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 Table of Contents  
CASE SNIPPET
Year : 2015  |  Volume : 1  |  Issue : 1  |  Page : 29-31

Isolated acute traumatic aortic injury following cardiopulmonary resuscitation with excessively forceful chest compressions


1 Department of Family Medicine, St. Luke's University Hospital Network, Bethlehem, Pennsylvania, USA
2 Department of Radiology, St. Luke's University Hospital Network, Bethlehem, Pennsylvania, USA
3 Department of Cardiology, St. Luke's University Hospital Network, Bethlehem, Pennsylvania, USA

Date of Submission20-Sep-2015
Date of Acceptance19-Oct-2015
Date of Web Publication29-Dec-2015

Correspondence Address:
Sudip Nanda
Department of Cardiology, St. Luke's University Hospital Network, 801 Ostrum Street, Bethlehem, Pennsylvania
USA
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Source of Support: None, Conflict of Interest: None


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  Abstract 

We report a rare cause of isolated acute traumatic aortic injury in a 58-year-old woman with a body mass index (BMI) of 19.4, following cardiopulmonary resuscitation (CPR). Our case is unique in that CPR was performed by a single CPR provider, no significant trauma occurred with the preceding syncope, and aortic injury occurred in isolation without fractures or other traumatic injury. Healthcare providers need to be aware that although chest compression of at least 2 inches depth is needed for effective CPR, the force required to achieve this compression is much less in an individual with a BMI of around 20 as opposed to a BMI of 40. Excessive chest compression can lead to acute traumatic aortic injury. We review appropriate resuscitation and chest compression depth, CPR associated injuries including aortic injuries and mechanisms of acute traumatic aortic injury.
The following core competencies are addressed in this article: Patient care and medical knowledge.

Keywords: Acute traumatic aortic injury, cardiopulmonary resuscitation-associated injuries, cardiopulmonary resuscitation-associated aortic injuries, osseous pinch, water-hammer effect


How to cite this article:
Fegley MW, Redstone EA, Singh A, Agrawal S, Shirani J, Nanda S. Isolated acute traumatic aortic injury following cardiopulmonary resuscitation with excessively forceful chest compressions. Int J Acad Med 2015;1:29-31

How to cite this URL:
Fegley MW, Redstone EA, Singh A, Agrawal S, Shirani J, Nanda S. Isolated acute traumatic aortic injury following cardiopulmonary resuscitation with excessively forceful chest compressions. Int J Acad Med [serial online] 2015 [cited 2019 Aug 21];1:29-31. Available from: http://www.ijam-web.org/text.asp?2015/1/1/29/172701


  Introduction Top


We report the first known case of isolated acute traumatic aortic injury following cardiopulmonary resuscitation (CPR) in a 58-year-old female. Review of literature reveals two cases of aortic injury in the setting of CPR. However, these two cases occurred in the setting of significant trauma preceding CPR, multiple CPR providers, and multiple bony injuries including fractures. We propose acute traumatic aortic injury occurred via the osseous pinch and water-hammer effect because of chest compression of excessive force. CPR providers need to be aware that chest compression of excessive force, especially in individuals with low body mass index (BMI), can cause isolated acute traumatic aortic injury.


  Case Report Top


A 58-year-old woman had syncope at home and fell. Her husband is a police officer by profession, trained in emergency medical services, found her pulseless and started CPR. Resuscitation was successful, and patient arrived to hospital service conscious. She has a known history of pulmonary embolism and was on warfarin. Her Crohn's disease had a recent flare-up with persistent diarrhea for the preceding days. She was hypokalemic with potassium of 2.8 mEq/L and her QTc was 528 ms.

Workup included spiral computed tomography (CT) and CT angiography which demonstrated new proximal descending aortic [Figure 1]a,[Figure 1]c, and [Figure 1]e, white arrows] and aortic root [Figure 1]b and [Figure 1]d, white arrows] mural injuries compared to prior CT 2 years ago. She most likely had polymorphic ventricular tachycardia/fibrillation precipitated in the setting of an acquired long QT induced by hypokalemia. She was treated conservatively, hypokalemia corrected which normalized her QTc, and was safely discharged without surgical intervention. Follow-up CT scan 6 months later demonstrated resolution of aortic injuries [Figure 1]f.
Figure 1: (a and b) Transverse computed tomography arteriogram images following aortic injury. (a) Mural injury highlighted by white arrow which was likely caused by aortic compression and torsion, spine highlighted by black arrow. (b) Mural injury to aortic root. (c and d) Coronal computed tomography arteriogram images following aortic injury. (c) Descending aortic injury highlighted by white arrow and proximity of spine, black arrow. (d) Aortic root injury highlighted by white arrow. (e) Axial, candy-cane, computed tomography arteriogram images following aortic injury. (e) Descending aortic injury highlighted by white arrow, likely caused by the water-hammer effect given the retrograde aortic root injury. (f) Axial, candy-cane, computed tomography arteriogram images at 6 months following aortic injury. (f) Resolution of aortic injuries. Black arrow indicates location of ligamentum arteriosum

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  Discussion Top


The most recent American Heart Association CPR and emergency cardiovascular care guidelines from 2010, state proper resuscitation technique on an adult is chest compression to a depth of at least 2 inches at a rate of at least 100 compressions/min.[1] The 2010 guidelines represent a change from previous guidelines recommending a compression depth of 1.5–2 inches. The most recent guidelines do not recommend an upper limit of chest compression depth.

Chest compressions are known to cause a variety of complications including those related to the ribs, thoracic and abdominal viscera, and cardiac and vascular structures. However, aortic injuries following chest compressions are rare.[2] Aortic injury following CPR has been described in two recent cases. The first patient wan an 86-year-old female who fell ten steps sustained hemothorax and multiple rib fractures. She needed CPR for acute cardiovascular decompensation, and a thoracic aortic dissection was seen on transesophageal echocardiogram.[3] The other patient, a 71-year-old female, had multiple cardiac arrests, CPR multiple times, thrombolytic therapy, and use of an automated chest compression device. She developed multiple injuries that included aortic intramural hematoma, hepatic pseudoaneurysm, several rib fractures, and liver lacerations.[4]

Our patient is distinct in that there was no significant deceleration injury, simple CPR of 3 min duration, no rib fractures, and yet she developed an isolated aortic intramural injury. Aortic injuries have an incidence of 5–10 patients/1,000,000 population in the United States, most commonly affecting male patients aged 50–70 years.[5] Acute traumatic aortic injury occurs via a variety of mechanisms.[6] Rapid deceleration is the most frequently described mechanism; however, the incidence of isolated deceleration mechanism appears to be rare.[7] Alternative mechanisms include (a) compression and upward motion of the heart placing torsion and shearing stress on the aorta and (b) lateral deforming forces to the chest can cause anterior displacement of the heart and sheering forces at the isthmus.[6] Two additional mechanisms, the first known as the osseous pinch can cause injury via compression of the aorta between the spine and anterior chest wall, and the second mechanism is known as the water-hammer effect.[8] The water-hammer effect occurs as a result of increased intravascular pressure which can exceed 2000 mmHg following direct pressure of the aorta which has been known to cause transverse tears at the isthmus and forces can travel retrograde resulting in aortic root injuries.[6],[9]

The most likely mechanisms of injury occurred via the osseous pinch and the water-hammer effect. In our patient, excessive force was transmitted in an anterior to posterior direction. The osseous pinch occurred via anterior chest wall compressing the aorta along the isthmus and ligamentum arteriosum [Figure 1]f, black arrows] and direct compression of the spine [Figure 1]a and [Figure 1]c, black arrows]. In addition, the water-hammer effect occurred likely due to the direct compression of the aorta between the chest wall and spine causing a transverse tear at the isthmus and retrograde aortic root injury [Figure 1]a and [Figure 1]b.

Our patient is 5´4˝ and 51.3 kg with a BMI of 19.4. Force required for chest compression will be very different for a patient with a BMI around 20 versus a patient with a BMI around 40. The CPR guidelines recommend 2 inches of chest compression which is a very appropriate recommendation. In a healthy, thin patient, such as ours special care needs to be taken to avoid overuse of force to prevent acute traumatic aortic injuries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S640-56.  Back to cited text no. 1
    
2.
Miller AC, Rosati SF, Suffredini AF, Schrump DS. A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries. Resuscitation 2014;85:724-31.  Back to cited text no. 2
    
3.
Oren-Grinberg A, Shahul S, Sarge T. Dissection of the thoracic aorta following cardiopulmonary resuscitation. Crit Ultrasound J 2011;3:25-7.  Back to cited text no. 3
    
4.
Juan YH, Saboo SS, Desai NS, Khandelwal K, Khandelwal A. Aortic intramural hematoma and hepatic artery pseudoaneurysm: unusual complication following resuscitation. Am J Emerg Med 2014;32:107.e1-4.  Back to cited text no. 4
    
5.
Papadimos TJ, Hofmann JP. Aortic dissection after forceful coughing. Anaesthesia 2006;61:71-2.  Back to cited text no. 5
    
6.
Steenburg SD, Ravenel JG, Ikonomidis JS, Schönholz C, Reeves S. Acute traumatic aortic injury: imaging evaluation and management. Radiology 2008;248:748-62.  Back to cited text no. 6
    
7.
Springer AN, Guletz MA, Sai-Sudhakar CB, Papadimos TJ. Traumatic aortic dissection associated with riding a roller coaster. Int J Crit Illn Inj Sci 2013;3:95.  Back to cited text no. 7
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8.
Crass JR, Cohen AM, Motta AO, Tomashefski JF Jr, Wiesen EJ. A proposed new mechanism of traumatic aortic rupture: the osseous pinch. Radiology 1990;176:645-9.  Back to cited text no. 8
    
9.
Creasy JD, Chiles C, Routh WD, Dyer RB. Overview of traumatic injury of the thoracic aorta. Radiographics 1997;17:27-45.  Back to cited text no. 9
    


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