Diaphragmatic rupture with inferior phrenic artery bleeding caused by cardiopulmonary resuscitation

Article information

Clin Exp Emerg Med. 2020;7(3):238-240

Publication date (electronic) : 2020 June 2

doi : https://doi.org/10.15441/ceem.19.044

Umberto G. Rossi^,1,2, Anna Maria Ierardi³, Maurizio Cariati²

¹Interventional Radiology Unit, Department of Diagnostic Imaging, E.O. Galliera Hospital, Genova, Italy

²Radiology and Interventional Radiology Unit, Advanced Technology Department of Diagnostic and Therapy, ASST Santi Paolo and Carlo, San Carlo Borromeo Hospital, Milano, Italy

³Radiology and Interventional Radiology Unit, Diagnostic and Interventional Radiology Department, ASST Santi Paolo and Carlo, San Paolo Hospital, University of Milan, Milano, Italy

Correspondence to: Umberto G. Rossi Interventional Radiology Unit, Department of Diagnostic Imaging, E.O. Galliera Hospital, Mura delle Cappuccine 14, Genova 16128, Italy E-mail: umberto.rossi@galliera.it

Received 2019 May 18; Revised 2019 July 2; Accepted 2019 July 9.

A 76-year-old hospitalized man developed acute ventricular fibrillation. The cardiology staff started cardiopulmonary resuscitation (CPR) with 30 chest compressions and two artificial ventilations, combined with automated external defibrillator use. The time to restore cardiac output was 25 minutes. Twelve hours later, he was extubated and started complaining of upper abdominal and back pain. Over this time, his hemoglobin level decreased from 13.4 to 8.7 mg/dL. Multidetector computed tomography revealed a lesion in the right crus of the diaphragm and hemoperitoneum (Fig. 1A, B). Selective lower thoracic and upper abdominal digital subtraction angiography showed active bleeding from a branch vessel of the right inferior phrenic artery (Fig. 2A). Active bleeding was stopped by coaxial superselective catheterization of the right inferior phrenic artery (Fig. 2B). The postoperative course was uneventful; he was discharged on day 10. Follow-up performed 24 months after embolization demonstrated no complications.

Fig. 1.

(A) Axial and (B) coronal views of multidetector computed tomography showing a 7.3×4.1-cm inhomogeneous lesion (*) in the right crus of the diaphragm (arrowheads) with hemoperitoneum (#).

Fig. 2.

(A) Selective digital subtraction angiography revealing active bleeding (white arrow) from a branch vessel of the right inferior phrenic artery. (B) Final selective angiography of the right inferior phrenic artery showing no signs of active bleeding after embolization with two 3-mm metallic microcoils (black arrows) using the endovascular “isolation technique.”

Diaphragmatic lesions (varying from tearing of a muscle bundle to full-strength breakage) with inferior phrenic artery bleeding due to blunt trauma is a rare emergency event [1-3]. Diaphragmatic rupture caused by CPR is even rarer [3]. To our knowledge, this is the first case involving a diaphragmatic lesion and inferior phrenic artery rupture caused by CPR, leading to hemoperitoneum. This is a potentially life-threatening condition requiring prompt diagnosis and treatment [1,2,4]. In selected cases involving active traumatic bleeding in thoraco-abdominal organs, transcatheter embolization techniques have been successfully used as the first-line treatment [5-7]. In conclusion, the possibility of injury to abdominal organs, such as the diaphragm, must be considered while performing vigorous CPR.