title: Minimal invasive treatment of life-threatening bleeding caused by cardiopulmonary resuscitation-associated liver injury: a case report.
abstract: BACKGROUND
  Life-threatening bleeding caused by liver injury due to chest compressions is a rare complication in otherwise successful cardiopulmonary resuscitation. Surgical intervention has been suggested to achieve bleeding control; however, reported mortality is high. In this report, we present a brief literature review and a case report in which use of a less invasive strategy was followed by an uneventful recovery.
  
  
  METHODS
  A 37-year-old white woman was admitted after out-of-hospital cardiac arrest. Bystander cardiopulmonary resuscitation was immediately performed, followed by advanced cardiopulmonary resuscitation that included tracheal intubation, mechanical chest compressions, and external defibrillation with return of spontaneous circulation. Upon hospital admission, the patient's blood pressure was 94/45 mmHg and her heart rate was 110 beats per minute. Her electrocardiogram showed no signs of ST-segment elevations or Q-wave development. Coronary angiography revealed a proximal thrombotic occlusion of the left anterior descending coronary artery. Successful recanalization, after thrombus aspiration and balloon dilation followed by stent implant, was verified with normalized anterograde flow. Immediately after the patient's arrival in the intensive cardiac care unit, a drop in her blood pressure to 60/30 mmHg and a hemoglobin concentration of 4.5 g/dl were noticed. Transfusion was started, and bedside abdominal ultrasound examination revealed free intraperitoneal fluid. Computed tomography of the abdomen revealed liver injury with active extravasation from the cranial surface of the right lobe and a massive hemoperitoneum. The patient was coagulopathic and acidotic with a body temperature of 33.5 °C. A minimally invasive treatment strategy, including angiography and selective trans-catheter arterial embolization, were performed in combination with percutaneous evacuation of 4.5 L of intraperitoneal blood. After completion of these procedures, the patient was hemodynamically stable. She was weaned off mechanical ventilation 2 days later and made an uneventful recovery. She was discharged to a local hospital on day 13 without neurological disability.
  
  
  CONCLUSIONS
  Although rare, bleeding caused by liver injury due to chest compressions can be life-threatening after successful cardiopulmonary resuscitation. Reported mortality is high after surgical intervention, and patients may benefit from less invasive treatment strategies such as those presented in this case report.
authors.affiliation: Department of Traumatology, Oslo University Hospital Ullevål, Nydalen Postbox 4956, N-0424, Oslo, Norway. paanae@ous-hf.no.|Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital Ullevål, Oslo, Norway. paanae@ous-hf.no.
authors.forename: Pål Aksel
authors.initials: PA
authors.lastname: Næss
authors.affiliation: Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.
authors.forename: Kristian
authors.initials: K
authors.lastname: Engeseth
authors.affiliation: Department of Radiology and Nuclear Medicine, Oslo University Hospital Ullevål, Oslo, Norway.
authors.forename: Ole
authors.initials: O
authors.lastname: Grøtta
authors.affiliation: Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.
authors.forename: Geir Øystein
authors.initials: GØ
authors.lastname: Andersen
authors.affiliation: Department of Traumatology, Oslo University Hospital Ullevål, Nydalen Postbox 4956, N-0424, Oslo, Norway.
authors.forename: Christine
authors.initials: C
authors.lastname: Gaarder
mesh_terms: D000328:Adult; D015901:Angiography, Digital Subtraction; D016887:Cardiopulmonary Resuscitation / Q000009:adverse effects*; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D006336:Heart Massage / Q000009:adverse effects*; D006470:Hemorrhage / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D006801:Humans; D008099:Liver / Q000098:blood supply / Q000000981:diagnostic imaging / Q000293:injuries*; D058687:Out-of-Hospital Cardiac Arrest / Q000628:therapy*; D014057:Tomography, X-Ray Computed
keywords: Angiographic embolization; Cardiopulmonary resuscitation; Case report; Liver injury