Complications of External Cardiac Resuscitation a Retrospective Review and Survey of the Literature

• Inquiry article
• Open Admission
• Published: 28 February 2019

Cardiopulmonary resuscitation (CPR) complications encountered in forensic autopsy cases

• Fotios Chatzinikolaou¹,
• Dimitrios Koutsoukis¹,
• Ioannis Chrysovergis¹ &
• Polychronis Voultsos¹

BMC Emergency Medicine volume 19, Commodity number:23 (2019) Cite this commodity

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Abstruse

Background

Cardiopulmonary resuscitation (CPR) provides a significant increase in survival charge per unit, fifty-fifty if performed by bystanders. However, bystanders may refrain from performing CPR for fear of eventual malpractice litigation. Currently lack Guidelines specifying whether a item CPR-related complication is in all likelihood unavoidable or not. To fulfill this gap a great number of studies is required to be published in the most relevant leading academic literature. This paper aims at making a contribution to addressing such a claiming.

Methods

A retrospective observational report based on forensic autopsy material aiming at recording injuries resulting from the application of CPR. The severity of injuries was forensically evaluated.

Results

Out of 88 cases autopsied, only 26.vii% had rib fractures (but 20% of which were located in the 6 lower ribs), 17.iv% had sternal fractures (85.7% of which were detected in the torso of the sternum and 14.3% in the manubrium). The ratio of sternal fractures to rib fractures is like to the ratio cited in other studies reported in the literature (2:3, approximately). The number of fractures was seven.86 (4.11 on the right side and 4.75 on the left side). 16% of the cases were found to be mild, 48% were moderate, and 35% of the cases were severe. When a physician was present, a (not statistically significant) tendency towards more severe complications was found.

Conclusion

The findings are in accord with other like studies reported in the literature referring to the classic external CPR. This report offers a proposal aiming at making a contribution to develop Guidelines specifying whether a item CPR-related complication is in all likelihood unavoidable or not.

Peer Review reports

Background

Cardiopulmonary Resuscitation (CPR) constitutes i of the most important interventions at the socio-medical level. It is a simple process which, yet, may upshot in significant increment of the rate of survival of patients who experience sudden cardiac arrest more often than not due to coronary eye disease [1].

In case of cardiac arrest resuscitation attempts should continue until acceptable spontaneous apportionment is achieved or until the death of the patient is ascertained [2]. Nevertheless, these attempts may cause considerable injuries to patients, thus increasing rescuer's exposure to legal risk [2].

The injuries associated with the application of CPR are classified according to their incidence [2] and localization [3,4,5,half dozen]. Interestingly, at that place are several publications reporting rare complications of CPR concerning both adults and minors [vii,8,9,x,eleven,12,13,14].

According to the official website of the American Heart Clan (AHA) [15], cardiac arrest is more frequent than the general public considers, and it may happen to anyone and at whatsoever fourth dimension. Therefore, CPR training should not only be worthy of medical and paramedical staff's concern, just too it should be considered worthy of anyone's business organization. According to the aforementioned source, four out of every five cases of cardiac arrest occur at home; thus, it is probable that a potentially life-saving CPR would be performed by a family unit fellow member [15].

Despite the fact that the potential beneficial effect of CPR has been established, less than i out of three victims of out-of-hospital cardiac arrest receives life-saving assistance from a bystander [16].

CPR has been described equally "fierce, painful and undignified" [17]. However, it must be applied to all patients since it provides a 4-fold increase in survival rate, even if it is performed past bystanders [one].

Although out-of-infirmary cardiopulmonary resuscitation (CPR) may result in a significant increase in survival rate even if information technology is performed past bystanders, certain CPR-related complications are unavoidable and, hence, bystanders in all likelihood may refrain from performing CPR for fear of eventual malpractice litigation even in jurisdictions where Samaritan laws are present. Currently lack Guidelines specifying whether a detail CPR-related complication is in all likelihood unavoidable or not. To fulfill this gap a cracking number of studies is required to be published in the most relevant leading bookish literature. This paper aims at making a contribution to address such a challenge.

Methods

Study design

The purpose of this study was to tape the incidence, localization, and severity of complications of CPR amongst individuals who did not survive their cardiac arrest in Thessaloniki (the second largest city in Greece) and associate them with the conditions under which CPR was performed, on the basis of our forensic dissection findings. Precise assessment of the complications of CPR tin can only be made using forensic autopsy, since in most cases these injuries go radiologically undiagnosed [18]. This is the first study based on forensic dissection fabric coming from Greece aiming at recording injuries resulting from the application of cardiopulmonary resuscitation. All the victims of cardiac arrest included in our written report had undergone transmission cardiopulmonary resuscitation. No i of them had undergone CPR including a mechanical chest compression device.

The records of 184 autopsies carried out in the Laboratory of Forensic Medicine and Toxicology of Aristotle Academy of Thessaloniki during a 12-month period in 2013 were examined. The report included all cases of violent and sudden deaths where CPR was performed.

Overall, 88 cases were included in the study. Our data involved demographic data, cause of expiry, type of death, number and skillfulness or experience of persons who performed CPR, presence and localization of soft tissue injuries, presence and localization of rib and sternal fractures, medications received, and location where CPR was performed. In cases where injuries due to CPR were identified, their severity was estimated forensically. Label of a category as "astringent" neither corresponds to the "severe bodily injury" described in the Greek Penal Code (article 310), which refers to a life-endangering injury, nor to any other similar distinctions constitute in the international literature (e.k., at least xiv day hospitalization, or pregnant inability for at least 28 days) [xix]. The injuries were classified into three categories (mild, moderate, severe) based on localization (proximity to the heart), number of fractured ribs (more than or less than half-dozen), history of medication interfering with the coagulation machinery (factor which is besides taken into consideration in other like studies), and medical history, i.due east., factors increasing the risk of complications. Whenever the number of fractures (with or without haemorrhage) was less than 6, injuries were considered mild. When the number of fractures ranged from 7 to 12, injuries were considered moderate, and when it ranged from xiii to 24, injuries were considered severe. The standard of "vi fractured ribs" might exist viewed as an arbitrary criterion, provided that the criteria used for classification of breast injuries depend on the criterion of 3 fractured ribs and on the clinical picture of the and then-called "flail chest" (Open injury scaling, Chest Wall) [20], which, however, is absent in our necrotomic thing. Indeed, the classification into three categories (mild, moderate, severe) is not based on «gold standard». However, in our stance a severity benchmark necessarily involves a degree of arbitrariness. For instance, such a benchmark should take into account both the number and the location of the injuries, provided that one only rib fracture located on the left half thorax and close to the heart may nigh probable lacerate it, even though, a greater number of rib fractures located on the right half thorax might be regarded as life-threatening injuries to a much lesser extent. Nosotros set our severity standards based on our forensic evaluation.

Statistical analysis

Values are expressed as mean ± standard difference (SD) or percentages. The independent samples t-test was employed for the comparison of means between groups. Pearson's chi-squared test was used to check the independence between categorical variables. Logistic regression was used for the cess of the touch on of historic period on the occurrence of rib fractures. P values less than 0.05 were considered statistically pregnant. Statistical assay was performed using SPSS v21.0 (IBM Corp, Armonk, NY). One-way analysis of variance was used to check differences between means of historic period for the unlike categories of injury severity.

Results

The bodies were those of 53 males and 35 females. At the time of expiry the historic period range was 18–87 years (lx.half dozen ± seven.5 years). Cardiovascular diseases were the nigh common cause of death (north = 62) and about deaths were non-tearing (northward = 76). There was no chest injury prior to the cardiac arrest in none of the cases. All the identified injuries were due to performance of CPR.

Incidence and location of the injuries

All the CPR-related rib fractures involved in our autopsy findingswere located in (or very close to) the midclavicular line. As regards the CPR-related sternal fractures, 85.7% of these injuries were identified in the body of the sternum and 14.iii% in the manubrium.

More specifically, out of 88 cases, only 26.1% had rib fractures. Nigh of them were located in the six upper ribs. The near mutual location of the fractures was the 2nd rib (in 39% of them bilaterally). In 8,6% of them a fracture of the 1st rib was co-existed. Moreover, 17.4% were accompanied with sternal fractures. Most of them were located in the body of the sternum (85.7%). Results are summarized in Tabular array one.

Table 1 Rib fractures (RF) location in association with sternal fractures (SF)

Full size tabular array

As regards soft tissue injuries, eighteen.two% of cases were accompanied with soft tissue injuries, mostly identified on the left side (Table ii).

Tabular array ii Soft tissue injuries

Full size tabular array

A history of osteoporosis was only institute in one example; however, no CPR-related injuries were identified.

All cases with sternal fractures referred to a single fracture.

Statistical correlations

Statistical assay showed independence between gender and rib or sternal fractures (p > 0.999 and p = 0.819, respectively).

Similarly, no correlation betwixt age and rib or sternal fractures was institute (p = 0.290 and p = 0.533 respectively).

Who performed CPR and where

In 96.6% of the cases, CPR was performed by specialized staff (medical, paramedical or both), and in 2% of the cases it was performed by both specialists and laypersons. Equally regards the specialized staff, in 52.3% of the cases it was paramedical staff, in about 20% of the cases it was medical staff, while a coexistence of medical and paramedical staff was reported in 28% of the cases, approximately. In 29.1% of the cases, more than than one person actively participated in the process (see Table three). A physician was present in 47.7% of the cases. More severe injuries were more ofttimes establish in cases where CPR was performed in the presence of a physician and in presence of more i other person, although without statistical significance (p = 0.59 and 0 + .195, respectively). Whenever a dr. was nowadays, injuries were moderate or severe at equal frequency (see below), only they were never mild. In addition, in 58% of cases where CPR was performed in the presence of a medico, at that place was a 2d person present in the area as well, which complicates the interpretation of this finding. It is possible that the trend towards more than severe injuries in the presence of a physician is either due to a more intensive application of CPR by the doctor, or to a repetitive application of CPR (e.g., the doc arrives at the surface area at a subsequently stage and repeats the procedure).

Table three Number of rescuers

Full size table

The identify where CPR was performed was the victim's dwelling house in 27.3% of the cases, a public place in 22.7%, and a medical surroundings in 46.vi% of the cases. This means that, in fifty% of the cases, CPR was performed in out-of-hospital settings.

The severity of injuries

None of the identified CPR-related injuries was lethal. The severity of injuries was evaluated in the aforementioned cases and information technology was found that 16% of them were balmy, 48% were moderate, and 35% of the cases were severe. When CPR was performed by more than one person, the injuries were moderate or severe at an equal charge per unit and they were never mild, whereas when it was performed by a unmarried person, in 23.8% of the cases it resulted in balmy injuries, in 47.6% information technology resulted in moderate injuries, and in 28.half dozen% it caused severe injuries (See Table four). Statistical assay showed no clan between severity of injuries and gender (chi-square = 1.022, df = three, p = 0.796) (see Table 5 and Tabular array 6). In addition, it was established that at that place is some independence between severity of injuries and blazon of staff (chi-square = vii.398, df = 6, p = 0.286) and also betwixt severity of injuries and place where CPR was performed (chi-square = 8.614, df = nine, p = 0.474).

Table 4 Number of rescuers and evaluation of injuries severity

Total size table

Table five Gender and rib fractures (RF)

Full size table

Table 6 Gender and rib fractures (RF)

Full size table

Word

The major finding of this written report were that the incidence of rib and sternal fractures and of soft tissue injuries caused by CPR is consistent with the corresponding rates of other studies [3, 5, 6, xviii] The ratio of rib to sternal fractures was like to the ratio cited in other studies [3, v, 6, eighteen].

A broad range of incidence rates of rib fractures caused past CPR (13–97%) [21] has been reported in the literature. Sternal fractures are reported at a rate usually ranging from 14 [3] to thirty% [22] even though frequencies as low every bit 1% and as high as 43% are also reported [21]. Lederer et al. reported rib and sternal fractures at a rate of 94.7% post-obit a successful CPR process [18]. In a forensic research conducted by the University of Edinburgh, which included 499 cases, Black et al. reported rib fractures in 29% of the cases (concerned mainly females) and sternal fractures in 14% of the cases [iii]. The incidence of sternal fractures reported by various authors is almost past half compared to the reported incidence of rib fractures [3]. Rib fracture incidence was positively associated with avant-garde age. In 97 cases, where at that place were "multiple" rib fractures, no significant difference was found between correct (four ribs) and left side (4 ribs) [3]. In our study the boilerplate fractures were vii.86 overall (4.11 on the right side and iv.75 on the left side). A Turkish study (University of Pamukkale) including 231 deaths, reported an incidence rate of thirteen.2% for rib and sternal fractures [half-dozen]. Rabl et al. written report an incidence rate of 28% for rib fractures and 16% for sternal fractures [23]. Similarly, Baubin et al. reported incidence rates of 55 and 30% [22], and Black et al. reported incidence rates of 29 and xiv%, respectively [iii]. Out of 96 autopsies overall, Hashimoto et al. reported incidence rates of 52% (43% on the correct side, 48% on the left side, and 39% bilaterally) and 39%, respectively (but 9% of which was not accompanied past rib fractures) [5]. The average fractured ribs were seven.three depending on the case. Hoke and Chamberlain report incidence rates of thirteen–97% and 1–43%, respectively, while they report almost zero incidence rates for children [21]. It is maintained in the literature that females accept sternal fractures more frequently (since they have smaller and thinner sternum) [24], besides as that the elderly are at higher risk for rib fractures [25]. The incidence of rib fractures increases with historic period. Nevertheless, this is not the example with sternal fractures [3]. Both rib and sternal fractures are rare amid persons under 20 years of age [v]. Rib and sternal fractures are reported far more rarely in infants and children. Rib fractures often occur at the 3rd, 4th, or fifth rib, located in the midclavicular line of the rib cage [four]. Withal, in lx% of our cases with rib fractures was establish a fracture of the second rib.

Accordingly, sternal fractures occur most frequently in the region between the level of tertiary and 4th rib, or between the level of 4th and 5th rib [4]. Interestingly, Krischer et al. maintain that fractures in these regions might be considered unavoidable [4]. In 20% of their cases, they identified some avoidable fractures (at very high or very low ribs, at a rate of 5% at both loftier and low ribs). They report a rate of 4% for sternal fractures. A high incidence rate of fractures at the first and, mostly, at the 2d rib, even bilaterally, was establish in our report. In no one of our case was constitute other CPR-related complication such every bit pericardial, pulmonary, cardiac trauma or thrombosis. Visceral injuries also as dangerous air embolism after cannulation of the external jugular vein are considered rare complications. In addition, os marrow embolism may be seen in peripheral vessels. Information technology is reported in 13% of the cases [v].

The results of our study are consistent with the findings of other studies showing that at that place is no departure in the incidence rate of adverse effects when comparing a specialized staff with laypersons [26]. Withal, Kim et al. showed that the presence of non-physician breast compressors in the Emergency Department was one of the contributing factors to the germination of rib fractures [27].

The here presented findings might contribute on the enrichment of literature apropos CPR-related rib and sterna fractures. Interestingly, the greater the number of cases in literature with CPR-related rib and sternal fractures, the more than reliable the consideration that sure CPR-related rib or sternal fractures were unavoidable, namely, should usually not raise malpractice litigation. Not surprisingly, it has been established that the adequate depth of breast pinch is a thing of the utmost importance for an increase in the possibility of achieving spontaneous circulation. The European Resuscitation Council (ERC) has inverse their recommendation well-nigh minimal compression depth from twoscore mm (2005) to 50 mm (2010) [28, 29]. The quality of chest compressions has improved significantly after the 2010 AHA guidelines; however, information technology is more than difficult for the rescuer to comply with the guidelines because of increased fatigue in long duration CPR [30].

According to Hellevuo et al. iatrogenic injuries increase as compression depth exceeds half dozen cm, peculiarly in case of male patient. However, it is worth noting that the injuries are characterized "by and large not fatal" [31].

Beneath, nosotros go into some details apropos eventual CPR-related liability. It is widely accepted that when performing CPR, certain complications are ordinary and unavoidable, even if CPR was performed lege artis and with the due diligence. The medico performing CPR is aware of these complications and accepts their occurrence equally necessary or, at least, as potential. This means ─ at to the lowest degree according to Greek and High german Criminal Police force ─ that there is some indirect "intent" (Intend 2nd Degree, namely, the physician knows that a certain incidental-perhaps undesired- upshot will occur) or provisional intent (Intend Third Caste, namely, the physician foresees the result every bit possible and accept it, albeit undesired) [32, 33]. Other complications, however, may be (fully or partially) due to an incorrect medical process (e.g., incorrect placing of the hands on the breast, excessive pressure level force, etc.). Such complications are difficult to distinguish from unavoidable complications. Such distinction is still immature both in theory/legal doctrine and in example-law. Nevertheless, such distinction is of vital importance whenever an issue of medical liability arises. The label of any complications equally unavoidable may belch a doctor from liability. Either in the context of the existing negligence-based legal system or in an alternative (reform) legal arrangement, due east.g. a "no-fault" bounty system [19]. Under the Greek legal framework both civil and criminal liability may arise for a physician who has performed CPR. Commodity 29 of the Greek Penal Code (PC) along with article 310§1 PC provide for a sentence for a severe unintentional bodily injury whose outcome is due to negligence (of rescuer in the instance of CPR).

Not surprisingly, in that location is a "grey zone" between avoidable and unavoidable CPR complications. However, there is a "core" of complications which may be considered "unavoidable" almost with certainty. Such complications tin be determined based on forensic studies which promise more than reliable results and involve a larger number of cases provided that spontaneous circulation and hemodynamic stability is accessible in only a minor number of cases.

Our study is an endeavor to contribute to determining the rib and sternum CPR-related injuries that might be viewed every bit "in all likelihood unavoidable". Only classic osseous injuries of the ribs and sternum were identified at a frequency similar to that reported in other studies, i.due east. as regards their locations. At that place was no correlation with factors such every bit gender, age, place where CPR is performed, or rescuer. This conclusion is considered to favour the classification of item os injuries amidst the unavoidable complications. However, it is crucial to bear in listen that it would be a hard chore to accurately determine the incidence of CPR-related rib and sternal fractures. Further inquiry is needed in this perspective. Miller et al. arguably state that "the incidence of reported CPR-associated cardiovascular and thoracic wall injuries varies widely" [34]. The authors put it best in maxim that "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 notice these injuries" [34]. Takayama et al. recently contend that "long elapsing of out-of-infirmary CPR was an contained adventure factor for chest injuries, perchance due to the difficulty of maintaining adequate quality of CPR." [35]. Kralj et al. showed that "increased pinch rate and depth cause more skeletal chest injuries (SCI)" [36]. Although "it is more often than not considered that at least ane/3 of resuscitated patients sustain rib fractures and at least 1/5 sustains sternum fractures", Kralj et al. showed that these injuries are much more than frequent [36].

Conclusion

In accordance with other like studies reported in the literature referring to the classic external CPR information technology is considered that rib and sternal fractures located at the 3rd, quaternary, and 5th ribs and at the corresponding office of the body of the sternum, non extending beyond the midclavicular line of the rib cage, might possibly be described as unavoidable injuries. This consideration presupposes that the average rib fractures should not exceed vii or 8, with virtually equal bilateral distribution (with a slight deviation for the left side). Besides, the ratio sternal fractures: rib fractures should exist equal to the fraction ii/3 (approximately).

Suggestion

In our stance, the findings of our study which are in accord with the available relevant literature encourage further research in the perspective of confirming the following Guideline:

In instance of developed patients, the following complications might be classified as unavoidable:

1. A)

   Rib fractures (of 3rd, quaternary, or fifth rib) which do not extend beyond the midclavicular line of the rib cage;

2. B)

   The full number of which does not exceed 6 fractures;

3. C)

   At that place is almost equal distribution of right- and left-sided rib fractures, with a slight departure for the left side;

4. D)

   There is one or two sternal fractures at a level respective to the third-5th rib.

Note, even so, that osteoporosis or whatsoever other anatomical variation of the chest should not be present. These are elements that must be considered in the forensic medical examination on a instance-by-case basis.

It is also suggested that more than rigorous forensic investigations (involving the consideration of the detailed anatomical and histological variations of whatever given breast wall, eventually using advertisement hoc models of CPR) is needed for greater certainty on the location and the number of fractures that might be regarded as "in all likelihood unavoidable complications".

Our proposal aims at making a contribution to develop Guidelines specifying with loftier degree of certainty whether a particular CPR-related complication is in all likelihood unavoidable or non.

These Guidelines are expected to forbid potential rescuers from practicing "negative defensive medicine" in the context of emergency medicine in terms of avoiding the performance of CRP due to fear of malpractice litigation. At any rate, it is crucial to bear in mind that those who provide emergency medical service should be secured "potential to provide better public service" [37].

Limitations

We accept no information on CPR duration. Provided that the longer the duration of CPR was, the greater the number of CPR-related complications might be, lack of data concerning the duration of CPR is a limitation of our report. Some other limitation of our study is that nosotros have no information apropos the gender of the rescuers.

Abbreviations

AHA:

American Heart Association

CPR:

Cardiopulmonary Resuscitation

ERC:

European Resuscitation Council

PC:

Penal Lawmaking

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Acknowledgements

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Funding

The authors declare no funding in this report.

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The datasets used and analysed during the current study are available from the corresponding author on reasonable asking.

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1. Department of Forensic Medicine & Toxicology, School of Medicine, Aristotle Academy of Thessaloniki, (Campus), School of Medicine, 54124, Thessaloniki, Greece

   Aspasia Deliliga, Fotios Chatzinikolaou, Dimitrios Koutsoukis, Ioannis Chrysovergis & Polychronis Voultsos

Contributions

AD and PV have equally contributed to the manuscript. Advertizement, PV and FC, along with DK and IC conceptualised the report, carried out the literature review, conducted the analysis, interpreted the information, and drafted and critically reviewed the manuscript. All authors have read and approved the manuscript.

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Correspondence to Polychronis Voultsos.

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The written report was canonical by the Ethics Committee of the Schoolhouse of Medicine of the Faculty of Wellness Sciences of Aristotle Academy, Thessaloniki, Greece (No: 1.43 / 21-xi-2018).

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Deliliga, A., Chatzinikolaou, F., Koutsoukis, D. et al. Cardiopulmonary resuscitation (CPR) complications encountered in forensic autopsy cases. BMC Emerg Med 19, 23 (2019). https://doi.org/10.1186/s12873-019-0234-five

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• Received: 24 November 2018

• Accepted: 18 Feb 2019

• Published: 28 Feb 2019

• DOI : https://doi.org/10.1186/s12873-019-0234-5

Keywords

• Cardiopulmonary resuscitation
• (un) avoidable CPR-related complications
• Rib fractures
• Sternal fractures

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Source: https://bmcemergmed.biomedcentral.com/articles/10.1186/s12873-019-0234-5

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