Hemorrhage from gastric mucosal tears complicating cardiopulmonary resuscitation

Gastric rupture after awake fibreoptic intubation in a patient with laryngeal carcinoma

An 86-yr-old man with recurrent laryngeal carcinoma developed gastric rupture after awake fibreoptic intubation before induction of general anaesthesia. Early clinical signs included a distended, tense and tympanic abdomen with pain and massive pneumoperitoneum (chest radiograph). Laparotomy revealed a 4-cm longitudinal perforation along the lesser curvature of the stomach. This case represents a rare but severe complication that may occur during fibreoptic intubation in the awake patient.

Gastric rupture after the Heimlich maneuver

Since 1975, the Heimlich maneuver has been widely applied to relieve upper airway obstruction caused by aspirated material. Life-threatening complications have been documented following this simple procedure. We report two cases of gastric rupture after use of the Heimlich maneuver. Both patients experienced pulmonary and abdominal symptoms. The diagnosis was confirmed in each case by the demonstration of free intraperitoneal air on an upright chest roentgenogram. Full-thickness gastric rupture along the lesser curvature of the stomach was repaired in both patients; one patient died. Abdominal pain or persistent abdominal distention despite nasogastric suction after the Heimlich maneuver should prompt evaluation for possible gastric rupture.

Autopsies and the pediatric intensive care unit

The pediatric autopsy can provide great benefits to families at a time when their world is falling apart. It can be invaluable in the processing of grief that families endure, helping them to plan their future. Autopsy results not only provide information but may also provide consolation by giving the family the opportunity to discuss the disease process that resulted in death. Autopsy results also provide information regarding the future and reassurance that appropriate care was given. Failure to perform a postmortem examination denies the family and the clinician knowledge regarding mechanisms of disease, confirmation or inclusion of unsuspected diagnoses, and the presence of iatrogenic complications. This missed information can be both informative to the current family's situation and potentially therapeutic in future cases. If death is the final chapter of life, then the physician's responsible relationship with the parents of the deceased patient should not end until a conference takes place several weeks or months after the child's death. The results of the postmortem examination provide a beginning point for discussion regarding the child's illness and death, the parents responses and coping, and the opportunity to help the family make sense of and bring closure to one of life's greatest crises.

Intra-abdominal complications following prolonged cardiopulmonary resuscitation

A patient who underwent prolonged cardiopulmonary resuscitation developed an acute abdomen in the early post-arrest period which required laparotomy. Operative findings were of a perisplenic haematoma and infarction of the caecum. The latter has not previously been reported in this setting. A review of the literature reveals that many abdominal complications may occur following external cardiac massage. Difficulties in investigation and management are discussed.

The clinical rationale of cardiac resuscitation

After failure of external defibrillation, return of cardiac activity with spontaneous circulation is contingent on rapid and effective reversal of myocardial ischemia. Closed-chest cardiopulmonary resuscitation (CPR) evolved about 30 years ago and was almost universally implemented by both professional providers and lay bystanders because of its technical simplicity and noninvasiveness. However, there is growing concern since the limited hemodynamic efficacy of precordial compression accounts for a disappointingly low success rate; especially so if there is a delay of more than 3 minutes before resuscitation is started. There is also increasing concern with the lack of objective hemodynamic measurements currently available for the assessment and quantitation of the effectiveness of resuscitation efforts. Accordingly, the resuscitation procedure proceeds without confirmation that it increases systemic and myocardial blood flows to levels that would be likely to restore spontaneous circulation. Continuous monitoring of end-tidal carbon dioxide (PETCO2) now appears to be a practical measurement which provides a noninvasive quantitative indication of both systemic blood flow and coronary perfusion pressure. Consequently, PETCO2 predicts the likelihood of successful resuscitation and guides the operator who may modify the technique of precordial compression to improve systemic and myocardial perfusion. Among the large polypharmacy for cardiac resuscitation, only alpha-adrenergic agents (which increase coronary perfusion pressure) and especially epinephrine are of proven benefit. Neither buffer agents nor calcium salts appear to improve outcome except under unique conditions. To the contrary, there is increasing awareness of adverse effects of pharmacologic interventions such that they may hinder the return of viable myocardial and cerebral function. This has constrained the routine use of all drugs except for the use of alpha-adrenergic agonists. More invasive interventions by which blood flow is restored such as open-chest cardiac massage or extra-corporeal pump oxygenation (ECPO) are consistently more effective than conventional CPR. Experimentally, both methods promptly restore systemic and myocardial perfusion to viable levels and thereby increase the likelihood that spontaneous circulation is restored even after prolonged cardiac arrest or failure of conventional CPR.

Adverse occurrences in the pediatric intensive care unit

This article is intended to provide a review of the literature describing adverse occurrences affecting children in the intensive care unit. In addition, information related to the care of critically ill children is inferred from studies of adult or neonatal patients. Finally, areas in need of future investigation are suggested.

The comparative pathology of open chest vs. mechanical closed chest cardiopulmonary resuscitation in dogs

We compared the pathologic changes following open-chest cardiopulmonary resuscitation (OCCPR) vs. closed chest cardiopulmonary resuscitation (CCCPR) in 28 healthy mongrel dogs subjected to experimentally induced ventricular fibrillation (VF). VF was induced in 29 dogs. No treatment was given for 3 min, then mechanical CCCPR was given for the next 12 min. External defibrillation (80 joules) was then attempted twice. One dog was resuscitated. The remaining 28 dogs were divided into 2 groups of 14 each. Group A received continued CCCPR and group B received OCCPR. All dogs received advanced cardiac life support and were followed until resuscitated or dead. All dogs were autopsied and gross pathology scores and histopathology scores were determined for each animal, and for each of 19 separate tissues within each animal. The mean gross pathology scores for the following tissues were significantly greater for dogs that received OCCPR vs. those that received CCCPR: skin (3.4 vs. 1.2; P less than 0.001), subcutaneous tissue (3.7 vs. 0.6; P less than 0.001), chest wall muscle (3.7 vs. 0.5; P less than 0.001), and pleura (1.9 vs. 0.1; P less than 0.001). The mean total gross pathology score was also greater in dogs that received OCCPR vs. those that received CCCPR (17.2 vs. 7.7; P less than 0.001). The mean histopathology scores for the following tissues were significantly greater for dogs that received OCCPR vs. those that received CCCPR: skin (2.5 vs. 0.0; P less than 0.001), subcutaneous tissue (2.2 vs. 0.1; P less than 0.001), muscle (2.3 vs. 0.1; P less than 0.001), pleura (1.6 vs. 0.0; P less than 0.001), pericardium (1.4 vs. 0.2; P less than 0.01), epicardium (2.5 vs. 0.2; P less than 0.001), myocardium (2.5 vs. 0.3; P less than 0.001), and endocardium (1.9 vs. 0.5; P less than 0.01). The mean total histopathology score was also greater in dogs that received OCCPR vs. those that received CCCPR (20.1 vs. 7.4; P less than 0.001). The histopathology score for brain tissue was greater for the CCCPR group than for the OCCPR group (1.9 vs. 0.4; P less than 0.05). This study showed that OCCPR in dogs following VF caused more severe pathologic changes than CCCPR. These changes were attributed to thoracotomy-induced chest wall injury and to internal defibrillation induced myocardial injury. However, OCCPR caused less severe microscopic brain lesions than CCCPR.