Abstract
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.
Supplementary Information
The online version contains supplementary material available at 10.1007/s00068-023-02421-7.
Keywords: Cardiopulmonary resuscitation, Mechanical CPR, Thoracic injury, Abdominal injury, Surgical stabilization of rib fractures
Introduction
Cardiopulmonary resuscitation (CPR) aims to extend the critical window during which a cardiac arrest’s underlying cause can potentially be reversed by rhythmically applying external force on the anterior chest wall [1]. However, effective CPR comes at a cost.
To compress the chest optimally, the chest wall has to be compressed at least 5 cm in depth [2]. Achieving this requires significant force applied to the chest wall, including the sternum and ribs, as well as adjacent vital structures such as the heart and lungs. Consequently, post-CPR injuries are a common occurrence, although the reported prevalence of these injuries exhibits substantial variability [3]. CPR-related injuries appear to be even more prevalent when mechanical compression devices are employed in conjunction with manual chest compressions [4]. These injuries can range from relatively minor, such as a single undisplaced rib fracture, to life-threatening, such as tension pneumothorax [5]. The wide range in the documented occurrence and severity of injuries following CPR may be attributed to the absence of standardized guidelines for diagnosing and treating CPR-related injuries in post-resuscitation care algorithms [2, 3].
The presence of more than six rib fractures, at least one displaced rib fracture, or a flail chest sustained during CPR is associated with extended hospital length of stay (HLOS) and intensive care unit length of stay (ICU LOS) in survivors of cardiopulmonary arrest [6, 7]. The advantages of surgical stabilization of rib fractures (SSRF) have been increasingly demonstrated, particularly for mechanically ventilated patients with a flail chest due to blunt thoracic trauma. SSRF in this population is associated with reduced pneumonia rates, shorter ICU LOS, and fewer ventilator days [8–11]. However, the evidence regarding the application and benefits of SSRF in patients with CPR-related rib fractures is currently limited [7, 12–18].
The primary objective of this systematic review and meta-analysis was to establish the prevalence of rib fractures and other thoracic and abdominal injuries following CPR for non-traumatic cardiopulmonary arrest, both in cases of manual and mechanically assisted CPR. The secondary objective was to provide an overview of the existing literature on the surgical treatment of rib fractures, which are the most common CPR-related injuries.
Methods
This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline (Supplementary Online Materials 1) [19]. A protocol was established before this review, but not published. No modifications to the protocol were made during the study’s execution. Approval from the Medical Research Ethics Committee was not deemed necessary.
Search strategy and selection criteria
The Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar were searched on September 12, 2022, for studies pertaining to CPR-related injuries [20]. The search strategies were adapted to accommodate the unique searching features of each database, including database-specific MESH and EMTREE controlled vocabulary terms. Searches were not limited by date, language, or publication status. The search strategy is provided in Supplementary Online Materials 2, which also includes a translated version for use in PubMed. Two reviewers (SFMVW and JTHP) independently screened title and abstract and subsequently reviewed full texts for eligibility. Any disagreements were resolved through consensus. Inclusion criteria encompassed all studies reporting on patients who (a) underwent CPR for non-traumatic cardiac arrest, (b) received chest compressions either manually only or assisted with a mechanical compression device, and (c) underwent autopsy or dedicated imaging enabling identification of CPR-related injuries. Excluded were animal studies, meta-analyses or literature reviews, guidelines or consensus statements, opinion articles, letters to the editor, or conference abstracts. Studies involving pediatric populations or those failing to report any of the CPR-related injuries of interest were also excluded. In cases where a specific population was used more than once in different manuscripts, only the index manuscript was included. Case reports were excluded from the primary prevalence objective but were included in the summary of post-CPR rib fracture management. The reference lists of all included studies were screened to add relevant publications that may have been overlooked in the original search.
Data extraction
A predefined data sheet was used to extract the data from the included studies. Two reviewers (SFMVW and JTHP) independently performed data extraction and resolved discrepancies through consensus. Extracted data encompassed study characteristics, demographics of the study population, CPR details (such as setting and method), and diagnostic modality for identifying CPR-related injuries.
For the primary objective of this systematic review, collected data were the number of patients and CPR-related injuries. This included the number of rib fractures, their fracture patterns (multiple rib fractures—defined as either two or three or more rib fractures depending on the study, lateral flail chest, and anterior flail segment or flail sternum- defined as three or more bilateral rib fractures in the costochondral or anterior sector of the ribs) [21], characteristics (type of fracture and displacement) [21], and the prevalence of other CPR-related skeletal, soft tissue, cardiac, pulmonary, vascular, and visceral injuries.
For the secondary aim, additional data and outcomes were extracted to summarize the literature about SSRF for CPR-related rib fractures. This included the specific indications, timing, and techniques for SSRF, as well as hospital length of stay, duration of mechanical ventilation, follow-up duration, and mortality.
Quality assessment and evaluation of publication bias
Two reviewers (SFMVW and JTHP) independently assessed the methodological quality of the included studies using the Methodological index for non-randomized studies (Minors) [22]. Twelve items for studies with a control group and 8 items for studies without a control group were assigned a score of 0 when the item was not reported, 1 when inadequately reported, and 2 when adequately reported (Supplementary Online Materials 3). The total score ranges from 0 (poor quality) to 24 (good quality). Evaluation of publication bias was conducted by visually inspecting funnel plots (Supplementary Online Materials 9–15).
Statistical analysis
Continuous data are presented as means with standard deviation (SD) or range. Categorical data are expressed as numbers and percentages. Pooled prevalences of CPR-related injuries were calculated using MedCalc (MedCalc Statistical Software version 18.2.1, MedCalc Software bvba, Ostend, Belgium; http://www.medcalc.org; 2018) and reported as percentages with corresponding 95% confidence intervals. Meta-analysis was conducted using ReviewManager (version 5.4, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2020) to compare the prevalence of CPR-related injuries between manual-only and mechanically assisted chest compressions. Heterogeneity was assessed with Cochran’s Q test and I2 statistic. A random effects model was used employed, irrespective of the Q test results, due to expected significant heterogeneity. These results are presented as pooled risk ratios with their 95% confidence intervals and p value. p values < 0.05 were considered statistically significant.
Results
Search
The database search identified 10,188 records and an additional 6 records were included in the meta-analysis through citation searching (Fig. 1). After removing duplicates, titles and abstracts of 6,278 records were screened. The full texts of 104 articles were assessed for eligibility. In total, 74 studies were selected to determine the prevalence of CPR-related injuries. An additional seven studies were selected for the secondary objective to summarize surgical treatment for CPR-related injuries, and one study contributed to both objectives [7, 12–18].
Fig. 1.
Flow diagram of study selection for aim 1 (prevalence of CPR-related injury) and aim 2 (overview of surgical stabilization for CPR-related rib fractures)
Study characteristics
The included 74 studies on the prevalence of CPR-related injuries encompassed 16,629 patients (Table 1 and Supplementary Online Materials 4–8). CPR-related injuries were diagnosed through autopsy in 36 studies involving 6,966 (52%) patients [5, 23–57], while CT scans were utilized in 36 studies covering 5,749 (43%) patients [5–7, 23, 34, 41, 43, 58–86]. Of the 74 studies, 45 with 9,931 patients described CPR for out-of-hospital cardiac arrest, while 6 studies with 743 patients reported exclusively on in-hospital cardiac arrest [41, 51, 52, 55, 62, 87]. Furthermore, 29 studies encompassing 2,052 patients detailed injuries following the use of mechanical cardiac compression devices [5, 6, 23–26, 29–32, 37–40, 42, 45, 47, 49–51, 58, 59, 68, 69, 80, 82, 88–90]. Eight other articles involved 57 patients who received surgical treatment for CPR-related rib fractures [7, 12–18].
Table 1.
Characteristics of studies included in systematic review of CPR-related injuries following non-traumatic cardiac arrest
| Author and year | Design | Study period | Diagnostic modality | Total population N |
Manual CPR N (%) |
Mechanical CPR N (%) |
Setting cardiac arrest OHCA N (%) |
Age mean (SD/P25-P75/range) |
Males N (%) |
|---|---|---|---|---|---|---|---|---|---|
| Adel et al. (2022) [58] | Retrospective | 2018–2021 | CT scan | 225 | NA | NA | 225 (100%) | 64 (13) | 170 (75%) |
| Azeli et al. (2022) [23] | Retrospective | 2016 | CT scan, radiograph, autopsy | 52 | 0 (0%) | 52 (100%) | 52 (100%) | 57 (49–66) | 33 (63%) |
| Karatasakis et al. (2022) [59] | Prospective | 2015–2018 | CT scan | 104 | 76 (73%) | 28 (27%) | 104 (100%) | 56 (15) | 73 (70%) |
| Katasako et al. (2022) [60] | Retrospective | 2017–2019 | CT scan | 306 | NA | NA | 306 (100%) | 81 (71–89) | 171 (56%) |
| Kawai et al. (2022) [61] | Retrospective | 2015–2019 | CT scan | 87 | NA | NA | 87 (100%) | 67 (59–75) | 55 (63.2%) |
| Kunz et al. (2022) [7]a | Retrospective | 2018–2019 | CT scan, radiograph | 109 | NA | NA | 59 (54%) | 69 (56–77) | 67 (61%) |
| Canakci et al. (2021) [62] | Retrospective | 2015–2020 | CT scan | 178 | 131 (74%) | 47 (26%) | 0 (0%) | 73 (65–80) | 99 (56%) |
| Gaisendrees et al. (2021) [88] | Retrospective | 2016–2020 | CT scan, US | 108 | 38 (35%) | 70 (65%) | NA | 55 (13) | 64 (59%) |
| Hokenek and Erdogan (2021) [63] | Retrospective | 2015–2019 | CT scan | 246 | NA | NA | NA | 73 (16) | 146 (59%) |
| Karasek et al. (2021) [24] | Retrospective | 2016–2018 | Autopsy | 630 | 559 (90%) | 64 (10%) | NA | 67 | 449 (71%) |
| Prins et al. (2021) [6] | Retrospective | 2007–2019 | CT scan | 344 | 325 (94%( | 19 (6%) | 344 (100%) | 66 (54–74) | 259 (75%) |
| Hwang et al. (2021) [64] | Retrospective | 2013–2018 | CT scan | 452 | NA | NA | 452 (100%) | 62 (16) | 284 (63%) |
| Moriguchi et al. (2021) [25] | Retrospective | 2011–2018 | Autopsy | 75 | 65 (87%) | 10 (13%) | NA | 59 (22) | 57 (76%) |
| Jang et al. (2020) [65] | Retrospective | 2009–2019 | CT scan | 43 | 43 (100%) | 0 (0%) | NA | 72 (2–98) | 27 (37%) |
| Kim et al. (2020) [66] | Retrospective | 2007–2016 | CT scan | 274 | 274 (100%) | 0 (0%) | 205 (75%) | 63 (15) | 180 (66%) |
| Milling et al. (2020) [26] | Prospective | 2016–2018 | Autopsy | 50 | 0 (0%) | 50 (100%) | 50 (100%) | 48 (38–62) | 32 (64%) |
| Oh and Kim (2020) [67] | Retrospective | 2009–2019 | CT scan | 368 | NA | NA | 323 (88%) | 64 | 244 (66%) |
| Sonnemans et al. (2020) [68] | Retrospective | 2012–2017 | Postmortem CT scan | 72 | 29 (40%) | 43 (60%) | 72 (100%) | 59 (47–77) | 48 (67%) |
| Viniol et al. (2020) [69] | Retrospective | 2016 | CT scan | 100 | 93 (93%) | 7 (7%) | 88 (88%) | 69 (13) | 73 (73%) |
| Zaidi et al. (2020) [70] | Retrospective | 2015–2020 | Radiograph, CT scan | 137 | 137 (100%) | 0 (0%) | 137 (100%) | 62 (54–70) | 63 (46%) |
| Zotzmann et al. (2020) [71] | Retrospective | 2010–2017 | CT scan | 103 | NA | NA | 67 (65%) | 57 (17) | 71 (69%) |
| Azeli et al. (2019) [27] | Prospective | 2014–2016 | Autopsy | 109 | 109 (100%) | 0 (0%) | 109 (100%) | 63 (49–70) | 74 (68%) |
| Deliliga et al. (2019) [28] | Retrospective | 2013 | Autopsy | 88 | 88 (100%) | 0 (0%) | 44 (50%) | 61 (7.5) | 53 (60%) |
| Friberg et al. (2019) [29] | Prospective | 2005–2013 | Autopsy | 414 | 52 (13%) | 362 (87%) | NA | 68 (58–77) | 284 (69%) |
| Iglesies et al. (2019) [89] | Prospective | 2016–2017 | Radiograph, CT scan | 65 | 54 (83%) | 11 (17%) | 65 (100%) | 64 (13%) | 51 (80%) |
| Milling et al. (2019) [30] | Retrospective | 2015–2017 | Autopsy, CT scan, US, radiograph, MRI | 437 | 353 (81%) | 84 (19%) | 437 (100%) | 61 (47–73) | 322 (74%) |
| Ondruschka et al. (2019) [31] | Retrospective | 2017 | Autopsy | 30 | 15 (50%) | 15 (50%) | NA | 59 (15) | 30 (100%) |
| Dunham et al. (2018) [72] | Retrospective | 2016 | CT scan | 39 | 39 (100%) | 0 (0%) | 39 (100%) | 52 (22) | 26 (67%) |
| Ondruschka et al. (2018) [32] | Retrospective | 2011–2017 | Autopsy | 614 | 501 (82%) | 113 (18%) | NA | 58 (17) | 456 (74%) |
| Setälä et al. (2018) [33] | Prospective | 2013–2014 | Autopsy | 149 | 149 (100%) | 0 (0%) | 149 (100%) | 68 (59–78) | 101 (68%) |
| Takayama et al. (2018) [73] | Retrospective | 2013–2016 | CT scan | 472 | 472 (100%) | 0 (0%) | 472 (100%) | 72 (14) | 291 (62%) |
| Yusufoglu et al. (2018) [74] | Retrospective | 2014–2016 | CT scan | 83 | NA | NA | NA | 67 (12) | 48 (58%) |
| Beom et al. (2017) [75] | Retrospective | 2006–2015 | CT scan | 185 | 185 (100%) | 0 (0%) | 130 (70%) | 63 (18) | 110 (59%) |
| Cha et al. (2017) [76] | Retrospective | 2006–2010 | CT scan | 91 | NA | NA | 91 (100%) | 60 (51–74) | 49 (54%) |
| Koster et al. (2017) [5] | RCT | 2008–2014 | Post-mortem CT, autopsy | 374 | 137 (37%) | 237 (63%) | 156 (42%) | 64 (16) | 244 (65%) |
| Nomura et al. (2017) [77] | Retrospective | 2016–2017 | CT scan | 100 | NA | NA | 100 (100%) | 71 (2) | 45 (45%) |
| Yamaguchi et al. (2017) [34] | Retrospective | 2012–2014 | Post-mortem CT, autopsy | 180 | 180 (100%) | 0 (0%) | 154 (86%) | 62 (43–73) | 119 (66%) |
| Oya et al. (2016) [78] | Retrospective | 2010–2012 | Radiograph, postmortem CT scan | 535 | 535 (100%) | 0 (0%) | 535 (100%) | 73 (16) | 305 (57%) |
| Ihnát Rudinská et al. (2016) [35] | Prospective | 2012–2015 | Autopsy | 80 | NA | NA | 80 (100%) | 58 (5) | 61 (76%) |
| Seung et al. (2016) [79] | Retrospective | 2009–2014 | CT scan | 148 | NA | NA | 89 (60%) | 64 (17) | 83 (56%) |
| Vahedian-Azimi et al. (2016) [87] | RCT | 2014 | Radiograph or autopsy | 80 | 80 (100%) | 0 (0%) | NA | 61 (13) | 31 (39%) |
| Boland et al. (2015) [80] | Retrospective | 2009–2012 | Radiograph, CT scan, MRI, echocardiogram | 235 | 131 (56%) | 104 (44%) | 235 (100%) | 64 (15) | 145 (62%) |
| Kaldırım et al. (2015) [36] | Retrospective | 2003–2012 | Autopsy | 203 | 203 (100%) | 0 (0%) | 90 (44%) | 47 (17) | 143 (70%) |
| Kashiwagi et al. (2015) [81] | Retrospective | 2008–2013 | CT scan postmortem and in survivors | 223 | 223 (100%) | 0 (0%) | NA | 75 (63–84) | 129 (58%) |
| Koga et al. (2015) [82] | Retrospective | 2009–2014 | Postmortem CT scan | 323 | 82 (25%) | 241 (75%) | 323 (100%) | 78 (66–85) | 185 (57%) |
| Kralj et al. (2015) [37] | Retrospective | 2004–2013 | Autopsy | 2,148 | 2014 (94%) | 134 (6%) | 1487 (69%) | 65 (18–100) | 1480 (69%) |
| Lardi et al. (2015) [38] | Retrospective | 2011–2013 | Autopsy | 58 | 32 (55%) | 26 (45%) | NA | 53 (18) | 38 (66%) |
| Štěchovský et al. (2015) [39] | Retrospective | 2012–2013 | Autopsy | 27 | 15 (56%) | 12 (44%) | 3 (11%) | 64 (14) | 18 (67%) |
| Choi et al. (2014) [83] | Retrospective | 2005–2011 | CT scan | 82 | NA | NA | 82 (100%) | 58 (14–90) | 49 (60%) |
| Smekal et al. (2014) [40] | Retrospective | 2008–2012 | Autopsy | 222 | 83 (37%) | 139 (63%) | 222 (100%) | 67 (21–100) | 152 (68%) |
| Cho et al. (2013) [84] | Retrospective | 2005–2011 | CT scan, radiograph | 44 | NA | NA | 44 (100%) | 57 (27–87) | 30 (68%) |
| Hellevuo et al. (2013) [41] | Prospective | 2009–2011 | CT scan, radiograph, autopsy | 170 | 170 (100%) | 0 (0%) | 0 (0%) | 72 (56–80) | 110 (65%) |
| Kim et al. (2013) [85] | Prospective | 2011 | CT scan | 71 | NA | NA | 57 (80%) | 65 (55–74) | 45 (63%) |
| Pinto et al. (2013) [42] | Retrospective | 2005–2009 | Autopsy | 175 | 87 (50%) | 88 (50%) | NA | 51 (15–89) | 102 (58%) |
| Smekal et al. (2013) [43] | Retrospective | 2008–2011 | CT scan, Autopsy | 31 | NA | NA | 31 (100%) | 62 (20) | 19 (61%) |
| Charaschaisri et al. (2011) [44] | Retrospective | 2006–2008 | Autopsy | 120 | NA | NA | NA | 40 (13) | 60 (79%) |
| Kim et al. (2011) [86] | Retrospective | 2009–2010 | CT scan, radiograph | 40 | NA | NA | NA | 61 (27–90) | 23 (58%) |
| Smekal et al. (2009) [45] | RCT | 2005–2007 | Autopsy | 85 | 47 (55%) | 38 (45%) | 71 (84%) | 69 (15) | 58 (68%) |
| Meron et al. (2007) [90] | Retrospective | 1991–2005 | Clinical evaluation, US, autopsy | 2,558 | 13 (87%) | 2 (13%) | 7 (47%) | 58 (53–67) | 1699 (66%) |
| Nishida et al. (2006) [46] | Prospective | Autopsy of the heart | 80 | NA | NA | 77 (96%) | 54 (21) | 48 (60%) | |
| Black et al. (2004) [47] | Retrospective | 2000–2001 | Autopsy | 499 | 485 (97%) | 14 (3%) | NA | 62 (1) | 343 (69%) |
| Lederer et al. (2004) [48] | Prospective | 1994–2000 | Radiograph, autopsy | 19 | NA | NA | 19 (100%) | 66 (16) | 13 (68%) |
| Oschatz et al. (2001) [91] | Prospective | 1997–1999 | Radiograph | 155 | 155 (100%) | 0 (0%) | NA | 58 (51–71) | 113 (73%) |
| Baubin et al. (1999) [49] | Prospective | Autopsy | 35 | 20 (57%) | 15 (43%) | 35 (100%) | 61 (23) | 25 (71%) | |
| Rabl et al. (1996) [50] | Retrospective | 1995 | Autopsy | 56 | 25 (45%) | 31 (55%) | NA | 57 (16–86) | 44 (78%) |
| Cohen et al. (1993) [51] | RCT | 1992–1993 | Radiograph, autopsy | 62 | 33 (53%) | 29 (47%) | 0 (0%) | 68 (2) | 45 (73%) |
| Bedell and Fulton (1986) [52] | Retrospective | 1981–1983 | Autopsy | 130 | 130 (100%) | 0 (0%) | 0 (0%) | 65 | 82 (63%) |
| Powner et al. (1984) [53] | Retrospective | NA | Autopsy | 70 | NA | NA | NA | 65 | 50 (72%) |
| Bjork et al. (1982) [92] | Prospective | NA | Clinical evaluation, Radiograph, autopsy | 63 | 63 (100%) | 0 (0%) | NA | 64 | 49 (78%) |
| Murtomaa and Korttila (1974) [93] | Retrospective | 1972 | Clinical evaluation, autopsy | 39 | 39 (100%) | 0 (0%) | 39 (100%) | NA | NA |
| Anthony and Tattersfield (1969) [54] | Retrospective | NA | Autopsy | 34 | 34 (100%) | 0 (0%) | NA | NA | NA |
| Saphir (1968) [55] | Prospective | 1966–1697 | Autopsy | 123 | NA | NA | 0 (0%) | NA | NA |
| Lundberg et al. (1967) [56] | Retrospective | 1964–1966 | Autopsy | 50 | 50 (100%) | 0 (0%) | NA | NA | NA |
| Minuck (1966) [57] | Retrospective | 1963–1965 | Autopsy | 63 | 63 (100%) | 0 (0%) | NA | (17–86) | 34 (54%) |
| SSRF studies | |||||||||
| DeVoe et al. (2022) [12] | Retrospective | 2019–2020 | NA | 5 | NA | NA | NA | 59 (12) | 5 (100%) |
| Kunz et al. (2022) [7]a | Retrospective | 2018–2019 | CT scan, radiograph | 4 | NA | NA | NA | 60 (4) | 4 (100%) |
| Prins et al. (2022) [18] | Retrospective | NA | CT scan | 39 | 34 (87%) | 5 (13%) | NA | 68 (60–73) | 34 (87%) |
| Claydon et al. (2020) [13] | Case series | 2013–2019 | NA | 4 | 4 (100%) | 0 (0%) | NA | 57 (12) | 4 (100%) |
| Lee et al. (2020) [14] | Case report | NA | CT scan | 1 | 1 (100%) | 0 (0%) | 0 (0%) | 57 | 0 (0%) |
| Drahos et al. (2019) [15] | Case report | NA | CT scan | 1 | 1 (100%) | 0 (0%) | 1 (100%) | 59 | 1 (100%) |
| Pouwels et al. (2018) [16] | Case series | NA | CT scan | 2 | 0 (0%) | 2 (100%) | 2 (100%) | 71 (8) | 2 (100%) |
| Ananiadou et al. (2010) [17] | Case report | NA | Physical examination | 1 | 1 (100%) | 0 (0%) | 0 (0%) | 59 | 1 (100%) |
CT computed tomography, NA not available, OHCA out-of-hospital cardiac arrest, RCT randomized clinical trial, SSRF surgical stabilization of rib fractures, US ultrasound
aThis study is mentioned twice because it provided data for both objectives
Quality assessment and evaluation of publication bias
The methodological quality assessment is presented in Supplementary Online Materials 3. The mean score across all included studies was 13 points (range 6–23). For the 33 studies with a control group, the mean score was 17 points (range 11–23) [5–7, 23, 24, 29–32, 38–40, 42, 44, 45, 49–51, 58–63, 68, 74, 75, 78, 79, 82, 87, 88, 91]. For the 41 studies without a control group, the mean score was 10 points (range 6–13) [25–28, 33–37, 41, 43, 46–48, 52–56, 64–67, 69–73, 76, 77, 80, 81, 83–86, 89, 90, 92–94]. The mean score for the studies addressing SSRF for post-CPR rib fractures was 10 points (range 7–18) [7,12–18]. Visual inspection of the funnel plots did not raise concerns regarding substantial publication bias (Supplementary Online Materials 9–13) [16, 17, 20, 21].
CPR-related injuries
The prevalence of any CPR-related injury was reported in 35 studies, involving 7,208 patients (Table 2 and Supplementary Online Materials 4–8) [6, 24–26, 31, 32, 35–38, 40, 41, 45, 48–53, 55, 57, 59, 60, 63, 65, 69, 70, 72, 73, 77, 80, 88, 89, 92, 93]. The pooled prevalence of any CPR-related injury was 60% (95% confidence interval [95% CI] 49–71). The most frequent skeletal injury was one or more rib fractures, with a pooled prevalence of 55% (95% CI 48–62) from 60 studies, totaling 12,110 patients [5–7, 23–25, 27–38, 40, 41, 43–45, 47–56, 58–63, 65–67, 69, 72–81, 83–87, 89, 93]. An anterior flail segment was described in five studies, with a pooled prevalence 36% (95% CI 22–50) in 923 patients [6, 7, 29, 59, 89]. The pooled prevalence of sternum fractures was 24% (95% CI 18–30) from 61 studies, encompassing 12,061 patients [5–7, 23–38, 40–45, 47–50, 52–55, 58–63, 65–69, 72–76, 79–87, 89, 93, 94]. The most common pulmonary injury was pulmonary contusion, with a pooled prevalence of 20% (95% CI 12–29) from 29 studies, involving 5,070 patients [5, 6, 24–26, 30, 33–36, 38, 41, 52, 59, 62, 63, 65–67, 69, 74–76, 79, 80, 83–85, 89]. A retrosternal hematoma was the most prevalent cardiac injury, with a pooled prevalence of 12% (95% CI 7.3–18) from 13 studies, covering 2,599 patients [27, 29, 40, 43, 45, 60, 65–67, 75, 76, 79, 82]. The highest prevalence of CPR-related abdominal injury was liver injury, with 3% (95% CI 12.1–4.5) from 27 studies, involving 9,369 patients [5, 24–27, 29, 30, 32–34, 36–38, 40–43, 45, 58, 68, 72, 80, 89, 90, 92–94]. Based on six studies with 905 patients, the prevalence of other abdominal injuries was 4% (95% CI 1.3–7.8), including blunt abdominal trauma without further specification, mesenteric injury, and retroperitoneal hemorrhage [34, 42, 64, 71, 82, 89].
Table 2.
Pooled prevalence of CPR-related injuries
| Studies | Population | Cases | Heterogeneity | Pooled prevalence (%) | ||
|---|---|---|---|---|---|---|
| N | N | N | Cochran’s Q (p value) |
I2 (%) (95% CI) |
(95% CI) | |
| Any CPR-related injury | 35 | 7,208 | 4,574 | 2,766 (< 0.001) | 99 (99–99) | 60.2 (49.3–70.7) |
| Thoracic wall injury | ||||||
| Sternum fracture | 61 | 12,061 | 3,813 | 4024 (< 0.001) | 99 (98–99) | 23.6 (17.5–30.2) |
| Upper third | 10 | 225 | 33 | 31 (< 0.001) | 72 (46–85) | 11.0 (4.31–20.3) |
| Middle third | 10 | 225 | 159 | 68 (< 0.001) | 87 (78–92) | 74.2 (56.5–88.6) |
| Lower third | 10 | 225 | 74 | 95 (< 0.001) | 91 (85–94) | 23.0 (7.61–43.5) |
| Flail sternum | 5 | 923 | 398 | 68 (< 0.001) | 94 (89–97) | 35.6 (22.2–50.3) |
| Rib fracture | 60 | 12,110 | 7,294 | 3435 (< 0.001) | 98 (98–98) | 55.2 (48.2–62.0) |
| Bilateral rib fractures | 19 | 2,420 | 1,093 | 751 (< 0.001) | 98 (97–98) | 37.1 (25.1–50.0) |
| Multiple rib fractures | 26 | 3,952 | 1,977 | 1381 (< 0.001) | 98 (98–98) | 50.3 (38.6–61.9) |
| Flail chest | 7 | 1,231 | 38 | 20 (0.003) | 70 (35–86) | 3.85 (2.00–6.30) |
| Clavicle fracture | 2 | 305 | 1 | 0 (0.682) | 0 (0–0) | 0.54 (0.03–1.67) |
| Scapula fracture | 4 | 662 | 9 | 2 (0.506) | 0 (0–83) | 1.52 (0.73–2.59) |
| Vertebral fracture | 15 | 3,795 | 36 | 48 (< 0.001) | 71 (51–83) | 1.17 (0.59–1.93) |
| Extrathoracic chest wall injury | 15 | 3,360 | 361 | 433 (< 0.001) | 97 (96–98) | 8.01 (3.58–14.01) |
| Pneumomediastinum | 8 | 1,149 | 33 | 17 (0.020) | 58 (8–81) | 3.22 (1.68–5.22) |
| Hemomediastinum | 22 | 4,068 | 175 | 115 (< 0.001) | 82 (73–88) | 4.80 (3.31–6.55) |
| Pulmonary injury | ||||||
| Hemothorax | 36 | 6,886 | 615 | 1007 (< 0.001) | 97 (96–97) | 10.1 (6.53–14.3) |
| Pneumothorax | 43 | 8,038 | 545 | 320 (< 0.001) | 87 (83–90) | 7.03 (5.49–8.74) |
| Tension pneumothorax | 4 | 833 | 9 | 3 (0.462) | 0 (0–85) | 1.23 (0.59–2.08) |
| Pulmonary contusion | 29 | 5,070 | 1,020 | 1601 (< 0.001) | 98 (98–99) | 20.2 (12.4–29.3) |
| Pulmonary hematoma | 6 | 1,123 | 36 | 41 (< 0.001) | 88 (76–94) | 3.28 (0.89–7.10) |
| Pulmonary laceration | 7 | 1,357 | 17 | 32 (< 0.001) | 81 (62–91) | 2.18 (0.65–4.58) |
| Bone marrow or fat embolism | 5 | 333 | 33 | 34 (< 0.001) | 88 (75–94) | 11.5 (3.36–23.7) |
| Other pulmonary injury | 3 | 823 | 117 | 167 (< 0.001) | 99 (98–99) | 29.4 (3.01–68.1) |
| Cardiac injury | ||||||
| Cardiac contusion | 10 | 1,725 | 66 | 70 (< 0.001) | 87 (78–92) | 6.43 (3.23–10.6) |
| Cardiac laceration, rupture, perforation | 13 | 2,954 | 50 | 27 (0.007) | 56 (18–76) | 1.98 (1.24–2.90) |
| Pericardial or epicardial injury | 28 | 5,490 | 282 | 305 (< 0.001) | 91 (88–93) | 5.72 (3.76–8.05) |
| Retrosternal hematoma | 13 | 2,599 | 304 | 190 (< 0.001) | 94 (91–96) | 11.9 (7.30–17.5) |
| Other cardiac injury | 11 | 2,234 | 105 | 90 (< 0.001) | 89 (82–93) | 4.62 (2.20–7.88) |
| Abdominal injury | ||||||
| Stomach injury | 9 | 3,515 | 16 | 44 (< 0.001) | 82 (66–90) | 1.42 (0.45–2.92) |
| Liver injury | 27 | 9,369 | 183 | 219 (< 0.001) | 88 (84–91) | 3.15 (2.07–4.46) |
| Spleen injury | 18 | 5,066 | 44 | 86 (< 0.001) | 80 (69–87) | 1.40 (0.66–2.40) |
| Pancreas injury | 3 | 901 | 3 | 2 (0.302) | 16 (0–97) | 0.44 (0.08–1.10) |
| Kidney injury | 5 | 1,031 | 11 | 16 (0.003) | 75 (39–90) | 2.01 (0.49–4.52) |
| Bowel injury | 3 | 797 | 4 | 0 (0.918) | 0 (0–61) | 0.67 (0.22–1.35) |
| Hemoperitoneum | 12 | 2,963 | 101 | 184 (< 0.001) | 94 (91–96) | 3.79 (1.37–7.34) |
| Pneumoperitoneum | 9 | 1,871 | 27 | 17 (0.028) | 54 (2–78) | 1.65 (0.89–2.65) |
| Other abdominal injury | 6 | 905 | 36 | 29 (< 0.001) | 83 (64–92) | 3.87 (1.25–7.83) |
| Vascular injury | ||||||
| Thoracic vascular injury | 22 | 5,664 | 57 | 85 (< 0.001) | 75 (63–84) | 1.83 (1.09–2.76) |
| Abdominal aorta injury | 3 | 338 | 3 | 2 (0.318) | 13 (0–97) | 1.21 (0.25–2.87) |
| Other injury | ||||||
| Trachea injury | 2 | 544 | 2 | 1 (0.355) | 0 (0–0) | 0.50 (0.08–1.26) |
| Diaphragm injury | 2 | 664 | 2 | 3 (0.096) | 64 (0–92) | 0.82 (0.05–4.10) |
CI confidence interval, CPR cardiopulmonary resuscitation
Manual only versus mechanically assisted CPR
Twenty studies compared CPR-related injury prevalence between manual-only and mechanically assisted CPR, encompassing a total of 2,336 patients in the manual and 1,716 patients in the mechanical group [5, 23, 24, 29–32, 38–40, 42, 45, 49, 50, 59, 62, 68, 82, 88, 89]. Overall, mechanical CPR was associated with a higher risk for all reported injuries. The risk ratio (RR) for any CPR-related injury was higher (1.36 (95% CI 1.17–1.59)) for the patients receiving CPR with mechanical compressions than for those receiving only manual compressions (Table 3 and Supplementary Online Materials 14, 15, 18, 19). Mechanical CPR was also associated with a higher risk of rib fractures with a RR 1.27 (95% CI 1.11–1.45). Other injuries with a higher risk associated with mechanical CPR included myocardial contusion (RR 8.71, 95% CI 3.02–25.1) and bowel injury (RR 7.93, 95% CI 1.12–56.3). Specifically, for piston type mechanical CPR devices, the risk ratio was higher for thoracic injuries, including sternum fractures (RR 1.81, 95% CI 1.30–2.53), flail chest (RR 4.29, 95% CI 1.23–14.99), hemothorax (RR 4.20, 95% CI 2.04–8.68), and especially myocardial contusion (RR 19.79, 95% CI 2.58–151.46). CPR with mechanical load distributing band devices was associated with a higher risk for pneumothorax (RR 2.61, 95% CI 1.00–6.78).
Table 3.
Comparison between the prevalence of CPR-related injuries between manual and mechanical compressions, and subdivided by mechanical device
| Outcome | Manual vs mechanical | Manual vs piston | Manual vs LDB | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Studies | Manual | Mechanical | RR | Studies | Manual | Piston | RR | Studies | Manual | LDB | RR | |
| Any CPR-related injury | 11 | 654/1450 (45%) | 439/550 (80%) | 1.36 (1.17–1.59) | 8 | 504/761 (66%) | 387/447 (87%) | 1.32 (1.13–1.55) | – | – | – | – |
| Thoracic wall injury | ||||||||||||
| Sternum fracture | 17 | 884/2272 (39%) | 640/1556 (41%) | 1.49 (1.14–1.95) | 10 | 262/1259(21%) | 514/870 (59%) | 1.81 (1.30–2.53) | 3 | 61/198 (31%) | 58/372 (16%) | 0.68 (0.25–1.84) |
| Flail sternum | 2 | 43/128 (34%) | 199/390 (51%) | 1.43 (0.38–5.32) | – | – | – | – | – | – | – | – |
| Rib fracture | 14 | 1160/2074 (56%) | 861/1184 (73%) | 1.27 (1.11–1.45) | 10 | 539/1259(43%) | 663/870 (76%) | 1.30 (1.12–1.51) | – | – | – | – |
| Multiple rib fractures | 4 | 147/535 (27%) | 464/623 (74%) | 1.46 (1.13–1.88) | 4 | 147/535 (27%) | 464/623 (74%) | 1.46 (1.13–1.88) | – | – | – | – |
| Flail chest | 2 | 12/405 (3,0%) | 195/446 (44%) | 4.29 (1.23–14.99) | 2 | 12/405 (3,0%) | 195/446 (44%) | 4.29 (1.23–14.99) | – | – | – | – |
| Vertebral fracture | 5 | 3/1612 (0,2%) | 10/531 (1,9%) | 4.73 (1.31–17.1) | 2 | 0/937 (0,0%) | 3/336 (0,9%) | 5.89 (0.66–52.92) | – | – | – | – |
| Extrathoracic chest wall injury | 4 | 131/984 (13%) | 83/374 (22%) | 9.44 (0.73–122.45) | 4 | 131/984 (13%) | 83/374 (22%) | 9.44 (0.73–122.45) | – | – | – | – |
| Hemomediastinum | 5 | 26/759 (3,4%) | 44/680 (6,5%) | 1.89 (1.16–3.08) | 4 | 21/683 (3,1%) | 39/652 (6,0%) | 1.87 (0.96–3.64) | – | – | – | – |
| Pulmonary injury | ||||||||||||
| Hemothorax | 9 | 42/1916 (2,2%) | 62/1304 (4,8%) | 1.79 (0.91–3.55) | 5 | 11/1120 (1,0%) | 25/745 (3,4%) | 4.20 (2.04–8.68) | 2 | 18/111 (16%) | 30/284 (11%) | 0.84 (0.52–1.36) |
| Pneumothorax | 11 | 40/1518 (2,6%) | 80/1376 (5,8%) | 1.86 (1.23–2.82) | 7 | 26/1205 (2,2%) | 22/853 (2,6%) | 1.45 (0.57–3.71) | 2 | 7/111 (6,3%) | 46/284 (16%) | 2.61 (1.00–6.78) |
| Pulmonary contusion | 6 | 111/1277(8,7%) | 50/460 (11%) | 1.56 (0.67–3.61) | 3 | 65/516 (13%) | 37/157 (24%) | 1.47 (0.29–7.44) | – | – | – | – |
| Pulmonary hematoma | 4 | 2/220 (0,9%) | 12/609 (2,0%) | 2.12 (0.62–7.29) | 4 | 2/220 (0,9%) | 12/609 (2,0%) | 1.92 (0.52–7.12) | – | – | – | – |
| Pulmonary laceration | 2 | 2/429 (0,5%) | 2/112 (1,8%) | 3.05 (0.58–16.02) | – | – | – | – | – | – | – | – |
| Other pulmonary injury | 2 | 45/530 (8,5%) | 51/156 (33%) | 1.91 (0.25–14.51) | – | – | – | – | – | – | – | – |
| Cardiac injury | ||||||||||||
| Cardiac contusion | 3 | 7/927 (0,8%) | 11/160 (6,9%) | 8.71 (3.02–25.10) | 2 | 0/368 (0,0%) | 8/96 (8,3%) | 19.79 (2.58–151.46) | – | – | – | – |
| Cardiac laceration, rupture, perforation | 4 | 10/1137 (0,9%) | 13/570 (2,3%) | 4.53 (1.92–10.70) | 3 | 2/578 (0,3%) | 11/506 (2,2%) | 5.14 (0.90–29.44) | – | – | – | – |
| Pericardial or epicardial injury | 11 | 74/1852 (4,0%) | 97/1208 (8,0%) | 1.81 (1.32–2.48) | 7 | 49/1106 (4,4%) | 62/832 (7,5%) | 1.91 (1.29–2.82) | 2 | 11/111 (10%) | 32/284 (11%) | 1.43 (0.79–2.61) |
| Retrosternal hematoma | 4 | 37/264 (14%) | 117/780 (15%) | 1.36 (0.98–1.89) | 3 | 21/182 (12%) | 62/539 (12%) | 1.49 (0.96–2.32) | - | – | – | – |
| Other cardiac injury | 5 | 37/1242 (3,0%) | 15/716 (2,1%) | 1.49 (0.77–2.89) | 4 | 12/683 (1,8%) | 12/652 (1,8%) | 1.70 (0.73–3.99) | – | – | – | – |
| Abdominal injury | ||||||||||||
| Stomach injury | 2 | 0/405 (0,0%) | 2/446 (0,4%) | 2.34 (0.09–62.85) | 2 | 0/405 (0,0%) | 2/446 (0,4%) | 2.34 (0.09–62.85) | – | – | – | – |
| Liver injury | 10 | 41/1869 (2,2%) | 67/1168 (5,7%) | 2.05 (0.84–5.03) | 6 | 14/1068 (1,3%) | 55/762 (7,2%) | 3.91 (1.97–7.73) | 2 | 12/116 (10%) | 8/131 (6,1%) | 0.46 (0.21–1.01) |
| Spleen injury | 5 | 19/1075 (1,8%) | 10/317 (3,2%) | 1.63 (0.40–6.59) | 2 | 1/400 (0,3%) | 3/122 (2,5%) | 6.24 (0.93–42.08) | 2 | 9/116 (7,8%) | 5/131 (3,8%) | 0.57 (0.07–4.40) |
| Pancreas injury | 2 | 0/405 (0,0%) | 2/446 (0,4%) | 2.34 (0.09–62.85) | 2 | 0/405 (0,0%) | 2/446 (0,4%) | 2.34 (0.09–62.85) | – | – | – | – |
| Kidney injury | 4 | 3/466 (0,6%) | 12/515 (2,3%) | 1.99 (0.69–5.71) | 3 | 1/437 (0,2%) | 10/472 (2,1%) | 3.46 (0.66–18.06) | – | – | – | – |
| Bowel injury | 2 | 0/440 (0,0%) | 3/172 (1,7%) | 7.93 (1.12–56.28) | – | – | – | – | – | – | – | |
| Hemoperitoneum | 5 | 16/1533 (1,0%) | 68/572 (11,9%) | 2.88 (1.64–5.07) | 3 | 9/892 (1,0%) | 28/267 (10%) | 2.71 (1.35–5.46) | – | – | – | – |
| Pneumoperitoneum | 3 | 1/237 (0,4%) | 10/495 (2,0%) | 2.56 (0.54–12.20) | – | – | – | – | 2 | 1/111 (0,9%) | 9/284 (3,2%) | 2.32 (0.38–14.25) |
| Other abdominal injury | 2 | 1/169 (0,6%) | 19/329 (5,8%) | 5.33 (0.96–29.48) | – | – | – | – | 2 | 1/169 (0,6%) | 19/329 (5,8%) | 4.99 (0.92–27.13) |
| Vascular injury | ||||||||||||
| Thoracic vascular injury | 6 | 7/753 (0,9%) | 21/748 (2,8%) | 2.86 (1.14–7.16) | 6 | 7/753 (0,9%) | 21/748 (2,8%) | 0.02 (0.01–0.04) | – | – | – | – |
| Abdominal aorta injury | 2 | 0/130 (0,0%) | 2/177 (1,1%) | 2.59 (0.28–23.70) | 2 | 0/130 (0,0%) | 2/177 (1,1%) | 2.58 (0.27–24.49) | – | – | – | – |
CI confidence interval, CPR cardiopulmonary resuscitation
Surgical management of CPR-related rib fractures
Despite pooling data from over 12,000 patients with CPR-related rib fractures, only eight studies reported on a total of 57 patients who underwent SSRF for these fractures [7, 12–18]. The largest study comprised 39 patients [18]. The pooled mean age was 65 (SD 10) years and, and a total of 51 patients (89%) were male. The most frequent indication for SSRF was the inability to wean patients with multiple rib fractures off mechanical ventilation, with a specific pattern being a flail sternum in the majority (93%) of patients. The time interval between CPR and SSRF ranged from 1 to 38 days. Several fixation systems were employed, including pectus bars, sternal fixation plates, and rib fixation systems including MatrixRIB™ (Synthes), RibFixBlu™ (Zimmer Biomet), and RibLoc® U + (Acute innovations). Postoperatively, 18 cases (41%) of pneumonia and one case (2%) of surgical site infection were reported. One study documented postoperative thoracic bleeding, occurring in six patients (15%). Successful weaning from mechanical ventilation was reported in 17 (94%) patients. The majority of patients (n = 44, 83%) were discharged alive.
Discussion
The primary objective of this systematic review and meta-analysis was to determine the prevalence of rib fractures and other thoracic and abdominal injuries associated with CPR for non-traumatic cardiopulmonary arrest. Two-thirds of the patients sustained CPR-related injuries, with rib fractures being the most common (55%). Additionally, over one-third of patients had a flail sternum following CPR. Notably, CPR-related injuries, including rib fractures and cardiac injuries, were more frequently identified after mechanically assisted CPR than after manual CPR alone. In particular, piston type mechanical CPR devices were associated with more injuries compared to load distributing band devices and manual-only CPR. In addition, surgical stabilization of CPR-related rib fractures is infrequently performed and the number of reports on surgical stabilization of CPR-related rib fractures was too limited to conduct a formal meta-analysis.
The prevalence of CPR-related injuries in this review exceeded the 32–45% reported in a systematic review published in 2014 [4]. Several factors may explain this increased prevalence, including the improved imaging by CT scans instead of plain radiographs and the utilization and development of mechanical devices to assist CPR. Other contributing factors to the increased prevalence and its range may include the quality of chest compressions, the setting in which CPR was administered, and the characteristics of the studied population.
The current review highlighted that CPR assisted with a mechanical device resulted in more injuries compared to manual compressions alone, consistent with previous literature [95]. For instance, prior studies have reported a two- to tenfold increase in the prevalence of rib and sternum fractures due to mechanically assisted CPR, with the extent of the increase varying depending on the type of mechanical device employed [4]. Nevertheless, the higher prevalence of cardiac injuries following mechanical CPR has not been previously described, which may be attributed to changes in resuscitation guidelines over the years. These guidelines currently recommend deeper chest compressions, potentially resulting in more injuries [96]. Furthermore, the inclusion of CT scans for diagnosing certain causes of cardiac arrest may have contributed to the increased identification of CPR related injuries, since CT is a significantly more sensitive modality for detecting CPR-related injuries than physical examination or radiographs alone [86]. Additionally, CT has also proven to be a valuable adjunct to autopsy for diagnosing CPR-related injuries [43].
To date, no literature reviews have been published on SSRF of CPR-related rib fractures, with most available publications being limited to case reports or case series involving a maximum of five patients [12]. Therefore, quantitative synthesis of these results was deemed not useful due to the selection of the cardiac arrest patients with the best anticipated outcome, coupled with a low number of patients in these studies. Nonetheless, the summarized findings suggest that SSRF of CPR-related rib fractures may lead to favorable respiratory outcomes in post-CPR patients with an anterior flail chest who fail to be weaned from mechanical ventilation. Important to note is that the number of post-CPR SSRF cases was low and surgical timing and technique were heterogeneous. Additionally, the current literature on SSRF generally does not address patients with CPR-related rib fractures, as these patients are typically excluded from clinical trials on the subject. Consequently, future comparative studies, preferably prospective ones, are required to provide guidance on the optimal management of CPR survivors with severe rib fracture patterns.
Several limitations should be acknowledged in this systematic review and meta-analysis. First, selection bias may have been present, as patients who underwent autopsy or diagnostic imaging following CPR could differ systematically from those who did not. Second, not all studies provided information the CPR setting, and some study populations included both out-of-hospital and in-hospital cardiac arrest cases. Additionally, the background of the CPR provider was not consistently reported, making it impossible to distinguish between chest compressions administered by healthcare providers, bystanders, or a combination of both. Third, the CPR duration, an important risk factor for CPR-related injuries, could not be consistently accounted for in the meta-analysis due to incomplete or inconsistent reporting of data [30, 32, 65, 77, 79, 81, 84]. Moreover, CPR-guidelines have evolved since their first description in 1960, potentially impacting the prevalence and patterns of CPR-related injuries over the past six decades, as deeper compressions are likely to result in more injuries [1, 2, 74, 75, 78]. Last, this meta-analysis included CPR-related injuries detected using different diagnostic modalities, including physical examination, radiographs, CT-scans conducted after return of spontaneous circulation, post-mortem CT, autopsy, or a combination of these modalities. Factors such as the study period, diagnostic modality, and survivor status may potentially have influenced the prevalence of injuries identified.
With the improved sensitivity of the diagnostic modalities in recent years, the true prevalence of CPR-related injury is becoming clearer. The added value of studies reporting on CPR-related injuries diagnosed solely with radiographs and without the current state-of-the-art diagnostic modalities is questionable. A meta-analysis that exclusively includes studies combining physical exams with high-resolution CT for survivors and/or autopsy for non-survivors would reveal a higher, yet more accurate CPR-related injury prevalence. The subsequent question would revolve around the optimal treatment for these CPR-related injuries, particularly in the case of CPR-related rib fractures, where the question arises of when and if to perform SSRF.
In conclusion, CPR-related thoracic injuries are frequently identified in post-CPR patients following a non-traumatic cardiopulmonary arrest. These injuries can be serious and consequential. Mechanically assisted CPR is associated with a higher risk of CPR-related compared to manual compressions alone. Surgical stabilization of CPR-related rib fractures is currently performed incidentally.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
The authors wish to thank Dr. Maarten F.M. Engel from the Erasmus MC Medical Library for developing and updating the literature search strategies.
Authors contribution
SFMW: conceptualization, formal analysis, investigation, data curation, writing—original draft, visualization, project administration. JTHP: validation, investigation, writing—review and editing. MHJV: conceptualization, resources, writing—review and editing, supervision. MMEW: conceptualization, writing—review and editing, supervision. EMML: conceptualization, formal analysis, data curation, writing—review and editing, visualization, supervision, project administration.
Funding
No funds, grants, or other support was received for the preparation of the manuscript.
Availability of data, code, and other materials
Upon request mailed to the corresponding author.
Declarations
Conflict of interest
The authors have no competing interests to declare relevant to the content of this article.
Ethical approval
Not applicable for this systematic review and meta-analysis.
References
- 1.Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA. 1960;173(10):1064–7. 10.1001/jama.1960.03020280004002. [DOI] [PubMed] [Google Scholar]
- 2.Perkins GD, Graesner JT, Semeraro F, Olasveengen T, Soar J, Lott C, et al. European Resuscitation Council Guidelines 2021: executive summary. Resuscitation. 2021;161:1–60. [DOI] [PubMed] [Google Scholar]
- 3.Ram P, Menezes RG, Sirinvaravong N, Luis SA, Hussain SA, Madadin M, et al. Breaking your heart—a review on CPR-related injuries. Am J Emerg Med. 2018;36(5):838–42. [DOI] [PubMed] [Google Scholar]
- 4.Miller AC, Rosati SF, Suffredini AF, Schrump DS. A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries. Resuscitation. 2014;85(6):724–31. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Koster RW, Beenen LF, van der Boom EB, Spijkerboer AM, Tepaske R, van der Wal AC, et al. Safety of mechanical chest compression devices AutoPulse and LUCAS in cardiac arrest: a randomized clinical trial for non-inferiority. Eur Heart J. 2017;38(40):3006–13. 10.1093/eurheartj/ehx318. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Prins JTH, Van Lieshout EMM, Van Wijck SFM, Scholte NTB, Den Uil CA, Vermeulen J, et al. Chest wall injuries due to cardiopulmonary resuscitation and the effect on in-hospital outcomes in survivors of out-of-hospital cardiac arrest. J Trauma Acute Care Surg. 2021;91(6):966–75. [DOI] [PubMed] [Google Scholar]
- 7.Kunz K, Petros S, Ewens S, Yahiaoui-Doktor M, Denecke T, Struck MF, et al. Chest compression-related flail chest is associated with prolonged ventilator weaning in cardiac arrest survivors. J Clin Med. 2022;11(8):2071. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002;52(4):727–32 (discussion 32). 10.1097/00005373-200204000-00020. [DOI] [PubMed]
- 9.Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. 2005;4(6):583–7. [DOI] [PubMed]
- 10.Cataneo AJ, Cataneo DC, de Oliveira FH, Arruda KA, El Dib R, de Oliveira Carvalho PE. Surgical versus nonsurgical interventions for flail chest. Cochrane Database Syst Rev. 2015(7):CD009919. [DOI] [PMC free article] [PubMed]
- 11.Schuurmans J, Goslings JC, Schepers T. Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review. Eur J Trauma Emerg Surg. 2017;43(2):163–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.DeVoe WB, Abourezk M, Goslin BJ, Saraswat N, Kiel B, Bach JA, et al. Surgical stabilization of severe chest wall injury following cardiopulmonary resuscitation. J Trauma Acute Care Surg. 2022;92(1):98–102. [DOI] [PubMed] [Google Scholar]
- 13.Claydon O, Benamore R, Belcher E. Outcomes of chest wall fixation in cardiopulmonary resuscitation-induced flail chest. Interact Cardiovasc Thorac Surg. 2020;31(3):417–8. [DOI] [PubMed] [Google Scholar]
- 14.Lee SK, Kim DH, Lee CH. Use of a pectus bar for surgical stabilization of cardiopulmonary resuscitation induced flail chest. J Card Surg. 2020;35(8):2064–6. [DOI] [PubMed] [Google Scholar]
- 15.Drahos A, Fitzgerald M, Ashley D, Christie DB 3rd. Chest wall stabilization with rib plating after cardiopulmonary resuscitation. J Thorac Dis. 2019;11(Suppl 8):S1103–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Pouwels NSA, van Embden D, Hoogendoorn JM. Ribfixatie bij fladderthorax na reanimatie [Rib fixation for flail chest after resuscitation]. Ned Tijdschr Geneeskd. 2018;162:D1861. [PubMed]
- 17.Ananiadou O, Karaiskos T, Givissis P, Drossos G. Operative stabilization of skeletal chest injuries secondary to cardiopulmonary resuscitation in a cardiac surgical patient. Interact Cardiovasc Thorac Surg. 2010;10(3):478–80. [DOI] [PubMed] [Google Scholar]
- 18.Prins JTH, Van Lieshout EMM, Eriksson EA, Barnes M, Blokhuis TJ, Caragounis EC, et al. Surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures following cardiopulmonary resuscitation: an international, retrospective matched case-control study (CWIS-CPR). J Trauma Acute Care Surg. 2022;93(6):727–35. [DOI] [PubMed] [Google Scholar]
- 19.Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. PLoS Med. 2021;18(3): e1003583. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Bramer WM, Rethlefsen ML, Kleijnen J, Franco OH. Optimal database combinations for literature searches in systematic reviews: a prospective exploratory study. Syst Rev. 2017;6(1):245. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Edwards JG, Clarke P, Pieracci FM, Bemelman M, Black EA, Doben A, et al. Taxonomy of multiple rib fractures: results of the chest wall injury society international consensus survey. J Trauma Acute Care Surg. 2020;88(2):e40–5. 10.1097/TA.0000000000002282. [DOI] [PubMed] [Google Scholar]
- 22.Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712–6. [DOI] [PubMed] [Google Scholar]
- 23.Azeli Y, Barbería E, Fernández A, García-Vilana S, Bardají A, Hardig BM. Chest wall mechanics during mechanical chest compression and its relationship to CPR-related injuries and survival. Resusc Plus. 2022;10: 100242. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Karasek J, Blankova A, Doubková A, Pitasova T, Nahalka D, Bartes T, et al. The comparison of cardiopulmonary resuscitation-related trauma: mechanical versus manual chest compressions. Forensic Sci Int. 2021;323: 110812. 10.1016/j.forsciint.2021.110812. [DOI] [PubMed] [Google Scholar]
- 25.Moriguchi S, Hamanaka K, Nakamura M, Takaso M, Baba M, Hitosugi M. Aging is only significant factor causing CPR-induced injuries and serious injuries. Leg Med (Tokyo). 2021;48: 101828. [DOI] [PubMed] [Google Scholar]
- 26.Milling L, Mikkelsen S, Astrup BS. Characteristics of mechanical CPR-related injuries: a case series. J Forensic Leg Med. 2020;70: 101918. [DOI] [PubMed] [Google Scholar]
- 27.Azeli Y, Barbería E, Jiménez-Herrera M, Ameijide A, Axelsson C, Bardaj A. Incidencia y variables asociadas a lesiones graves secundarias a reanimación cardiopulmonar [Serious injuries secondary to cardiopulmonary resuscitation: incidence and associated factors]. Emergencias. 2019;31(5):327–34. [PubMed] [Google Scholar]
- 28.Deliliga A, Chatzinikolaou F, Koutsoukis D, Chrysovergis I, Voultsos P. Cardiopulmonary resuscitation (CPR) complications encountered in forensic autopsy cases. BMC Emerg Med. 2019;19(1):23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Friberg N, Schmidbauer S, Walther C, Englund E. Skeletal and soft tissue injuries after manual and mechanical chest compressions. Eur Heart J Qual Care Clin Outcomes. 2019;5(3):259–65. [DOI] [PubMed] [Google Scholar]
- 30.Milling L, Astrup BS, Mikkelsen S. Prehospital cardiopulmonary resuscitation with manual or mechanical chest compression: a study of compression-induced injuries. Acta Anaesthesiol Scand. 2019;63(6):789–95. [DOI] [PubMed] [Google Scholar]
- 31.Ondruschka B, Baier C, Bernhard M, Buschmann C, Dreßler J, Schlote J, et al. Frequency and intensity of pulmonary bone marrow and fat embolism due to manual or automated chest compressions during cardiopulmonary resuscitation. Forensic Sci Med Pathol. 2019;15(1):48–55. [DOI] [PubMed] [Google Scholar]
- 32.Ondruschka B, Baier C, Bayer R, Hammer N, Dreßler J, Bernhard M. Chest compression-associated injuries in cardiac arrest patients treated with manual chest compressions versus automated chest compression devices (LUCAS II)—a forensic autopsy-based comparison. Forensic Sci Med Pathol. 2018;14(4):515–25. [DOI] [PubMed] [Google Scholar]
- 33.Setälä P, Hellevuo H, Huhtala H, Kämäräinen A, Tirkkonen J, Hoppu S. Risk factors for cardiopulmonary resuscitation-related injuries sustained during out-of-hospital cardiac arrests. Acta Anaesthesiol Scand. 2018;62(9):1290–6. [DOI] [PubMed] [Google Scholar]
- 34.Yamaguchi R, Makino Y, Chiba F, Torimitsu S, Yajima D, Inokuchi G, et al. Frequency and influencing factors of cardiopulmonary resuscitation-related injuries during implementation of the American Heart Association 2010 Guidelines: a retrospective study based on autopsy and postmortem computed tomography. Int J Legal Med. 2017;131(6):1655–63. [DOI] [PubMed] [Google Scholar]
- 35.Ihnát Rudinská L, Hejna P, Ihnát P, Tomášková H, Smatanová M, Dvořáček I. Intra-thoracic injuries associated with cardiopulmonary resuscitation—frequent and serious. Resuscitation. 2016;103:66–70. [DOI] [PubMed] [Google Scholar]
- 36.Kaldırım U, Toygar M, Karbeyaz K, Arziman I, Tuncer S, Eyi Y, et al. Complications of cardiopulmonary resuscitation in non-traumatic cases and factors affecting complications. Egypt J Forensic Sci. 2015;6:270–4. 10.1016/j.ejfs.2015.07.005. [Google Scholar]
- 37.Kralj E, Podbregar M, Kejžar N, Balažic J. Frequency and number of resuscitation related rib and sternum fractures are higher than generally considered. Resuscitation. 2015;93:136–41. [DOI] [PubMed] [Google Scholar]
- 38.Lardi C, Egger C, Larribau R, Niquille M, Mangin P, Fracasso T. Traumatic injuries after mechanical cardiopulmonary resuscitation (LUCAS2): a forensic autopsy study. Int J Legal Med. 2015;129(5):1035–42. [DOI] [PubMed] [Google Scholar]
- 39.Štěchovský C, Hájek P, Cipro Š, Veselka J. Risk of myocardial contusion in cardiac arrest patients resuscitated with mechanical chest compression device. Int J Cardiol. 2015;182:50–1. [DOI] [PubMed] [Google Scholar]
- 40.Smekal D, Lindgren E, Sandler H, Johansson J, Rubertsson S. CPR-related injuries after manual or mechanical chest compressions with the LUCAS™ device: a multicentre study of victims after unsuccessful resuscitation. Resuscitation. 2014;85(12):1708–12. [DOI] [PubMed] [Google Scholar]
- 41.Hellevuo H, Sainio M, Nevalainen R, Huhtala H, Olkkola KT, Tenhunen J, et al. Deeper chest compression—more complications for cardiac arrest patients? Resuscitation. 2013;84(6):760–5. [DOI] [PubMed] [Google Scholar]
- 42.Pinto DC, Haden-Pinneri K, Love JC. Manual and automated cardiopulmonary resuscitation (CPR): a comparison of associated injury patterns. J Forensic Sci. 2013;58(4):904–9. [DOI] [PubMed] [Google Scholar]
- 43.Smekal D, Hansen T, Sandler H, Rubertsson S. Comparison of computed tomography and autopsy in detection of injuries after unsuccessful cardiopulmonary resuscitation. Resuscitation. 2013;84(3):357–60. [DOI] [PubMed] [Google Scholar]
- 44.Charaschaisri W, Jongprasartsuk K, Rungruanghiranya S, Kaufman L. Forensic aspect of cause of subendocardial hemorrhage in cardiopulmonary resuscitation cases: chest compression or adrenaline. Am J Forensic Med Pathol. 2011;32(1):58–60. [DOI] [PubMed] [Google Scholar]
- 45.Smekal D, Johansson J, Huzevka T, Rubertsson S. No difference in autopsy detected injuries in cardiac arrest patients treated with manual chest compressions compared with mechanical compressions with the LUCAS device—a pilot study. Resuscitation. 2009;80(10):1104–7. [DOI] [PubMed] [Google Scholar]
- 46.Nishida N, Chiba T, Ohtani M, Ikeda N, Katayama Y, Yoshioka N. Relationship between cardiopulmonary resuscitation and injuries of the cardiac conduction system: pathological features and pathogenesis of such injuries. Crit Care Med. 2006;34(2):363–7. [DOI] [PubMed] [Google Scholar]
- 47.Black CJ, Busuttil A, Robertson C. Chest wall injuries following cardiopulmonary resuscitation. Resuscitation. 2004;63(3):339–43. [DOI] [PubMed] [Google Scholar]
- 48.Lederer W, Mair D, Rabl W, Baubin M. Frequency of rib and sternum fractures associated with out-of-hospital cardiopulmonary resuscitation is underestimated by conventional chest X-ray. Resuscitation. 2004;60(2):157–62. [DOI] [PubMed] [Google Scholar]
- 49.Baubin M, Sumann G, Rabl W, Eibl G, Wenzel V, Mair P. Increased frequency of thorax injuries with ACD-CPR. Resuscitation. 1999;41(1):33–8. [DOI] [PubMed] [Google Scholar]
- 50.Rabl W, Baubin M, Broinger G, Scheithauer R. Serious complications from active compression-decompression cardiopulmonary resuscitation. Int J Legal Med. 1996;109(2):84–9. [DOI] [PubMed] [Google Scholar]
- 51.Cohen TJ, Goldner BG, Maccaro PC. A comparison of active compression-decompression cardiopulmonary resuscitation with standard cardiopulmonary resuscitation for cardiac arrests occurring in the hospital. N Engl J Med. 1993;329(26):1918–21. 10.1056/NEJM199312233292603. [DOI] [PubMed] [Google Scholar]
- 52.Bedell SE, Fulton EJ. Unexpected findings and complications at autopsy after cardiopulmonary resuscitation (CPR). Arch Intern Med. 1986;146(9):1725–8. [PubMed] [Google Scholar]
- 53.Powner DJ, Holcombe PA, Mello LA. Cardiopulmonary resuscitation-related injuries. Crit Care Med. 1984;12(1):54–5. [DOI] [PubMed] [Google Scholar]
- 54.Anthony PP, Tattersfield AE. Gastric mucosal lacerations after cardiac resuscitation. Br Heart J. 1969;31(1):72–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 55.Saphir R. External cardiac massage. Prospective analysis of 123 cases and review of the literature. Medicine (Baltimore). 1968;47(1):73–87. [DOI] [PubMed]
- 56.Lundberg GD, Mattei IR, Davis CJ, Nelson DE. Hemorrhage from gastroesophageal lacerations following closed-chest cardiac massage. JAMA. 1967;202(3):195–8. [PubMed] [Google Scholar]
- 57.Minuck M. Organization and experiences of a cardiac resuscitation service. Can Anaesth Soc J. 1966;13(1):52–61. [DOI] [PubMed] [Google Scholar]
- 58.Adel J, Akin M, Garcheva V, Vogel-Claussen J, Bauersachs J, Napp LC, et al. Computed-tomography as first-line diagnostic procedure in patients with out-of-hospital cardiac arrest. Front Cardiovasc Med. 2022;9: 799446. 10.3389/fcvm.2022.799446. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 59.Karatasakis A, Sarikaya B, Liu L, Gunn ML, Kudenchuk PJ, Gatewood MO, et al. Prevalence and patterns of resuscitation-associated injury detected by head-to-pelvis computed tomography after successful out-of-hospital cardiac arrest resuscitation. J Am Heart Assoc. 2022;11(3): e023949. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 60.Katasako A, Kawakami S, Koga H, Kitahara K, Komiya K, Mizokami K, et al. The association between the duration of chest compression and thoracic injuries in patients with non-traumatic out-of-hospital cardiac arrest. Circ J. 2022;86:1572–8. 10.1253/circj.CJ-22-0193. [DOI] [PubMed] [Google Scholar]
- 61.Kawai Y, Takano K, Miyazaki K, Yamamoto K, Tada Y, Asai H, et al. Association of multiple rib fractures with the frequency of pneumonia in the post-resuscitation period. Resusc Plus. 2022;11: 100267. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 62.Canakci ME, Parpucu Bagceci K, Acar N, Ozakin E, Baloglu Kaya F, Kuas C, et al. Computed tomographic findings of injuries after mechanical and manual resuscitation: a retrospective study. Cureus. 2021;13(5): e15131. 10.7759/cureus.15131. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 63.Hokenek NM, Erdogan MO. Effect of differences in thorax volume and dimensions on cpr-related injuries. J Coll Phys Surg Pak. 2021;31(3):267–72. 10.29271/jcpsp.2021.03.267. [DOI] [PubMed] [Google Scholar]
- 64.Hwang CW, Chowdhury MAB, Curtis DZ, J DW, Agarwal A, Climenhage BP, et al. A descriptive analysis of cross-sectional imaging findings in patients after non-traumatic sudden cardiac arrest. Resusc Plus. 2021;5:100077. 10.1016/j.resplu.2021.100077. [DOI] [PMC free article] [PubMed]
- 65.Jang SJ, Cha YK, Kim JS, Do HH, Bak SH, Kwack WG. Computed tomographic findings of chest injuries following cardiopulmonary resuscitation: more complications for prolonged chest compressions? Medicine (Baltimore). 2020;99(33): e21685. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 66.Kim HI, Cha KC, Chung WJ, Noh YI, Kim OH, Cha YS, et al. Effect of chest compression on skeletal chest injuries: a retrospective study. Eur J Emerg Med. 2020;27(1):59–63. [DOI] [PubMed] [Google Scholar]
- 67.Oh JH, Kim HI. Analysis of the cardiopulmonary resuscitation-related complications based on computed tomography. J Korean Soc Emerg Med. 2020;31(5):431–9. [Google Scholar]
- 68.Sonnemans LJP, Bayat AR, Bruinen ARC, van Wely MH, Brouwer MA, Bosboom D, et al. Comparing thoracoabdominal injuries of manual versus load-distributing band cardiopulmonary resuscitation. Eur J Emerg Med. 2020;27(3):197–201. [DOI] [PubMed] [Google Scholar]
- 69.Viniol S, Thomas RP, König AM, Betz S, Mahnken AH. Early whole-body CT for treatment guidance in patients with return of spontaneous circulation after cardiac arrest. Emerg Radiol. 2020;27(1):23–9. [DOI] [PubMed] [Google Scholar]
- 70.Zaidi HQ, Li S, Beiser DG, Tataris KL, Sharp WW. The utility of computed tomography to evaluate thoracic complications after cardiopulmonary resuscitation. Resusc Plus. 2020;3: 100017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 71.Zotzmann V, Rilinger J, Lang CN, Duerschmied D, Benk C, Bode C, et al. Early full-body computed tomography in patients after extracorporeal cardiopulmonary resuscitation (eCPR). Resuscitation. 2020;146:149–54. [DOI] [PubMed] [Google Scholar]
- 72.Dunham GM, Perez-Girbes A, Bolster F, Sheehan K, Linnau KF. Use of whole body CT to detect patterns of CPR-related injuries after sudden cardiac arrest. Eur Radiol. 2018;28(10):4122–7. [DOI] [PubMed] [Google Scholar]
- 73.Takayama W, Koguchi H, Endo A, Otomo Y. The association between cardiopulmonary resuscitation in out-of-hospital settings and chest injuries: a retrospective observational study. Prehosp Disaster Med. 2018;33(2):171–5. [DOI] [PubMed] [Google Scholar]
- 74.Yusufoğlu K, Erdoğan M, Tayfur İ, Afacan MA, Çolak Ş. CPR-related thoracic injuries: comparison of CPR guidelines between 2010 and 2015. Turk J Med Sci. 2018;48(1):24–7. [DOI] [PubMed] [Google Scholar]
- 75.Beom JH, You JS, Kim MJ, Seung MK, Park YS, Chung HS, et al. Investigation of complications secondary to chest compressions before and after the 2010 cardiopulmonary resuscitation guideline changes by using multi-detector computed tomography: a retrospective study. Scand J Trauma Resusc Emerg Med. 2017;25(1):8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 76.Cha KC, Kim YW, Kim HI, Kim OH, Cha YS, Kim H, et al. Parenchymal lung injuries related to standard cardiopulmonary resuscitation. Am J Emerg Med. 2017;35(1):117–21. [DOI] [PubMed] [Google Scholar]
- 77.Nomura T, Yanagawa Y, Nagasawa H, Takeuchi I, Jitsuiki K, Kondo A, et al. Risk factors of occurrence of rib fracture or pneumothorax after chest compression for patients with cardiac arrest. Sch J App Med Sci. 2017;5(10B):3897–900. [Google Scholar]
- 78.Oya S, Shinjo T, Fujii Y, Kamo J, Teruya H, Kinoshita H. CPR related thoracic injury: a comparison of CPR guidelines between 2005 and 2010. Acute Med Surg. 2016;3(4):351–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 79.Seung MK, You JS, Lee HS, Park YS, Chung SP, Park I. Comparison of complications secondary to cardiopulmonary resuscitation between out-of-hospital cardiac arrest and in-hospital cardiac arrest. Resuscitation. 2016;98:64–72. [DOI] [PubMed] [Google Scholar]
- 80.Boland LL, Satterlee PA, Hokanson JS, Strauss CE, Yost D. Chest compression injuries detected via routine post-arrest care in patients who survive to admission after out-of-hospital cardiac arrest. Prehosp Emerg Care. 2015;19(1):23–30. [DOI] [PubMed] [Google Scholar]
- 81.Kashiwagi Y, Sasakawa T, Tampo A, Kawata D, Nishiura T, Kokita N, et al. Computed tomography findings of complications resulting from cardiopulmonary resuscitation. Resuscitation. 2015;88:86–91. [DOI] [PubMed] [Google Scholar]
- 82.Koga Y, Fujita M, Yagi T, Nakahara T, Miyauchi T, Kaneda K, et al. Effects of mechanical chest compression device with a load-distributing band on post-resuscitation injuries identified by post-mortem computed tomography. Resuscitation. 2015;96:226–31. [DOI] [PubMed] [Google Scholar]
- 83.Choi SJ, Kim HS, Kim EY, Choi HY, Cho J, Yang HJ, et al. Thoraco-abdominal CT examinations for evaluating cause of cardiac arrest and complications of chest compression in resuscitated patients. Emerg Radiol. 2014;21(5):485–90. [DOI] [PubMed] [Google Scholar]
- 84.Cho SH, Kim EY, Choi SJ, Kim YK, Sung YM, Choi HY, et al. Multidetector CT and radiographic findings of lung injuries secondary to cardiopulmonary resuscitation. Injury. 2013;44(9):1204–7. [DOI] [PubMed] [Google Scholar]
- 85.Kim MJ, Park YS, Kim SW, Yoon YS, Lee KR, Lim TH, et al. Chest injury following cardiopulmonary resuscitation: a prospective computed tomography evaluation. Resuscitation. 2013;84(3):361–4. [DOI] [PubMed] [Google Scholar]
- 86.Kim EY, Yang HJ, Sung YM, Cho SH, Kim JH, Kim HS, et al. Multidetector CT findings of skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation. 2011;82(10):1285–8. [DOI] [PubMed] [Google Scholar]
- 87.Vahedian-Azimi A, Hajiesmaeili M, Amirsavadkouhi A, Jamaati H, Izadi M, Madani SJ, et al. Effect of the Cardio First Angel™ device on CPR indices: a randomized controlled clinical trial. Crit Care. 2016;20(1):147. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 88.Gaisendrees C, Gerfer S, Ivanov B, Sabashnikov A, Merkle J, Luehr M, et al. Outcomes after mechanical versus manual chest compressions in eCPR patients. Expert Rev Med Devices. 2021;18(10):1023–8. 10.1080/17434440.2021.1970528. [DOI] [PubMed] [Google Scholar]
- 89.Iglesies J, Loma-Osorio P, Aboal J, Núñez M, Brugada R. Mechanical chest compressions and traumatic complications in out-of-hospital cardiac arrest. Is there a price to pay? Rev Esp Cardiol (Engl Ed). 2019;72(3):259–61. [DOI] [PubMed]
- 90.Meron G, Kurkciyan I, Sterz F, Susani M, Domanovits H, Tobler K, et al. Cardiopulmonary resuscitation-associated major liver injury. Resuscitation. 2007;75(3):445–53. [DOI] [PubMed] [Google Scholar]
- 91.Oschatz E, Wunderbaldinger P, Sterz F, Holzer M, Kofler J, Slatin H, et al. Cardiopulmonary resuscitation performed by bystanders does not increase adverse effects as assessed by chest radiography. Anesth Analg. 2001;93(1):128–33. [DOI] [PubMed] [Google Scholar]
- 92.Bjork RJ, Snyder BD, Campion BC, Loewenson RB. Medical complications of cardiopulmonary arrest. Arch Intern Med. 1982;142(3):500–3. [PubMed] [Google Scholar]
- 93.Murtomaa M, Korttila K. Experience of cardiopulmonary resuscitation outside hospital by a mobile intensive care unit. Resuscitation. 1974;3(3):211–4. [DOI] [PubMed] [Google Scholar]
- 94.Minuck M. Organization and experiences of a cardiac resuscitation service. Can J Anaesth. 1966;13(1):52–61. 10.1007/bf03002164. [DOI] [PubMed] [Google Scholar]
- 95.Gao Y, Sun T, Yuan D, Liang H, Wan Y, Yuan B, et al. Safety of mechanical and manual chest compressions in cardiac arrest patients: a systematic review and meta-analysis. Resuscitation. 2021;169:124–35. [DOI] [PubMed] [Google Scholar]
- 96.Daya MR, Schmicker RH, Zive DM, Rea TD, Nichol G, Buick JE, et al. Out-of-hospital cardiac arrest survival improving over time: results from the Resuscitation Outcomes Consortium (ROC). Resuscitation. 2015;91:108–15. [DOI] [PMC free article] [PubMed] [Google Scholar]
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Data Availability Statement
Upon request mailed to the corresponding author.