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Gastric rupture due to cardiopulmonary resuscitation
Injury Vol. 29,No. 5,pp. 399-400, 1998 0 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0020-1383/98 $19.00+0.00
PII: SOO20-1383(97)00068-O
Gastric rupture resuscitation
due to cardiopulmonary
Carissa M. Oh and Peter M. Hewitt Department of Surgery, St George Hospital, Kogarah, Australia
Injury, Vol. 29, No. 5, 399-400, 1998
and the peritoneal cavity was thoroughly cleansed by
Introduction
saline lavage. Post-operatively it was evident that the patient also had significant pulmonary contusion and she required ventilatory support for 3 days. She was
Closed chest cardiopulmonary resuscitation (CPR) is currently the only hope of survival for most victims of out-of-hospital cardiac arrest. The effectiveness of this intervention is mainly dependent on rapid response. When an individual develops ventricular fibrillation, he or she has about a 30 per cent chance of surviving the cardiac arrest if basic life support is initiated within 4 min and defibrillation is attempted within 8 min, but survival is practically nil if these critical time intervals double’. Not surprisingly, the actions of bystanders invariably determine outcome, however, when CPR is performed by untrained individuals it may be associated with significant morbidity.
Case report A 66-year-old woman was socializing at a club when she collapsed-there was no palpable pulse and no spontaneousbreathing. CPR was immediately commenced by two club employees.This was continued for 20 min and was only interrupted to reposition the patient and clear her airway after she vomited blood and undigested food. When ambulancepersonnelarrived, shewas intubated and ventilated, and was defibrillated three times before sinus rhythm returned. On admission to the emergency department, her Glasgow Coma Score was 3T/15, pulse 116/min, BP 170/80mmHg and she was breathing spontaneously.Apart from bilateral upper limb hypertonicity, neurological findings were unremarkable, but she was noted to have a flail chest with decreasedair entry on the left side and her abdomen was grossly distended and tympanitic. A nasogastric tube was inserted and blood-stained gastric contents were aspirated. Chest X-ray confirmed multiple bilateral rib fractures, a fractured sternum and pneumoperitoneum. Brain CT scan showed only minimal cerebral swelling. At laparotomy, a 12-cm laceration of the lesser curvature of the stomach was found. This was closed in two layers
discharged from hospital after 24days with only mild cognitive presumed
dysfunction. The cause for to have been cardiac arrhythmia.
her
arrest
was
Discussion Cardiopulmonary resuscitation has been associated with numerous injuries, particularly rib fractures, which are seen in approximately 30 per cent of cases. Sternal fractures are less frequent. There is also a risk of mediastinal haemorrhage and cardiac contusion or even lethal complications such as laceration of the heart, great vessels, liver or spleen’,‘. Minor injuries of the gastric mucosa may occur in up to 12 per cent of patients undergoing cardiopulmonary resuscitation, but rupture is rare”. Bintz et al. were only able to find 18 cases described in the literature”. The injury often occurs on a full stomach when intragastric pressure can be raised sufficiently to cause bursting”. Sudden compression of the pylorus and cardia against the spine may also prevent egress of air. Our patient had consumed a number of carbonated drinks which would have resulted in gastric distension and this may have been aggravated by mouth-to-mouth ventilation. The site of rupture is usually the lesser curve, as it is the least elastic part of the stomach’. This differs from blunt trauma due to motor vehicle accidents, where the anterior wall and greater curvature are more prone to rupture” and may be explained by the fact that the latter are often deceleration injuries where shear forces are implicated. The diagnosis should be considered if dramatic distension of the abdomen occurs during CPR; however, a high index of suspicion is necessary in all cases. We would recommend gastric tube placement in any unconscious patient after CPR, as well as further X-rays to exclude the presence of free intraperitoneal air or contrast radiography where the diagnosis is in question. If pneumoperitoneum is
400
Injury:
International
and severe enough to compromise ventilation circulation, it requires immediate needle decompression. Definitive treatment entails early repair of the stomach and aggressive peritoneal toilet. The risks of CPR-related complications are increased when less experienced operators assume unconventional positions, compress at inappropriate sites, or apply excessive force, especially in elderly patients’. On questioning the bystanders involved in this case, it was revealed that they had been trained by a first-aid organization and indeed, it was not the first time they had administered CPR successfully. They admitted to being rather vigorous in their efforts and had noted cracking of the patient’s ribs, but they did not remember if force had been exerted over the xiphisternum. Although this case highlights the potential for serious morbidity and the need for education in the proper use of CPR, it should not discourage its use in appropriate circumstances.
References 1 Gazmuri R. J. and Becker J. Cardiac resuscitation: the search for hemodynamically more effective methods.
Journal
of the Care of the Injured
Vol. 29, No. 5,1998
Chest 1997; 111: 712-723. Bintz M. and Cogbill T. H. Gastric rupture after the heimlich maneuver. ]ournnl of Tramn 1996; 40: 159-160. Halpern P., Sorkine P., Leykin Y. and Geller E. Rupture of the stomach in a diving accident with attempted resuscitation. Britidz \wrmd of Awzesthesia 1986; 58: 1059-1061. Dharap S. B., Murthy B. N. S., Sheth H. B., Sawant A. S. and Changlani T. T. Gastric rupture from blunt abdominal injury. Iujwy 1996; 27: 753-754. Brunsting L. A. and Morton J. H. Gastric rupture from blunt abdominal trauma. \uur)znl of Trnumn 1987; 27: 887-891.
Paper accepted 28 January 1998.
Requests for rqvrilh should De addressed to: Dr Peter M. Hewitt, Department of Surgery, St George Hospital, Kogarah, NSW 2217, Australia. Tel.: 61 (02) 9350 2070; fax: 61 (02) 9350 3997.
PII: SOO20-1383(97)00068-O
Gastric rupture resuscitation
due to cardiopulmonary
Carissa M. Oh and Peter M. Hewitt Department of Surgery, St George Hospital, Kogarah, Australia
Injury, Vol. 29, No. 5, 399-400, 1998
and the peritoneal cavity was thoroughly cleansed by
Introduction
saline lavage. Post-operatively it was evident that the patient also had significant pulmonary contusion and she required ventilatory support for 3 days. She was
Closed chest cardiopulmonary resuscitation (CPR) is currently the only hope of survival for most victims of out-of-hospital cardiac arrest. The effectiveness of this intervention is mainly dependent on rapid response. When an individual develops ventricular fibrillation, he or she has about a 30 per cent chance of surviving the cardiac arrest if basic life support is initiated within 4 min and defibrillation is attempted within 8 min, but survival is practically nil if these critical time intervals double’. Not surprisingly, the actions of bystanders invariably determine outcome, however, when CPR is performed by untrained individuals it may be associated with significant morbidity.
Case report A 66-year-old woman was socializing at a club when she collapsed-there was no palpable pulse and no spontaneousbreathing. CPR was immediately commenced by two club employees.This was continued for 20 min and was only interrupted to reposition the patient and clear her airway after she vomited blood and undigested food. When ambulancepersonnelarrived, shewas intubated and ventilated, and was defibrillated three times before sinus rhythm returned. On admission to the emergency department, her Glasgow Coma Score was 3T/15, pulse 116/min, BP 170/80mmHg and she was breathing spontaneously.Apart from bilateral upper limb hypertonicity, neurological findings were unremarkable, but she was noted to have a flail chest with decreasedair entry on the left side and her abdomen was grossly distended and tympanitic. A nasogastric tube was inserted and blood-stained gastric contents were aspirated. Chest X-ray confirmed multiple bilateral rib fractures, a fractured sternum and pneumoperitoneum. Brain CT scan showed only minimal cerebral swelling. At laparotomy, a 12-cm laceration of the lesser curvature of the stomach was found. This was closed in two layers
discharged from hospital after 24days with only mild cognitive presumed
dysfunction. The cause for to have been cardiac arrhythmia.
her
arrest
was
Discussion Cardiopulmonary resuscitation has been associated with numerous injuries, particularly rib fractures, which are seen in approximately 30 per cent of cases. Sternal fractures are less frequent. There is also a risk of mediastinal haemorrhage and cardiac contusion or even lethal complications such as laceration of the heart, great vessels, liver or spleen’,‘. Minor injuries of the gastric mucosa may occur in up to 12 per cent of patients undergoing cardiopulmonary resuscitation, but rupture is rare”. Bintz et al. were only able to find 18 cases described in the literature”. The injury often occurs on a full stomach when intragastric pressure can be raised sufficiently to cause bursting”. Sudden compression of the pylorus and cardia against the spine may also prevent egress of air. Our patient had consumed a number of carbonated drinks which would have resulted in gastric distension and this may have been aggravated by mouth-to-mouth ventilation. The site of rupture is usually the lesser curve, as it is the least elastic part of the stomach’. This differs from blunt trauma due to motor vehicle accidents, where the anterior wall and greater curvature are more prone to rupture” and may be explained by the fact that the latter are often deceleration injuries where shear forces are implicated. The diagnosis should be considered if dramatic distension of the abdomen occurs during CPR; however, a high index of suspicion is necessary in all cases. We would recommend gastric tube placement in any unconscious patient after CPR, as well as further X-rays to exclude the presence of free intraperitoneal air or contrast radiography where the diagnosis is in question. If pneumoperitoneum is
400
Injury:
International
and severe enough to compromise ventilation circulation, it requires immediate needle decompression. Definitive treatment entails early repair of the stomach and aggressive peritoneal toilet. The risks of CPR-related complications are increased when less experienced operators assume unconventional positions, compress at inappropriate sites, or apply excessive force, especially in elderly patients’. On questioning the bystanders involved in this case, it was revealed that they had been trained by a first-aid organization and indeed, it was not the first time they had administered CPR successfully. They admitted to being rather vigorous in their efforts and had noted cracking of the patient’s ribs, but they did not remember if force had been exerted over the xiphisternum. Although this case highlights the potential for serious morbidity and the need for education in the proper use of CPR, it should not discourage its use in appropriate circumstances.
References 1 Gazmuri R. J. and Becker J. Cardiac resuscitation: the search for hemodynamically more effective methods.
Journal
of the Care of the Injured
Vol. 29, No. 5,1998
Chest 1997; 111: 712-723. Bintz M. and Cogbill T. H. Gastric rupture after the heimlich maneuver. ]ournnl of Tramn 1996; 40: 159-160. Halpern P., Sorkine P., Leykin Y. and Geller E. Rupture of the stomach in a diving accident with attempted resuscitation. Britidz \wrmd of Awzesthesia 1986; 58: 1059-1061. Dharap S. B., Murthy B. N. S., Sheth H. B., Sawant A. S. and Changlani T. T. Gastric rupture from blunt abdominal injury. Iujwy 1996; 27: 753-754. Brunsting L. A. and Morton J. H. Gastric rupture from blunt abdominal trauma. \uur)znl of Trnumn 1987; 27: 887-891.
Paper accepted 28 January 1998.
Requests for rqvrilh should De addressed to: Dr Peter M. Hewitt, Department of Surgery, St George Hospital, Kogarah, NSW 2217, Australia. Tel.: 61 (02) 9350 2070; fax: 61 (02) 9350 3997.