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Studies in which cardiopulmonary resuscitation-related fractures found

The following is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.

 

Overview

  • Rib fractures are a rare complication of cardiopulmonary resuscitation (CPR) in children, with the reported incidence at 0-4.3% in ten 1-3,5,7,9-13 / 11 studies 1-3,5-7,9-13, six of which showed no rib fractures 2,5,7,9,11,12
    • A single study recorded an incidence of 18.7% 6
  • Where details were given, the fractures associated with CPR were all multiple, anterior / anterolateral, unilateral or bilateral.
  • There were no posterior rib fractures due to CPR
  • One study noted a rise in incidence and hypothesised that this was associated with the introduction of two-thumb rather than two-finger resuscitation 10, 14,15
  • One new study noted two infants with rib fractures ascribed to CPR, one anterior and one postero-lateral following bimanual chest compression 4

 

Details

  • Rib fractures were sought at post-mortem in ten studies. No authors referred to the use of specimen radiography 1-3,6-8,10-13

  • Nine studies explored the prevalence of rib fractures following CPR  1-3,5-7,9,11,12

    • These fractures occurred in the following children: a two month old; a three month old who died of sudden infant death syndrome; a five year old who drowned. Trained personnel resuscitated all three cases: the three month old was also resuscitated by untrained personnel for a total of 75 minutes.  There was no concern about child abuse in any of these cases 1,3

    • 15/80 children in Lin et al’s study of children aged 0-18 years sustained rib fractures on early chest x-ray but no details were available. Abuse had been excluded, although admission was trauma-related 6

    • Of these nine studies, six did not record any children with CPR-related fractures 2,5,7,9,11,12

    • In a study of 382 children undergoing CPR, no cases developed rib fractures having had a post-mortem examination including rib palpation and stripping of the parietal pleura 7
    • The children who did not sustain rib fractures were resuscitated for 1 – 540 minutes 11
  • 24/546 SUDI cases sustained rib fractures 13
    • 15 were healing fractures, 10 of which had features of abusive injury 13
    • Of nine acute fractures, seven had no features of abusive injury and were thought to be CPR related.  These were multiple, anterolateral, and involving 3rd – 6th ribs; bilateral in one case 13
    • 14/15 healing rib fractures were visible on post-mortem skeletal survey (SS), one case had only antemortem chest radiographs 13
    • Only 2/9 acute rib fractures were visible on post-mortem SS, found only by inspection of ribs following stripping of the pleura 13
  • A case series of five children sustaining rib fractures post-CPR noted that all children had by-stander CPR using one-handed and two-handed techniques 8
    • The fractures found were anterolateral, 3 – 6 ribs, 2/5 bilateral 8
  • 19/571 infants aged 0-6months exhibited rib fractures attributed to CPR, the duration of CPR was 21-260 minutes, fractures were all anterior to lateral. Almost three times as many fractures occurred between 2006-2008 versus 1997-2005 10,14,15
  • This is hypthothesised as correlating with the change in CPR technique as recommended by the International Liaison Committee on Resuscitation (ILCOR), however no attempt was made to determine what method of CPR had been conducted 10,14,15

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References

  1. Betz P, Liebhardt E. Rib fractures in children - resuscitation or child abuse? International Journal of Legal Medicine. 1994;106(4):215-218 [Pubmed]
  2. Boz B, Erdur B, Acar K, Ergin A, Turkcuer I, Ergin N. [Frequency of skeletal chest injuries associated with cardiopulmonary resuscitation: forensic autopsy]. [Turkish]. Ulusal Travma ve Acil Cerrahi Dergisi [Turkish Journal of Trauma & Emergency Surgery]. 2008;14(3):216-220 [Pubmed]
  3. Bush CM, Jones JS, Cohle SD, Johnson H. Pediatric injuries from cardiopulmonary resuscitation. Annals of Emergency Medicine. 1996;28(1):40-44 [Pubmed]
  4. Cosway B, Mathura N, Mott A, Bredow M, Fraser J, Rawlinson A, Wei C, Thyagarajan M, Harrison S, Kemp A. Occult rib fractures: Defining the cause. Child Abuse Review. 2013. [Early View - Abstract available from Wiley online library]

  5. Feldman KW, Brewer DK. Child abuse, cardiopulmonary resuscitation, and rib fractures. Pediatrics. 1984;73(3):339-342 [Pubmed]
  6. Lin YR, Li CJ, Wu TK, Chang YJ, Lai SC, Liu TA, Hsiao MH, Chou CC, Chang CF. Post-resuscitative clinical features in the first hour after achieving sustained ROSC predict the duration of survival in children with non-traumatic out-of-hospital cardiac arrest. Resuscitation. 2010;81(4):410-417 [Pubmed]
  7. Matshes EW, Lew EO. Do Resuscitation-Related Injuries Kill Infants and Children? American Journal of Forensic Medicine and Pathology. 2010;31(2):178-185 [Pubmed]
  8. Matshes EW, Lew EO. Two-handed cardiopulmonary resuscitation can cause rib fractures in infants. American Journal of Forensic Medicine and Pathology. 2010;31(4):303-307 [Pubmed]
  9. Price EA, Rush LR, Perper JA, Bell MD. Cardiopulmonary resuscitation-related injuries and homicidal blunt abdominal trauma in children. The American Journal of Forensic Medicine and Pathology. 2000;21(4):307-310 [Pubmed]
  10. Reyes JA, Somers GR, Taylor GP, Chiasson DA. Increased incidence of CPR-related rib fractures in infants - is it related to changes in CPR technique? Resuscitation. 2011;82(5):545-548 [Pubmed]
  11. Ryan MP, Young SJ, Wells DL. Do resuscitation attempts in children who die, cause injury? Emergency Medicine Journal. 2003;20(1):10-12 [Pubmed]
  12. Spevak MR, Kleinman PK, Belanger PL, Primack C, Richmond JM. Cardiopulmonary resuscitation and rib fractures in infants. A postmortem radiologic-pathologic study. The Journal of the American Medical Association. 1994;272(8):617-618 [Pubmed]
  13. Weber MA, Risdon RA, Offiah AC, Malone M, Sebire NJ. Rib fractures identified at post-mortem examination in sudden unexpected deaths in infancy (SUDI). Forensic Science International. 2009;189(1-3):75-81 [Pubmed]
  14. Martin, P. S.;Jones, M. D.;Maguire, S. A.;Theobald, P. S.;Kemp, A. M. Increased incidence of CPR-related rib fractures in infants - Is it related to changes in CPR technique? Resuscitation. 2012;83(4):E109-E109 [Pubmed]

  15. Reyes, J. A.;Somers, G. R.;Taylor, G. P.;Chiasson, D. A. Response to Letter: Increased incidence of CPR-related rib fractures in infants - Is it related to changes in CPR technique? Resuscitation.2012;83(4):E111-E111 [Abstract available from Science Direct]

 

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