotomy, a 4cm laceration was found in the lesser curvature of the stomach. Review of the literature suggests that the lesser curvature is particularly susceptible to perforation following over-distension. Emergency personnel should be aware of this rare, but serious, complication. Expansion of community and first responder naloxone use in the proper clinical setting may further diminish utilization of rescue breathing. Butterfield M , Peredy T . On-scene rescue breathing resulting in gastric perforation and massive pneumoperitoneum. Prehosp Disaster Med. 2017;32(6):682-683.

Freshwater drowning in a child: A case study demonstrating the role of post-mortem computed tomography

In recent years, modern imaging techniques have gained ground in forensics. A crucial question is whether virtual autopsy is capable of replacing traditional autopsy. Forensic diagnosis of freshwater drowning (FWD) is based on the evidence of findings from external inspection (e.g. frothy fluid exuding from the mouth and nostrils), internal examination (e.g. pulmonary congestion, enlargement of heart chambers) and biochemical analysis (haemodilution), findings which are non-specific. The detection of diatoms in organs of the systemic circulation may be of some assistance, but this analysis is rarely performed and is of debatable validity. An 18-month-old child was found dead at home in a swimming pool. Considering the family's wishes to avoid autopsy, the district attorney authorised a whole-body post-mortem computed tomography scan (PMCT). The main imaging findings were frothy fluid in the upper airways, fluid in the trachea and main bronchi, many pulmonary nodular ground glass opacities (GGO) in non-dependent regions and haemodilution. CT imaging did not show any other forensically relevant abnormality.A high concordance was found between the CT findings reported in the literature in cases of FWD and the imaging results. Thus, after the exclusion of other causes of death, advised by the forensic pathologist, the district attorney closed the case and the death was attributed to FWD. This case report demonstrates that PMCT imaging in cases of suspected FWD can provide some important findings for the diagnosis of FWD as the cause of death.

Gastric Rupture following Nasopharyngeal Catheter Oxygen Delivery—A Report of Two Cases

Iatrogenic gastric distension and subsequent rupture following nasal or nasopharyngeal catheter oxygen delivery is a rare but life-threatening condition that requires urgent laparotomy. We report two cases recently encountered at our institution. Both patients exhibited symptoms of abdominal pain and distension following oxygen delivery involving a nasopharyngeal catheter during procedural sedation. Oxygen flow rates were 4 l/minute in both cases. The diagnosis was made by urgent imaging. Both patients survived following laparotomy and repair of gastric rupture. Seventeen cases have been reported previously in the literature. We recommend avoidance of nasal or nasopharyngeal catheters and the use of alternative oxygen delivery methods such as nasal prongs and face masks.

Development of pneumoperitoneum after CPR

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Penumoperitoneum is rarely reported complication of chest compressions.

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Possible risk factors include peptic ulcers and airway disease.

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Presence of an OG tube during CPR may have been a contributing factor.

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Clinicians must decide if patient is stable enough to warrant laparotomy for repair of perforation.

INTRODUCTION

Chest compressions are performed routinely and have several well-known complications, however one of the rare complications is pneumoperitoneum caused by air entry through a perforation of the viscus. The exact cause of the perforation is not always clear. Furthermore, this rarely reported condition does not have clear management guidelines.

PRESENTATION OF CASE

We present an uncommon complication of pneumoperitoneum following successful resuscitation possibly caused by the presence of an orogastric tube at the time of compressions in a 79 year old Hispanic male. Following chest compressions, a distended and tympanic abdomen was noted and air seen under the diaphragm in X-ray imaging.

DISCUSSION

A review of previous case reports along with etiology and evaluation of risk factors is presented.

CONCLUSION

Although the exact cause of pneumoperitoneum cannot be confirmed, emergency personnel should be aware of the risk factors associated with viscus perforation during chest compressions.

Intraperitoneal explosion following gastric perforation

The object of this study is to report a rare case of explosion during laparotomy where diathermy ignited intraperitoneal gas from a spontaneous stomach perforation. Fortunately, the patient survived but the surgeon experienced a finger burn. A literature review demonstrates other examples of intraoperative explosion where gastrointestinal gases were the fuel source. Lessons learned from these cases provide recommendations to prevent this potentially lethal event from occurring.

Compression, distortion and dislodgement of large caliber stents in congenital heart defects caused by cardiopulmonary resuscitation: a case series and review of the literature

Stenting of vascular, extracardiac or lately intracardiac stenosis has become an established interventional treatment for a variety of problems in congenital or acquired heart disease. Most stent procedures are completed successfully and the long-term outcome is favorable in the majority of cases. Stent collapse or deformation is a well recognized entity in peripheral stents and can be attributed to insufficient radial force; it can also be attributed to excessive external forces, like deformation of stents in the right ventricular outflow tract, where external compression is combined with continuous movement caused by the beating heart. The protection of the thoracic cage may prove to be insufficient in extraordinary circumstances, such as chest compression in trauma or cardiopulmonary resuscitation (CPR). In this case series, we describe three patients in whom large endovascular stents were placed to treat significant stenosis of the aorta, the aortic arch or the venous system of the inferior vena cava close to the atrium. In all patients, CPR was necessary during their clinical course for various reasons; after adequate CPR, including appropriate chest compression all patients survived the initial resuscitation phase. Clinical, echocardiographic as well as radiologic re-evaluation after resuscitation revealed significant stent distortion, compression, displacement or additional vascular injury. The possibility of mechanical deformation of large endovascular stents needs to be considered and recognized when performing CPR; if CPR is successful, immediate re-evaluation of the implanted stents--if possible by biplane fluoroscopy--seems mandatory.

Gastric perforation after cardiopulmonary resuscitation

Gastric rupture is a rare complication after cardiopulmonary resuscitation (CPR). In most cases, incorrect management of airways during CPR is the main cause. Therefore, a medical emergency becomes a surgical emergency also. We present a case of gastric perforation in a middle-aged patient after CPR performed by his family. He eventually presented with bloody vomitus and a tympanic abdomen. When faced with a patient with abdominal signs post-CPR, surgical complications of CPR should be considered.

Cadaver study of oesophageal insufflation with supraglottic airway devices during positive pressure ventilation in an obstructed airway

BACKGROUND

Supraglottic airway devices (SADs) play an increasing role in airway management in clinical anaesthesia and emergency medicine. Until now, no data exist concerning the extent of oesophageal insufflation when oropharyngeal leak pressures are exceeded.

METHODS

Laryngeal masks LMA-Supreme™ and LMA-ProSeal™, laryngeal tubes LTS-D and LTS II, Combitube™, and I-Gel were inserted into unfixed human cadavers. The oesophagus was connected to a volumeter, while the trachea was closed surgically to simulate complete airway obstruction. Volumes of oesophageal insufflation resulting from pressure-controlled ventilation at inspiratory pressures of 20, 40, and 60 mbar were measured.

RESULTS

No oesophageal insufflation could be detected at a ventilation pressure of 20 mbar in any device. Using inspiratory pressures of 40 and 60 mbar, oesophageal insufflation occurred in all devices, with significantly higher volumes of intraoesophageal air for both laryngeal tubes.

CONCLUSIONS

The use of SADs with inspiratory pressures of 20 mbar appears to be safe regarding the risk of intragastric insufflation. Higher inspiratory pressures should be strictly avoided.

Injuries sustained by children inside clothes dryers: a report of a fatality and review of the literature

We report a case of a 4-year-old child found dead at his home inside a domestic clothes (tumble) dryer. The child had been reported missing in the morning by his mother and found a short time later inside the dryer with the door shut. The child was pronounced dead at the scene. A pre-autopsy computed tomography scan identified findings associated with aggressive resuscitation attempts. Post-mortem examination showed generalised blunt trauma to his head and limbs, a thin film subdural haemorrhage and burns from contact with hot components and hot air whilst being trapped alive inside the active dryer. A forensic examination of the dryer revealed that it was possible for the child to become trapped in the dryer by his own action and that the dryer could operate for sufficient time to allow for the causation of the injuries to the child. A review of the medical literature and media reports of deaths related to clothes dryer, injuries sustained to survivors and use of dryers as a body disposal site is presented.

Unexplained Massive Pneumoperitoneum following Cardiopulmonary Resuscitation

Pneumoperitoneum following cardiopulmonary resuscitation (CPR) had been described as a rare complication. Pneumoperitoneum after CPR could be due to gastric perforation or intrathoracic air tracking into the abdominal cavity via the diaphragm as a result of bag-valve-mask ventilation, external chest compression or improper intubation. In most reported cases, the specific injuries could be identified. We reported an unusual case of pneumoperitoneum following CPR in which the specific cause was not definitely established. Emergency physicians should be aware of the mechanism and clinical signs suggesting of pneumoperitoneum during or after CPR.