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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., (© 2024. The Author(s).)

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., Competing Interests: Declaration of competing interest The authors declare no competing interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Blunt trauma acting against the human body presents the fundamental cause of pulmonary fat embolism (PFE) and fat embolism syndrome. The aim of the present study was to investigate PFE in non-survivors after cardiopulmonary resuscitation (CPR)., Methods: This was a prospective cohort study conducted in University Hospital Ostrava, Czech Republic. Within a 4-year study period, all non-survivors after CPR because of out-of-hospital cardiac arrest were assessed for the study eligibility. The presence/seriousness of PFE was determined by microscopic examination of cryo-sections of lung tissue (staining with Oil Red O)., Results: In total, 106 persons after unsuccessful CPR were enrolled in the study. The most frequent cause of death in the study population (63.2% of cases) was cardiac disease (ischemic heart disease); PFE was not determined as the cause of death in any of our study cases. Sternal fractures were identified 66.9%, rib fractures (usually multiple) in 80.2% of study cases; the median number of rib fractures was 10.2 fractures per person. Serious intra-thoracic injuries were found in 34.9% of cases. Microscopic examination of lung cryo-sections revealed PFE in 40 (37.7%) study cases; PFE was most frequently evaluated as grade I or II. Occurrence of sternal and rib fractures was significantly higher in persons with PFE than between persons without PFE (p = 0.033 and p = <0.001). Number of rib fractures was also significantly higher in persons with PFE. The occurrence of serious intra-thoracic injuries was comparable in both our study groups (p = 0.089)., Conclusions: PFE presents a common resuscitation injury which can be found in more than 30% of persons after CPR. Persons with resuscitation skeletal chest fractures have significantly higher risk of PFE development. During autopsy of persons after unsuccessful CPR, it is necessary to distinguish CPR-associated injuries including PFE from injuries that arise from other mechanisms., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

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., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Cardiopulmonary resuscitation (CPR)-related injuries have not been assessed since the 2015 Resuscitation Guidelines were established., Aim: 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., Methods: 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)., Results: 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., Conclusion: 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., Competing Interests: Declaration of Competing Interest All authors declare no conflict of interests with this manuscript., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Blunt chest trauma after mechanical resuscitation manoeuvres appears to have a significant impact on the often complicated course. Due to a lack of data in the literature, the purpose of this study was to investigate the feasibility and immediate outcome of chest wall stabilization for flail chest in this vulnerable patient population., Methods: We retrospectively reviewed the medical records of patients after cardiopulmonary resuscitation between January 2014 and December 2018 who were diagnosed with flail chest. We attempted to compare patients after surgery with those after conservative treatment., Results: Of a total of 56 patients with blunt chest trauma after mechanical resuscitation and after coronary angiography, 25 were diagnosed with flail chest. After the exclusion of 2 patients because of an initial decision to palliate, 13 patients after surgical stabilization could be compared with 10 patients after conservative therapy. Although there was no significant difference in the total duration of ventilatory support, there was a significant advantage when the time after stabilization to extubation was compared with the duration of ventilation in the conservative group. The presence of pulmonary contusion, poor Glasgow Coma Scale score or the development of pneumonia negatively affected the outcome, but additional sternal fracture did not., Conclusions: Surgical stabilization for chest wall instability is well tolerated even by this vulnerable patient population. Our results should be used for further randomized controlled approaches. It is necessary to evaluate the situation with all parameters in an interdisciplinary manner and to decide on a possible surgical therapy at an early stage if possible., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: Current studies focus primarily on skeletal injuries following cardiopulmonary resuscitation (CPR). Few studies report on intrathoracic injuries (ITI) and none, to our knowledge, focus exclusively on cardiovascular injuries related to cardiac massage. This study was based on autopsy findings and assessed the incidence of non-skeletal CPR related injuries related to chest compression., Methods: This was a retrospective forensic autopsy cohort study conducted in a single institution after resuscitation. Pathologists recorded autopsy data using standardized protocol contained information from external and internal examination of the body., Results: Thirty-eight autopsy reports (21 males and 17 females), post- CPR-failure were studied. Heart lesions were reported in 19 patients (group A). The average age was 65.7 years (69.05 group A and 66.5 group B). Median weight was 75.2 Kg and was significantly higher in group B ( p = 0.01). Pericardial lesions were identified in 6 patients in group A and 2 in group B ( p = 0.2 ns). No significant difference was observed among the two groups (Table 4) with the exception of the average number of rib fractures which was higher in group A ( p = 0.04). Autopsy findings revealed heart injuries in 50% of patients with a high prevalence (52.6%) of left ventricle injuries., Conclusion: Cardiac lesions represent frequent and serious complications of unsuccessful CPR. Correct performance of chest compressions according to guidelines is the best way to avoid these complications., Competing Interests: The authors declare no conflict of interest., (© 2022 The Author(s). Published by IMR Press.)

Background: Guidelines for depth of chest compressions in pediatric cardiopulmonary resuscitation (CPR) are based on sparse evidence., Objective: We sought to evaluate the performance of the two most widely recommended chest compression depth levels for pediatric CPR (1.5 in. and 1/3 the anterior-posterior diameter- APd) in a controlled swine model of asphyxial cardiac arrest., Methods: We executed a 2-group, randomized laboratory study with an adaptive design allowing early termination for overwhelming injury or benefit. Forty mixed-breed domestic swine (mean weight = 26 kg) were sedated, anesthetized and paralyzed along with endotracheal intubation and mechanical ventilation. Asphyxial cardiac arrest was induced with fentanyl overdose. Animals were untreated for 9 min followed by mechanical CPR with a target depth of 1.5 in. or 1/3 the APd. Advanced life support drugs were administered IV after 4 min of basic resuscitation followed by defibrillation at 14 min. The primary outcomes were return of spontaneous circulation (ROSC), hemodynamics and CPR-related injury severity., Results: Enrollment in the 1/3 APd group was stopped early due to overwhelming differences in injury. Twenty-three animals were assigned to the 1.5 in. group and 15 assigned to the 1/3 APd group, per an adaptive group design. The 1/3 APd group had increased frequency of rib fracture (6.7 vs 1.7, p < 0.001) and higher proportions of several anatomic injury markers than the 1.5 in. group, including sternal fracture, hemothorax and blood in the endotracheal tube (p < 0.001). ROSC and hemodynamic measures were similar between groups., Conclusion: In this pediatric model of cardiac arrest, chest compressions to 1/3APd were more harmful without a concurrent benefit for resuscitation outcomes compared to the 1.5 in. compression group., Competing Interests: Declaration of Competing Interest Dr. Salcido performs fee-for-service work for ZOLL Medical. Drs. Salcido and Menegazzi hold a patent on a system for cardiopulmonary resuscitation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Cardiopulmonary resuscitation (CPR) contributes to significant chest wall injury similar to blunt trauma. With benefits realized for surgical stabilization of rib fractures (SSRFs) for flail injuries and severely displaced fractures following trauma, SSRF for chest wall injury following CPR could be advantageous, provided good functional and neurologic outlook. Experience is limited. We present a review of patients treated with SSRF at our institution following CPR., Methods: A retrospective analysis of patients undergoing SSRF following CPR was performed between 2019 and 2020. Perioperative inpatient data were collected with outpatient follow-up as able., Results: Five patients underwent SSRF over the course of the 2-year interval. All patients required invasive ventilation preoperatively or had impending respiratory. Mean age was 59 ± 12 years, with all patients being male. Inciting events for cardiac arrest included respiratory, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, and anaphylaxis. Time to operation was 6.6 ± 3 days. Four patients demonstrated anterior flail injury pattern with or without sternal fracture, with one patient having multiple severely displaced fractures. Surgical stabilization of rib fracture was performed appropriately to restore chest wall stability. Mean intensive care unit length of stay was 9.8 ± 6.4 days and overall hospital length of stay 24.6 ± 13.2 days. Median postoperative ventilation was 2 days (range, 1-15 days) with two patients developing pneumonia and one requiring tracheostomy. There were no mortalities at 30 days. One patient expired in hospice after a prolonged hospitalization. Disposition destination was variable. No hardware complications were noted on outpatient follow-up, and all surviving patients were home., Conclusion: Chest wall injuries are incurred frequently following CPR. Surgical stabilization of these injuries can be considered to promote ventilator liberation and rehabilitation. Careful patient selection is paramount, with surgery offered to those with reversible causes of arrest and good functional and neurologic outcome. Experience is early, with further investigation needed., Level of Evidence: Therapeutic, Level V., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: This study aimed to assess the prevalence of chest wall injuries due to cardiopulmonary resuscitation for out-of-hospital cardiac arrest (OHCA) and to compare in-hospital outcomes in patients with versus without chest wall injuries., Methods: A retrospective cohort study of all intensive care unit (ICU)-admitted patients who underwent cardiopulmonary resuscitation for OHCA between January 1, 2007, and December 2019 was performed. The primary outcome was the occurrence of chest wall injuries, as diagnosed on chest computed tomography. Chest wall injury characteristics such as rib fracture location, type, and dislocation were collected. Secondary outcomes were in-hospital outcomes and subgroup analysis of patients with good neurological recovery to identify those who could possibly benefit from the surgical stabilization of rib fractures., Results: Three hundred forty-four patients were included, of which 291 (85%) sustained chest wall injury. Patients with chest wall injury had a median of 8 fractured ribs (P25-P75, 4-10 ribs), which were most often undisplaced (on chest computed tomography) (n = 1,574 [72.1%]), simple (n = 1,948 [89.2%]), and anterior (n = 1,785 [77.6%]) rib fractures of ribs 2 to 7. Eight patients (2.3%) had a flail segment, and 136 patients (39.5%) had an anterior flail segment. Patients with chest wall injury had fewer ventilator-free days (0 days [P25-P75, 0-16 days] vs. 13 days [P25-P75, 2-22 days]; p = 0.006) and a higher mortality rate (n = 102 [54.0%] vs. n = 8 [22.2%]; p < 0.001) than those without chest wall injury. For the subgroup of patients with good neurological recovery, the presence of six or more rib fractures or a single displaced rib fracture was associated with longer hospital and ICU length of stay, respectively., Conclusion: Cardiopulmonary resuscitation-related chest wall injuries in survivors of OHCA and especially rib fractures are common. Patients with chest wall injury had fewer ventilator-free days and a higher mortality rate. Patients with good neurological recovery might represent a subgroup of patients who could benefit from surgical stabilization of rib fractures., Level of Evidence: Therapeutic, level IV; Epidemiological, Level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To investigate the relationship between the prevalence of cardiopulmonary resuscitation (CPR) related thoracic injury and patients' thoracic volume and dimensions., Study Design: Observational study., Place and Duration of Study: Kartal Dr. Lütfi Kırdar City Hospital, İstanbul, Turkey, from August 2015 to August 2019., Methodology: Patients, who were in hospital due to a non-traumatic cause, had experienced cardiac arrest and subsequently had a post-CPR thorax tomography, were included in the study. Thorax dimensions were measured on sagittal, transverse, and longitudinal axes, while thorax volumes were calculated using a 3D computer programme. This data was later compared to trauma findings., Results: A total of 246 patients were included in the study. The sagittal measurements ranged from 130 - 302 mm, with an average of 228.42 ± 25.61 mm; the transverse measurements ranged from 160-293 mm, average 238.60 ± 22.25 mm, and longitudinal measurements ranged from 99-259 mm, average 187.94 ± 29.76 mm; while thorax volumes were between 4670 - 21512 cc, with an average of 10118.19 ± 2438.01 cc. Trauma was present in 34.1% of patients.  Sagittal, longitudinal dimensions, and thorax volume were lower for the group positive for trauma compared to the non-trauma group (p=0.019, p=0.023 and p=0.002). Thorax volume and longitudinal dimensions were found to be lower in patients who experienced rib fractures (p=0.021, p<0.05). Sagittal dimensions were also found to be significantly lower in the group with pneumothorax (p<0.05)., Conclusion: Lower thorax volume and sagittal dimensions were associated with an increased prevalence of traumatic findings. Key Words: Cardiopulmonary resuscitation, Thoracic injuries, Pneumothorax, Rib fracture.

Aims: To describe whether haemorrhage into the fracture gap, bone marrow, or periosteum, and loss of osteocyte nuclei from infant rib fracture margins, are true markers of vitality or may be seen solely as a consequence of cardiopulmonary resuscitation attempts., Methods and Results: A description is provided of histological findings in sampled rib fractures in a retrospective consecutive series of infants, aged 1 month to 1 year, who suffered sudden death. All had undergone cardiopulmonary resuscitation (CPR) and were investigated by use of skeletal survey, whole body computed tomography (CT), and invasive postmortem (PM). There was no suspicion of child abuse. 15 infants were studied, 9 of whom had anterior/anterolateral rib fractures; slides were available with consent for use in seven. Skeletal survey identified no fractures. CT and PM showed 46 fractures, 27 of which were examined histologically. Marrow cavity haemorrhage> 2 mm in diameter was seen in 55% of fractures; easily identifiable red cells were seen in the fracture gap in 36%, and beneath the periosteum in 36%. Loss of intact osteocytes from lacunae in bone fragments at the fracture margins relative to distant areas was obvious in 50% of fractures., Conclusions: Anterior rib fractures, visible on CT and histologically, are common after CPR in infants. Empty lacunae and bleeding into the fracture gap, into the marrow cavity and beneath the periosteum are all frequent in CPR-related infant rib fractures, and should not be used to discriminate between true in-vivo injury and perimortem injury., (© 2020 John Wiley & Sons Ltd.)

Background: Cardiopulmonary resuscitation (CPR) sometime cause severe injuries and can affect quality of life, lead to long-term disabilities or death of the patient. The aim of this study is to identify the risk factors causing CPR-induced injuries and those of serious injuries., Methods: This was a retrospective forensic autopsy study in a single institution. Among 885 forensic autopsies undertaken between 2011 and 2018, those in which the victim had undergone CPR immediately after cardiac arrest were recorded. 'Serious injuries' were defined as an Abbreviated Injury Scale (AIS) score ≥ 3. CPR-induced injuries were evaluated by three experienced forensic pathologists. With the background and history of the patient, the circumstances of cardiac arrest and risks of causing CPR-induced injuries were determined by multivariate analyses., Results: Seventy-five victims comprised the study cohort. CPR-induced injuries were found in 52 victims (69.3%). Rib fracture was the most common (60.0%), followed by sternal fracture (37.3%), heart injury (21.3%) and liver injury (8.0%). Multivariate analysis revealed higher age to be an independent factor causing CPR-induced injuries (odds ratio [OR], 1.07, P < 0.001). Thirty-six victims had 39 serious injuries in the chest or abdomen: fracture of ≥ 3 ribs (35 cases), aortic dissection (two), lung contusion (one) and rupture of the heart (one). Multivariate analysis revealed higher age to be an independent factor causing CPR-induced serious injuries (OR, 1.09; P < 0.001)., Conclusion: Aging was the significant factor causing CPR-induced injuries and serious injuries., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: To ensure that patients survive cardiac arrest, cardiopulmonary resuscitation (CPR) is needed. However, the procedure itself can lead to severe injuries. This study aims to examine both possibilities of resuscitation - mechanical or manual - with regard to their risk of injury. To this end, we compare the injuries patterns in both groups of patients after successful resuscitation based on computer tomography (CT)., Methods: This single-centre retrospective study included 32 patients (female: 21.87 %, male: 78.12 %, Mean age: 60.22 ± 13.93 years) with cardiac arrest followed by successful mechanical CPR, who underwent an early whole-body CT. A control group of 32 patients (female: 21.87 %, male: 78.12 %, mean age: 60.75 ± 13.34 years) that had been resuscitated successfully with manual CPR was matched according to gender and age for a better statistical comparison. Patients with cardiac arrest due to trauma were excluded from the study population., Results: Mechanically resuscitated patients showed significantly more CPR-related injuries than those who were resuscitated manually (100 % vs. 84.37 %; p = 0.02). In particular, dislocated rib fractures (40.47 vs. 23.80 mean rank, p < 0.01), sternal fractures (74.19 % vs. 25 %; p < 0,01), bleeding complications (29.03 % vs. 3.12 %; p = 0.01), pneumothorax (38.71 % vs. 9.37 %; p = 0.01), mediastinal haematomas (58.01 % vs. 25 %, p = 0.01) and liver lacerations (29.03 % vs. 0 %, p = 0.04) were observed significantly more in patients after mechanical CPR compared to those with manual resuscitation., Conclusions: The guideline-based use of mechanical CPR results in a significant increase of internal and musculoskeletal injuries compared to manual CPR., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Chest wall injury is a common complication of cardiopulmonary resuscitation. Chest wall fixation of flail chest has been shown to improve outcomes in patients in whom trauma is the primary pathology. Its efficacy in the post-cardiopulmonary resuscitation setting where the primary event is cardiac arrest is yet to be determined. We report outcomes in a series of 4 patients who underwent rib fixation in the setting of cardiopulmonary resuscitation-induced flail chest., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Chest injuries are common and inevitable complications of chest compressions during cardiopulmonary resuscitation (CPR). This study aimed to investigate lung parenchymal and thoracic skeletal injuries after CPR by using computed tomography (CT) and to analyze the correlation between the duration of CPR and related complications.We examined 43 non-traumatic cardiac arrest patients who were successfully resuscitated after CPR and had chest CT scans within 24 hours of CPR. Lung parenchymal injuries were assessed by quantifying the lung contusion score (LCS) on the CT images, and each skeletal injury was investigated by classifying the location and the distribution. Other CPR-related chest injuries were also described, such as pleural effusion/hemothorax, pneumothorax, and retrosternal hematoma. Statistical analysis was conducted to determine whether the duration of CPR was correlated with each complication.Lung contusions were found in all of the patients (mean LCS: 22, range: 5-47). The distribution of lung contusions were predominantly in the bilateral dependent portions of the lungs (41 patients). All of the rib fractures occurred in the anterior arc (43 patients), and the sternal fractures occurred predominantly in the mid-sternal body (31 patients). In patients younger than 70 years old, the number of rib fractures significantly increased among those who underwent CPR for more than 25 minutes compared to those who received CPR for less than 25 minutes (median 4.5 vs 9; mean 8.3 vs 5.6 per person, respectively; P = .035). The risk of sternal fracture tended to be higher for patients who received CPR for more than 10 minutes compared to those who received CPR for less than 10 minutes (odds ratio: 3.60; 95% confidence interval: 0.86-15.06; P = .079). However, there was no statistically significant correlation between the duration of CPR and LCS or other CPR-related chest injuries.The duration of CPR was associated with the number of rib fractures and the occurrence of sternal fractures, but it did not affect the extent of CPR-related lung contusions or other CPR-related chest injuries. All of the rib fractures occurred in the anterior arc, while the sternal fractures occurred predominantly in the mid-sternal body. However, since this study was conducted in a single institution, the number of patients included was relatively small, thus limiting the statistical analysis.

Objective: To identify and compare manual and load-distributing band (LDB) cardiopulmonary resuscitation (CPR)-related injuries., Methods: Retrospective observational cohort study. Adult, nontraumatic deaths with a postmortem computed tomography scan (PMCT) performed were classified into two groups: deceased after LDB CPR or after manual CPR. PMCT scans were reviewed for thoracoabdominal injuries such as fractures, pneumothorax and hemorrhage. The injuries between groups were compared., Results: LDB CPR (n = 43) showed increased incidences of posterior rib fractures (53 vs 18%, P = 0.006), pneumothorax (23 vs 4%, P = 0.04) and more pericardial fluid (median 12  vs 6 mm, P = 0.002) compared with manual CPR (n = 29). Multivariable regression analysis revealed that LDB CPR was significantly associated with posterior rib fractures [odds ratio (OR) 5.37, 95% confidence interval (CI): 1.44-20.09, P = 0.01). Pneumothorax (OR 6.80, 95% CI: 0.73-62.99, P = 0.09) and the amount of pericardial fluid (OR 3.40, 95% CI: 0.20-56.32) were not significantly associated with LDB CPR. No significant difference was found for anterolateral rib fractures, sternal fractures, vertebral fractures, pleural fluid, hemothorax, hemopericardium, pneumoperitoneum, perihepatic, perisplenic and perirenal hemorrhage., Conclusion: Rib fractures, sternal fractures, hemothorax and hemopericardium are common CPR-related injuries. LDB CPR is significantly associated with more posterior rib fractures and a trend toward more pneumothoraces is observed when compared with manual CPR. This knowledge is important for caretakers in the case of ongoing CPR, as a pneumothorax may attribute to not achieving persistent return of spontaneous circulation, and to improve postresuscitation care of survivors.

Objective: Reports indicate that chest compression may induce skeletal chest injuries. We aimed to assess the factors associated with skeletal chest injuries and the probability of skeletal chest injuries following cardiopulmonary resuscitation (CPR) in patients who were successfully resuscitated after cardiac arrest., Methods: This retrospective analysis used data from adult patients who were successfully resuscitated after cardiac arrest. Skeletal chest injuries were assessed by chest computed tomography images. Multiple logistic regression analysis was used to identify factors associated with skeletal chest injuries and a cubic spline was fitted to visualize the predicted probability of skeletal chest injuries., Results: Among 274 patients (mean age: 62.6 years, 180 males), 185 (68%) had skeletal chest injuries. Patients with skeletal chest injuries were older in age (66.4 ± 12 vs 54.7 ± 17 years, P < 0.001), had a higher frequency of prehospital CPR (78.9 vs 66.3%, P = 0.024), and had a longer CPR duration (26.3 ± 19.4 vs 21.5 ± 14.8 minutes, P = 0.022). Multiple logistic regression analysis showed that age and CPR duration were associated with skeletal chest injuries [odds ratio (OR): 1.06, 95% confidence interval (CI): 1.04-1.08, P < 0.001 for age; OR: 1.03, 95% CI: 1.01-1.04, P = 0.006 for CPR duration). The probability of skeletal chest injuries was higher in patients over 60 years of age than those in patients under 60 years., Conclusion: In our study, advanced age and CPR duration were factors associated with a greater risk of skeletal chest injuries in adult patients who were resuscitated after cardiac arrest.

Aims: To determine the rate of injuries related to cardiopulmonary resuscitation (CPR) in cardiac arrest non-survivors, comparing manual CPR with CPR performed using the Lund University Cardiac Assist System (LUCAS)., Methods and Results: We prospectively evaluated 414 deceased adult patients using focused, standardized post-mortem investigation in years 2005 through 2013. Skeletal and soft tissue injuries were noted, and soft tissue injuries were evaluated with respect to degree of severity. We found sternal fracture in 38%, rib fracture in 77%, and severe soft tissue injury in 1.9% of cases treated with CPR with manual chest compressions (n = 52). Treatment with LUCAS CPR (n = 362) was associated with significantly higher rates of sternal fracture (80% of cases), rib fracture (96%), and severe soft tissue injury (10%), including several cases of potentially life-threatening injuries., Conclusion: LUCAS CPR causes significantly more CPR-related injuries than manual CPR, while providing no proven survival benefit on a population basis. We suggest judicious use of the LUCAS device for cardiac arrest., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: We aimed to determine the incidence of and associated risk factors for cardiopulmonary resuscitation (CPR)-related injuries in non-survivors of out-of-hospital cardiac arrests (OHCAs) in an emergency medical service (EMS) system in which all CPR procedures are performed on scene and patients are not routinely transported to the hospital with ongoing CPR., Material and Methods: We conducted this prospective observational study between 1 June 2013, and 31 May 2014. Data were collected from EMS datasheets and forensic autopsy records. The exclusion criteria were OHCAs due to trauma in the thoracic or abdominal area. EMS adhered to the European Resuscitation Council Resuscitation Guidelines (2010) during the resuscitation attempts., Results: Emergency medical service provided CPR in 280 attended OHCAs with 207 cases terminated on scene. A total of 149 patients underwent a forensic autopsy and 47% had a CPR-related injury. The most common injuries were multiple rib fractures (43%), with 22% of patients having more than eight fractured ribs. Abdominal visceral injuries or injuries related to airway management were rare. The injuries were associated with older age, male gender, initial shockable rhythm and public location of the cardiac arrest (P < .05 respectively). In the multivariable regression analysis, older age, male gender, and public location were independent predictors for injuries. There were no differences in the durations of the CPR attempt between the injured and non-injured groups., Conclusion: Older age, male gender, and public location were independently associated with CPR-related injuries. The duration of the resuscitation attempts did not affect the incident of injuries., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Although many clinical trials have demonstrated its efficacy during active compression-decompression cardiopulmonary resuscitation (ACD-CPR), the Ambu® CardioPump seems likely to cause severe and sometimes lethal injuries. In this paper, we report two cases observed at the Institute of Legal Medicine of Nancy, France. A 67-year-old man collapsed in the street, in the presence of witnesses, and without any sign of trauma. The autopsy revealed a flail chest, a wound of the left ventricle, a rupture of the right ventricle, and a wrenching of the inferior vena cava. A 71-year-old woman was found in her apartment during an accidental fire. The autopsy revealed a sternal fracture, many rib fractures, and a perforation of the superior vena cava, the pericardium, and the heart. Despite articles focusing on complications of the use of the CardioPump in the late 1990s, this technique is still used in practice. These two cases emphasize that iatrogenic injuries must be taken into account in the CardioPump benefit/risk balance and the relevance of its daily use.

Background/aim: This study aimed to evaluate traumatic thorax complications in post-CPR patients and to investigate whether or not there has been a decrease in these complications since the adoption of current chest compression recommendations. Materials and methods: Post-CPR patients with return of spontaneous circulation (ROSC) were admitted between January 2014 and January 2016 were analyzed retrospectively. Patients admitted to the ED in 2014 were resuscitated according to 2010 AHA CPR guidelines, while those admitted to the ED in 2015 were resuscitated according to current ERC CPR guidelines. Results: The study population comprised 48 male and 35 female patients. Of the 2010 AHA guideline patients, 39.21% experienced pulmonary contusion, while 54.83% of 2015 ERC guideline patients had pulmonary contusion. It was found that 11.76% of 2010 AHA guideline patients and 3.22% of 2015 ERC guideline patients had pneumothorax, while 9.8% of 2010 AHA guideline patients and 12.9% of 2015 ERC guideline patients experienced hemothorax. Incidence rates of lung contusion, pneumothorax, and hemothorax were higher in patients with rib fractures. Conclusion: In this study, traumatic thoracic complications were investigated in patients with ROSC after CPR. The incidence of CRP-related injuries did not decrease on application of the new 2015 ERC CPR guideline recommendations. The most common injury in this study was rib fracture, followed by sternal fracture, lung contusion, hemothorax, and pneumothorax. Statistically, rib fracture had a positive relationship with lung contusion, hemothorax, and pneumothorax.

Following the death of a woman with blunt force chest trauma, the question was asked how common was the finding at autopsy of a flail chest in decedents after failed cardiopulmonary resuscitation. It was suggested in court that this was an uncommon occurrence. To address this issue, autopsy cases in adults (>18 years) with rib fractures attributable to cardiopulmonary resuscitation were taken from the files of Forensic Science SA over a 7-year period from 2008 to 2014. Flail chest injuries were defined as those arising from fractures at two sites in at least three consecutive ribs. From 236 cases with rib fractures attributed to resuscitation, a total of 43 flail chest injuries were found in 35 cases (14.8%). The majority occurred in the 60-79-year-old age group. These data suggest that flail chest injuries are a more common sequelae of cardiopulmonary resuscitation than has been previously appreciated in autopsy cases, particularly in the elderly., (© 2017 American Academy of Forensic Sciences.)

A 84-year-old man who had experienced cardiac arrest in the ambulance was brought to the emergency room. He had been followed at outpatient after surgery for colon cancer and known to be suffered from mild renal impairment. The cardio pulmonary arrest was likely to be caused by acute exacerbation of that. He was resuscitated and immediately recovered without severe hypoxic encephalopathy or deterioration of renal function. However, the flail chest by manual cardiac compression sustained. It urged him to be managed under the ventilator and he seemed difficult to leave from that within a couple of weeks. So we decided to perform surgery. The course after surgery was favorable.

Background: The purpose of this study was to determine complications of resuscitation seen during autopsies and evaluate the effectiveness of basic life support training., Methods: Autopsy case reports conducted in The Forensic Branch Manager of Muğla were retrospectively examined. Demographic data of the patients with resuscitation complications such as age, gender, manner of death, and kinds and features of the complications were recorded., Results: In total, seventy-fourof the 100 cases with resuscitation complications were males. The autopsies in most of these cases were performed during the summer season. Among the patients, 68% died for non-traumatic reasons. Rib fractures were detected in seventy-one patients and sternum fractures in thirty-two patients. Moreover, damage to the pericardium (2%) and lung parenchymal (4%), heart lesions (4%), and liver lacerations (2%) were detected. Regarding rib fractures, fractures were found between the first and eighth ribs on both sides, with the highest numbers occurring in the fourth rib., Conclusion: Resuscitation complications are important since they can be presumed to have carried out for traumatic reasons.Resuscitation complications seen in autopsy cases with non-traumatic causes can be perceived as traumatic events. They can be assumed incorrectly as trauma symptoms. These complications can be reduced with a good resuscitation training of the health personnel.

Objective: To determine the effects of cardiopulmonary resuscitation (CPR) with AutoPulse™ (LDB-CPR) on post-resuscitation injuries identified by post-mortem computed tomography (PMCT). AutoPulse™ is a novel mechanical chest-compression device with a load-distributing band (LDB) that may affect post-resuscitation injury identified by PMCT., Methods: We conducted a retrospective cohort study of non-traumatic adult out-of-hospital cardiac arrest patients whose death was confirmed in our emergency department between October 2009 and September 2014. Patients were divided according to whether LDB-CPR (LDB-CPR group) or manual CPR only (manual CPR only group) was performed. The background characteristics and post-resuscitation injuries identified by PMCT were compared between both groups. Logistic regression was used to identify risk factors for posterior rib fracture and abdominal injury., Results: Overall, 323 patients were evaluated, with 241 (74.6%) in the LDB-CPR group. The total duration of CPR was significantly longer in the LDB-CPR group than in the manual CPR only group. Posterior rib fracture, hemoperitoneum, and retroperitoneal hemorrhage were significantly more frequent in the LDB-CPR group. The frequencies of anterior/lateral rib and sternum fracture were similar in both groups. Pneumothorax tended to be more frequent in the LDB-CPR group, although not significantly. LDB-CPR was an independent risk factor for posterior rib fracture (odds ratio 30.57, 95% confidence interval 4.15-225.49, P=0.001) and abdominal injury (odds ratio 4.93, 95% confidence interval 1.88-12.95, P=0.001)., Conclusions: LDB-CPR was associated with higher frequencies of posterior rib fracture and abdominal injury identified by PMCT. PMCT findings should be carefully examined after LDB-CPR., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Aim: The aim of our study was to compare traumatic injuries observed after cardiopulmonary resuscitation (CPR) by means of standard (manual) or assisted (mechanical) chest compression by Lund University Cardiopulmonary Assist System, 2nd generation (LUCAS2) device., Methods: A retrospective study was conducted including cases from 2011 to 2013, analysing consecutive autopsy reports in two groups of patients who underwent medicolegal autopsy after unsuccessful CPR. We focused on traumatic injuries from dermal to internal trauma, collecting data according to a standardised protocol., Results: The study group was comprised of 26 cases, while 32 cases were included in the control group. Cardiopulmonary resuscitation performed by LUCAS2 was longer than manual CPR performed in control cases (study group: mean duration 51.5 min; controls 29.4 min; p = 0.004). Anterior chest lesions (from bruises to abrasions) were described in 18/26 patients in the LUCAS2 group and in 6/32 of the control group. A mean of 6.6 rib fractures per case was observed in the LUCAS2 group, but this was only 3.1 in the control group (p = 0.007). Rib fractures were less frequently observed in younger patients. The frequency of sternal factures was similar in both groups. A few trauma injuries to internal organs (mainly cardiac, pulmonary and hepatic bruises), and some petechiae (study 46%; control 41 %; p = 0.79) were recorded in both groups., Conclusion: LUCAS™2-CPR is associated with more rib fractures than standard CPR. Typical round concentric skin lesions were observed in cases of mechanical reanimation. No life-threatening injuries were reported. Petechiae were common findings.

Aim of the Study: This study aimed to establish the incidence, number and location of CPR-related skeletal chest injuries (SCI) and to investigate the influence of age, gender, changes in resuscitation guidelines and technique of resuscitation., Methods: We analysed SCI in 2148 patients who had undergone resuscitation for non-traumatic cardiac arrest, as shown by autopsies performed at the Institute of Forensic Medicine in Ljubljana in the period 2004-2013., Results: External cardiac massage caused SCI in 86% of males and in 91% of females; sternum fractures occurred in 59% of males and 79% of females, rib fractures in 77% of males and 85% of females and sternocostal separations in 33% of males and 12% of females. The average number of all SCI per person was thus almost the same in males and females: 10.95 vs. 10.96. The percentage of patients injured and the number of SCI increased with age. Changes in resuscitation guidelines were also identified as a factor contributing to the incidence and number of SCI. No adverse effect of the use of LUCAS was found., Conclusion: It is generally considered that at least 1/3 of resuscitated patients sustain rib fractures and at least 1/5 sustains sternum fractures. However, our study showed that these injuries are much more frequent and that increased compression rate and depth cause more SCI. Since in the period 2011-2013 accompanying severe injuries occurred in only 1.85% of cases, the resuscitation technique has not yet jeopardised patient's safety, but further close monitoring is needed., (Copyright © 2015 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

Introduction: This retrospective study was conducted to evaluate injuries related to cardiopulmonary resuscitation (CPR) and their associated factors using postmortem computed tomography (PMCT) and whole body CT after successful resuscitation., Methods: The inclusion criteria were adult, non-traumatic, out-of-hospital cardiac arrest patients who were transported to our emergency room between April 1, 2008 and March 31, 2013. Following CPR, PMCT was performed in patients who died without return of spontaneous circulation (ROSC). Similarly, CT scans were performed in patients who were successfully resuscitated within 72h after ROSC. The injuries associated with CPR were analysed retrospectively on CT images., Results: During the study period, 309 patients who suffered out-of hospital cardiac arrest were transported to our emergency room and received CPR; 223 were enrolled in the study. The CT images showed that 156 patients (70.0%) had rib fractures, and 18 patients (8.1%) had sternal fractures. Rib fractures were associated with older age (78.0 years vs. 66.0 years, p<0.01), longer duration of CPR (41min vs. 33min, p<0.01), and lower rate of ROSC (26.3% vs. 55.3%, p<0.01). All sternal fractures occurred with rib fractures and were associated with a greater number of rib fractures, higher age, and a lower rate of ROSC than rib fractures only cases. Bilateral pneumothorax was observed in two patients with rib fractures., Conclusions: PMCT is useful for evaluating complications related to chest compression. Further investigations with PMCT are needed to reduce complications and improve the quality of CPR., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

The recovery of cardiac arrest patients with pulmonary embolism who are given an ultra-long duration of cardiopulmonary resuscitation(CPR) with manual chest compressions is very rare. We reported a 52-year-old woman who came to the hospital because of paroxysmal dyspnea. She experienced in hospital cardiac arrest and underwent prolonged CPR with manual chest compressions for 160 minutes. The patient presented with several episodes of cardiac electrical activity that lasted 10 to 20 seconds without consciousness. Blood gas analysis revealed pH 7.27, PaO2 51 mm Hg, and D-dimer 3723 ìg/mL. In addition,acute pulmonary embolism was considered due to the patient's symptoms. Thrombolytic therapy was given 100 minutes after the CPR was implemented. Sixty minutes later, her sinus rhythm was restored.After the continuous renal replacement therapy for renal failure was administered and other conservative treatments were given for the complications after the CPR with thrombolytic therapy, she finally recovered and was discharged. This case report supports the use of persistent ongoing CPR efforts and the use of thrombolytic therapy.

Posterior rib fractures are highly indicative of non-accidental trauma (NAT) in infants. Since 2000, the "two-thumbs" technique for cardiopulmonary resuscitation (CPR) of newborns and infants has been recommended by the American Heart Association (AHA). This technique is similar to the grip on an infant's thorax while shaking. Is it possible that posterior rib fractures in newborns and infants could be caused by the "two-thumbs" technique? Using computerized databases from three German children's hospitals, we identified all infants less than 12 months old who underwent professional CPR within a 10-year period. We included all infants with anterior-posterior chest radiographs taken after CPR. Exclusion criteria were sternotomy, osteopenia, various other bone diseases and NAT. The radiographs were independently reviewed by the Chief of Pediatric Radiology (MB) and a Senior Pediatrician, Head of the local Child Protection Team (IF). Eighty infants with 546 chest radiographs were identified, and 50 of those infants underwent CPR immediately after birth. Data concerning the length of CPR was available for 41 infants. The mean length of CPR was 11min (range: 1-180min, median: 3min). On average, there were seven radiographs per infant. A total of 39 infants had a follow-up radiograph after at least 10 days. No rib fracture was visible on any chest X-ray. The results of this study suggest rib fracture after the use of the "two-thumbs" CPR technique is uncommon. Thus, there should be careful consideration of abuse when these fractures are identified, regardless of whether CPR was performed and what technique used. The discovery of rib fractures in an infant who has undergone CPR without underlying bone disease or major trauma warrants a full child protection investigation., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Rib and sternal fractures are relatively common following conventional cardiopulmonary resuscitation (CPR). This case demonstrates the 18F-FDG PET/CT appearances of typical CPR-related multiple rib and sternal fractures in a 55-year-old man with suspected cardiac sarcoidosis. The PET/CT scan was performed to assess disease activity of cardiac sarcoidosis, and no active cardiac inflammation was detected. The patient initially presented with an out-of-hospital cardiac arrest and successfully received bystander CPR.

Introduction: Traumatic chest injuries may occur following cardiopulmonary resuscitation (CPR). The aim of this study was to address the frequency of injuries, especially rib and sternal fractures, and also to identify factors that contribute to post-CPR trauma., Methods: This study was a prospective cross-sectional study conducted in the emergency departments (ED) of eight academic tertiary care centers. To evaluate injuries secondary to CPR, we performed chest computed tomography (CT) in patients who were successfully resuscitated from cardiac arrest. Contributing factors that might be related to injuries were also investigated., Results: We enrolled 71 patients between 1 January 2011 and 30 June 2011. Rib and sternal fractures were diagnosed in 22 and 3 patients, respectively. Females were more susceptible to rib fracture (p=0.036). When non-physicians participated as chest compressors in the ED, more ribs were fractured (p=0.048). The duration of CPR and number of compressors were not contributing factors to trauma secondary to CPR. There was a wide variation in the frequency of rib fractures from hospital to hospital (0-83.3%). In high-risk hospitals (in which more than 50% of patients had rib fractures), the average age of the patients was higher, and non-physicians took part in ED CPR more often than they did at low-risk hospitals., Conclusion: The incidence of rib fracture following CPR was different in various hospitals. The presence of non-physician chest compressors in the ED was one of the contributing factors to rib fracture. Further studies on the influence of resuscitators and relation between quality of chest compression and CPR-induced injuries are warranted to reduce complications following CPR., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Aim: Computed tomography (CT) has been suggested as an aid or even a replacement for autopsy. The aim of this trial was to study the conformity of the two methods in finding injuries in non-surviving patients after unsuccessful cardiopulmonary resuscitation., Methods: In this prospective study, 31 patients were submitted to a CT prior to autopsy after unsuccessful resuscitation attempts. Pathological findings were noted by both the radiologist and the pathologists in a specified protocol. The pathologists and radiologist were blinded from each other's results., Results: CT and autopsy revealed rib fractures in 22 and 24 patients respectively (kappa=0.83). In 8 patients, CT revealed more rib fractures than autopsy; and in 12 patients, autopsy revealed more rib fractures than CT. In 7 patients, neither method showed any rib fractures. The mean difference between the two methods in detecting rib fractures was 0.16 (S.D.: ± 3.174, limits of agreement: -6.19 to 6.51). The kappa value for sternal fractures was 0.49. A total of 260 pathological findings were noted by CT and 244 by autopsy. The average patient showed a median of 9 injuries (every fracture counted as one injury), independent of the method used in detecting the injuries., Conclusions: There was a strong concordance between the two methods in finding rib fractures but not sternal fractures and these results support the concept of CT as a valuable complement to autopsy in detecting rib fractures after unsuccessful cardiopulmonary resuscitation but not as a replacement. Other injuries did not show the same concordance., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Rib and sternal fractures are frequent complications of cardiopulmonary resuscitation (CPR) in adults. This is the first study to evaluate the MDCT findings of chest injuries secondary to CPR, by comparing with the findings of radiography., Methods: For 40 patients who underwent MDCT after CPR for a non-traumatic cause of cardiac arrest, we evaluated the MDCT findings of the CPR associated traumatic chest injuries and compared the diagnostic performance of chest radiography and MDCT for the evaluation of chest injuries., Results: MDCT revealed that 26 patients (65%) had rib fractures and 12 patients (30%) had sternal fractures. However, radiography detected only 10 patients who had rib fractures. In 25 of the 26 cases, multiple ribs were fractured (ranging up to 13 rib fractures), and the rib fractures were bilateral in 18 of these cases. The majority of rib fractures were located in the anterior part of the thoracic cage. Six of the patients had fracture-related complications (pneumothorax=1, subclavian vein injury=1, chest wall hematoma=4). The sternal fractures predominantly occurred in the middle and lower third of the sternal body (five each for the middle and lower third of the sternal body)., Conclusion: Rib and sternal fractures are frequent complications in patients who underwent CPR. MDCT is useful for the evaluation of chest injuries secondary to CPR as compared with that of radiography and also for the evaluation of the fracture-related complications., (Crown Copyright © 2011. Published by Elsevier Ireland Ltd. All rights reserved.)

We report a case of cardiopulmonary resuscitation involving chest compressions performed with the rescuer's knee. The substantial injuries caused by this unorthodox technique could have been mistaken for the cause of death were it not for careful scene investigation and documentation.

Lung herniation is a rare event that can occur spontaneously or traumatically. Thoracic hernias are usually associated with a chest-wall defect. We report a case of thoracic lung hernia that occurred 2 days after traumatic cardiopulmonary resuscitation, after the formation of a large hemothorax.

Objective: A recent increase in the number of infants presenting at autopsy with rib fractures associated with cardio-pulmonary resuscitation (CPR) precipitated a study to determine whether such a phenomenon was related to recent revision of paediatric resuscitation guidelines., Methods: We conducted a review of autopsy reports from 1997 to 2008 on 571 infants who had CPR performed prior to death., Results: Analysis of the study population revealed CPR-related rib fractures in 19 infants (3.3%), 14 of whom died in the 2006-2008 period. The difference in annual frequency of CPR-related fractures between the periods before and after revision of paediatric CPR guidelines was statistically highly significant., Conclusions: The findings indicate that CPR-associated rib fractures have become more frequent in infants since changes in CPR techniques were introduced in 2005. This has important implications for both clinicians and pathologists in their assessment of rib fractures in this patient population., (Crown Copyright © 2011. Published by Elsevier Ireland Ltd. All rights reserved.)

The objective of this study was to evaluate and compare the complications of cardiopulmonary resuscitation after manual or mechanical chest compressions in a swine model of ventricular fibrillation. In this retrospective study, 106 swine were treated with either manual (n=53) or mechanical chest compressions with the LUCAS device (n=53). All swine cadavers underwent necropsy. The animals with no autopsy findings were significantly fewer in the LUCAS group (P=0.004). Sternal fractures were identified in 18 animals in the manual and only two in the LUCAS group (P=0.003). Rib fractures were present in 16 animals in the manual and only four in the LUCAS group (P=0.001). Nine animals in the manual, and two in the LUCAS group had liver hematomas (P=0.026%). In the manual group, eight animals were detected with spleen hematomas whereas no such injury was identified in the LUCAS group (P=0.003). LUCAS devise minimized the resuscitation-related trauma compared with manual chest compressions in a swine model of cardiac arrest.