Abstracts
We describe the case of a patient with an intramural hematoma and floating thrombus after cardiopulmonary resuscitation. The 92-year old man had a cardiac arrest due to ventricular fibrillation and witnesses immediately initiated manual cardiopulmonary resuscitation. Transesophageal echocardiography was performed immediately on hospital admission because the patient was in cardiogenic shock. In addition to an akinetic anterior wall, examination of the descending thoracic aorta demonstrated an intramural hematoma and a floating intra-aortic thrombus at a distance of 40cm from the dental arch. There was no aortic dissection. The thrombus was attributed to aortic compression during cardiopulmonary resuscitation. Although the aortic thrombus and intramural hematoma were not associated with any complications in this patient, insertion of an intra-aortic balloon may have led to aortic rupture or embolic events. Transesophageal echocardiography should be performed, when available, prior to insertion of an intra-aortic balloon for counterpulsation in patients who have undergone cardiopulmonary resuscitation.
Cardiopulmonary resuscitation/complications; Hematoma/etiology; Thrombosis/etiology; Echocardiography; Anticoagulants/therapeutic use; Case reports
Descrevemos o caso de um paciente com hematoma intramural e trombo flutuante após ressuscitação cardiopulmonar. Esse homem, de 92 anos de idade, teve uma parada cardíaca causada por fibrilação atrial e testemunhas iniciaram imediatamente manobras manuais de ressuscitação cardiopulmonar. Ao ser admitido no hospital, o paciente apresentava-se em choque cardiogênico, sendo, então, imediatamente submetido a ecocardiografia transesofágica. Além de uma parede anterior acinética, o exame da aorta torácica descendente mostrou um hematoma intramural e um trombo intra-aórtico flutuante a uma distância de 40cm do arco dental. Não havia dissecção da aorta. O trombo foi atribuído à compressão aórtica durante a ressuscitação cardiopulmonar. Embora o trombo aórtico e o hematoma intramural não tenham se associado a qualquer complicação nesse paciente, a inserção de um balão intra-aórtico poderia ter levado a uma ruptura da aorta ou a eventos embólicos. Recomenda-se a realização de ecocardiografia transesofágica, quando disponível, antes da inserção de um balão intra-aórtico de contrapulsação em pacientes submetidos à ressuscitação cardiopulmonar.
Ressuscitação cardiopulmonar/complicações; Hematoma/etiologia; Trombose/etiologia; Ecocardiografia; Anticoagulantes/uso terapêutico; Relatos de casos
INTRODUCTION
Cardiopulmonary resuscitation (CPR) is a life saving procedure. However, it can be
associated with thoracic and especially skeletal injuries, although direct cardiac
damage is rare.(
11. Hoke RS, Chamberlain D. Skeletal chest injuries secondary to
cardiopulmonary resuscitation. Resuscitation. 2004;63(3):327-38.
2. Lafuente-Lafuente C, Melero-Bascones M. Active chest
compression-decompression for cardiopulmonary resuscitation. Cochrane Database Syst
Rev. 2004;(2):CD002751. Update of Cochrane Database Syst Rev.
2002;(3):CD002751.
3. Rabl W, Baubin M, Broinger G, Scheithauer R. Serious complications
from active compression-decompression cardiopulmonary resuscitation. Int J Legal Med.
1996;109(2):84-9.
4. Englund E, Kongstad PC. Active compression-decompression CPR
necessitates follow-up post mortem. Resuscitation. 2006;68(1):161-2.
5. Smekal D, Johansson J, Huzevka T, Rubertsson S. No difference in
autopsy detected injuries in cardiac arrest patients treated with manual chest
compressions compared with mechanical compressions with the LUCAS device--a pilot
study. Resuscitation. 2009;80(10):1104-7.
-
66. Kim MJ, Park YS, Kim SW, Yoon YS, Lee KR, Lim TH, et al. Chest injury
following cardiopulmonary resuscitation: a prospective computed tomography
evaluation. Resuscitation. 2013;84(3):361-4.
) A few cases of acute intramural
aortic hematoma leading to fatal aortic rupture have been described.(
44. Englund E, Kongstad PC. Active compression-decompression CPR
necessitates follow-up post mortem. Resuscitation. 2006;68(1):161-2.
,
77. Bjork RJ, Snyder BD, Campion BC, Loewenson RB. Medical complications
of cardiopulmonary arrest. Arch Intern Med. 1982;142(3):500-3.
) We describe a case of aortic hematoma combined with a
floating intraluminal thrombus associated with manual CPR.
CASE REPORT
A 92-year old male experienced cardiac arrest due to ventricular fibrillation. Witnesses immediately initiated manual CPR, relayed by a medical team upon arrival on site. Circulation was restored after 20 minutes. Electrocardiogram showed an anterior ST segment elevation myocardial infarction suggesting an occlusion of the left anterior descending artery. Hypothermia was initiated during transfer to the hospital. The patient was admitted to the emergency room in cardiogenic shock, requiring immediate administration of norepinephrine. Transesophageal echocardiography was performed immediately to evaluate cardiac function. In addition to an akinetic anterior wall, examination of the aorta, before possible insertion of an aortic counterpulsation balloon in this elderly patient, showed an intramural hematoma and a floating intraluminal thrombus in the descending aorta, at a distance of 40cm from the dental arch (Figures 1 and 2, videos available in electronic supplement electronic supplement ). There was no aortic dissection. The thrombus was attributed to aortic compression during CPR. Of note, there were no other signs of thoracic trauma (no rib nor sternum fracture). Shortly after admission, a coronary angiogram was performed using radial arterial access and occlusion of the left main coronary artery was treated by endovascular stenting. In view of the advanced age of the patient, presence of an intra-aortic hematoma( 88. Maraj R, Rerkpattanapipat P, Jacobs LE, Makornwattana P, Kotler MN. Meta-analysis of 143 reported cases of aortic intramural hematoma. Am J Cardiol. 2000;86(6):664-8. , 99. Evangelista A, Dominguez R, Sebastia C, Salas A, Permanyer-Miralda G, Avegliano G, et al. Long-term follow-up of aortic intramural hematoma: predictors of outcome. Circulation. 2003;108(5):583-9. ) and persistent cardiogenic shock, stenting of the aorta was not performed. The patient was treated with unfractionated heparin and clopidogrel. A second transesophageal echocardiography performed 2 days later showed that the intra-aortic thrombus had disappeared but the intramural hematoma persisted. There was no evidence of systemic embolization. The patient made a good neurologic recovery but died of severe cardiac failure on the 9th day. An autopsy could not be performed due to relative refusal.
Transverse view of descending aorta. An intramural hematoma and intraluminal clot are visualized at 40cm from the dental arch.
DISCUSSION
Aortic thrombus may occur spontaneously in patients with a normal aorta or in the presence of atherosclerotic plaques. It can also occur in aortic trauma.( 1010. Cogert G, Siegel RJ. Giant floating aortic thrombus: a rare finding on transesophageal echocardiography. Am J Cardiol. 2007;99(5):739-40. ) In this patient, the thrombus may have been related to aortic trauma induced by chest compressions during CPR.
Manual compression CPR can result in significant thoracic trauma with multiple rib
fractures, bilateral pulmonary contusions, lacerations of intercostal arteries,
myocardial laceration and hemopericardium.(
11. Hoke RS, Chamberlain D. Skeletal chest injuries secondary to
cardiopulmonary resuscitation. Resuscitation. 2004;63(3):327-38.
2. Lafuente-Lafuente C, Melero-Bascones M. Active chest
compression-decompression for cardiopulmonary resuscitation. Cochrane Database Syst
Rev. 2004;(2):CD002751. Update of Cochrane Database Syst Rev.
2002;(3):CD002751.
3. Rabl W, Baubin M, Broinger G, Scheithauer R. Serious complications
from active compression-decompression cardiopulmonary resuscitation. Int J Legal Med.
1996;109(2):84-9.
4. Englund E, Kongstad PC. Active compression-decompression CPR
necessitates follow-up post mortem. Resuscitation. 2006;68(1):161-2.
-
55. Smekal D, Johansson J, Huzevka T, Rubertsson S. No difference in
autopsy detected injuries in cardiac arrest patients treated with manual chest
compressions compared with mechanical compressions with the LUCAS device--a pilot
study. Resuscitation. 2009;80(10):1104-7.
) Acute
intramural aortic hematomas, which rarely lead to fatal aortic
rupture,(
44. Englund E, Kongstad PC. Active compression-decompression CPR
necessitates follow-up post mortem. Resuscitation. 2006;68(1):161-2.
,
77. Bjork RJ, Snyder BD, Campion BC, Loewenson RB. Medical complications
of cardiopulmonary arrest. Arch Intern Med. 1982;142(3):500-3.
) have been described as an uncommon
complication of CPR. To the best of our knowledge, there is no report of endoluminal
thrombus (combined with intramural hematoma) associated with CPR in the
literature.
Given the paucity of reports in the literature, it is difficult to identify factors associated with CPR-induced aortic lesions. The use of mechanical devices may be involved in some cases( 44. Englund E, Kongstad PC. Active compression-decompression CPR necessitates follow-up post mortem. Resuscitation. 2006;68(1):161-2. ) although they do not increase the incidence of serious complications.( 22. Lafuente-Lafuente C, Melero-Bascones M. Active chest compression-decompression for cardiopulmonary resuscitation. Cochrane Database Syst Rev. 2004;(2):CD002751. Update of Cochrane Database Syst Rev. 2002;(3):CD002751. ) Of note, only manual compressions were used in the patient we describe. The age of the patient and the fact that the CPR was performed by laypersons may perhaps have played a role. Indeed skeletal injuries are more frequent in older than in younger patients and when CPR is performed by bystanders rather than trained personnel.( 66. Kim MJ, Park YS, Kim SW, Yoon YS, Lee KR, Lim TH, et al. Chest injury following cardiopulmonary resuscitation: a prospective computed tomography evaluation. Resuscitation. 2013;84(3):361-4. ) Nevertheless, age alone should not be used as a reason for not performing CPR, because old patients also benefit from CPR, especially when associated with neuroprotective measures as in this patient.( 1111. Mosier J, Itty A, Sanders A, Mohler J, Wendel C, Poulsen J, et al. Cardiocerebral resuscitation is associated with improved survival and neurologic outcome from out-of-hospital cardiac arrest in elders. Acad Emerg Med. 2010;17(3):269-75. )
Optimal treatment for such aortic lesions is debated. Mobile aortic thrombi are often associated with thromboembolic events.( 1212. Piffaretti G, Tozzi M, Mariscalco G, Bacuzzi A, Lomazzi C, Rivolta N, et al. Mobile thrombus of the thoracic aorta: management and treatment review. Vasc Endovascular Surg. 2008;42(5):405-11. ) Heparin remains the first-line therapy for mobile aortic thrombi,( 1313. Moriwaki Y, Sugiyama M, Tahara Y, Iwashita M, Kosuge T, Harunari N, et al. Complications of bystander cardiopulmonary resuscitation for unconscious patients without cardiopulmonary arrest. J Emerg Trauma Shock. 2012;5(1):3-6. , 1414. Bowdish ME, Weaver FA, Liebman HA, Rowe VL, Hood DB. Anticoagulation is an effective treatment for aortic mural thrombi. J Vasc Surg. 2002;36(4):713-9. ) and thrombectomy through direct aortotomy and aortic stenting can also be considered.( 1313. Moriwaki Y, Sugiyama M, Tahara Y, Iwashita M, Kosuge T, Harunari N, et al. Complications of bystander cardiopulmonary resuscitation for unconscious patients without cardiopulmonary arrest. J Emerg Trauma Shock. 2012;5(1):3-6. , 1515. Fueglistaler P, Wolff T, Guerke L, Stierli P, Eugster T. Endovascular stent graft for symptomatic mobile thrombus of the thoracic aorta. J Vasc Surg. 2005;42(4):781-3. ) Usually, post-CPR aortic lesions are diagnosed at autopsy.( 44. Englund E, Kongstad PC. Active compression-decompression CPR necessitates follow-up post mortem. Resuscitation. 2006;68(1):161-2. ) Although the aortic thrombus and intramural hematoma were not associated with any complications in this patient, insertion of an intra-aortic balloon may have resulted in aortic rupture or embolic events.
CONCLUSION
Transesophageal echocardiography should be performed, when available, prior to insertion of intra-aortic balloon counterpulsation in patients who have undergone cardiopulmonary resuscitation.
electronic supplement
REFERÊNCIAS
-
1Hoke RS, Chamberlain D. Skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation. 2004;63(3):327-38.
-
2Lafuente-Lafuente C, Melero-Bascones M. Active chest compression-decompression for cardiopulmonary resuscitation. Cochrane Database Syst Rev. 2004;(2):CD002751. Update of Cochrane Database Syst Rev. 2002;(3):CD002751.
-
3Rabl W, Baubin M, Broinger G, Scheithauer R. Serious complications from active compression-decompression cardiopulmonary resuscitation. Int J Legal Med. 1996;109(2):84-9.
-
4Englund E, Kongstad PC. Active compression-decompression CPR necessitates follow-up post mortem. Resuscitation. 2006;68(1):161-2.
-
5Smekal D, Johansson J, Huzevka T, Rubertsson S. No difference in autopsy detected injuries in cardiac arrest patients treated with manual chest compressions compared with mechanical compressions with the LUCAS device--a pilot study. Resuscitation. 2009;80(10):1104-7.
-
6Kim MJ, Park YS, Kim SW, Yoon YS, Lee KR, Lim TH, et al. Chest injury following cardiopulmonary resuscitation: a prospective computed tomography evaluation. Resuscitation. 2013;84(3):361-4.
-
7Bjork RJ, Snyder BD, Campion BC, Loewenson RB. Medical complications of cardiopulmonary arrest. Arch Intern Med. 1982;142(3):500-3.
-
8Maraj R, Rerkpattanapipat P, Jacobs LE, Makornwattana P, Kotler MN. Meta-analysis of 143 reported cases of aortic intramural hematoma. Am J Cardiol. 2000;86(6):664-8.
-
9Evangelista A, Dominguez R, Sebastia C, Salas A, Permanyer-Miralda G, Avegliano G, et al. Long-term follow-up of aortic intramural hematoma: predictors of outcome. Circulation. 2003;108(5):583-9.
-
10Cogert G, Siegel RJ. Giant floating aortic thrombus: a rare finding on transesophageal echocardiography. Am J Cardiol. 2007;99(5):739-40.
-
11Mosier J, Itty A, Sanders A, Mohler J, Wendel C, Poulsen J, et al. Cardiocerebral resuscitation is associated with improved survival and neurologic outcome from out-of-hospital cardiac arrest in elders. Acad Emerg Med. 2010;17(3):269-75.
-
12Piffaretti G, Tozzi M, Mariscalco G, Bacuzzi A, Lomazzi C, Rivolta N, et al. Mobile thrombus of the thoracic aorta: management and treatment review. Vasc Endovascular Surg. 2008;42(5):405-11.
-
13Moriwaki Y, Sugiyama M, Tahara Y, Iwashita M, Kosuge T, Harunari N, et al. Complications of bystander cardiopulmonary resuscitation for unconscious patients without cardiopulmonary arrest. J Emerg Trauma Shock. 2012;5(1):3-6.
-
14Bowdish ME, Weaver FA, Liebman HA, Rowe VL, Hood DB. Anticoagulation is an effective treatment for aortic mural thrombi. J Vasc Surg. 2002;36(4):713-9.
-
15Fueglistaler P, Wolff T, Guerke L, Stierli P, Eugster T. Endovascular stent graft for symptomatic mobile thrombus of the thoracic aorta. J Vasc Surg. 2005;42(4):781-3.
Publication Dates
-
Publication in this collection
Oct-Dec 2013
History
-
Received
29 Oct 2013 -
Accepted
11 Nov 2013