Gastric rupture during cardiopulmonary resuscitation

Abstract

Key wordsCARDIOPIJLMONARY RESUSCITATION: complication, endotracheal intubation, mouth-to-mouth ventilation.Effective management of the cardiopulmonary arrest victim includes adequate control of the airway and delivery of oxygen. Techniques employed range from head and neck extension with mouth-to-mouth ventilation to advanced techniques such as endotracheal intubation in association with gas powered oxygen delivery devices, a Gastric rupture and pneumoperitoneum associated with these manoeuvres is a rare occurrence. During the past three years, we have seen two cases of gastric rupture during cardiopulmonary resuscitation. In two other cases the clinical presentation was highly suggestive of gastric rupture although confirmation of this complication was lacking.From the Department of Anaesthesia, University of Manitoba, Winnipeg, Manitoba.Address correspondence to: Nell Donen rio, Department of Anesthesia, St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6. Case reports Case 1A 75-year-old woman presented to the emergency department with symptoms and signs of an acute brain stem stroke. While awaiting transfer to the ward the patient suffered a cardiopulmonary arrest. Resuscitative measures were instituted. Airway management involved immediate attempts at endotracheal intubation. Initially, the oesophagus was intubated and the patient manually ventilated with a bag-valve unit (resuscitation bag) for approximately 15 seconds. The second attempt at tracheal intubation was successful. During the resuscitation it was noted that the patient's abdomen had become grossly distended and tympanitic. Following reestablishment of a stable cardiac rhythm, reexamination of the abdomen confirmed these findings. Chest x-ray revealed air under both diaphragms (Figure 1). A subsequent abdominal x-ray confirmed the massive pneumoperitoneum.The etiology of the abdominal distention was uncertain. An exploratory ]aparotomy was postponed because of the severe brain stem lesion. The patient expired 24 hours later. Autopsy findings confirmed the recent mid-brain infarction. Examination of the stomach revealed a full thickness tear on the lesser curvature, close to the cardia. Case 2A 78-year-old woman sustained an in-hospital cardiopulmonary arrest. Resuscitative measures were instituted. Initial airway management ineluded mouth-to-mouth ventilation, insertion of an oral airway and manual ventilation with a hag-valve unit and mask. Attempts at endotracheal intubation resulted in intubation of the oesophagus and the patient was manually ventilated for a short period of time before the error was noted and the trachea CAN ANAESTH SOC J 19S4 1 3l: 3 / pp319-322

CT scan findings in oesophagogastric perforation after out of hospital cardiopulmonary resuscitation

“…The normal site of rupture in this situation is along the lesser curvature of the stomach. This area has fewer mucosal folds, is less elastic and is fixed by the hepatogastric ligament 4. In our patient, the multiple small gas bubbles detectable in the region of the oesophagogastric junction (fig 1) and the pneumoperitoneum (fig 2) suggest, however, a rupture at this junction.…”

Gastric mucosal tears and wall micro perforations after cardiopulmonary resuscitation in a drowning case

“…12 According to different Authors, the lesions reported by Rabl et al have the same location we describe: after external cardiac massage for events different from drowning, the gastric injuries may locate at the cardias and lesser curve of the stomach too. [2][3][4][5][6][7][8][9][10][11][12] The location of the lesions we describe suggests also a combined effect by gastric water filling and external cardiac massage forces.…”

“…[1][2][3][4] Initial emergency external cardiac massage procedures in drowning subjects could also increase gastric pressure, causing gastric lesions or ruptures. [5][6][7][8][9] We report a case of gastric mucosal tears and wall micro perforations due to cardiopulmonary resuscitation in a woman after drowning in a swimming pool and examine medico-legal implications.…”

Gastric Perforation Secondary to Bag-Valve Mask Ventilation Following Opioid Overdose

“…As stated previously, the lesser curvature should be closely examined and if still unclear peritoneal lavage with inspection for bubbling can identify the site. 3 Upper endoscopy can also assist with localization of the injury as it did in this case. With many of these injuries occurring after CPR, immediate operative management may have prohibitive risks.…”