Review articleA systematic review and pooled analysis of CPR-associated cardiovascular and thoracic 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A systematic search was performed to capture published and unpublished pre-clinical and clinical studies of CPR-associated cardiac, vascular and thoracic injuries.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.
References (99)
- et al.
European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators
Resuscitation
(2010) - et al.
European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support
Resuscitation
(2010) - et al.
Complications of cardiac resuscitation
Chest
(1987) - et al.
Pediatric injuries from cardiopulmonary resuscitation
Ann Emerg Med
(1996) - et al.
No difference in autopsy detected injuries in cardiac arrest patients treated with manual chest compressions compared with mechanical compressions with the LUCAS device – a pilot study
Resuscitation
(2009) - et al.
Cardiac rupture by penetration of fractured sternum: a rare complication of cardiopulmonary resuscitation
Resuscitation
(2000) - et al.
Atrial rupture in a child from cardiac massage by his parent
Ann Thorac Surg
(1987) - et al.
Cardiac tamponade secondary to cardiopulmonary resuscitation in a patient receiving antiplatelet therapy
Am J Emerg Med
(2000) - et al.
Exsanguination due to right ventricular rupture during closed-chest cardiopulmonary resuscitation
J Emerg Med
(2002) - et al.
Intracavitary cardiac thromboembolism: a complication of external cardiac massage
Chest
(1972)
Rupture of papillary-muscle of tricuspid valve – complication of cardiopulmonary resuscitation and a rare cause of tricuspid insufficiency
Am J Cardiol
Dissecting hematoma (aneurysm) of coronary arteries
Am J Med
Pseudoaneurysm of the thoracic aorta due to cardiopulmonary resuscitation: diagnosis by transesophageal echocardiography
Am Heart J
Active compression–decompression CPR necessitates follow-up post mortem
Resuscitation
Sternum fracture and haemorrhage after cardiopulmonary resuscitation
Resuscitation
Chest wall injuries following cardiopulmonary resuscitation
Resuscitation
Multidetector CT findings of skeletal chest injuries secondary to cardiopulmonary resuscitation
Resuscitation
Frequency of rib and sternum fractures associated with out-of-hospital cardiopulmonary resuscitation is underestimated by conventional chest X-ray
Resuscitation
Increased frequency of thorax injuries with ACD-CPR
Resuscitation
Chest injuries after active compression–decompression cardiopulmonary resuscitation (ACD-CPR) in cadavers
Resuscitation
Review of active compression–decompression cardiopulmonary resuscitation (ACD-CPR) – analysis of iatrogenic complications and their biomechanical explanation
Forensic Sci Int
Successful repair of myocardial free wall rupture after thrombolytic therapy for acute infarction
Ann Thorac Surg
Cardiac rupture associated with thrombolytic therapy: Impact of time to treatment in the late assessment of thrombolytic efficacy (LATE) study
J Am Coll Cardiol
Timing of ventricular septal rupture after acute myocardial infarction and its relation to thrombolytic therapy
Am J Cardiol
A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction
J Am Coll Cardiol
Cardiac tamponade early after thrombolysis for acute myocardial infarction: a rare but not reported hemorrhagic complication
J Am Coll Cardiol
Dose-related efficacy and bleeding complications of double-chain tissue plasminogen-activator in acute myocardial-infarction
Am J Cardiol
Haemopericardium following thrombolysis for acute myocardial infarction
Int J Cardiol
Sudden hemorrhagic tamponade simulating subacute ventricular rupture after acute myocardial infarction [2]
Int J Cardiol
Frequency of complications of cardiopulmonary resuscitation after thrombolysis during acute myocardial infarction
Am J Cardiol
Mortality risk assessment and the role of thrombolysis in pulmonary embolism
Crit Care Clin
Major bleeding complications in cardiopulmonary resuscitation: the place of thrombolytic therapy in cardiac arrest due to massive pulmonary embolism
Resuscitation
Focused assessment with sonography for trauma (FAST) after successful cardiopulmonary resuscitation
Resuscitation
Hemorrhagic shock after cardiopulmonary resuscitation, bedside ultrasonography interest
Ann Fr Anesth Reanim
Chest injury following cardiopulmonary resuscitation: a prospective computed tomography evaluation
Resuscitation
Lung injuries secondary to mechanical chest compressions
Resuscitation
Part 5: adult basic life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
Circulation
Part 7: CPR techniques and devices: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
Circulation
Cardiopulmonary resuscitation-related injuries
Crit Care Med
Causes of death after external cardiac massage: analysis of observations of fifty consecutive autopsies
Cleve Clin Q
Complications of external cardiac resuscitation: a retrospective review and survey of the literature
Med Ann Dist Columbia
Serious complications from active compression–decompression cardiopulmonary resuscitation
Int J Legal Med
Left ventricular rupture following external chest compression
Acta Anaesthesiol Scand
Clinical conference: rupture of right ventricle complicating closed chest cardiac massage
Circulation
Penetrating laceration of the pericardium and myocardium and myocardial rupture following closed-chest cardiac massage
Acta Med Scand
Closed-chest cardiac resuscitation. A prospective clinical and pathological study
N Engl J Med
Massive injury to the heart after attempted active compression–decompression cardiopulmonary resuscitation
Int J Legal Med
Complications of CPR
Crit Care Med
External cardiac massage
N Engl J Med
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.