Elsevier

Resuscitation

Volume 84, Issue 3, March 2013, Pages 361-364
Resuscitation

Chest injury following cardiopulmonary resuscitation: A prospective computed tomography evaluation

https://doi.org/10.1016/j.resuscitation.2012.07.011Get rights and content

Abstract

Introduction

Traumatic chest injuries may occur following cardiopulmonary resuscitation (CPR). The aim of this study was to address the frequency of injuries, especially rib and sternal fractures, and also to identify factors that contribute to post-CPR trauma.

Methods

This study was a prospective cross-sectional study conducted in the emergency departments (ED) of eight academic tertiary care centers. To evaluate injuries secondary to CPR, we performed chest computed tomography (CT) in patients who were successfully resuscitated from cardiac arrest. Contributing factors that might be related to injuries were also investigated.

Results

We enrolled 71 patients between 1 January 2011 and 30 June 2011. Rib and sternal fractures were diagnosed in 22 and 3 patients, respectively. Females were more susceptible to rib fracture (p = 0.036). When non-physicians participated as chest compressors in the ED, more ribs were fractured (p = 0.048). The duration of CPR and number of compressors were not contributing factors to trauma secondary to CPR. There was a wide variation in the frequency of rib fractures from hospital to hospital (0–83.3%). In high-risk hospitals (in which more than 50% of patients had rib fractures), the average age of the patients was higher, and non-physicians took part in ED CPR more often than they did at low-risk hospitals.

Conclusion

The incidence of rib fracture following CPR was different in various hospitals. The presence of non-physician chest compressors in the ED was one of the contributing factors to rib fracture. Further studies on the influence of resuscitators and relation between quality of chest compression and CPR-induced injuries are warranted to reduce complications following CPR.

Introduction

Chest compression is a vital component of cardiopulmonary resuscitation (CPR). According to the European Resuscitation Council (ERC) Guidelines and American Heart Association (AHA) guidelines, a rate of 100–120 compressions per minute and a depth of 5–6 cm is recommended for high-quality CPR.1, 2 Moreover, as agonal gasping delays the start of CPR, the guidelines emphasize that the lay rescuer immediately begin CPR on victims who are breathing abnormally. This policy could increase bystander CPR prevalence, while the possibility of administering CPR to unresponsive patients not in cardiac arrest would also be increased. Before the 2010 guidelines were implemented, White et al.3 reported that 18% of patients to whom dispatchers offered CPR instructions were not in arrest, but still received bystander chest compression.

Traditionally, high quality chest compressions have been emphasized to improve the survivability of patients in cardiac arrest; therefore, we investigated exactly how many involuntary injuries resulted from CPR. Previous studies have shown varied incidences of rib and sternum fractures related to CPR.3, 4, 5, 6 We performed chest computed tomography (CT) in patients who were successfully resuscitated from cardiac arrest to investigate chest injuries secondary to CPR. The aim of this study was to address the frequency of injuries (especially rib and sternal fractures) and to identify contributing factors.

Section snippets

Methods

This study was a prospective cross-sectional, multicenter study involving patients who survived cardiac arrest after CPR in the emergency departments (ED) of eight academic tertiary care centers. Research staff at participating hospitals endeavored to provide high-quality CPR and post-resuscitation care according to the 2010 ERC and AHA guidelines.7, 8 Each hospital's institutional review board approved the study protocol.

Eligible patients were enrolled between January 1, 2011 and June 30,

Results

During the study period, 608 patients received cardiopulmonary resuscitation: 455 (75%) out-of-hospital cardiac arrests and 153 (25%) in-hospital cardiac arrests. Spontaneous circulation was restored in 285 (47%) patients. Among them, we excluded 15 patients under the age of 18, 31 patients with traumatic cardiac arrest and 12 patients who did not receive chest compressions. And we could not performed CT in 156 patients for various reasons such as unstable medical condition preventing transport

Discussion

Various rates of skeletal injury were reported in previous studies that investigated complications after CPR; 13–97% for rib fracture and 1–43% for sternal fracture.4, 9, 10 The incidence of fractures could vary depending on the diagnostic tool used. Lederer et al. reported that postmortem autopsy was more accurate for detecting rib and sternum fractures than X-ray.5 As this study investigated the rate of skeletal chest injury in successfully resuscitated patients, we adopted multidetector CT

Limitations

This study has several limitations. First, we could not clarify the occupations and characteristics of non-physicians in the ED that influenced the risk of rib fracture. These non-physicians could have been nurses and paramedics who were affiliated with the ED or medical students training in emergency medicine. Those involved in resuscitations also could have varied depending on the situation at each hospital. Further research into human factors, such as BLS education level and CPR experience,

Conclusion

The number of rib fractures arising from chest compression was relatively high. However, the incidence of rib fracture varied greatly from hospital to hospital. Female patients and participation of non-physician chest compressors in ED CPR were associated with a higher incidence of rib fractures. Further studies to investigate the cause of variability in complications by hospital after CPR and the influence of chest compression properties on CPR complication should be conducted.

Conflict of interest

None of the authors have any conflict of interest, financial or otherwise, relevant to the conduct or reporting of this study.

References (24)

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    The incidence of skeletal fracture was nearly 30% while the incidence of pneumothorax was approximately 9% of imaged patients. The incidence of these complications is within the expected range reported in literature and aligns with the most common reports of complication rates.6,7,17–20 The majority of these injuries were not discovered on portable plain film radiography with sensitivity of x-ray at 7.5% and 50% of these two complications, respectively.

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    Chest wall injuries are the most common CPR-related injuries [8]. The prevalence of rib fractures varies widely between studies and is reported to range between 27 and 90% in non-traumatic cardiac arrest [4-9,22]. The difference in the reported prevalence of rib fractures may be explained by the difference in methods of detecting rib fractures, with chest radiography being less sensitive than computed tomography (CT) and autopsy [9,23,24].

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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.07.011.

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