Prevalence and Patterns of Resuscitation-Associated Injury Detected by Head-to-Pelvis Computed Tomography After Successful Out-of-Hospital Cardiac Arrest Resuscitation

Aris Karatasakis, Basar Sarikaya, Linda Liu, Martin L Gunn, Peter J Kudenchuk, Medley O Gatewood, Charles Maynard, Michael R Sayre, Catherine R Counts, David J Carlbom, Rachael M Edwards, Kelley R H Branch, Aris Karatasakis, Basar Sarikaya, Linda Liu, Martin L Gunn, Peter J Kudenchuk, Medley O Gatewood, Charles Maynard, Michael R Sayre, Catherine R Counts, David J Carlbom, Rachael M Edwards, Kelley R H Branch

Abstract

Background Patients resuscitated from out-of-hospital circulatory arrest (OHCA) frequently have cardiopulmonary resuscitation injuries identifiable by computed tomography, although the prevalence, types of injury, and effects on clinical outcomes are poorly characterized. Methods and Results We assessed the prevalence of resuscitation-associated injuries in a prospective, observational study of a head-to-pelvis sudden-death computed tomography scan within 6 hours of successful OHCA resuscitation. Primary outcomes included total injuries and time-critical injuries (such as organ laceration). Exploratory outcomes were injury associations with mechanical cardiopulmonary resuscitation and survival to discharge. Among 104 patients with OHCA (age 56±15 years, 30% women), 58% had bystander cardiopulmonary resuscitation, and total cardiopulmonary resuscitation time was 15±11 minutes. The prevalence of resuscitation-associated injury was high (81%), including 15 patients (14%) with time-critical findings. Patients with resuscitation injury were older (58±15 versus 46±13 years; P<0.001), but had otherwise similar baseline characteristics and survival compared with those without. Mechanical chest compression systems (27%) had more frequent sternal fractures (36% versus 12%; P=0.009), including displaced fractures (18% versus 1%; P=0.005), but no difference in survival (46% versus 41%; P=0.66). Conclusions In patients resuscitated from OHCA, head-to-pelvis sudden-death computed tomography identified resuscitation injuries in most patients, with nearly 1 in 7 with time-critical complications, and one-half with extensive rib-cage injuries. These data suggest that sudden-death computed tomography may have additional diagnostic utility and treatment implications beyond evaluating causes of OHCA. These important findings need to also be taken in context of the certain fatal outcome without resuscitation efforts. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03111043.

Keywords: cardiopulmonary resuscitation; computed tomography; out‐of‐hospital cardiac arrest; out‐of‐hospital circulatory arrest; resuscitation complications; rib fracture; sudden‐death CT.

Figures

Figure 1. Resuscitation‐associated injuries including time‐critical injuries.
Figure 1. Resuscitation‐associated injuries including time‐critical injuries.
Figure 2. Illustrative radiographic examples of cardiopulmonary…
Figure 2. Illustrative radiographic examples of cardiopulmonary resuscitation complications.
(A and C) Anterior mediastinal hematoma (arrow, A) and left thigh medial compartment hematoma (circle) associated with a femoral artery catheter (arrow, C), both exhibiting active extravasation in a patient with disseminated intravascular coagulation treated with massive transfusion. (B) Extensive subcapsular liver hematoma with multiple foci of active extravasation (circle, arrow) and several lacerations treated conservatively because of a poor prognosis with multiple transfusions and eventual autotamponade of bleeding. (D) Right lower lobe pulmonary laceration (arrow) associated with bilateral rib and sternal fractures in a patient with hereditary pheochromocytoma/paraganglioma syndrome who underwent prolonged resuscitation.
Figure 3. Anatomical distribution of rib fractures.
Figure 3. Anatomical distribution of rib fractures.
Distribution of rib fractures by transverse sector (anterolateral, 0–72 °; lateral 73–108 °; posterolateral, 109–180 °) shown by rib number (left) and for the overall sector (right). Numbers are shown as percentage of total rib fractures (N=519); circle size is proportionate to frequency in respective anatomic location.

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