C2005 Evidence Evaluation Template - Nov.11, 2003.doc

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REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT

WORKSHEET for PROPOSED Evidence-Based GUIDELINE RECOMMENDATIONSNOTE: Save worksheet using the following filename format: Taskforce.Topic.Author.Date.Doc where Taskforce is a=ACLS, b=BLS, p=Pediatric, n=neonatal and i=Interdisciplinary. Use 2 or 3 letter abbreviation for author’s name and 30Jul03 as sample date format.Worksheet Author: G Nichol

Taskforce/Subcommittee: _x_BLS __ACLS __PEDS __ID __PROAD__Other:

Author’s Home Resuscitation Council:

_x_AHA __ANZCOR __CLAR __ERC __HSFC

__HSFC __RCSA ___IAHF ___Other:

Date Submitted to Subcommittee: Aug 19, 2004; Revised October 10, 2004; December 2, 2004

STEP 1: STATE THE PROPOSAL. State if this is a proposed new guideline; revision to current guideline; or deletion of current guideline.Existing guideline, practice or training activity, or new guideline: New guidelineStep 1A: Refine the question; state the question as a positive (or negative) hypothesis. State proposed guideline recommendation as a specific, positive hypothesis. Use single sentence if possible. Include type of patients; setting (in- /out-of-hospital); specific interventions (dose, route); specific outcomes (ROSC vs. hospital discharge).CPR is safe for victims.

Step 1B: Gather the Evidence; define your search strategy. Describe search results; describe best sources for evidence.ECC EndNote library (Aug 10, 2004) was searched using text word combination “CPR” OR “resuscitation” AND “adverse effects”MEDLINE (July 1, 2004), EMBASE (July 1, 2004) were searched using the following terms: exp heart arrest OR CPR$.mp OR resuscitation.mp OR cardiac arrest.mp AND adverse effects. Year of publication was not restricted. The reference lists from pertinent articles were reviewed to assure no relevant citations were missed. There were no relevant reviews archived in the Cochrane Database.2,046 citations were identified.

The electronic databases searched included AHA EndNote 7 Master library [http://ecc.heart.org/], Cochrane database for systematic reviews and Central Register of Controlled Trials [http://www.cochrane.org/], MEDLINE [http://www.ncbi.nlm.nih.gov/PubMed/ ], and hand searches of journals, review articles, and books.

• State major criteria you used to limit your search; state inclusion or exclusion criteria (e.g., only human studies with control group? no animal studies? N subjects > minimal number? type of methodology? peer-reviewed manuscripts only? no abstract-only studies?)

Included were human studies. Excluded were animal studies (26), duplicate studies (7) or those that did not describe adverse effects in victims of cardiac arrest who received CPR (1887).

• Number of articles/sources meeting criteria for further review: Create a citation marker for each study (use the author initials and date or Arabic numeral, e.g., “Cummins-1”). . If possible, please supply file of best references; EndNote 6+ required as reference manager using the ECC reference library.126 citations met criteria for further review.

STEP 2: ASSESS THE QUALITY OF EACH STUDYStep 2A: Determine the Level of Evidence. For each article/source from step 1, assign a level of evidence—based on study design and methodology.

Level of Evidence

Definitions(See manuscript for full details)

Level 1 Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effectsLevel 2 Randomized clinical trials with smaller or less significant treatment effectsLevel 3 Prospective, controlled, non-randomized, cohort studiesLevel 5 Historic, non-randomized, cohort or case-control studiesLevel 5 Case series: patients compiled in serial fashion, lacking a control groupLevel 6 Animal studies or mechanical model studiesLevel 7 Extrapolations from existing data collected for other purposes, theoretical analysesLevel 8 Rational conjecture (common sense); common practices accepted before evidence-based guidelines

http://www.ncbi.nlm.nih.gov/PubMed/

http://www.cochrane.org/

http://ecc.heart.org/



Step 2B: Critically assess each article/source in terms of research design and methods. Was the study well executed? Suggested criteria appear in the table below. Assess design and methods and provide an overall rating. Ratings apply within each Level; a Level 1 study can be excellent or poor as a clinical trial, just as a Level 6 study could be excellent or poor as an animal study. Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study. For more detailed explanations please see attached assessment form.

Component of Study and Rating Excellent Good Fair Poor UnsatisfactoryDesign &

Methods

Highly appropriate sample or model, randomized, proper controls ANDOutstanding accuracy, precision, and data collection in its class

Highly appropriate sample or model, randomized, proper controlsOROutstanding accuracy, precision, and data collection in its class

Adequate, design, but possibly biased

ORAdequate under the circumstances

Small or clearly biased population or model

ORWeakly defensible in its class, limited data or measures

Anecdotal, no controls, off target end-points

ORNot defensible in its class, insufficient data or measures

A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpointB = Survival of event D = Intact neurological survival Italics = animal studies

Step 2C: Determine the direction of the results and the statistics: supportive? neutral? opposed?

DIRECTION of study by results & statistics: SUPPORT the proposal NEUTRAL OPPOSE the proposal

ResultsOutcome of proposed guideline superior, to a clinically important degree, to current approaches

Outcome of proposed guideline no different from current approach

Outcome of proposed guideline inferior to current approach

Step 2D: Cross-tabulate assessed studies by a) level, b) quality and c) direction (ie, supporting or neutral/ opposing); combine and summarize. Exclude the Poor and Unsatisfactory studies. Sort the Excellent, Good, and Fair quality studies by both Level and Quality of evidence, and Direction of support in the summary grids below. Use citation marker (e.g. author/ date/source). In the Neutral or Opposing grid use bold font for Opposing studies to distinguish them from merely neutral studies. Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study.

Supporting EvidenceCPR is safe for victims

Qu

alit

y of

Evi

den

ce

Excellent

Good

Fair



1 2 3 4 5 6 7 8

Level of EvidenceA = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpoint (e.g., ischemic injury)B = Survival of event D = Intact neurological survival F = Administration of 100% O2

Neutral or Opposing EvidenceCPR is safe for victims

Excellent

Good


REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMATQ

ual

ity

of E

vid

ence

Fair

Adams1(1)E Aguilar1(2)EAzuma1(3)E Batra1(4)EBedell1(5)E Benbow1(6)EBerg1(7).E Bernard1(8)EBrady1(9)E Burdett-Smith1(10)EBush1(11)E Cafri1(12)ECameron1(13)E Chatson1(14)EClinch1(15)E Corbett1(16)ECuster1(17)E Darke1(18)EDelanye1(19)E Dohi1(20)EDucable1(21)E Elliot1(22)EEnarson1(23)E Enat1(24)EEngelstein1(25)E Evans1(26)EFeldman1(27)E Fitchet1(28)EFletcher1(29)E Floret1(30)EFlowers1(31)E Fosse1(32)EGainant1(33)E Gallagher1(34)EGerry1(35)E Gillies1(36)EGilliland1(37)E Goetting1(38)EGoldberg1(39)E Gordon1(40)EGregersen1(41)E Gueugniaud1(42)EHachiro1(43)E Hargarten1(44)EHarm1(45)E Hartoko1(46)EHashimoto1(47)E Haugeberg1(48)EHillman1(49)E Hood1(50)E Hulewicz1(51)E Jeong1(52)EKam1(53)E Kanter1(54)EKaplan1(55)E Katz1(56)EKempen1(57)E Kendall1(58)EKloss1(59)E Kordas1(60)EKramer1(61)E Krause1(62)EKrischer1(63)E Krumholz1(64)EKurkciyan1(65)E Lawes1(66)ELelcuk1(67)E Linch1(68)ELockett1(69)E Low1(70)EMa1(71)E Machii1(72)EMatikainen1(73)E Mattana1(74)EMcGrath1(75)E Mehta1(76)EMensah1(77)E Menzies1(78)EMills1(79)E Minor1(80)EMiro1(81)E Mirow1(82)ENagel1(83)E Nelson1(84)ENorfleet1(85)E Novotny1(86)EOdom1(87)E Offerman1(88)EOh1(89)E Oschatz1(90)EParke1(91)E Pestaner1(92)EPetersen1(93)E Pezzi1(94)EPowner1(95)E Reardon1(96)ERegister1(97)E Reinartz1(98)ERello1(99)E Robbins1(100)ERobinson1(101)E Samet1(102)EScholz1(103)E Schroeder1(104)ESclarovsky1(105)E Sewell1(106)EShemesh1(107)E Shulman1(108)ESmith1(109)E Sokolove1(110)ESperry1(111)E Stallard1(112)EStrear1(113)E Takada1(114)ETenaglia1(115)E Thompson1(116)EVan Hoeyweghen1(117)EVinen1(118)E Wagner1(119)EWalley1(120)E Windecker1(121)EWolcke1(122)E Wong1(123)EWoods1(124)E Yamaki1(125)EZuzarte1(126)E

1 2 3 4 5 6 7 8

Level of EvidenceA = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpoint (e.g., ischemic injury)B = Survival of event D = Intact neurological survival

STEP 3. DETERMINE THE CLASS OF RECOMMENDATION. Select from these summary definitions.

CLASS CLINICAL DEFINITION REQUIRED LEVEL OF EVIDENCE



Class IDefinitely recommended. Definitive, excellent evidence provides support.

• Always acceptable, safe• Definitely useful • Proven in both efficacy & effectiveness• Must be used in the intended manner for proper clinical indications.

• One or more Level 1 studies are present (with rare exceptions) • Study results consistently positive and compelling

Class II:Acceptable and useful

• Safe, acceptable• Clinically useful• Not yet confirmed definitively

• Most evidence is positive• Level 1 studies are absent, or inconsistent, or lack power • No evidence of harm

• Class IIa : Acceptable and usefulGood evidence provides support

• Safe, acceptable• Clinically useful • Considered treatments of choice

• Generally higher levels of evidence• Results are consistently positive

• Class IIb: Acceptable and usefulFair evidence provides support

• Safe, acceptable • Clinically useful• Considered optional or alternative treatments

• Generally lower or intermediate levels of evidence• Generally, but not consistently, positive results

Class III: Not acceptable, not useful, may be harmful

• Unacceptable• Not useful clinically• May be harmful.

• No positive high level data• Some studies suggest or confirm harm.

Indeterminate• Research just getting started.• Continuing area of research• No recommendations until further research

• Minimal evidence is available• Higher studies in progress • Results inconsistent, contradictory• Results not compelling

STEP 3: DETERMINE THE CLASS OF RECOMMENDATION. State a Class of Recommendation for the Guideline Proposal. State either a) the intervention, and then the conditions under which the intervention is either Class I, Class IIA, IIB, etc.; or b) the condition, and then whether the intervention is Class I, Class IIA, IIB, etc.Indicate if this is a __Condition or _X_InterventionFinal Class of recommendation: __Class I-Definitely Recommended __Class IIa-Acceptable & Useful; good evidence __Class IIb-Acceptable & Useful; fair evidence __Class III – Not Useful; may be harmful _X_Indeterminate-minimal evidence or inconsistent

REVIEWER’S PERSPECTIVE AND POTENTIAL CONFLICTS OF INTEREST: Briefly summarize your professional background, clinical specialty, research training, AHA experience, or other relevant personal background that define your perspective on the guideline proposal. List any potential conflicts of interest involving consulting, compensation, or equity positions related to drugs, devices, or entities impacted by the guideline proposal. Disclose any research funding from involved companies or interest groups. State any relevant philosophical, religious, or cultural beliefs or longstanding disagreements with an individual.

I am a general internist with postgraduate training in clinical research. I volunteer as a member of the American Heart Association’s Emergency Cardiovascular Care committee, immediate past chair of the Association’s BLS subcommittee, and chair of the Association’s AED Task Force. In the last five years, I have held unrestricted grants from Medtronic Physio-Control (now Medtronic ERS), Cardiac Science, Zoll, Philips Heartstream in support of a registry of out of hospital cardiac arrest. I am a coinvestigator responsible for economic analysis of public access defibrillation trial, funded by NHLBI, AHA, and industry. I am also a coinvestigator responsible for economic analysis of a trial of cardiac resynchronization therapy, funded by Medtronic and Canadian Institutes of Health Research. I am sponsor of an Investigational Device Exemption from the FDA for a randomized trial of a wearable cardioverter defibrillator. Director of University of Washington – Harborview Prehospital Research and Training Center Medical Director of University of Washington Clinical Trial Center. These Centers participate in or coordinate several industry or agency-sponsored trials that are evaluating resuscitation interventions, including the Resuscitation Outcomes Consortium. I have never received consulting fees, salary, or equity related to drugs, devices or entities impacted by this guideline proposal.

REVIEWER’S FINAL COMMENTS AND ASSESSMENT OF BENEFIT / RISK: Summarize your final evidence integration and the rationale for the class of recommendation. Describe any mismatches between the evidence and your final Class of Recommendation. “Mismatches” refer to selection of a class of recommendation that is heavily influenced by other factors than just the evidence. For example, the evidence is strong, but implementation is difficult or expensive; evidence weak, but future definitive evidence is unlikely to be obtained. Comment on contribution of animal or mechanical model studies to your final recommendation. Are results within animal studies homogeneous? Are animal results consistent with results from human studies? What is the frequency of adverse events? What is the possibility of harm? Describe any value or utility judgments you may have made, separate from the evidence. For example, you believe evidence-supported interventions should be limited to in-hospital use because you think proper use is too difficult for pre-hospital providers. Please include relevant key figures or tables to support your assessment.



CPR is generally safe for individuals in cardiac arrest. (Indeterminate). Although the evidence supporting the safety of receiving CPR is weak, there is a substantial publication bias. Adverse effects are more likely to be reported than lack of adverse effects. Thousands of individuals have received CPR but there are no large studies that objectively assessed or recorded adverse events associated with CPR provision. The denominator of individuals who have received CPR is unknown so it is difficult to assess the frequency of adverse events. Receipt of CPR is associated with rib fractures (5) and occasionally associated with intrathoracic, intraabdominal, vascular or other injuries. However the consequences of not receiving CPR when it is required are devastating. There are no reports of individuals acquiring infections after receiving CPR. Common sense suggests that providers take appropriate safety precautions when feasible and when resources are available to do so, especially if a victim is known or suspected to have a serious infection (e.g. HIV, SARS.)Furthermore, it is difficult to determine the causality or clinical impact of many of these injuries given the current poor overall outcome after cardiac arrest. Risk of adverse effects associated with CPR adjuncts, drugs or defibrillators were not assessed in this review, nor were differences assessed by type of provider.

Preliminary draft/outline/bullet points of Guidelines revision: Include points you think are important for inclusion by the person assigned to write this section. Use extra pages if necessary.

Publication: Chapter: Pages:

Topic and subheading:

Based on more than 100 LOE 5 case reports and case series, CPR is generally safe for individuals in cardiac arrest. (Indeterminate). CPR is frequently associated with rib fractures in older victims and occasionally associated with other injuries. Patients who exhibit hemodynamic or other instability after resuscitation should be reassessed and reevalauted for resuscitation-related injuries.

Attachments: Bibliography in electronic form using the Endnote Master Library. It is recommended that the bibliography be provided in annotated

format. This will include the article abstract (if available) and any notes you would like to make providing specific comments on the quality, methodology and/or conclusions of the study.



Citation List

Citation Marker Full Citation*Adams1 Reference Type: Journal Article

Record Number: 8818Author: Adams, H. A.; Schmitz, C. S.; Block, G.; Schlichting, C.Year: 1995Title: Intra-abdominal bleeding after myocardial infarction with cardiopulmonary resuscitation and thrombolytic therapyJournal: AnaesthesistVolume: 44Issue: 8Pages: 585-9.Keywords: excluded

AbdomenAdultAnesthesiaCardiopulmonary Resuscitation/*adverse effectsElectrocardiographyEnglish AbstractFibrinolytic Agents/*adverse effects/therapeutic useHumanMaleMiddle AgedMyocardial Infarction/*complicationsPostoperative Hemorrhage/chemically induced/*etiology/physiopathologyAbstract: Adverse effects of resuscitation due to closed-chest cardiac massage are common, and the incidence is increased when an incorrect technique is used. Nevertheless, thrombolytic therapy of a myocardial infarction can become necessary even after cardiopulmonary resuscitation (CPR). In these patients, the risk of thrombolytic therapy-induced bleeding is immanent. CASE REPORTS. Within 9 months, two male patients aged 44 and 52 years were admitted to the intensive care unit after out-of-hospital CPR for myocardial infarction with cardiac arrest. In both cases, thrombolytic therapy was undertaken due to the cardiovascular situation or echocardiographic results. Thrombolytic therapy was successful with regard to the ECG changes, but a few hours later both patients demonstrated increasing cardiovascular instability. After abdominal sonography, intra-abdominal bleeding was suspected. Emergency laparotomy became unavoidable, although the coagulation profile was severely impaired in both patients (Tables 1 and 2). Anaesthetic management was characterised by introduction of central venous and intra-arterial catheters, replacement of volume and oxygen carriers using large-bore IV lines, restoration of coagulation factors with fresh frozen plasma, and the choice of "modified neuroleptanaesthesia" with blood pressure-adjusted, small doses of fentanyl, midazolam, and pancuronium. Intraoperatively, a liver injury due to closed-chest cardiac massage was found in both cases. The postoperative courses were complicated by respiratory problems, which led to prolonged mechanical ventilation, but both patients survived without remarkable neurological deficits. CONCLUSION. In patients with thrombolytic therapy after CPR and persisting cardio-vascular instability, a resuscitation injury with consequent haemorrhagic shock should be suspected. For diagnosis, chest X-ray films and abdominal and thoracic sonography are useful and practicable, even at the bedside. Anaesthetic management should focus on adequate monitoring, replacement of volume and oxygen carriers, fast restoration of plasma coagulation, and careful, blood pressure-adjusted maintenance of anaesthesia.Notes: Two case reports on thrombolysis after cardiac arrest due to myocardial infarction.

Two case reports of intra-abdominal bleeding after cardiopulmonary resuscitation and thrombolytic therapy. No abstract provided. Level 5 Fair.

Aguilar1 Reference Type: Journal Article



Record Number: 1414Author: Aguilar, J. C.Year: 1981Title: Fatal gastric hemorrhage: a complication of cardiorespiratory resuscitationJournal: Journal of Trauma-Injury Infection & Critical CareVolume: 21Issue: 7Pages: 573-5Date: JulAccession Number: 6973026Keywords: ScreenAbstract: Clinical courses of 16 patients with documented gastric trauma resulting from cardiopulmonary resuscitation were reviewed from seven published manuscripts (1-7). Three patients with gastric rupture survived the therapy (2, 3, 7), two ultimately died of their original disease, and one recovered completely (2). Of the 15 who died, the gastric trauma contributed very little to the fatal outcome of the patients. The case reported here suffered death from gastric mucosal lacerations caused by cardiopulmonary resuscitation resulting in a fatal massive gastric hemorrhage.

Review of 16 published cases with documented gastric trauma after CPR. 1 recovered completely; 15 died but the trauma did not contribute to their fatal outcome. Level 5 Fair.

Azuma1 Reference Type: Journal ArticleRecord Number: 9874Author: Azuma, S.S.; Mashiyama, E.T.; Goldsmith, C.I.; Abbasi, A.S.Year: 1986Title: Chest compression-induced vertebral fractures.Journal: ChestVolume: 89Issue: 1Pages: 154-155Alternate Journal: ChestAccession Number: 3940778Keywords: agedarticlecase reportfemalefracturehumanmalepressureresuscitationspine injurytechniqueAbstract: Two cases with chest compression-induced thoracolumbar transvertebral fractures are discussed. This is a previously unreported complication of cardiopulmonary resuscitation. Dorsal kyphosis and osteopenia were present in both of these cases. There was no spinal cord injury documented, though the potential for injury and paraplegia exists. Care should be taken to avoid this complication, especially in the elderly with kyphosis; however, adequate compressions to insure support of circulation should be maintained.Author Address: Azuma, S.S.

Two cases with chest compression-induced thoracolumbar transvertebral fractures. Dorsal kyphosis and ostepenia present in both cases. Level 5 Fair.

Batra1 Reference Type: Journal ArticleRecord Number: 1234Author: Batra, A. K.Year: 1986



Title: Lung herniation after CPRJournal: Critical Care MedicineVolume: 14Issue: 6Pages: 595-6Date: JunAccession Number: 3709206Keywords: Screen

Case report of lung herniation after CPR associated with sternal fracture, rib fracture and costal cartilage separation. Level 5 Fair.

Bedell1 Reference Type: Journal ArticleRecord Number: 1225Author: Bedell, S. E.; Fulton, E. J.Year: 1986Title: Unexpected findings and complications at autopsy after cardiopulmonary resuscitation (CPR)Journal: Archives of Internal MedicineVolume: 146Issue: 9Pages: 1725-8Date: SepAccession Number: 3753112Keywords: ScreenAbstract: To evaluate the importance of diagnoses undetected before cardiac arrest in the hospital, we studied autopsy findings on 130 patients who died after an attempt at cardiopulmonary resuscitation (CPR). We also studied the complications that occurred in these patients as a result of CPR. Twenty-one percent of the patients had at least one complication as a result of CPR Patients resuscitated on the wards were more likely to have a complication than those treated in the intensive care unit. This suggests that more proficient technique in CPR may reduce morbidity from this procedure. In 14% of the cases, there was a major missed diagnosis. The two diseases most frequently undetected clinically were ischemic bowel and pulmonary embolus, which together accounted for 89% of all major missed diagnoses discovered at autopsy. We conclude that diseases that require a high prior clinical suspicion (bowel infarction and pulmonary embolus) are common accompaniments of cardiac arrest in the hospital. Consideration of these diagnoses in critically ill patients may prevent future cardiac arrest and death from pulmonary embolus and ischemic bowel.

Retrospective cohort study of autopsy findings in 130 patients who died at a single hospital after undergoing CPR. 21% of patients had at least one complication as a result of CPR: fractured ribs, fractured sternum, bone marrow emboli, epicardial hemorrhage, mediastinal hematomas, aspiration pneumonia, epicardial contusion, intra-atrial hemorrhage, LV laceration, LV hemorrhage, RV hemorrhage, pulmonary contusions, perforation of anterior wall of RV, submucosal hemorrhage of trachea. Level 5 Fair.

Benbow1 Reference Type: Journal ArticleRecord Number: 1010Author: Benbow, E. W.; Humphrey, G. M.Year: 1991Title: So what really causes gastric mucosal tears?[comment]Journal: Medicine, Science & the LawVolume: 31Issue: 1Pages: 87Date: JanAccession Number: 2005776Keywords: Screen



Review speculating on cause of gastric mucosal tears observed after CPR. Level 5 Fair.

Berg1 Reference Type: Journal ArticleRecord Number: 676Author: Berg, M. D. ; Idris, A. H. ; Berg, R. A.Year: 1998Title: Severe ventilatory compromise due to gastric distention during pediatric cardiopulmonary resuscitation.Journal: ResuscitationVolume: 36Issue: 1Pages: 71-73Date: 1998 JanLabel: 28050Keywords: Cardiopulmonary Resuscitation*adverse effectsCase ReportHeart Arrest*therapyHumanInfantIntubation, IntratrachealMaleRespiratory MechanicsStomach Dilatation*etiology19980421 02:02Abstract: We describe a child in cardiac arrest with severe ventilatory compromise due to gastric distention. During cardiopulmonary resuscitation (CPR), positive pressure ventilation may lead to gastric insufflation because of decreased pulmonary compliance and decreased lower esophageal sphincter tone. Essentially, gas delivered will follow the path of least resistance, which may be to the stomach. In our patient, gastric distention precluded effective ventilation and gastric decompression relieved ventilatory compromise. The values and pitfalls of clinical evaluation and capnography are presented.Notes: ProCite field[38]: 98209068

Case report of child in cardiac arrest with severe ventilatory compromise due to gastric distention. Level 5 Fair.

Bernard1 Reference Type: Journal ArticleRecord Number: 870Author: Bernard, S. A.; Jones, B. M.; Scott, W. J.Year: 1993Title: Intra-abdominal complications following prolonged cardiopulmonary resuscitationJournal: Australian & New Zealand Journal of SurgeryVolume: 63Issue: 4Pages: 312-4Date: AprAccession Number: 8311820Keywords: ScreenAbstract: A patient who underwent prolonged cardiopulmonary resuscitation developed an acute abdomen in the early post-arrest period which required laparotomy. Operative findings were of a perisplenic haematoma and infarction of the caecum. The latter has not previously been reported in this setting. A review of the literature reveals that many abdominal complications may occur following external cardiac massage. Difficulties in investigation and management are discussed. [References: 14]Notes: Review



Case report of a patient who underwent prolonged CPR and subsequently developed an acute abdomen that required laparotomy. Operative findings were perisplenic hematoma and infarcted cecum. Level 5 Fair.

Brady1 Reference Type: Journal ArticleRecord Number: 703Author: Brady, K. M.; Hiles, D. A.Year: 1996Title: Brown's syndrome as a complication of cardiopulmonary resuscitationJournal: British Journal of OphthalmologyVolume: 80Issue: 3Pages: 268-9Date: MarAccession Number: 8703868Keywords: Screen

Case report of Brown’s syndrome (an ocular motility disorder consisting of difficulty with active and passive elevation in adduction) in a 2 year-old who received CPR after drowning. Level 5 Fair.

Burdett-Smith1 Reference Type: Journal ArticleRecord Number: 10046Author: Burdett-Smith, P.; Jaffey, L.Year: 1996Title: Tension pneumoperitoneumJournal: Journal of Accident and Emergency MedicineVolume: 13Issue: 3Pages: 220-221Alternate Journal: Journal of Accident and Emergency MedicineAccession Number: 1996164067Keywords: adultarticleasthmacase reportdecompressionhumanintravenous drug administrationmalepneumoperitoneumpneumothoraxrespiratory arrestresuscitationadrenalinAbstract: Tension pneumoperitoneum developing in a middle aged asthmatic male during resuscitation after a respiratory arrest is reported. This was associated with bilateral tension pneumothorax and caused severe respiratory embarrassment which was relieved by needle decompression, after decompression of the pneumothoraces. The chest is not the only body cavity that can contain air under tension.Author Address: Burdett-Smith, P., Dept Accident and Emergency Medicine, Royal Liverpool University Hospital, Liverpool L7 8XP, United Kingdom

Case report of tension pneumoperitoneum in asthmatic male during resuscitation after respiratory arrest. No abstract available. Level 5 Fair.

Bush1 Reference Type: Journal ArticleRecord Number: 2559Author: Bush, C. M. ; Jones, J. S. ; Cohle, S. D. ; Johnson, H.Year: 1996



Title: Pediatric injuries from cardiopulmonary resuscitation.Journal: Ann Emerg MedVolume: 28Issue: 1Pages: 40-44Date: 1996 JulLabel: 4980Keywords: Cardiopulmonary Resuscitation*adverse effectsmortalityCause of DeathChildChild, PreschoolEmergency Medical Services*standardsFemaleHeart Arrestmortality*therapyHumanInfantInfant, NewbornMaleMichiganepidemiologyPopulation SurveillanceRetrospective StudiesWounds and Injuries*etiologymortality19960701 00:00Abstract: STUDY OBJECTIVE: To assess the type, rate, and severity of unanticipated complications of CPR (external cardiac compressions and ventilation) in a pediatric population. METHODS: A retrospective review was undertaken of the records from all deceased children ( < 12 years old) who had been given CPR during an 8-year period (1988 through 1995). Patients with historical or physical evidence of preceding trauma were excluded. Clinical and autopsy records were abstracted for patient demographics, clinical findings, duration of CPR, persons administering CPR, and medical examiner summaries. RESULTS: Two hundred eleven children (mean age, 19.0 months) met the inclusion criteria and were entered into the study. The most common cause of cardiac arrest was sudden infant death syndrome (56%), followed by drowning (8%), congenital heart disease (7%), and pneumonia (4%). Mean duration of CPR was 45 minutes (range, 3 to 180 minutes). Fifteen children (7%) had at least one injury as a result of CPR; 7 (3%) had injuries that were considered medically significant. These included retroperitoneal hemorrhage (n = 2), pneumothorax (n = 1), pulmonary hemorrhage (n = 1), epicardial hematoma (n = 1), and gastric perforation (n = 1); in spite of prolonged resuscitation performed with variable degrees of skill, only one patient was noted to have rib fractures. CONCLUSION: Significant iatrogenic injuries are rare in children who receive CPR; they occur in approximately 3% of cases. Recognizing the possibility of a complication may help in the management of children who survive cardiac arrest. Regardless of resuscitation history, abuse should be considered whenever traumatic injuries are encountered.Notes: ProCite field[38]: 96266189

Retrospective cohort of all deceased children who had been given CPR. Two-hundred eleven children included. 7% had at least one injury as a result of CPR: retroperitoneal hemorrhage, pneumothorax, pulmonary hemorrhage, epicardial hematoma. Conclusion: injuries rare in kids.



Level 5 Fair.

Cafri1 Reference Type: Journal ArticleRecord Number: 8829Author: Cafri, C.; Gilutz, H.; Ilia, R.; Abu-ful, A.; Battler, A.Year: 1997Title: Unusual bleeding complications of thrombolytic therapy after cardiopulmonary resuscitation. Three case reportsJournal: AngiologyVolume: 48Issue: 10Pages: 925-8.Keywords: excluded

AgedCardiopulmonary Resuscitation/*adverse effectsEsophagogastric Junction/injuriesFibrinolytic Agents/*adverse effectsGastrointestinal Hemorrhage/etiologyHemangioma/complicationsHemoperitoneum/etiologyHemorrhage/*etiologyHemothorax/etiologyHumanLiver/injuriesLiver Neoplasms/complicationsMaleMiddle AgedMyocardial Infarction/drug therapyRetrospective StudiesRuptureStreptokinase/adverse effectsThrombolytic Therapy/*adverse effectsAbstract: The authors present three case reports retrospectively casting doubt on the benefit of thrombolysis after external cardiac massage.Notes: Case series with three patients experiencing bleeding complications following thrombolysis after CPR.

Case series n=3 (intra-abdominal bleed, hemothorax, Mallory-Weiss syndrome) when lytics given after CPR. Only abbreviated abstract presented. Level 5 Fair.

Cameron1 Reference Type: Journal ArticleRecord Number: 1001Author: Cameron, P. A.; Rosengarten, P. L.; Johnson, W. R.; Dziukas, L.Year: 1991Title: Tension pneumoperitoneum after cardiopulmonary resuscitationJournal: Medical Journal of AustraliaVolume: 155Issue: 1Pages: 44-7Date: Jul 1Accession Number: 2067438Keywords: ScreenAbstract: OBJECTIVE: To increase awareness of the unusual complication of pneumoperitoneum after cardiopulmonary resuscitation. CLINICAL FEATURES: A 57-year-old male farmer with a history of chronic renal failure and heart disease, as well as severe oesophageal reflux for which fundoplication had been performed, developed a tension pneumoperitoneum after cardiopulmonary resuscitation. This resulted in lower limb cyanosis and an erection, a previously unreported complication. INTERVENTION AND OUTCOME: The tension was relieved by uncapping a peritoneal dialysis catheter that was in situ. The cyanosis and erection resolved immediately, suggesting that the



tension pneumoperitoneum had caused significant venous obstruction. A 3 cm defect in the posterior wall of the stomach was repaired. CONCLUSION: The likelihood of pneumoperitoneum is reduced if standard guidelines for cardiopulmonary resuscitation are adhered to.

Case report of CPR that resulted in tension pneumoperitoneum with lower limb cyanosis and erection, due to gastric rupture. Level 5 Fair.

Chatson1 Reference Type: Journal ArticleRecord Number: 1087Author: Chatson, G.; Gallagher, R.; Quahliero, D.; Ruffett, D.; Allmendinger, P.Year: 1989Title: Ventricular pseudoaneurysm associated with cardiopulmonary resuscitation 6 weeks after mitral valve replacementJournal: Annals of Thoracic SurgeryVolume: 48Issue: 5Pages: 719-20Date: NovAccession Number: 2818068Keywords: ScreenAbstract: Trauma to the heart and mediastinum is associated with external cardiac massage. A patient had undergone a redo mitral valve replacement and experienced an uneventful postoperative course. During a visit to her physician 6 weeks after operation, she experienced ventricular fibrillation that required external cardiac massage and subsequent defibrillation. Postresuscitation evaluation revealed a posterior pseudoaneurysm of the ventricle. This was repaired via a transthoracic approach with the use of profound hypothermia.

Ventricular pseudoaneurysm associated with CPR 6 weeks after mitral valve replacement. MVR may predispose to formation of ventricular pseudoaneurysm. No symptoms observed after replacement; only after CPR. This suggests CPR may have caused the pseudoaneurysm. Level 5 Fair.

Clinch1 Reference Type: Journal ArticleRecord Number: 1362Author: Clinch, S. L.; Thompson, J. S.; Edney, J. A.Year: 1983Title: Pneumoperitoneum after cardiopulmonary resuscitation: a therapeutic dilemmaJournal: Journal of Trauma-Injury Infection & Critical CareVolume: 23Issue: 5Pages: 428-30Date: MayAccession Number: 6854681Keywords: ScreenAbstract: We report a patient who developed pneumoperitoneum after cardiopulmonary resuscitation. Ten cases have been reported in the literature. Despite the patient's serious condition, celiotomy was performed to rule out perforation of a hollow viscus and none was found. The likelihood of visceral perforation in this setting is high and despite increasing recognition of pneumoperitoneum that does not require surgical intervention, nonoperative management should not be entertained in this setting unless visceral perforation can be excluded.

Case report n=1 and review of literature n=10 of pneumoperitoneum after CPR. No control group, but stated that operative management best. Level 5 Fair.

Corbett1 Reference Type: Journal ArticleRecord Number: 660



Author: Corbett, S. W.; O'Callaghan, T.Year: 1997Title: Detection of traumatic complications of cardiopulmonary resuscitation by ultrasoundJournal: Annals of Emergency MedicineVolume: 29Issue: 3Pages: 317-21; discussion 322Date: MarAccession Number: 9055769Keywords: ScreenAbstract: STUDY OBJECTIVE: We conducted a pilot study to assess the feasibility of ultrasonography in the detection of traumatic complications of CPR. METHODS: A prospective case series was undertaken with a convenience sample of 21 emergency department patients who sustained nontraumatic cardiopulmonary arrest. A 5- to 7-minute ultrasound examination was performed during resuscitation. The presence or absence of free fluid was noted in the left and right upper quadrants, coronal views of the kidneys, the pelvis, and the pericardium; autopsies to determine the source of fluid were not performed. Cardiac activity and the concurrent electrical rhythm were also noted. All ultrasonographers had previously been trained in the use of this technique for the evaluation of trauma patients. Examinations were stored on videotape for further review. RESULTS: Seven of 20 patients (29%) had findings on ultrasound that could have resulted from CPR-related trauma. In one additional case, findings of free fluid were probably the result of preexisting illness (ascites). Pericardial effusion was found in three patients, perihepatic fluid in four, pleural fluid in one, perirenal fluid in four, perisplenic fluid in two, and pelvic fluid in three; several patients had multiple findings. Cardiac motion with pulseless electrical activity was noted in seven patients. Five patients had return of spontaneous circulation and survived to hospitalization, and one survived to discharge. CONCLUSION: Traumatic complications of CPR are well known but typically difficult to assess. Ultrasonography may identify injuries, help guide procedures, and serve as a means to assess pharmacologic effects on cardiac performance during CPR. It is a readily available, noninvasive means to assess these critically ill patients.

Case series of n=21 patients with nontraumatic cardiopulmonary arrest. Ultrasound (US) performed during resuscitation. 7 out of 20 had findings that could have been CPR-related trauma. Other case had free fluid likely due to preexisting ascites. Conclusion: US may identify injuries. Comment: No evidence that US changes management. Level 5 Fair.

Custer1 Reference Type: Journal ArticleRecord Number: 1200Author: Custer, J. R.; Polley, T. Z., Jr.; Moler, F.Year: 1987Title: Gastric perforation following cardiopulmonary resuscitation in a child: report of a case and review of the literatureJournal: Pediatric Emergency CareVolume: 3Issue: 1Pages: 24-7Date: MarAccession Number: 3562308Keywords: ScreenAbstract: We report a case of gastric rupture complicating cardiopulmonary resuscitation in a 13 year old. The tear occurred on the lesser curvature of the stomach as in reported adult cases. A tear was not discovered until autopsy, despite extensive premortem investigation. In a comatose or paralyzed patient, laparotomy may be indicated in the evaluation of pneumoperitoneum following cardiopulmonary resuscitation.

Case report n=1 and review of literature n=16 gastric perforation following CPR. Level 5 Fair.

Darke1 Reference Type: Journal ArticleRecord Number: 1575Author: Darke, S. G.; Bloomfield, E.



Year: 1975Title: Case of complete gastric rupture complicating resuscitationJournal: British Medical JournalVolume: 3Issue: 5980Pages: 414-5Date: Aug 16Accession Number: 1156790Keywords: Screen

Case report of gastric rupture after CPR. Level 5 Fair.

Delanye1 Reference Type: Journal ArticleRecord Number: 9073Author: Delanaye, P.; De Fooz, G.; Nchimi, A.; Richardy, M.; Pierard, L.; Lancellotti, P.Year: 2003Title: L'image du mois. Hematome hepatique apres une reanimation cardio-pulmonaireJournal: Revue Medicale de LiegeVolume: 58Issue: 7-8Pages: 463-4Keywords: Aged*Cardiopulmonary Resuscitation/ae [Adverse Effects]*Hematoma/et [Etiology]Hematoma/ra [Radiography]Human*Liver Diseases/et [Etiology]Liver Diseases/ra [Radiography]MaleNotes: [Image of the month. Hematoma of the liver after cardiopulmonary resuscitation].French

Case report of hepatic hematoma after CPR. Level 5 Fair.

Dohi1 Reference Type: Journal ArticleRecord Number: 1364Author: Dohi, S.Year: 1983Title: Postcardiopulmonary resuscitation pulmonary edemaJournal: Critical Care MedicineVolume: 11Issue: 6Pages: 434-7Date: JunAccession Number: 6851601Keywords: ScreenAbstract: Although severe pulmonary edema is encountered occasionally in patients needing CPR, there has been no definitive description on the mortality and morbidity of pulmonary edema after CPR. The author experienced severe pulmonary edema after standard CPR in 20 of 71 patients who suffered sudden, unexpected cardiac arrest and regained heart function by CPR. The varied onset of pulmonary edema, which may have developed when massive pink frothy secretions exited from the endotracheal tube, ranged from a few minutes to 45 min after the re-establishment of heart beat. These 20 patients showed a significantly higher P(A-a)O2, insignificant lower plasma protein concentrations, and high plasma osmolarities as compared with those who did not develop pulmonary edema. Only 2 patients with pulmonary edema survived. During CPR, many factors could cause pulmonary edema, including external cardiac massage (ECM), administration or release of catecholamines, hypoxia, acidosis, overhydration, etc. This study indicates that patients who need CPR have a high likelihood of developing pulmonary edema.



71 patients subjected to 78 resuscitations. Of these, 20 developed pulmonary edema within 45 minutes of reestablishment of heart beat. Mechanism for this unclear. Level 5 Fair.

Ducable1 Reference Type: Journal ArticleRecord Number: 1491Author: Ducable, G.; Chamoun, S.; Leturgie, C.; Watelet, J.; Winckler, C.Year: 1978Title: [Gastric ruptures after resuscitation]Journal: Anesthesie, Analgesie, ReanimationVolume: 35Issue: 6Pages: 1153-8Date: Nov-DecAccession Number: 754561Keywords: ScreenNotes: French


Elliot1 Reference Type: Journal ArticleRecord Number: 1321Author: Elliot, D. L.; Goldberg, L.; Shlitt, S. C.; Girard, D. E.Year: 1984Title: Emphysematous cholecystitis following cardiopulmonary resuscitationJournal: Archives of Internal MedicineVolume: 144Issue: 3Pages: 635-6Date: MarAccession Number: 6703835Keywords: ScreenAbstract: Emphysematous cholecystitis developed in a 65-year-old man 24 hours following resuscitation from cardiac arrest. Our findings in this case support the importance of ischemia in this disease process.

Case report of emphysematous cholecystitis that developed within 24 hours of resuscitation. Level 5 Fair.

Enarson1 Reference Type: Journal ArticleRecord Number: 1520Author: Enarson, D. A.; Didier, E. P.; Gracey, D. R.Year: 1977Title: Flail chest as a complication of cardiopulmonary resuscitationJournal: Heart & Lung: Journal of Acute & Critical CareVolume: 6Issue: 6Pages: 1020-2Date: Nov-DecAccession Number: 244316Keywords: ScreenAbstract: Records of all patients who developed flail chest after cardiopulmonary resuscitation at Rochester Methodist Hospital between January, 1966 and March 1976 were reviewed. Also, for comparison, records of patients with flail chest resulting from motor vehicle accidents and those of a matched group of patients who underwent cardiopulmonary resuscitation without developing flail chest were reviewed. The incidence of flail chest after cardiopulmonary resuscitation was about 5.6 per 100 survivors. The groups who did and did not have flail chest after cardiopulmonary resuscitation were alike in age and in frequency and duration of the resuscitation. Stabilization of the flail chest required mechanical ventilation for 1 to 24 days (mean, 10.7). Flail chest did not significantly lengthen the hospitalization of patients who survived after cardiopulmonary resuscitation. The occurrence of flail chest after cardiopulmonary resuscitation did not



seem to increase the mortality rate.

Case-control study of flail chest after CPR. Incidence estimated at 5.6% of survivors. No abstract provided. Level 5 Fair.

Enat1 Reference Type: Journal ArticleRecord Number: 1477Author: Enat, R.; Pollack, S.; Wiener, M.; Barzilai, D.Year: 1979Title: Osteomyelitis in fractured sternum after cardiopulmonary resuscitationJournal: New England Journal of MedicineVolume: 301Issue: 2Pages: 108-9Date: Jul 12Accession Number: 449937Keywords: Screen

Case report of osteomyelitis in fractured sternum after CPR. Patient recovered after nonsurgical management. Level 5 Fair.

Engelstein1 Reference Type: Journal ArticleRecord Number: 1325Author: Engelstein, D.; Stamler, B.Year: 1984Title: Gastric rupture complicating mouth-to-mouth resuscitationJournal: Israel Journal of Medical SciencesVolume: 20Issue: 1Pages: 68-70Date: JanAccession Number: 6698775Keywords: Screen

Case report of a patient who choked on a cake, received forced air blown into his mouth. He felt better, then vomited food mixed with blood In the ED, he was found to have a large pneumoperitoneum. Subsequently found to have large laceration below GE junction. Level 5 Fair.

Evans1 Reference Type: Journal ArticleRecord Number: 1408Author: Evans, R. D.; Lighton, J. E.Year: 1981Title: Gastric rupture as a complication of cardiopulmonary resuscitation: report of case and review of literatureJournal: Journal of the American Osteopathic AssociationVolume: 80Issue: 12Pages: 830-1Date: AugAccession Number: 7263324Keywords: Screen

Case report and review of literature of gastric rupture after CPR. Ventilated with “portable air bag” then underwent difficult intubation. Level 5 Fair.

Feldman1 Reference Type: Journal ArticleRecord Number: 2572Author: Feldman, K. W. ; Brewer, D. K.Year: 1984Title: Child abuse, cardiopulmonary resuscitation, and rib fractures.Journal: Pediatrics



Volume: 73Issue: 3Pages: 339-342Date: 1984 MarLabel: 6140Keywords: AdultAge FactorsChild*Child AbuseChild, PreschoolComparative StudyDiagnosis, DifferentialHumanInfantInfant, NewbornResuscitation*adverse effectsRib Fractures*etiology19840301 00:00Abstract: Rib fractures have occasionally been described in children receiving cardiopulmonary resuscitation (CPR). Because child abuse is sometimes suspected in these cases, it is both medically and legally important to establish whether the rib fractures are secondary to abuse or CPR. One hundred thirteen children, including 41 victims of child abuse, 50 patients who had CPR, and 22 patients who had rib fractures, were studied. Twenty-nine patients had rib fractures; 14/29 (48%) were abusive. Other causes of fracture were: motor vehicle accidents (four), rickets/osteoporosis (five), surgery (five), and osteogenesis imperfecta (one). In spite of prolonged resuscitation performed with variable degrees of skill, no fractures could be attributed to CPR. On the other hand, rib fractures occurred frequently in abused children (6/41 or 15%). Abusive fractures were often multiple, of different ages, and affected multiple adjacent ribs. Patients with abusive rib fracture also had other physical and radiologic signs of abuse or neglect.Notes: ProCite field[38]: 84143903

Case-control study of n=41 victims of child abuse, n=50 children who had CPR, n=22 who had incidental rib fractures. Fractures frequently observed in abused children, especially multiple fractures; not observed after CPR. Level 5 Fair.

Fitchet1 Reference Type: Journal ArticleRecord Number: 6078Author: Fitchet, A.; Neal, R.; Bannister, P.Year: 2001Title: Lesson of the week: Splenic trauma complicating cardiopulmonary resuscitationJournal: BMJVolume: 322Issue: 7284Pages: 480-481Date: Feb 24Accession Number: 11222427Keywords: Cardiopulmonary Resuscitation/*adverse effectsCase ReportFemaleHeart Arrest/therapyHumanMaleMiddle AgeSplenic Rupture/*etiology/radiographySupport, Non-U.S. Gov't



Tomography, X-Ray ComputedNotes: 0959-8138Journal ArticleURL: http://bmj.com/cgi/content/full/322/7284/480http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11222427Author Address: Manchester Heart Centre, Manchester Royal Infirmary, Manchester M13 9WL, UK. Alan. [email protected]

N=2 case reports of splenic trauma after CPR. Level 5 Fair.

Fletcher1 Reference Type: Journal ArticleRecord Number: 1717Author: Fletcher, G. F.Year: 1969Title: Hazardous complications of "closed chest" cardiopulmonary resuscitationJournal: American Heart JournalVolume: 77Issue: 3Pages: 431-2Date: MarAccession Number: 5766731Keywords: Screen

N=4 case reports (n=3 tension pneumothorax, n=1 pneumoperitoneum with abdominal distension.

Floret1 Reference Type: Journal ArticleRecord Number: 1187Author: Floret, D.; Melki, I.; Philibert, N.; Takvorian, P.Year: 1987Title: [Gastric rupture and resuscitation maneuvers]Journal: PediatrieVolume: 42Issue: 2Pages: 95-7Accession Number: 3615143Keywords: ScreenAbstract: Near drowning in a bathtub occurred to a 3 years 7 months old boy. He was resuscitated at home by the firemen before admission in hospital, where he presented coma, convulsions and a massive distension of the abdomen. Surgical procedure revealed a 3 cm long perforation on the smaller curvature, which was repaired. This aspect and the localisation of the rupture resemble those related to resuscitation procedures: oxygenotherapy by nasal catheter, external cardiac massage, mouth-to-mouth ventilation. The stomach is filled with air because inadequate position of the catheter. It also may be related to relaxation of crico-pharyngeal sphincter during anesthesia or coma.Notes: French

Case report of gastric rupture after CPR given after near drowning. Level 5 Fair.

Flowers1 Reference Type: Journal ArticleRecord Number: 1799Author: Flowers, R.Year: 1965Title: Complications of cardiac resuscitation in cardiac arrests accompanying myocardial infarctionJournal: Medical Services Journal, CanadaVolume: 21Issue: 7Pages: 429-36Date: Jul-Aug



Accession Number: 5850823Keywords: Screen

N=5 case reports. Frequent rib fractures observed; some bone marrow and fat emboli. No comparison group. No abstract provided. Level 5 Fair.

Fosse1 Reference Type: Journal ArticleRecord Number: 705Author: Fosse, E.; Lindberg, H.Year: 1996Title: Left ventricular rupture following external chest compressionJournal: Acta Anaesthesiologica ScandinavicaVolume: 40Issue: 4Pages: 502-4Date: AprAccession Number: 8738698Keywords: ScreenAbstract: A case of a 62-year-old woman suffering an acute cardiac arrest during a court dispute is presented. Cardiopulmonary resuscitation was immediately started by bystanders. In hospital there were signs of intrathoracic bleeding. A left thoracotomy revealed a cardiac rupture of the left ventricle and a large pericardial tear. Intraoperative evaluation of the heart as well as postoperative enzyme levels and ECG did not indicate acute myocardial infarction. The rupture may therefore be traumatic. The cardiac rupture was sutured five hours after the initial resuscitation, and the patient discharged from the intensive care unit two days after the rupture without clinical signs of neurological injury. A precordial thump is advised before start of external chest compression. One beneficial effect may be that the ventricles empty and the risk of traumatic rupture during compression is reduced.

Case report of 62 year-old women who had out of hospital cardiac arrest followed by CPR. Diagnosed as having ventricular rupture, but not acute MI. Surgical repair then discharge. Level 5 Fair.

Gainant1 Reference Type: Journal ArticleRecord Number: 1306Author: Gainant, A.; Gobeaux, R. F.; Renaudie, J.; Voultoury, J. C.; Cubertafond, P.; Gay, R.Year: 1984Title: [Pneumoperitoneum following cardiorespiratory resuscitation procedures]Journal: Presse MedicaleVolume: 13Issue: 30Pages: 1845-6Date: Sep 1-8Accession Number: 6236448Keywords: ScreenNotes: French

Case report of pneumoperitoneum after CPR. French. No abstract provided. Level 5 Fair.

Gallagher1 Reference Type: Journal ArticleRecord Number: 1209Author: Gallagher, J. T.; Holmes, W.; Cunningham, J. D.Title: Tympanic injury and cardiopulmonary resuscitationPages: 464-7Accession Number: 3824453Keywords: ScreenNotes: Transactions - Pennsylvania Academy of Ophthalmology & Otolaryngology 1986;38(2)



Case report of tympanic membrane perforation and sensorineural hearing loss after CPR. Related to increased pressure, possibly in conjunction with emesis, transmitted through Eustachian tube. No abstract provided. Level 5 Fair.

Gerry1 Reference Type: Journal ArticleRecord Number: 1523Author: Gerry, J. L., Jr.; Bulkley, B. H.; Hutchins, G. M.Year: 1977Title: Rupture of the papillary muscle of the tricuspid valve. A complication of cardiopulmonary resuscitation and a rare cause of tricuspid insufficiencyJournal: American Journal of CardiologyVolume: 40Issue: 5Pages: 825-8Date: NovAccession Number: 920621Keywords: ScreenAbstract: Rupture of a papillary muscle is a rare occurrence. Two patients are described in whom rupture of a papillary muscle of the tricuspid valve developed after external cardiac massage during cardiopulmonary resuscitation. One of these patients survived briefly with clinical evidence of triscupid regurgitation immediately after resuscitation. Although tricuspid valve papillary muscle rupture has been described as a complication of bacterial endocarditis, chest trauma and myocardial infarction, it is a generally unrecognized complication of external cardia massage. Findings in the two patients reported here suggest that patients with a dilated right ventricle may be more susceptible to this rare complication of cardiopulmonary resuscitation.

Case report (n=2) of papillary muscle rupture after CPR. Related to preexisting dilated RV. No abstract provided. Level 5 Fair.

Gillies1 Reference Type: Journal ArticleRecord Number: 6029Author: Gillies, M.; Hogarth, I.Year: 2001Title: Liver rupture after cardiopulmonary resuscitation during peri-operative cardiac arrestJournal: AnaesthesiaVolume: 56Issue: 4Pages: 387-388Date: AprAccession Number: 11284853Keywords: Cardiopulmonary Resuscitation/*adverse effectsCase ReportHeart Arrest/*therapyHumanLiver/*injuriesMaleMiddle AgePreoperative Care/methodsRupture/etiologyNotes: 0003-2409LetterURL: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11284853

Case report and review of literature of liver rupture after CPR. Not associated with overlying rib fractures. No abstract provided. Level 5 Fair.



Gilliland1 Reference Type: Journal ArticleRecord Number: 871Author: Gilliland, M. G.; Luckenbach, M. W.Year: 1993Title: Are retinal hemorrhages found after resuscitation attempts? A study of the eyes of 169 childrenJournal: American Journal of Forensic Medicine & PathologyVolume: 14Issue: 3Pages: 187-92Date: SepAccession Number: 8311048Keywords: ScreenAbstract: Resuscitation attempts have been hypothecated to explain retinal hemorrhages in infants who are suspected victims of child abuse. This study was undertaken to test that hypothesis by postmortem ocular examinations following unsuccessful resuscitation attempts on a sample of 169 children selected by 19 prosectors willing to contribute to the study. Cardiopulmonary resuscitation had been attempted for a minimum of 30 min in 131 of the children, whereas 38 controls did not have such protracted attempts; 70 children with prolonged resuscitation attempts had no retinal hemorrhages, including eight children whose fatal blunt force injuries of the trunk represented extremes of the forces used in resuscitation attempts. Children who died of asphyxia, respiratory illnesses, sudden infant death syndrome, and various other causes had no hemorrhages; neither did 21 children who died of head injury or central nervous system (CNS) diseases, nor did 29 controls. Retinal hemorrhages were present in 70 children, 61 with prolonged resuscitation attempts and nine controls. Among those with attempted resuscitation, 56 had head injuries, and four had CNS diseases and sepsis, all recognized causes of retinal hemorrhages. The other death that involved a resuscitation attempt and retinal hemorrhages was an officially "undetermined" death. The child had come from a household with two prior child deaths and documented abuse. No case is found in this study to support the hypothesis that retinal hemorrhages are caused by resuscitation attempts.

Case control study of 169 children: 131 after prolonged resuscitation; 38 without resuscitation. Retinal hemorrhages not observed after resuscitation. Implies if observed, should consider other cause of morbidity or mortality. Level 5 Fair.

Goetting1 Reference Type: Journal ArticleRecord Number: 1063Author: Goetting, M. G.; Sowa, B.Year: 1990Title: Retinal hemorrhage after cardiopulmonary resuscitation in children: an etiologic reevaluation.[see comment]Journal: PediatricsVolume: 85Issue: 4Pages: 585-8Date: AprAccession Number: 2314970Keywords: Screen

Case series of 20 children after resuscitation; 10% had retinal hemorrhages not observed after resuscitation. Implies if observed, may be related to resuscitation rather than other cause of morbidity or mortality. No abstract provided. Level 5 Fair.

Goldberg1 Reference Type: Journal ArticleRecord Number: 10512Author: Goldberg, R.M.; Rowan, L.; Anderson, R.E.Year: 1988Title: Thoracic vertebral fracture as a complication of cardiopulmonary resuscitationJournal: Journal of Emergency Medicine



Volume: 6Issue: 3Pages: 177-178Alternate Journal: Journal of Emergency MedicineAccession Number: 1988174858Keywords: autopsycase reportheart massagehumannormal humanresuscitationvertebra fractureAbstract: We report the case of a 76-year-old woman who suffered cardiopulmonary arrest three days after being hospitalized with an acute myocardial infarction. She underwent standard cardiopulmonary resuscitative measures for approximately 25 min before being pronounced dead. Autopsy examination revealed a recent myocardial infarction, as well as an acutely fractured tenth thoracic vertebra. Thoracic vertebral fractures are a previously unrecognized complication of cardiopulmonary resuscitation.

Case report of a 76 year-old women who had cardiopulmonary arrest after a recent MI. Acutely fractured tenth thoracic vertebra observed at autopsy; attributed to CPR. Level 5 Fair.

Gordon1 Reference Type: Journal ArticleRecord Number: 1681Author: Gordon, H. L.; Walkup, J. L.Year: 1970Title: Scrotal pneumatocele as an unusual sign of pneumoperitoneum: report of a case and review of the literatureJournal: Journal of UrologyVolume: 104Issue: 3Pages: 441-2Date: SepAccession Number: 5459979Keywords: Screen

Scrotal pneumatocele observed as extension of pneumoperitoneum after resuscitation. Level 5 Fair.

Gregersen1 Reference Type: Journal ArticleRecord Number: 1421Author: Gregersen, M.; Vesterby, A.Year: 1981Title: Iatrogenic fractures of the hyoid bone and the thyroid cartilage. A case reportJournal: Forensic Science InternationalVolume: 17Issue: 1Pages: 41-3Date: Jan-FebAccession Number: 7216081Keywords: ScreenAbstract: A case of fracture of the hyoid bone and the thyroid cartilage is reported as a complication to resuscitation. This gave rise to many forensic as well as police investigations and stresses the importance of detailed information at medicolegal autopsies as regards the resuscitation carried out.

Case report of hyoid bone and thyroid cartilage fracture after CPR. Attributed to intubation. No abstract provided. Level 5 Fair.

Gueugniaud1 Reference Type: Journal ArticleRecord Number: 1204



Author: Gueugniaud, P. Y.Year: 1987Title: Subarachnoid hemorrhage: a complication of CPR?Journal: Critical Care MedicineVolume: 15Issue: 3Pages: 284-5Date: MarAccession Number: 3816272Keywords: Screen

Case report of traumatic subarachnoid hemorrhage after CPR. Attributed to elevated CVP during 45 minutes of external cardiac massage. Level 5 Fair.

Hachiro1 Reference Type: Journal ArticleRecord Number: 840Author: Hachiro, Y. ; Okada, H. ; Hayakawa, T. ; Matsubara, I. ; Maekawa, K. ; Tanaka, T.Year: 2000Title: Cardiac tamponade secondary to cardiopulmonary resuscitation in a patient receiving antiplatelet therapy [letter]Journal: Am J Emerg MedVolume: 18Issue: 7Pages: 836-837Date: 2000 NovLabel: 48500Keywords: 20001205 11:00Notes: ProCite field[38]: 20552105

Case report of tamponade after CPR given to a patient receiving ticlopidine. No fracture of sternum or ribs. No abstract provided. Level 5 Fair.

Hargarten1 Reference Type: Journal ArticleRecord Number: 1147Author: Hargarten, K. M.; Aprahamian, C.; Mateer, J.Year: 1988Title: Pneumoperitoneum as a complication of cardiopulmonary resuscitationJournal: American Journal of Emergency MedicineVolume: 6Issue: 4Pages: 358-61Date: JulAccession Number: 3291885Keywords: ScreenAbstract: A case of pneumoperitoneum following cardiopulmonary resuscitation (CPR) is reported and 11 cases in the literature are reviewed. Four patients had laparotomies failing to demonstrate any visceral perforation or evidence of peritonitis in spite of the massive pneumoperitoneum present. Operative intervention immediately after resuscitation is associated with potentially high morbidity and mortality. Several diagnostic tools are used, including peritoneal lavage and contrast media tests, to accurately diagnose perforated viscus. To avoid an unnecessary celiotomy a clinical treatment protocol has been developed for patients with pneumoperitoneum secondary to CPR. Such diagnostic tools as peritoneal lavage and water-soluble contrast medium test are reviewed and included in this protocol. A nonsurgical approach to patient management may be reasonable if certain criteria are met. [References: 30]Notes: Review

Case report N=1 and review of literature of pneumoperitoneum after CPR. No abstract provided. Stated that operative intervention immediately after CPR has high morbidity and mortality;



nonsurgical approach reasonable. Level 5 Fair.

Harm1 Reference Type: Journal ArticleRecord Number: 1340Author: Harm, T.; Rajs, J.Year: 1983Title: Face and neck injuries due to resuscitation versus throttlingJournal: Forensic Science InternationalVolume: 23Issue: 2-3Pages: 109-16Date: Nov-DecAccession Number: 6662437Keywords: ScreenAbstract: Face and neck injuries of 21 patients who died of other causes than mechanic asphyxia and who were resuscitated in connection to dying were analyzed during a 3-year period, 1980-1982. The injuries were predominantly of the type nail impression marks (85%) and showed a regular symmetric distribution tending to form circles around the nostrils and mouth. Injuries inflicted upon mouth-to-mouth ventilation were localized to the nose and at jaw-thrust to the mandibular margins and were easy to differ from those due to throttling. Injuries inflicted on the cheeks upon removal of vomit from the mouth were similar to those seen after violent oral occlusion and those occurring at carotid pulse palpation as indicated by throttling. No fractures of the laryngeal skeleton and no conjunctival haemorrhages were seen.

Case control study of 21 patients who died of causes other than airway obstruction and required resuscitation (cases) and 21 who were throttled. Of cases, 16 (76%) had bruises and abrasions on face and at mandibular margins but none had conjunctival hemorrhages or laryngeal fractures. Throttle patients had bruises and abrasions on the neck. Level 5 Fair.

Hartoko1 Reference Type: Journal ArticleRecord Number: 1005Author: Hartoko, T. J.; Demey, H. E.; Rogiers, P. E.; Decoster, H. L.; Nagler, J. M.; Bossaert, L. L.Year: 1991Title: Pneumoperitoneum--a rare complication of cardiopulmonary resuscitationJournal: Acta Anaesthesiologica ScandinavicaVolume: 35Issue: 3Pages: 235-7Date: AprAccession Number: 2038930Keywords: ScreenAbstract: Pneumoperitoneum following cardiopulmonary resuscitation (CPR) results from a thoracic air leak (pneumothorax, pneumomediastinum) with escape of the air through diaphragmatic apertures (mostly foramen of Winslow) or primary perforation of the gastrointestinal tract (stomach or esophagus). We report three cases of pneumoperitoneum complicating CPR. As there was no clinical evidence of peritonitis, and the patients remained stable, a conservative approach was followed without surgical exploration. All patients recovered completely.

N=3 cases of pneumoperitoneum after CPR. All managed conservatively and had good outcome; nonsurgical approach reasonable. Level 5 Fair.

Hashimoto1 Reference Type: Journal ArticleRecord Number: 2316Author: Hashimoto, Y. ; Yamaki, T. ; Sakakibara, T. ; Matsui, J. ; Matsui, M.Year: 2000Title: Cerebral air embolism caused by cardiopulmonary resuscitation after cardiopulmonary arrest on arrival.Journal: J Trauma



Volume: 48Issue: 5Pages: 975-977Date: 2000 MayLabel: 50600Keywords: Accidents, TrafficAdultCardiopulmonary Resuscitation*adverse effectsinstrumentationmethodsCase ReportEmbolism, Air*etiologyradiographyFatal OutcomeHeart Arrestetiology*therapyHemopneumothoraxcomplicationsradiographyHumanIntracranial Embolism*etiologyradiographyMaleRisk FactorsThoracic InjuriescomplicationsradiographyTomography, X-Ray Computed20000610 09:00Notes: ProCite field[38]: 20281055

Case report n=1 of patient with cerebral air embolism after CPR and central venous cannulation. No skull fracture or pnuemocephalus. Attributed to shunt from major bronchus to pulmonary artery after trauma. No abstract provided. Level 5 Fair.

Haugeberg1 Reference Type: Journal ArticleRecord Number: 1099Author: Haugeberg, G.; Bonarjee, V.; Dickstein, K.Year: 1989Title: Fatal intrathoracic haemorrhage after cardiopulmonary resuscitation and treatment with streptokinase and heparin.[see comment]Journal: British Heart JournalVolume: 62Issue: 2Pages: 157-8Date: AugAccession Number: 2765328Keywords: ScreenAbstract: A 66 year old man with acute myocardial infarction underwent cardiopulmonary resuscitation before being treated with streptokinase and heparin. Seventeen hours later he died of an intrathoracic haemorrhage caused by multiple fractures of the sternum and ribs.

Case report of patient with acute MI treated with CPR, then Streptokinase and heparin. Died 17



hours later of intrathoracic hemorrhage associated with multiple fractures of sternum and ribs. Level 5 Fair.

Hillman1 Reference Type: Journal ArticleRecord Number: 1231Author: Hillman, K.; Albin, M.Year: 1986Title: Pulmonary barotrauma during cardiopulmonary resuscitationJournal: Critical Care MedicineVolume: 14Issue: 7Pages: 606-9Date: JulAccession Number: 3720308Keywords: ScreenAbstract: Despite the large variety of ventilatory equipment and conditions under which CPR is performed, there have been few cases of pulmonary barotrauma, which is surprising since the transpulmonary pressures developed during CPR are relatively high. This report cites four cases demonstrating different mechanisms by which pulmonary barotrauma can be caused during CPR, and reviews their pathophysiologic consequences. The suggested levels of transpulmonary pressure needed for effective simultaneous chest compression and ventilation are even higher than those used for conventional CPR and are likely to contribute to the incidence of barotrauma during CPR.

Case series n=4 of pulmonary barotraumas after CPR: subcutaneous emphysema, mediastinal emphysema, pneumothoraces. Attributed to high peak airway pressures during CPR: failure of one-way valve to open during resuscitation, vigorous cardiac massage. Recommend avoid overventilation, and use pressure-limiting valve. Level 5 Fair.

Hood1 Reference Type: Journal ArticleRecord Number: 1157Author: Hood, I.; Ryan, D.; Spitz, W. U.Year: 1988Title: Resuscitation and petechiaeJournal: American Journal of Forensic Medicine & PathologyVolume: 9Issue: 1Pages: 35-7Date: MarAccession Number: 3354520Keywords: ScreenAbstract: Petechiae can be important corroborative evidence of asphyxia, but are also seen in persons who have died of other means. It is not uncommon to encounter them in cases in which cardiopulmonary resuscitation has reestablished blood flow and pressure in small vessels already damaged by hypoxia resulting in the formation of petechiae. This report documents some representative cases.

Case series of 4 patients autopsied after unsuccessful CPR. Two with gunshot wound to head, one with recent MI, and one with history of seizures found unresponsive at home. All had fine petechiae of eyelids and cheeks. No abstract provided. Level 5 Fair.

Hulewicz1 Reference Type: Journal ArticleRecord Number: 1052Author: Hulewicz, B.Year: 1990Title: Gastric trauma following cardiopulmonary resuscitation.[see comment]Journal: Medicine, Science & the LawVolume: 30Issue: 2Pages: 149-52Date: Apr



Accession Number: 2348769Keywords: ScreenAbstract: Three cases of gastric trauma following cardiopulmonary resuscitation are reported. In two cases there were full thickness lacerations of the gastric wall resulting in pneumoperitoneum and in one case subcutaneous emphysema. In the third case, gastric mucosal lacerations resulted in gastric haemorrhage. In all three cases it was thought that the gastric lesions did not contribute to death and were resuscitation artefacts.

Case series n=3 of gastric trauma after CPR. Level 5 Fair.

Jeong1 Reference Type: Journal ArticleRecord Number: 10758Author: Jeong, Y.G.; Caccamo, L.P.Year: 1975Title: Letter: Cardiac resuscitation and vertebral fracture.Journal: Journal of the American Medical AssociationVolume: 234Pages: 1223%N 12Alternate Journal: Journal of the American Medical AssociationAccession Number: 1242744Keywords: adultarticlecardioversioncase reportfemalefractureheart infarctionheart massagehumanresuscitationspine injuryAuthor Address: Jeong, Y.G.

Case report of fractured thoracic vertebra after CPR. No abstract provided. Level 5 Fair.

Kam1 Reference Type: Journal ArticleRecord Number: 807Author: Kam, A. C.; Kam, P. C.Year: 1994Title: Scapular and proximal humeral head fractures. An unusual complication of cardiopulmonary resuscitationJournal: AnaesthesiaVolume: 49Issue: 12Pages: 1055-7Date: DecAccession Number: 7864320Keywords: ScreenAbstract: We report a patient who sustained fractures of the scapula and proximal humeral head as a result of cardioversion during cardiopulmonary resuscitation. It is postulated that the fractures were the result of tetanic muscular contractions involving the proximal humeral heads and the shoulder girdles. This appears to be a previously unreported injury.

Case report of patient who experienced fractured scapula and proximal humeral head attributed to cardioversion during CPR. Level 5 Fair.

Kanter1 Reference Type: Journal ArticleRecord Number: 13765Author: Kanter, R.K.



Year: 1986Title: Retinal hemorrhage after cardiopulmonary resuscitation or child abuseJournal: Journal of PediatricsVolume: 108Issue: 3Pages: 430-432Alternate Journal: Journal of PediatricsAccession Number: 1986115028Keywords: artificial ventilationautopsycentral nervous systemchild abusechildclassificationclinical articlecomputer analysiscomputer assisted tomographycontrolled studydiagnosiseducationetiologyfatalityforensic medicinehistologyhuman cellhumaninfantinjurypreliminary communicationpreschool childpriority journalrespiratory systemresuscitationretina hemorrhagetherapyvisual systemAbstract: Retinal hemorrhage in a comatose infant is characteristically a sign of central nervous system injury resulting from child abuse. Caffey speculated that elevated intrathoracic venous pressure transmitted to the head during cardiopulmonary resuscitation or positive pressure breathing could also lead to hemorrhagic brain or eye damage. The significance of this suggestion has never been clinically evaluated. In our study, funduscopic examinations were carried out to determine the extent to which retinal hemorrhage is a complication of CPR in the absence of preceding trauma. Resolution of this question is necessary to clarify the diagnostic importance of retinal hemorrhage as a clue to occult trauma and child abuse, as opposed to iatrogenic injury associated with CPR.

Case series of 54 children after CPR who underwent fundoscopic examination. 9 had prior trauma; 5 (56%) of these had retinal hemorrhages. 45 had no prior trauma; 1 (2%) had retinal hemorrhage. Significant difference between groups: p=0.0002. No abstract provided. Level 5 Fair.

Kaplan1 Reference Type: Journal ArticleRecord Number: 200Author: Kaplan, J. A. ; Fossum, R. M.Year: 1994Title: Patterns of facial resuscitation injury in infancy.Journal: Am J Forensic Med PatholVolume: 15Issue: 3Pages: 187-191



Date: 1994 SepLabel: 41350Keywords: Cardiopulmonary Resuscitation*adverse effectsFacial Injuriesetiology*pathologyHumanInfantInfant, NewbornRespiration, ArtificialinstrumentationSudden Infant Deathpathology19940901 00:00Abstract: Cardiopulmonary resuscitation (CPR)-related artifacts in pediatric rescue that have the potential for serious complications in surviving patients have been well described in the medical literature. Medically trivial soft-tissue injuries, especially of the face and neck, carry predominantly forensic significance and have received less attention. We describe such injuries in nine of 25 consecutive cases of infants who received CPR, and correlate those injuries with specific rescue maneuvers. Techniques for effective investigation and interpretation of such injuries are suggested.Notes: ProCite field[38]: 95126080

Case series of 25 consecutive children with unexpected death who received CPR. Of these 9 had facial injuries related to bag-valve-mask ventilation, mouth-to-mouth ventilation or endotracheal intubation. Level 5 Fair.

Katz1 Reference Type: Journal ArticleRecord Number: 10819Author: Katz, A.; Henkin, J.; Ovsyshcher, I.A.Year: 1989Title: Transient complete atrioventricular block induced by a chest thump in a patient with ventricular tachycardiaJournal: International Journal of CardiologyVolume: 23Issue: 3Pages: 395-396Alternate Journal: International Journal of CardiologyAccession Number: 1989129461Keywords: agedatrioventricular blockcase reportelectrocardiogramheart ventricle tachycardiahumanmaleprecordial thumpingpriority journalthoraxAbstract: We describe an unusual case of transient complete atrioventricular block induced by a chest thump during resuscitation in a patient with ventricular tachycardia.

Case report of patient who developed transient AV block induced by a chest thump during resuscitation in a patient with VT. Level 5 Fair.

Kempen1 Reference Type: Journal ArticleRecord Number: 448Author: Kempen, P. M.; Allgood, R.



Year: 1999Title: Right ventricular rupture during closed-chest cardiopulmonary resuscitation after pneumonectomy with pericardiotomy: a case reportJournal: Critical Care MedicineVolume: 27Issue: 7Pages: 1378-9Date: JulAccession Number: 10446834Keywords: ScreenAbstract: SETTING: The collapse of a patient immediately after right pneumonectomy with right pericardiotomy resulted in closed-chest cardiopulmonary resuscitation, subsequent thoracotomy, and demise secondary to right ventricular rupture. Interventions: Closed-chest resuscitation with opened and closed chest tubes and medical and fluid interventions were inadequate, necessitating subsequent thoracotomy. MAIN RESULTS AND CONCLUSIONS: Right ventricular rupture during resuscitation was found during subsequent thoracotomy. This rupture and inadequacy of closed-chest resuscitation were felt to be associated with the operative pneumonectomy and pericardiotomy. Pathophysiology and the role of open-heart vs. closed-chest resuscitative measures are discussed.

Case report of RV rupture after external cardiac massage. Level 5 Fair.

Kendall1 Reference Type: Journal ArticleRecord Number: 893Author: Kendall, I. G.; Wynn, S. M.; Quinton, D. N.Year: 1993Title: A study of patients referred from A&E for coroners post-mortemJournal: Archives of Emergency MedicineVolume: 10Issue: 2Pages: 86-90Date: JunAccession Number: 8329084Keywords: ScreenAbstract: A review of 179 autopsies was undertaken over a 1-year period to determine if clinically useful information was obtainable from coroners post mortems performed on patients referred from the A&E department. Fifty-six patients had undergone unsuccessful resuscitation. The leading causes of death were heart disease and trauma. Discrepancies between the diagnosis made during resuscitation and the cause of death found at autopsy were revealed especially in those dying from noncardiac causes. Iatrogenic trauma from resuscitation attempts occurred in a significant number of cases. It is suggested that review of selected Coroners post mortems should be part of departmental audit, with a view to improving clinical skills.

Cohort study of 179 consecutive autopsies performed upon patients referred from an A and E (emergency) department. Of these, 45 had medical arrest. Of these, 7 had iatrogenic injuries including fractured sternum, fractured ribs, flail segment, bruised LV, lacerated pericardium. Level 5 Fair.

Kloss1 Reference Type: Journal ArticleRecord Number: 1346Author: Kloss, T.; Puschel, K.; Wischhusen, F.; Welk, I.; Roewer, N.; Jungck, E.Year: 1983Title: [Resuscitation injuries]Journal: Anasthesie, Intensivtherapie, NotfallmedizinVolume: 18Issue: 4Pages: 199-203Date: AugAccession Number: 6638422



Keywords: ScreenAbstract: This investigation is based on 140 autopsy protocols of unsuccessful resuscitation procedures (Resuscitation Center of the Army Hospital, Hamburg); injections and closed-chest cardiac massage had been performed in every case. - Most of the patients had collapsed because of cardiac shock; patients with thoracic or abdominal injury were excluded from this study. In individual cases only, the following severe complications originated from the resuscitation procedures: fracture of a chest vertebra, serial fractures of ribs resulting in an unstable thorax, bilateral haemothorax, tension pneumothorax, rupture of kidney and of spleen (but not of liver). In one case the lesions caused by the resuscitation measures must be considered as responsible for the lethal outcome. Fractures of ribs and/or sternum were found in 45.9% of all cases, the frequency increasing with age. The number of fractured ribs ranged up to 16, mainly 3-8 ribs were fractured. Fractures of rib No. 1 and 8-12 were very rare. The fractures were located between the parasternal and axillary lines.--In a comparative study the site of rib fractures after heavy blunt thoracic injuries was preferably found in the dorsal region.Notes: German

Case series of 160 autopsies after unsuccessful CPR. Excluded those with thoracic or abdominal injury. 74 (46%) had fractured ribs. Other injuries included vertebral fractures, bilateral hemothorax, tension pneumothorax, rupture of kidney, splenic rupture. No abstract provided. Level 5 Fair.

Kordas1 Reference Type: Journal ArticleRecord Number: 1571Author: Kordas, J.; Kotulski, J.; Zolnierczyk, J.Year: 1975Title: [Transient diabetes insipidus following cardiologic resuscitation in a patient with myocardial infarct]Journal: Wiadomosci LekarskieVolume: 28Issue: 20Pages: 1701-8Date: Oct 15Accession Number: 1179738Keywords: ScreenNotes: Polish

Case report of transient diabetes observed after resuscitation. No abstract provided. Level 5 Fair.

Kramer1 Reference Type: Journal ArticleRecord Number: 203Author: Kramer, K. ; Goldstein, B.Year: 1993Title: Retinal hemorrhages following cardiopulmonary resuscitation.Journal: Clin PediatrVolume: 32Issue: 6Pages: 366-368Date: 1993 JunLabel: 41380Keywords: Adenoviridae InfectionscomplicationsCardiopulmonary Resuscitation*adverse effectsCase ReportDehydrationcomplicationsFemaleGastroenteritiscomplicationsHuman



InfantRetinal Hemorrhagediagnosis*etiologypathologyphysiopathology19930601 00:00Notes: ProCite field[38]: 93345187

Case report of 17 month old with nontraumatic cardiac arrest who had retinal hemorrhages after CPR. Level 5 Fair.

Krause1 Reference Type: Journal ArticleRecord Number: 1314Author: Krause, S.; Donen, N.Year: 1984Title: Gastric rupture during cardiopulmonary resuscitationJournal: Canadian Anaesthetists' Society JournalVolume: 31Issue: 3 Pt 1Pages: 319-22Date: MayAccession Number: 6722623Keywords: ScreenAbstract: Gastric rupture following ventilation during cardiopulmonary resuscitation is a rare occurrence. We report two cases of documented gastric rupture plus two additional cases in which the clinical diagnosis of pneumoperitoneum was made and gastric rupture was assumed to be the mechanism. Review of the literature reveals the lesser curvature of the stomach to be the common site of rupture. This complication emphasizes the necessities of correct positioning of the jaw with mouth-to-mouth ventilation and careful assessment of air entry and chest movement following endotracheal intubation.


Krischer1 Reference Type: Journal ArticleRecord Number: 991Author: Krischer, J. P. ; Fine, E. G. ; Davis, J. H. ; Nagel, E. L.Year: 1987Title: Complications of cardiac resuscitation.Journal: ChestVolume: 92Issue: 2Pages: 287-291Date: 1987 AugLabel: 8890Keywords: Abdominal InjuriesetiologyFemaleFracturesetiologyHeart InjuriesetiologyHemorrhageetiologyHumanLarynxinjuries



MaleMediastinal DiseasesetiologyMiddle AgeProspective StudiesPulmonary EdemaetiologyResuscitation*adverse effectsRib FracturesetiologySternuminjuriesSupport, U.S. Gov't, P.H.S.19870801 00:00Abstract: In a prospective study of the complications of cardiac resuscitation, 705 cases were autopsied to identify the cause of death and the pathologic findings attributable to cardiac resuscitation. Thoracic complications were observed in 42.7 percent of the cases. A total of 31.6 percent had rib fractures, 21.1 percent had sternal fractures, and 18.3 percent were reported as having anterior mediastinal hemorrhage; 20.4 percent of the cases had an upper airway complication. Abdominal visceral complications were noted in 30.8 percent of the cases, and pulmonary complications occurred in 13 percent of the resuscitation population. Life-threatening complications, such as heart and great vessel injuries, occurred in less than .5 percent of the cases.Notes: ProCite field[38]: 87275114

705 of 2187 cases of out of hospital cardiac arrest autopsied. Observed were rib fractures (32%), sternal fractures (21%), anterior mediastinal hemorrhage (18%), upper airway complication (20%), abdominal visceral problems (31%), pulmonary complications (13%). Lifethreatening complications were rare (<0.5%). Level 5 Fair.

Krumholz1 Reference Type: Journal ArticleRecord Number: 1163Author: Krumholz, A.; Stern, B. J.; Weiss, H. D.Year: 1988Title: Outcome from coma after cardiopulmonary resuscitation: relation to seizures and myoclonusJournal: NeurologyVolume: 38Issue: 3Pages: 401-5Date: MarAccession Number: 3347343Keywords: ScreenAbstract: We studied the effect of seizures and myoclonus following cardiopulmonary resuscitation (CPR) on the outcome of all comatose adult survivors of CPR over an 8-year period. Either seizures or myoclonus occurred in 50 of 114 patients (44%): seizures in 41 patients (36%) and myoclonus in 40 (35%). Status epilepticus or status myoclonus occurred in 36 patients (32%), and 19 (17%) had myoclonic status epilepticus (MSE). Seizures and myoclonus per se were not significantly related to outcome, but status epilepticus, status myoclonus, and, particularly, MSE were predictive of poor outcome as judged by survival and recovery of consciousness.

Cohort study of all comatose adult survivors of CPR over an 8-year period. Observed were seizures (36%) and myoclonus (35%). Level 5 Fair.

Kurkciyan1 Reference Type: Journal ArticleRecord Number: 8674Author: Kurkciyan, I.; Meron, G.; Sterz, F.; Mullner, M.; Tobler, K.; Domanovits, H.;



Schreiber, W.; Bankl, H. C.; Laggner, A. N.Year: 2003Title: Major bleeding complications after cardiopulmonary resuscitation: impact of thrombolytic treatmentJournal: J Intern MedVolume: 253Issue: 2Pages: 128-35Date: FebAccession Number: 12542552Keywords: AdultAgedAged, 80 and overCardiopulmonary Resuscitation/*adverse effectsCohort StudiesFemaleHeart Arrest/*therapyHemorrhage/*chemically inducedHumanMaleMiddle AgedMyocardial Infarction/*drug therapyRetrospective StudiesSurvival AnalysisThrombolytic Therapy/*methodsAbstract: OBJECTIVE: The risk of bleeding complications caused by thrombolysis in patients with cardiac arrest and prolonged cardiopulmonary resuscitation is unclear. We evaluate the complication rate of systemic thrombolysis in patients with out-of-hospital cardiac arrest caused by acute myocardial infarction, especially in relation to duration of cardiopulmonary resuscitation. DESIGN: The study was designed as retrospective cohort study, the risk factor being systemic thrombolysis and the end-point major haemorrhage, defined as life-threatening and/or need for transfusion. Over 10.5 years, emergency cardiac care data, therapy, major haemorrhage and outcome of 265 patients with acute myocardial infarction admitted to an emergency department after successful cardiopulmonary resuscitation were registered. RESULTS: We observed major haemorrhage in 13 of 132 patients who received thrombolysis (10%, 95% confidence interval 5-15%), five of these survived to discharge, none died because of this complication. Major haemorrhage occurred in seven of 133 patients in whom no thrombolytic treatment had been given (5%, 95% confidence interval 1-9%), two of these survived to discharge. Taking into account baseline imbalances between the groups, the risk of bleeding was slightly increased if thrombolytics were used (odds ratio 2.5, 95% confidence interval 0.9-7.4) but this was not significant (P = 0.09). There was no clear association between duration of resuscitation and bleeding complications (z for trend = 1.52, P = 0.12). Survival was not significantly better in patients receiving thrombolysis (odds ratio 1.6, 0.9-3.0, P = 0.12). CONCLUSIONS: Bleeding complications after cardiopulmonary resuscitation are frequent, particularly in patients with thrombolytic treatment, but do not appear to be related to the duration of resuscitation. In the light of possible benefits on outcome, thrombolytic treatment should not be withheld in carefully selected patients.Notes: 0954-6820Journal ArticleURL: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12542552Author Address: Department of Emergency Medicine, Institute of Clinical Pathology, General Hospital of Vienna, University of Vienna, Wahringer Gurtel 18-20/6D, 1090 Vienna, Austria.

Cohort study of 265 patients admitted to a single emergency department after successful CPR. 13 of 132 patients who received thrombolysis had major hemorrhage. 5 survived to discharge. 7 of



133 patients who did not receive thrombolysis had major hemorrhage. 2 survived to discharge. Nonsignificant increase in risk of bleeding with thrombolytics: OR 2.5; 95% CI 0.9, 7.4. Level 5 Fair.

Lawes1 Reference Type: Journal ArticleRecord Number: 2122Author: Lawes, E. G. ; Baskett, P. J.Year: 1987Title: Pulmonary aspiration during unsuccessful cardiopulmonary resuscitation.Journal: Intensive Care MedVolume: 13Issue: 6Pages: 379-382Date: 1987Label: 40200Keywords: AdolescenceAdultAgedAged, 80 and overChildCricoid CartilagephysiopathologyFemaleHumanMaleMiddle AgePneumonia, Aspirationepidemiology*etiologyphysiopathologyPressureResuscitation*adverse effectsmortality19870101 00:00Abstract: The incidence of pulmonary aspiration in a group of patients who did not respond to cardiopulmonary resuscitation (CPR) was assessed at autopsy and found to be 29%. This figure is undoubtedly an underestimate of the total problem, and some indication of the potential for aspiration during CPR is revealed by the fact that 46% of the patients studied had full stomaches at autopsy. Clearly this fact has implications for CPR methods as suggested by Cummings and Eisenberg. The problem could be reduced by incorporating the use of cricoid pressure into the techniques of Basic CPR but this will require modification of current teaching.Notes: ProCite field[38]: 88034023

Cohort study of all cases of sudden death (within 24 hours of admission) from a single hospital reported to Coroner. Excluded those with anesthesia or surgery prior to CPR; pneumonia, gastrointestinal obstruction including gastrointestinal malignancy. 29% had aspiration, defined as macroscopic evidence at autopsy of respiratory tract contamination by food matter or blood. Level 5 Fair.

Lelcuk1 Reference Type: Journal ArticleRecord Number: 1058Author: Lelcuk, S.; Leibovitch, I.; Kaplan, O.; Rozin, R. R.Year: 1990Title: Stomach rupture caused by false intubation of the esophagusJournal: Israel Journal of Medical SciencesVolume: 26Issue: 3



Pages: 167-8Date: MarAccession Number: 2329042Keywords: Screen

N=2 cases of stomach rupture associated with esophageal intubation. Both discharged to home. Level 5 Fair.

Linch1 Reference Type: Journal ArticleRecord Number: 1473Author: Linch, D.; McDonald, A.; McNicol, L.Year: 1979Title: Tension pneumoperitoneum complicating cardiac resuscitationJournal: Intensive Care MedicineVolume: 5Issue: 2Pages: 94-4Date: MayAccession Number: 458041Keywords: ScreenAbstract: A case of gastric rupture and tension pneumonperitoneum following cardiac resuscitation is presented. Respiratory embarrassment necessitated emergency decompression by needle puncture of the peritoneal cavity, followed by laparotomy and repair of the gastric tear. The post-operative course has been satisfactory. The aetiology of the gastric rupture is discussed and recommendations are made for the prevention and treatment of this unusual complication of combined mouth to mouth respiration and external cardiac massage.

Case report of patient with gastric rupture and tension pneumoperitoneum after CPR. Repaired, then patient discharged home. Level 5 Fair.

Lockett1 Reference Type: Journal ArticleRecord Number: 1525Author: Lockett, F. C.; Rothfeld, B.; Meckelnburg, R.; Sagar, V. V.Year: 1977Title: Detection of bone trauma after cardiopulmonary resuscitationJournal: Maryland State Medical JournalVolume: 26Issue: 11Pages: 78-9Date: NovAccession Number: 916745Keywords: Screen

Case report of patient resuscitated with CPR. Tc99 pyrophosphate imaging documented bone trauma. Survived to discharge. Level 5 Fair.

Low1 Reference Type: Journal ArticleRecord Number: 820Author: Low, L. L.; Ripple, G. R.; Bruderer, B. P.; Harrington, G. R.Year: 1994Title: Non-operative management of gastric perforation secondary to cardiopulmonary resuscitationJournal: Intensive Care MedicineVolume: 20Issue: 6Pages: 442-3Date: JulAccession Number: 7798450Keywords: Screen



Abstract: We report the case of a 72-year-old male who suffered a cardiac arrest during an early positive treadmill stress test. After successful resuscitation the patient had evidence of a gastric perforation. Because of his hemodynamic stability, lack of peritoneal signs, and prohibitively high surgical risk, a non-operative management approach was successfully administered. Although not the standard approach to traumatic gastric perforation, this case is not unlike the management of peptic ulcer perforations. A non-operative approach should be considered as an option in selected patients.

Case report of patient with gastric rupture after CPR. Not operated on; survived to discharge. Level 5 Fair.

Ma1 Reference Type: Journal ArticleRecord Number: 840Author: Ma, M. H.; Huang, G. T.; Wang, S. M.; Tai, T. Y.; Shyu, K. G.; Hwang, J. J.; Tseng, Y. Z.; Lien, W. P.Year: 1994Title: Aortic valve disruption and regurgitation complicating CPR detected by transesophageal echocardiographyJournal: American Journal of Emergency MedicineVolume: 12Issue: 5Pages: 601-2Date: SepAccession Number: 8060413Keywords: Screen

Case report of aortic valve disruption and aortic regurgitation that developed during CPR as documented by transesophageal ECHO. Level 5 Fair.

Machii1 Reference Type: Journal ArticleRecord Number: 2398Author: Machii, M. ; Inaba, H. ; Nakae, H. ; Suzuki, I. ; Tanaka, H.Year: 2000Title: Cardiac rupture by penetration of fractured sternum: a rare complication of cardiopulmonary resuscitation.Journal: ResuscitationVolume: 43Issue: 2Pages: 151-153Date: 2000 JanLabel: 51440Keywords: AgedAged, 80 and overCardiopulmonary Resuscitation*adverse effectsCase ReportFractures*etiologyHeart Injuries*etiologyHumanMaleSternum*injuries20000311 09:00Abstract: We report an 82-year-old man in whom cardiopulmonary resuscitation (CPR) was unsuccessful. The postmortem examination revealed right atrial ruptures and pericardial sac perforation by a fractured sternal edge. Even though CPR-related cardiac rupture is rare, emergency medical staff should be aware of this complication.



Notes: ProCite field[38]: 20155868

Case report of cardiac rupture by penetration of fractured sternum. Deceased. Level 5 Fair.

Matikainen1 Reference Type: Journal ArticleRecord Number: 1504Author: Matikainen, M.Year: 1978Title: Rupture of the stomach: a rare complication of resuscitation. Case reportJournal: Acta Chirurgica ScandinavicaVolume: 144Issue: 1Pages: 61-2Accession Number: 654838Keywords: ScreenAbstract: Rupture of the stomach following resuscitation is a rare event and only five such cases have been published before. A case is presented and the pathological anatomy, clinical picture and treatment discussed.

Case report of a 39 year-old who had respiratory arrest. After CPR, distended abdomen noted on admission. Patient died during surgical repair of gastric rupture. Level 5 Fair.

Mattana1 Reference Type: Journal ArticleRecord Number: 954Author: Mattana, J.; Singhal, P. C.Year: 1992Title: Determinants of elevated creatine kinase activity and creatine kinase MB-fraction following cardiopulmonary resuscitationJournal: ChestVolume: 101Issue: 5Pages: 1386-92Date: MayAccession Number: 1582302Keywords: ScreenAbstract: OBJECTIVE: We undertook this study to determine the occurrence and the determinants of elevation of serum creatine kinase (CK) levels and CK MB-fraction following cardiopulmonary resuscitation (CPR). DESIGN: Four hundred twenty consecutive adult admissions to the Long Island Jewish Medical Center from January 1989 through December 1990 with a diagnosis of cardiac arrest were reviewed. SETTING: The Long Island Jewish Medical Center, New Hyde Park, NY, the Long Island Campus for the Albert Einstein College of Medicine, Bronx, NY. PATIENTS: Sixty-three patients survived for at least 12 h following cardiac arrest for evaluation of post-CPR CK levels and were included into the study. MEASUREMENTS: Clinical features, biochemical profiles, and administered drug profiles were studied in these patients. The clinical and biochemical features of the patients with (CK greater than 224 IU/L [3.7 mu kat/L]) and without rhabdomyolysis were also compared. MAIN RESULTS: Two major determinants responsible for elevated CK levels emerged, including physical injury (number of chest compressions during CPR) and electrical injury (cumulative number of joules administered during defibrillation). Post-CPR CK levels showed positive correlations with both the number of chest compressions given (p less than 0.001) and the number of joules administered during defibrillation (p less than 0.001). Post-CPR CK-MB levels also showed a positive correlation with the number of joules administered (p less than 0.005) and the number of chest compressions (p less than 0.02). Forty-three (68.3 percent) of the 63 patients developed rhabdomyolysis. Serum CK levels were higher (p less than 0.005) in the patients who received electrical countershock therapy as well as chest compressions when compared with patients who received chest compressions alone. There were no significant differences in electrolyte levels between patients with and without rhabdomyolysis. Thirty patients had a history of coronary artery disease (CAD) and 18 (60.0 percent) of these had a positive MB-fraction post-CPR while only ten of the 33 patients without known CAD had a positive MB-fraction post-CPR (30.3 percent, p less



than 0.05). Patients with no known CAD but positive CK-MB fraction had significantly higher total CK levels, physical injury, and electrical injury compared with patients with negative CK-MB fraction. Twenty patients survived CPR and were discharged from the hospital without significant neurologic sequelae. The remaining 43 either died or suffered severe neurologic injury. The patients who survived CPR had a significantly shorter duration of CPR (p less than 0.01) compared with those who did not. Patients who did not have long-term survival following CPR were more likely to have elevated serum potassium, phosphate, and creatinine values. CONCLUSIONS: CK elevation is a common finding following successful CPR after cardiac arrest and this elevation of post-CPR CK levels is related to both physical as well as electrical injury sustained during CPR. Elevation of post-CPR CK-MB fraction seems to be only a crude indicator of preexisting CAD; however, a positive CK-MB fraction in patients without CAD is related to severity of physical injury and electrical injury during CPR. Patients who survive CPR without neurologic impairment appear to be those with a shorter duration of CPR. Elevated serum potassium, phosphate, and creatinine values may be related to an adverse effect on long-term survival.

Cohort of 420 consecutive adult admissions after cardiac arrest. 63 survived >12 hours. Linear association between number of chest compressions and post-CPR CK (r=0.498, p<0.02); number of chest compressions and post-CPR CK-MB (r=0.474, p<0.001); Joules of energy and post-CPR CK (r=0.742, p<0.001); Joules of energy and post-CPR CK-MB (r=0.655, p<0.005). Level 5 Fair.

McGrath1 Reference Type: Journal ArticleRecord Number: 1373Author: McGrath, R. B.Year: 1983Title: Gastroesophageal lacerations. A fatal complication of closed chest cardiopulmonary resuscitationJournal: ChestVolume: 83Issue: 3Pages: 571-2Date: MarAccession Number: 6600676Keywords: ScreenAbstract: A case of fatal gastrointestinal hemorrhage from gastric mucosal lacerations related to the closed chest cardiac compression of cardiopulmonary resuscitation is reported. Previous autopsy series suggest that gastroesophageal lacerations may occur in 12 percent of cases not surviving cardiopulmonary resuscitation (CPR). In the presence of increasing out-of-hospital and lay-initiated resuscitation, recognition of this complication of closed chest compression seems to be of particular importance. Attention to the technique of chest compression and ventilation, including early intubation and gastric decompression, may help to minimize the incidence of gastric mucosal laceration occurring during CPR.

Case report of a patient who initially responded to CPR. Postmortem showed massive gastric hemorrhage. No abstract provided. Level 5 Fair.

Mehta1 Reference Type: Journal ArticleRecord Number: 1623Author: Mehta, B.; Briggs, D. K.; Sommers, S. C.; Karpatkin, M.Year: 1972Title: Disseminated intravascular coagulation following cardiac arrest: a study of 15 patientsJournal: American Journal of the Medical SciencesVolume: 264Issue: 5Pages: 353-63Date: NovAccession Number: 4650128Keywords: Screen



Case series of 15 patients resuscitated after cardiac arrest who were studied after resuscitation from cardiac arrest. Observed reduced platelet count in 7 (47%), prolonged PT in 11 (73%), prolonged thrombin time in 2 (13%), decreased fibrinogen in 8 (53%), decreased factor II in 3 (20%), decreased factor V in 12 (80%), decreased factor VIII in 10 (67%), increase fibrinogen degradation products in 5 (34%). No fragments. Coagulation not tested at consistent times. If repeated, abnormalities corrected. No abstract provided. Level 5 Fair.

Mensah1 Reference Type: Journal ArticleRecord Number: 1137Author: Mensah, G. A.; Gold, J. P.; Schreiber, T.; Isom, O. W.Year: 1988Title: Acute purulent mediastinitis and sternal osteomyelitis after closed chest cardiopulmonary resuscitation: a case report and review of the literatureJournal: Annals of Thoracic SurgeryVolume: 46Issue: 3Pages: 353-5Date: SepAccession Number: 3046524Keywords: ScreenAbstract: Numerous complications have been associated with cardiopulmonary resuscitation. Acute purulent staphylococcal mediastinitis and sternal osteomyelitis are, however, unusual and do not appear to have been reported previously in association with closed chest resuscitation. Sternal fracture during chest compressions and subsequent hematogenous seeding of the resultant retrosternal hematoma with Staphylococcus aureus led to purulent mediastinitis and sternal osteomyelitis in our patient. The source of bacteremia may have been a resolving phlebitis at an intravenous catheter insertion site. Early diagnosis, aggressive surgical debridement, and antibiotic therapy were key to a successful outcome. [References: 8]Notes: Review

Case report of sternal fracture during CPR, hematogenous seeding of the subsequent hematoma with staph aureus that led to purulent mediatinitis, sternal osteomyelitis. No abstract provided. Level 5 Fair.

Menzies1 Reference Type: Journal ArticleRecord Number: 1007Author: Menzies, D.; Noble, J. G.; Dent, C. M.; Cox, P. J.Year: 1991Title: Pneumoscrotum--an unusual complication of cardiopulmonary resuscitationJournal: British Journal of UrologyVolume: 67Issue: 4Pages: 440-1Date: AprAccession Number: 2032090Keywords: Screen

Case report of pneumoscrotum observed after CPR. Level 5 Fair.

Mills1 Reference Type: Journal ArticleRecord Number: 1374Author: Mills, S. A.; Paulson, D.; Scott, S. M.; Sethi, G.Year: 1983Title: Tension pneumoperitoneum and gastric rupture following cardiopulmonary resuscitationJournal: Annals of Emergency MedicineVolume: 12Issue: 2Pages: 94-5



Date: FebAccession Number: 6600589Keywords: ScreenAbstract: Inadvertent esophageal intubation during cardiopulmonary resuscitation following aortocoronary bypass grafting resulted in gastric rupture and tension pneumoperitoneum in a 65-year-old patient. Rapid hemodynamic deterioration necessitated emergency laparotomy with successful repair of the gastric rupture. The patient's recovery was uneventful, and he was doing well at six months follow up. Awareness of this unusual complication may lead to early recognition and successful treatment.

Case report of inadvertent esophageal intubation during CPR after CABS, resulted in gastric rupture and tension pneumoperitoneum. Repaired surgically. Discharged home. Level 5 Fair.

Minor1 Reference Type: Journal ArticleRecord Number: 1069Author: Minor, R. L., Jr.; Chandran, P. K.; Williams, C. L.Year: 1990Title: Rhabdomyolysis and myoglobinuric renal failure following cardioversion and CPR for acute MIJournal: ChestVolume: 97Issue: 2Pages: 485-6Date: FebAccession Number: 2298078Keywords: ScreenAbstract: A 50-year-old man suffered an MI with VFIB at work, and efforts at resuscitation were initiated immediately. Ninety minutes of CPR and 14 cardioversions were given by trained personnel before VFIB converted to sinus rhythm. Reversible myoglobinuric renal failure ensued, requiring two weeks of hemodialysis. Scanning with technetium-99m pyrophosphate revealed extensive muscle injury in the regions of cardioversion and a large anterolateral MI Prolonged resuscitative efforts involving repeated cardioversion may predispose to myoglobinuric renal failure.

Case report of man with acute MI, ventricular fibrillation, immediate CPR. After 90 minutes of CPR, 14 cardioversions, developed reversible myoglobinuria requiring hemodialysis for 2 weeks. Tc99 scan demonstrated extensive muscle injury in regions of cardioversion and large anterolateral MI. Discharged home. Level 5 Fair.

Miro1 Reference Type: Journal ArticleRecord Number: 797Author: Miro, O.; Chamorro, A.; del Mar Lluch, M.; Nadal, P.; Milla, J.; Urbano-Marquez, A.Year: 1994Title: Posthypoxic myoclonus in intensive careJournal: European Journal of Emergency MedicineVolume: 1Issue: 3Pages: 120-2Date: SepAccession Number: 9422152Keywords: ScreenAbstract: Posthypoxic myoclonus (Lance-Adams' syndrome) is a rare complication of cardiorespiratory arrest. It has a better prognosis than other movement disorders secondary to brain ischaemia. We report a case of posthypoxic myoclonus in a 66-year-old woman after acute myocardial infarction and cardiopulmonary arrest. She had action and intention myoclonus, and these movements were also initiated by acoustic and pain stimuli. The origin of the myoclonus was probably subcortical, and it improved with clonazepam 2 mg t.i.d. We emphasize that early diagnosis is necessary in intensive care units in order to avoid misinterpretation of this syndrome and to start appropriate



treatment.

Case report of posthypoxic myoclonus after successful CPR. Survived to discharge. No abstract provided. Level 5 Fair.

Mirow1 Reference Type: Journal ArticleRecord Number: 853Author: Mirow, N.; Minami, K.; Vogt, J.; Korfer, R.Year: 1994Title: Rupture of gastroepiploic-coronary bypass graft due to cardiopulmonary resuscitationJournal: Journal of Cardiovascular SurgeryVolume: 35Issue: 2Pages: 177-8Date: AprAccession Number: 8195282Keywords: Screen

Case report of rupture of gastroepiploic artery bypass graft at the peripheral anastamotic site. Patient died. Level 5 Fair.

Nagel1 Reference Type: Journal ArticleRecord Number: 2556Author: Nagel, E. L. ; Fine, E. G. ; Krischer, J. P. ; Davis, J. H.Year: 1981Title: Complications of CPR.Journal: Crit Care MedVolume: 9Issue: 5Pages: 424Date: 1981 MayLabel: 4450Keywords: Allied Health PersonnelFollow-Up StudiesHumanResuscitation*adverse effectsSupport, U.S. Gov't, P.H.S.19810501 00:00Notes: ProCite field[38]: 81163650

Cohort study of 2228 out of hospital cardiac arrests. Rate of complications observed at autopsy: oropharyngeal vomitus 9.5%, tracheal vomitus 8.9%, ETT misplacement 3.9%, rib fracture 34%, sternal fracture 22.2%, pneumonia 1.3%, pulmonary edema 46%, liver rupture 1.9%, gastric dilation 28%, pericardial tamponade 8.1%, myocardial contusion 1.3%. Autopsies done on maximum of 738 cases; denominator not same for all complications. No abstract provided. Level 5 Fair.

Nelson1 Reference Type: Journal ArticleRecord Number: 1280Author: Nelson, B. K.Year: 1985Title: Tension pneumothorax following CPR or mechanical ventilationJournal: Annals of Emergency MedicineVolume: 14Issue: 6Pages: 615Date: Jun



Accession Number: 3994094Keywords: Screen

Case report of a woman who had surgery for perforated duodenal ulcer, then postoperative cardiac arrest. Autopsy showed fractured ribs, LV laceration, pericardial tamponade. Fractures appeared to overlie laceration and tamponade. Level 5 Fair.

Norfleet1 Reference Type: Journal ArticleRecord Number: 1038Author: Norfleet, R. G.; Smith, G. H.Year: 1990Title: Mallory-Weiss syndrome after cardiopulmonary resuscitationJournal: Journal of Clinical GastroenterologyVolume: 12Issue: 5Pages: 569-72Date: OctAccession Number: 2230001Keywords: ScreenAbstract: We report hematemesis from Mallory-Weiss tears after successful cardiopulmonary resuscitation (CPR). A computer search of the English language literature disclosed only 3 similar cases, and we review them. This complication of CPR may occur more frequently than recognized and should be prevented by careful technique. [References: 21]Notes: Review

Case report of a woman with witnessed cardiac arrest, immediate CPR. She awoke and vomited. ~30 mins later vomited bright red blood. Endoscopy showed Mallory-Weiss tear. Survived to discharge. Level 5 Fair.

Novotny1 Reference Type: Journal ArticleRecord Number: 179Author: Novotny, A. R.; Brauer, R. B.; Brandl, R.; Matevossian, E.; Stangl, M. J.Year: 2003Title: Posterior fossa stroke during cardiopulmonary resuscitation secondary to haemodialysis arterio-venous fistulaJournal: Nephrology Dialysis TransplantationVolume: 18Issue: 1Pages: 221-3Date: JanAccession Number: 12480997Keywords: Screen

Case report of a patient with ESRD and above elbow AV fistula with Gortex graft, postoperative cardiac arrest. Noted to be hypotensive during resuscitation. Spontaneous circulation restored but persistent coma with no response to light. CT head showed bilateral hypodense lesions of occipital cortex consistent with ischemic infarction. Doppler US showed retrograde flow in left vertebral artery, reverse by manual compression of hemodialysis shunt. All attributed to hemodynamically induced cerebral infarction during CPR in combination with a subclavian steal induced by low resistance of AV shunt. Patient died. Level 5 Fair.

Odom1 Reference Type: Journal ArticleRecord Number: 580Author: Odom, A.; Christ, E.; Kerr, N.; Byrd, K.; Cochran, J.; Barr, F.; Bugnitz, M.; Ring, J. C.; Storgion, S.; Walling, R.; Stidham, G.; Quasney, M. W.Year: 1997Title: Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: a prospective studyJournal: PediatricsVolume: 99



Issue: 6Pages: E3Date: JunAccession Number: 9164799Keywords: ScreenAbstract: OBJECTIVE: Child abuse occurs in 1% of children in the United States every year; 10% of the traumatic injuries suffered by children under 5 years old are nonaccidental, and 5% to 20% of these nonaccidental injuries are lethal. Rapid characterization of the injury as nonaccidental is of considerable benefit to child protection workers and police investigators seeking to safeguard the child care environment and apprehend and prosecute those who have committed the crime of child abuse. Physically abused children present with a variety of well-described injuries that are usually easily identifiable. In some cases, however, particularly those involving children with the shaken baby syndrome, obvious signs of physical injury may not exist. Although external signs of such an injury are infrequent, the rapid acceleration-deceleration forces involved often cause subdural hematomas and retinal hemorrhages, hallmarks of the syndrome. Frequently, retinal hemorrhages may be the only presenting sign that child abuse has occurred. Complicating the interpretation of the finding of retinal hemorrhages is the belief by some physicians that retinal hemorrhages may be the result of chest compressions given during resuscitative efforts. The objective of this study is to determine the prevalence of retinal hemorrhages after inpatient cardiopulmonary resuscitation (CPR) in pediatric patients hospitalized for nontraumatic illnesses in an intensive care unit. DESIGN: Prospective clinical study. SETTING: Pediatric intensive care unit. PATIENTS: Forty-three pediatric patients receiving at least 1 minute of chest compressions as inpatients and surviving long enough for a retinal examination. Patients were excluded if they were admitted with evidence of trauma, documented retinal hemorrhages before the arrest, suspicion of child abuse, or diagnosis of near-drowning or seizures. All of the precipitating events leading to cardiopulmonary arrest occurred in our intensive care unit, eliminating the possibility of physical abuse as an etiology. INTERVENTIONS: None. MEASUREMENTS: Examination of the retina was performed by one of two pediatric ophthalmologists within 96 hours of CPR. The chart was reviewed for pertinent demographic information; the platelet count, prothrombin time, and partial thromboplastin time proximate to the CPR were recorded if they had been determined. RESULTS: A total of 43 pediatric patients hospitalized with nontraumatic illnesses survived 45 episodes of inpatient CPR. The mean age was 23 months (range, 1 month to 15.8 years), and 84% of the patients were under 2 years old. The majority of the patients (44%) were admitted to the intensive care unit after surgery for congenital heart disease, and another 21% were admitted for respiratory failure. The mean duration of chest compressions was 16.4 minutes +/- 17 minutes with 58% lasting between 1 and 10 minutes. Five patients had chest compressions lasting >40 minutes, and two patients had open chest cardiac massage. All patients survived their resuscitative efforts. Ninety-three percent of patients had an elevated prothrombin time and/or partial thromboplastin time while 49% were thrombocytopenic. Sixty-two percent of the patients had low platelet counts and an elevated prothrombin time and/or partial thromboplastin time. Small punctate retinal hemorrhages were found in only one patient. CONCLUSIONS: Retinal hemorrhages are rarely found after chest compressions in pediatric patients with nontraumatic illnesses, and those retinal hemorrhages that are found appear to be different from the hemorrhages found in the shaken baby syndrome. Despite the small number of patients in this prospective study, we believe that these data support the idea that chest compressions do not result in retinal hemorrhages in children with a normal coagulation profile and platelet count. A larger number of patients should be evaluated in a prospective multi-institutional study to achieve statistical significance

Case series of 43 children with nontraumatic illness who survived 45 episodes of inpatient CPR. Direct fundoscopic exam performed within 96 hours of arrest. 93% had elevated PT or PTT; 49% had low platelets. Small retinal hemorrhage found in one patient. Survival to discharge not stated. Level 5 Fair.

Offerman1 Reference Type: Journal ArticleRecord Number: 5866



Author: Offerman, S. R.; Holmes, J. F.; Wisner, D. H.Year: 2001Title: Gastric rupture and massive pneumoperitoneum after bystander cardiopulmonary resuscitationJournal: J Emerg MedVolume: 21Issue: 2Pages: 137-139Date: AugAccession Number: 11489402Keywords: AdultCardiopulmonary Resuscitation/*adverse effectsCase ReportEmergenciesHumanMalePneumoperitoneum/*etiology/radiographyStomach Rupture/diagnosis/*etiologyTreatment OutcomeAbstract: Gastric perforation is a rare complication of cardiopulmonary resuscitation. The majority of reported cases have been associated with difficult airway management or esophageal intubation. There has been only one previous case report in which this complication could be attributed solely to mouth-to-mouth ventilation. We present a case of simple bystander cardiopulmonary resuscitation that resulted in gastric perforation.Notes: 0736-4679Journal ArticleURL: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11489402Author Address: Department of Internal Medicine, Division of Emergency Medicine and Department of Surgery, Sacramento, California 95817, USA.

Case report of man who received bystander CPR c/o mouth to mouth and chest compressions. Naloxone given for heroin overdose, then patient awoke and complained of chest pain and dyspnea. Later diagnosed as having gastric rupture and pneumoperitoneum. Surgically repaired, discharged home. Level 5 Fair.

Oh1 Reference Type: Journal ArticleRecord Number: 532Author: Oh, C. M.; Hewitt, P. M.Year: 1998Title: Gastric rupture due to cardiopulmonary resuscitationJournal: InjuryVolume: 29Issue: 5Pages: 399-400Date: JunAccession Number: 9813691Keywords: Screen

Case report of women who collapsed, with no pulse or spontaneous breathing. CPR started immediately and done for 20 minutes. Stopped briefly when she vomited blood and undigested food. Intubated, ventilated, defibrillated X 3 before sinus rhythm. Noted to have flail chest, fractured sternum, pneumoperitoneum. Laparotomy showed gastric rupture. Discharged home. Level 5 Fair.

Oschatz1 Reference Type: Journal ArticleRecord Number: 5920Author: Oschatz, E.; Wunderbaldinger, P.; Sterz, F.; Holzer, M.; Kofler, J.; Slatin, H.; Janata, K.; Eisenburger, P.; Bankier, A. A.; Laggner, A. N.Year: 2001Title: Cardiopulmonary resuscitation performed by bystanders does not increase adverse



effects as assessed by chest radiographyJournal: Anesth AnalgVolume: 93Issue: 1Pages: 128-133Date: JulAccession Number: 11429353Keywords: AgedBlood Gas AnalysisCardiopulmonary Resuscitation/*adverse effects*Emergency Medical ServicesFemaleHeart Arrest/radiography/*therapyHeart Massage/adverse effectsHumanMaleMiddle AgeOxygen Consumption/physiologyProspective Studies*Radiography, ThoracicAbstract: Important adverse effects of bystander cardiopulmonary resuscitation (CPR) are well known. We describe the number of nonmedical professional CPR-related complications in patients surviving cardiac arrest, as assessed by chest radiograph. Within 2 yr, all consecutive patients admitted to the department of emergency medicine at a university hospital who had a witnessed, nontraumatic, normothermic cardiac arrest were studied. Radiologically evaluated adverse effects were compared with Mann-Whitney U-tests between patients who received bystander basic life support (Bystander group) and patients who did not receive bystander basic life support before advanced life support was started (ALS group). For assessment of bystander CPR-associated complications, chest radiographs were used. Of 224 patients, 173 were eligible. The median age was 58 yr (interquartile range, 51-71 yr), and 126 patients (73%) were men. The incidence of adverse effects associated with assisted-ventilation maneuvers and external chest compressions did not differ significantly between groups (severe gastric insufflation, 17% vs 18% between the Bystander group [n = 59] and the ALS group [n = 96], respectively; suspicion of aspiration, 22% vs 17%, respectively; soft tissue emphysema, 2% vs 1%, respectively; and serial rib fractures, 8% vs 8%, respectively). CPR administered by nonmedical personnel did not increase the number of life support-related adverse effects in patients surviving cardiac arrest as assessed by means of chest radiograph on admission. Implications: Complications related to cardiopulmonary bypass (CPR) are not increased when CPR is administered by nonmedical personnel, as assessed by chest radiograph.These data may be valuable in motivating lay people to perform basic life support.Notes: 0003-2999Clinical TrialJournal ArticleURL: http://www.anesthesia-analgesia.org/cgi/content/full/93/1/128http://www.anesthesia-analgesia.org/cgi/content/abstract/93/1/128http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11429353Author Address: University Clinic of Emergency Medicine and Radiology, University of Vienna, Austria.

Cohort of consecutive cases admitted to emergency medicine at academic hospital after witnessed nontraumatic, normothermic cardiac arrest. Of 224 patients, 173 included. Complications similar after bystander CPR (n=59) vs. ALS (n=96): aspiration 22% vs. 17%; soft tissue emphysema 2% vs. 1%; serial rib fractures 8% vs 8%. Level 5 Fair.

Parke1 Reference Type: Journal ArticleRecord Number: 873Author: Parke, T. R.



Year: 1993Title: Unexplained pneumoperitoneum in association with basic cardiopulmonary resuscitation effortsJournal: ResuscitationVolume: 26Issue: 2Pages: 177-81Date: OctAccession Number: 8290812Keywords: ScreenAbstract: During the mouth to mouth ventilation of basic life support, the high inflation pressures generated may result in later complications. Pulmonary barotrauma may result in pneumothorax or pneumomediastinum, and high pressures applied to the gastrointestinal tract may lead to gastric rupture and pneumoperitoneum. A case is reported of pneumoperitoneum in the absence of pneumothorax, pneumomediastinum or gastrointestinal perforation and the literature relating to this unusual condition is reviewed.

Case report of a woman with out of hospital cardiac arrest (apneic, cyanosed, no pulse) who received bystander CPR. Paramedic rated CPR done according to guidelines. Normal sinus rhythm on monitor by paramedic and palpable pulse so CPR discontinued. On arrival in ED, no paradoxical chest wall movement or rib fractures but distended abdomen. CXR showed dilated stomach with free air under hemidiaphragm. Pneumoperitoneum but no perforated viscus on laparotomy. Survived to discharge. Level 5 Fair.

Pestaner1 Reference Type: Journal ArticleRecord Number: 7295Author: Pestaner, J. P.; Smialek, J. E.Year: 2002Title: Splenic rupture following cardiopulmonary resuscitationJournal: ResuscitationVolume: 54Issue: 2Pages: 216Date: AugAccession Number: 12161303Keywords: Cardiopulmonary Resuscitation/*adverse effectsCase ReportHumanMaleMiddle AgeSplenic Rupture/*etiologyNotes: 221517550300-9572CommentLetterURL: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12161303

Case report of a 50 year-old man with unwitnessed cardiac arrest, then CPR. Post-mortem autopsy showed splenic rupture. Level 5 Fair.

Petersen1 Reference Type: Journal ArticleRecord Number: 7163Author: Petersen, P.; Boysen, G.; Godtfredsen, J.; Andersen, E. D.; Andersen, B.Year: 1989Title: Placebo-controlled, randomised trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation. The Copenhagen AFASAK studyJournal: Lancet



Volume: 1Issue: 8631Pages: 175-9Date: Jan 28Accession Number: 2563096Keywords: AdultAgedAged, 80 and overAspirin/administration & dosage/adverse effects/*therapeutic useAtrial Fibrillation/*complicationsChronic DiseaseClinical TrialsComparative StudyDenmarkDouble-Blind MethodDrug Administration ScheduleFemaleFollow-Up StudiesHumanMaleMiddle AgeRandom AllocationSupport, Non-U.S. Gov'tThromboembolism/etiology/*prevention & controlWarfarin/administration & dosage/adverse effects/*therapeutic useURL: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=2563096Author Address: Department of Neurology, University Hospital, Copenhagen, Denmark.

Case report of man with cardiomyopathy who had cardiac arrest shortly after arrival in emergency room. Had CPR, intracardiac medication and central venous line via percutaneous subclavian line. CVP elevated so had pericardiocentesis which was positive for blood. Attributed to avulsion of IVC from right atrium during CPR. Outcome not reported. Level 5 Fair.

Pezzi1 Reference Type: Journal ArticleRecord Number: 8864Author: Pezzi, A.; Pasetti, G.; Lombardi, F.; Fiorentini, C.; Iapichino, G.Year: 1999Title: Liver rupture after cardiopulmonary resuscitation (CPR) and thrombolysisJournal: Intensive Care MedVolume: 25Issue: 9Pages: 1032.Keywords: excluded

Cardiopulmonary Resuscitation/*adverse effectsFatal OutcomeHumanLiver/*injuriesMaleMiddle AgedMyocardial Infarction/complications/therapyRupture/etiologyThrombolytic Therapy/*adverse effectsTime FactorsNotes: Case report on a fatal bleeding in a patient receiving thrombolytic therapy after resuscitation.

Case report of a man with out of hospital VF. After resuscitated, ECG suggested acute MI. TPA and IV heparin given. Later had hypotension then died. Autopsy should hemoperitoneum, liver



laceration and overlying rib fractures. Level 5 Fair.

Powner1 Reference Type: Journal ArticleRecord Number: 201Author: Powner, D. J. ; Holcombe, P. A. ; Mello, L. A.Year: 1984Title: Cardiopulmonary resuscitation-related injuries.Journal: Crit Care MedVolume: 12Issue: 1Pages: 54-55Date: 1984 JanLabel: 41360Keywords: AgedArizonaFemaleHumanMaleMiddle AgeResuscitation*adverse effectsRetrospective StudiesRib Fracturesepidemiology*etiology19840101 00:00Notes: ProCite field[38]: 84083368

Case series of 717 in hospital cardiac arrests. 456 (64%) resuscitated. Autopsies done in 70 (29%) of 261 unsuccessful attempts. Observed fractured ribs 19%, fractured sternum 9%, bone marrow emboli lung 17%, mediastinal bleed 4%, vegetable material in pulmonary artery, pericardial bleed, subcutaneous emphysema, mediastinal emphysema, bone marrow emboli to heart. Level 5 Fair.

Reardon1 Reference Type: Journal ArticleRecord Number: 1197Author: Reardon, M. J.; Gross, D. M.; Vallone, A. M.; Weiland, A. P.; Walker, W. E.Year: 1987Title: Atrial rupture in a child from cardiac massage by his parentJournal: Annals of Thoracic SurgeryVolume: 43Issue: 5Pages: 557-8Date: MayAccession Number: 3579415Keywords: ScreenAbstract: A 4-year-old boy presented with a single seizure following a viral syndrome. He had a pericardial effusion on admission, and this increased suddenly on the third day of hospitalization, producing cardiac tamponade. After blood was aspirated from the child's pericardial cavity, the father revealed that he performed cardiac massage on his son following the seizure. A laceration of the right atrium was repaired at operation, and the boy made a good recovery. Cardiopulmonary resuscitation by lay persons is not without hazard, and patients with such a history should be watched carefully for the possibility of damage to intrathoracic structures.

Case report of 4 year-old boy who presented with single seizure. Pericardial effusion noted on admission. Later father reported that he had performed chest compressions on his son after the seizure. Patient had surgical procedure then discharged alive. Level 5 Fair.



Register1 Reference Type: Journal ArticleRecord Number: 1283Author: Register, S. D.; Downs, J. B.; Tabeling, B. B.Year: 1985Title: Gastric mucosal lacerations: a complication of cardiopulmonary resuscitationJournal: AnesthesiologyVolume: 62Issue: 4Pages: 513-4Date: AprAccession Number: 3872610Keywords: Screen

Case report of gastric mucosal lacerations after successful resuscitation. Had laparotomy. Discharged alive. Level 5 Fair.

Reinartz1 Reference Type: Journal ArticleRecord Number: 1105Author: Reinartz, H.Year: 1989Title: [Blunt upper abdominal trauma as a complication of cardiac resuscitation]Journal: Anasthesie, Intensivtherapie, NotfallmedizinVolume: 24Issue: 2Pages: 111-4Date: AprAccession Number: 2729533Keywords: ScreenAbstract: The case of a combined manifold rupture of the liver and spleen give rise to the discussion of the blunt abdominal trauma after extern cardiopulmonary resuscitation. A survey concerning the recent status of the diagnostic possibilities will be given according to the literature and our own experiences. The values of the different diagnostic procedures, advantages and disadvantages will be discussed.Notes: German

Case report of ruptured liver and spleen after resuscitation. Outcome unclear. [German] Level 5 Fair.

Rello1 Reference Type: Journal ArticleRecord Number: 766Author: Rello, J.; Valles, J.; Jubert, P.; Ferrer, A.; Domingo, C.; Mariscal, D.; Fontanals, D.; Artigas, A.Year: 1995Title: Lower respiratory tract infections following cardiac arrest and cardiopulmonary resuscitationJournal: Clinical Infectious DiseasesVolume: 21Issue: 2Pages: 310-4Date: AugAccession Number: 8562736Keywords: ScreenAbstract: All episodes of lower respiratory tract infection that developed among 96 patients surviving for > 24 hours after cardiac arrest were prospectively studied over an 18-month period. Pneumonia developed in 23 (24.0%) of patients after a mean of 7 days (SD, +/- 6.2 days). The development of four superinfections raised the cumulative incidence to 28.1%. Purulent tracheobronchitis was diagnosed in three instances. The causative agent of pneumonia was identified in 18 episodes, three of which were polymicrobial. Gram-positive cocci represented 57.1% of isolates, and Staphylococcus aureus--the most frequently isolated microorganism in this population--accounted for two-thirds of all gram-positive cocci. Pseudomonas aeruginosa was isolated in six episodes,



five of which were associated with previous antibiotic use. Nine (39.1%) of the 23 patients in the group with pneumonia died, but only one of these deaths was considered to be directly related to pneumonia. In conclusion, pneumonia is a common complication of patients surviving cardiac arrest, but, with adequate treatment, its influence on outcome is marginal. Gram-positive cocci are the predominant pathogens, although infection with P. aeruginosa should be considered among patients receiving antibiotics.

Cohort study (n=96) of those resuscitated and ventilated after cardiac arrest. 23 (24%) developed pneumonia after resuscitation. 44 (62%) of those without pneumonia discharged alive, 14 (62%) of those with pneumonia discharged alive (p=NS calculated from data). Level 5 Fair.

Robbins1 Reference Type: Journal ArticleRecord Number: 744Author: Robbins, P. M.; Train, J. J.Year: 1995Title: Pneumocephalus: an unusual complication of resuscitationJournal: Anaesthesia & Intensive CareVolume: 23Issue: 6Pages: 747-9Date: DecAccession Number: 8669616Keywords: Screen

Case report of a 57 year-old who required CPR after jumping from a building. CPR at scene. Bilateral periorbital hematomas noted; lateral skull X-ray showed pneumocephalus. Burrhole performed, patient survived and discharged. Level 5 Fair.

Robinson1 Reference Type: Journal ArticleRecord Number: 877Author: Robinson, A. M.; Walsh, J. T.; Triger, D. R.Year: 1993Title: Iatrogenic osteomyelitis following closed cardiopulmonary resuscitation.[see comment]Journal: British Journal of Hospital MedicineVolume: 50Issue: 6Pages: 340-1Date: Sep 15-Oct 5Accession Number: 8242220Keywords: Screen

Case report of a 31 year-old woman admitted for alcohol detoxification. Had seizure then cardiopulmonary arrest. Resuscitated with overdrive pacing. Had sternal abscess 13 d later at site of fractured rib. Level 5 Fair.

Samet1 Reference Type: Journal ArticleRecord Number: 1185Author: Samet, J. H.; Flinn, M. S.; Balady, G.; Skinner, M.Year: 1987Title: Costochondritis: a morbid complication in a survivor of cardiopulmonary resuscitationJournal: American Journal of MedicineVolume: 83Issue: 2Pages: 362-4Date: AugAccession Number: 3618638Keywords: ScreenAbstract: Complications from closed-chest cardiopulmonary resuscitation (CPR) have been described almost exclusively on the basis of autopsy results. A survivor of CPR with



clinical costochondritis resulting from resuscitation is described for the first time in the medical literature. In this case, the confounding presence of post-CPR costochondritis in a patient with documented coronary artery disease was suggested by marked local tenderness of the affected costochondral junctions. Differentiation between costochondritis and coronary artery disease was established by injection therapy of the involved costochondral joints.

Case report of a 49 year-old woman resuscitated after cardiac arrest. 3 mos. later diagnosed as having costochondritis localized to left 4th-6th ribs. Level 5 Fair.

Scholz1 Reference Type: Journal ArticleRecord Number: 8874Author: Scholz, K. H.; Tebbe, U.; Herrmann, C.; Wojcik, J.; Lingen, R.; Chemnitius, J. M.; Brune, S.; Kreuzer, H.Year: 1992Title: Frequency of complications of cardiopulmonary resuscitation after thrombolysis during acute myocardial infarctionJournal: Am J CardiolVolume: 69Issue: 8Pages: 724-8.Label: 92188926Keywords: AdultAgedAged, 80 and overCardiopulmonary Resuscitation/*adverse effectsChi-Square DistributionCombined Modality TherapyFemaleHemorrhage/*etiologyHumanIncidenceMaleMiddle AgeMyocardial Infarction/drug therapy/*therapyRetrospective StudiesThrombolytic Therapy/*adverse effectsTime FactorsAbstract: Prolonged external cardiac massage is often regarded as a contraindication for thrombolytic therapy because of the risk of fatal hemorrhage. The influence of cardiopulmonary resuscitation on complications of thrombolytic bleeding was assessed analyzing data of all patients with myocardial infarction admitted to our clinic during the 10-year period between 1978 and 1987. From the total of 2,147 patients with acute myocardial infarction, 590 received thrombolytic therapy (intracoronary in 229, intravenous in 400). Of these, 43 patients underwent prolonged cardiopulmonary resuscitation and received thrombolysis within a time interval of less than 24 hours. In 21 patients, resuscitation was performed within a short period of time (5 minutes to 20 hours) after thrombolysis (10 intracoronary, 10 intravenous, 1 intravenous + intracoronary) had been initiated; 9 of these patients survived (43%). In the other 22 patients, thrombolytic therapy was initiated during ongoing resuscitation (n = 6: intravenous in 5, intravenous + intracoronary in 1) or in the early phase (10 to 120 minutes) after successful resuscitation (n = 16: intracoronary in 10, intravenous in 4, intravenous + intracoronary in 2). From this group, 14 patients survived (in-hospital mortality 36%). The mean duration of cardiopulmonary resuscitation was 36 +/- 32 minutes (range 4 to 120). Autopsy studies were performed in 16 of 20 decreased patients. Bleeding complications occurred in 8 of 43 patients. No case of bleeding was directly related to cardiocompression despite the often traumatic procedure with rib fractures verified in 17 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Cohort study (n=2147) patients with MI, 590 (27%) of whom received thrombolytics, 43 (7%) of



whom required CPR within 24 hours, 8 (19%) of whom had bleeding complications. No bleeding directly related to CPR. Level 5 Fair.

Schroeder1 Reference Type: Journal ArticleRecord Number: 886Author: Schroeder, J.; Stevens, J. S.Year: 1993Title: CPR-induced rib fractures. Characteristic scintigraphic appearanceJournal: Clinical Nuclear MedicineVolume: 18Issue: 8Pages: 717Date: AugAccession Number: 8403711Keywords: Screen

Case report of a 55 year-old women with rib fractures and sternal fracture after CPR. No adverse outcome. Level 5 Fair.

Sclarovsky1 Reference Type: Journal ArticleRecord Number: 13943Author: Sclarovsky, S.; Kracoff, O. H.; Agmon, J.Year: 1981Title: Acceleration of ventricular tachycardia induced by a chest thumpJournal: ChestVolume: 80Issue: 5Pages: 596-9Date: NovAccession Number: 7297151Keywords: AgedDigitalis Glycosides/adverse effectsElectric Countershock/*adverse effectsHeart RateHumanMaleTachycardia/chemically induced/*physiopathology/therapyAbstract: Chest thump is accepted as a simple and effective maneuver for terminating a paroxysm of ventricular tachycardia. This report describes three patients receiving digitalis in whom chest thump caused an acceleration of the rate of ventricular tachycardia. Following discontinuation of digitalis therapy, chest thump converted to sinus rhythm recurrence of ventricular tachycardia in two patients and did not cause acceleration of the ventricular rate in the third. It is suggested that in patients taking digitalis with ventricular tachycardia, chest thump should be used with caution.Notes: Case ReportsJournal Article

Case series (n=3) of patients with ventricular tachycardia. Chest thump followed by acceleration of ventricular rate. No adverse outcome. Level 5 Fair.

Sewell1 Reference Type: Journal ArticleRecord Number: 2052Author: Sewell, R. D. ; Steinberg, M. A.Year: 2000Title: Chest compressions in an infant with osteogenesis imperfecta type II: No new rib fracturesJournal: PediatricsVolume: 106Issue: 5Pages: E71



Date: 2000 NovLabel: 48840Keywords: 20001104 11:00Abstract: The case report of a newborn female with osteogenesis imperfecta type II who underwent cardiopulmonary resuscitation (CPR) with manual chest compressions for several minutes is presented. Chest radiographs taken before and after the chest compressions were administered were reviewed by several radiologists from 3 different hospitals and demonstrated no new radiographically visible rib fractures. Collagen analysis, the patient's clinical appearance, and clinical course, as well as a consultant's opinion aided in confirmation of the diagnosis of osteogenesis imperfecta type II. A review of 4 previous studies concerning rib fractures and CPR is included. This unique case supports previous articles that have concluded that rib fractures rarely, if ever, result from CPR in pediatrics, even in children with a lethal underlying bone disease, such as osteogenesis imperfecta type II. cardiopulmonary resuscitation, chest compressions, osteogenesis imperfecta, rib fractures, bone disease.Notes: ProCite field[38]: 20526013

Case report of an infant with osteogenesis imperfecta who underwent CPR. No fractures observed. Interpreted by authors as indicating that rib fractures unlikely after CPR in children. Level 5 Fair.

Shemesh1 Reference Type: Journal ArticleRecord Number: 1345Author: Shemesh, E.; Dreznik, Z.; Shechter, P.; Wolfstein, I.Year: 1983Title: Rupture of stomach due to external cardiac resuscitationJournal: Israel Journal of Medical SciencesVolume: 19Issue: 9Pages: 853-4Date: SepAccession Number: 6643028Keywords: Screen

Case report of 65 year-old man with cardiac arrest, CPR complicated by gastric rupture. Patient had surgical repair then discharge. Level 5 Fair.

Shulman1 Reference Type: Journal ArticleRecord Number: 1171Author: Shulman, D.; Beilin, B.; Olshwang, D.Year: 1987Title: Pulmonary barotrauma during cardiopulmonary resuscitationJournal: ResuscitationVolume: 15Issue: 3Pages: 201-7Date: SepAccession Number: 2823358Keywords: ScreenAbstract: Two cases are presented of pulmonary barotrauma developing during cardiopulmonary resuscitation. This was attributed to high airway pressures developed during ventilation. One patient was ventilated with a self-inflating bag and the second with the Robertshaw demand valve. Both devices were used appropriately. Three other cases of pulmonary barotrauma during resuscitation have been recorded with the use of the latter device during CPR by ambulance personnel in Israel. The Robertshaw demand valve may generate excessively high airway pressures during normal use or when malfunctioning. For these reasons, the use of the Robertshaw demand valve has been discontinued in the Israeli Emergency Medical Services ambulances.



Case series of patients with pulmonary barotrauma after CPR, attributed to ventilation with high pressure. Level 5 Fair.

Smith1 Reference Type: Journal ArticleRecord Number: 1082Author: Smith, R. E.; Martin, J. E.; Mills, P. G.Year: 1989Title: Myocardial abscess and sternal osteomyelitis following myocardial infarction and resuscitationJournal: Postgraduate Medical JournalVolume: 65Issue: 766Pages: 589-90Date: AugAccession Number: 2602260Keywords: ScreenAbstract: A 58 year old man presented with an anterior myocardial infarction requiring repeated resuscitation. He had impaired glucose tolerance. He died five weeks later and post-mortem examination revealed a myocardial abscess and sternal osteomyelitis due to Staphylococcus aureus. These had not been apparent clinically. The possible aetiology and difficulties in diagnosis are discussed.

Case report of 58 year-old man with cardiac arrest after myocardial infarction, CPR. 5 weeks later, diagnosed as having myocardial abscess and sternal osteomyelitis, then died. Level 5 Fair.

Sokolove1 Reference Type: Journal ArticleRecord Number: 11658Author: Sokolove, P.E.; Willis-Shore, J.; Panacek, E.A.Year: 2002Title: Exsanguination due to right ventricular rupture during closed-chest cardiopulmonary resuscitationJournal: Journal of Emergency MedicineVolume: 23Issue: 2Pages: 161-164Alternate Journal: Journal of Emergency MedicineAccession Number: 2002416329Keywords: adultartery injuryarticleautopsyblood transfusionbradycardiacase reportclinical featureconsciousnessdefibrillationdisease courseelectrocardiogramemergency warderythrocyte concentratefemaleheart arrestheart infarctionheart rateheart ruptureheart ventricle tachycardiahemodynamic monitoringhemostasishumanlung auscultation



lung embolismlung injurypalpationpericardiumpriority journalpulse raterecurrent diseaseresuscitationrib fracturesinus rhythmsinus tachycardiasternumsurgical techniquesystolic blood pressurethoracotomythorax radiographytreatment failureAbstract: 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. (copyright) 2002 Elsevier Science Inc.Author Address: Sokolove, P.E., Division of Emergency Medicine, Univ. of California Davis Med. Ctr., PSSB 2100, Sacramento, CA 95817, United States

Case report of 61 year-old woman with cardiac arrest, CPR. Resuscitated initially then died. Post-mortem autopsy showed sternal fracture, pulmonary laceration and cardiac rupture. Level 5 Fair.

Sperry1 Reference Type: Journal ArticleRecord Number: 1066Author: Sperry, K.Year: 1990Title: Anterior thoracic wall trauma in elderly homicide victims. The "CPR defense"Journal: American Journal of Forensic Medicine & PathologyVolume: 11Issue: 1Pages: 50-5Date: MarAccession Number: 2305752Keywords: ScreenAbstract: During the course of medicolegal postmortem examinations, forensic pathologists often encounter the sequelae of cardiopulmonary resuscitation (CPR) that was administered by medical and paramedical personnel. A wide variety of CPR-related injuries have been described since the institution nearly 30 years ago of this now common-place emergency technique. The forensic pathologist must be aware of both typical and unusual CPR-related trauma patterns in order to differentiate between injury produced during emergency therapy procedures and injury sustained through other mechanisms (for example, during an assault or an accident). This article describes two recent separate and unrelated incidents in which an elderly woman was murdered. In each instance, bony injuries of the anterior thoracic wall structures were identified during the autopsy. Defense attorneys in each case attempted to use these injuries as proof that their accused clients had performed external cardiac massage on their victims, thus indicating that the homicides had not been intentional, and that the perpetrators showed remorse. These cases are presented, with a discussion of the typical features of CPR-related thoracic wall trauma as compared with willfully inflicted injury.

Case series (n=91) of infants < 1 year of age who died after CPR and underwent autopsy or post



mortem radiography. No rib fractures observed. Level 5 Fair.

Stallard1 Reference Type: Journal ArticleRecord Number: 11674Author: Stallard, N.; Findlay, G.; Smithies, M.Year: 1997Title: Splenic rupture following cardiopulmonary resuscitationJournal: ResuscitationVolume: 35Issue: 2Pages: 171-173Alternate Journal: ResuscitationAccession Number: 1997278645Keywords: agedarticlecase reportclinical featurefemaleheart arresthumanhypotensionpriority journalresuscitationspleen rupturesplenectomyadrenalinatropineAbstract: Cardiopulmonary resuscitation has improved outcome from cardiac arrest. However complications may occur secondary to the resuscitation efforts. We present a case of intraabdominal haemorrhage, due to traumatic rupture of the spleen and discuss the problems of diagnosing intraabdominal haemorrhage in the post cardiac arrest patient, whose hypotension may be ascribed to myocardial dysfunction.Author Address: Findlay, G., Dept. Anaesthesia Intensive Care, University Hospital of Wales, Cardiff, South Glamorgan CF4 4XW, United Kingdom

Case report of 66 year-old female with cardiac arrest, CPR complicated by splenic rupture. Patient had surgical repair then died. Level 5 Fair.

Strear1 Reference Type: Journal ArticleRecord Number: 555Author: Strear, C. M.; Jarnagin, W. R.; Schecter, W.; Mackersie, R. C.; Hickey, M. S.Year: 1998Title: Gastric rupture and tension pneumoperitoneum complicating cardiopulmonary resuscitation: case reportJournal: Journal of Trauma-Injury Infection & Critical CareVolume: 44Issue: 5Pages: 930-2Date: MayAccession Number: 9603105Keywords: Screen

Case report of 79 year-old female with cardiac arrest, CPR complicated by gastric rupture. Patient had surgical repair then discharged. Level 5 Fair.

Takada1 Reference Type: Journal ArticleRecord Number: 102Author: Takada, A.; Saito, K.; Kobayashi, M.Year: 2003Title: Cardiopulmonary resuscitation does not cause left ventricular rupture of the heart



with acute myocardial infarction: a pathological analysis of 77 autopsy casesJournal: Legal MedicineVolume: 5Issue: 1Pages: 27-33Date: MarAccession Number: 12935647Keywords: ScreenAbstract: Cardiac rupture during acute myocardial infarction (AMI) is one of the most frequent causes of sudden cardiac death. However, some reports have indicated the possibility that the cardiac rupture during AMI may occur by external cardiac massage. We pathologically examined the hearts of 77 patients who died suddenly due to ventricular free wall rupture during AMI (51 men and 26 women; aged 47-94 years; mean age: 69.9 years). We divided the cases into two groups, 44 cases with and 33 cases without cardiopulmonary resuscitation (CPR), and compared the two groups with respect to 12 pathological items. There were no statistical differences in any of the investigated items between the two groups (P>0.05). In addition, mural thrombi were identified along the rupture tract in all cases. Moreover, they were more matured at the subendocardial zone than at the subepicardial or middle zone, irrespective of the groups. From the pathological findings, we concluded that the rupture of the left ventricle during AMI originates from the subendocardial region and precedes the external cardiac massage. Our present study strongly suggests that CPR does not cause the left ventricular rupture of the heart during AMI.

Case-control study of patients with ventricular wall rupture after myocardial infarction with (n=44) and without (n=33) CPR. Unable to ascertain denominator (i.e. number of patients with myocardial infarction. Mural thrombi identified along rupture tract in all cases. Interpreted as demonstrating that rupture preceded CPR. Level 5 Fair.

Tenaglia1 Reference Type: Journal ArticleRecord Number: 8880Author: Tenaglia, A. N.; Califf, R. M.; Candela, R. J.; Kereiakes, D. J.; Berrios, E.; Young, S. Y.; Stack, R. S.; Topol, E. J.Year: 1991Title: Thrombolytic therapy in patients requiring cardiopulmonary resuscitationJournal: Am J CardiolVolume: 68Issue: 10Pages: 1015-9.Label: 92025884Keywords: Aged*Cardiopulmonary Resuscitation/adverse effectsElectric CountershockFemaleHumanMaleMiddle AgeMyocardial Infarction/*drug therapy/mortality/physiopathologyRecurrenceSupport, Non-U.S. Gov'tSupport, U.S. Gov't, P.H.S.*Thrombolytic Therapy/adverse effects/contraindicationsAbstract: Cardiopulmonary resuscitation (CPR) is often considered a contraindication to thrombolytic therapy for acute myocardial infarction. Of 708 patients involved in the first 3 Thrombolysis and Angioplasty in Myocardial Infarction trials of lytic therapy for acute infarction, 59 patients required less than 10 minutes of CPR before receiving lytic therapy (CPR greater than 10 minutes was an exclusion of the trials) or required CPR within 6 hours of treatment. The patients receiving CPR were similar to the remainder of the group with respect to baseline demographics. The indication for CPR was usually ventricular fibrillation (73%) or ventricular tachycardia (24%). The median duration of CPR was 1



minute, with twenty-fifth and seventy-fifth percentiles of 1 and 5 minutes, respectively. The median number of cardioversions/defibrillations performed was 2 (twenty-fifth and seventy-fifth percentiles of 1 and 3 minutes, respectively). Patients receiving CPR were more likely to have anterior infarctions (66 vs 39%), the left anterior descending artery as the infarct-related artery (63 vs 38%) and lower ejection fractions on the initial ventriculogram (46 +/- 11 vs 52 +/- 12%) than those not receiving CPR. In-hospital mortality was 12 vs 6% with most deaths due to pump failure (57%) or arrhythmia (29%) in the CPR group and pump failure (38%) or reinfarction (25%) in the non-CPR group. At 7 day follow-up the CPR group had a significant increase in ejection fraction (+5 +/- 9%) compared with no change in non-CPR group. There were no bleeding complications directly attributed to CPR.(ABSTRACT TRUNCATED AT 250 WORDS)

Case-control study of patients enrolled in TIMI trials of thrombolytic therapy who (n=59) required < 10 mins. CPR before or within 6 hours of treatment; (n=22) prolonged CPR, or no CPR (n=649). CPR >= 10 mins. was an exclusion criterion in TIMI trials. Mortality was 7 (6%), and 40 (6%) (p=NS). Level 5 Fair.

Thompson1 Reference Type: Journal ArticleRecord Number: 2145Author: Thompson, R. G.; Cobb, L. A.Year: 1982Title: Hypokalemia after resuscitation from out-of-hospital ventricular fibrillationJournal: JamaVolume: 248Issue: 21Pages: 2860-3Date: Dec 3Accession Number: 7143648Keywords: Bicarbonates/therapeutic useComparative StudyCoronary Disease/bloodDiuretics/therapeutic useHeart Arrest/therapyHumanHypokalemia/*etiologyMyocardial Infarction/bloodPotassium/blood/metabolismRespiration, Artificial*ResuscitationVentricular Fibrillation/*therapyAbstract: We studied serum electrolyte levels, blood gas values, and diuretic history in 115 patients immediately after resuscitation from out-of-hospital ventricular fibrillation. Comparisons were made with 84 patients admitted for acute myocardial infarction and with 88 ambulatory patients with coronary heart disease. Admission serum potassium values of 3.60 mEq/L or lower were found in 56 (49%) of the resuscitated patients, compared with 16 (19%) and eight (9%) of the comparison groups, respectively. In the resuscitated patients, the mean serum potassium level was 3.70 +/- 0.72 (SD) mEq/L, compared with 4.09 +/- 0.66 and 4.17 +/- 0.35 mEq/L in the respective comparison groups. Reduced serum potassium concentration was not related to simple extracellular alkalosis. However, the absence of a causative relationship to diuretic use suggested that it occurred during cardiac arrest and resuscitation. Rapid correction of extracellular acidosis by bicarbonate therapy and ventilation may have produced a shift of extracellular potassium into the intracellular compartment even in the absence of extracellular alkalosis.Notes: 0098-7484Journal ArticleURL: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=7143648



Hypokalemia observed after resuscitation, associated with bicarbonate therapy independent of pH and with elevated catecholamines of endogenous or exogenous cause, or overventilation. Level 5 Fair.

Van Hoeyweghen1 Reference Type: Journal ArticleRecord Number: 883Author: Van Hoeyweghen, R. J.; Bossaert, L. L.; Mullie, A.; Calle, P.; Martens, P.; Buylaert, W. A.; Delooz, H.Year: 1993Title: Quality and efficiency of bystander CPR. Belgian Cerebral Resuscitation Study GroupJournal: ResuscitationVolume: 26Issue: 1Pages: 47-52Date: AugAccession Number: 8210731Keywords: ScreenAbstract: Incorrectly performed bystander CPR might compromise survival of the cardiac arrest patient. We therefore evaluated the outcome in 3306 out-of-hospital primary cardiac arrests of which 885 received bystander CPR. bystanders performed CPR correctly in 52%, incorrectly in 11%, 31% performed only external chest compressions (ECC) and 6% only mouth-to-mouth ventilation (MMV). The initial ECG in cases without bystander CPR was ventricular fibrillation in 28% (95% confidence interval: 27-30%); 45% (41-50%) and 39% (29-48%), respectively when bystander CPR was performed correctly or incorrectly; 43% (37-49%) when only ECC was applied and 22% (11-33%) when only MMV was practiced. Long term survival, defined as being awake 14 days after CPR, was 16% (13-19%) in patients with correct bystander CPR; 10% (7-14%) and 2% (0-9%), respectively when only ECC or only MMV was performed; 7% (6-8%) when no bystander was involved; 4% (0-8%) when bystander CPR was performed incorrectly. Bystander CPR might have a beneficial effect on survival by maintaining the heart in ventricular fibrillation by ECC. A negative effect of badly performed bystander CPR was not observed compared to cases which had not received bystander CPR.

Cohort study (n=3306) of out of hospital cardiac arrest. No adverse effects reported. Level 5 Fair.

Vinen1 Reference Type: Journal ArticleRecord Number: 1227Author: Vinen, J. D.; Gaudry, P. L.Year: 1986Title: Pneumoperitoneum complicating cardiopulmonary resuscitationJournal: Anaesthesia & Intensive CareVolume: 14Issue: 2Pages: 193-6Date: MayAccession Number: 3740392Keywords: Screen

71 year-old women who arrested after anaphylactoid reaction. Difficulty with intubation. CPR performed. Pneumoperitoneum due to gastric rupture. Surgical repair followed by discharge. Level 5 Fair.

Wagner1 Reference Type: Journal ArticleRecord Number: 786Author: Wagner, R. B.Year: 1995Title: Massive hemothorax secondary to foreign body and CPRJournal: Annals of Thoracic SurgeryVolume: 59Issue: 5



Pages: 1241-2Date: MayAccession Number: 7733738Keywords: Screen

Patient swallowed a needle then complained of chest pain. Had cardiopulmonary arrest requiring CPR. Hemothorax noted afterwards. At surgery, needle embedded in sternum with pericardial hole. Level 5 Fair.

Walley1 Reference Type: Journal ArticleRecord Number: 1013Author: Walley, V. M.; Guindi, M. M.; Stinson, W. A.Year: 1991Title: Regurgitation of fat and marrow emboli into coronary veins during resuscitationJournal: Archives of Pathology & Laboratory MedicineVolume: 115Issue: 1Pages: 65-7Date: JanAccession Number: 1987916Keywords: ScreenAbstract: Three groups of patients were examined at autopsy for the presence of fat and marrow emboli in the lungs, heart, and other organs. Group 1 was composed of patients with massive pulmonary thromboembolism and attempted cardiopulmonary resuscitation; group 2, patients with pulmonary thromboembolism and without attempted cardiopulmonary resuscitation; and group 3, patients without pulmonary thromboembolism and with attempted cardiopulmonary resuscitation. The results confirm that pulmonary fat and marrow emboli are frequent in those patients who are resuscitated. A novel observation is the finding of multiple coexistent cardiac venous emboli in those resuscitated patients who have pulmonary artery obstruction with pulmonary thromboemboli. These findings suggest that these emboli regurgitate from the right side of the heart to the coronary sinus and cardiac veins in cases of pulmonary artery hypertension.

Case control study of patients with PE and CPR (n=12); PE but no CPR (n=8); no PE but CPR (n=13). 10/12, 1/8 and 5/13 had pulmonary artery emboli or marrow emboli (p=0.05 calculated from data); 5/13, 1/12 and 0/13 had cardiac vein emboli (p=0.05 calculated from data). Level 5 Fair.

Windecker1 Reference Type: Journal ArticleRecord Number: 833Author: Windecker, S. ; Maier, W. ; Eberli, F. R. ; Meier, B. ; Hess, O. M.Year: 2000Title: Mechanical compression of coronary artery stents: potential hazard for patients undergoing cardiopulmonary resuscitation.Journal: Catheter Cardiovasc IntervVolume: 51Issue: 4Pages: 464-467Date: 2000 DecLabel: 48490Keywords: 20001207 11:00Abstract: Mechanical compression of coronary artery stents may be associated with a fatal outcome as the result of refractory myocardial ischemia. We present the history of an 83-yr-old patient, who died owing to hemorrhagic shock 3 days after stent implantation, despite immediate cardiopulmonary resuscitation (CPR). Postmortem examination showed stent compression, probably due to mechanical deformation during CPR. This complication has been reported in two other cases in the literature, suggesting that CPR



may be hazardous to patients with coronary artery stents. Cathet. Cardiovasc. Intervent. 51:464-467, 2000. Copyright 2000 Wiley-Liss, Inc.Notes: ProCite field[38]: 20561116

83 year-old patient who underwent intracoronary stent insertion then had cardiopulmonary arrest and died three days later. Autopsy showed stent compression, attributed to mechanical compression during CPR. Level 5 Fair.

Wolcke1 Reference Type: Journal ArticleRecord Number: 107Author: Wolcke, B. B.; Mauer, D. K.; Schoefmann, M. F.; Teichmann, H.; Provo, T. A.; Lindner, K. H.; Dick, W. F.; Aeppli, D.; Lurie, K. G.Year: 2003Title: Comparison of standard cardiopulmonary resuscitation versus the combination of active compression-decompression cardiopulmonary resuscitation and an inspiratory impedance threshold device for out-of-hospital cardiac arrest.[see comment]Journal: CirculationVolume: 108Issue: 18Pages: 2201-5Date: Nov 4Accession Number: 14568898Keywords: DupAbstract: BACKGROUND: Active compression-decompression (ACD) CPR combined with an inspiratory impedance threshold device (ITD) improves vital organ blood flow during cardiac arrest. This study compared survival rates with ACD+ITD CPR versus standard manual CPR (S-CPR). METHODS AND RESULTS: A prospective, controlled trial was performed in Mainz, Germany, in which a 2-tiered emergency response included early defibrillation. Patients with out-of-hospital arrest of presumed cardiac pathogenesis were sequentially randomized to ACD+ITD CPR or S-CPR by the advanced life support team after intubation. Rescuers learned which method of CPR to use at the start of each work shift. The primary end point was 1-hour survival after a witnessed arrest. With ACD+ITD CPR (n=103), return of spontaneous circulation and 1- and 24-hour survival rates were 55%, 51%, and 37% versus 37%, 32%, and 22% with S-CPR (n=107) (P=0.016, 0.006, and 0.033, respectively). One- and 24-hour survival rates in witnessed arrests were 55% and 41% with ACD+ITD CPR versus 33% and 23% in control subjects (P=0.011 and 0.019), respectively. One- and 24-hour survival rates in patients with a witnessed arrest in ventricular fibrillation were 68% and 58% after ACD+ITD CPR versus 27% and 23% after S-CPR (P=0.002 and 0.009), respectively. Patients randomized > or =10 minutes after the call for help to the ACD+ITD CPR had a 3 times higher 1-hour survival rate than control subjects (P=0.002). Hospital discharge rates were 18% after ACD+ITD CPR versus 13% in control subjects (P=0.41). In witnessed arrests, overall neurological function trended higher with ACD+ITD CPR versus control subjects (P=0.07). CONCLUSIONS: Compared with S-CPR, ACD+ITD CPR significantly improved short-term survival rates for patients with out-of-hospital cardiac arrest. Additional studies are needed to evaluate potential long-term benefits of ACD+ITD CPR.

Randomized trial of standard CPR vs. ACD+ITD CPR. Of 107 who received standard CPR, 14 (13%) had rib fractures, 2 (2%) had ecchymosis, 0 (0% had pulmonary edema, 8 (7%) vomited during CPR. Level 5 Fair.

Wong1 Reference Type: Journal ArticleRecord Number: 12803Author: Wong, S.S.; Lazarus, J.H.; Weston, C.F.M.Year: 1991Title: Extensive subcutaneous bleeding after cardiopulmonary resuscitation and thrombolytic therapyJournal: Archives of Emergency MedicineVolume: 8Issue: 2Pages: 140-143



Alternate Journal: Archives of Emergency MedicineAccession Number: 1991207896Keywords: acute heart infarctionadultarticlebleedingcase reportdrug contraindicationfemalehumanintravenous drug administrationoral drug administrationresuscitationskin blood flowsubcutaneous drug administrationacetylsalicylic acidanistreplasefibrinolytic agentheparinAbstract: A patient with acute myocardial infarction, complicated by pre-hospital cardiac arrest, was treated with anistreplase, heparin and aspirin following resuscitation She developed a large lower lip haematoma and extensive bruising over the chest wall ten hours after thrombolytic therapy. A blood transfusion was required.

Case report of s 59 year-old with acute myocardial infarction with prehospital cardiac arrest and intubation, and subsequent thrombolytic, heparin and aspirin. She developed large lip hematoma and extensive bruising over chest. Transfusion required but life discharge. Level 5 Fair.

Woods1 Reference Type: Journal ArticleRecord Number: 1212Author: Woods, S. D.; Hutchinson, G.; Johnson, W. R.; Masterton, J. P.Year: 1986Title: Gastric rupture following cardiopulmonary resuscitationJournal: Australian & New Zealand Journal of SurgeryVolume: 56Issue: 9Pages: 733-5Date: SepAccession Number: 3467706Keywords: ScreenAbstract: Three cases are reported in which gastric rupture occurred during cardiopulmonary resuscitation. Precipitating factors are considered and discussed with reference to the literature. This condition has been considered to be rare. Its occurrence greatly adds to the morbidity and mortality of the underlying disease. Possible precautions to limit its occurrence are discussed.

Case series (n=3) of gastric rupture after CPR. Operated (n=3) and live discharge (n=2). Level 5 Fair.

Yamaki1 Reference Type: Journal ArticleRecord Number: 1113Author: Yamaki, T.; Ando, S.; Ohta, K.; Kubota, T.; Kawasaki, K.; Hirama, M.Year: 1989Title: CT demonstration of massive cerebral air embolism from pulmonary barotrauma due to cardiopulmonary resuscitationJournal: Journal of Computer Assisted TomographyVolume: 13Issue: 2Pages: 313-5Date: Mar-AprAccession Number: 2925920



Keywords: ScreenAbstract: A 77-year-old man with loss of consciousness, circulatory collapse, and apnea caused by myocardial infarction underwent cardiopulmonary resuscitation with intratracheal intubation and manual bag ventilation. Computed tomography of the head demonstrated massive air embolism in the entire cerebral circulation. The patient was diagnosed as brain dead the next day. Demonstration of massive cerebral air embolism on head CT is presented.

Case report of 77 year-old with massive air embolus after CPR. Patient died. Level 5 Fair.

Zuzarte1 Reference Type: Journal ArticleRecord Number: 1031Author: Zuzarte, J.; Chung-Park, M.; Bahler, R.; Cohen, A. M.Year: 1990Title: Bilateral intrapulmonary hematomasJournal: American Review of Respiratory DiseaseVolume: 142Issue: 6 Pt 1Pages: 1449-52Date: DecAccession Number: 2252266Keywords: ScreenAbstract: A 67-yr-old man, known to have chronic obstructive lung disease, developed bilateral localized pulmonary densities on chest radiographs after cardiopulmonary resuscitation. An autopsy disclosed bilateral intrapulmonary hematomas without communication with bronchi, pulmonary arteries, or pleural cavities. We suggest blunt pulmonary injury is the most probable cause of the hematomas and discuss its pathogenic mechanism. Intrapulmonary hematomas should be considered in the differential diagnosis of pulmonary densities developing after a vigorous resuscitation.

Case report of a 67 year-old man with bilateral localized pulmonary densities on chest radiography after CPR. Post-mortem autopsy showed bilateral intrapulmonary hematomas. Level 5 Fair.

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