A 38y.o. woman arrested after an opiate overdose. Immediate cpr was done by her boyfriend and she was revived.

She had chest pain following cpr and pneumomediastinum was noted.

 

opiodarrowpneumomediastinum and L pleural effusion jpg.jpg

Something else was noted on the barium swallow; what was it?

opiod 1stagnant contrast in lesser sac jpg.jpg

Our patient had a ruptured stomach after CPR.  On the image shown it looks like there is contrast in the stomach which is actually in the lesser sac.  There is also free air over the dome of the stomach. Gastric rupture has been reported following both CPR and the Heimlich procedure.The lesser sac is a space behind the stomach which can be seen below.

lesser sac.JPG
lessersac 2.JPG
 free air

free air

CPR has been associated with injuries in between 21 and 65% of cases.  CPR complications are often encountered during the medico-legal postmortem examination and sometimes it is not clear if they contributed to the death.  Rib fractures are common, with liver rupture, gastric rupture and cardiac rupture being less common. More commonly,   hemopericardium, epicardial hematoma, myocardial contusion, and rupture of the vena cava close to its junction with the R atrium are the cardiac injuries  reported.

Presumably, many CPR associated injuries are never discovered since the patients do not have an autopsy. 

Our patient was resuscitated by her boyfriend with CPR and developed severe abdominal pain over the next six hours. After the swallow showed no esophageal injury but free air in the abdomen; the abdomen was opened anda 3 cm rent in the posterior fundus of the stomach was seen. Bile and fibrinous material was irrigated from the abdomen, the defect was excised, and the wound stapled. G and J tubes were placed and the patient was sent home with them in place to be removed in two weeks. 

Case courtesy of Keith Naunheim

 

 

Fearing MN, Harrision PB. Complications of the Heimlich maneuver: case report and literature review. J Trauma 2002; 53(5): 978-9. 

Tattoli L, Maselli E, Romanelli MC et al. Complete cardiac Rupture associated with closed chest cardiac massage: case report and review of the literature.  J Rorensic Sci 2014;59(2):564-567.

Kusunokia S, Tanigawab K, Kondoa T, Kawamotoa M.  Safety of the inter –nipple line hand position landmark for chest compression. Resuscitation. 2009;80:1175-1180. 

Darok M. Insuries resulting from resuscitation procedures.  In: Tsokos M, editor. Forrensic Pathology Reviews, Vol1. Totowa, New Jersey Humana Press; 2004. P. 1175-1180.

Hanganu B, Neagu M, Iorga M, et al. Cardiac rupture during cardio-pulmonary resuscitation case presentation and literature data.  2017Romania Journal of Leg Med (25)44-48.