Clinical Communications: Adults DELAYED VISCERAL BLEEDING FROM LIVER INJURY AFTER CARDIOPULMONARY RESUSCITATION Hidemichi Kouzu, MD,* Mamoru Hase, MD,† Nobuaki Kokubu, MD,* Junichi Nishida, MD,* Mina Kawamukai, MD,* Yoko Usami, MD,‡ Naoki Hirokawa, MD,‡ Makoto Meguro, MD,† Kazufumi Tsuchihashi, MD,* Tetsuji Miura, MD,* Yasufumi Asai, MD,† and Kazuaki Shimamoto, MD* *Second Department of Internal Medicine, †Department of Traumatology and Critical Care Medicine, and ‡Department of Radiology, Sapporo Medical University School of Medicine, Sapporo, Japan Reprint Address: Hidemichi Kouzu, MD, Second Department of Internal Medicine, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo 060-8543, Japan , Abstract—Background: Visceral injury is a life-threaten- ing complication of cardiopulmonary resuscitation (CPR); however, the clinical significance has been masked by the lethal outcome of out-of-hospital cardiac arrest (OHCA). Objective: The objective is to share our experience of successful treatment of OHCA patients with serious, CPR-related vis- ceral complications. Case Reports: We report two cases of cardiac-origin OHCA with liver injury exacerbated by hepa- rinization during mechanical circulatory support. Although both patients presented with delayed massive liver bleeding (intrahepatic or peritoneal) that compromised hemodynamic status, one patient was successfully treated by selective trans- catheter arterial embolization and the other by a surgical procedure. Conclusion: Preventive measures such as careful CPR, as well as interventional or surgical repair after the early diagnosis of visceral injury, are required to improve the outcome in some cases of OHCA. Ó 2012 Elsevier Inc. , Keywords—liver injury; cardiopulmonary resuscita- tion; cardiac arrest; heparinization; mechanical circulatory support INTRODUCTION Visceral injuries from cardiopulmonary resuscitation (CPR) can affect the morbidity and mortality of cardiac arrest patients despite early successful resuscitation. We report two cases of successful management of serious liver bleeding associated with CPR, and subsequent anticoagulation therapy. CASE REPORT Case 1 A 53-year-old man with a history of coronary artery bypass grafting 7 years prior presented with a witnessed, out-of- hospital cardiac arrest. Bystander CPR was not performed. Because the initial cardiac rhythm was ventricular fibrilla- tion (VF) and there was no return of spontaneous circula- tion (ROSC) despite automatic external defibrillation, basic life support was performed during transportation by emergency medical technicians. These individuals had passed a state examination for qualification and were permitted to insert an intravenous line and an alternative airway management device and to use a semi-automated external defibrillator provided that they had online confir- mation by a medical doctor. Soon after arrival at the emergency department (ED), ROSC was achieved by a monophasic shock of 150 J. The duration of CPR was 10 min. The emergent coronary angiography showed the patency of the bypass grafts and good collateral perfusion; therefore, VF was presumed to be a consequence of the old RECEIVED: 15 January 2010; FINAL SUBMISSION RECEIVED: 2 April 2010; ACCEPTED: 19 May 2010 e245 The Journal of Emergency Medicine, Vol. 43, No. 4, pp. e245–e248, 2012 Copyright Ó 2012 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter doi:10.1016/j.jemermed.2010.05.074