Elsevier

Resuscitation

Volume 85, Issue 6, June 2014, Pages 724-731
Resuscitation

Review article
A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries,☆☆

https://doi.org/10.1016/j.resuscitation.2014.01.028Get rights and content

Abstract

Objective

The incidence of thoracic injuries resulting from cardiopulmonary resuscitation (CPR) is not well characterized. We describe a case in which a CPR-associated atrial rupture was identified with ultrasound and successfully managed in the intensive care unit with a bedside thoracotomy and atrial repair. We then describe a systematic review with pooled data analysis of CPR-associated cardiovascular, pulmonary, pleural, and thoracic wall injuries.

Data sources

PubMed, Scopus, EMBASE, and Web of Science were searched to identify relevant published studies. Unpublished studies were identified by searching the Australian and New Zealand Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform, Cochrane Library, ClinicalTrials.gov, Current Controlled Trials, and Google.

Study selection

Inclusion criteria for the pooled analysis were any clinical or autopsy study in which (a) patients underwent cardiopulmonary resuscitation, (b) chest compressions were administered either manually or with the assistance of active compression–decompression devices, and (c) autopsy or dedicated imaging assessments were conducted to identify complications. Exclusion criteria for the pooled analysis were pre-clinical studies, case reports and abstracts.

Data extraction

Nine-hundred twenty-eight potentially relevant references were identified. Twenty-seven references met inclusion criteria.

Data synthesis

A systematic review of the literature is provided with pooled data analysis.

Conclusions

The incidence of reported CPR-associated cardiovascular and thoracic wall injuries varies widely. CPR with active compression–decompression devices has a higher reported incidence of cardiopulmonary injuries. Bedside ultrasound may be a useful adjunct to assess and risk-stratify patients to identify serious or life-threatening CPR-associated injuries.

Introduction

Effective chest compression remains the cornerstone of successful cardiopulmonary resuscitation (CPR). International guidelines note the critical importance of the quality of manual chest compression components including hand position, rescuer and victim position, and the depth and rate of compression and decompression.1, 2 In attempts to improve outcomes with CPR, several devices have been developed to improve the consistency and quality of chest compression and CPR. While none of these circulatory adjuncts are currently recommended because of insufficient data, some are being used routinely in resuscitation as alternatives to standard manual chest compressions.3, 4 These include active compression–decompression (ACD) devices based on suction-cup technology and automated devices using either piston technology or a load-distributing band.

The incidence of CPR-associated thoracic injuries in the setting of manual chest compressions or with circulatory adjuncts using active compression–decompression technology is not well characterized. Injuries to the thoracic wall, pulmonary and cardiovascular systems may cause significant morbidity and mortality and may represent potentially reversible causes of resuscitation failure. We describe a case in which an atrial rupture associated with standard manual CPR was identified with ultrasound and successfully managed in the intensive care unit with a bedside thoracotomy and atrial repair. This case was the impetus for us to perform a systematic review with pooled data analysis of CPR-associated cardiovascular, pulmonary, pleural, and thoracic wall injuries.

Section snippets

Case

A 44-year-old woman with a 16-year history of synovial cell sarcoma and a recent asymptomatic pulmonary embolism underwent a right thoracotomy with parietal pleurectomy, extra-pericardial resection of a large inferior mediastinal mass extending from the carina to the diaphragmatic hiatus, and excision of several right pulmonary metastases by parenchyma sparing techniques. The patient's sarcoma had originated in the right thigh, and had been definitively treated with surgery and adjuvant

Methods

A systematic search was performed to capture published and unpublished pre-clinical and clinical studies of CPR-associated cardiac, vascular and thoracic injuries. PubMed, Scopus, EMBASE, and Web of Science were searched to identify relevant published studies. The search strategies were adapted to accommodate the unique searching features of each database, including database-specific MESH and EMTREE controlled vocabulary terms. Searches were not limited by date, language or publication status.

Results and discussion

Our search strategy identified 928 potentially relevant studies. Additional references were identified from bibliography assessments. Twenty-seven references met inclusion criteria. For resuscitation non-survivors, injuries were detected post-mortem by autopsy assessments. For resuscitation survivors, injuries were detected by plain radiographs, CT scan, ultrasound assessment, or combinations of these modalities. The data from the pooled analysis is summarized in Table 1, Table 2, Table 3,

Conclusion

The incidence of reported CPR-associated cardiovascular and thoracic wall injuries varies widely. This may reflect several factors including the quality of the chest compressions and CPR, the diligence in defining these complications in survivors and non-survivors and the varying sensitivity of different diagnostic modalities to detect these injuries. Patients who undergo CPR with circulatory adjuncts using automated or active compression–decompression devices have a higher reported incidence

Conflict of interest statement

The authors have no conflicts of interest to declare.

Author's contributions

Drs. Miller, Rosati, Suffredini, and Schrump contributed to all stages of patient care. Drs. Miller and Suffredini researched and wrote the manuscript. Drs. Miller, Suffredini, and Schrump were involved in manuscript editing and revision.

Acknowledgements

We thank Lydia Kubiuk for her artistry in drawing Fig. 2 for this manuscript. Additionally, we thank Judith Welsh for her assistance and expertise with the literature search and search strategies.

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  • Cited by (0)

    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.2014.01.028.

    ☆☆

    This work was supported by the Intramural Research Program of the Clinical Center and the National Cancer Institute, National Institutes of Health.

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