Figure 1
Teaching Case
SectionChest imaging
Case TypeClinical Cases
AuthorsDr Seema Malik, Foundation Trainee, Dept. Of Radiology, University Hospital of North Durham, Durham, United Kingdom. Dr Vishwanath Nanjundiah, Consultant Radiologist, University Hospitals of North Durham, Durham, United Kingdom.
Connected authors
52 years, female
Case report of a 52-year-old woman with asymptomatic calcified intrathoracic haematoma noted months after a Heimlich manoeuvre was carried out. Differential diagnosis was wide as history was not very
forthcoming in view of learning difficulty of the patient.
Partially calcified Intrathoracic haematoma following Haeimlich's Manoeuvre
A 52-year-old woman with Down’s syndrome was being investigated for an ischemic ulcer on her right gluteal region by Dermatology. Chest X-ray (Figure 1) organised as a part of the
investigations revealed a calcified lesion in the right lateral wall of the chest. This lesion measured 14cm x 8cm. It had a large soft tissue component and was associated with a small right-sided
pleural effusion. On further examination, she had a slight asymmetry of the affected side of the chest and a large lipoma on her back. A CT Scan (Figure 2) of her chest revealed a large lesion in the
right postero-lateral chest wall with heterogenous attenuation. The lesion had both soft tissue and calcified components, almost mimicking malignancy. The lung parenchyma was not involved. Findings
were suggestive of a partially calcified haematoma. Going back through her records, she had no such findings on her previous Chest X-ray from 2004. The answer lay in the history obtained from her
carers. She was resident in a care home and had an episode of choking while eating peanuts, a few months back, for which the staff present carried out the Heimlich’s Manoeuvre, which seemed to
relieve her obstruction. On account of her learning difficulty she was not able to communicate the pain following the traumatic manoeuvre. Retrospective correlation with the history provided the
right explanation for her asymptomatic clinical picture.
Heimlich Manoeuvre was first described by Henry Heimlich in June 1974.1 Following its widespread use, it was reported to have saved tens of lives within the first nine months. Fractured
ribs in two cases were the only major problems reported in the original article.1Currently, in the APLS guidelines, the words ‘abdominal thrusts’ are used instead of the phrase
‘Heimlich Manoeuvre’, primarily to define the indication and procedure more scientifically. ‘Abdominal thrusts are indicated following witnessed aspiration of foreign body where the
victim is conscious but has a very weak and ineffective cough.2 There is recognition of the fact that abdominal thrusts can cause serious injury which has prompted an explanatory note
stating that all victims receiving abdominal thrusts should be examined for injury by a doctor. Although the incidence of complications from the manoeuvre is low, serious complications can occur,
some of which may be fatal, if undetected. Most common complication reported is rib fracture3 followed by gastric rupture (1.7%).4-9 Gastric rupture has mostly been seen in
people over the age of 65 yrs or those neurologically impaired and in most cases multiple attempts were made. A variety of others have featured, mainly as case reports. A review of the literature
revealed a case of dislodgement of thrombus from an atherosclerotic non-aneurysmal aorta which resulted in thromboembolic occlusion of both lower extremities.10 In another case, repeated
Heimlich’s manoeuvre dislodged the foreign body further down in the trachea and may have contributed to rapid development of surgical emphysema, pneumomediastinum and
pneumopericardium.11 The following table (Table 1) collates the rare complications reported from Heimlich Manoeuvre over the years as published recently.12 Most of the reported
complications have involved rupture of a hollow viscous. This article also described a case of hepatic rupture following Heimlich’s Manoeuvre reported for the first time. Correct technique does
not preclude complications24,25. In most published cases of complications of Heimlich’s manoeuvre, specific information regarding technique is not provided26,27,28,29,30.
Our case of Calcified Haematoma, which was diagnosed months following the manoeuvre, is the first to be reported in medical literature and caused a distinctive diagnostic dilemma. Our case emphasizes
two important points. First, the importance of seeking medical help immediately after this manoeuvre is carried out on a victim12,27,31 and second that the complications from this
manoeuvre can come to light weeks to months afterwards and can pose a diagnostic dilemma later on. Also finding of significant injuries in any institutionalised individuals should raise the suspicion
of assault and specific questions regarding the technique used should always be asked.
References
[1] Heimlich H: A life saving maneuver to prevent food choking. JAMA 1975;234(4):398-401. (PMID: 1174371)
[2] Advanced Paediatric Life Support-The Practical Approach, 4th Edition, 2005.
[3] Fearing NM, Harrison PB. Complications of the Heimlich maneuver: Case report and literature review. J Trauma. 2002;53:978-979. (PMID: 12435952)
[4] Van der Harn AC, Lange JF. Traumatic rupture of the stomach after Heimlich manoeuvre. J Emerg Med. 1990;8:713-715. (PMID: 2096168)
[5] Bintz M, Cogbill TH. Gastric rupture after the Heimlich maneuver. J Trauma. 1996;40:159-160. (PMID: 8576987)
[6] Dupre MW, Edibaldo S, Brotman S. Traumatic rupture of the stomach secondary to Heimlich manoeuvre. Am J Emerg Med. 1993;11:611-612. (PMID: 8240565)
[7] Cowan M, Bardole J, Dlesk A. Perforated stomach following the Heimlich manoeuvre. Am J Emerg Med. 1987;5:121-122. (PMID: 3828013)
[8] Croom DW. Rupture of stomach after attempted Heimlich manoeuvre. JAMA. 1983;250:2602-2603. (PMID: 6632154)
[9] Visintine RE, Baick CH. Ruptured stomach after Heimlich manoeuvre. JAMA. 1975;234:415-416. (PMID: 1174375)
[10] Mack L, Forbes TL, Harris KA. Acute aortic thrombosis following incorrect application of the Heimlich manoeuvre. Ann Vasc Surgery. 2002;16:130-133. (PMID: 11904818)
[11] Nowitz A, Lewer BM, Galletly DC. An interesting complication of the Heimlich manoeuvre. Resuscitation. 1998;39:129-131. (PMID: 9918460)
[12] Palleiro MM, Lopez CB, Pretel MC, Fernandes JS. Hepatic rupture after Heimlich manoeuvre. Ann of Emerg Med. 2007;49:825-826. (PMID: 17512872)
[13] Agla GA, Hurst DJ. Pneumomediastinum following the Heimlich manoeuvre. JACEP. 1979;8:473-475. (PMID: 502110)
[14] Fink JA, Klein RL. Complications of the Heimlich maneouver. J Pediatr Surg. 1989;24:486-487. (PMID: 2738812)
[15] Haynes DE, Haynes BE, Yong YV. Esophageal rupture complicating Heimlich manoeuvre. Am J Emerg Med. 1984;2:507-509. (PMID: 6529464)
[16] Meredith MJ, Liebowitz R. Rupture of the esophagus caused by Heimlich manoeuvre. Ann Emerg Med. 1986;15:106-107. (PMID: 3942346)
[17] Rasaboni RM, Brathwaite CE, Dwyer WA. Ruptured jejunum following Heimlich manoeuvre. J Emerg Med. 1986;4:95-98. (PMID: 3794276)
[18] Valero V. Mesentric laceration complicating a Heimlich manoeuvre. Ann Emerg Med. 1986;15:105-106.
[19] Ujjin V, Ratanasit S, Nagendran T. Diaphragmatic Hernia as a complication of the Heimlich manoeuvre. Int Surg. 1984;69:175-176. (PMID: 6500885)
[20] Rakotoharinandransana H, Petit E, Dumas P, et al. Internal carotid artery dissection after Heimlich maneuver. Ann Fr Anesth Reanim. 2003;22:43-45. (PMID: 12738019)
[21] Roehm EF, Twiest MW, Williams RC. Abdominal aortic thrombosis in association with an attempted Heimlich manouever. JAMA. 1983;249:1186-7. (PMID: 6823081)
[22] Chapman JH, Menapace FJ, Howell RR. Ruptured aortic valve cusp: a complication of the Heimlich manoeuvre. Ann Emerg Med. 1983;12:446-448. (PMID: 6881635)
[23] Feldman T, Mallon SM, Bolooki H, Trohman RG. Fatal aortic regurgitation in a person performing the Heimlich manoeuvre. N Engl J Med. 1986;315:1613. (PMID: 3785328)
[24] Haynes DE, Haynes BE, Yong YV. Esophageal rupture complicating Heimlich maneuver. Am J Emerg Med 1984;2:507-9. (PMID: 6529464)
[25] Agia GA, Hurst DJ. Pneumomediastinum following Heimlich maneuver. JACEP 1979;8:473-5. (PMID: 502110)
[26] Visintine RE, Baick CH. Ruptured stomach after Heimlich maneuver. JAMA 1975;234:415. (PMID: 1174375)
[27] Majumdar A, Sedman PC. Gastric rupture secondary to successful Heimlich manoeuvre. Postgrad Med J 1998;74:609-10. (PMID: 10211358)
[28] Razaboni RM, Braithwaite CEM, Dwyer WA. Ruptured jejunum following Heimlich maneuver. J Emerg Med 1986;4:95-8. (PMID: 3794276)
[29] Ujjin V, Ratanasit S, Nagendran T. Diaphragmatic hernia as a complication of Heimlich maneuver. Int Surg 1984;69:175-6. (PMID: 6500885)
[30] Orlowski JP. Vomiting as a complication of the Heimlich maneuver. JAMA 1987;258:512-3. (PMID: 3599349)
[31] Fearing NM, Harrison PB. Complications of Heimlich maneuver: Case report and literature review. J TRAUMA 2002;53:978-979. (PMID: 12435952)
Case information
| URL: | https://www.eurorad.org/case/6109 |
| DOI: | 10.1594/EURORAD/CASE.6109 |
| ISSN: | 1563-4086 |
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