Deeper chest compression – More complications for cardiac arrest patients?

doi:10.1016/j.resuscitation.2013.02.015

Resuscitation

Volume 84, Issue 6, June 2013, Pages 760-765

https://doi.org/10.1016/j.resuscitation.2013.02.015 Get rights and content

Abstract

Aim of the study

Sternal and rib fractures are frequent complications caused by chest compressions during cardiopulmonary resuscitation (CPR). This study aimed to investigate the potential association of CPR-related thoracic and abdominal injuries and compression depth measured with an accelerometer.

Methods

We analysed the autopsy records, CT scans or chest radiographs of 170 adult patients, suffering in-hospital cardiac arrest at the Tampere University Hospital during the period 2009–2011 to investigate possible association of chest compressions and iatrogenic injuries. The quality of manual compressions during CPR was recorded on a Philips, HeartStart MRx Q-CPR™-defibrillator.

Results

Patients were 110 males and 60 females. Injuries were found in 36% of male and 23% of female patients. Among male patients CPR-related injuries were associated with deeper mean – and peak compression depths (p < 0.05). No such association was observed in women. The frequency of injuries in mean compression depth categories <5, 5–6 and >6 cm, was 28%, 27% and 49% (p = 0.06). Of all patients 27% sustained rib fractures, 11% sternal fracture and eight patients had haematomas/ruptures in the myocardium. In addition, we observed one laceration of the stomach without bleeding, one ruptured spleen, one mediastinal haemorrhage and two pneumothoraxes.

Conclusion

The number of iatrogenic injuries in male patients was associated with chest compressions during cardiopulmonary resuscitation increased as the measured compression depth exceeded 6 cm. While there is an increased risk of complications with deeper compressions it is important to realize that the injuries were by and large not fatal.

Introduction

Ever since Peter Safar developed cardiopulmonary resuscitation (CPR) in the 1960s, there has been discussion about iatrogenic injuries associated with chest compressions.1, 2, 3, 4 Sternal and rib fractures are frequent complications of chest compressions4, 5, 6, 7 but sometimes CPR can result in intra-thoracic or intra-abdominal lacerations and haemorrhage which may even prove fatal.8, 9

The European Resuscitation Council (ERC) published new guidelines for resuscitation in 2010. High quality chest compressions are an essential part of these guidelines. Compression depth should be 5–6 cm and the rate at least 100 compressions per minute.10, 11, 12 It has been suggested that an increased compression depth may be associated with a higher incidence of iatrogenic injuries. Although there are studies on CPR-related injuries in adults and infants,13, 14, 15 none of them has investigated the potential association between the actual compression depth as measured with the accelerometer and the incidence and severity of complications after CPR. The purpose of this study was to investigate a possible association between CPR-related thoracic and abdominal injuries and objectively measured compression depth. Our hypothesis was that the risk of injuries increases as the compression depth increases.

Section snippets

Study design

This observational study was performed under approval of the Pirkanmaa Hospital District's Science Center and the Ethics Committee of the Tampere University Hospital (Approval no: R08116; clinicaltrials.gov NCT00951704). Data from the resuscitations were collected prospectively as a part of our on-going studies on the quality of resuscitation and also for educational purposes. The injuries were analysed retrospectively from the autopsy reports and thorax/CT-scans. Authorization to analyse

Injuries in the whole study population

Of the 370 patients resuscitated by MET a total of 170 SCA patients were included in this study. A flowchart of the patients is shown in Fig. 1. Of all the patients 32% (n = 54) had sustained injuries. When these injuries were analysed year by year, the incidence of injuries during the three-year period was 25%, 32% and 40% respectively (p = 0.21). The incidence of injuries in patients subjected to forensic autopsy, was 30%, 42% and 64% in 2009, 2010 and 2011, respectively (p = 0.03). Injuries are

Discussion

This is the first clinical study to suggest an association between increasing compression depth and injuries related to chest compressions during CPR. The majority of the injuries in the present study were spontaneously healing fractures and the frequency of the injuries was comparable to those reported in earlier studies.7, 15 Life-threatening ruptures of the myocardium were detected only in patients with acute myocardial infarction. It is very difficult to establish the causality between

Limitations of the study

This study has a number of limitations. First, we do not know the quality of chest compressions during the short resuscitation attempt before MET has arrived and started to use the sternal force/depth sensor. Second, even though all resuscitations were performed using a backboard to decrease the mattress effect, there is no technology available to enable us to know the absolute compression depth in all cases. Yet we have to bear in mind that all the earlier studies about sufficient compression

Conclusions

The number of iatrogenic injuries in male patients due to chest compressions during cardiopulmonary resuscitation increased as the compression depth exceeded 6 cm. No such association was seen in female patients. The majority of the injuries was spontaneously healing rib fractures or haematomas having only a minor impact on patients’ recovery from resuscitation. While there is an increased risk of complications with deeper compressions it is important to realize that the injuries were by and

Conflicts of interest statement

This study was funded by the Instru Science Foundation, Helsinki, Finland and by the Competitive Research Funding of the Tampere University Hospital (Grant 9M105). The funding organizations had no involvement in any aspect of the study.

Dr. Jyrki Tenhunen is a member of international advisory board for SuPARnostic (Virogates, Copenhagen, Denmark) and CMO and shareholder of SenSem Technologies (Tampere, Finland) and Medieta Ltd (Helsinki, Finland).

Dr. Sanna Hoppu has provided paid consultancy for

Acknowledgments

We would like to acknowledge the Tampere University Hospital ICU MET-nurses for help in gathering the data for this study. We also extend our warmest thanks to Sirkka Goebeler, MD, PhD. from National Institute for Health and Welfare and to the forensic autopsy technicians, the forensic pathologists and the secretary of the Department of Forensic Medicine, Tampere University Hospital.

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Study of risk factors for injuries due to cardiopulmonary resuscitation with special focus on the role of the heart: A machine learning analysis of a prospective registry with multiple sources of information (ReCaPTa Study)
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The study of thoracic injuries and biomechanics during CPR requires detailed studies that are very scarce. The role of the heart in CPR biomechanics has not been determined. This study aimed to determine the risk factors importance for serious ribcage damage due to CPR.
Data were collected from a prospective registry of out-of-hospital cardiac arrest between April 2014 and April 2017. This study included consecutive out-of-hospital CPR attempts undergoing an autopsy study focused on CPR injuries. Cardiac mass ratio was defined as the ratio of real to expected heart mass. Pearson’s correlation coefficient was used to select clinically relevant variables and subsequently classification tree models were built. The Gini index was used to determine the importance of the associated serious ribcage damage factors. The LUCAS® chest compressions device forces and the cardiac mass were analyzed by linear regression.
Two hundred CPR attempts were included (133 manual CPR and 67 mechanical CPR). The mean age of the sample was 60.4 ± 13.5, and 56 (28%) were women. In all, 65.0% of the patients presented serious ribcage damage. From the classification tree build with the clinically relevant variables, age (0.44), cardiac mass ratio (0.26), CPR time (0.22), and mechanical CPR (0.07), in that order, were the most influential factors on serious ribcage damage. The chest compression forces were greater in subjects with higher cardiac mass.
The heart plays a key role in CPR biomechanics being cardiac mass ratio the second most important risk factor for CPR injuries.
Comparison of chest compression quality between the overlapping hands and interlocking hands techniques: A randomised cross-over trial
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Performing quality chest compressions is fundamental to the management of cardiopulmonary arrest. The aim of this study was to compare the efficacy of two hand positions: overlapping versus interlocking for performing chest compressions during cardiopulmonary arrest.
The HP2C (for Hands Position and Chest Compression) was a prospective, randomised, open-label, cross-over, single-centre study. Participants were recruited from the Emergency Medical Service (EMS) teams and the prehospital firefighter teams. They were randomised to start chest compressions either with overlapping or interlocking hands and then performed the other technique after a washout period. The judgement criteria were the overall chest compressions success score generated by software in accordance with ILCOR recommendations, the quality of compression, release, rate and subjective intensity measured with the Borg scale.
A total of 100 participants were included in the study. The mean age of the caregivers was 38 ± 9.3 years. The median CPR score was 79.5% IQR [48.5–94.0] in the overlapping hands group and 71% IQR [38.0–92.8] in the interlocking hands group (p-value = 0.37). There was no significant difference for the other criteria, especially no difference in term of intensity of effort. However, there was a trend towards better results with overlapping hands.
This study failed to demonstrate a difference in effectiveness between overlapping and interlocking hand chest compressions during cardiopulmonary resuscitation.
The effect of hand position on chest compression quality during CPR in young children: Findings from the Videography in Pediatric Resuscitation (VIPER) collaborative
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To determine the effect of hand position on chest compression (CC) quality during CPR in young children.
Prospective observational exploratory study. Patients < 8 years receiving CC for > 2 minutes were enrolled. Data was collected from video review and CC monitor device and analyzed in ‘CC segments’ (periods of CC by individual providers). Four techniques were compared: two thumbs (2 T), hands encircling the chest; two fingers (2F) on the sternum; one hand on sternum (1H); two hands on sternum (2H). Univariate analysis of CC rate and depth between hand positions was performed through nonparametric testing, stratified by age category.
47 patients received 824 minutes of CC. Among 270 CC segments in infants < 1 yo, 2 T was used in 27%; 2F 3%; 1H 18%; 2H 26%. Among 189 CC segments in children aged 1 to 8 yo, 1H was used in 26%; 2H 74%. Across all segments, median CC rate was 117 cpm (IQR 110–125). Median depth was 2.92 cm (IQR 2.44 – 4.04) in infants < 1 yo, 3.56 cm (IQR 2.92 – 4.14) in children 1 to 8 yo. 1H achieved greater depth than 2 T in infants (p < 0.01), and 2H achieved greater depth than 1H in children > 1 (p < 0.001).
In infants, 1H resulted in greater CC depth than 2 T. In children 1 to 8 yo, 2H resulted in greater depth than 1H.. These data suggest that different hand position during CPR in young children from what is currently recommended may result in better CPR quality.
Trauma associated with cardiopulmonary resuscitation based on autopsy reports after the 2015 ERC guidelines
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Cardiopulmonary resuscitation (CPR)-related injuries have not been assessed since the 2015 Resuscitation Guidelines were established.
To describe the incidence and severity of CPR-related injuries, and to evaluate the impact of the 2015 European Resuscitation Council (ERC) guidelines on the objective assessment of injuries.
This multicenter, retrospective study analyzed autopsy reports of patients who underwent CPR. The most severe injuries were objectively assessed using the Abbreviated Injury Scale (AIS) and all injuries were summarized according to the New Injury Severity Score (NISS).
Among 628 autopsy reports analyzed, patient characteristics and case details were distributed as follows: male sex, 71.1%; median age, 67 years; out-of-hospital cardiac arrest, 89.2%; bystander CPR, 56.8%. CPR-related injuries included: rib(s) 94.6%; lung(s), 9.9%; sternum, 62.4%; liver, 2.5%; and spleen, 1.8%. The incidence of bystander-provided CPR and severity of injury were similar to CPR provided only by professionals. There were no difference between mechanical and manual compressions. Females were older (p = 0.0001) and, although the frequency of their injuries was similar to males, they were significantly more severe (p = 0.01). Patients with life-threatening injury exhibited a baseline profile similar to those without injury . The median score (according to AIS) of the most severe injury was 3 and the median of summary of injuries was 13 according to the NISS–low risk of fatal injury.
CPR-related injuries occurred frequently, although those that were life-threatening accounted for only 3% of cases. There were no differences between patients who were resuscitated by bystander(s) or by professionals and no differences between mechanical chest devices or manual resuscitation. Compared with a study based on the 2010 guidelines, similar injuries were found, but with more rib fractures, less visceral organ damage, and fewer life-threatening injuries.
Association of multiple rib fractures with the frequency of pneumonia in the post-resuscitation period
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Successful cardiopulmonary resuscitation is associated with a high incidence of chest wall injuries. However, few studies have examined chest wall injury as a risk factor for respiratory complications after cardiopulmonary resuscitation. Therefore, herein, we investigated the association of multiple rib fractures on the incidence of post-resuscitation pneumonia.
This single-centre retrospective cohort study enrolled adult, nontraumatic, out-of-hospital cardiac arrest patients who maintained circulation for more than 48 h between June 2015 and May 2019. Rib fractures were evaluated by computed tomography on the day of hospital admission. The association with newly developed pneumonia within 7 days of hospitalisation was analysed using a Fine-Gray proportional hazards regression model adjusted for the propensity score of multiple rib fractures estimated from age, sex, presence of witnessed status, bystander CPR, initial rhythm, and total CPR time and for previously reported risk factors for pneumonia (therapeutic hypothermia and prophylactic antibiotics).
Overall, 683 patients with out-of-hospital cardiac arrest were treated; 87 eligible cases were enrolled for analysis. Thirty-two (36.8%) patients had multiple rib fractures identified on computed tomography, and 35 (40.2%) patients developed pneumonia. The presence of multiple rib fractures was significantly associated with a higher incidence of pneumonia, consistently both with and without adjustment for background factors (unadjusted hazard ratio 4.63, 95% confidence interval: 2.35–9.13, p < 0.001; adjusted hazard ratio 4.03, 95% confidence interval: 2.08–7.82, p < 0.001).
Multiple rib fractures are independently associated with the development of pneumonia after successful resuscitation.
Evaluation of mountain rescuers’ (non-)technical skills during simulated resuscitation
2022, Studies in Educational Evaluation
Mountain rescuers work voluntarily but must provide high-quality cardiopulmonary resuscitations (CPR). As demands for their services rise, the factors influencing CPR skills are investigated. Research has shown that technical skills (TS), non-technical skills (NTS), experience, experienced patient deaths, and monitoring impact resuscitation performance. This study explores the influence of these factors for this kind of voluntary medical personnel. A total of 103 mountain rescuers participated. A specially created NTS observation form, questionnaires and simulation manikin were used to measure NTS, TS, experience, and monitoring skills. Results indicate that NTS and TS did not correlate significantly. Only the number of real resuscitations differed significantly between the TS of experienced and inexperienced mountain rescuers. Experienced patient deaths were not significantly related to CPR performance. Furthermore, mountain rescuers could not fully correctly assess their colleagues during simulation. The study shows that previous research results might not hold true in a different medical domain.

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^?: A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.02.015.

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Clinical paperDeeper chest compression – More complications for cardiac arrest patients??

Abstract

Aim of the study

Methods

Results

Conclusion

Introduction

Section snippets

Study design

Injuries in the whole study population

Discussion

Limitations of the study

Conclusions

Conflicts of interest statement

Acknowledgments

Resuscitation

Resuscitation

Resuscitation

Resuscitation

J Emerg Med

Resuscitation

Resuscitation

Resuscitation

Leg Med

Resuscitation

Resuscitation

Resuscitation

Chest

Clinical paper
Deeper chest compression – More complications for cardiac arrest patients??