INTRODUCTION

Cardiac compression is the most crucial component of successful cardiopulmonary resuscitation (CPR), as it helps maintain circulation to the coronary artery and other vital organs. It is recommended that cardiac compressions be performed with a depth of 5 cm and at a rate of 100 to 120 compressions per minute, ensuring full recoil after each compression. The proper hand placement for compressions is on the lower half of the sternum [1]. There is always a risk of various complications during the CPR procedure. Even if the CPR provider performs cardiac compressions according to the recommended guidelines, post-CPR complications are inevitable. These complications often include injuries such as fractures of the ribs and clavicle, as well as damage to solid organs. Liver injuries, for instance, have been reported with an incidence of about 0.6% to 3% [2,3].

CASE REPORT

A 25-year-old woman with a history of psychiatric issues was found hanged in her apartment. The patient's last known normal time was at 23:15, when she informed her boyfriend during a phone call of her intent to commit suicide. Ten minutes later, upon his arrival, he found the patient in a state of hanging. He immediately began performing bystander CPR, estimating that approximately 10 minutes had elapsed between the cardiac arrest and the initiation of CPR. The boyfriend continued bystander CPR for about 9 minutes, after which CPR with an AutoPulse device (Zoll Medical Corp) was administered for 20 minutes during transport to the first hospital. Upon arrival, CPR with a LUCAS device (Stryker Medical) was conducted for approximately 2 minutes until the patient achieved return of spontaneous circulation. The total duration of CPR was estimated to be about 31 minutes, though the exact amount of hands-off time was not recorded. Following resuscitation, an abdomen-pelvis computed tomography (CT) scan revealed a liver injury. Consequently, the patient was transferred to Korea University Trauma Center (Seoul, Korea) for specialized trauma care. She was admitted to the surgical intensive care unit for ventilator therapy and inotropic management. The liver injury was located in the plane between the sternum and spine, indicative of a compressive injury from CPR (Figs. 1, 2). There was no evidence of extravasation or active bleeding, allowing for conservative management of the liver injury. The patient's level of consciousness remained at Glasgow Coma Scale score of 3 (eye response, 1; verbal response, 1; motor response, 1) with no improvement. Although no significant abnormalities were detected in the brain parenchyma on CT, there was a slight reduction in brain stem enhancement (Fig. 3). However, due to the liver injury, target temperature management was not considered a viable treatment option because of the risk of coagulopathy and potential intra-abdominal bleeding. By hospital day 4, the patient's pupil reflex had completely disappeared. A brain death examination was conducted, and electroencephalography showed generalized attenuation, indicating severe global brain damage. Despite this, spontaneous breathing was weakly maintained. These responses did not meet the criteria for brain death. Therefore, we decided to terminate acute phase treatment, and the patient was transferred to a secondary hospital.

Ethics statement

Informed consent for publication of the research details and clinical images was obtained from the patient. The study was conducted in compliance with the principles of the Declaration of Helsinki.

DISCUSSION

Liver injury is a relatively rare complication after CPR. A retrospective analysis of a cardiac arrest registry found a 0.6% incidence of liver injury. In a prospective study examining complications of CPR in both in-hospital and out-of-hospital cardiac arrest cases, the incidence of liver injury was 2.1% [4]. Improper hand placement during CPR can lead to liver injury [5]. Anatomically, the liver is partially situated between the sternum and the spine. The lower end of the sternum is shaped like an inverted triangle, similar to a sword. Thus, if the CPR provider's hands are placed too low or excessive pressure is applied, the sternum can potentially injure the left side of the liver. In cases where patients have a history of breast implant surgery, it is presumed that compressing the lower half of the sternum might be challenging due to the presence of breast implants. The provider's hands could slip due to the smooth and resilient nature of the breast implant, and the space for compression may become restricted. However, the soft implant might reduce the impact by dispersing the pressure from chest compressions (Fig. 4). Therefore, it remains unclear whether breast implants contribute to liver damage during CPR. Confirming this would require experimental or statistical verification, as studies on CPR complications in patients with breast implants are scarce. Analysis of autopsy data from individuals who underwent CPR following cardiac arrest revealed that one out of 58 cases involved a breast implant rupture [6]. However, internal organ injury can occur even with correct hand placement or with minimal pressure [7–9]. The patient was unable to undergo target temperature management due to a liver laceration. It is believed that the patient's poor neurological outcome was primarily due to the prolonged initial resuscitation time. Unfortunately, the treatment options available were limited due to the liver laceration.

Because not all patients who undergo CPR are autopsied, accurately determining the incidence of liver injury in these patients is challenging. However, it is plausible that blood loss from liver injury could interfere with successful resuscitation. If a patient does not experience blood loss due to liver injury, they may maintain better cerebral perfusion, potentially altering the outcome. Given the significant advancements in CPR techniques, there is now a growing consensus that research should focus on minimizing complications.

ARTICLE INFORMATION

Conflicts of interest

The author has no conflicts of interest to declare.

Funding

The author received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

The end of the sternum coincides with the line of the liver laceration (dotted line), suggesting that the laceration was caused by sternum compression. (A) Location of sternum in computed tomography coronal view. (B) Liver laceration connected in a straight line with the sternum xiphoid process.

Fig. 2.

Liver laceration occurring just below the sternum (dotted line).

Fig. 3.

On brain computed tomography, the contrast enhancement of the brain stem appeared to be somewhat reduced.

Fig. 4.

The heart is covered by the implant. Therefore, it is presumed that direct compression on the heart was disturbed, and excessive pressure was applied.

REFERENCES

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Figure & Data

References

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