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C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
C2005 Evidence Evaluation Template - Nov.11, 2003.doc
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C2005 Evidence Evaluation Template - Nov.11, 2003.doc

  1. 1. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 1 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT WORKSHEET for PROPOSED Evidence-Based GUIDELINE RECOMMENDATIONS NOTE: Save worksheet using the following filename format: Taskforce.Topic.Author.Date.Doc where Taskforce is a=ACLS, b=BLS, p=Pediatric, n=neonatal and i=Interdisciplinary. Use 2 or 3 letter abbreviation for author’s name and 30Jul03 as sample date format. Worksheet Author: G Nichol Taskforce/Subcommittee: _x_BLS __ACLS __PEDS __ID __PROAD __Other: Author’s Home Resuscitation Council: _x_AHA __ANZCOR __CLAR __ERC __HSFC __HSFC __RCSA ___IAHF ___Other: Date Submitted to Subcommittee: Aug 19, 2004; Revised October 10, 2004; December 2, 2004 STEP 1: STATE THE PROPOSAL. State if this is a proposed new guideline; revision to current guideline; or deletion of current guideline. Existing guideline, practice or training activity, or new guideline: New guideline Step 1A: Refine the question; state the question as a positive (or negative) hypothesis. State proposed guideline recommendation as a specific, positive hypothesis. Use single sentence if possible. Include type of patients; setting (in- /out-of-hospital); specific interventions (dose, route); specific outcomes (ROSC vs. hospital discharge). CPR is safe for victims. Step 1B: Gather the Evidence; define your search strategy. Describe search results; describe best sources for evidence. ECC EndNote library (Aug 10, 2004) was searched using text word combination “CPR” OR “resuscitation” AND “adverse effects” MEDLINE (July 1, 2004), EMBASE (July 1, 2004) were searched using the following terms: exp heart arrest OR CPR$.mp OR resuscitation.mp OR cardiac arrest.mp AND adverse effects. Year of publication was not restricted. The reference lists from pertinent articles were reviewed to assure no relevant citations were missed. There were no relevant reviews archived in the Cochrane Database. 2,046 citations were identified. The electronic databases searched included AHA EndNote 7 Master library [http://ecc.heart.org/], Cochrane database for systematic reviews and Central Register of Controlled Trials [http://www.cochrane.org/], MEDLINE [http://www.ncbi.nlm.nih.gov/PubMed/ ], and hand searches of journals, review articles, and books. • State major criteria you used to limit your search; state inclusion or exclusion criteria (e.g., only human studies with control group? no animal studies? N subjects > minimal number? type of methodology? peer-reviewed manuscripts only? no abstract-only studies?) Included were human studies. Excluded were animal studies (26), duplicate studies (7) or those that did not describe adverse effects in victims of cardiac arrest who received CPR (1887). • Number of articles/sources meeting criteria for further review: Create a citation marker for each study (use the author initials and date or Arabic numeral, e.g., “Cummins-1”). . If possible, please supply file of best references; EndNote 6+ required as reference manager using the ECC reference library. 126 citations met criteria for further review. STEP 2: ASSESS THE QUALITY OF EACH STUDY Step 2A: Determine the Level of Evidence. For each article/source from step 1, assign a level of evidence—based on study design and methodology. Level of Evidence Definitions (See manuscript for full details) Level 1 Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects Level 2 Randomized clinical trials with smaller or less significant treatment effects Level 3 Prospective, controlled, non-randomized, cohort studies Level 5 Historic, non-randomized, cohort or case-control studies Level 5 Case series: patients compiled in serial fashion, lacking a control group Level 6 Animal studies or mechanical model studies Level 7 Extrapolations from existing data collected for other purposes, theoretical analyses Level 8 Rational conjecture (common sense); common practices accepted before evidence-based guidelines
  2. 2. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 2 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Step 2B: Critically assess each article/source in terms of research design and methods. Was the study well executed? Suggested criteria appear in the table below. Assess design and methods and provide an overall rating. Ratings apply within each Level; a Level 1 study can be excellent or poor as a clinical trial, just as a Level 6 study could be excellent or poor as an animal study. Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study. For more detailed explanations please see attached assessment form. Component of Study and Rating Excellent Good Fair Poor Unsatisfactory Design & Methods Highly appropriate sample or model, randomized, proper controls AND Outstanding accuracy, precision, and data collection in its class Highly appropriate sample or model, randomized, proper controls OR Outstanding accuracy, precision, and data collection in its class Adequate, design, but possibly biased OR Adequate under the circumstances Small or clearly biased population or model OR Weakly defensible in its class, limited data or measures Anecdotal, no controls, off target end-points OR Not defensible in its class, insufficient data or measures A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpoint B = Survival of event D = Intact neurological survival Italics = animal studies Step 2C: Determine the direction of the results and the statistics: supportive? neutral? opposed? DIRECTION of study by results & statistics: SUPPORT the proposal NEUTRAL OPPOSE the proposal Results Outcome of proposed guideline superior, to a clinically important degree, to current approaches Outcome of proposed guideline no different from current approach Outcome of proposed guideline inferior to current approach Step 2D: Cross-tabulate assessed studies by a) level, b) quality and c) direction (ie, supporting or neutral/ opposing); combine and summarize. Exclude the Poor and Unsatisfactory studies. Sort the Excellent, Good, and Fair quality studies by both Level and Quality of evidence, and Direction of support in the summary grids below. Use citation marker (e.g. author/ date/source). In the Neutral or Opposing grid use bold font for Opposing studies to distinguish them from merely neutral studies. Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study. Supporting Evidence CPR is safe for victims QualityofEvidence Excellent Good
  3. 3. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 3 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Fair 1 2 3 4 5 6 7 8 Level of Evidence A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpoint (e.g., ischemic injury) B = Survival of event D = Intact neurological survival F = Administration of 100% O2 Neutral or Opposing Evidence CPR is safe for victims QualityofEvidence Excellent Good
  4. 4. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 4 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Fair Adams1(1)E Aguilar1(2)E Azuma1(3)E Batra1(4)E Bedell1(5)E Benbow1(6)E Berg1(7).E Bernard1(8)E Brady1(9)E Burdett-Smith1(10)E Bush1(11)E Cafri1(12)E Cameron1(13)E Chatson1(14)E Clinch1(15)E Corbett1(16)E Custer1(17)E Darke1(18)E Delanye1(19)E Dohi1(20)E Ducable1(21)E Elliot1(22)E Enarson1(23)E Enat1(24)E Engelstein1(25)E Evans1(26)E Feldman1(27)E Fitchet1(28)E Fletcher1(29)E Floret1(30)E Flowers1(31)E Fosse1(32)E Gainant1(33)E Gallagher1(34)E Gerry1(35)E Gillies1(36)E Gilliland1(37)E Goetting1(38)E Goldberg1(39)E Gordon1(40)E Gregersen1(41)E Gueugniaud1(42)E Hachiro1(43)E Hargarten1(44)E Harm1(45)E Hartoko1(46)E Hashimoto1(47)E Haugeberg1(48)E Hillman1(49)E Hood1(50)E Hulewicz1(51)E Jeong1(52)E Kam1(53)E Kanter1(54)E Kaplan1(55)E Katz1(56)E Kempen1(57)E Kendall1(58)E Kloss1(59)E Kordas1(60)E Kramer1(61)E Krause1(62)E Krischer1(63)E Krumholz1(64)E Kurkciyan1(65)E Lawes1(66)E Lelcuk1(67)E Linch1(68)E Lockett1(69)E Low1(70)E Ma1(71)E Machii1(72)E Matikainen1(73)E Mattana1(74)E McGrath1(75)E Mehta1(76)E Mensah1(77)E Menzies1(78)E Mills1(79)E Minor1(80)E Miro1(81)E Mirow1(82)E Nagel1(83)E Nelson1(84)E Norfleet1(85)E Novotny1(86)E Odom1(87)E Offerman1(88)E Oh1(89)E Oschatz1(90)E Parke1(91)E Pestaner1(92)E Petersen1(93)E Pezzi1(94)E Powner1(95)E Reardon1(96)E Register1(97)E Reinartz1(98)E Rello1(99)E Robbins1(100)E Robinson1(101)E Samet1(102)E Scholz1(103)E Schroeder1(104)E Sclarovsky1(105)E Sewell1(106)E Shemesh1(107)E Shulman1(108)E Smith1(109)E Sokolove1(110)E Sperry1(111)E Stallard1(112)E Strear1(113)E Takada1(114)E Tenaglia1(115)E Thompson1(116)E Van Hoeyweghen1(117)E Vinen1(118)E Wagner1(119)E Walley1(120)E Windecker1(121)E Wolcke1(122)E Wong1(123)E Woods1(124)E Yamaki1(125)E Zuzarte1(126)E 1 2 3 4 5 6 7 8 Level of Evidence A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpoint (e.g., ischemic injury) B = Survival of event D = Intact neurological survival STEP 3. DETERMINE THE CLASS OF RECOMMENDATION. Select from these summary definitions.
  5. 5. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 5 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT CLASS CLINICAL DEFINITION REQUIRED LEVEL OF EVIDENCE Class I Definitely recommended. Definitive, excellent evidence provides support. • Always acceptable, safe • Definitely useful • Proven in both efficacy & effectiveness • Must be used in the intended manner for proper clinical indications. • One or more Level 1 studies are present (with rare exceptions) • Study results consistently positive and compelling Class II: Acceptable and useful • Safe, acceptable • Clinically useful • Not yet confirmed definitively • Most evidence is positive • Level 1 studies are absent, or inconsistent, or lack power • No evidence of harm • Class IIa: Acceptable and useful Good evidence provides support • Safe, acceptable • Clinically useful • Considered treatments of choice • Generally higher levels of evidence • Results are consistently positive • Class IIb: Acceptable and useful Fair evidence provides support • Safe, acceptable • Clinically useful • Considered optional or alternative treatments • Generally lower or intermediate levels of evidence • Generally, but not consistently, positive results Class III: Not acceptable, not useful, may be harmful • Unacceptable • Not useful clinically • May be harmful. • No positive high level data • Some studies suggest or confirm harm. Indeterminate • Research just getting started. • Continuing area of research • No recommendations until further research • Minimal evidence is available • Higher studies in progress • Results inconsistent, contradictory • Results not compelling STEP 3: DETERMINE THE CLASS OF RECOMMENDATION. State a Class of Recommendation for the Guideline Proposal. State either a) the intervention, and then the conditions under which the intervention is either Class I, Class IIA, IIB, etc.; or b) the condition, and then whether the intervention is Class I, Class IIA, IIB, etc. Indicate if this is a __Condition or _X_Intervention Final Class of recommendation: __Class I-Definitely Recommended __Class IIa-Acceptable & Useful; good evidence __Class IIb-Acceptable & Useful; fair evidence __Class III – Not Useful; may be harmful _X_Indeterminate-minimal evidence or inconsistent REVIEWER’S PERSPECTIVE AND POTENTIAL CONFLICTS OF INTEREST: Briefly summarize your professional background, clinical specialty, research training, AHA experience, or other relevant personal background that define your perspective on the guideline proposal. List any potential conflicts of interest involving consulting, compensation, or equity positions related to drugs, devices, or entities impacted by the guideline proposal. Disclose any research funding from involved companies or interest groups. State any relevant philosophical, religious, or cultural beliefs or longstanding disagreements with an individual. I am a general internist with postgraduate training in clinical research. I volunteer as a member of the American Heart Association’s Emergency Cardiovascular Care committee, immediate past chair of the Association’s BLS subcommittee, and chair of the Association’s AED Task Force. In the last five years, I have held unrestricted grants from Medtronic Physio-Control (now Medtronic ERS), Cardiac Science, Zoll, Philips Heartstream in support of a registry of out of hospital cardiac arrest. I am a coinvestigator responsible for economic analysis of public access defibrillation trial, funded by NHLBI, AHA, and industry. I am also a coinvestigator responsible for economic analysis of a trial of cardiac resynchronization therapy, funded by Medtronic and Canadian Institutes of Health Research. I am sponsor of an Investigational Device Exemption from the FDA for a randomized trial of a wearable cardioverter defibrillator. Director of University of Washington – Harborview Prehospital Research and Training Center Medical Director of University of Washington Clinical Trial Center. These Centers participate in or coordinate several industry or agency-sponsored trials that are evaluating resuscitation interventions, including the Resuscitation Outcomes Consortium. I have never received consulting fees, salary, or equity related to drugs, devices or entities impacted by this guideline proposal. REVIEWER’S FINAL COMMENTS AND ASSESSMENT OF BENEFIT / RISK: Summarize your final evidence integration and the rationale for the class of recommendation. Describe any mismatches between the evidence and your final Class of Recommendation. “Mismatches” refer to selection of a class of recommendation that is heavily influenced by other factors than just the evidence. For example, the evidence is strong, but implementation is difficult or expensive; evidence weak, but future definitive evidence is unlikely to be obtained. Comment on contribution of animal or mechanical model studies to your final recommendation. Are results within animal studies homogeneous? Are animal results consistent with results from human studies? What is the frequency of adverse events? What is the possibility of harm? Describe any value or utility judgments you may have made, separate from the evidence. For example, you
  6. 6. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 6 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT believe evidence-supported interventions should be limited to in-hospital use because you think proper use is too difficult for pre-hospital providers. Please include relevant key figures or tables to support your assessment. CPR is generally safe for individuals in cardiac arrest. (Indeterminate). Although the evidence supporting the safety of receiving CPR is weak, there is a substantial publication bias. Adverse effects are more likely to be reported than lack of adverse effects. Thousands of individuals have received CPR but there are no large studies that objectively assessed or recorded adverse events associated with CPR provision. The denominator of individuals who have received CPR is unknown so it is difficult to assess the frequency of adverse events. Receipt of CPR is associated with rib fractures (5) and occasionally associated with intrathoracic, intraabdominal, vascular or other injuries. However the consequences of not receiving CPR when it is required are devastating. There are no reports of individuals acquiring infections after receiving CPR. Common sense suggests that providers take appropriate safety precautions when feasible and when resources are available to do so, especially if a victim is known or suspected to have a serious infection (e.g. HIV, SARS.) Furthermore, it is difficult to determine the causality or clinical impact of many of these injuries given the current poor overall outcome after cardiac arrest. Risk of adverse effects associated with CPR adjuncts, drugs or defibrillators were not assessed in this review, nor were differences assessed by type of provider. Preliminary draft/outline/bullet points of Guidelines revision: Include points you think are important for inclusion by the person assigned to write this section. Use extra pages if necessary. Publication: Chapter: Pages: Topic and subheading: Based on more than 100 LOE 5 case reports and case series, CPR is generally safe for individuals in cardiac arrest. (Indeterminate). CPR is frequently associated with rib fractures in older victims and occasionally associated with other injuries. Patients who exhibit hemodynamic or other instability after resuscitation should be reassessed and reevalauted for resuscitation-related injuries. Attachments:  Bibliography in electronic form using the Endnote Master Library. It is recommended that the bibliography be provided in annotated format. This will include the article abstract (if available) and any notes you would like to make providing specific comments on the quality, methodology and/or conclusions of the study.
  7. 7. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 7 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Citation List Citation Marker Full Citation* Adams1 Reference Type: Journal Article Record Number: 8818 Author: Adams, H. A.; Schmitz, C. S.; Block, G.; Schlichting, C. Year: 1995 Title: Intra-abdominal bleeding after myocardial infarction with cardiopulmonary resuscitation and thrombolytic therapy Journal: Anaesthesist Volume: 44 Issue: 8 Pages: 585-9. Keywords: excluded Abdomen Adult Anesthesia Cardiopulmonary Resuscitation/*adverse effects Electrocardiography English Abstract Fibrinolytic Agents/*adverse effects/therapeutic use Human Male Middle Aged Myocardial Infarction/*complications Postoperative Hemorrhage/chemically induced/*etiology/physiopathology Abstract: Adverse effects of resuscitation due to closed-chest cardiac massage are common, and the incidence is increased when an incorrect technique is used. Nevertheless, thrombolytic therapy of a myocardial infarction can become necessary even after cardiopulmonary resuscitation (CPR). In these patients, the risk of thrombolytic therapy-induced bleeding is immanent. CASE REPORTS. Within 9 months, two male patients aged 44 and 52 years were admitted to the intensive care unit after out-of-hospital CPR for myocardial infarction with cardiac arrest. In both cases, thrombolytic therapy was undertaken due to the cardiovascular situation or echocardiographic results. Thrombolytic therapy was successful with regard to the ECG changes, but a few hours later both patients demonstrated increasing cardiovascular instability. After abdominal sonography, intra-abdominal bleeding was suspected. Emergency laparotomy became unavoidable, although the coagulation profile was severely impaired in both patients (Tables 1 and 2). Anaesthetic management was characterised by introduction of central venous and intra- arterial catheters, replacement of volume and oxygen carriers using large-bore IV lines, restoration of coagulation factors with fresh frozen plasma, and the choice of "modified neuroleptanaesthesia" with blood pressure-adjusted, small doses of fentanyl, midazolam, and pancuronium. Intraoperatively, a liver injury due to closed-chest cardiac massage was found in both cases. The postoperative courses were complicated by respiratory problems, which led to prolonged mechanical ventilation, but both patients survived without remarkable neurological deficits. CONCLUSION. In patients with thrombolytic therapy after CPR and persisting cardio-vascular instability, a resuscitation injury with consequent haemorrhagic shock should be suspected. For diagnosis, chest X-ray films and abdominal and thoracic sonography are useful and practicable, even at the bedside. Anaesthetic management should focus on adequate monitoring, replacement of volume and oxygen carriers, fast restoration of plasma coagulation, and careful, blood pressure- adjusted maintenance of anaesthesia. Notes: Two case reports on thrombolysis after cardiac arrest due to myocardial infarction. Two case reports of intra-abdominal bleeding after cardiopulmonary resuscitation and thrombolytic therapy. No abstract provided. Level 5 Fair. Aguilar1 Reference Type: Journal Article
  8. 8. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 8 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Record Number: 1414 Author: Aguilar, J. C. Year: 1981 Title: Fatal gastric hemorrhage: a complication of cardiorespiratory resuscitation Journal: Journal of Trauma-Injury Infection & Critical Care Volume: 21 Issue: 7 Pages: 573-5 Date: Jul Accession Number: 6973026 Keywords: Screen Abstract: Clinical courses of 16 patients with documented gastric trauma resulting from cardiopulmonary resuscitation were reviewed from seven published manuscripts (1-7). Three patients with gastric rupture survived the therapy (2, 3, 7), two ultimately died of their original disease, and one recovered completely (2). Of the 15 who died, the gastric trauma contributed very little to the fatal outcome of the patients. The case reported here suffered death from gastric mucosal lacerations caused by cardiopulmonary resuscitation resulting in a fatal massive gastric hemorrhage. Review of 16 published cases with documented gastric trauma after CPR. 1 recovered completely; 15 died but the trauma did not contribute to their fatal outcome. Level 5 Fair. Azuma1 Reference Type: Journal Article Record Number: 9874 Author: Azuma, S.S.; Mashiyama, E.T.; Goldsmith, C.I.; Abbasi, A.S. Year: 1986 Title: Chest compression-induced vertebral fractures. Journal: Chest Volume: 89 Issue: 1 Pages: 154-155 Alternate Journal: Chest Accession Number: 3940778 Keywords: aged article case report female fracture human male pressure resuscitation spine injury technique Abstract: Two cases with chest compression-induced thoracolumbar transvertebral fractures are discussed. This is a previously unreported complication of cardiopulmonary resuscitation. Dorsal kyphosis and osteopenia were present in both of these cases. There was no spinal cord injury documented, though the potential for injury and paraplegia exists. Care should be taken to avoid this complication, especially in the elderly with kyphosis; however, adequate compressions to insure support of circulation should be maintained. Author Address: Azuma, S.S. Two cases with chest compression-induced thoracolumbar transvertebral fractures. Dorsal kyphosis and ostepenia present in both cases. Level 5 Fair. Batra1 Reference Type: Journal Article Record Number: 1234 Author: Batra, A. K. Year: 1986
  9. 9. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 9 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Title: Lung herniation after CPR Journal: Critical Care Medicine Volume: 14 Issue: 6 Pages: 595-6 Date: Jun Accession Number: 3709206 Keywords: Screen Case report of lung herniation after CPR associated with sternal fracture, rib fracture and costal cartilage separation. Level 5 Fair. Bedell1 Reference Type: Journal Article Record Number: 1225 Author: Bedell, S. E.; Fulton, E. J. Year: 1986 Title: Unexpected findings and complications at autopsy after cardiopulmonary resuscitation (CPR) Journal: Archives of Internal Medicine Volume: 146 Issue: 9 Pages: 1725-8 Date: Sep Accession Number: 3753112 Keywords: Screen Abstract: To evaluate the importance of diagnoses undetected before cardiac arrest in the hospital, we studied autopsy findings on 130 patients who died after an attempt at cardiopulmonary resuscitation (CPR). We also studied the complications that occurred in these patients as a result of CPR. Twenty-one percent of the patients had at least one complication as a result of CPR Patients resuscitated on the wards were more likely to have a complication than those treated in the intensive care unit. This suggests that more proficient technique in CPR may reduce morbidity from this procedure. In 14% of the cases, there was a major missed diagnosis. The two diseases most frequently undetected clinically were ischemic bowel and pulmonary embolus, which together accounted for 89% of all major missed diagnoses discovered at autopsy. We conclude that diseases that require a high prior clinical suspicion (bowel infarction and pulmonary embolus) are common accompaniments of cardiac arrest in the hospital. Consideration of these diagnoses in critically ill patients may prevent future cardiac arrest and death from pulmonary embolus and ischemic bowel. Retrospective cohort study of autopsy findings in 130 patients who died at a single hospital after undergoing CPR. 21% of patients had at least one complication as a result of CPR: fractured ribs, fractured sternum, bone marrow emboli, epicardial hemorrhage, mediastinal hematomas, aspiration pneumonia, epicardial contusion, intra-atrial hemorrhage, LV laceration, LV hemorrhage, RV hemorrhage, pulmonary contusions, perforation of anterior wall of RV, submucosal hemorrhage of trachea. Level 5 Fair. Benbow1 Reference Type: Journal Article Record Number: 1010 Author: Benbow, E. W.; Humphrey, G. M. Year: 1991 Title: So what really causes gastric mucosal tears?[comment] Journal: Medicine, Science & the Law Volume: 31 Issue: 1 Pages: 87 Date: Jan Accession Number: 2005776 Keywords: Screen
  10. 10. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 10 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Review speculating on cause of gastric mucosal tears observed after CPR. Level 5 Fair. Berg1 Reference Type: Journal Article Record Number: 676 Author: Berg, M. D. ; Idris, A. H. ; Berg, R. A. Year: 1998 Title: Severe ventilatory compromise due to gastric distention during pediatric cardiopulmonary resuscitation. Journal: Resuscitation Volume: 36 Issue: 1 Pages: 71-73 Date: 1998 Jan Label: 28050 Keywords: Cardiopulmonary Resuscitation *adverse effects Case Report Heart Arrest *therapy Human Infant Intubation, Intratracheal Male Respiratory Mechanics Stomach Dilatation *etiology 1998 04 21 02:02 Abstract: We describe a child in cardiac arrest with severe ventilatory compromise due to gastric distention. During cardiopulmonary resuscitation (CPR), positive pressure ventilation may lead to gastric insufflation because of decreased pulmonary compliance and decreased lower esophageal sphincter tone. Essentially, gas delivered will follow the path of least resistance, which may be to the stomach. In our patient, gastric distention precluded effective ventilation and gastric decompression relieved ventilatory compromise. The values and pitfalls of clinical evaluation and capnography are presented. Notes: ProCite field[38]: 98209068 Case report of child in cardiac arrest with severe ventilatory compromise due to gastric distention. Level 5 Fair. Bernard1 Reference Type: Journal Article Record Number: 870 Author: Bernard, S. A.; Jones, B. M.; Scott, W. J. Year: 1993 Title: Intra-abdominal complications following prolonged cardiopulmonary resuscitation Journal: Australian & New Zealand Journal of Surgery Volume: 63 Issue: 4 Pages: 312-4 Date: Apr Accession Number: 8311820 Keywords: Screen Abstract: A patient who underwent prolonged cardiopulmonary resuscitation developed an acute abdomen in the early post-arrest period which required laparotomy. Operative findings were of a perisplenic haematoma and infarction of the caecum. The latter has not previously been reported in this setting. A review of the literature reveals that many abdominal complications may occur following external cardiac massage. Difficulties in investigation and management are discussed. [References: 14] Notes: Review
  11. 11. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 11 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Case report of a patient who underwent prolonged CPR and subsequently developed an acute abdomen that required laparotomy. Operative findings were perisplenic hematoma and infarcted cecum. Level 5 Fair. Brady1 Reference Type: Journal Article Record Number: 703 Author: Brady, K. M.; Hiles, D. A. Year: 1996 Title: Brown's syndrome as a complication of cardiopulmonary resuscitation Journal: British Journal of Ophthalmology Volume: 80 Issue: 3 Pages: 268-9 Date: Mar Accession Number: 8703868 Keywords: Screen Case report of Brown’s syndrome (an ocular motility disorder consisting of difficulty with active and passive elevation in adduction) in a 2 year-old who received CPR after drowning. Level 5 Fair. Burdett-Smith1 Reference Type: Journal Article Record Number: 10046 Author: Burdett-Smith, P.; Jaffey, L. Year: 1996 Title: Tension pneumoperitoneum Journal: Journal of Accident and Emergency Medicine Volume: 13 Issue: 3 Pages: 220-221 Alternate Journal: Journal of Accident and Emergency Medicine Accession Number: 1996164067 Keywords: adult article asthma case report decompression human intravenous drug administration male pneumoperitoneum pneumothorax respiratory arrest resuscitation adrenalin Abstract: Tension pneumoperitoneum developing in a middle aged asthmatic male during resuscitation after a respiratory arrest is reported. This was associated with bilateral tension pneumothorax and caused severe respiratory embarrassment which was relieved by needle decompression, after decompression of the pneumothoraces. The chest is not the only body cavity that can contain air under tension. Author Address: Burdett-Smith, P., Dept Accident and Emergency Medicine, Royal Liverpool University Hospital, Liverpool L7 8XP, United Kingdom Case report of tension pneumoperitoneum in asthmatic male during resuscitation after respiratory arrest. No abstract available. Level 5 Fair. Bush1 Reference Type: Journal Article Record Number: 2559 Author: Bush, C. M. ; Jones, J. S. ; Cohle, S. D. ; Johnson, H.
  12. 12. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 12 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Year: 1996 Title: Pediatric injuries from cardiopulmonary resuscitation. Journal: Ann Emerg Med Volume: 28 Issue: 1 Pages: 40-44 Date: 1996 Jul Label: 4980 Keywords: Cardiopulmonary Resuscitation *adverse effects mortality Cause of Death Child Child, Preschool Emergency Medical Services *standards Female Heart Arrest mortality *therapy Human Infant Infant, Newborn Male Michigan epidemiology Population Surveillance Retrospective Studies Wounds and Injuries *etiology mortality 1996 07 01 00:00 Abstract: STUDY OBJECTIVE: To assess the type, rate, and severity of unanticipated complications of CPR (external cardiac compressions and ventilation) in a pediatric population. METHODS: A retrospective review was undertaken of the records from all deceased children ( < 12 years old) who had been given CPR during an 8-year period (1988 through 1995). Patients with historical or physical evidence of preceding trauma were excluded. Clinical and autopsy records were abstracted for patient demographics, clinical findings, duration of CPR, persons administering CPR, and medical examiner summaries. RESULTS: Two hundred eleven children (mean age, 19.0 months) met the inclusion criteria and were entered into the study. The most common cause of cardiac arrest was sudden infant death syndrome (56%), followed by drowning (8%), congenital heart disease (7%), and pneumonia (4%). Mean duration of CPR was 45 minutes (range, 3 to 180 minutes). Fifteen children (7%) had at least one injury as a result of CPR; 7 (3%) had injuries that were considered medically significant. These included retroperitoneal hemorrhage (n = 2), pneumothorax (n = 1), pulmonary hemorrhage (n = 1), epicardial hematoma (n = 1), and gastric perforation (n = 1); in spite of prolonged resuscitation performed with variable degrees of skill, only one patient was noted to have rib fractures. CONCLUSION: Significant iatrogenic injuries are rare in children who receive CPR; they occur in approximately 3% of cases. Recognizing the possibility of a complication may help in the management of children who survive cardiac arrest. Regardless of resuscitation history, abuse should be considered whenever traumatic injuries are encountered. Notes: ProCite field[38]: 96266189 Retrospective cohort of all deceased children who had been given CPR. Two-hundred eleven children included. 7% had at least one injury as a result of CPR: retroperitoneal hemorrhage,
  13. 13. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 13 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT pneumothorax, pulmonary hemorrhage, epicardial hematoma. Conclusion: injuries rare in kids. Level 5 Fair. Cafri1 Reference Type: Journal Article Record Number: 8829 Author: Cafri, C.; Gilutz, H.; Ilia, R.; Abu-ful, A.; Battler, A. Year: 1997 Title: Unusual bleeding complications of thrombolytic therapy after cardiopulmonary resuscitation. Three case reports Journal: Angiology Volume: 48 Issue: 10 Pages: 925-8. Keywords: excluded Aged Cardiopulmonary Resuscitation/*adverse effects Esophagogastric Junction/injuries Fibrinolytic Agents/*adverse effects Gastrointestinal Hemorrhage/etiology Hemangioma/complications Hemoperitoneum/etiology Hemorrhage/*etiology Hemothorax/etiology Human Liver/injuries Liver Neoplasms/complications Male Middle Aged Myocardial Infarction/drug therapy Retrospective Studies Rupture Streptokinase/adverse effects Thrombolytic Therapy/*adverse effects Abstract: The authors present three case reports retrospectively casting doubt on the benefit of thrombolysis after external cardiac massage. Notes: Case series with three patients experiencing bleeding complications following thrombolysis after CPR. Case series n=3 (intra-abdominal bleed, hemothorax, Mallory-Weiss syndrome) when lytics given after CPR. Only abbreviated abstract presented. Level 5 Fair. Cameron1 Reference Type: Journal Article Record Number: 1001 Author: Cameron, P. A.; Rosengarten, P. L.; Johnson, W. R.; Dziukas, L. Year: 1991 Title: Tension pneumoperitoneum after cardiopulmonary resuscitation Journal: Medical Journal of Australia Volume: 155 Issue: 1 Pages: 44-7 Date: Jul 1 Accession Number: 2067438 Keywords: Screen Abstract: OBJECTIVE: To increase awareness of the unusual complication of pneumoperitoneum after cardiopulmonary resuscitation. CLINICAL FEATURES: A 57- year-old male farmer with a history of chronic renal failure and heart disease, as well as severe oesophageal reflux for which fundoplication had been performed, developed a tension pneumoperitoneum after cardiopulmonary resuscitation. This resulted in lower limb cyanosis and an erection, a previously unreported complication. INTERVENTION
  14. 14. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 14 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT AND OUTCOME: The tension was relieved by uncapping a peritoneal dialysis catheter that was in situ. The cyanosis and erection resolved immediately, suggesting that the tension pneumoperitoneum had caused significant venous obstruction. A 3 cm defect in the posterior wall of the stomach was repaired. CONCLUSION: The likelihood of pneumoperitoneum is reduced if standard guidelines for cardiopulmonary resuscitation are adhered to. Case report of CPR that resulted in tension pneumoperitoneum with lower limb cyanosis and erection, due to gastric rupture. Level 5 Fair. Chatson1 Reference Type: Journal Article Record Number: 1087 Author: Chatson, G.; Gallagher, R.; Quahliero, D.; Ruffett, D.; Allmendinger, P. Year: 1989 Title: Ventricular pseudoaneurysm associated with cardiopulmonary resuscitation 6 weeks after mitral valve replacement Journal: Annals of Thoracic Surgery Volume: 48 Issue: 5 Pages: 719-20 Date: Nov Accession Number: 2818068 Keywords: Screen Abstract: Trauma to the heart and mediastinum is associated with external cardiac massage. A patient had undergone a redo mitral valve replacement and experienced an uneventful postoperative course. During a visit to her physician 6 weeks after operation, she experienced ventricular fibrillation that required external cardiac massage and subsequent defibrillation. Postresuscitation evaluation revealed a posterior pseudoaneurysm of the ventricle. This was repaired via a transthoracic approach with the use of profound hypothermia. Ventricular pseudoaneurysm associated with CPR 6 weeks after mitral valve replacement. MVR may predispose to formation of ventricular pseudoaneurysm. No symptoms observed after replacement; only after CPR. This suggests CPR may have caused the pseudoaneurysm. Level 5 Fair. Clinch1 Reference Type: Journal Article Record Number: 1362 Author: Clinch, S. L.; Thompson, J. S.; Edney, J. A. Year: 1983 Title: Pneumoperitoneum after cardiopulmonary resuscitation: a therapeutic dilemma Journal: Journal of Trauma-Injury Infection & Critical Care Volume: 23 Issue: 5 Pages: 428-30 Date: May Accession Number: 6854681 Keywords: Screen Abstract: We report a patient who developed pneumoperitoneum after cardiopulmonary resuscitation. Ten cases have been reported in the literature. Despite the patient's serious condition, celiotomy was performed to rule out perforation of a hollow viscus and none was found. The likelihood of visceral perforation in this setting is high and despite increasing recognition of pneumoperitoneum that does not require surgical intervention, nonoperative management should not be entertained in this setting unless visceral perforation can be excluded. Case report n=1 and review of literature n=10 of pneumoperitoneum after CPR. No control group, but stated that operative management best. Level 5 Fair.
  15. 15. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 15 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Corbett1 Reference Type: Journal Article Record Number: 660 Author: Corbett, S. W.; O'Callaghan, T. Year: 1997 Title: Detection of traumatic complications of cardiopulmonary resuscitation by ultrasound Journal: Annals of Emergency Medicine Volume: 29 Issue: 3 Pages: 317-21; discussion 322 Date: Mar Accession Number: 9055769 Keywords: Screen Abstract: STUDY OBJECTIVE: We conducted a pilot study to assess the feasibility of ultrasonography in the detection of traumatic complications of CPR. METHODS: A prospective case series was undertaken with a convenience sample of 21 emergency department patients who sustained nontraumatic cardiopulmonary arrest. A 5- to 7-minute ultrasound examination was performed during resuscitation. The presence or absence of free fluid was noted in the left and right upper quadrants, coronal views of the kidneys, the pelvis, and the pericardium; autopsies to determine the source of fluid were not performed. Cardiac activity and the concurrent electrical rhythm were also noted. All ultrasonographers had previously been trained in the use of this technique for the evaluation of trauma patients. Examinations were stored on videotape for further review. RESULTS: Seven of 20 patients (29%) had findings on ultrasound that could have resulted from CPR-related trauma. In one additional case, findings of free fluid were probably the result of preexisting illness (ascites). Pericardial effusion was found in three patients, perihepatic fluid in four, pleural fluid in one, perirenal fluid in four, perisplenic fluid in two, and pelvic fluid in three; several patients had multiple findings. Cardiac motion with pulseless electrical activity was noted in seven patients. Five patients had return of spontaneous circulation and survived to hospitalization, and one survived to discharge. CONCLUSION: Traumatic complications of CPR are well known but typically difficult to assess. Ultrasonography may identify injuries, help guide procedures, and serve as a means to assess pharmacologic effects on cardiac performance during CPR. It is a readily available, noninvasive means to assess these critically ill patients. Case series of n=21 patients with nontraumatic cardiopulmonary arrest. Ultrasound (US) performed during resuscitation. 7 out of 20 had findings that could have been CPR-related trauma. Other case had free fluid likely due to preexisting ascites. Conclusion: US may identify injuries. Comment: No evidence that US changes management. Level 5 Fair. Custer1 Reference Type: Journal Article Record Number: 1200 Author: Custer, J. R.; Polley, T. Z., Jr.; Moler, F. Year: 1987 Title: Gastric perforation following cardiopulmonary resuscitation in a child: report of a case and review of the literature Journal: Pediatric Emergency Care Volume: 3 Issue: 1 Pages: 24-7 Date: Mar Accession Number: 3562308 Keywords: Screen Abstract: We report a case of gastric rupture complicating cardiopulmonary resuscitation in a 13 year old. The tear occurred on the lesser curvature of the stomach as in reported adult cases. A tear was not discovered until autopsy, despite extensive premortem investigation. In a comatose or paralyzed patient, laparotomy may be indicated in the evaluation of pneumoperitoneum following cardiopulmonary resuscitation. Case report n=1 and review of literature n=16 gastric perforation following CPR. Level 5 Fair.
  16. 16. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 16 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Darke1 Reference Type: Journal Article Record Number: 1575 Author: Darke, S. G.; Bloomfield, E. Year: 1975 Title: Case of complete gastric rupture complicating resuscitation Journal: British Medical Journal Volume: 3 Issue: 5980 Pages: 414-5 Date: Aug 16 Accession Number: 1156790 Keywords: Screen Case report of gastric rupture after CPR. Level 5 Fair. Delanye1 Reference Type: Journal Article Record Number: 9073 Author: Delanaye, P.; De Fooz, G.; Nchimi, A.; Richardy, M.; Pierard, L.; Lancellotti, P. Year: 2003 Title: L'image du mois. Hematome hepatique apres une reanimation cardio-pulmonaire Journal: Revue Medicale de Liege Volume: 58 Issue: 7-8 Pages: 463-4 Keywords: Aged *Cardiopulmonary Resuscitation/ae [Adverse Effects] *Hematoma/et [Etiology] Hematoma/ra [Radiography] Human *Liver Diseases/et [Etiology] Liver Diseases/ra [Radiography] Male Notes: [Image of the month. Hematoma of the liver after cardiopulmonary resuscitation]. French Case report of hepatic hematoma after CPR. Level 5 Fair. Dohi1 Reference Type: Journal Article Record Number: 1364 Author: Dohi, S. Year: 1983 Title: Postcardiopulmonary resuscitation pulmonary edema Journal: Critical Care Medicine Volume: 11 Issue: 6 Pages: 434-7 Date: Jun Accession Number: 6851601 Keywords: Screen Abstract: Although severe pulmonary edema is encountered occasionally in patients needing CPR, there has been no definitive description on the mortality and morbidity of pulmonary edema after CPR. The author experienced severe pulmonary edema after standard CPR in 20 of 71 patients who suffered sudden, unexpected cardiac arrest and regained heart function by CPR. The varied onset of pulmonary edema, which may have developed when massive pink frothy secretions exited from the endotracheal tube, ranged from a few minutes to 45 min after the re-establishment of heart beat. These 20 patients showed a significantly higher P(A-a)O2, insignificant lower plasma protein concentrations, and high plasma osmolarities as compared with those who did not develop pulmonary edema. Only 2 patients with pulmonary edema survived. During CPR, many factors could cause pulmonary edema, including external cardiac massage (ECM), administration or
  17. 17. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 17 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT release of catecholamines, hypoxia, acidosis, overhydration, etc. This study indicates that patients who need CPR have a high likelihood of developing pulmonary edema. 71 patients subjected to 78 resuscitations. Of these, 20 developed pulmonary edema within 45 minutes of reestablishment of heart beat. Mechanism for this unclear. Level 5 Fair. Ducable1 Reference Type: Journal Article Record Number: 1491 Author: Ducable, G.; Chamoun, S.; Leturgie, C.; Watelet, J.; Winckler, C. Year: 1978 Title: [Gastric ruptures after resuscitation] Journal: Anesthesie, Analgesie, Reanimation Volume: 35 Issue: 6 Pages: 1153-8 Date: Nov-Dec Accession Number: 754561 Keywords: Screen Notes: French Case report of gastric rupture after CPR. Level 5 Fair. Elliot1 Reference Type: Journal Article Record Number: 1321 Author: Elliot, D. L.; Goldberg, L.; Shlitt, S. C.; Girard, D. E. Year: 1984 Title: Emphysematous cholecystitis following cardiopulmonary resuscitation Journal: Archives of Internal Medicine Volume: 144 Issue: 3 Pages: 635-6 Date: Mar Accession Number: 6703835 Keywords: Screen Abstract: Emphysematous cholecystitis developed in a 65-year-old man 24 hours following resuscitation from cardiac arrest. Our findings in this case support the importance of ischemia in this disease process. Case report of emphysematous cholecystitis that developed within 24 hours of resuscitation. Level 5 Fair. Enarson1 Reference Type: Journal Article Record Number: 1520 Author: Enarson, D. A.; Didier, E. P.; Gracey, D. R. Year: 1977 Title: Flail chest as a complication of cardiopulmonary resuscitation Journal: Heart & Lung: Journal of Acute & Critical Care Volume: 6 Issue: 6 Pages: 1020-2 Date: Nov-Dec Accession Number: 244316 Keywords: Screen Abstract: Records of all patients who developed flail chest after cardiopulmonary resuscitation at Rochester Methodist Hospital between January, 1966 and March 1976 were reviewed. Also, for comparison, records of patients with flail chest resulting from motor vehicle accidents and those of a matched group of patients who underwent cardiopulmonary resuscitation without developing flail chest were reviewed. The incidence of flail chest after cardiopulmonary resuscitation was about 5.6 per 100 survivors. The groups who did and did not have flail chest after cardiopulmonary resuscitation were alike
  18. 18. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 18 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT in age and in frequency and duration of the resuscitation. Stabilization of the flail chest required mechanical ventilation for 1 to 24 days (mean, 10.7). Flail chest did not significantly lengthen the hospitalization of patients who survived after cardiopulmonary resuscitation. The occurrence of flail chest after cardiopulmonary resuscitation did not seem to increase the mortality rate. Case-control study of flail chest after CPR. Incidence estimated at 5.6% of survivors. No abstract provided. Level 5 Fair. Enat1 Reference Type: Journal Article Record Number: 1477 Author: Enat, R.; Pollack, S.; Wiener, M.; Barzilai, D. Year: 1979 Title: Osteomyelitis in fractured sternum after cardiopulmonary resuscitation Journal: New England Journal of Medicine Volume: 301 Issue: 2 Pages: 108-9 Date: Jul 12 Accession Number: 449937 Keywords: Screen Case report of osteomyelitis in fractured sternum after CPR. Patient recovered after nonsurgical management. Level 5 Fair. Engelstein1 Reference Type: Journal Article Record Number: 1325 Author: Engelstein, D.; Stamler, B. Year: 1984 Title: Gastric rupture complicating mouth-to-mouth resuscitation Journal: Israel Journal of Medical Sciences Volume: 20 Issue: 1 Pages: 68-70 Date: Jan Accession Number: 6698775 Keywords: Screen Case report of a patient who choked on a cake, received forced air blown into his mouth. He felt better, then vomited food mixed with blood In the ED, he was found to have a large pneumoperitoneum. Subsequently found to have large laceration below GE junction. Level 5 Fair. Evans1 Reference Type: Journal Article Record Number: 1408 Author: Evans, R. D.; Lighton, J. E. Year: 1981 Title: Gastric rupture as a complication of cardiopulmonary resuscitation: report of case and review of literature Journal: Journal of the American Osteopathic Association Volume: 80 Issue: 12 Pages: 830-1 Date: Aug Accession Number: 7263324 Keywords: Screen Case report and review of literature of gastric rupture after CPR. Ventilated with “portable air bag” then underwent difficult intubation. Level 5 Fair. Feldman1 Reference Type: Journal Article Record Number: 2572
  19. 19. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 19 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Author: Feldman, K. W. ; Brewer, D. K. Year: 1984 Title: Child abuse, cardiopulmonary resuscitation, and rib fractures. Journal: Pediatrics Volume: 73 Issue: 3 Pages: 339-342 Date: 1984 Mar Label: 6140 Keywords: Adult Age Factors Child *Child Abuse Child, Preschool Comparative Study Diagnosis, Differential Human Infant Infant, Newborn Resuscitation *adverse effects Rib Fractures *etiology 1984 03 01 00:00 Abstract: Rib fractures have occasionally been described in children receiving cardiopulmonary resuscitation (CPR). Because child abuse is sometimes suspected in these cases, it is both medically and legally important to establish whether the rib fractures are secondary to abuse or CPR. One hundred thirteen children, including 41 victims of child abuse, 50 patients who had CPR, and 22 patients who had rib fractures, were studied. Twenty-nine patients had rib fractures; 14/29 (48%) were abusive. Other causes of fracture were: motor vehicle accidents (four), rickets/osteoporosis (five), surgery (five), and osteogenesis imperfecta (one). In spite of prolonged resuscitation performed with variable degrees of skill, no fractures could be attributed to CPR. On the other hand, rib fractures occurred frequently in abused children (6/41 or 15%). Abusive fractures were often multiple, of different ages, and affected multiple adjacent ribs. Patients with abusive rib fracture also had other physical and radiologic signs of abuse or neglect. Notes: ProCite field[38]: 84143903 Case-control study of n=41 victims of child abuse, n=50 children who had CPR, n=22 who had incidental rib fractures. Fractures frequently observed in abused children, especially multiple fractures; not observed after CPR. Level 5 Fair. Fitchet1 Reference Type: Journal Article Record Number: 6078 Author: Fitchet, A.; Neal, R.; Bannister, P. Year: 2001 Title: Lesson of the week: Splenic trauma complicating cardiopulmonary resuscitation Journal: BMJ Volume: 322 Issue: 7284 Pages: 480-481 Date: Feb 24 Accession Number: 11222427 Keywords: Cardiopulmonary Resuscitation/*adverse effects Case Report Female Heart Arrest/therapy Human
  20. 20. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 20 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Male Middle Age Splenic Rupture/*etiology/radiography Support, Non-U.S. Gov't Tomography, X-Ray Computed Notes: 0959-8138 Journal Article URL: http://bmj.com/cgi/content/full/322/7284/480 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11222427 Author Address: Manchester Heart Centre, Manchester Royal Infirmary, Manchester M13 9WL, UK. Alan. Fitchet@mhc.cmht.nwest.nhs.uk N=2 case reports of splenic trauma after CPR. Level 5 Fair. Fletcher1 Reference Type: Journal Article Record Number: 1717 Author: Fletcher, G. F. Year: 1969 Title: Hazardous complications of "closed chest" cardiopulmonary resuscitation Journal: American Heart Journal Volume: 77 Issue: 3 Pages: 431-2 Date: Mar Accession Number: 5766731 Keywords: Screen N=4 case reports (n=3 tension pneumothorax, n=1 pneumoperitoneum with abdominal distension. Floret1 Reference Type: Journal Article Record Number: 1187 Author: Floret, D.; Melki, I.; Philibert, N.; Takvorian, P. Year: 1987 Title: [Gastric rupture and resuscitation maneuvers] Journal: Pediatrie Volume: 42 Issue: 2 Pages: 95-7 Accession Number: 3615143 Keywords: Screen Abstract: Near drowning in a bathtub occurred to a 3 years 7 months old boy. He was resuscitated at home by the firemen before admission in hospital, where he presented coma, convulsions and a massive distension of the abdomen. Surgical procedure revealed a 3 cm long perforation on the smaller curvature, which was repaired. This aspect and the localisation of the rupture resemble those related to resuscitation procedures: oxygenotherapy by nasal catheter, external cardiac massage, mouth-to-mouth ventilation. The stomach is filled with air because inadequate position of the catheter. It also may be related to relaxation of crico-pharyngeal sphincter during anesthesia or coma. Notes: French Case report of gastric rupture after CPR given after near drowning. Level 5 Fair. Flowers1 Reference Type: Journal Article Record Number: 1799 Author: Flowers, R. Year: 1965 Title: Complications of cardiac resuscitation in cardiac arrests accompanying myocardial infarction Journal: Medical Services Journal, Canada
  21. 21. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 21 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Volume: 21 Issue: 7 Pages: 429-36 Date: Jul-Aug Accession Number: 5850823 Keywords: Screen N=5 case reports. Frequent rib fractures observed; some bone marrow and fat emboli. No comparison group. No abstract provided. Level 5 Fair. Fosse1 Reference Type: Journal Article Record Number: 705 Author: Fosse, E.; Lindberg, H. Year: 1996 Title: Left ventricular rupture following external chest compression Journal: Acta Anaesthesiologica Scandinavica Volume: 40 Issue: 4 Pages: 502-4 Date: Apr Accession Number: 8738698 Keywords: Screen Abstract: A case of a 62-year-old woman suffering an acute cardiac arrest during a court dispute is presented. Cardiopulmonary resuscitation was immediately started by bystanders. In hospital there were signs of intrathoracic bleeding. A left thoracotomy revealed a cardiac rupture of the left ventricle and a large pericardial tear. Intraoperative evaluation of the heart as well as postoperative enzyme levels and ECG did not indicate acute myocardial infarction. The rupture may therefore be traumatic. The cardiac rupture was sutured five hours after the initial resuscitation, and the patient discharged from the intensive care unit two days after the rupture without clinical signs of neurological injury. A precordial thump is advised before start of external chest compression. One beneficial effect may be that the ventricles empty and the risk of traumatic rupture during compression is reduced. Case report of 62 year-old women who had out of hospital cardiac arrest followed by CPR. Diagnosed as having ventricular rupture, but not acute MI. Surgical repair then discharge. Level 5 Fair. Gainant1 Reference Type: Journal Article Record Number: 1306 Author: Gainant, A.; Gobeaux, R. F.; Renaudie, J.; Voultoury, J. C.; Cubertafond, P.; Gay, R. Year: 1984 Title: [Pneumoperitoneum following cardiorespiratory resuscitation procedures] Journal: Presse Medicale Volume: 13 Issue: 30 Pages: 1845-6 Date: Sep 1-8 Accession Number: 6236448 Keywords: Screen Notes: French Case report of pneumoperitoneum after CPR. French. No abstract provided. Level 5 Fair. Gallagher1 Reference Type: Journal Article Record Number: 1209 Author: Gallagher, J. T.; Holmes, W.; Cunningham, J. D. Title: Tympanic injury and cardiopulmonary resuscitation Pages: 464-7
  22. 22. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 22 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Accession Number: 3824453 Keywords: Screen Notes: Transactions - Pennsylvania Academy of Ophthalmology & Otolaryngology 1986;38(2) Case report of tympanic membrane perforation and sensorineural hearing loss after CPR. Related to increased pressure, possibly in conjunction with emesis, transmitted through Eustachian tube. No abstract provided. Level 5 Fair. Gerry1 Reference Type: Journal Article Record Number: 1523 Author: Gerry, J. L., Jr.; Bulkley, B. H.; Hutchins, G. M. Year: 1977 Title: Rupture of the papillary muscle of the tricuspid valve. A complication of cardiopulmonary resuscitation and a rare cause of tricuspid insufficiency Journal: American Journal of Cardiology Volume: 40 Issue: 5 Pages: 825-8 Date: Nov Accession Number: 920621 Keywords: Screen Abstract: Rupture of a papillary muscle is a rare occurrence. Two patients are described in whom rupture of a papillary muscle of the tricuspid valve developed after external cardiac massage during cardiopulmonary resuscitation. One of these patients survived briefly with clinical evidence of triscupid regurgitation immediately after resuscitation. Although tricuspid valve papillary muscle rupture has been described as a complication of bacterial endocarditis, chest trauma and myocardial infarction, it is a generally unrecognized complication of external cardia massage. Findings in the two patients reported here suggest that patients with a dilated right ventricle may be more susceptible to this rare complication of cardiopulmonary resuscitation. Case report (n=2) of papillary muscle rupture after CPR. Related to preexisting dilated RV. No abstract provided. Level 5 Fair. Gillies1 Reference Type: Journal Article Record Number: 6029 Author: Gillies, M.; Hogarth, I. Year: 2001 Title: Liver rupture after cardiopulmonary resuscitation during peri-operative cardiac arrest Journal: Anaesthesia Volume: 56 Issue: 4 Pages: 387-388 Date: Apr Accession Number: 11284853 Keywords: Cardiopulmonary Resuscitation/*adverse effects Case Report Heart Arrest/*therapy Human Liver/*injuries Male Middle Age Preoperative Care/methods Rupture/etiology Notes: 0003-2409 Letter URL: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11284853
  23. 23. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 23 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Case report and review of literature of liver rupture after CPR. Not associated with overlying rib fractures. No abstract provided. Level 5 Fair. Gilliland1 Reference Type: Journal Article Record Number: 871 Author: Gilliland, M. G.; Luckenbach, M. W. Year: 1993 Title: Are retinal hemorrhages found after resuscitation attempts? A study of the eyes of 169 children Journal: American Journal of Forensic Medicine & Pathology Volume: 14 Issue: 3 Pages: 187-92 Date: Sep Accession Number: 8311048 Keywords: Screen Abstract: Resuscitation attempts have been hypothecated to explain retinal hemorrhages in infants who are suspected victims of child abuse. This study was undertaken to test that hypothesis by postmortem ocular examinations following unsuccessful resuscitation attempts on a sample of 169 children selected by 19 prosectors willing to contribute to the study. Cardiopulmonary resuscitation had been attempted for a minimum of 30 min in 131 of the children, whereas 38 controls did not have such protracted attempts; 70 children with prolonged resuscitation attempts had no retinal hemorrhages, including eight children whose fatal blunt force injuries of the trunk represented extremes of the forces used in resuscitation attempts. Children who died of asphyxia, respiratory illnesses, sudden infant death syndrome, and various other causes had no hemorrhages; neither did 21 children who died of head injury or central nervous system (CNS) diseases, nor did 29 controls. Retinal hemorrhages were present in 70 children, 61 with prolonged resuscitation attempts and nine controls. Among those with attempted resuscitation, 56 had head injuries, and four had CNS diseases and sepsis, all recognized causes of retinal hemorrhages. The other death that involved a resuscitation attempt and retinal hemorrhages was an officially "undetermined" death. The child had come from a household with two prior child deaths and documented abuse. No case is found in this study to support the hypothesis that retinal hemorrhages are caused by resuscitation attempts. Case control study of 169 children: 131 after prolonged resuscitation; 38 without resuscitation. Retinal hemorrhages not observed after resuscitation. Implies if observed, should consider other cause of morbidity or mortality. Level 5 Fair. Goetting1 Reference Type: Journal Article Record Number: 1063 Author: Goetting, M. G.; Sowa, B. Year: 1990 Title: Retinal hemorrhage after cardiopulmonary resuscitation in children: an etiologic reevaluation.[see comment] Journal: Pediatrics Volume: 85 Issue: 4 Pages: 585-8 Date: Apr Accession Number: 2314970 Keywords: Screen Case series of 20 children after resuscitation; 10% had retinal hemorrhages not observed after resuscitation. Implies if observed, may be related to resuscitation rather than other cause of morbidity or mortality. No abstract provided. Level 5 Fair. Goldberg1 Reference Type: Journal Article Record Number: 10512
  24. 24. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 24 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Author: Goldberg, R.M.; Rowan, L.; Anderson, R.E. Year: 1988 Title: Thoracic vertebral fracture as a complication of cardiopulmonary resuscitation Journal: Journal of Emergency Medicine Volume: 6 Issue: 3 Pages: 177-178 Alternate Journal: Journal of Emergency Medicine Accession Number: 1988174858 Keywords: autopsy case report heart massage human normal human resuscitation vertebra fracture Abstract: We report the case of a 76-year-old woman who suffered cardiopulmonary arrest three days after being hospitalized with an acute myocardial infarction. She underwent standard cardiopulmonary resuscitative measures for approximately 25 min before being pronounced dead. Autopsy examination revealed a recent myocardial infarction, as well as an acutely fractured tenth thoracic vertebra. Thoracic vertebral fractures are a previously unrecognized complication of cardiopulmonary resuscitation. Case report of a 76 year-old women who had cardiopulmonary arrest after a recent MI. Acutely fractured tenth thoracic vertebra observed at autopsy; attributed to CPR. Level 5 Fair. Gordon1 Reference Type: Journal Article Record Number: 1681 Author: Gordon, H. L.; Walkup, J. L. Year: 1970 Title: Scrotal pneumatocele as an unusual sign of pneumoperitoneum: report of a case and review of the literature Journal: Journal of Urology Volume: 104 Issue: 3 Pages: 441-2 Date: Sep Accession Number: 5459979 Keywords: Screen Scrotal pneumatocele observed as extension of pneumoperitoneum after resuscitation. Level 5 Fair. Gregersen1 Reference Type: Journal Article Record Number: 1421 Author: Gregersen, M.; Vesterby, A. Year: 1981 Title: Iatrogenic fractures of the hyoid bone and the thyroid cartilage. A case report Journal: Forensic Science International Volume: 17 Issue: 1 Pages: 41-3 Date: Jan-Feb Accession Number: 7216081 Keywords: Screen Abstract: A case of fracture of the hyoid bone and the thyroid cartilage is reported as a complication to resuscitation. This gave rise to many forensic as well as police investigations and stresses the importance of detailed information at medicolegal autopsies as regards the resuscitation carried out.
  25. 25. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 25 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Case report of hyoid bone and thyroid cartilage fracture after CPR. Attributed to intubation. No abstract provided. Level 5 Fair. Gueugniaud1 Reference Type: Journal Article Record Number: 1204 Author: Gueugniaud, P. Y. Year: 1987 Title: Subarachnoid hemorrhage: a complication of CPR? Journal: Critical Care Medicine Volume: 15 Issue: 3 Pages: 284-5 Date: Mar Accession Number: 3816272 Keywords: Screen Case report of traumatic subarachnoid hemorrhage after CPR. Attributed to elevated CVP during 45 minutes of external cardiac massage. Level 5 Fair. Hachiro1 Reference Type: Journal Article Record Number: 840 Author: Hachiro, Y. ; Okada, H. ; Hayakawa, T. ; Matsubara, I. ; Maekawa, K. ; Tanaka, T. Year: 2000 Title: Cardiac tamponade secondary to cardiopulmonary resuscitation in a patient receiving antiplatelet therapy [letter] Journal: Am J Emerg Med Volume: 18 Issue: 7 Pages: 836-837 Date: 2000 Nov Label: 48500 Keywords: 2000 12 05 11:00 Notes: ProCite field[38]: 20552105 Case report of tamponade after CPR given to a patient receiving ticlopidine. No fracture of sternum or ribs. No abstract provided. Level 5 Fair. Hargarten1 Reference Type: Journal Article Record Number: 1147 Author: Hargarten, K. M.; Aprahamian, C.; Mateer, J. Year: 1988 Title: Pneumoperitoneum as a complication of cardiopulmonary resuscitation Journal: American Journal of Emergency Medicine Volume: 6 Issue: 4 Pages: 358-61 Date: Jul Accession Number: 3291885 Keywords: Screen Abstract: A case of pneumoperitoneum following cardiopulmonary resuscitation (CPR) is reported and 11 cases in the literature are reviewed. Four patients had laparotomies failing to demonstrate any visceral perforation or evidence of peritonitis in spite of the massive pneumoperitoneum present. Operative intervention immediately after resuscitation is associated with potentially high morbidity and mortality. Several diagnostic tools are used, including peritoneal lavage and contrast media tests, to accurately diagnose perforated viscus. To avoid an unnecessary celiotomy a clinical treatment protocol has been developed for patients with pneumoperitoneum secondary to CPR. Such diagnostic tools as peritoneal lavage and water-soluble contrast medium test are reviewed and included in this protocol. A nonsurgical approach to patient management
  26. 26. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 26 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT may be reasonable if certain criteria are met. [References: 30] Notes: Review Case report N=1 and review of literature of pneumoperitoneum after CPR. No abstract provided. Stated that operative intervention immediately after CPR has high morbidity and mortality; nonsurgical approach reasonable. Level 5 Fair. Harm1 Reference Type: Journal Article Record Number: 1340 Author: Harm, T.; Rajs, J. Year: 1983 Title: Face and neck injuries due to resuscitation versus throttling Journal: Forensic Science International Volume: 23 Issue: 2-3 Pages: 109-16 Date: Nov-Dec Accession Number: 6662437 Keywords: Screen Abstract: Face and neck injuries of 21 patients who died of other causes than mechanic asphyxia and who were resuscitated in connection to dying were analyzed during a 3-year period, 1980-1982. The injuries were predominantly of the type nail impression marks (85%) and showed a regular symmetric distribution tending to form circles around the nostrils and mouth. Injuries inflicted upon mouth-to-mouth ventilation were localized to the nose and at jaw-thrust to the mandibular margins and were easy to differ from those due to throttling. Injuries inflicted on the cheeks upon removal of vomit from the mouth were similar to those seen after violent oral occlusion and those occurring at carotid pulse palpation as indicated by throttling. No fractures of the laryngeal skeleton and no conjunctival haemorrhages were seen. Case control study of 21 patients who died of causes other than airway obstruction and required resuscitation (cases) and 21 who were throttled. Of cases, 16 (76%) had bruises and abrasions on face and at mandibular margins but none had conjunctival hemorrhages or laryngeal fractures. Throttle patients had bruises and abrasions on the neck. Level 5 Fair. Hartoko1 Reference Type: Journal Article Record Number: 1005 Author: Hartoko, T. J.; Demey, H. E.; Rogiers, P. E.; Decoster, H. L.; Nagler, J. M.; Bossaert, L. L. Year: 1991 Title: Pneumoperitoneum--a rare complication of cardiopulmonary resuscitation Journal: Acta Anaesthesiologica Scandinavica Volume: 35 Issue: 3 Pages: 235-7 Date: Apr Accession Number: 2038930 Keywords: Screen Abstract: Pneumoperitoneum following cardiopulmonary resuscitation (CPR) results from a thoracic air leak (pneumothorax, pneumomediastinum) with escape of the air through diaphragmatic apertures (mostly foramen of Winslow) or primary perforation of the gastrointestinal tract (stomach or esophagus). We report three cases of pneumoperitoneum complicating CPR. As there was no clinical evidence of peritonitis, and the patients remained stable, a conservative approach was followed without surgical exploration. All patients recovered completely. N=3 cases of pneumoperitoneum after CPR. All managed conservatively and had good outcome; nonsurgical approach reasonable. Level 5 Fair. Hashimoto1 Reference Type: Journal Article Record Number: 2316
  27. 27. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 27 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Author: Hashimoto, Y. ; Yamaki, T. ; Sakakibara, T. ; Matsui, J. ; Matsui, M. Year: 2000 Title: Cerebral air embolism caused by cardiopulmonary resuscitation after cardiopulmonary arrest on arrival. Journal: J Trauma Volume: 48 Issue: 5 Pages: 975-977 Date: 2000 May Label: 50600 Keywords: Accidents, Traffic Adult Cardiopulmonary Resuscitation *adverse effects instrumentation methods Case Report Embolism, Air *etiology radiography Fatal Outcome Heart Arrest etiology *therapy Hemopneumothorax complications radiography Human Intracranial Embolism *etiology radiography Male Risk Factors Thoracic Injuries complications radiography Tomography, X-Ray Computed 2000 06 10 09:00 Notes: ProCite field[38]: 20281055 Case report n=1 of patient with cerebral air embolism after CPR and central venous cannulation. No skull fracture or pnuemocephalus. Attributed to shunt from major bronchus to pulmonary artery after trauma. No abstract provided. Level 5 Fair. Haugeberg1 Reference Type: Journal Article Record Number: 1099 Author: Haugeberg, G.; Bonarjee, V.; Dickstein, K. Year: 1989 Title: Fatal intrathoracic haemorrhage after cardiopulmonary resuscitation and treatment with streptokinase and heparin.[see comment] Journal: British Heart Journal Volume: 62 Issue: 2 Pages: 157-8 Date: Aug Accession Number: 2765328 Keywords: Screen Abstract: A 66 year old man with acute myocardial infarction underwent cardiopulmonary
  28. 28. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 28 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT resuscitation before being treated with streptokinase and heparin. Seventeen hours later he died of an intrathoracic haemorrhage caused by multiple fractures of the sternum and ribs. Case report of patient with acute MI treated with CPR, then Streptokinase and heparin. Died 17 hours later of intrathoracic hemorrhage associated with multiple fractures of sternum and ribs. Level 5 Fair. Hillman1 Reference Type: Journal Article Record Number: 1231 Author: Hillman, K.; Albin, M. Year: 1986 Title: Pulmonary barotrauma during cardiopulmonary resuscitation Journal: Critical Care Medicine Volume: 14 Issue: 7 Pages: 606-9 Date: Jul Accession Number: 3720308 Keywords: Screen Abstract: Despite the large variety of ventilatory equipment and conditions under which CPR is performed, there have been few cases of pulmonary barotrauma, which is surprising since the transpulmonary pressures developed during CPR are relatively high. This report cites four cases demonstrating different mechanisms by which pulmonary barotrauma can be caused during CPR, and reviews their pathophysiologic consequences. The suggested levels of transpulmonary pressure needed for effective simultaneous chest compression and ventilation are even higher than those used for conventional CPR and are likely to contribute to the incidence of barotrauma during CPR. Case series n=4 of pulmonary barotraumas after CPR: subcutaneous emphysema, mediastinal emphysema, pneumothoraces. Attributed to high peak airway pressures during CPR: failure of one-way valve to open during resuscitation, vigorous cardiac massage. Recommend avoid overventilation, and use pressure-limiting valve. Level 5 Fair. Hood1 Reference Type: Journal Article Record Number: 1157 Author: Hood, I.; Ryan, D.; Spitz, W. U. Year: 1988 Title: Resuscitation and petechiae Journal: American Journal of Forensic Medicine & Pathology Volume: 9 Issue: 1 Pages: 35-7 Date: Mar Accession Number: 3354520 Keywords: Screen Abstract: Petechiae can be important corroborative evidence of asphyxia, but are also seen in persons who have died of other means. It is not uncommon to encounter them in cases in which cardiopulmonary resuscitation has reestablished blood flow and pressure in small vessels already damaged by hypoxia resulting in the formation of petechiae. This report documents some representative cases. Case series of 4 patients autopsied after unsuccessful CPR. Two with gunshot wound to head, one with recent MI, and one with history of seizures found unresponsive at home. All had fine petechiae of eyelids and cheeks. No abstract provided. Level 5 Fair. Hulewicz1 Reference Type: Journal Article Record Number: 1052 Author: Hulewicz, B. Year: 1990 Title: Gastric trauma following cardiopulmonary resuscitation.[see comment]
  29. 29. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 29 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Journal: Medicine, Science & the Law Volume: 30 Issue: 2 Pages: 149-52 Date: Apr Accession Number: 2348769 Keywords: Screen Abstract: Three cases of gastric trauma following cardiopulmonary resuscitation are reported. In two cases there were full thickness lacerations of the gastric wall resulting in pneumoperitoneum and in one case subcutaneous emphysema. In the third case, gastric mucosal lacerations resulted in gastric haemorrhage. In all three cases it was thought that the gastric lesions did not contribute to death and were resuscitation artefacts. Case series n=3 of gastric trauma after CPR. Level 5 Fair. Jeong1 Reference Type: Journal Article Record Number: 10758 Author: Jeong, Y.G.; Caccamo, L.P. Year: 1975 Title: Letter: Cardiac resuscitation and vertebral fracture. Journal: Journal of the American Medical Association Volume: 234 Pages: 1223%N 12 Alternate Journal: Journal of the American Medical Association Accession Number: 1242744 Keywords: adult article cardioversion case report female fracture heart infarction heart massage human resuscitation spine injury Author Address: Jeong, Y.G. Case report of fractured thoracic vertebra after CPR. No abstract provided. Level 5 Fair. Kam1 Reference Type: Journal Article Record Number: 807 Author: Kam, A. C.; Kam, P. C. Year: 1994 Title: Scapular and proximal humeral head fractures. An unusual complication of cardiopulmonary resuscitation Journal: Anaesthesia Volume: 49 Issue: 12 Pages: 1055-7 Date: Dec Accession Number: 7864320 Keywords: Screen Abstract: We report a patient who sustained fractures of the scapula and proximal humeral head as a result of cardioversion during cardiopulmonary resuscitation. It is postulated that the fractures were the result of tetanic muscular contractions involving the proximal humeral heads and the shoulder girdles. This appears to be a previously unreported injury.
  30. 30. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 30 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Case report of patient who experienced fractured scapula and proximal humeral head attributed to cardioversion during CPR. Level 5 Fair. Kanter1 Reference Type: Journal Article Record Number: 13765 Author: Kanter, R.K. Year: 1986 Title: Retinal hemorrhage after cardiopulmonary resuscitation or child abuse Journal: Journal of Pediatrics Volume: 108 Issue: 3 Pages: 430-432 Alternate Journal: Journal of Pediatrics Accession Number: 1986115028 Keywords: artificial ventilation autopsy central nervous system child abuse child classification clinical article computer analysis computer assisted tomography controlled study diagnosis education etiology fatality forensic medicine histology human cell human infant injury preliminary communication preschool child priority journal respiratory system resuscitation retina hemorrhage therapy visual system Abstract: Retinal hemorrhage in a comatose infant is characteristically a sign of central nervous system injury resulting from child abuse. Caffey speculated that elevated intrathoracic venous pressure transmitted to the head during cardiopulmonary resuscitation or positive pressure breathing could also lead to hemorrhagic brain or eye damage. The significance of this suggestion has never been clinically evaluated. In our study, funduscopic examinations were carried out to determine the extent to which retinal hemorrhage is a complication of CPR in the absence of preceding trauma. Resolution of this question is necessary to clarify the diagnostic importance of retinal hemorrhage as a clue to occult trauma and child abuse, as opposed to iatrogenic injury associated with CPR. Case series of 54 children after CPR who underwent fundoscopic examination. 9 had prior trauma; 5 (56%) of these had retinal hemorrhages. 45 had no prior trauma; 1 (2%) had retinal hemorrhage. Significant difference between groups: p=0.0002. No abstract provided. Level 5 Fair. Kaplan1 Reference Type: Journal Article Record Number: 200 Author: Kaplan, J. A. ; Fossum, R. M.
  31. 31. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 31 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Year: 1994 Title: Patterns of facial resuscitation injury in infancy. Journal: Am J Forensic Med Pathol Volume: 15 Issue: 3 Pages: 187-191 Date: 1994 Sep Label: 41350 Keywords: Cardiopulmonary Resuscitation *adverse effects Facial Injuries etiology *pathology Human Infant Infant, Newborn Respiration, Artificial instrumentation Sudden Infant Death pathology 1994 09 01 00:00 Abstract: Cardiopulmonary resuscitation (CPR)-related artifacts in pediatric rescue that have the potential for serious complications in surviving patients have been well described in the medical literature. Medically trivial soft-tissue injuries, especially of the face and neck, carry predominantly forensic significance and have received less attention. We describe such injuries in nine of 25 consecutive cases of infants who received CPR, and correlate those injuries with specific rescue maneuvers. Techniques for effective investigation and interpretation of such injuries are suggested. Notes: ProCite field[38]: 95126080 Case series of 25 consecutive children with unexpected death who received CPR. Of these 9 had facial injuries related to bag-valve-mask ventilation, mouth-to-mouth ventilation or endotracheal intubation. Level 5 Fair. Katz1 Reference Type: Journal Article Record Number: 10819 Author: Katz, A.; Henkin, J.; Ovsyshcher, I.A. Year: 1989 Title: Transient complete atrioventricular block induced by a chest thump in a patient with ventricular tachycardia Journal: International Journal of Cardiology Volume: 23 Issue: 3 Pages: 395-396 Alternate Journal: International Journal of Cardiology Accession Number: 1989129461 Keywords: aged atrioventricular block case report electrocardiogram heart ventricle tachycardia human male precordial thumping priority journal thorax Abstract: We describe an unusual case of transient complete atrioventricular block induced by a chest thump during resuscitation in a patient with ventricular tachycardia.
  32. 32. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 32 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Case report of patient who developed transient AV block induced by a chest thump during resuscitation in a patient with VT. Level 5 Fair. Kempen1 Reference Type: Journal Article Record Number: 448 Author: Kempen, P. M.; Allgood, R. Year: 1999 Title: Right ventricular rupture during closed-chest cardiopulmonary resuscitation after pneumonectomy with pericardiotomy: a case report Journal: Critical Care Medicine Volume: 27 Issue: 7 Pages: 1378-9 Date: Jul Accession Number: 10446834 Keywords: Screen Abstract: SETTING: The collapse of a patient immediately after right pneumonectomy with right pericardiotomy resulted in closed-chest cardiopulmonary resuscitation, subsequent thoracotomy, and demise secondary to right ventricular rupture. Interventions: Closed-chest resuscitation with opened and closed chest tubes and medical and fluid interventions were inadequate, necessitating subsequent thoracotomy. MAIN RESULTS AND CONCLUSIONS: Right ventricular rupture during resuscitation was found during subsequent thoracotomy. This rupture and inadequacy of closed-chest resuscitation were felt to be associated with the operative pneumonectomy and pericardiotomy. Pathophysiology and the role of open-heart vs. closed-chest resuscitative measures are discussed. Case report of RV rupture after external cardiac massage. Level 5 Fair. Kendall1 Reference Type: Journal Article Record Number: 893 Author: Kendall, I. G.; Wynn, S. M.; Quinton, D. N. Year: 1993 Title: A study of patients referred from A&E for coroners post-mortem Journal: Archives of Emergency Medicine Volume: 10 Issue: 2 Pages: 86-90 Date: Jun Accession Number: 8329084 Keywords: Screen Abstract: A review of 179 autopsies was undertaken over a 1-year period to determine if clinically useful information was obtainable from coroners post mortems performed on patients referred from the A&E department. Fifty-six patients had undergone unsuccessful resuscitation. The leading causes of death were heart disease and trauma. Discrepancies between the diagnosis made during resuscitation and the cause of death found at autopsy were revealed especially in those dying from noncardiac causes. Iatrogenic trauma from resuscitation attempts occurred in a significant number of cases. It is suggested that review of selected Coroners post mortems should be part of departmental audit, with a view to improving clinical skills. Cohort study of 179 consecutive autopsies performed upon patients referred from an A and E (emergency) department. Of these, 45 had medical arrest. Of these, 7 had iatrogenic injuries including fractured sternum, fractured ribs, flail segment, bruised LV, lacerated pericardium. Level 5 Fair. Kloss1 Reference Type: Journal Article Record Number: 1346 Author: Kloss, T.; Puschel, K.; Wischhusen, F.; Welk, I.; Roewer, N.; Jungck, E. Year: 1983
  33. 33. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 33 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Title: [Resuscitation injuries] Journal: Anasthesie, Intensivtherapie, Notfallmedizin Volume: 18 Issue: 4 Pages: 199-203 Date: Aug Accession Number: 6638422 Keywords: Screen Abstract: This investigation is based on 140 autopsy protocols of unsuccessful resuscitation procedures (Resuscitation Center of the Army Hospital, Hamburg); injections and closed-chest cardiac massage had been performed in every case. - Most of the patients had collapsed because of cardiac shock; patients with thoracic or abdominal injury were excluded from this study. In individual cases only, the following severe complications originated from the resuscitation procedures: fracture of a chest vertebra, serial fractures of ribs resulting in an unstable thorax, bilateral haemothorax, tension pneumothorax, rupture of kidney and of spleen (but not of liver). In one case the lesions caused by the resuscitation measures must be considered as responsible for the lethal outcome. Fractures of ribs and/or sternum were found in 45.9% of all cases, the frequency increasing with age. The number of fractured ribs ranged up to 16, mainly 3-8 ribs were fractured. Fractures of rib No. 1 and 8-12 were very rare. The fractures were located between the parasternal and axillary lines.--In a comparative study the site of rib fractures after heavy blunt thoracic injuries was preferably found in the dorsal region. Notes: German Case series of 160 autopsies after unsuccessful CPR. Excluded those with thoracic or abdominal injury. 74 (46%) had fractured ribs. Other injuries included vertebral fractures, bilateral hemothorax, tension pneumothorax, rupture of kidney, splenic rupture. No abstract provided. Level 5 Fair. Kordas1 Reference Type: Journal Article Record Number: 1571 Author: Kordas, J.; Kotulski, J.; Zolnierczyk, J. Year: 1975 Title: [Transient diabetes insipidus following cardiologic resuscitation in a patient with myocardial infarct] Journal: Wiadomosci Lekarskie Volume: 28 Issue: 20 Pages: 1701-8 Date: Oct 15 Accession Number: 1179738 Keywords: Screen Notes: Polish Case report of transient diabetes observed after resuscitation. No abstract provided. Level 5 Fair. Kramer1 Reference Type: Journal Article Record Number: 203 Author: Kramer, K. ; Goldstein, B. Year: 1993 Title: Retinal hemorrhages following cardiopulmonary resuscitation. Journal: Clin Pediatr Volume: 32 Issue: 6 Pages: 366-368 Date: 1993 Jun Label: 41380 Keywords: Adenoviridae Infections complications Cardiopulmonary Resuscitation
  34. 34. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 34 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT *adverse effects Case Report Dehydration complications Female Gastroenteritis complications Human Infant Retinal Hemorrhage diagnosis *etiology pathology physiopathology 1993 06 01 00:00 Notes: ProCite field[38]: 93345187 Case report of 17 month old with nontraumatic cardiac arrest who had retinal hemorrhages after CPR. Level 5 Fair. Krause1 Reference Type: Journal Article Record Number: 1314 Author: Krause, S.; Donen, N. Year: 1984 Title: Gastric rupture during cardiopulmonary resuscitation Journal: Canadian Anaesthetists' Society Journal Volume: 31 Issue: 3 Pt 1 Pages: 319-22 Date: May Accession Number: 6722623 Keywords: Screen Abstract: Gastric rupture following ventilation during cardiopulmonary resuscitation is a rare occurrence. We report two cases of documented gastric rupture plus two additional cases in which the clinical diagnosis of pneumoperitoneum was made and gastric rupture was assumed to be the mechanism. Review of the literature reveals the lesser curvature of the stomach to be the common site of rupture. This complication emphasizes the necessities of correct positioning of the jaw with mouth-to-mouth ventilation and careful assessment of air entry and chest movement following endotracheal intubation. Case report of gastric rupture after CPR. Level 5 Fair. Krischer1 Reference Type: Journal Article Record Number: 991 Author: Krischer, J. P. ; Fine, E. G. ; Davis, J. H. ; Nagel, E. L. Year: 1987 Title: Complications of cardiac resuscitation. Journal: Chest Volume: 92 Issue: 2 Pages: 287-291 Date: 1987 Aug Label: 8890 Keywords: Abdominal Injuries etiology Female
  35. 35. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 35 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Fractures etiology Heart Injuries etiology Hemorrhage etiology Human Larynx injuries Male Mediastinal Diseases etiology Middle Age Prospective Studies Pulmonary Edema etiology Resuscitation *adverse effects Rib Fractures etiology Sternum injuries Support, U.S. Gov't, P.H.S. 1987 08 01 00:00 Abstract: In a prospective study of the complications of cardiac resuscitation, 705 cases were autopsied to identify the cause of death and the pathologic findings attributable to cardiac resuscitation. Thoracic complications were observed in 42.7 percent of the cases. A total of 31.6 percent had rib fractures, 21.1 percent had sternal fractures, and 18.3 percent were reported as having anterior mediastinal hemorrhage; 20.4 percent of the cases had an upper airway complication. Abdominal visceral complications were noted in 30.8 percent of the cases, and pulmonary complications occurred in 13 percent of the resuscitation population. Life-threatening complications, such as heart and great vessel injuries, occurred in less than .5 percent of the cases. Notes: ProCite field[38]: 87275114 705 of 2187 cases of out of hospital cardiac arrest autopsied. Observed were rib fractures (32%), sternal fractures (21%), anterior mediastinal hemorrhage (18%), upper airway complication (20%), abdominal visceral problems (31%), pulmonary complications (13%). Lifethreatening complications were rare (<0.5%). Level 5 Fair. Krumholz1 Reference Type: Journal Article Record Number: 1163 Author: Krumholz, A.; Stern, B. J.; Weiss, H. D. Year: 1988 Title: Outcome from coma after cardiopulmonary resuscitation: relation to seizures and myoclonus Journal: Neurology Volume: 38 Issue: 3 Pages: 401-5 Date: Mar Accession Number: 3347343 Keywords: Screen Abstract: We studied the effect of seizures and myoclonus following cardiopulmonary resuscitation (CPR) on the outcome of all comatose adult survivors of CPR over an 8-year period. Either seizures or myoclonus occurred in 50 of 114 patients (44%): seizures in 41 patients (36%) and myoclonus in 40 (35%). Status epilepticus or status myoclonus occurred in 36 patients (32%), and 19 (17%) had myoclonic status epilepticus (MSE).
  36. 36. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 36 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Seizures and myoclonus per se were not significantly related to outcome, but status epilepticus, status myoclonus, and, particularly, MSE were predictive of poor outcome as judged by survival and recovery of consciousness. Cohort study of all comatose adult survivors of CPR over an 8-year period. Observed were seizures (36%) and myoclonus (35%). Level 5 Fair. Kurkciyan1 Reference Type: Journal Article Record Number: 8674 Author: Kurkciyan, I.; Meron, G.; Sterz, F.; Mullner, M.; Tobler, K.; Domanovits, H.; Schreiber, W.; Bankl, H. C.; Laggner, A. N. Year: 2003 Title: Major bleeding complications after cardiopulmonary resuscitation: impact of thrombolytic treatment Journal: J Intern Med Volume: 253 Issue: 2 Pages: 128-35 Date: Feb Accession Number: 12542552 Keywords: Adult Aged Aged, 80 and over Cardiopulmonary Resuscitation/*adverse effects Cohort Studies Female Heart Arrest/*therapy Hemorrhage/*chemically induced Human Male Middle Aged Myocardial Infarction/*drug therapy Retrospective Studies Survival Analysis Thrombolytic Therapy/*methods Abstract: OBJECTIVE: The risk of bleeding complications caused by thrombolysis in patients with cardiac arrest and prolonged cardiopulmonary resuscitation is unclear. We evaluate the complication rate of systemic thrombolysis in patients with out-of-hospital cardiac arrest caused by acute myocardial infarction, especially in relation to duration of cardiopulmonary resuscitation. DESIGN: The study was designed as retrospective cohort study, the risk factor being systemic thrombolysis and the end-point major haemorrhage, defined as life-threatening and/or need for transfusion. Over 10.5 years, emergency cardiac care data, therapy, major haemorrhage and outcome of 265 patients with acute myocardial infarction admitted to an emergency department after successful cardiopulmonary resuscitation were registered. RESULTS: We observed major haemorrhage in 13 of 132 patients who received thrombolysis (10%, 95% confidence interval 5-15%), five of these survived to discharge, none died because of this complication. Major haemorrhage occurred in seven of 133 patients in whom no thrombolytic treatment had been given (5%, 95% confidence interval 1-9%), two of these survived to discharge. Taking into account baseline imbalances between the groups, the risk of bleeding was slightly increased if thrombolytics were used (odds ratio 2.5, 95% confidence interval 0.9-7.4) but this was not significant (P = 0.09). There was no clear association between duration of resuscitation and bleeding complications (z for trend = 1.52, P = 0.12). Survival was not significantly better in patients receiving thrombolysis (odds ratio 1.6, 0.9-3.0, P = 0.12). CONCLUSIONS: Bleeding complications after cardiopulmonary resuscitation are frequent, particularly in patients with thrombolytic treatment, but do not appear to be related to the duration of resuscitation. In the light of possible benefits on outcome, thrombolytic treatment should not be withheld in carefully selected patients. Notes: 0954-6820
  37. 37. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 37 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Journal Article URL: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12542552 Author Address: Department of Emergency Medicine, Institute of Clinical Pathology, General Hospital of Vienna, University of Vienna, Wahringer Gurtel 18-20/6D, 1090 Vienna, Austria. Cohort study of 265 patients admitted to a single emergency department after successful CPR. 13 of 132 patients who received thrombolysis had major hemorrhage. 5 survived to discharge. 7 of 133 patients who did not receive thrombolysis had major hemorrhage. 2 survived to discharge. Nonsignificant increase in risk of bleeding with thrombolytics: OR 2.5; 95% CI 0.9, 7.4. Level 5 Fair. Lawes1 Reference Type: Journal Article Record Number: 2122 Author: Lawes, E. G. ; Baskett, P. J. Year: 1987 Title: Pulmonary aspiration during unsuccessful cardiopulmonary resuscitation. Journal: Intensive Care Med Volume: 13 Issue: 6 Pages: 379-382 Date: 1987 Label: 40200 Keywords: Adolescence Adult Aged Aged, 80 and over Child Cricoid Cartilage physiopathology Female Human Male Middle Age Pneumonia, Aspiration epidemiology *etiology physiopathology Pressure Resuscitation *adverse effects mortality 1987 01 01 00:00 Abstract: The incidence of pulmonary aspiration in a group of patients who did not respond to cardiopulmonary resuscitation (CPR) was assessed at autopsy and found to be 29%. This figure is undoubtedly an underestimate of the total problem, and some indication of the potential for aspiration during CPR is revealed by the fact that 46% of the patients studied had full stomaches at autopsy. Clearly this fact has implications for CPR methods as suggested by Cummings and Eisenberg. The problem could be reduced by incorporating the use of cricoid pressure into the techniques of Basic CPR but this will require modification of current teaching. Notes: ProCite field[38]: 88034023 Cohort study of all cases of sudden death (within 24 hours of admission) from a single hospital reported to Coroner. Excluded those with anesthesia or surgery prior to CPR; pneumonia, gastrointestinal obstruction including gastrointestinal malignancy. 29% had aspiration, defined as
  38. 38. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 38 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT macroscopic evidence at autopsy of respiratory tract contamination by food matter or blood. Level 5 Fair. Lelcuk1 Reference Type: Journal Article Record Number: 1058 Author: Lelcuk, S.; Leibovitch, I.; Kaplan, O.; Rozin, R. R. Year: 1990 Title: Stomach rupture caused by false intubation of the esophagus Journal: Israel Journal of Medical Sciences Volume: 26 Issue: 3 Pages: 167-8 Date: Mar Accession Number: 2329042 Keywords: Screen N=2 cases of stomach rupture associated with esophageal intubation. Both discharged to home. Level 5 Fair. Linch1 Reference Type: Journal Article Record Number: 1473 Author: Linch, D.; McDonald, A.; McNicol, L. Year: 1979 Title: Tension pneumoperitoneum complicating cardiac resuscitation Journal: Intensive Care Medicine Volume: 5 Issue: 2 Pages: 94-4 Date: May Accession Number: 458041 Keywords: Screen Abstract: A case of gastric rupture and tension pneumonperitoneum following cardiac resuscitation is presented. Respiratory embarrassment necessitated emergency decompression by needle puncture of the peritoneal cavity, followed by laparotomy and repair of the gastric tear. The post-operative course has been satisfactory. The aetiology of the gastric rupture is discussed and recommendations are made for the prevention and treatment of this unusual complication of combined mouth to mouth respiration and external cardiac massage. Case report of patient with gastric rupture and tension pneumoperitoneum after CPR. Repaired, then patient discharged home. Level 5 Fair. Lockett1 Reference Type: Journal Article Record Number: 1525 Author: Lockett, F. C.; Rothfeld, B.; Meckelnburg, R.; Sagar, V. V. Year: 1977 Title: Detection of bone trauma after cardiopulmonary resuscitation Journal: Maryland State Medical Journal Volume: 26 Issue: 11 Pages: 78-9 Date: Nov Accession Number: 916745 Keywords: Screen Case report of patient resuscitated with CPR. Tc99 pyrophosphate imaging documented bone trauma. Survived to discharge. Level 5 Fair. Low1 Reference Type: Journal Article Record Number: 820 Author: Low, L. L.; Ripple, G. R.; Bruderer, B. P.; Harrington, G. R.
  39. 39. c2005-evidence-evaluation-template-nov11-2003doc248.doc Page 39 of 71 REMEMBER TO SAVE THE BLANK WORKSHEET TEMPLATE USING THE FILENAME FORMAT Year: 1994 Title: Non-operative management of gastric perforation secondary to cardiopulmonary resuscitation Journal: Intensive Care Medicine Volume: 20 Issue: 6 Pages: 442-3 Date: Jul Accession Number: 7798450 Keywords: Screen Abstract: We report the case of a 72-year-old male who suffered a cardiac arrest during an early positive treadmill stress test. After successful resuscitation the patient had evidence of a gastric perforation. Because of his hemodynamic stability, lack of peritoneal signs, and prohibitively high surgical risk, a non-operative management approach was successfully administered. Although not the standard approach to traumatic gastric perforation, this case is not unlike the management of peptic ulcer perforations. A non- operative approach should be considered as an option in selected patients. Case report of patient with gastric rupture after CPR. Not operated on; survived to discharge. Level 5 Fair. Ma1 Reference Type: Journal Article Record Number: 840 Author: Ma, M. H.; Huang, G. T.; Wang, S. M.; Tai, T. Y.; Shyu, K. G.; Hwang, J. J.; Tseng, Y. Z.; Lien, W. P. Year: 1994 Title: Aortic valve disruption and regurgitation complicating CPR detected by transesophageal echocardiography Journal: American Journal of Emergency Medicine Volume: 12 Issue: 5 Pages: 601-2 Date: Sep Accession Number: 8060413 Keywords: Screen Case report of aortic valve disruption and aortic regurgitation that developed during CPR as documented by transesophageal ECHO. Level 5 Fair. Machii1 Reference Type: Journal Article Record Number: 2398 Author: Machii, M. ; Inaba, H. ; Nakae, H. ; Suzuki, I. ; Tanaka, H. Year: 2000 Title: Cardiac rupture by penetration of fractured sternum: a rare complication of cardiopulmonary resuscitation. Journal: Resuscitation Volume: 43 Issue: 2 Pages: 151-153 Date: 2000 Jan Label: 51440 Keywords: Aged Aged, 80 and over Cardiopulmonary Resuscitation *adverse effects Case Report Fractures *etiology Heart Injuries *etiology

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