Case Report

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American Journal of Emergency Medicine

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Life-threatening hemothorax due to azygos vein rupture after chest compression during cardiopulmonary resuscitation?

Abstract

Hemothorax is not an uncommon cardiopulmonary resuscitation (CPR)-related complication. But hemothorax related to azygos vein injury (AVI) is a Rare condition following blunt chest trauma, with no report of CPR-related AVI in the literature. We present a case of azygos vein rupture in a middle-aged woman after repeated chest compres- sion during 1 hour of CPR. She eventually presented with massive hemothorax due to azygos vein rupture diagnosed by computed tomography (CT). When faced with a patient with massive hemo- thorax after chest compression, azygos vein rupture should be considered as a complication.

Great vessel injury in chest cage may be secondary to blunt, penetrating, blast or iatrogenic trauma. Isolated AVI is a rare condition that is mainly associated with sudden deceleration trauma and penetrating accident. Diagnosis is based on radiologic evidence of hemothorax and hypovolemic shock. Early surgical intervention and adequate volume replacement including transfusion are the most important treatments. To our knowledge, AVI has never been reported to be a complication following chest compression during CPR. We introduce the case of azygos vein rupture as a complicated result of chest compression.

A 52-year-old woman without recent trauma history visited the emergency department complaining of vomiting with nausea for 3 days. On medical history, she had been treated for right breast cancer with radical mastectomy and chemotherapy 5 years before. She did not take any other agents that cause bleeding. Her initial vital signs were 70/42 mm Hg, 94 beats per minute, 24 breaths per minute, and 36.7?C. We immediately started hydration with normal saline via intravenous route and monitored the patient closely. A laboratory study showed hemoglobin 14.9 g/dL and hematocrit 42.3%. On the initial chest radiograph, there was no active lesion (Fig. 1). As soon as she was collapsed suddenly, we started airway management and chest com- pression immediately. Peripheral venoarterial extracorporeal mem- brane oxygenation was commenced approximately 1 hour after first collapse with full support flow, and then she showed recovery of spontaneous circulation. Complete opacity of right hemothorax was found on post CPR chest radiograph (Fig. 2). Her hemoglobin was lowered to 3.2 g/dL just after CPR. The CT scan revealed sternum fracture, right hemothorax, and suspicious AVI (Figs. 3 and 4). The chest tube drained 1700 mL of blood at initial replacement, and blood loss was ongoing. At emergent thoracotomy, about 2000 mL of venous blood accumulation in the right thoracic cavity was revealed because of ruptured azygos vein. After injured vessels ligation for Bleeding control,

? We have no conflict of interest and any copyright constraints.

she was transferred to the intensive care unit. Unfortunately, she expired at the intensive care unit 6 days after surgery.

Chest compression is a significant component of CPR. Recently, high-quality chest compression such as “Push hard and Push fast” has been emphasized to improve the survivability of patients in cardiac arrest. However, many studies have documented unintended chest and abdominal injuries resulting from CPR, such as rib fractures, sternum fractures, pulmonary injury, hepatic or splenic laceration, great vessel injury, and cardiac contusion or laceration [1,2]. Most CPR-related complications are inSignificant injuries, and life-threat- ening complications are extremely rare. Krischer et al [3] noted the prevalence of Life-threatening complications to be less than 0.5% in their analysis of 705 post-CPR autopsied patients.

To our knowledge, there have been no reports of fatal AVI after CPR. Less than 25 cases of AVI secondary to blunt chest trauma have been published in the medical literature [4]. Several mechanisms have been suggested to describe how the azygos vein is injured in blunt chest trauma [5-8]. As in these mechanisms, we presumed that CPR-induced AVI is caused by an abrupt increase in venous pressure resulting from compression of the heart between the sternum and vertebral column in performing CPR [7]. There is no specific clinical sign of AVI, which is usually first suspected when a widened mediastinum and right hemothorax are found on chest radiograph [9]. For this reason, we should always check the chest radiograph after CPR. Initial blood loss may not be significant, but major hemorrhage is the rule within a Short period of time. Good treatment of the AVI requires rapid evaluation and resuscitation in the emergency department. When AVI is suspected, immediate thoracotomy is required for ligation of the azygos vein [10]. This case shows CPR-related azygos vein rupture with sternum fracture after a longer duration of chest compression. But not much is known in regard to the relationship between the length of CPR duration and CPR-related injury because of only a few conflicting studies [1,3,11,12]. Azygos vein injury is uncommon but potentially fatal if diagnosis and treatment are delayed. When faced with a patient with massive hemothorax after CPR, azygos vein rupture

should be considered as a fatal complication.

Euiseok Yang, MD WonJoon Jeong, MD JunWan Lee, MD SeungWhan Kim, MD, PhD?

Department of Emergency Medicine College of Medicine

Chungnam National University Daejeon, Republic of Korea

?Corresponding author

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.04.019

0735-6757/(C) 2014

References

Fig. 1. Initial chest AP simple radiograph.

Fig. 3. Aorta CT (coronal view) demonstrating right hemothorax and azygos vein (black arrow) injury with extravasation of contrast media (white arrow).

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Fig. 2. Chest AP simple radiograph 1 hour after chest compression.

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Fig. 4. Aorta CT (sagittal view) demonstrating right hemothorax and azygos vein (black arrow) injury with extravasation of contrast media (white arrow).