Clinical paperDeeper chest compression – More complications for cardiac arrest patients??
Introduction
Ever since Peter Safar developed cardiopulmonary resuscitation (CPR) in the 1960s, there has been discussion about iatrogenic injuries associated with chest compressions.1, 2, 3, 4 Sternal and rib fractures are frequent complications of chest compressions4, 5, 6, 7 but sometimes CPR can result in intra-thoracic or intra-abdominal lacerations and haemorrhage which may even prove fatal.8, 9
The European Resuscitation Council (ERC) published new guidelines for resuscitation in 2010. High quality chest compressions are an essential part of these guidelines. Compression depth should be 5–6 cm and the rate at least 100 compressions per minute.10, 11, 12 It has been suggested that an increased compression depth may be associated with a higher incidence of iatrogenic injuries. Although there are studies on CPR-related injuries in adults and infants,13, 14, 15 none of them has investigated the potential association between the actual compression depth as measured with the accelerometer and the incidence and severity of complications after CPR. The purpose of this study was to investigate a possible association between CPR-related thoracic and abdominal injuries and objectively measured compression depth. Our hypothesis was that the risk of injuries increases as the compression depth increases.
Section snippets
Study design
This observational study was performed under approval of the Pirkanmaa Hospital District's Science Center and the Ethics Committee of the Tampere University Hospital (Approval no: R08116; clinicaltrials.gov NCT00951704). Data from the resuscitations were collected prospectively as a part of our on-going studies on the quality of resuscitation and also for educational purposes. The injuries were analysed retrospectively from the autopsy reports and thorax/CT-scans. Authorization to analyse
Injuries in the whole study population
Of the 370 patients resuscitated by MET a total of 170 SCA patients were included in this study. A flowchart of the patients is shown in Fig. 1. Of all the patients 32% (n = 54) had sustained injuries. When these injuries were analysed year by year, the incidence of injuries during the three-year period was 25%, 32% and 40% respectively (p = 0.21). The incidence of injuries in patients subjected to forensic autopsy, was 30%, 42% and 64% in 2009, 2010 and 2011, respectively (p = 0.03). Injuries are
Discussion
This is the first clinical study to suggest an association between increasing compression depth and injuries related to chest compressions during CPR. The majority of the injuries in the present study were spontaneously healing fractures and the frequency of the injuries was comparable to those reported in earlier studies.7, 15 Life-threatening ruptures of the myocardium were detected only in patients with acute myocardial infarction. It is very difficult to establish the causality between
Limitations of the study
This study has a number of limitations. First, we do not know the quality of chest compressions during the short resuscitation attempt before MET has arrived and started to use the sternal force/depth sensor. Second, even though all resuscitations were performed using a backboard to decrease the mattress effect, there is no technology available to enable us to know the absolute compression depth in all cases. Yet we have to bear in mind that all the earlier studies about sufficient compression
Conclusions
The number of iatrogenic injuries in male patients due to chest compressions during cardiopulmonary resuscitation increased as the compression depth exceeded 6 cm. No such association was seen in female patients. The majority of the injuries was spontaneously healing rib fractures or haematomas having only a minor impact on patients’ recovery from resuscitation. While there is an increased risk of complications with deeper compressions it is important to realize that the injuries were by and
Conflicts of interest statement
This study was funded by the Instru Science Foundation, Helsinki, Finland and by the Competitive Research Funding of the Tampere University Hospital (Grant 9M105). The funding organizations had no involvement in any aspect of the study.
Dr. Jyrki Tenhunen is a member of international advisory board for SuPARnostic (Virogates, Copenhagen, Denmark) and CMO and shareholder of SenSem Technologies (Tampere, Finland) and Medieta Ltd (Helsinki, Finland).
Dr. Sanna Hoppu has provided paid consultancy for
Acknowledgments
We would like to acknowledge the Tampere University Hospital ICU MET-nurses for help in gathering the data for this study. We also extend our warmest thanks to Sirkka Goebeler, MD, PhD. from National Institute for Health and Welfare and to the forensic autopsy technicians, the forensic pathologists and the secretary of the Department of Forensic Medicine, Tampere University Hospital.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.02.015.