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HOME > Kosin Med J > Volume 35(2); 2020 > Article
Case Reports
Subcapsular Hepatic Hematoma after Cardiopulmonary Resuscitation
Song-I Lee
Kosin Medical Journal 2020;35(2):156-162.
DOI: https://doi.org/10.7180/kmj.2020.35.2.156
Published online: December 31, 2020
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Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea

• Received: June 16, 2020   • Revised: October 11, 2020   • Accepted: October 28, 2020

Copyright © 2020 by Korean Association of Medical Journal Editors

Articles published in Kosin Medical Journal are open-access, distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • Cardiopulmonary resuscitation (CPR) is an important life-saving procedure in emergency care. However, CPR is associated with various complications. A 41-year-old man was admitted to the intensive care unit after CPR. A sudden decrease in the blood pressure and hematocrit level was recorded. An abdominal computed tomography (CT) showed a large subcapsular hematoma in the left lobe of the liver. With conservative treatment, the hematoma reduced in size, but it was later managed with percutaneous drainage. The patient recovered and was discharged. We obtained a favorable outcome with conservative, nonsurgical treatment. Subcapsular hepatic hematoma is a potential life-threatening complication that should be considered in CPR survivors.
Cardiopulmonary resuscitation (CPR) is an important, life-saving, emergency care procedure. CPR comprises chest compressions and artificial ventilation; during the former, the lower half of the sternum should be depressed to approximately one-third of the chest cavitary depth in each compression.
Complications of CPR include lung injuries (e.g., pneumothorax), rib fractures and contusion, damage to abdominal organs, and chest and/or abdominal pain.13 However, damage to abdominal organs is a rare complication of CPR. Here, we report a case of subcapsular hepatic hematoma, a rare complication of CPR.46
A 41-year-old man was hospitalized with a complaint of muscle weakness that was diagnosed as Guillain–Barres syndrome and appropriately treated. The patient experienced a sudden in-hospital cardiac arrest, was resuscitated, and there was return of spontaneous circulation (ROSC) after 5 minutes of CPR. Subsequently, the patient was admitted in the medical intensive care unit (ICU). Following ROSC, the blood pressure (BP) and heart rate were 105/84 mmHg and 129 beats/min, respectively. The patient was intubated and placed on mechanical ventilation.
Transthoracic echocardiography revealed the preserved left ventricular function without regional wall motion abnormality. The laboratory tests after CPR showed a white blood cell count of 15.14 × 109/L (neutrophils 70.4%), a hemoglobin level of 15.6 g/dL, a platelet count of 282 × 103/μL, an aspartate aminotransferase (AST) level of 66 U/L, an alanine aminotransferase (ALT) level of 115 U/L, a blood urea nitrogen level (BUN) of 37.0 mg/dL, pH 7.43, a partial pressure of carbon dioxide of 40 mmHg, a partial pressure of oxygen of 75 mmHg, a bicarbonate concentration of 26.4 mmol/L, and an oxygen saturation of 95.3%. Serum creatinine, albumin, and cardiac enzyme levels; partial thromboplastin time; and prothrombin time were all within normal limits.
On the third day in the ICU, the patient’s BP decreased to 87/64 mmHg, and follow-up laboratory tests showed a rapid reduction in the hemoglobin level (7.7 g/dL). Esophagoduodenoscopy did not reveal any active upper gastrointestinal bleeding. Hence, abdominal computed tomography (CT) was performed to identify the source of bleeding, which showed a large subcapsular hematoma (17.8 × 7.9 cm2) in the left lobe of the liver (Fig. 1). We initially undertook a blood transfusion and conservative, nonsurgical treatment approach and the patient recovered slowly. The hemoglobin level returned to the normal range. There was no increase in the size of the hematoma on follow-up CT (Fig. 2A). In consultation with the surgical team, we inserted a percutaneous drain into the hematoma 1 month after the bleeding was detected (Fig. 2B). After 1 month of PCD insertion, the follow-up CT showed a decrease in hematoma (Fig. 3). Therefore, PCD was removed 1 month after PCD insertion. Subsequently, the patient recovered uneventfully and was discharged.
This case report describes a male patient with a subcapsular hepatic hematoma that developed after CPR. For effective CPR, the sternum needs to be depressed 4–5 cm in each compression. Rib fractures are the commonest complication of CPR and can occur in up to 50% of patients.13 Other chest complications include hemothorax, pneumothorax, hemopericardium, and sternal fracture. Intra-abdominal injuries including hepatic, splenic, or intestinal trauma and retroperitoneal hematoma have been reported after CPR.4,68 However, liver injury occurs rarely (0.6%–2%) and is usually associated with anticoagulation therapy.4,9
In our case, a subcapsular hepatic hematoma of the left lobe was noted. Liver injury most often occurs in the left lobe during CPR. The most important contributory factor for this is the close anatomical relationship of the left lobe of the liver with lower part of the sternum.6,10 Hemodynamic instability is a leading symptom of intra-abdominal bleeding. Measuring the hematocrit level might be a useful test in the post-resuscitation phase.9 When a subcapsular hematoma of the liver is diagnosed, it is important to perform continuous imaging tests and blood tests such as hemoglobin in determining conservative or surgical treatment and to monitor whether the hematoma does not progress.11 In general, subcapsular hematoma that does not rupture is treated conservatively, and the prognosis is good. In spite of symptomatic treatment, selective embolization of the hepatic artery branch may be considered to control hematoma enlarged or continued bleeding, and octreotide may be used to reduce bleeding.12 Surgical treatment is recommended for subcapsular hematoma rupture or imminent rupture. Typically, 75% of patients die when the hematoma is ruptured. However, CPR-induced liver injury is usually addressed with conservative management and embolization.5,6,13 About 7 – 20% of the patients with complications died from the cause of CPCR (eg, cardiac arrest, pulmonary theomboembolism, etc.), but one of them died due to massive bleeding.46,810,1317 Most of the surviving patients recovered without any specific liver-related complications.46,810,1317 In our patient, the vital signs were stable after transfusion, and conservative treatment was recommended on surgical consultation.
Compression during CPR is emphasized with the revision in the resuscitation guideline and is the essential component of basic life support.18 Frequent interruption of chest compressions does not provide circulatory support for more than half of the resuscitation effort. Such interruptions can be a major cause of the consistent poor results, which manifest as a heart attack.19 Compression should remain as undisturbed as possible during CPR. With the focus on compression, unusual complications such as a subcapsular hepatic hematoma have been discovered. 5,17 To reduce the occurrence of such complications, it is important to apply compression in the right position with the correct pressure.
In Korea, Wi et al. reported a case of liver laceration with hemoperitoneum after CPR.6 A 72-year-old female patient developed severe hemoperitoneum associated with liver injury after CPR and underwent emergency embolization, but she died.6 In addition, in Korea, there have been cases of spontaneous liver injury occurring after delivery,20 after endoscopic retrograde cholangiopancreatography,21 during hemodialysis,22 liver abscess,23 idiopathic24 and recovery with conservative treatment in most cases. However, in our case, conservative treatment alone recovered liver injury following CPR.
In patients with a sudden drop in hematocrit level and blood pressure after CPR, it is important to evaluate the hemorrhagic foci. Despite liver injury being an uncommon finding in such an evaluation, it is important to consider it in the differential diagnosis to facilitate correct diagnosis and treatment, which will improve the patient’s prognosis.

CONFLICT OF INTEREST

The authors have no conflicts of interest.

Fig. 1
Abdominal computed tomography showing a large subscapular hematoma (17.8 × 7.9 cm2) in the left lobe of the liver (A) and small, diluted hemoperitoneum extending to the perisplenic space, mesenteric, and bilateral paracolic gutter and into the pelvic cavity
kmj-35-2-156f1.jpg
Fig. 2
(A) Follow-up abdominal computed tomography showing subtle decrease in the size of the subscapular hepatic hematoma (14.9 cm from 17.8 cm, in axial size) in the left lobe of the liver and no abnormal fluid collection, (B) Abdominal X-ray showing percutaneous insertion of an abdominal drainage catheter into the subcapsular hepatic hematoma
kmj-35-2-156f2.jpg
Fig. 3
After 1 month of PCD insertion, the follow-up CT showed decreased in size of large amount of subcapsular hematoma in left lobe of liver (17.8 cm from 9.0 cm, in axial size).
kmj-35-2-156f3.jpg
  • 1. Black CJ, Busuttil A, Robertson C. Chest wall injuries following cardiopulmonary resuscitation. Resuscitation 2004;63:339–43.ArticlePubMed
  • 2. Deliliga A, Chatzinikolaou F, Koutsoukis D, Chrysovergis I, Voultsos P. Cardiopulmonary resuscitation (CPR) complications encountered in forensic autopsy cases. BMC Emerg Med 2019;19:23.ArticlePubMedPMC
  • 3. Kim MJ, Park YS, Kim SW, Yoon YS, Lee KR, Lim TH, et al. Chest injury following cardiopulmonary resuscitation: a prospective computed tomography evaluation. Resuscitation 2013;84:361–4.ArticlePubMed
  • 4. Koutserimpas C, Ioannidis A, Siaperas P, Skarpas A, Tellos A, Velimezis G, et al. Intra-Abdominal Hemorrhage following Cardiopulmonary Resuscitation: A Report of Two Cases. Case Rep Emerg Med 2018;2018:5243105.Article
  • 5. Monsuez JJ, Charniot JC, Veilhan LA, Mougué F, Bellin MF, Boissonnas A. Subcapsular liver haematoma after cardiopulmonary resuscitation by untrained personnel. Resuscitation 2007;73:314–7.ArticlePubMed
  • 6. Wi J, Shin D. Liver Laceration with Hemoperitoneum after Cardiopulmonary Resuscitation. Korean J Crit Care Med 2014;29:141–3.Article
  • 7. Powner DJ, Holcombe PA, Mello LA. Cardiopulmonary resuscitation-related injuries. Crit Care Med 1984;12:54–5.ArticlePubMed
  • 8. Zahn G, Hauck M, Pearson DA, Green JM, Heffner AC. Major hemorrhage from hepatic laceration after cardiopulmonary resuscitation. Am J Emerg Med 2015;33:991.e3–4.Article
  • 9. Meron G, Kurkciyan I, Sterz F, Susani M, Domanovits H, Tobler K, et al. Cardiopulmonary resuscitation-associated major liver injury. Resuscitation 2007;75:445–53.ArticlePubMed
  • 10. Beydilli H, Balci Y, Erbas M, Acar E, Isik S, Savran B. Liver laceration related to cardiopulmonary resuscitation. Turk J Emerg Med 2016;16:77–9.ArticlePubMedPMC
  • 11. Ndzengue A, Hammoudeh F, Brutus P, Ajah O, Purcell R, Leadon J, et al. An obscure case of hepatic subcapsular hematoma. Case Rep Gastroenterol 2011;5:223–6.ArticlePubMedPMC
  • 12. Wagner WH, Lundell CJ, Donovan AJ. Percutaneous angiographic embolization for hepatic arterial hemorrhage. Arch Surg 1985;120:1241–9.ArticlePubMed
  • 13. Ziegenfuss MD, Mullany DV. Traumatic liver injury complicating cardio-pulmonary resuscitation. The value of a major intensive care facility: a report of two cases. Crit Care Resusc 2004;6:102–4.PubMed
  • 14. Machii M, Inaba H, Nakae H, Suzuki I, Tanaka H. Cardiac rupture by penetration of fractured sternum: a rare complication of cardiopulmonary resuscitation. Resuscitation 2000;43:151–3.ArticlePubMed
  • 15. Nishimura T, Okamoto A, Fujisaki N, Shirai K, Yamada I, Nakao A, et al. LIVER INJURY ASSOCIATED WITH CHEST COMPRESSION IN CARDIOPULMONARY ARREST PATIENTS. Journal of the Japanese Association for the Surgery of Trauma 2017;31:17–23.Article
  • 16. Oualha D, Aissaoui A, Belhaj M, Mesrati MA, Moussa A, Salem NH, et al. Liver Subcapsular Hematoma: A Rare Cause of Sudden Unexpected Death. Am J Forensic Med Pathol 2017;38:9–10.ArticlePubMed
  • 17. Joseph JR, Freundlich RE, Abir M. Ruptured subcapsular liver haematoma following mechanically-assisted cardiopulmonary resuscitation. BMJ Case Rep 2016;2016.Article
  • 18. Soar J, Maconochie I, Wyckoff MH, Olasveengen TM, Singletary EM, Greif R, et al. 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2019;145:95–150.PubMed
  • 19. Valenzuela TD, Kern KB, Clark LL, Berg RA, Berg MD, Berg DD, et al. Interruptions of chest compressions during emergency medical systems resuscitation. Circulation 2005;112:1259–65.ArticlePubMed
  • 20. Lee CS, Lee GY, Park CG, Yang YC, Kim DH, Lee JH, et al. A Case of Subscapsular Hematoma of Liver During the Postpartum Period. The Korean Journal of Gastroenterology 1998;32:830–3.
  • 21. Jo HU, Kim HK, Choi WS, Kim DH, Lee KS, Lee JS, et al. Subcapsular Hepatic Hematoma after Endoscopic Retrograde Cholangiopancreatography. Korean J Med 2017;92:401–5.Article
  • 22. Bok Jin H, Eun Sook MDK, Hee Yeon MDL MD, et al. Spontaneous Subcapsular Hematoma of the Liver in a Patient on Maintenance Hemodialysis. Kidney Research and Clinical Practice 2007;26:637–40.
  • 23. Lee SJ, Lee MH, Choi DY, Park SK, Yoon HS, Jung DY, et al. A Case of Pyogenic Liver Abscess with Spontaneous Subcapsular Hemorrhage. The Korean Journal of Gastroenterology 2001;38:449–52.
  • 24. Choi JS, Kim Y, Park SY, Lee SY, Lee EJ, Sinn DH. Recurrent Spontaneous Subcapsular Hematoma of the Liver. Korean J Med 2017;92:177–81.Article

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