Exsanguination due to right ventricular rupture during closed-chest cardiopulmonary resuscitation

The Journal of Emergency Medicine, Vol. 23, No. 2, pp. 161-164, 2002 Copyright © 2002 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/02 $–see front matter

PII S0736-4679(02)00504-8

Clinical Communications

EXSANGUINATION DUE TO RIGHT VENTRICULAR RUPTURE DURING CLOSEDCHEST CARDIOPULMONARY RESUSCITATION Peter E. Sokolove,

MD,*

Jason Willis-Shore,

MD,†

and Edward A. Panacek,

MD, MPH*

*Division of Emergency Medicine, University of California Davis Medical Center, Sacramento, California and †Department of Emergency Medicine, Oregon Health Sciences University, Portland, Oregon Reprint Address: Peter E. Sokolove, MD, Division of Emergency Medicine, University of California Davis Medical Center, 2315 Stockton Blvd., PSSB 2100, Sacramento, CA 95817

e Abstract—We report on a 61-year-old woman in whom cardiopulmonary resuscitation (CPR) was unsuccessful. While the patient was initially resuscitated from the primary cardiac arrest, with evidence of neurologic recovery, she ultimately succumbed to injuries resulting directly from closed-chest CPR. Autopsy revealed multiple rib fractures, a sternal fracture, pulmonary laceration, and cardiac rupture. In a patient with deteriorating vital signs following successful closed-chest CPR, such injuries should be considered. © 2002 Elsevier Science Inc.

of aggressive life-saving measures. We present a case of a 61-year-old woman who was successfully resuscitated from cardiac arrest, but who ultimately expired because of the cardiac and pulmonary injuries incurred during closed-chest CPR.

CASE REPORT A 61-year-old woman was witnessed to suddenly collapse in a busy hospital parking garage. According to her daughter, she was a hospital visitor and had a history of diabetes and ‘heart disease‘ but had been feeling well that day. The daughter reported that she and the patient had successfully jump-started their car battery, and as the daughter was putting the cables away, she turned and no longer saw the patient standing where she had been a moment before. The daughter ran around the car and found the patient lying face down on the cement floor. Within a minute, two resident physicians arrived and confirmed absence of breathing or a pulse. They were both certified in Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) and immediately initiated mouth-to-mouth breathing and closed-chest CPR. The Emergency Department (ED) was called, and approximately 10 min later, two ED attending physicians arrived on the scene with airway equipment and a med-

e Keywords— cardiac rupture; pulmonary laceration; sternal fracture; CPR; cardiopulmonary resuscitation

INTRODUCTION Since its introduction in the 1960s, closed-chest cardiac massage has been widely accepted as a standard resuscitative technique (1). Each year, American Heart Association and American Red Cross instructors train more than five million people in the technique of closed-chest cardiopulmonary resuscitation (CPR) (2). Along with its widespread use, many studies have documented complications resulting from closed-chest CPR (3-6). These injuries, while frequently requiring therapy and prolonging hospitalization, have generally not been life-threatening, and are considered to be acceptable consequences

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ication bag. The patient was intubated, administered 1 mg of epinephrine by intracardiac route, as IV access was not yet established, and closed-chest CPR was resumed. A monitor-defibrillator was delivered to the scene and revealed coarse ventricular fibrillation. The patient was defibrillated at 300 joules, restoring normal sinus rhythm and a strong carotid pulse. IV access was established, and following administration of 100 mg of IV lidocaine, the patient was transported to the ED. Transport took less than 5 min. On arrival in the ED, the patient remained unresponsive but in sinus rhythm with a heart rate in the 90s and a systolic blood pressure of 74 mm Hg by palpation. Wide open normal saline was administered IV. Auscultation of the lungs revealed decreased breath sounds over the right chest. A chest tube was placed in the right chest with a return of air and less than 100 mL of blood. A second bolus of 50 mg of IV lidocaine was given and a lidocaine drip was begun at 4 mg/min. A dopamine drip was initiated at 5 mcg/kg/min, increasing her systolic blood pressure to 120 mm Hg. The patient became more responsive and followed simple commands. An electrocardiogram (EKG) showed sinus rhythm with occasional PVCs, normal intervals, and nonspecific ST segment and T-wave changes. A chest X-ray confirmed good placement of the chest tube, but the endotracheal tube tip was in the left mainstem bronchus. The endotracheal tube was repositioned and arrangements were made to admit the patient to the Cardiac Monitoring Unit (CMU). The CMU did not have a bed immediately available, and the patient remained in the ED. The patient’s cardiac rhythm was sinus tachycardia, but after 10 min her systolic blood pressure dropped to 74 mm Hg. She then developed ventricular tachycardia and was cardioverted with 100 joules into a sinus rhythm with a systolic blood pressure of 120 mm Hg. An IV bolus of 350 mg of bretylium was slowly administered. Over the next 30 min, the patient continued to have recurrent episodes of ventricular tachycardia and ventricular fibrillation responsive to defibrillation, but resistant to lidocaine and bretylium. Even when in sinus rhythm, she was no longer responsive. Her systolic blood pressure was less than 90 mm Hg despite dopamine at 20 mcg/kg/min and 3 liters of normal saline. A norepinephrine drip was initiated. Auscultation of the lungs revealed diminished breath sounds over the right chest. A second chest tube was placed in the right chest with a rush of air and over 1500 mL of blood was drained. Her systolic pressure remained below 80 mm Hg and she became bradycardic. Two units of O-negative packed red blood cells were infused, and a right lateral thoracotomy was performed. Exposure revealed a right lung laceration, which was oversewn with good hemostasis. However, shortly thereafter the patient deteriorated further and became pulseless. The cardiac

P. E. Sokolove et al.

monitor showed a wide-complex agonal rhythm. The pericardium was opened via the right thoracotomy, revealing pericardial blood and a large defect of the right ventricle. There was good exposure of the heart, but attempts at manual occlusion of the defect were unsuccessful. Because of the size of the lesion, oversewing was not felt to be feasible and was not attempted. At that point, the patient had been in asystole for at least 15 min. The resuscitation was stopped, and the patient was pronounced dead. Autopsy examination revealed multiple fractures of the thorax including the sternum, right ribs 4 to 8 laterally and left ribs 2 to 6 laterally. In addition, there was a prominent bony splinter of the right 5th rib anteriorly projecting into the chest cavity. The overall chest anatomy was grossly normal. There was a sutured 5 cm laceration of the right lung with adherent fresh thrombus underlying the right 5th rib splinter. There was a large hole in the anterior wall of the right ventricle below the atrioventricular (AV) junction near the area of the 5th rib fracture, and a small epicardial tear at the posterior base of the heart was noted. The hole appeared to be because of rupture of the right ventricle, rather than a direct puncture injury. The great vessels were intact. The puncture site of the intracardiac injection was visible in the wall of the left ventricle without any myocardial or coronary artery damage at that site. There was no evidence of prior myocardial infarction. The cause of death was felt to be exsanguination from traumatic laceration of the lung and traumatic rupture of the heart.

DISCUSSION It is not surprising that the extreme measures required to resuscitate patients in cardiopulmonary arrest can have adverse effects. Common complications reported in the literature include regurgitation, aspiration, rib and sternal fractures, and pulmonary contusions (3-7). When complications do occur, they are rarely isolated. Rib fractures, a very common complication of closed-chest CPR, are usually multiple, bilateral, and frequently concomitant with sternal fractures (3). Severe life-threatening complications of closed-chest CPR, which may thwart any possibility of successful resuscitation, are comparatively rare. Krischer et al. noted the prevalence of life-threatening complications to be less than 0.5% in their analysis of 705 post-CPR autopsied patients (3). Cardiac rupture secondary to closed-chest CPR is exceedingly rare. In an analysis of 2,659 autopsied patients, Bodily and Fischer reported only three cases of right ventricular rupture induced by closed-chest CPR (7). The patient in the current case was found to have two

Cardiac Rupture During CPR

significant injuries: a laceration of the right lung and, most significantly, an anterior rupture of the right ventricle. The close approximation of the lateral 5th right rib splinter with the underlying lung laceration supports a probable role of the fractured rib in this injury. While the cardiac injury appeared to be because of myocardial rupture, given the proximity of the right ventricle to the fractured sternum, penetration of the myocardium by sternal splinters is also possible. Machii et al. recently reported a case of right atrial rupture and pericardial sac perforation by a fractured sternal edge following closedchest CPR (8). In addition, in each of the three cases of right ventricular rupture reported by Bodily and Fisher, the examining pathologist concluded that myocardial penetration by rib or sternal fracture spicules caused the laceration (7). Baldwin and Edwards reported two cases of right ventricular rupture in the absence of any fracture of ribs or sternum (9). They concluded that the rupture during closed-chest CPR was precipitated by high ventricular wall tension caused, in one case, by a massive pulmonary embolism (PE), and in the other case, by the simultaneous closure of the right ventricular outflow tract and the tricuspid valve caused by pressure applied at a position too high upon the sternum. Kempen and Allgood reported a case of fatal right ventricular rupture during closed-chest CPR associated with right pneumonectomy and pericardiotomy (10). These authors suggest that both increased right ventricular afterload (due to the missing right lung) and rightward displacement of the heart (due to the missing right lung and the right pericardial opening) placed extreme tension on the right ventricular wall during closed-chest CPR, leading to rupture. In cases of right ventricular rupture assumed secondary to increased ventricular pressures, the rupture occurred at the ventricular apex, whereas in the cases assumed secondary to bony fragment penetration, the laceration occurred in the anterior right ventricular wall (7,9-11). Because the location of our patient’s cardiac injury is most consistent with a penetrating mechanism, it is possible that a penetrating sternal splinter initiated the myocardial rupture. The role of closed-chest CPR technique must be considered when complications result from the procedure. Current guidelines advise compressions of 1.5 to 2 inches over the lower half of the sternum for the normalsized adult (12). Compressions applied too high on the sternum may lead to an increased rate of sternal and rib fractures. Overly vigorous efforts, which can readily evolve over the course of a difficult resuscitation, can likewise increase the incidence of thoracic fractures and other adverse effects. Elderly patients or others with more fragile bones are at increased risk for these complications. These observations highlight the importance of proper training for practitioners of closed-chest CPR.

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In this case, all the physicians who performed CPR were BLS certified, and there was no evidence of improper technique. However, given the increasing frequency with which the lay public is now trained in basic CPR techniques, physicians evaluating patients who have been administered closed-chest CPR in the pre-hospital setting may want to be more vigilant for the associated complications. The use of intracardiac injection of epinephrine for cardiac resuscitation is an uncommon practice that once was popular. It was used in this case because IV access had not been established, and there were no means to be certain of endotracheal tube position at the scene. In addition, the treating emergency physician was experienced and comfortable with the procedure. Complications of intracardiac injections include damage to the myocardium and coronary arteries, but not cardiac rupture. In this case, there was no autopsy evidence of damage from the intracardiac injection of epinephrine. The current case is especially noteworthy because it is one in which the patient was successfully resuscitated from the primary cardiac arrest, with evidence of neurologic recovery, but ultimately succumbed to injuries resulting directly from closed-chest CPR. Because the patient’s cardiac arrest most likely resulted from a primary dysrhythmia, it is possible that the patient would have survived had the rupture been recognized early. In a patient with deteriorating vital signs following successful closed-chest CPR, it may be appropriate to consider a lung laceration or a myocardial laceration or rupture. In retrospect, as soon as 1500 cc of blood was seen with placement of the second chest tube, the patient should have undergone immediate transfer to the operating room (OR) or open thoracotomy. With the increasing availability of ultrasound by emergency physicians, rapid bedside ultrasonography may affect earlier detection of cardiac injuries such as occurred in this patient (13,14). In the setting of recognized thoracic fractures after closed-chest CPR, it may even be appropriate to routinely screen for more severe adverse effects.

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164 6. Nagel EL, Fine EG, Krischer JP, Davis JH. Complications of CPR. Crit Care Med 1981;9:424. 7. Bodily K, Fischer RP. Aortic rupture and right ventricular rupture induced by closed chest cardiac massage. Minnesota Med 1979; 62:225-7. 8. Machii M, Inaba H, Nakae H, Suzuki I, Tanaka H. Cardiac rupture by penetration of fractured sternum: a rare complication of cardiopulmonary resuscitation. Resuscitation 2000;43:151-3. 9. Baldwin JJ, Edwards JE. Clinical conference: rupture of right ventricle complicating closed chest cardiac massage. Circulation 1976;53:562-4. 10. Kempen PM, Allgood R. Right ventricular rupture during closedchest cardiopulmonary resuscitation after pneumonectomy with pericardiotomy: a case report. Crit Care Med 1999;27:1378-9.

P. E. Sokolove et al. 11. Sethi GK, Scott SM, Takaro T. Complications of external cardiac massage: report of a case of laceration of the right ventricular outflow tract. J Cardiovasc Surg 1977;18:187-90. 12. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Part 3: adult basic life support. Circulation 2000;102(Suppl 8):I22– 59. 13. Symbas NP, Bongiorno PF, Symbas PN. Blunt cardiac rupture: the utility of emergency department ultrasound. Ann Thorac Surg 1999;67:1274-6. 14. Plummer D, Ruiz E, Clinton J, Brunette D. Emergency department two-dimensional echocardiography in the diagnosis of nontraumatic rupture. Ann Emerg Med 1994;23:1333-42.