Elsevier

Resuscitation

Volume 63, Issue 3, December 2004, Pages 327-338
Resuscitation

Skeletal chest injuries secondary to cardiopulmonary resuscitation

https://doi.org/10.1016/j.resuscitation.2004.05.019Get rights and content

Abstract

Objective: To review the evidence on the incidence of rib and sternal fractures after conventional closed-chest compression in the treatment of cardiac arrest in adults and children, and after active compression–decompression cardiopulmonary resuscitation (ACD-CPR). Methods: Medline search and additional review of the cited literature in the articles found. Results: Reports on conventional CPR in adults suggest an incidence of rib fractures ranging from 13 to 97%, and of sternal fractures from 1 to 43%. Reports on CPR in children suggest an incidence of rib fractures of 0–2%, and no sternal fractures. ACD-CPR has been reported as causing rib fractures in 4–87%, and sternal fractures in 0–93% of cases. 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 that an increased complication rate is associated with ACD-CPR. Rib or sternal fractures are unlikely to increase mortality, as they rarely cause severe internal organ damage. Further prospective studies are desirable to assess complications by post-mortem examinations that explicitly address them. In particular, clinical evaluation of mechanical CPR devices should be accompanied by a thorough assessment of the associated complications because data specific to this modality are not available.

Resumo

Objectivo:Rever os dados existentes relativos à incidência de fracturas esternais e costais após compressão torácica fechada convencional no tratamento da paragem cardíaca nos adultos e crianças, e após reanimação cardio–pulmonar com compressão-descompressão activa (ACD-CPR). Método:Pesquisa Medline e revisão adicional da literatura citada nos artigos encontrados. Resultados: Descrição da CPR convencional nos adultos sugere uma incidência de fracturas costais que varia de 13 a 97%, e de fracturas esternais de 1 a 43%. Descrição da CPR nas crianças sugere uma incidência de fracturas costais de 0–2%, e nenhuma fractura esternal. Tem sido descrito que a ACD-CPR causa fracturas costais em 4–87%, e fracturas esternais em 0–93% dos casos. Conclusão: Não há estudos metodológicos sobre as fracturas torácicas devidas à compressão torácica e os estudos disponíveis não podem ser comparados entre si. Nas crianças pequenas e nos lactentes, a CPR manual raramente causa lesões esqueléticas torácicas. Nos adultos, as fracturas esternais ocorrem em pelo menos um quinto e as fracturas costais bem como as fracturas costais e/ ou esternais em pelo menos um terço dos doentes durante a CPR convencional. Não há evidência que mostre uma taxa de complicações aumentada associadas com ACD-CPR. É improvável que as fracturas esternais ou costais aumentem a mortalidade, já que raramente causam lesão grave de órgãos internos. São necessários mais estudos prospectivos, que explicitamente abordem este problema, para avaliar as complicações através da realização de exames após a morte. A avaliação clínica dos aparelhos de CPR em particular deve ser acompanhada por uma cuidadosa avaliação das complicações associadas porque os dados específicos a esta modalidade não estão disponíveis.

Resumen

Objetivo: Revisar la evidencia sobre la incidencia de fracturas costales y de esternón después de compresión torácica convencional a tórax cerrado en el tratamiento de paro cardíaco en adultos y niños, y después de resucitación cardiopulmonar con compresión y descompresión activa (ACD-CPR). Métodos: Búsqueda en Medline y revisión adicional de la literatura citada en los artículos encontrados. Resultados: Reportes sobre CPR convencional en adultos sugieren una incidencia de fracturas costales en un rango de 13 a 97%, y de fracturas costales de 1 a 43%. Los reportes sobre CPR en niños sugieren una incidencia de fracturas costales entre 0 –2%, y ausencia de fracturas esternales. Se ha reportado que la ACD-CPR causaría fracturas costales en 4–87%, y fracturas esternales en 0–93% de los casos. Conclusiones: No existen estudios metodológicamente adecuados sobre fracturas costales y los estudios disponibles no pueden ser comparados uno con otro. En niños y lactantes, la RCP manual raramente causa lesiones esqueléticas del tórax. En adultos, las fracturas esternales ocurren en al menos un quinto y las fracturas costales al igual que fracturas costales y/o esternales en al menos un tercio de los pacientes durante la CPR convencional. No hay evidencia que muestre que una tasa aumentada de complicaciones esté asociada con ACD-CPR. No es probable que las fracturas costales o esternales aumenten la mortalidad, ya que rara vez causan daño severo a órganos internos. Sería deseable que se realicen estudios prospectivos ulteriores para evaluar complicaciones por medio de exámenes post mortem que los evalúen en forma explícita. En particular, la evaluación clínica de dispositivos mecánicos de CPR debería ser acompañada por una evaluación profunda de las complicaciones asociadas porque no se dispone de datos específicos de este tipo.

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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