Life-threatening hemothorax due to azygos vein rupture after chest compression during cardiopulmonary resuscitation SeungWhan Kim MD, Ph D, Euiseok Yang MD, WonJoon Jeong MD, JunWan Lee MD PII: DOI: Reference:
S0735-6757(14)00263-0 doi: 10.1016/j.ajem.2014.04.019 YAJEM 54249
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
31 March 2014 1 April 2014
Please cite this article as: Kim SeungWhan, Yang Euiseok, Jeong WonJoon, Lee JunWan, Life-threatening hemothorax due to azygos vein rupture after chest compression during cardiopulmonary resuscitation, American Journal of Emergency Medicine (2014), doi: 10.1016/j.ajem.2014.04.019
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Life-threatening hemothorax due to azygos vein rupture after chest compression during cardiopulmonary resuscitation
RI P
T
1. Title
“Life-threatening hemothorax due to azygos vein rupture after chest compression during
SC
cardiopulmonary resuscitation”
“Case Report” 3. Corresponding author “SeungWhan Kim, MD, Ph D”
ED
4. Coworker
MA NU
2. Brief description
“Euiseok Yang, MD, WonJoon Jeong, MD, JunWan Lee, MD
”
PT
5. The affiliation of the authors
CE
“Department of Emergency Medicine, Chungnam National University Hospital,
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Daejeon, Republic of Korea (All)” 6. Word count “786 words” 7. Key words “Chest compression; Complication; Azygos vein injury; Hemothorax” 8. Copyright of constraints “We have no conflict of interest and any copyright constraints” 9. Contact address “Department of Emergency Medicine, Chungnam National University Hospital, 640 Daesa-dong, Jung-gu, Daejeon, Republic of Korea 301-721”
ACCEPTED MANUSCRIPT 10. Phone number “82-42-280-8006 (phone)
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82-42-280-8082 (Fax.)” 11.e-mail address
Hemothorax
is
not
an
MA NU
SC
“ [email protected]”
uncommon
cardiopulmonary
resuscitation
(CPR)-related
complication. But hemothorax related to azygos vein injury (AVI) is a rare condition following blunt chest trauma with no report of CPR-related AVI in the literature. We present a case of azygos vein rupture in a middle-aged female after repeated chest compression during 1 hour
ED
CPR. She eventually presented with massive hemothorax due to azygos vein rupture diagnosed by computed tomography. When faced with a patient with massive hemothorax
PT
after chest compression, azygos vein rupture should be considered as a complication. Great vessel injury in chest cage may be secondary to blunt, penetrating, blast or
CE
iatrogenic trauma. Isolated azygos vein injury is a rare condition that is mainly associated with sudden deceleration trauma and penetrating accident. Diagnosis is based on radiologic evidence of hemothorax and hypovolemic shock. Early surgical intervention and adequate
AC
volume replacement including transfusion are the most important treatments. To our knowledge azygos vein injury has never been reported to be a complication following chest compression during cardiopulmonary resuscitation (CPR). We introduce the case of azygos vein rupture as a complicated result of chest compression. A 52-year-old woman without recent trauma history visited the emergency department complaining of vomiting with nausea for 3days. On past medical history, she had been treated for right breast cancer with radical mastectomy and chemotherapy 5 years before. She did not take any other agents that cause bleeding. Her initial vital signs were 70/42 mmHg, 94 beats/min, 24 breaths/min, 36.7 ℃. We immediately started hydration with normal saline via intravenous route and monitored the patient closely. A laboratory study showed hemoglobin 14.9g/dL and hematocrit 42.3%. On the initial chest X-ray there was no active lesion (Fig. 1). As soon as she was collapsed suddenly we started airway management and chest
ACCEPTED MANUSCRIPT compression immediately. Peripheral Venoarterial Extracorporeal Membrane Oxygenation (VA ECMO) was commenced approximately 1 hour after first collapse with full support flow. And then she showed recovery of spontaneous circulation. Complete opacity of right
T
hemothorax was found on post CPR chest x-ray film (Fig. 2). Her hemoglobin was lowered to
RI P
3.2g/dL just after CPR. The CT scan revealed sternum fracture, right hemothorax, and suspicious azygos vein injury (Fig. 3 & 4). The chest tube drained 1,700ml of blood at initial
SC
replacement and blood loss was ongoing. At emergent thoracotomy, about 2000ml of venous blood accumulation in right thoracic cavity was revealed due to ruptured azygos vein. After
MA NU
injured vessels ligation for bleeding control, she transferred to intensive care unit. Unfortunately, she expired at intensive care unit 6 days after surgery. Chest compression is a significant component of CPR. Recently, high quality chest compression such as “Push hard and Push fast” have been emphasized to improve the survivability of patients in cardiac arrest. However, many studies have documented
ED
unintended chest and abdominal injuries resulting from CPR, such as rib fractures, sternum fractures, pulmonary injury, hepatic or splenic laceration, great vessel injury, and cardiac contusion or laceration [1,2]. Most CPR-related complications are insignificant injuries and
PT
life-threatening complications are extremely rare. Krischer et al noted the prevalence of life-threatening complications to be less than 0.5% in their analysis of 705 post-CPR
CE
autopsied patients [3].
To our knowledge, there have been no reports of fatal azygos vein injury after CPR. Less
AC
than 25 case of azygos vein injury secondary to blunt chest trauma have been published in the medical literature [4]. Several mechanism have been suggested to describe how the azygos vein is injured in blunt chest trauma [5-8]. As in these mechanisms, we presumed that CPR induced azygos vein injury is caused by an abrupt increase in venous pressure resulting from compression of the heart between the sternum and vertebral column in performing CPR [7]. There is no specific clinical sign of azygos vein injury, which is usually first suspected when a widened mediastinum and right hemothorax are found on chest x-ray [9]. For this reason, we should always check the chest X-ray after CPR. Initial blood loss may not be significant but major haemorrhage is the rule within a short period of time. Good treatment of the azygos vein injury requires rapid evaluation and resuscitation in the emergency department. When azygos vein injury is suspected, immediate thoracotomy is required for ligation of the azygos vein [10]. This case shows CPR-related azygos vein rupture with sternum fracture after a longer
ACCEPTED MANUSCRIPT duration of chest compression. But not much is known in regards to the relationship between the length of CPR duration and CPR-related injury because of only a few conflicting studies [1,3,11,12]. Azygos vein injury is uncommon but potentially fatal if diagnosis and treatment
RI P
SC
rupture should be considered as a fatal complication.
T
are delayed. When faced with a patient with massive hemothorax after CPR, azygos vein
REFERENCES
MA NU
[1] Kim MJ, Park YS, Kim SW, Yoon YS, Lee KR, Lim TH, et al. Chest injury following cardiopulmonary resuscitation: a prospective computed tomography evaluation. Resuscitation 2013;84:361–4. [2] Black CJ, Busuttil A, Robertson C. Chest wall injuries following cardiopulmonary resuscitation. Resuscitation 2004;63:339–43.
ED
[3] Krischer JP, Fine EG, Davis JH, Nagel EL. Complications of cardiac resuscitation. Chest 1987;92:287–91. [4] Endara SA, Davalos GA, Nuñez MF, Manzano JE. Azygous vein laceration secondary to blunt thoraco-abdominal trauma. Interact Cardiovasc Thorac Surg 2010;11:342–4.
PT
[5] Spagliardi E, Palombo D. A case of isolated rupture of the azygos vein. Minerva Cardioangiol 1978;26:637–9.
CE
[6] Snyder CL, Eyer SD. Blunt chest trauma with transection of the azygos vein: case report. J Trauma 1989;29:889–90.
AC
[7] Salizzoni M, Ardissone F, Borasio P, Dei Poli M. Isolated rupture of the azygos vein caused by contusive thoracic trauma. Minerva Chir 1980;35:1255–6. [8] Sharma OP, Rawitscher RE. Blunt vena azygos trauma: report of a case and review of world literature. J Trauma Acute Care Surg 1999;46:192–5. [9] Sugimoto K, Asari Y, Hirata M, Imai H, Ohwada T. The diagnostic problem associated with blunt traumatic azygous vein injury: delayed appearance of right haemothorax after blunt chest trauma. Injury 1998;29:380–2. [10] Butler DA, Schneider RF, Jadali M. Traumatic injury to the azygous vein: case report. J Trauma Acute Care Surg 1995;39:761–2. [11] Baubin M, Sumann G, Rabl W, Eibl G, Wenzel V, Mair P. Increased frequency of thorax injuries with ACD-CPR. Resuscitation 1999;41:33-8 [12] Foo NP, Chang JH, Lin HJ, Guo HR. Rescuer fatigue and cardiopulmonary resuscitation positions: A randomized controlled crossover trial. Resuscitation 2010;81:579-84
T
ACCEPTED MANUSCRIPT
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Fig. 1. Initial simple chest AP simple X-ray.
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Fig. 2. One hour after chest compression chest AP simple X-ray.
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Fig. 3. Aorta CT (coronal view) demonstrating right hemothorax and azygos vein (black arrow) injury with extravasation of contrast media (white arrow).
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Fig. 4. Aorta CT (saggital view) demonstrating right hemothorax and azygos vein (black arrow) injury with extravasation of contrast media (white arrow).
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Figure 1
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Figure 2
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S0735-6757(14)00263-0 doi: 10.1016/j.ajem.2014.04.019 YAJEM 54249
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
31 March 2014 1 April 2014
Please cite this article as: Kim SeungWhan, Yang Euiseok, Jeong WonJoon, Lee JunWan, Life-threatening hemothorax due to azygos vein rupture after chest compression during cardiopulmonary resuscitation, American Journal of Emergency Medicine (2014), doi: 10.1016/j.ajem.2014.04.019
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Life-threatening hemothorax due to azygos vein rupture after chest compression during cardiopulmonary resuscitation
RI P
T
1. Title
“Life-threatening hemothorax due to azygos vein rupture after chest compression during
SC
cardiopulmonary resuscitation”
“Case Report” 3. Corresponding author “SeungWhan Kim, MD, Ph D”
ED
4. Coworker
MA NU
2. Brief description
“Euiseok Yang, MD, WonJoon Jeong, MD, JunWan Lee, MD
”
PT
5. The affiliation of the authors
CE
“Department of Emergency Medicine, Chungnam National University Hospital,
AC
Daejeon, Republic of Korea (All)” 6. Word count “786 words” 7. Key words “Chest compression; Complication; Azygos vein injury; Hemothorax” 8. Copyright of constraints “We have no conflict of interest and any copyright constraints” 9. Contact address “Department of Emergency Medicine, Chungnam National University Hospital, 640 Daesa-dong, Jung-gu, Daejeon, Republic of Korea 301-721”
ACCEPTED MANUSCRIPT 10. Phone number “82-42-280-8006 (phone)
RI P
T
82-42-280-8082 (Fax.)” 11.e-mail address
Hemothorax
is
not
an
MA NU
SC
“ [email protected]”
uncommon
cardiopulmonary
resuscitation
(CPR)-related
complication. But hemothorax related to azygos vein injury (AVI) is a rare condition following blunt chest trauma with no report of CPR-related AVI in the literature. We present a case of azygos vein rupture in a middle-aged female after repeated chest compression during 1 hour
ED
CPR. She eventually presented with massive hemothorax due to azygos vein rupture diagnosed by computed tomography. When faced with a patient with massive hemothorax
PT
after chest compression, azygos vein rupture should be considered as a complication. Great vessel injury in chest cage may be secondary to blunt, penetrating, blast or
CE
iatrogenic trauma. Isolated azygos vein injury is a rare condition that is mainly associated with sudden deceleration trauma and penetrating accident. Diagnosis is based on radiologic evidence of hemothorax and hypovolemic shock. Early surgical intervention and adequate
AC
volume replacement including transfusion are the most important treatments. To our knowledge azygos vein injury has never been reported to be a complication following chest compression during cardiopulmonary resuscitation (CPR). We introduce the case of azygos vein rupture as a complicated result of chest compression. A 52-year-old woman without recent trauma history visited the emergency department complaining of vomiting with nausea for 3days. On past medical history, she had been treated for right breast cancer with radical mastectomy and chemotherapy 5 years before. She did not take any other agents that cause bleeding. Her initial vital signs were 70/42 mmHg, 94 beats/min, 24 breaths/min, 36.7 ℃. We immediately started hydration with normal saline via intravenous route and monitored the patient closely. A laboratory study showed hemoglobin 14.9g/dL and hematocrit 42.3%. On the initial chest X-ray there was no active lesion (Fig. 1). As soon as she was collapsed suddenly we started airway management and chest
ACCEPTED MANUSCRIPT compression immediately. Peripheral Venoarterial Extracorporeal Membrane Oxygenation (VA ECMO) was commenced approximately 1 hour after first collapse with full support flow. And then she showed recovery of spontaneous circulation. Complete opacity of right
T
hemothorax was found on post CPR chest x-ray film (Fig. 2). Her hemoglobin was lowered to
RI P
3.2g/dL just after CPR. The CT scan revealed sternum fracture, right hemothorax, and suspicious azygos vein injury (Fig. 3 & 4). The chest tube drained 1,700ml of blood at initial
SC
replacement and blood loss was ongoing. At emergent thoracotomy, about 2000ml of venous blood accumulation in right thoracic cavity was revealed due to ruptured azygos vein. After
MA NU
injured vessels ligation for bleeding control, she transferred to intensive care unit. Unfortunately, she expired at intensive care unit 6 days after surgery. Chest compression is a significant component of CPR. Recently, high quality chest compression such as “Push hard and Push fast” have been emphasized to improve the survivability of patients in cardiac arrest. However, many studies have documented
ED
unintended chest and abdominal injuries resulting from CPR, such as rib fractures, sternum fractures, pulmonary injury, hepatic or splenic laceration, great vessel injury, and cardiac contusion or laceration [1,2]. Most CPR-related complications are insignificant injuries and
PT
life-threatening complications are extremely rare. Krischer et al noted the prevalence of life-threatening complications to be less than 0.5% in their analysis of 705 post-CPR
CE
autopsied patients [3].
To our knowledge, there have been no reports of fatal azygos vein injury after CPR. Less
AC
than 25 case of azygos vein injury secondary to blunt chest trauma have been published in the medical literature [4]. Several mechanism have been suggested to describe how the azygos vein is injured in blunt chest trauma [5-8]. As in these mechanisms, we presumed that CPR induced azygos vein injury is caused by an abrupt increase in venous pressure resulting from compression of the heart between the sternum and vertebral column in performing CPR [7]. There is no specific clinical sign of azygos vein injury, which is usually first suspected when a widened mediastinum and right hemothorax are found on chest x-ray [9]. For this reason, we should always check the chest X-ray after CPR. Initial blood loss may not be significant but major haemorrhage is the rule within a short period of time. Good treatment of the azygos vein injury requires rapid evaluation and resuscitation in the emergency department. When azygos vein injury is suspected, immediate thoracotomy is required for ligation of the azygos vein [10]. This case shows CPR-related azygos vein rupture with sternum fracture after a longer
ACCEPTED MANUSCRIPT duration of chest compression. But not much is known in regards to the relationship between the length of CPR duration and CPR-related injury because of only a few conflicting studies [1,3,11,12]. Azygos vein injury is uncommon but potentially fatal if diagnosis and treatment
RI P
SC
rupture should be considered as a fatal complication.
T
are delayed. When faced with a patient with massive hemothorax after CPR, azygos vein
REFERENCES
MA NU
[1] Kim MJ, Park YS, Kim SW, Yoon YS, Lee KR, Lim TH, et al. Chest injury following cardiopulmonary resuscitation: a prospective computed tomography evaluation. Resuscitation 2013;84:361–4. [2] Black CJ, Busuttil A, Robertson C. Chest wall injuries following cardiopulmonary resuscitation. Resuscitation 2004;63:339–43.
ED
[3] Krischer JP, Fine EG, Davis JH, Nagel EL. Complications of cardiac resuscitation. Chest 1987;92:287–91. [4] Endara SA, Davalos GA, Nuñez MF, Manzano JE. Azygous vein laceration secondary to blunt thoraco-abdominal trauma. Interact Cardiovasc Thorac Surg 2010;11:342–4.
PT
[5] Spagliardi E, Palombo D. A case of isolated rupture of the azygos vein. Minerva Cardioangiol 1978;26:637–9.
CE
[6] Snyder CL, Eyer SD. Blunt chest trauma with transection of the azygos vein: case report. J Trauma 1989;29:889–90.
AC
[7] Salizzoni M, Ardissone F, Borasio P, Dei Poli M. Isolated rupture of the azygos vein caused by contusive thoracic trauma. Minerva Chir 1980;35:1255–6. [8] Sharma OP, Rawitscher RE. Blunt vena azygos trauma: report of a case and review of world literature. J Trauma Acute Care Surg 1999;46:192–5. [9] Sugimoto K, Asari Y, Hirata M, Imai H, Ohwada T. The diagnostic problem associated with blunt traumatic azygous vein injury: delayed appearance of right haemothorax after blunt chest trauma. Injury 1998;29:380–2. [10] Butler DA, Schneider RF, Jadali M. Traumatic injury to the azygous vein: case report. J Trauma Acute Care Surg 1995;39:761–2. [11] Baubin M, Sumann G, Rabl W, Eibl G, Wenzel V, Mair P. Increased frequency of thorax injuries with ACD-CPR. Resuscitation 1999;41:33-8 [12] Foo NP, Chang JH, Lin HJ, Guo HR. Rescuer fatigue and cardiopulmonary resuscitation positions: A randomized controlled crossover trial. Resuscitation 2010;81:579-84
T
ACCEPTED MANUSCRIPT
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Fig. 1. Initial simple chest AP simple X-ray.
SC
Fig. 2. One hour after chest compression chest AP simple X-ray.
MA NU
Fig. 3. Aorta CT (coronal view) demonstrating right hemothorax and azygos vein (black arrow) injury with extravasation of contrast media (white arrow).
AC
CE
PT
ED
Fig. 4. Aorta CT (saggital view) demonstrating right hemothorax and azygos vein (black arrow) injury with extravasation of contrast media (white arrow).
AC
Figure 1
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PT
ED
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Figure 2
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