abdominal complications after cpr · buschmann ct, tsokos, m. frequent and rare complications of...

Abdominal Complications after CPR

Daniel Kim, M.D.

Kings County Medical Center

February 26, 2015

www.downstatesurgery.org

Case Presentation

87 year old female

PMH/PSH HTN CHF (EF 40%) NSTEMI (August 2014); Cardiac Cath and stent ESRD on HD via AVF

Medications Aspirin, metoprolol, enalapril, hydralazine, simvastatin


Complaint: SOB

Vitals: Temp 98.6, HR 88, BP 157/74, RR 22, O2: 100% 2L

Exam: Bilateral coarse breath sounds Abdomen soft, non-distended, non-tender No peripheral edema

Laboratory: K 4.5, BUN/Cr 41/6.2, BNP 6650, Trop 0.059, INR 1.2

CXR…


Presenter

Presentation Notes

Routinely complained of SOB with hospitalizations at least 4 times a year for fluid overload


Presenter

Presentation Notes

Stable Cardiomegaly and mild pulmonary venous congestion without focal consolidation

Hospital Day 1

Admitted to a medical service…many hours later…

Hemodialysis removed 3 liters over 3 hours

Post-Dialysis vitals: BP 142/29, HR 111, RR 34, 100% 2L

Agonal breathing, lethargy and then asystole

ACLS with ROSC

CXR repeated…


Presenter

Presentation Notes

HTN treated with IV hydralazine, Tachypnea treated with oxygen and nebulizers, Patient complained of emesis and impending doom prior to dialysis and was treated with zofran and antihypertensives During the code, a nasogastric tube was placed

Hospital Day 2

Surgical Consultation

Vitals: Temp 99, HR 72, BP 93/52

Abdominal exam with tenderness and distention

Medications: Levophed drip and broad antibiotics

Family discussion: Full code and all surgical measures

CT scan…


Presenter

Presentation Notes

Surgical consultation was placed Evaluation

Operative Findings

Exploratory Laparotomy

Minimal contamination noted

9 cm gastric perforation of the lesser curvature with inflamed tissue and hematoma

Debridement with hand-sewn closure of defect

JP drain adjacent to resection margin


Postoperative Course

NSTEMI

Respiratory failure and pneumonia (Pseudomonas)

Bacteremia: Serratia

POD 16: Gastric leak with attempted endoscopic clipping followed by cardiac arrest x2 and increased pressor requirements

POD 21: DNR; patient succumbed same day

Pathology: Perforation with transmural hemorrhage and acute inflammation. H. Pylori positive


Presenter

Presentation Notes

Broad abx with vanco zosyn then meropenem Also received Protonix IV BID

Complications of CPR

Upper aerodigestive Intubation related

Thoracic Musculoskeletal Cardiac Pulmonary

Abdominal Organ lacerations/perforation Retroperitoneal Other



Presenter

Presentation Notes

79 year old female with Multiple medical problems including ARF, hepatic failure with coagulopathy, Afib, EF 25% 6cm gastric laceration along the lesser curvature

Prospective study analyzing autopsy data (1977-1979)

N = 705 (Cardiac arrest recognized and treated by trained personnel and autopsy by medical examiner)

Abdominal visceral complications noted in 30.8% Gastric dilation 29.1% Liver injury 2.9% Splenic injury 0.3% Gastric injury 1% Gastric perforation 0.1% Omental hemorrhage 0.1% Retroperitoneal hemorrhage 0.1%


Presenter

Presentation Notes

Liver and splenic injuries include laceration, hematoma, rupture

Literature search (online, up to August 2009)

67 cases of gastric perforation after CPR (ages 5-87 years)

3 most common risk factors: bystander provided BLS, use of bag mask, difficult airway (esophageal intubation)

All gastric perforations on the lesser curvature adjacent to the GE juntion Least elastic portion with fewer mucosal folds Tethering by the gastrohepatic ligament and GE junction

Gastric Mucosal lacerations: 9-12%


Presenter

Presentation Notes

Keywords: perforation or rupture or pneumoperitoneum or laceration; and gastric or stomach; and resuscitation or BLS or CPR or ALS

Retrospective review (1988-1995) of children <12 years old given CPR

15/211 (7%) patients had post-CPR complications

1 Gastric perforation and 2 Retroperitoneal hematomas

Multiple injuries noticed after CPR may suggest physical abuse


Presenter

Presentation Notes

Annals of emergency medicine Grand Rapids, Michigan Pathology: (SIDS, drowning, congenital heart disease, pneumonia

Take Home Points

Life threatening abdominal complications after CPR occur less than 0.5% of the time

Abdominal free air or fluid after CPR does not always require surgery – but hemodynamic or exam changes acutely after successful resuscitation warrant suspicion

Risk factors for abdominal visceral injury after CPR include untrained personnel, extensive chest compressions and anticoagulation

Risk factors for gastric perforation with CPR include maneuvers that move air into the stomach such as esophageal intubation or bag mask ventilation and lack of gastric decompression before chest compressions


References

Isabelle Spoormansa, Kim Van Hoorenbeecka, Lee Balliu b, Philippe G. Jorensa. Gastric perforation after cardiopulmonary resuscitation: Review of the literature. Resuscitation. 2010; 81: 272-280

Buschmann CT, Tsokos, M. Frequent and rare complications of resuscitation attempts. Intensive Care Med. 2009; 35:397-404

Krischer JP, Fine EG, Davis JH, Nagel EL. Complications of cardiac resuscitation. Chest. 1987;92(2):287-291

Mills SA, Paulson D, Scott SM, Sethi G. Tension pneumoperitoneum and gastric rupture following cardiopulmonary resuscitation. Ann Emerg Med. 1983;12(2):94-95.

Hulewicz B. Gastric trauma following cardiopulmonary resuscitation. Med Sci Law. 1990;30(2):149-152.


abdominal complications after cpr · buschmann ct, tsokos, m. frequent and rare complications of...

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