Skeletal chest injuries secondary to cardiopulmonary resuscitation
Introduction
Chest compression has been one of the cornerstones of cardiopulmonary resuscitation since it was rediscovered by Kouwenhoven and colleagues in 1960 [1]. Together with expired air ventilation and external defibrillation, it made survival from cardiac arrest a real possibility. Recently, the importance of compressions has been re-emphasized by studies suggesting that for delayed resuscitation they should be given electively even before defibrillation [2], [3]. There are also circumstances when compressions alone might be used appropriately in basic life support [4], [5], [6].
Chest compression is a traumatic procedure, however. Concerns were expressed about possible complications from the outset. The authors who popularized the technique recognized quickly that fractured or cracked ribs were the most common of them, but also pointed out that sternal pressure applied correctly will usually avert side effects [7]. The widespread application of chest compression as a first aid measure within the community inevitably has a potential for harm as well as benefit. Relatively little attention has been paid to this potential problem, in part no doubt because the balance of risk is accepted as being overwhelmingly favourable. Detailed knowledge of the complication rate and factors that promote them are nevertheless important for both clinical and medico-legal reasons, particularly with the increasing emphasis on compression numbers. This review therefore addresses the specific issue of rib and sternal fractures by providing a comprehensive analysis of the information currently available in the relevant literature.
Section snippets
Methods
Separate analyses were planned for: (1) conventional cardiopulmonary resuscitation (STD-CPR) in adults, i.e. manual CPR without any adjuvants; (2) conventional CPR in children; (3) automatic mechanical CPR, i.e. CPR with application of an automatic mechanical device to perform chest compression; and (4) active compression–decompression CPR (ACD-CPR). Original papers were included in this review if they reported on skeletal chest injuries in at least 20 patients undergoing chest compression for
Results
The MEDLINE search yielded seven articles for STD-CPR in adults, three for CPR in children, none for automatic mechanical CPR, and five for ACD-CPR. A subsequent review of the literature referenced in these publications revealed eight more articles that matched the search criteria for STD-CPR in adults, two more for CPR in children, and an additional four for ACD-CPR.
Critical review of the methodologies used
Though the influence of age, gender, quality, and duration of CPR need to be discussed, their impact may be minor, compared with the methodological problems of the studies. The incidence reported for rib fractures secondary to standard CPR varies enormously between 13 [13] and 97% [21]. The studies in Table 1, Table 4 are not strictly comparable, however, because of essential differences in the patients studied, the setting, the protocol, data collection, and data presentation.
Fractures have
Clinical implications
Rib and sternal fractures are among the most common complications of CPR. Clinicians should be aware of the soft-tissue damages that may sometimes occur as a result.
In children, the detection of rib fractures after CPR has a forensic dimension in relation to the possibility of preceding child abuse [28], [68]. Rib fractures should raise a strong suspicion of child abuse and must be followed by a thorough exploration of: (a) the circumstances of the cardiac arrest; and (b) the child's body for
Conclusions
Sound methodological studies on thoracic fractures due to chest compression do not exist and the available studies cannot be compared one with another. In infants and toddlers, manual CPR rarely causes skeletal chest injuries. In adults, sternal fractures occur in at least one-fifth and rib fractures as well as rib and/or sternal fractures in at least one-third of the patients during conventional CPR. There is no compelling evidence to show an increased complication rate is associated with
Acknowledgements
This review was undertaken whilst RSH was holding a student research fellowship at the Wales Heart Research Institute, University of Wales College of Medicine, Cardiff, which was supported by the German Academic Exchange Service, Bonn. DAC is supported by a research grant (expenses only) from the Laerdal Foundation.
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