U n 1 J

Fig. 28. Rib fractures. (A) Massive anterior rib and sternal fractures (insertion of chest tube through left chest wall defect). (B) Multiple posterior rib fractures indicated by subpleural hemorrhage (arrows). These injuries are appreciated only if the chest cavity is examined following the removal of organs.

Fig. 29. Fracture of sternum (two cases). (A) The undersurface of the sternum showed an apparent "laceration" of the internal mammary artery (tip of probe), but this was an artifact of the scalpel cut (arrows) during removal of sternum. (B) Run-over. Sternum reflected superiorly (partly covered by label). Undersurface shows internal mammary vein tear (probe inserted into torn end).

Fig. 29. Fracture of sternum (two cases). (A) The undersurface of the sternum showed an apparent "laceration" of the internal mammary artery (tip of probe), but this was an artifact of the scalpel cut (arrows) during removal of sternum. (B) Run-over. Sternum reflected superiorly (partly covered by label). Undersurface shows internal mammary vein tear (probe inserted into torn end).

Table 1

Complications of Closed-Chest Cardiac Resuscitation

Chest wall

Ribs ± sternum fracture-dislocation (151-160)

• Costochondral junction separation (163-165) Chest wall hemorrhage (166,167) Hemothorax (151,152,155,164,168,169)

Other fractures (clavicle, scapula, cervical spine, thoracolumbar [155,162,164,170]) Diaphragm rupture (167) Cardiovascular system

Pericardial laceration (152,156,171) Hemopericardium (151,153,155,158,164,172)

• Cardiac rupture

• Pericardiocentesis, pacemaker, central venous line (157,173-175) Myocardial contusion (152,155,158)

Intramural hemorrhage (posteroseptal left ventricle common [154,155,157,164,169]) Myocardial rupture

• Ventricles

° Normal myocardium (156,157,160,168,171,177) ° Myocardial infarct (156,172,173,178) ° By fractured rib or vertebral osteophyte (171,179)

• Papillary muscle (180) Coronary artery laceration (152)

Aortic intimal laceration/rupture (ascending/descending thoracic aorta-associated atherosclerosis [152,156,164,168,181]) Aortic dissection (associated atherosclerosis [182])

Venous laceration (e.g., inferior vena cava, splenic vein, renal vein, internal mammary vein

[155,159,164,169,183]) Respiratory system Pleural laceration (152)

Pulmonary contusion/laceration (157,160,164,183)

Pulmonary barotrauma (pneumothorax, pneumopericardium, pneumoperitoneum, pneumomediastinum, pulmonary interstitial and subcutaneous emphysema [151,155,164,168,169,173,174,184]) Tracheal laceration/hemorrhage (157,184) Intra-abdominal organs Rupture of esophagus, stomach, colon (151,158,167,179,185-189) Laceration of esophagus, stomach (167,184,189,190) Gastric dilatation (155,158)

Hepatic laceration (151,154,155,158,159,164,168,169,191)

• Hepatic artery laceration (192) Hepatic subcapsular hematoma (155,164) Splenic laceration (154,155,159,164,168,169) Pancreatic hemorrhage; pancreatitis (159,193-195) Omental hemorrhage (155)

Table 1 (Continued)

Retroperitoneal space

Hemorrhage (155,159,164,184,194) Adrenal hemorrhage (169) Bone marrow and fat embolism (see Subheadings 12.1. and 12.2.) Rhabdomyolysis—renal failure (see Heading 13; ref. 196) Retinal hemorrhage (children)—see Subheading 6.2 and ref. 197)

Fig. 30. Examination of sternum removed at autopsy revealed midline vertical fracture resulting from cardiopulmonary resuscitation.

and about three-fourths had bilateral involvement (155). Autopsy studies of CPR-caused chest wall fractures show a variable frequency. One study showed one to four rib fractures in 8.4% of adult cases and more than five fractures in 2.6% (164). Another older study found 2 to 8 fractures in 31% of cases, and more than 8 in 3.8% (153). Weakened bone structure from osteoporosis, excessive force, and misdirected application of chest compression increase the possibility of chest wall fractures and visceral trauma (132,134,155-157,160,169,198). Typically, fractures involve the anterolateral third to seventh ribs and mid-sternum (132). "High" hand placement results in upper rib (first, second) and sternal fractures (155). "Low" compression results in lower rib (below the sixth rib) and sternal fractures, and possible intra-abdominal injury (155,159). Hemorrhage at fracture sites indicates that cardiac output was achieved during chest compressions.

Rib fractures in children are unusual and considered suspicious of child abuse; however, they have been observed arising from CPR (134,159,169). Retinal hemorrhages in children after CPR are associated with prior severe trauma (197).

Tearing of a viscus or vessel can be the result of penetration by a fracture fragment (160). Increased hydrostatic pressure also contributes. Any serious injuries that arise from resuscitation must be interpreted in the context of an agonal event (152,155). If the person is revived, then resuscitation-related trauma can contribute to morbidity and mortality. More than one injury can occur. In one study, 33% of individuals with CPR-related thoracic trauma had abdominal complications, 23% upper airway trauma, and about 15% pulmonary or cardiovascular sequelae (155). Life-threatening complications were seen in fewer than 1% of patients.

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