SESSION TITLE: Miscellaneous Student/Resident Case Report Posters I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Cardiopulmonary resuscitation (CPR) can be associated with rib or sternal fractures, pneumothorax, heart contusion or small, localized hematoma. However, it is extremely rare to develop a huge chest wall hematoma requiring massive blood transfusion as a consequence of CPR. 3months later, the hematoma was complicated with a large abscess requiring incision and drainage.
CASE PRESENTATION: A 55-year-old male with history of type 2 diabetes, pulmonary embolism status post inferior vena cava filter and anoxic brain injury after cardiac arrests in 2007 and 2012, was admitted for sepsis secondary to urinary tract infection. On day 6, patient went into respiratory distress and asystole so CPR was initiated by hospital staff. Therapeutic dose of enoxaparin was started for possible pulmonary embolism. After 72hours, patient became hypotensive; not responding to several fluid boluses. Hemoglobin dropped from 8.9 to 4.4g/dL in 24hours. There was no evidence of occult/overt blood in stool and urine.Later, he was noted to have a large bruise on left lateral chest.(Fig.1) CT chest revealed a large left-sided chest wall hematoma in evolution and multiple minimally-displaced rib fractures from 4th-8th ribs (Fig. 2 circle). A total of 13units of blood were transfused over the next 3days. Repeat CT chest 4days after the episode showed an isolated left chest wall hematoma, measuring 17x19x12cm in dimensions.(Fig.2 arrow) Cardiothoracic surgery recommended evacuation of the hematoma but patient declined it. He was discharged home after 20days of hospitalization. 3months later, patient was readmitted with left chest wall abscess and cellulitis. 750ml of frank pus was drained, and fibrinous clotted material was evacuated. He was also treated with appropriate antibiotics.
DISCUSSION: Skeletal chest injuries after CPR are not uncommon complications. Chest X-rays have low detection rate for rib or sternal fractures after CPR compared to CT chest. Major bleeding risk increases with anticoagulation. It is important to find the possible source of bleeding in a patient with profound hypotension after CPR. In our case, morbid obesity obscures early recognition of the huge chest wall hematoma.Although the hematoma can be reabsorbed by itself, an early evacuation may be considered to prevent secondary infection.
CONCLUSIONS: Large chest wall hematoma developed after CPR can lead to hemorrhagic shock. The hematoma, unless evacuated, may be complicated with a secondary infection.
Reference #1: Kim EY, et al. “Multidetector CT findings of skeletal chest injuries secondary to cardiopulmonary resuscitation”. Resuscitation 2011 Oct;82(10):1285-8.doi:10.1016/j.resuscitation.2011.05.023.Epub 2011 Jun 12.
Reference #2: Black CJ, et al. “Chest wall injuries following cardiopulmonary resuscitations.” Resuscitation.2004 Dec;63(3):339-43
Reference #3: I. Kurkciyan, et al. “Major bleeding complications after cardiopulmonary resuscitation: impact of thrombolytic treatment.” Journal of Internal Medicine 2003;253:128-135
DISCLOSURE: The following authors have nothing to disclose: Nang Kham, Viral Doshi, Joseph Henkle
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