ID:159 FC-D09-8 Sudden Hemodynamic Collapse Post-ROSC on ECPR: Unmasking a Fatal CPR-Related Cardiac Trauma

Background: Cardiopulmonary resuscitation (CPR) is essential for sudden cardiac arrest. For refractory cases, extracorporeal cardiopulmonary resuscitation (ECPR) plays a crucial role in providing critical hemodynamic support and improving survival. However, CPR may cause severe complications. While skeletal fractures are common, CPR-induced cardiac injuries, such as coronary artery rupture, are exceedingly rare and typically detected post-mortem. Clinical course: A 60-year-old man collapsed from sudden cardiac arrest presenting with refractory VT. He received chest compressions, defibrillation, anti-arrhythmic agents, and ECPR. Return of spontaneous circulation (ROSC) occurred at 56 minutes. However, 53 minutes post-ROSC, he developed severe hemodynamic instability. Bedside ultrasound revealed new cardiac tamponade with right ventricular (RV) collapse. Following emergency pericardiocentesis (>500mL bloody fluid drained), emergent surgery was performed. Surgeons discovered a ruptured right coronary artery (RCA) and an RV anterior wall injury directly beneath a sharp sternal fracture, confirming a CPR-induced etiology. The lesions were successfully repaired under extracorporeal mechanical support, and the patient was discharged 105 days post-admission. Discussion: Post-resuscitation deterioration requires rapid evaluation for reversible causes, including cardiac tamponade. The exact anatomical match between the fractured sternal edge and the RCA/RV lesions confirmed a CPR-related trauma. Unlike most cases which are only identified at autopsy, ECPR stabilized his hemodynamics long enough for a definitive diagnosis and intervention. Because CPR-related blunt cardiac injuries are easily overlooked but potentially fatal, early targeted point-of-care ultrasound is a critical diagnostic tool for post-arrest patients. Conclusion: While ECPR introduces potential complications from cannulation and extracorporeal circulation, physicians must also remain vigilant for life-threatening injuries caused by the initial CPR. If the clinical condition rapidly deteriorates post-ROSC, routine bedside ultrasound is highly recommended for the immediate detection and management of these rare but fatal complications.