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A3456 - May the Force Be with You: Acute Aortic Dissection a Rare Complication of Cardiopulmonary Resuscitation
Author Block: A. A. Khan1, B. Pannu1, A. Dhillon2, N. Sher1, S. Saleem1; 1Internal Medicine, Presence Saint Joseph Hospital, Chicago, IL, United States, 2Internal Medicine, Chicago Medical School, North Chicago, IL, United States.
Effective chest compressions during cardiopulmonary resuscitation (CPR) are associated with improved survival and functional outcomes. This requires significant force to be applied to a patient’s chest and can result in various iatrogenic injuries such as rib fractures (97%) and sternal fractures (43%). Other complications include gastric distention, anterior mediastinal hematoma, pneumothorax, hemothorax, and pulmonary contusions. Less than 1% of all cases include gastric rupture, rhabdomyolysis, splenic lacerations, air embolism and aortic injuries. Aortic dissection is a rare, sparsely-reported complication of CPR that is commonly associated with external compression-decompression devices. An 86 year old male presented with a traumatic cervical spine fracture. He underwent a cervical spine fusion procedure. Past medical history was significant for coronary artery disease, atrial fibrillation, congestive heart failure, hypertension and residual right arm weakness from a previous stroke. He was on warfarin for atrial fibrillation. Chest x-ray prior to surgery revealed a tortuous aorta. CT Chest also confirmed mild prominence of ascending aorta. On post-op day four, he developed atrial fibrillation with rapid ventricular response progressing to Aflutter with a 2:1 block followed by cardiac arrest. CPR was initiated. Initial cardiac rhythm showed asystole. After 13 minutes of CPR and 2 doses of epinephrine, the patient achieved ROSC. He remained in atrial fibrillation with hypotension necessitating vasopressors. Echocardiography demonstrated compromised LV ejection fraction of 20% with normal right ventricular wall motion. CT angiography was performed which revealed aortic dissection arising distal to left subclavian artery extending to the origin of superior mesenteric artery. Chest X ray showed numerous bilateral rib fractures, pneumothorax and subcutaneous emphysema. A chest tube was placed to treat pneumothorax. Given his irreversible brain stem injury, poor prognosis and advanced age, there was extensive discussion leading to withdrawal of care and subsequent death. Our case draws attention to iatrogenic injuries as an important consideration in patients who remain unstable post-CPR. Risk factors for serious injuries include high-energy attempts, older age, prolonged CPR, and out-of-hospital cardiac arrest. In our patient, a tortuosity of ascending aorta and prolonged CPR likely contributed to aortic dissection. Rapid diagnosis of this high mortality complication is crucial. Immediate management of type-B dissection is conservative with aggressive blood pressure control and consideration for surgical or endovascular intervention in select cases. Such patients also highlight the value of reviewing iatrogenic complications of CPR when discussing goals of care.