Elsevier

Resuscitation

Volume 60, Issue 2, February 2004, Pages 157-162
Resuscitation

Frequency of rib and sternum fractures associated with out-of-hospital cardiopulmonary resuscitation is underestimated by conventional chest X-ray

https://doi.org/10.1016/j.resuscitation.2003.10.003Get rights and content

Abstract

Objective: Fractured ribs and sternum are frequent complications of thoracic compression during CPR in adults. This study was conducted to determine whether findings of plain chest radiography (CXR) correlate with post-mortem findings in patients who underwent cardiopulmonary resuscitation (CPR) after out-of-hospital cardiac arrest. Methods: CXR findings and autopsy results of CPR-related chest injuries comprising rib and sternum fractures were compared prospectively in 19 patients. Results: Fractures were diagnosed in nine of 19 patients by means of radiology and in 18 of 19 patients by autopsy (rib fractures in 6/19 versus 17/19, P=0.002; sternum fractures in 5/19 versus in 9/19, P=0.227). The total number of isolated bone fractures detected by CXR was 18 (12 rib and six sternum fractures) and by autopsy 92 (83 rib and nine sternum fractures). The majority of rib fractures was located in the anterior part of the thoracic cage. Sternum fractures predominantly occurred in the lower third. Eight of 19 patients received either thrombolytic or antithrombotic treatment during CPR but no major bleeding complication associated with CPR was detected by autopsy. Conclusions: The findings of this study indicate that fractures associated with CPR are underreported in conventional radiographic investigations. No major bleeding complications related to CPR-associated fractures was detected.

Sumàrio

Objectivo: As fracturas costais e esternais são complicações frequentes das compressões torácicas durante a RCP em adultos. Este estudo pretendeu determinar se os achados da radiografia torácica (CXR) tinham correlação com os achados pós-mortem em doentes submetidos a reanimação cardio-pulmonar (RCP) após paragem cardı́aca pré-hospitalar. Métodos: Os achados de CXR e autópsia resultantes de lesões torácicas relacionadas com RCP, compreendendo fracturas costais e esternais, foram comparadas prospectivamente em 19 doentes. Resultados: Foram diagnosticadas fracturas em 9 de 19 doentes através da radiologia e em 18 de 19 doentes pela autópsia (fracturas costais em 6/19 versus 17/19, P = 0.002; fracturas esternais 5/19 versus em 9/19, P = 0.227). O número total de fracturas ósseas isoladas detectadas por CXR foi de 18 (12 costais e 6 esternais) e por autópsia de 92 (83 costais e 9 esternais). A maioria das fracturas costais estava localizada na parte anterior da grade torácica. As fracturas esternais ocorreram predominantemente no terço inferior. Oito de 19 doentes receberam tratamento anti-trombótico ou trombolı́tico durante a RCP mas não foram detectadas, pela autópsia, complicações hemorrágicas major associadas a RCP. Conclusões: Os achados deste estudo indicam que as fracturas associadas a CPR são subdiagnosticadas em investigações radiográficas convencionais. Não foram detectadas complicações hemorrágicas relacionadas com as fracturas associadas a RCP.

Resumen

Objetivos: Las fracturas costales y esternales son complicaciones frecuentes de las compresiones torácicas durante CPR en adultos. Este estudio fue conducido para ver si los hallazgos en la Rx de tórax simple (CXR) se correlacionan con los hallazgos postmortem en pacientes que fueron sometidos a reanimación cardiopulmonar (CPR) después de un paro cardiorrespiratorio extrahospitalario. Métodos: Se compararon prospectivamente los hallazgos en CRX y en autopsia, de lesiones torácicas relacionadas con CPR que comprometı́an fracturas de costillas y de esternón. Resultados: Se diagnosticaron fracturas costales en 9 de 19 pacientes por medio de radiologı́a y en 18 de 19 por medio de autopsia (fracturas costales en 6/19 versus 17/19, P = 0.002; fractura esternal en 5/19 versus en 9/19, P = 0.227). El número total de fracturas aisladas detectadas por CXR fue 18 (12 fracturas costales y seis esternales) y por autopsia 92 (83 fracturas costales y 9 esternales). La mayorı́a de las fracturas costales estaba localizada en la parte anterior de la jaula torácica. Las fracturas esternales ocurrieron predominantemente en el tercio inferior. Ocho de los 19 pacientes tratamiento trombolı́tico o antiarrı́tmico durante la CPR, pero no se detectaron complicaciones hemorrágicas mayores durante las autopsias. Conclusiones: Los hallazgos en este estudio indican que las fracturas asociadas con CPR son subdiagnosticadas en las investigaciones radiológicas convencionales. No se detectaron complicaciones hemorrágicas mayores relacionadas con la CPR.

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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