Splenic trauma complicating cardiopulmonary resuscitationBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7284.480 (Published 24 February 2001) Cite this as: BMJ 2001;322:480
- A Fitchet, specialist registrar in cardiology ()a,
- R Neal, specialist registrar in elderly medicineb,
- P Bannister, consultant physicianc
- a Manchester Heart Centre, Manchester Royal Infirmary, Manchester M13 9WL
- b Blackburn Royal Infirmary, Bolton Road, Blackburn BB2 3LR
- c Department of Medicine, Manchester Royal Infirmary
- Correspondence to: A Fitchet
- Accepted 17 July 2000
Cardiopulmonary resuscitation can result in trauma to abdominal organs. We report two cases of splenic rupture causing life threatening haemorrhage.
Unexplained hypotension after cardiopulmonary resuscitation might be due to intra-abdominal trauma and concealed haemorrhage
Case 1—A 64 year old woman who had undergone coronary artery bypass grafting 10 years previously had a cardiorespiratory arrest at a railway station late one night. Cardiopulmonary resuscitation was started immediately by bystanders and continued for 20 minutes until paramedics arrived. Ventricular fibrillation was confirmed, and she was externally defibrillated. On arrival at hospital she was alert and breathing spontaneously but hypotensive with a blood pressure of 80/40 mm Hg and a sinus tachycardia of 100 beats/min. Clinical examination suggested hypovolaemia with lowered central venous pulse pressure, normal heart sounds, and clear breath sounds. Electrocardiography confirmed an acute inferior myocardial infarction. Thrombolysis was not given because of prolonged resuscitation. She clinically improved on challenge with intravenous fluid. The central venous pulse became visible and her blood pressure rose to 120/70 mm Hg. Over the next hour progressive hypotension recurred, once again with clinical evidence of hypovolaemia. Blood pressure was restored with further intravenous fluid. An echocardiogram excluded major pericardial effusion, showing a non-dilated left ventricle with inferior wall akinesia and overall moderate function. At this stage the patient complained of left sided abdominal pain, with tenderness elicited over the left hypochondrium. Chest x ray films taken in the erect position showed no evidence of rib fractures or subdiaphragmatic gas. Ultrasonography showed free fluid in the abdominal cavity, and aspiration of this fluid confirmed blood. Computed tomography of the abdomen showed a tear in the upper pole of the spleen (figure). At emergency laparotomy 2 litres of free blood were found, and the ruptured but histologically normal spleen was removed. She made a full recovery after a prolonged postoperative course, and she was discharged from hospital six weeks later.
Case 2—A 50 year old man attended the casualty department with general malaise. Examination revealed lower limb cellulitis. He had a fever at 37.9°C, and his blood pressure was 114/70 mm Hg and heart rate 120 beats/min. Initial investigations showed a haemoglobin concentration of 36 g/l (normal range 130-180) (mean corpuscular volume 96 fl (80-97)), white cell count of 2×109/l (4-11), and platelet count of l34×109/l (150-400); a bone marrow aspirate later confirmed megaloblastic anaemia. Intravenous piperacillin and gentamicin were started. Soon after this he developed bradycardia followed by a cardiorespiratory arrest requiring two brief episodes of cardiopulmonary resuscitation and insertion of a temporary pacing wire. He was transferred to the intensive care unit and was transfused 12 units of blood over the next 48 hours. He was given folate and vitamin B-12 supplementation. Blood cultures taken before insertion of the pacing wire confirmed Staphylococcus aureus septicaemia. Haemoglobin concentration increased to 90 g/l with transfusion over 48 hours and then decreased to 66 g/l over the next 24 hours. Ultrasonography and computed tomography of the abdomen showed free fluid in the peritoneum (aspiration revealed this to be blood), but neither showed a definite bleeding site. An emergency laparotomy was performed revealing 6 litres of free blood and a tear in the posterior aspect of the spleen. The enlarged but histologically normal spleen was removed. No further bradycardic episodes occurred once the patient's condition improved and the temporary pacing wire was removed. He was discharged from hospital six weeks later.
The effectiveness of external cardiac massage in maintaining a cardiac output was first described by Kouwenhoven et al in 1960.1 External cardiac massage combined with artificial ventilation and early defibrillation are the only interventions proved to improve outcome after cardiac arrest.2 External cardiac massage is not, however, without complications. These range from the common such as rib fractures to the more unusual such as pneumoscrotum. 3 4 Intra-abdominal injuries include gastric rupture and solid organ disruption. Hepatic lacerations have been reported in 3% of patients after cardiopulmonary resuscitation and can result in massive haemorrhage, particularly after thrombolysis.5 Splenic laceration is less common, being described in 0.3% of a series of 705 patients at post mortem examination,6 and only a handful of splenic injuries resulting in clinically important haemorrhage have been reported. Vitello et al described a case of splenic laceration in a 75 year old man who received two brief episodes of cardiopulmonary resuscitation after a cardiac arrest out of hospital.7 Bernard et al reported a case of splenic haematoma and caecal infarction in a 59 year old woman after prolonged cardiopulmonary resuscitation out of hospital.8 Both patients underwent splenectomy and made full recoveries. Stallard et al reported acute splenic rupture in a 66 year old woman who had received cardiopulmonary resuscitation for 10 minutes out of hospital after massive pulmonary embolism.9 She died despite emergency laparotomy and splenectomy.
External cardiac massage is essentially a form of blunt trauma. It is therefore theoretically possible to cause any of several thoracoabdominal injuries either through direct compression or, in the case of abdominal injuries, as a result of transmitted forces through the diaphragm to the abdominal viscera. Incorrect placement of the hands is more likely to cause rib fractures, and if the hands are placed too low over the xiphisternum this may increase the risk of injury to the abdominal organs.7 Ischaemia secondary to reduced cardiac output may contribute to the risk of visceral damage.9 Pathologically abnormal or enlarged spleens may be more liable to injury.7
Early diagnosis of occult intra-abdominal bleeding may be difficult in a patient soon after an acute cardiac event complicated by cardiac arrest, when hypotension will likely to be attributed to cardiogenic shock. Also reduced consciousness owing to the effects of cerebral hypoxia or opioid analgesics may prevent reporting of abdominal pain. In the first patient we were alerted to the possibility of hypovolaemia by careful clinical examination, repeated clinical response to challenge with intravenous fluid, and satisfactory left ventricular function on echocardiography. In cases of suspected intra-abdominal injury chest x ray films taken in the erect position may reveal subdiaphragmatic air. Early ultrasonography should be performed to detect free intra-abdominal fluid, which if detected may be aspirated under ultrasound guidance to confirm bleeding. The site of bleeding may then be sought either by computed tomography or, if the patient's condition is sufficiently unstable, by immediate laparotomy.
Occult intra-abdominal injury should be considered in any patient who develops hypotension after cardiopulmonary resuscitation, particularly if features of recurrent hypovolaemia are present.
We thank Dr RW Whitehouse, consultant radiologist, Manchester Royal Infirmary, for his interpretation of the radiological investigations and help with the selection of the image for this paper.
Contributors: AF was involved in the diagnosis and management of case 1, was the main author, and is the guarantor. RN was involved in the diagnosis and management of case 1 and writing the manuscript. PB was the consultant in charge of both cases and was involved in revising the manuscript.
Funding Department of Medicine, Manchester Royal Infirmary.
Competing interests None declared.