https://orcid.org/0000-0002-4015-9089
Figures
Abstract
Background
Both cardiopulmonary resuscitation (CPR) and ischaemia could lead to abdominal organ injury. However, the importance of abdominal injury in cardiac arrest remains uncertain. We aimed to systematically review indexed literature to describe incidence of abdominal injury after non-traumatic cardiac arrest and associations with outcome.
Methods
We searched MEDLINE/PubMed, Embase, The Cochrane Database of Systematic Reviews and Scopus up to 12th September 2024 for studies reporting differences in outcomes between patients with and without abdominal injury, and all studies reporting abdominal adverse events after cardiac arrest. Two independent reviewers screened articles for eligibility. One reviewer extracted data and assessed risk of bias using the Critical Appraisal Skills Programme checklist. Injuries were defined as traumatic or ischaemic, either in the studies or otherwise by the reviewers. Results were summarized and presented in tables and Forest plots. We followed the PRISMA guidelines, and registered the study in PROSPERO.
Results
We included 68 studies and 140 case reports. Most studies were single-centre. Quantitative synthesis of evidence was not feasible given high heterogeneity and risk of bias. Traumatic injuries affected mostly liver and spleen, with incidences from 0% to 15%, reaching 29% in one study of mechanical chest compressions. Life-threatening injuries were uncommon. The incidence of ischaemic injury was dependent on assessment method; 7% to 28% had liver injury, 0.7% to 2.5% was diagnosed with non-occlusive mesenteric ischaemia, 82% to 100% had intestinal injury measured by biomarkers. Ischaemic injuries were associated with mortality.
Conclusion
In this comprehensive review of abdominal injuries following cardiac arrest, CPR-related traumatic injuries were uncommon, but should be considered in patients with unexplained clinical deterioration. Ischaemic injury incidence ranged from 0.7% to 100%, and was consistently associated with mortality. Whether abdominal ischaemia independently contributes to poor outcomes remains unresolved and warrants further investigation.
PROSPERO ID: CRD42022311508.
Citation: Hoftun Farbu B, Hagemo J, Rehn M (2025) Abdominal organ injury in cardiac arrest: Systematic literature review. PLoS One 20(8): e0329164. https://doi.org/10.1371/journal.pone.0329164
Editor: Nik Hisamuddin Nik Ab. Rahman, Universiti Sains Malaysia, MALAYSIA
Received: February 17, 2025; Accepted: July 13, 2025; Published: August 1, 2025
Copyright: © 2025 Hoftun Farbu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting information files.
Funding: The Norwegian Air Ambulance Foundation funded the review. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: CT, Computed tomography; CPR, Cardiopulmonary resuscitation; ECPR, Extracorporeal cardio-pulmonary resuscitation; FAST, Focused Assessment With Sonography in Trauma; ICU, Intensive care unit; IFABP, Intestinal fatty acid binding protein; IHCA, In-hospital cardiac arrest; LUCAS, Lund University Cardiopulmonary Assist System; MeSH, Medical Subject Headings; NOMI, Non-occlusive mesenteric ischaemia; OHCA, Out-of-hospital cardiac arrest; PICOS, Population, Intervention/Exposure, Comparator, Outcome, Study design; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analyses; RCT, Randomised controlled trial; REBOA, Resuscitative endovascular balloon occlusion of the aorta; ROSC, Return of spontaneous circulation.
Introduction
Patients who are successfully resuscitated from cardiac arrest frequently develop multiple organ failure. In the initial days following resuscitation, circulatory failure is the leading cause of death, while hypoxic-ischaemic brain injury accounts for the majority of deaths overall. The pathophysiologic mechanisms linking cardiac arrest to multiple organ failure are incompletely understood, but are believed to involve a systemic ischaemia-reperfusion injury [1].
The role of abdominal injury after cardiac arrest remains poorly defined. Liver injury has been associated with circulatory failure and poor neurological outcome, but has not been consistenly linked to mortality [2,3]. Ischaemic lesions of the upper gastro-intestinal tract has been reported as common and may correlate with unfavorable neurolocial outcome [4]. Additional studies have demonstrated associations between intestinal injury and increased risk of organ dysfunction, poor neurological outcome, and death [5–7]. Administration of adrenaline (epinephrine), the main drug of resuscitation, may exacerbate splanchnic ischemia via vasoconstriction of mesenteric vessels [4,6,8,9]. Moreover, cardiopulmonary resuscitation (CPR)-related traumatic injuries might be more common with mechanical chest compressions [10]. Both ischaemic and CPR-related abdominal injuries could contribute to ischaemia-reperfusion injury, circulatory failure and a poor outcome. Nonetheless, the incidence and prognostic implications of abdominal injury following non-traumatic cardiac arrest remain uncertain.
We aimed to systematically review indexed literature to characterize the incidence of abdominal injury after non-traumatic cardiac arrest and to assess its association with clinical outcomes.
Materials and methods
Literature search
We searched MEDLINE/PubMed, Embase, and The Cochrane Database of Systematic Reviews up to 12th September 2024, and conducted a citing reference search in Scopus up to 15th November 2024. There was no limitation for language or year of publication. Grey literature was not searched.
The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines including the PICO methodology (Population, Intervention/exposure, Comparator, Outcome) [11]. The PRISMA checklist is provided in S1 Appendix. The PICO question was: Do patients with adult or paediatric, out-of-hospital or in-hospital, non-traumatic cardiac arrest (P), with abdominal organ injury in any form (I), compared to patients without abdominal organ injury C), have different short- or long-term survival, neurological outcome at discharge and/or long-term, or other outcome as defined in the study (O). The protocol was registered in the international prospective register of systematic reviews, PROSPERO (ID CRD42022311508).
The search strategy consisted of both controlled terms (Medical Subject Headings [MeSH], Emtree) and free text words for two basic concepts: 1. Cardiac arrest and 2. Abdominal organ injury. The first set of entry terms described the patient group, and the second set described the exposure. We used Boolean operators for term combinations and included synonyms. Proximity operators and field specification were applied when available and suitable. The complete search strategy is available in S2 Appendix.
Study selection
Records from the literature search were imported into the online Covidence tool [12]. Two pairs of authors (BHF paired with MR or JH) screened all titles and abstracts independently, and studies clearly not meeting the inclusion criteria were excluded. We reviewed potentially eligible studies in full text, and reasons for non-eligibility are reported in a PRISMA flow chart. Disagreements were solved through discussion until consensus was reached. Reference lists of included publications were searched manually.
Studies fulfilling one of the following two criteria were included: 1) Randomized trials, non-randomized controlled trials, observational studies (cohort studies and case-control studies) reporting data about differences in terms of clinical outcomes between patients with and without abdominal organ injury, or 2) Case reports/series and other studies when they reported abdominal adverse events. Exclusion criteria were animal studies, editorials, comments and letters to the editor, literature reviews, studies published solely as abstracts, and studies of mixed populations where exposure was not specifically stated for cardiac arrest patients.
We made the following amendments to protocol. “And other studies” was added to criterion 2) in the inclusion criteria, and we specified “abdominal” adverse events. We added three exclusion criteria (reviews, abstracts, mixed populations), but chose to not exclude articles without abstract. We present incidence rather than prevalence, and risk ratios rather than odds ratios. Quality appraisal was done by one reviewer.
Data extraction and quality assessment
One reviewer (BHF) extracted data using the Covidence online tool with predefined variables regarding demographic, Utstein cardiac arrest data, exposure, treatment, and outcome. The same reviewer used the Critical Appraisal Skills Programme checklist for quality appraisal [13].
Definitions
Cardiac arrest was defined as all situations where CPR had been performed, or otherwise as defined in the study. Traumatic cardiac arrest was defined as all cases caused by trauma, including electrocution and avalanche. Drowning and strangulation were deemed non-traumatic.
Abdominal organs in this study were liver, stomach, small and large intestine, rectum, pancreas, and spleen, but not kidney and urogenital organs. Any form of injury was part of the study, as judged by radiologic examination, surgery, endoscopy, biomarker, post-mortem examination, physicians discretion, or other injury as defined in the study.
Injuries were referred to as traumatic or ischaemic as defined in the studies. If not defined, the following injuries were referred to as traumatic: hollow viscus perforation, pneumoperitoneum, hemoperitoneum, tear, laceration, contusion, rupture, hematoma, and hemorrhage. Rise in biomarkers, e.g., transaminases, and mucosal lesions were referred to as ischaemic injury.
Statistical methods
Incidences are presented as percentages when referring to the range among several studies, and percentage (proportion) when referring to separate studies. Risk ratio with 95% confidence intervals for mortality and organ injury according to the prespecified subgroup treated with mechanical compressions were calculated using 2x2 tables with exposure and outcome as dichotomised in the studies, and presented as Forest plots. If required data were unavailable, we contacted the corresponding authors. Heterogeneity was assessed through manual evaluation, without statistical estimation. Given the absence of a quantitative synthesis, only the data at hand were reported, and no formal steps were taken to address missing data. The statistical calculations were conducted with Stata 18.0 (StataCorp LCC, Collage Station, TX).
Results
The study selection is presented in a PRISMA flow chart (Fig 1). The search retrieved 1783 studies, of which 328 were duplicates. Of 1460 publications screened for title and abstract, we assessed 329 studies in full-text for eligibility. Reasons for exclusion are presented in Fig 1. We included 208 studies in the review.
Characteristics of included studies
Among the 208 studies, there were 52 retrospective and 10 prospective cohort studies, one case control study, one non-randomised and four randomised controlled trials (RCT) [2–7,14–75]. There were 140 case reports of abdominal injuries (references are provided in S3 Appendix). The cohort and controlled studies were all published in English, except one in Slovak, and came from the United States of America (n = 17), France (9), Germany (7), Austria (6), Republic of Korea (5), Japan (4), Czech Republic (2), Finland (2), Norway (2), Sweden (2), Switzerland (2), Turkey (2) and one study from Belgium, Canada, China, Denmark, the Netherlands, Republic of Singapore, Spain, and Thailand, respectively. Twenty-five studies were of out-of-hospital cardiac arrest (OHCA) patients, seven of in-hospital cardiac arrest (IHCA) patients, 21 studies of mixed OHCA and IHCA. Otherwise location of arrest remained unreported. The case reports came from all continents except Africa, and were written in a language familiar to the reviewers, or had an English abstract with sufficient information.
Due to a large number of studies in various populations, the studies were stratified post-hoc and are presented in the following six groups: Studies reporting abdominal injuries in general [14–34], studies comparing mechanical and manual chest compressions [35–46], organ specific studies [2–7,47–56], studies of extracorporeal cardiopulmonary resuscitation (ECPR) patients [57–64], paediatric studies [65–70], and miscellaneous [71–75]. Quantitative synthesis of evidence was not feasible given high heterogeneity among studies in participants, exposure, and outcome reported [76].
Quality of included studies
Many studies were small, single-centre, and of various sub-populations, such as forensic studies or patients with registered abdominal computed tomography (CT). Most studies addressed a focused issue, but in several studies the measure of exposure was subjective and/or not clearly defined. Outcomes on the other hand were clearly defined. The results were often presented with wide confidence intervals. The quality appraisal is presented in S4 Appendix.
Incidence
CPR-related traumatic injuries were mostly diagnosed by CT or autopsy, and incidences of the most common injuries are presented in Fig 2. The risk ratios for abdominal injury in patients treated with mechanical compared to manual compressions, are presented as a Forest plot in Fig 3. Ischaemic injury were often diagnosed by biomarkers or endoscopy, but also CT and autopsy. The incidence was highly dependent on assessment method and are presented in Tables 1–3. Incidences of abdominal injury are also presented separately for each group in the main text.
Reported incidences of abdominal organ injury in general according to various assessment and post-mortem assessment only, respectively. Multimodal assessment includes one or more of the following: Medical records, computed tomography (CT), register data, and autopsy. Only incidences which are explicitly reported are shown. Injuries to organs not reported are not shown, either it was not looked for, or not found. “Other” injury: Duodenal perforation, pancreatic injury, intraperitoneal hemorrhage or pneumoperitoneum.
Unadjusted risk ratios for organ injury are presented for the two most commonly injured organs, liver and spleen. N is the number of patients with cardiac arrest in each study. CI: Confidence interval. LUCAS: Lund University Cardiopulmonary Assist System. CT: Computed tomography. CPR: Cardiopulmonary resuscitation.
Outcome
Outcomes reported were mortality in ICU, in-hospital, at day 6, 28, 30 and 6 months, and neurological outcome at hospital discharge, day 28, 3 and 6 months. Poor neurological outcome was defined as Cerebral Performance Category (CPC) 3–5 in all studies. Few studies reported comparable outcomes for patients with and without CPR-related traumatic injury. Risk ratios for mortality in patients with severe compared to less severe abdominal ischaemia, as dichotomised in the studies, are presented as a Forest plot in Fig 4. Outcomes for each group are otherwise noted whenever available.
Unadjusted risk ratios are presented for patients with severe ischaemia compared to less severe ischaemia, as dichotomised in the study. CI: Confidence interval, ICU: Intensive care unit, CT: Computed tomography, PT-ratio: Prothrombin time ratio, ECPR: Extracorporeal cardiopulmonary resuscitation.
Abdominal injury
Abdominal injuries in general.
Several studies examined abdominal injuries using varied diagnostic methods including imaging (CT and/or ultrasound), and post-mortem examination (including post-mortem CT). Across these studies, the incidence of abdominal injuries were low, regardless of assessment modality and patient population.
Four studies employed multimodal examinations [14–17]. In a French registry of 1310 patients, six cases of CPR-related liver injury were identified, of whom three survived. One case of gastric perforation was reported, resulting in death [14]. In another registry, there were numerically more abdominal hemorrhages among patients treated with thrombolysis than without, but no difference in survival [15]. In a Czech cohort, all patients who died prior to hospital admission underwent autopsy, while there was no systematic screening for injuries in the intensive care unit (ICU). Liver injury was detected in 2.5% (16/628) of autopsies, compared to 1.7% (4/231) of ICU admissions; splenic injury was found in 1.8% (11/628) and 0.9% (2/231), respectively [17]. In a study from 1982, gastrointestinal haemorrhage occurred in 25 of 63 patients [16].
Five studies reported findings from abdominal CT within 6 hours of admission [18–22]. In one study, 363 of 597 patients underwent CT. Bowel ischaemia was identified in 24 patients, along with pancreatitis (n = 9), splenic or hepatic laceration (n = 7), hemoperitoneum (n = 4), and pneumoperitoneum (n = 1). None of the patients with bowel ischaemia survived. Outcomes related to abdominal injury were not consistently reported in other studies [18,20–22]. Less frequent findings included paralytic small bowel ileus, duodenal perforation, unspecific mesenteric lymphadenitis, ascites, acute cholecystitis, mesenteric vascular occlusion and ruptured abdominal aortic aneurism [19,20]. Among 104 patients, cardiac arrest was attributed to a perforated viscus in two cases and mesenteric ischemia in one [21]. In a study of Focused Assessment With Sonography in Trauma (FAST), five of 21 patients had free abdominal fluid, and none survived [23].
Two studies assessed CT findings not restricted to the early phase [24,25]. Pneumoperitoneum was observed in 1.7% and 4.5% of IHCA and OHCA cases, and haemoperitoneum in 3.4% and 0%, respectively [24]. The second study assessed the relationship between CPR compression depth and abdominal complications but did not report outcome data [25]. Two additional studies reported no association between thoracic anatomy and injury, and no injuries among 23 patients, respectively [26,27].
Among studies reporting solely post-mortem data, the incidence of liver injury ranged from 0.7% to 15%, and splenic injury from 0% to 3.8%. Most injuries were superficial (e.g., subcapsular tears or hematomas), although three were deemed serious and one life-threatening [28–33]. In one autopsy series from 1986, ischaemic bowel was considered a major diagnosis in nine of 130 patients, no other abdominal complications were noted [34].
Mechanical compared to manual chest compressions.
In studies comparing mechanical and manual chest compressions, the reported incidence of liver injury ranged from 1.1% to 29.0% for mechanical, and 0% to 3.1% for manual compressions [35,37–42]. The incidence of spleen injury ranged from 0% to 2.4%, and 0% to 3.1%, respectively [35–37]. Unadjusted risk ratios for liver and spleen injury are presented in Fig 4. Due to a high level of heterogeneity, a quantitative synthesis was not feasible. No studies reported outcomes separately for patients with abdominal injuries.
In the study reporting an incidence of 29.0% for liver injury in the mechanical group, the resuscitation time was nearly twice the manual group, and most of the 32 patients were treated with a load-distributing band system [37]. In another comparison of load-distributing band system with manual compressions, there were haemoperitoneum in 17% (40/241) and 5% (4/82; p = 0.004), and pneumoperitoneum in 3% (7/241) and 0% (0/82; p = 0.13), respectively [43].
A Danish study of 1440 OHCA patients evaluated a piston-type compression device (Lund University Cardiopulmonary Assist System, LUCAS). Of the 207 patients treated with LUCAS, 84 sustained injuries, including four liver contusions, two kidney contusions, two spleen ruptures, one pancreas contusion, one gastric rupture, and one haemoperitoneum. Among patients treated with only manual compressions, a single liver contusion was reported. After adjusting for CPR duration, the overall incidence of injuries, including non-abdominal injuries, did not differ significantly between groups [36]. In a RCT comparing LUCAS and manual compressions, liver parenchymal injury occurred in 3.6% (5/139) and 1.2% (1/83), respectively, in a subset of patients with similar CPR duration [44]. In another two studies, two of thirteen patients treated with LUCAS during angiography developed liver haematomas, whereas no liver lacerations were found in mechanically resuscitated patients in a 1978 series [45,46].
Organ specific studies.
Liver injury was assessed in six cohort studies (Table 1) [2,3,47–50]. Major CPR-related liver injury was found in 0.6% (15/2558), and nearly half (7/15) was considered life-threatening [47]. Hypoxic hepatitis was found in 7.2% to 20.5% of patients, and was consistently associated with mortality [2,48–50]. Acute liver failure was observed in 16.0% to 55.6% of patients and was associated with mortality in one study, while the other did not report mortality outcomes separately [3,48]. Seventy-five case reports described liver injury. Most cases occured after manual CPR, though some were after mechanical compressions, peri-arrest thrombolysis, and ECPR. Ultrasonography frequently revealed abdominal free fluid, and some patients had profound hemorragic shock. Management strategies included conservative treatment, angioembolisation, and surgical intervention via laparotomy (S3 Appendix).
Gastric mucosal lesions were assessed in three studies using endoscopy and autopsy (Table 1) [4,51,52]. Endoscopic findings revealed mucosal lesions to be common, however, only the most severe lesions were associated with increased mortality in the study by Grimaldi and collegues [4,51]. A total of 72 case reports described gastric rupture, typically involving the lesser curvature and resulting in pneumoperitoneum. Four cases presented with tension pneumoperitoneum characterized by hypotension and tachycardia. Several cases of gastric rupture occurred following brief periods of with mouth-to-mouth ventilation by lay responders. While some patients were managed conservatively, the majority required surgical intervention. 27 of the 72 patients died (S3 Appendix).
Intestinal ischaemia was assessed using clinical signs, biomarkers and multimodal diagnostic approaches, including CT, endoscopy, and surgical exploration (Table 1) [5–7,53–56]. Early diarrhoea was reported in 9.6% of patients. Non-occlusive mesenteric ischaemia (NOMI) occurred in 0.7% to 2.5% of cases. Elevated levels of intestinal fatty acid binding protein (IFABP), a biomarker of enterocyte injury, were observed in 82.0% to 100% of patients [5,7,54–56]. Mortality outcomes varied. One study reported no significant difference in mortality between patients with and without NOMI, whereas another reported a mortality rate of 96% among patients with suspected or confirmed NOMI [54,55]. Mortality was also significantly higher in patients with diarrhoea and elevated IFABP levels [5–7]. Thirteen case reports described intestinal ischemia, with additional reports of intestinal bleeding and transection. Most patients underwent surgical management with bowel resection, except in cases where further intervention was considered futile (S3 Appendix).
No cohort studies were identified that assessed splenic or pancreatic injury following CPR. However, 25 case reports described splenic rupture and six pancreatic injury. Most cases occured in conjunction with injuries to the liver or stomach. Splenic bleeding was typically managed with splenectomy, and thirteen of the 25 patients died. Pancreatic injuries were reported as either ischaemic and traumatic in origin. One case occurred following mechanical CPR. Management strategies included conservative treatment and drainage. Three of the six patients with pancreatic injury died (S3 Appendix).
Abdominal injuries in ECPR-patients.
Eight studies reported abdominal injuries in patients undergoing ECPR (Table 2) [57–64]. The overall incidence of traumatic injury was 10.7% (11/103), and intra-abdominal haemorrhage occurred in 3.4% (3/87), with no significant difference in survival between patients with and without these complications [57,58]. Among 37 reported deaths, intra-abdominal bleeding was identified as the cause in two cases, and bowel infarction in one [59]. Intestinal ischaemia was reported in two studies, with an incidence of 12.8% (5/39) overall, and 5.6% (5/90) among patients receiving enteral nutrition [60,62]. In one study, all patients with intestinal ischaemia died, contributing to an overall ICU mortality rate of 56% (22/39) [60]. Hypoxic hepatitis occurred in 24.7% to 27.8% of patients and was identified as an independent predictor of mortality in both studies reporting this outcome [61,63].
Abdominal injuries in children.
Abdominal injuries in children were evaluated in three post-mortem studies (Table 3). Among 211 children with a mean age of 19 months, one case of gastric perforation was identified, but no abdominal injuries were reported in the other two studies [65–67]. In a retrospective review of neonate medical records, the incidence of intestinal perforation was significantly higher in infants weighting more than 1000g who received CPR compared to those who did not (3.6% [7/194] vs 1.3% [73/5564]; p < 0.01). No significant difference was observed in infants weighing less than 1000g (p = 0.84). Clinical outcomes were not reported [68]. In two cohorts of children treated with ECPR, a hepatic dysfunction score was worse among non-survivors, and all patients with hepatic failure died [69,70].
Miscellaneous.
In a retrospective study of 9408 peripartum women, eleven experienced cardiac arrest. Among the three women with liver injury, two died [71]. In a study of liver transplantation, transaminase levels were elevated in donors with a history of cardiac arrest, however, neither the occurrence of cardiac arrest nor the degree of transaminase elevation correlated with graft failure [72]. In three studies evaluating interposed abdominal compressions during CPR, no abdominal injuries were reported [73–75].
Discussion
In this systematic review, we identified 208 reports of abdominal injury following cardiac arrest, including140 case reports. Many cohort studies were predominantly single-centre and focused on specific sub-populations, contributing to substantial heterogeneity. Overall, the incidence of CPR-related traumatic abdominal injuries was low, with liver and spleen being the most frequently affected organs. Although these injuries were potentially life-threatening, most were managed successfully through conservative treatment, surgery or angioembolisation, and did not appear to influence overall outcomes. Ischaemic complications demonstrated a broader range of incidence, largely dependent on the diagnostic modality employed. NOMI was reported in less than 3% of patients, while ischaemic liver injury occurred in 7% to 28%. Biomarkers indicative of intestinal injury, such as IFABP, were elevated in 82–100% of patients. Ischaemic abdominal injuries were consistently associated with increased mortality, regardless of assessment method.
The pattern of traumatic injuries observed resembled that of blunt abdominal trauma in general, with the liver and spleen most commonly affected, followed by hollow viscus and pancreatic injuries [77]. Unlike high-energy blunt trauma, CPR represents repetitive low-energy trauma, which may explain the low incidence of abdominal injuries [77,78]. An exception was noted in peripartum women, with cardiac arrest, where nearly 30% of those who experienced cardiac arrest sustained liver injury [71]. The primary impact of chest compressions is the sternum, and accordingly the incidences of abdominal injuries were lower than that reported for thoracic injuries [79]. While traumatic abdominal injuries were not associated with population-level outcomes, several cases were life-threatening, underscoring the importance of clinical vigilance in patients who deteriorate after initial resuscitation. However, the rarity of severe injuries does not support routine abdominal imaging in all patients following CPR.
Several studies reported a higher incidence of abdominal organ injury with mechanical compared to manual chest compressions. In one study involving a load-distributing band system, liver injury occurred in 29% of patients [37]. Although a trial of this device was previously terminated early due to safety concerns, abdominal complications were not specifically reported [80]. Thoracic injuries have also been more frequently reported with mechanical compared to manual compressions [79]. However, patients receiving mechanical compressions often have prolonged resuscitation times, which may confound these findings. Notably, three RCT´s comparing mechanical and manual chest compressions reported no significant difference in survival [81–83]. Only the LINC-trial reported abdominal adverse events separately [44,81–83]. Despite the lack of systematic assessment, current evidence does not suggest that mechanical compressions significantly impact outcomes via increased abdominal injury.
Ischaemic abdominal injuries showed highly variable incidence rates, depending on diagnostic method. This variability may reflect both the subtlety of ischaemic injury and the inherent difficulty in diagnosis [84–86]. Ischaemia is common in other organs following cardiac arrest, acute kidney injury occurs in 50% of patients, and hypoxic-ischaemic brain injury remains the leading cause of death [1,87]. Given that all patients likely experience some degree of ischaemia during cardiac arrest, even with high-quality CPR, ischaemic injury may represent a continuum rather than a binary event [1]. Biomarkers like IFABP may offer greater sensitivity, although their clinical utility remains uncertain [2,7]. For instance, IFABP was not predictive of outcomes in patients with refractory cardiac arrest in a recent study, and was inconsistently associated with clinical manifestations of NOMI [88]. Future research should aim to enhance diagnostic strategies for abdominal ischaemia and explore the timing and mechanisms by which abdominal injury contributes to organ dysfunction and mortality [89].
Determining the true incidence of abdominal injury is challenging. In addition to diagnostic limitations, assessing only sub-populations might lead to both under- and overestimation [85]. For example, injuries may be missed in patients who do not undergo imaging, while autopsy-based studies might overestimate the incidence of severe injuries in non-survivors [4,20,90,91].
Most studies reported an association between abdominal ischaemia and increased mortality. We presented risk ratios for mortality in a Forest plot to illustrate this relationship. However, interpretation requires caution. First, defining a threshold for ischaemic injury is inherently problematic given its continuum. Second, confounding factors such as time to return of spontaneous circulation (ROSC) were not adjusted for, raising the possibility that abdominal injury may simply reflect whole-body ischaemia. Accordingly, severe intestinal ischaemia requiring surgical resection was uncommon [54,55]. However, a recent study reported that clinical signs of NOMI was associated with poor neurological outcomes in an adjusted analysis [92].
Ischaemic abdominal injury may contribute to poor outcomes by adding to the total ischaemic burden and triggering systemic inflammation [1]. Although several trials explored anti-inflammatory therapies after cardiac arrest, none have demonstrated clear benefits on patient-centered outcomes [93–95]. Our previous work suggest that the inflammatory consequences of intestinal injury may be limited [96]. Nonetheless, the clinical impact of abdominal ischaemia after cardiac arrest remains uncertain. Emerging interventions such as resuscitative endovascular balloon occlusion of the aorta (REBOA), which may aggravate abdominal ischaemia, should be implemented cautiously [97,98].
Our review has several limitations. Despite a comprehensive search strategy, some studies were identified through hand-searching, and grey literature was not included. Most included studies were of low to moderate quality with variability in patient populations, exposures, and outcomes. Many lacked clear inclusion criteria or standardized definitions, complicating synthesis. We categorized injuries as traumatic or ischaemic for the ease of interpretation, although this dichotomy it is not always clinically or pathophysiologically distinct.
Conclusion
In this comprehensive review of abdominal injuries following cardiac arrest, CPR-related traumatic injuries were uncommon, but should be considered in patients with unexplained clinical deterioration. Ischaemic injury incidence ranged from 0.7% to 100%, and was consistently associated with increased mortality. Whether abdominal ischaemia independently contributes to poor outcomes remains unresolved and warrants further investigation.
Supporting information
S3 Appendix. References to all case reports and case series.
https://doi.org/10.1371/journal.pone.0329164.s003
(DOCX)
S4 Appendix. Quality appraisal of included studies.
https://doi.org/10.1371/journal.pone.0329164.s004
(DOCX)
S6 Table. All included studies except case reports.
https://doi.org/10.1371/journal.pone.0329164.s006
(DOCX)
S7 File. Included studies.
Excel spreadsheat.
https://doi.org/10.1371/journal.pone.0329164.s007
(XLSX)
S8 File. Excluded studies with reasons.
Excel spreadsheat.
https://doi.org/10.1371/journal.pone.0329164.s008
(XLSX)
S9 Fig. Data supporting figure in excel spreadsheat.
https://doi.org/10.1371/journal.pone.0329164.s009
(XLSX)
S10 Fig. Data supporting figure in excel spreadsheat.
https://doi.org/10.1371/journal.pone.0329164.s010
(XLSX)
S11 Fig. Data supporting figure in excel spreadsheat.
https://doi.org/10.1371/journal.pone.0329164.s011
(XLSX)
Acknowledgments
We would like to thank Ingrid Ingeborg Riphagen, Katrine Aronsen and the other staff at the Medicine and Health Library, Norwegian University of Science and Technology, for their assistance and cooperation with this systematic review.
References
- 1. Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation. 2021;161:220–69. pmid:33773827
- 2. Roedl K, Spiel AO, Nürnberger A, Horvatits T, Drolz A, Hubner P, et al. Hypoxic liver injury after in- and out-of-hospital cardiac arrest: Risk factors and neurological outcome. Resuscitation. 2019;137:175–82. pmid:30831218
- 3. Delignette M-C, Stevic N, Lebossé F, Bonnefoy-Cudraz E, Argaud L, Cour M. Acute liver failure after out-of-hospital cardiac arrest: An observational study. Resuscitation. 2024;197:110136. pmid:38336284
- 4. Grimaldi D, Legriel S, Pichon N, Colardelle P, Leblanc S, Canouï-Poitrine F, et al. Ischemic injury of the upper gastrointestinal tract after out-of-hospital cardiac arrest: a prospective, multicenter study. Crit Care. 2022;26(1):59. pmid:35287719
- 5. Piton G, Belin N, Barrot L, Belon F, Cypriani B, Navellou J-C, et al. Enterocyte Damage: A Piece in the Puzzle of Post-Cardiac Arrest Syndrome. Shock. 2015;44(5):438–44. pmid:26196845
- 6. Krychtiuk KA, Richter B, Lenz M, Hohensinner PJ, Huber K, Hengstenberg C, et al. Epinephrine treatment but not time to ROSC is associated with intestinal injury in patients with cardiac arrest. Resuscitation. 2020;155:32–8. pmid:32522698
- 7. Hoftun Farbu B, Langeland H, Ueland T, Michelsen AE, Jørstad Krüger A, Klepstad P, et al. Intestinal injury in cardiac arrest is associated with multiple organ dysfunction: A prospective cohort study. Resuscitation. 2023;185:109748. pmid:36842675
- 8. Studer W, Wu X, Siegemund M, Seeberger M. Resuscitation from cardiac arrest with adrenaline/epinephrine or vasopressin: effects on intestinal mucosal tonometer pCO(2) during the postresuscitation period in rats. Resuscitation. 2002;53(2):201–7. pmid:12009224
- 9. Prengel AW, Lindner KH, Wenzel V, Tugtekin I, Anhäupl T. Splanchnic and renal blood flow after cardiopulmonary resuscitation with epinephrine and vasopressin in pigs. Resuscitation. 1998;38(1):19–24. pmid:9783505
- 10. Spoormans I, Van Hoorenbeeck K, Balliu L, Jorens PG. Gastric perforation after cardiopulmonary resuscitation: review of the literature. Resuscitation. 2010;81(3):272–80. pmid:20064683
- 11. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. pmid:19621072
- 12.
Covidence. covidence.org Melbourne, Australia: Covidence; 2020 [cited 2020 11.05.20]. Available from: covidence.org
- 13.
Critical Appraisal Skills Programme 2020 [cited 2020 11.05.20]. Available from: casp-uk.net
- 14. Champigneulle B, Haruel PA, Pirracchio R, Dumas F, Geri G, Arnaout M, et al. Major traumatic complications after out-of-hospital cardiac arrest: Insights from the Parisian registry. Resuscitation. 2018;128:70–5. pmid:29698751
- 15. Kurkciyan I, Meron G, Sterz F, Müllner M, Tobler K, Domanovits H, et al. Major bleeding complications after cardiopulmonary resuscitation: impact of thrombolytic treatment. J Intern Med. 2003;253(2):128–35. pmid:12542552
- 16. Bjork RJ, Snyder BD, Campion BC, Loewenson RB. Medical complications of cardiopulmonary arrest. Arch Intern Med. 1982;142(3):500–3. pmid:6978115
- 17. Karasek J, Slezak J, Stefela R, Topinka M, Blankova A, Doubková A, et al. CPR-related injuries after non-traumatic out-of-hospital cardiac arrest: Survivors versus non-survivors. Resuscitation. 2022;171:90–5. pmid:34995685
- 18. Tam J, Soufleris C, Ratay C, Frisch A, Elmer J, Case N, et al. Diagnostic yield of computed tomography after non-traumatic out-of-hospital cardiac arrest. Resuscitation. 2023;189:109898. pmid:37422167
- 19. Viniol S, Thomas RP, König AM, Betz S, Mahnken AH. Early whole-body CT for treatment guidance in patients with return of spontaneous circulation after cardiac arrest. Emerg Radiol. 2020;27(1):23–9. pmid:31468207
- 20. Christ M, von Auenmueller KI, Noelke JP, Sasko B, Amirie S, Trappe H-J. Early computed tomography in victims of non-traumatic out-of-hospital cardiac arrest. Intern Emerg Med. 2016;11(2):237–43. pmid:26597877
- 21. Branch KRH, Strote J, Gunn M, Maynard C, Kudenchuk PJ, Brusen R, et al. Early head-to-pelvis computed tomography in out-of-hospital circulatory arrest without obvious etiology. Acad Emerg Med. 2021;28(4):394–403. pmid:33606342
- 22. Dunham GM, Perez-Girbes A, Bolster F, Sheehan K, Linnau KF. Use of whole body CT to detect patterns of CPR-related injuries after sudden cardiac arrest. Eur Radiol. 2018;28(10):4122–7. pmid:29124382
- 23. Corbett SW, O’Callaghan T. Detection of traumatic complications of cardiopulmonary resuscitation by ultrasound. Ann Emerg Med. 1997;29(3):317–21; discussion 322. pmid:9055769
- 24. Seung MK, You JS, Lee HS, Park YS, Chung SP, Park I. Comparison of complications secondary to cardiopulmonary resuscitation between out-of-hospital cardiac arrest and in-hospital cardiac arrest. Resuscitation. 2016;98:64–72. pmid:26610377
- 25. Hellevuo H, Sainio M, Nevalainen R, Huhtala H, Olkkola KT, Tenhunen J, et al. Deeper chest compression - more complications for cardiac arrest patients? Resuscitation. 2013;84(6):760–5. pmid:23474390
- 26. Ümit TB, Sogut O, Az A, Cakmak S, Demirel I. Relationship between measures of thoracic diameter and cardiopulmonary resuscitation-induced thoracoabdominal injury. Rev Assoc Med Bras (1992). 2022;68(10):1470–5. pmid:36417655
- 27. Choi SJ, Kim HS, Kim EY, Choi H-Y, Cho J, Yang HJ, et al. Thoraco-abdominal CT examinations for evaluating cause of cardiac arrest and complications of chest compression in resuscitated patients. Emerg Radiol. 2014;21(5):485–90. pmid:24771034
- 28. Moriguchi S, Hamanaka K, Nakamura M, Takaso M, Baba M, Hitosugi M. Aging is only significant factor causing CPR-induced injuries and serious injuries. Leg Med (Tokyo). 2021;48:101828. pmid:33370635
- 29. Wannasri T, Peonim V, Worasuwannarak W. Cardiopulmonary resuscitated complications encountered in forensic autopsy cases: A 5-year retrospective analysis in ramathibodi hospital. Indian Journal of Forensic Medicine and Toxicology. 2021;15(3):4621–30. https://dx.doi.org/10.37506/ijfmt.v15i3.16019.
- 30. Yamaguchi R, Makino Y, Chiba F, Torimitsu S, Yajima D, Inokuchi G, et al. Frequency and influencing factors of cardiopulmonary resuscitation-related injuries during implementation of the American Heart Association 2010 Guidelines: a retrospective study based on autopsy and postmortem computed tomography. Int J Legal Med. 2017;131(6):1655–63. pmid:28905100
- 31. Setälä P, Hellevuo H, Huhtala H, Kämäräinen A, Tirkkonen J, Hoppu S. Risk factors for cardiopulmonary resuscitation-related injuries sustained during out-of-hospital cardiac arrests. Acta Anaesthesiol Scand. 2018;62(9):1290–6. pmid:29797706
- 32. Girotti P, Rizzuto A, Orsini V, Hodja V, Koenigsrainer I. Heart injuries related to cardiopulmonary resuscitation: a risk often overlooked. Rev Cardiovasc Med. 2022;23(2):61. pmid:35229552
- 33. Ihnát Rudinská L, Hejna P, Smatanová M, Ihnát P, Dvořáček I. Injuries associated with cardiopulmonary resuscitation in non-survivors after out-of-hospital cardiac arrest (autopsy study). Soud Lek. 2017;62(2):18–21. pmid:28597665
- 34. Bedell SE, Fulton EJ. Unexpected findings and complications at autopsy after cardiopulmonary resuscitation (CPR). Arch Intern Med. 1986;146(9):1725–8. pmid:3753112
- 35. Smekal D, Johansson J, Huzevka T, Rubertsson S. No difference in autopsy detected injuries in cardiac arrest patients treated with manual chest compressions compared with mechanical compressions with the LUCAS device--a pilot study. Resuscitation. 2009;80(10):1104–7. pmid:19595496
- 36. Milling L, Astrup BS, Mikkelsen S. Prehospital cardiopulmonary resuscitation with manual or mechanical chest compression: A study of compression‐induced injuries. Acta Anaesthesiol Scand. 2019;63(6):789–95.
- 37. Viniol S, Thomas RP, Gombert S, König AM, Betz S, Mahnken AH. Comparison of different resuscitation methods with regard to injury patterns in cardiac arrest survivors based on computer tomography. Eur J Radiol. 2020;131:109244. pmid:32905956
- 38. Lardi C, Egger C, Larribau R, Niquille M, Mangin P, Fracasso T. Traumatic injuries after mechanical cardiopulmonary resuscitation (LUCAS2): a forensic autopsy study. Int J Legal Med. 2015;129(5):1035–42. pmid:25874665
- 39. Pinto DC, Haden-Pinneri K, Love JC. Manual and automated cardiopulmonary resuscitation (CPR): a comparison of associated injury patterns. J Forensic Sci. 2013;58(4):904–9. pmid:23692387
- 40. Preda T, Nafi M, Villa M, Cassina T. Traumatic injuries after manual and automatic mechanical compression during cardiopulmonary resuscitation, a retrospective cohort study. Resusc Plus. 2023;16:100465. pmid:37711684
- 41. Koster RW, Beenen LF, van der Boom EB, Spijkerboer AM, Tepaske R, van der Wal AC, et al. Safety of mechanical chest compression devices AutoPulse and LUCAS in cardiac arrest: a randomized clinical trial for non-inferiority. Eur Heart J. 2017;38(40):3006–13. pmid:29088439
- 42. Ondruschka B, Baier C, Bayer R, Hammer N, Dreßler J, Bernhard M. Chest compression-associated injuries in cardiac arrest patients treated with manual chest compressions versus automated chest compression devices (LUCAS II) - a forensic autopsy-based comparison. Forensic Sci Med Pathol. 2018;14(4):515–25. pmid:30203237
- 43. Koga Y, Fujita M, Yagi T, Nakahara T, Miyauchi T, Kaneda K, et al. Effects of mechanical chest compression device with a load-distributing band on post-resuscitation injuries identified by post-mortem computed tomography. Resuscitation. 2015;96:226–31. pmid:26335044
- 44. Smekal D, Lindgren E, Sandler H, Johansson J, Rubertsson S. CPR-related injuries after manual or mechanical chest compressions with the LUCAS™ device: a multicentre study of victims after unsuccessful resuscitation. Resuscitation. 2014;85(12):1708–12. pmid:25277343
- 45. Larsen AI, Hjørnevik AS, Ellingsen CL, Nilsen DWT. Cardiac arrest with continuous mechanical chest compression during percutaneous coronary intervention. A report on the use of the LUCAS device. Resuscitation. 2007;75(3):454–9. pmid:17618034
- 46. Taylor GJ, Rubin R, Tucker M, Greene HL, Rudikoff MT, Weisfeldt ML. External cardiac compression. A randomized comparison of mechanical and manual techniques. JAMA. 1978;240(7):644–6. pmid:671684
- 47. Meron G, Kurkciyan I, Sterz F, Susani M, Domanovits H, Tobler K, et al. Cardiopulmonary resuscitation-associated major liver injury. Resuscitation. 2007;75(3):445–53. pmid:17640792
- 48. Iesu E, Franchi F, Zama Cavicchi F, Pozzebon S, Fontana V, Mendoza M, et al. Acute liver dysfunction after cardiac arrest. PLoS One. 2018;13(11):e0206655. pmid:30395574
- 49. Oh SH, Kim HJ, Park KN, Kim SH, Kim YM, Youn CS, et al. Hypoxic hepatitis in survivors of out-of-hospital cardiac arrest. Am J Emerg Med. 2015;33(9):1166–70. pmid:26032661
- 50. Champigneulle B, Geri G, Bougouin W, Dumas F, Arnaout M, Zafrani L, et al. Hypoxic hepatitis after out-of-hospital cardiac arrest: Incidence, determinants and prognosis. Resuscitation. 2016;103:60–5. pmid:27068401
- 51. L’Her E, Cassaz C, Le Gal G, Cholet F, Renault A, Boles J-M. Gut dysfunction and endoscopic lesions after out-of-hospital cardiac arrest. Resuscitation. 2005;66(3):331–4. pmid:16039032
- 52. McDonnell PJ, Hutchins GM, Hruban RH, Brown CG. Hemorrhage from gastric mucosal tears complicating cardiopulmonary resuscitation. Ann Emerg Med. 1984;13(4):230–3. pmid:6608297
- 53. Schriefl C, Steininger P, Clodi C, Mueller M, Poppe M, Ettl F, et al. The association of early diarrhea after successful resuscitation following out-of-hospital cardiac arrest with neurological outcome: A retrospective observational study. Medicine (Baltimore). 2021;100(49):e28164. pmid:34889287
- 54. Wurm R, Cho A, Arfsten H, van Tulder R, Wallmüller C, Steininger P, et al. Non-occlusive mesenteric ischaemia in out of hospital cardiac arrest survivors. Eur Heart J Acute Cardiovasc Care. 2018;7(5):450–8. pmid:28045326
- 55. Paul M, Bougouin W, Legriel S, Charpentier J, Jaubert P, Savary G, et al. Frequency, risk factors, and outcomes of non-occlusive mesenteric ischaemia after cardiac arrest. Resuscitation. 2020;157:211–8. pmid:33027618
- 56. Grimaldi D, Guivarch E, Neveux N, Fichet J, Pène F, Marx J-S, et al. Markers of intestinal injury are associated with endotoxemia in successfully resuscitated patients. Resuscitation. 2013;84(1):60–5. pmid:22743354
- 57. Zotzmann V, Rilinger J, Lang CN, Duerschmied D, Benk C, Bode C, et al. Early full-body computed tomography in patients after extracorporeal cardiopulmonary resuscitation (eCPR). Resuscitation. 2020;146:149–54. pmid:31811881
- 58. Maruhashi T, Katsuta K, Wada K, Kobashi S, Kon Y, Kon A. Effects of extracorporeal cardiopulmonary resuscitation complications on resuscitation outcomes. Gazz Med Ital - Arch Sci Med. 2018;177(3).
- 59. Bartos JA, Carlson K, Carlson C, Raveendran G, John R, Aufderheide TP, et al. Surviving refractory out-of-hospital ventricular fibrillation cardiac arrest: Critical care and extracorporeal membrane oxygenation management. Resuscitation. 2018;132:47–55. pmid:30171974
- 60. Renaudier M, de Roux Q, Bougouin W, Boccara J, Dubost B, Attias A, et al. Acute mesenteric ischaemia in refractory shock on veno-arterial extracorporeal membrane oxygenation. Eur Heart J Acute Cardiovasc Care. 2020;10(1):62–70. pmid:33609105
- 61. Lee YI, Kang MG, Ko R-E, Park TK, Chung CR, Cho YH, et al. The Impact of Hypoxic Hepatitis on Clinical Outcomes after Extracorporeal Cardiopulmonary Resuscitation. J Clin Med. 2020;9(9):2994. pmid:32948044
- 62. Gutierrez A, Carlson C, Kalra R, Elliott AM, Yannopoulos D, Bartos JA. Outcomes associated with delayed enteral feeding after cardiac arrest treated with veno-arterial extracorporeal membrane oxygenation and targeted temperature management. Resuscitation. 2021;164:20–6. pmid:33965476
- 63. Pang PYK, Wee GHL, Huang MJ, Hoo AEE, Tahir Sheriff IM, Lim SL, et al. Therapeutic Hypothermia May Improve Neurological Outcomes in Extracorporeal Life Support for Adult Cardiac Arrest. Heart Lung Circ. 2017;26(8):817–24. pmid:28159528
- 64. Johnson NJ, Acker M, Hsu CH, Desai N, Vallabhajosyula P, Lazar S, et al. Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest. Resuscitation. 2014;85(11):1527–32. pmid:25201611
- 65. Bush CM, Jones JS, Cohle SD, Johnson H. Pediatric injuries from cardiopulmonary resuscitation. Ann Emerg Med. 1996;28(1):40–4. pmid:8669737
- 66. Price EA, Rush LR, Perper JA, Bell MD. Cardiopulmonary resuscitation-related injuries and homicidal blunt abdominal trauma in children. Am J Forensic Med Pathol. 2000;21(4):307–10. pmid:11111786
- 67. Matshes EW, Lew EO. Do resuscitation-related injuries kill infants and children? Am J Forensic Med Pathol. 2010;31(2):178–85. pmid:20436339
- 68. Soraisham AS, Lodha AK, Singhal N, Aziz K, Yang J, Lee SK, et al. Neonatal outcomes following extensive cardiopulmonary resuscitation in the delivery room for infants born at less than 33 weeks gestational age. Resuscitation. 2014;85(2):238–43. pmid:24513125
- 69. Kramer P, Mommsen A, Miera O, Photiadis J, Berger F, Schmitt KRL. Survival and Mid-Term Neurologic Outcome After Extracorporeal Cardiopulmonary Resuscitation in Children. Pediatr Crit Care Med. 2020;21(6):e316–24. pmid:32343108
- 70. Ozturk Z, Kesici S, Ertugrul İ, Aydin A, Yilmaz M, Bayrakci B. Resuscitating the resuscitation: A single-centre experience on extracorporeal cardiopulmonary resuscitation. J Paediatr Child Health. 2023;59(2):335–40. pmid:36453833
- 71. Cox TR, Crimmins SD, Shannon AM, Atkins KL, Tesoriero R, Malinow AM. Liver lacerations as a complication of CPR during pregnancy. Resuscitation. 2018;122:121–5. pmid:29097198
- 72. Totsuka E, Fung JJ, Urakami A, Moras N, Ishii T, Takahashi K, et al. Influence of donor cardiopulmonary arrest in human liver transplantation: possible role of ischemic preconditioning. Hepatology. 2000;31(3):577–80. pmid:10706545
- 73. Howard M, Carrubba C, Foss F, Janiak B, Hogan B, Guinness M. Interposed abdominal compression-CPR: its effects on parameters of coronary perfusion in human subjects. Ann Emerg Med. 1987;16(3):253–9. pmid:3813159
- 74. Barranco F, Lesmes A, Irles JA, Blasco J, Leal J, Rodriguez J, et al. Cardiopulmonary resuscitation with simultaneous chest and abdominal compression: comparative study in humans. Resuscitation. 1990;20(1):67–77. pmid:2171119
- 75. Sack JB, Kesselbrenner MB, Jarrad A. Interposed abdominal compression-cardiopulmonary resuscitation and resuscitation outcome during asystole and electromechanical dissociation. Circulation. 1992;86(6):1692–700. pmid:1451240
- 76.
Deeks JJ HJ, Altman DG (editors). Chapter 10: Analysing data and undertaking meta-analyses. Cochrane Handbook for Systematic Reviews of Interventions version 64 (updated August 2023). 2023.
- 77. Wiik Larsen J, Søreide K, Søreide JA, Tjosevik K, Kvaløy JT, Thorsen K. Epidemiology of abdominal trauma: An age- and sex-adjusted incidence analysis with mortality patterns. Injury. 2022;53(10):3130–8. pmid:35786488
- 78. Soar J, Berg KM, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, et al. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2020;156:A80–119. pmid:33099419
- 79. Miller AC, Rosati SF, Suffredini AF, Schrump DS. A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries. Resuscitation. 2014;85(6):724–31. pmid:24525116
- 80. Hallstrom A, Rea TD, Sayre MR, Christenson J, Anton AR, Mosesso VN Jr, et al. Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial. JAMA. 2006;295(22):2620–8. pmid:16772625
- 81. Wik L, Olsen J-A, Persse D, Sterz F, Lozano M Jr, Brouwer MA, et al. Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial. Resuscitation. 2014;85(6):741–8. pmid:24642406
- 82. Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, et al. Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA. 2014;311(1):53–61. pmid:24240611
- 83. Perkins GD, Lall R, Quinn T, Deakin CD, Cooke MW, Horton J, et al. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet. 2015;385(9972):947–55. pmid:25467566
- 84. Theodore S, Xia T, Saillant N. The Evaluation and Management of Intestinal Ischemia. NEJM Evid. 2024;3(4):EVIDra2400057. pmid:38776634
- 85. Moonen P-J, Reintam Blaser A, Starkopf J, Oudemans-van Straaten HM, Van der Mullen J, Vermeulen G, et al. The black box revelation: monitoring gastrointestinal function. Anaesthesiol Intensive Ther. 2018;50(1):72–81. pmid:29152710
- 86. Björck M, Koelemay M, Acosta S, Bastos Goncalves F, Kölbel T, Kolkman JJ, et al. Editor’s Choice - Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;53(4):460–510. pmid:28359440
- 87. Sandroni C, Dell’anna AM, Tujjar O, Geri G, Cariou A, Taccone FS. Acute kidney injury after cardiac arrest: a systematic review and meta-analysis of clinical studies. Minerva Anestesiol. 2016;82(9):989–99. pmid:26957119
- 88. Smalcova J, Brodska LH, Suen J, Vanickova Z, Kavalkova P, White N, et al. Intestinal fatty acid-binding protein as a marker of prognosis and non-occlusive mesenteric ischemia in refractory cardiac arrest patients: a pilot study. Resusc Plus. 2025;24:100972. pmid:40486105
- 89. Reintam Blaser A, Preiser J-C, Fruhwald S, Wilmer A, Wernerman J, Benstoem C, et al. Gastrointestinal dysfunction in the critically ill: a systematic scoping review and research agenda proposed by the Section of Metabolism, Endocrinology and Nutrition of the European Society of Intensive Care Medicine. Crit Care. 2020;24(1):224. pmid:32414423
- 90. Acosta S, Ogren M, Sternby N-H, Bergqvist D, Björck M. Fatal nonocclusive mesenteric ischaemia: population-based incidence and risk factors. J Intern Med. 2006;259(3):305–13. pmid:16476108
- 91. Marcoen B, Blot KH, Vogelaers D, Blot S. Clinical vs. autopsy diagnostic discrepancies in the intensive care unit: a systematic review and meta-analysis of autopsy series. Intensive Care Med. 2024;50(12):1971–82. pmid:39287650
- 92. Smalcova J, Suen J, Huptych M, Franek O, Kavalkova P, Brodska HL, et al. The significance of possible non-occlusive mesenteric ischemia in relation to neurological outcomes in patients with refractory cardiac arrest - Secondary analysis of the Prague OHCA study. Resuscitation. 2025;214:110642. pmid:40381979
- 93. Meyer MAS, Wiberg S, Grand J, Meyer ASP, Obling LER, Frydland M, et al. Treatment Effects of Interleukin-6 Receptor Antibodies for Modulating the Systemic Inflammatory Response After Out-of-Hospital Cardiac Arrest (The IMICA Trial): A Double-Blinded, Placebo-Controlled, Single-Center, Randomized, Clinical Trial. Circulation. 2021;143(19):1841–51. pmid:33745292
- 94. Obling LER, Beske RP, Meyer MAS, Grand J, Wiberg S, Nyholm B, et al. Prehospital high-dose methylprednisolone in resuscitated out-of-hospital cardiac arrest patients (STEROHCA): a randomized clinical trial. Intensive Care Med. 2023;49(12):1467–78. pmid:37943300
- 95. Andersen LW, Isbye D, Kjærgaard J, Kristensen CM, Darling S, Zwisler ST, et al. Effect of Vasopressin and Methylprednisolone vs Placebo on Return of Spontaneous Circulation in Patients With In-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021;326(16):1586–94. pmid:34587236
- 96. Farbu BH, Lydersen S, Mohus RM, Ueland T, Mollnes TE, Klepstad P, et al. The detrimental effects of intestinal injury mediated by inflammation are limited in cardiac arrest patients: A prospective cohort study. Resusc Plus. 2024;18:100639. pmid:38666252
- 97. Brede JR, Skulberg AK, Rehn M, Thorsen K, Klepstad P, Tylleskär I, et al. REBOARREST, resuscitative endovascular balloon occlusion of the aorta in non-traumatic out-of-hospital cardiac arrest: a study protocol for a randomised, parallel group, clinical multicentre trial. Trials. 2021;22(1):511. pmid:34332617
- 98. Kim HE, Chu S-E, Jo YH, Chiang W-C, Jang D-H, Chang C-H, et al. Effect of resuscitative endovascular balloon occlusion of the aorta in nontraumatic out-of-hospital cardiac arrest: a multinational, multicenter, randomized, controlled trial. Trials. 2024;25(1):118. pmid:38347550