Chest Compression-Related Flail Chest Is Associated with Prolonged Ventilator Weaning in Cardiac Arrest Survivors

Rib fractures and other injuries after cardiopulmonary resuscitation for non-traumatic cardiac arrest: a systematic review and meta-analysis

PURPOSE

This study aims to ascertain the prevalence of rib fractures and other injuries resulting from CPR and to compare manual with mechanically assisted CPR. An additional aim was to summarize the literature on surgical treatment for rib fractures following CPR.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar.

REVIEW METHODS

The databases were searched to identify studies reporting on CPR-related injuries in patients who underwent chest compressions for a non-traumatic cardiopulmonary arrest. Subgroup analysis was conducted to compare the prevalence of CPR-related injuries in manual versus mechanically assisted chest compressions. Studies reporting on surgery for CPR-related rib fractures were also reviewed and summarized.

RESULTS

Seventy-four studies reporting CPR-related injuries were included encompassing a total of 16,629 patients. Any CPR-related injury was documented in 60% (95% confidence interval [95% CI] 49-71) patients. Rib fractures emerged as the most common injury, with a pooled prevalence of 55% (95% CI 48-62). Mechanically assisted CPR, when compared to manual CPR, was associated with a higher risk ratio for CPR-related injuries of 1.36 (95% CI 1.17-1.59). Eight studies provided information on surgical stabilization of CPR-related rib fractures. The primary indication for surgery was the inability to wean from mechanical ventilation in the presence of multiple rib fractures.

CONCLUSION

Rib fractures and other injuries frequently occur in patients who undergo CPR after a non-traumatic cardiopulmonary arrest, especially when mechanical CPR is administered. Surgical stabilization of CPR-related rib fractures remains relatively uncommon.

LEVEL OF EVIDENCE

Level III, systematic review and meta-analysis.

Favourable outcome in survivors of CPR-related chest wall injuries

BACKGROUND

There is a lack of studies focusing on long-term chest function after chest wall injury due to cardiopulmonary resuscitation (CPR). The purpose of this cross-sectional study was to investigate long-term pain, lung function, physical function, and fracture healing after manual or mechanical CPR and in patients with and without flail chest.

METHODS

Patients experiencing out-of-hospital cardiac arrest between 2013 and 2020 and transported to Sahlgrenska University Hospital were identified. Survivors who had undergone a computed tomography (CT) showing chest wall injury were contacted. Thirty-five patients answered a questionnaire regarding pain, physical function, and quality of life and 25 also attended a clinical examination to measure the respiratory and physical functions 3.9 (SD 1.7, min 2-max 8) years after the CPR. In addition, 22 patients underwent an additional CT scan to evaluate fracture healing.

RESULTS

The initial CT showed bilateral rib fractures in all but one patient and sternum fracture in 69 %. At the time of the follow-up none of the patients had persistent pain, however, two patients were experiencing local discomfort in the chest wall. Lung function and thoracic expansion were significantly lower compared to reference values (FVC 14 %, FEV1 18 %, PEF 10 % and thoracic expansion 63 %) (p < 0.05). Three of the patients had remaining unhealed injuries. Patients who had received mechanical CPR in additional to manual CPR had a lower peak expiratory flow (80 vs 98 % of predicted values) (p=0.030) =0.030) and those having flail chest had less range of motion in the thoracic spine (84 vs 127 % of predicted) (p = 0.019) otherwise the results were similar between the groups.

CONCLUSION

None of the survivors had long-term pain after CPR-related chest wall injuries. Despite decreased lower lung function and thoracic expansion, most patients had no limitations in physical mobility. Only minor differences were seen after manual vs. mechanical CPR or with and without flail chest.

[Treatment strategy for an unstable chest wall after cardiopulmonary resuscitation]

Every year ca. 60,000 people in Germany undergo cardiopulmonary resuscitation (CPR). The two most frequent underlying causes are of cardiopulmonary and traumatic origin. According to the current CPR guidelines chest compressions should be performed in the middle of the sternum with a pressure frequency of 100-120/min and to a depth of 5-6 cm. In contrast to trauma patients where different injury patterns can arise depending on the accident mechanism, both the type of trauma and the injury pattern are similar in patients after CPR due to repetitive thorax compression. It is known that an early reconstruction of the thoracic wall and the restoration of the physiological breathing mechanics in trauma patients with unstable thoracic injuries reduce the rates of pneumonia and weaning failure and shorten the length of stay in the intensive care unit. As a result, it is increasingly being propagated that an unstable thoracic injury as a result of CPR should also be subjected to surgical treatment as soon as possible. In the hospital of the authors an algorithm was formulated based on clinical experience and the underlying evidence in a traumatological context and a surgical treatment strategy was designed, which is presented and discussed taking the available evidence into account.

Isolated injury of the caudate lobe of the liver due to cardiopulmonary resuscitation

Chest compressions are the mainstay of cardiopulmonary resuscitation. Secondary injuries are frequently reported, most frequently to the thorax and less frequently to the abdomen. Review of existing literature highlights liver lacerations as the most common abdominal injury following cardiopulmonary resuscitation; however, an isolated hepatic caudate lobe injury due to CPR has not yet been reported. We discuss existing literature regarding resuscitation-related injuries, report a case of an isolated hepatic caudate lobe injury due to cardiopulmonary resuscitation, and discuss possible mechanisms of injury.

Injury pattern and clinical outcome in patients with and without chest wall injury after cardiopulmonary resuscitation

BACKGROUND

Cardiopulmonary resuscitation (CPR), although lifesaving may cause chest wall injury (CWI) because of the physical force exerted on the thorax. The impact of CWI on clinical outcome in this patient group is unclear. The primary aim of this study was to investigate the incidence of CPR-related CWI and the secondary aim to study injury pattern, length of stay (LOS), and mortality in patients with and without CWI.

METHODS

This is a retrospective study of adult patients who were admitted to our hospital due to cardiac arrest (CA) during 2012 to 2020. Patients were identified in the Swedish CPR Registry and those undergoing CT of the thorax within 2 weeks after CPR were included. Patients with traumatic CA, chest wall surgery prior or after CA were excluded. Demographic data, type and length of CPR, type of CWI, LOS on mechanical ventilator (MV), in intensive care unit (ICU) and in hospital (H), and mortality were studied.

RESULTS

Of 1,715 CA patients, 245 met the criteria for inclusion. The majority (79%) of the patients suffered from CWI. Chondral injuries and rib fractures were more common than sternum fractures (95% vs. 57%), and 14% had a radiological flail segment. Patients with CWI were older (66.5 ± 15.4 vs. 52.5 ± 15.2, p < 0.001). No difference was seen in MV-LOS (3 [0-43] vs. 3 [0-22]; p = 0.430), ICU-LOS (3 [0-48] vs. 3 [0-24]; p = 0.427), and H-LOS (5.5 [0-85] vs. 9.0 [1-53]; p = 0.306) in patients with or without CWI. Overall mortality within 30 days was higher with CWI (68% vs. 47%, p = 0.007).

CONCLUSION

Chest wall injuries are common after CPR and 14% of patients had a flail segment on CT. Elderly patients have an increased risk of CWI, and a higher overall mortality is seen in patients with CWI.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.