Gastric perforation following cardiopulmonary resuscitation in a child: report of a case and review of the literature

Pediatric gastric perforation beyond neonatal period: 8-year experience with 20 patients

BACKGROUND

To describe the characteristics, treatments, and prognosis of pediatric gastric perforation patients beyond neonatal period.

METHODS

Twenty pediatric patients beyond neonatal period were included in this study. Medical records were reviewed and clinical characteristics were analyzed. According to the outcomes, patients were divided into the survival group and the death group. Death time was documented, and survival patients were followed up. The degree of severity was calculated using pediatric critical illness score (PCIS). Differences between the two groups were analyzed by the Student's t-test, Mann-Whitney test and Chi-square test appropriately.

RESULTS

Gastric perforation was diagnosed in 20 pediatric patients beyond neonatal period, including 6 males (30%) and 14 females (70%), with the age of 37.18 (15.90, 107.12) months, and the range was from 4.30 months to 14.17 years old. They had different manifestations, etiologies, sites of perforation and surgery procedures. Among the 20 cases, 14 (70%) survived and 6 (30%) died. Age, gender, length and number of perforation had no statistically difference between the two groups. However, PCIS, ischemia of gastrointestinal wall, and transmural necrosis of gastric wall were statistically different. For the survival group, during a follow-up period of 50 (36, 68) months, ranging from 2 months to 8 years and 7 months, one patient had a second-time perforation, another 3 patients had brain injury symptoms, and the rest 10 patients had good quality of lives.

CONCLUSIONS

Gastric perforation of pediatric patients beyond neonatal period causes a mortality of 30% on this study. Spontaneous great curvature of gastric wall perforation has the highest morbidity. Low PCIS predicts for unfavorable prognosis. Most of the survival patients have satisfactory living quality after operation.

Cardiopulmonary resuscitation (CPR) complications encountered in forensic autopsy cases

Background

Cardiopulmonary resuscitation (CPR) provides a significant increase in survival rate, even if performed by bystanders. However, bystanders may refrain from performing CPR for fear of eventual malpractice litigation. Currently lack Guidelines specifying whether a particular CPR-related complication is in all likelihood unavoidable or not. To fulfill this gap a great number of studies is required to be published in the most relevant leading academic literature. This paper aims at making a contribution to addressing such a challenge.

Methods

A retrospective observational study based on forensic autopsy material aiming at recording injuries resulting from the application of CPR. The severity of injuries was forensically evaluated.

Results

Out of 88 cases autopsied, only 26.7% had rib fractures (only 20% of which were located in the 6 lower ribs), 17.4% had sternal fractures (85.7% of which were detected in the body of the sternum and 14.3% in the manubrium). The ratio of sternal fractures to rib fractures is similar to the ratio cited in other studies reported in the literature (2:3, approximately). The number of fractures was 7.86 (4.11 on the right side and 4.75 on the left side). 16% of the cases were found to be mild, 48% were moderate, and 35% of the cases were severe. When a physician was present, a (not statistically significant) trend towards more severe complications was found.

Conclusion

The findings are in accordance with other similar studies reported in the literature referring to the classic external CPR. This study offers a proposal aiming at making a contribution to develop Guidelines specifying whether a particular CPR-related complication is in all likelihood unavoidable or not.

Mallory-Weiss Tear After Cardiopulmonary Resuscitation in a Patient Suffering From Acute Myocardial Infarction

A report of a 79 year old male patient suffering from acute myocardial infarction with Mallory-Weiss tear after successful cardiopulmonary resuscitation(CPR) by emergency medical technician in the swimming pool is presented. Successful percutaneous coronary intervention(PCI) was done after appropriate transfusion. The patient survived and discharged without major complications after admitting 11days in the hospital. Importance of CPR in AMI patient is reiterated as complication such as Mallory-Weiss tear may arise.

Stomach perforation post cardiopulmonary resuscitation-A case report

•

Stomach perforation after cardiopulmonary resuscitation is rare.

•

CPR performed by non-medical personnel is the main cause.

•

Training of medical and non-medical persons in CPR is to be encouraged.

•

Correct management of airway during CPR is important.

•

High degree of vigilance is required in patients presenting after CPR.

Introduction

Stomach perforation after cardiopulmonary resuscitation is a rare finding. This is mainly caused by incorrect management of the airway during CPR performed by non-medical personnel.

Presentation of case

We report a case of 72 year old female who sustained a stomach perforation during prolonged CPR in an out of hospital arrest situation. This was diagnosed on a computed tomography scan of the abdomen requiring midline laparotomy and a primary repair of the stomach.

Discussion

The training of medical and non-medical persons in cardiopulmonary resuscitation is to be encouraged. However it should be emphasized that any technique which breaches the normal integrity of the body can itself lead to life-threatening complications.

Conclusion

A high degree of vigilance is required in patients presenting after a cardiac arrest and CPR.

Cardiopulmonary Resuscitation Injuries in Children

Cardiopulmonary resuscitation (CPR) is an emergency intervention to maintain circulation and breathing in an unresponsive individual suffering from cardiopulmonary arrest. However, CPR is not without its own risks. Injuries secondary to compression and ventilation are well documented in the medical and scientific literature. Most of these injuries are minor, but some can result in significant morbidity and even death. It is important to identify those injuries that could be secondary to CPR versus inflicted traumatic injuries of child maltreatment.

Injuries sustained by children inside clothes dryers: a report of a fatality and review of the literature

We report a case of a 4-year-old child found dead at his home inside a domestic clothes (tumble) dryer. The child had been reported missing in the morning by his mother and found a short time later inside the dryer with the door shut. The child was pronounced dead at the scene. A pre-autopsy computed tomography scan identified findings associated with aggressive resuscitation attempts. Post-mortem examination showed generalised blunt trauma to his head and limbs, a thin film subdural haemorrhage and burns from contact with hot components and hot air whilst being trapped alive inside the active dryer. A forensic examination of the dryer revealed that it was possible for the child to become trapped in the dryer by his own action and that the dryer could operate for sufficient time to allow for the causation of the injuries to the child. A review of the medical literature and media reports of deaths related to clothes dryer, injuries sustained to survivors and use of dryers as a body disposal site is presented.

Do resuscitation-related injuries kill infants and children?

Occasionally, individuals accused of inflicting fatal injuries on infants and young children will claim some variant of the "CPR defense," that is, they attribute the cause of injuries found at autopsy to their "untrained" resuscitative efforts. A 10-year (1994-2003) historical fixed cohort study of all pediatric forensic autopsies at the Miami-Dade County Medical Examiner Department was undertaken. To be eligible for inclusion in the study, children had to have died of atraumatic causes, with or without resuscitative efforts (N(atraumatic) = 546). Of these, 382 had a history of cardiopulmonary resuscitation (CPR; average age of 4.17 years); 248 had CPR provided by trained individuals only; 133 had CPR provided by both trained and untrained individuals; 1 had CPR provided by untrained individuals only. There was no overlap between these 3 distinct groups. Twenty-two findings potentially attributable to CPR were identified in 19:15 cases of orofacial injuries compatible with attempted endotracheal intubation; 4 cases with focal pulmonary parenchymal hemorrhage; 1 case with prominent anterior mediastinal emphysema; and 2 cases with anterior chest abrasions. There were no significant hollow or solid thoracoabdominal organ injuries. There were no rib fractures. The estimated relative risk of injury subsequent to resuscitation was not statistically different between the subset of decedents whose resuscitative attempts were made by trained individuals only, and the subset who received CPR from both trained and untrained individuals. In the single case of CPR application by an untrained individual only, no injuries resulted. The remaining 164 children dying from nontraumatic causes and who did not undergo resuscitative efforts served as a control group; no injuries were identified. This study indicates that in the pediatric population, injuries secondary to resuscitative efforts are infrequent or rare, pathophysiologically inconsequential, and predominantly orofacial in location. In our population, CPR did not result in any rib fractures or significant visceral injuries. Participation of nonmedical or untrained individuals in resuscitation did not increase the likelihood of injury.

Gastric perforation after cardiopulmonary resuscitation: review of the literature

The risk of complications of cardiopulmonary resuscitation (CPR) does not outweigh the benefit of a successful restoration of a spontaneous circulation. Despite the frequent occurrence of gastric distension (caused by air entering the stomach because of too forceful and/or too quick rescue breathing), there are few reports of massive gastric distension causing gastric rupture and pneumoperitoneum after CPR. We reviewed all 67 case reports of gastric perforation that have been reported after CPR. Although uncommon, this review stresses the need to consider this potentially lethal complication after initial successful resuscitation.

Pneumoperitoneum Due to Gastric Perforation After Cardiopulmonary Resuscitation: Case Report

Background Pneumoperitoneum after cardiopulmonary resuscitation may be due to mediastinal air tracking into the peritoneal cavity via the diaphragmatic hiatus or to gastric perforation.

Case Report A 79-year-old woman received Advanced Cardiac Life Support measures in the intensive care unit. Chest compressions and endotracheal intubation were performed; a stable cardiac rhythm and perfusion were restored. A chest radiograph after resuscitation revealed pneumoperitoneum without pneumomediastinum. The patient underwent laparotomy; a 6-cm perforation of the posterior gastric wall along the lesser curve was detected and repaired.

Conclusion Gastric perforation after cardiopulmonary resuscitation should be suspected when chest radiographs obtained after resuscitation show pneumo-peritoneum without pneumomediastinum. Prompt laparotomy allows detection of gastric perforations and decreases the morbidity associated with rupture of a hollow organ. The incidence of gastric perforation after cardiopulmonary resuscitation may be decreased with early endotracheal intubation, avoidance of esophageal intubation, and expeditious placement of an orogastric tube.

Do resuscitation attempts in children who die, cause injury?

OBJECTIVE

To determine the incidence, type, and pattern of injury related to resuscitation attempts in children who die.

DESIGN

Retrospective review of ambulance, hospital, and necropsy case records.

METHOD

All children who died aged 0-14 years between 1994 and 1996, and underwent a full necropsy at the Victorian Institute of Forensic Medicine (Melbourne, Australia) were identified. Children who were subject to recognised trauma before resuscitation or died because of a congenital abnormality were excluded. The records of all remaining children were reviewed. Children were grouped according to whether resuscitation was attempted or not.

RESULTS

From a total of 346 children who died, 204 (58.6%) were identified as meeting the inclusion criteria. Resuscitation was performed in 153 (75%) children and was started before ambulance arrival in 123 (60.3%) children. Injuries were detected at necropsy in 65 (42.5%) of children who had resuscitation compared with six (11.7%) of children who had no resuscitation (p<0.0001) chi(2) test. All but two of these injuries were of a minor nature consisting principally of bruises or abrasions. Two significant injuries were identified both occurring as a result of readily identifiable resuscitation procedures. The likelihood of injury increased with the length of resuscitation. In children resuscitated for less than 60 minutes the incidence of injury was 27% compared with 62% for children resuscitated for longer ( p<0.0001).

CONCLUSION

This study has shown that cardiopulmonary resuscitation commonly causes minor injuries such as superficial bruises and abrasions and the likelihood of such injury increases with the duration of the cardiopulmonary resuscitation. This information should reassure parents and caregivers that basic life support may be instituted without fear of causing significant injury or adversely affecting outcome in the child with cardiorespiratory arrest. Caution must be exercised when attributing significant injuries to resuscitation attempts and alternative causes must be fully investigated.

Gastric distension, cerebral palsy and unexpected death

Two cases of unexpected death from massive gastric dilatation in individuals with severe spastic quadraparesis aged 14 and 20 years, respectively, are reported. Spontaneous rupture of the stomach occurred in one case. Predisposing factors to gastric dilatation associated with cerebral palsy include autonomic neuropathy, neuromuscular incoordination, air swallowing and malposition of the stomach. Death may be due to compromise of respiratory function caused by lung compression by the dilated stomach, or to peritonitis with sepsis. Acute gastric dilatation, with or without rupture, should be considered a potential cause of unexpected death in individuals with severe mental and physical disabilities.

Cardiopulmonary resuscitation-related injuries and homicidal blunt abdominal trauma in children

Defendants accused of inflicting fatal abdominal injuries to children occasionally raise the defense that the injuries were caused by cardiopulmonary resuscitation (CPR). The purpose of this study is to answer the question: Does closed chest CPR result in fatal blunt abdominal injuries that can be mistaken for homicidal assault? To that end, a retrospective study was conducted of all homicidal blunt abdominal injuries in children 10 years and younger from the Dade, Broward, and Palm Beach Medical Examiner's Offices from 1981 through 1997. These were compared to cases of children who died of natural causes during the same time period in Broward County who had CPR (control group 1) and to children who died of nonvehicular accidental blunt abdominal trauma (control group 2). Children with life-threatening head injuries were excluded. Medical examiner records, autopsy reports, documenting photographs, and clinical records were reviewed. The data analyzed included subject demographics, whether CPR was performed and by whom, and autopsy findings. Thirty-three child homicides with fatal abdominal injuries were reviewed. Twenty-four (73%) of the homicides received CPR. There was no difference in the nature and severity of injuries between the 24 children who received CPR and the 9 who did not. Three hundred and twenty-four cases of pediatric natural deaths were reviewed, all of which had CPR. No traumatic abdominal injuries were found in any of the children who died of natural causes. Only four children who died of natural causes had evidence of extraabdominal trauma related to CPR. No cases of nonvehicular accidental blunt abdominal trauma were identified during the 17-year period, although there were nonvehicular accidental fatalities due to extraabdominal injuries. The likelihood of CPR-related primary abdominal trauma in child homicides is very low.

Influence of tidal volume, respiratory rate, and supplemental oxygen flow on delivered oxygen fraction using a mouth to mask ventilation device

We examined the influence of the following parameters in determining the FiO2 delivered to a pediatric lung model using the mouth-to-mask method of resuscitation: rate of ventilation, inspiratory tidal volumes, and supplemental oxygen flow. With a ventilator rate of 20/min and tidal volumes (Vt) < or = 100 mL, an FiO2 of approximately .50 was observed with a supplemental oxygen flow of 5 L/min. Increasing the supplemental oxygen flow to 15 L/m did not appreciably increase the FiO2 (FiO2 = .53 versus FiO2 = .60, respectively), but did cause a significant and unintended increase in Vt. Similar results were noted with a ventilator rate of 12/min and Vt < or = 100 mL (FiO2 = .68 versus FiO2 = .73, respectively). We also observed a potentially hazardous situation involving the positioning of the supplemental oxygen port that might result in high inspiratory pressures (stacking of breaths) to the pediatric patient. We believe additional testing is warranted prior to widespread use of this device in children.

Pneumoperitoneum--a rare complication of cardiopulmonary resuscitation

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.