Frequency of rib and sternum fractures associated with out-of-hospital cardiopulmonary resuscitation is underestimated by conventional chest X-ray
Introduction
Fractures of ribs and sternum due to chest compressions during CPR are frequently reported complications in adult patients [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]. The frequency is particularly high when active compression–decompression is performed [12], [13], [14], [15]. Broken ribs usually do not cause complications, unless fractured in several places and dislocated. Multiple fractures of neighbouring ribs on both sides of the thoracic cage, however, can produce a flail chest, which itself may interfere with efficacy of chest compressions. In addition, projecting fragments of ribs and sternum may cause injury to the heart and lungs including haemothorax and pneumothorax [14], [16], [17]. Aortic injury by penetration of a fractured rip has been reported [18]. Rupture of the liver following penetration by a rib fragment may cause life-threatening bleeding, especially when thrombolytic therapy has been administered [19]. In survivors from cardiac arrest it is important to diagnose rib and sternal fractures that occurred during CPR, as in about half of patients with rib fractures complications can be expected that may influence therapy [20]. Fractures not only increase the likelihood of damage to underlying organs but also may impair ventilation and complicate recovery.
The frequency of detection of injuries to the chest differs according to the mode of investigation. In physical examination fractures can be diagnosed by chest instability and crepitation between bone fragments. To estimate the number and location of fractures is very difficult particularly when these run through the costosternal region [21], [22]. Even the experienced observer may miss fractured ribs on conventional CXR is performed. Sternal fractures are especially likely to remain undiagnosed on CXR [13], [23].
This study was designed to determine whether there is a correlation between post-mortem findings by CXR and by autopsy. The frequency of occurrence of CPR-related chest injuries, in particular rib and sternum fractures, was assessed.
Section snippets
Design
This was a prospective study comparing post-mortem findings of chest X-ray and forensic autopsy results in patients after attempted cardiopulmonary resuscitation. Data from a cohort of 19 out-of-hospital cardiac arrests with resuscitation attempts by the Emergency Medical Service (EMS) in Innsbruck, Austria, between March 1998 and June 2000 were analysed. A comprehensive literature review was performed.
Setting
A university-affiliated emergency medical system. The EMS Innsbruck is an urban
Results
A total of 19 patients who underwent attempted resuscitation after out-of-hospital cardiac arrest was enrolled in this study, namely 13 male and 6 female patients. Mean age was 66.4±16.3 (range: 34–85). Cardiac arrest was witnessed in 13 of 19 cases (68%) cases. Bystander CPR was performed in six cases (32%) prior to arrival of EMS. (Table 1.) Seven patients received thrombolytic treatment either with 50 mg alteplase (21%; n=4) or 10 I.U. reteplase (16%; n=3) combined with heparin 5000 I.U. and
Discussion
A comparative study of prospectively collected patients was performed, with post-mortem findings of chest injuries associated with CPR being evaluated by CXR and autopsy. Fractures of ribs and sternal bone appeared to be common complications of CPR and apparently underreported in CXR.
There are, however, certain limitations to our study. Although the study was conducted prospectively over 28 months, the number of patients enrolled is small. The frequency of detection of rib fractures depends on
Acknowledgements
We would like to acknowledge the enthusiastic and conscientious work of the EMS teams. In particular, we are very grateful to Dr. H. Ulmer, Department of Biostatistics, for his scientific advice in statistical methodology.
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