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Serious Injuries Secondary to Cardiopulmonary Resuscitation: Incidence and Associated Factors

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Serious Injuries Secondary to Cardiopulmonary Resuscitation: Incidence and Associated Factors Emergencias 2019;31:327-334 ORIGINAL ARTICLE Serious injuries secondary to cardiopulmonary resuscitation: incidence and associated factors Youcef Azeli1-3, Eneko Barbería4,5, María Jiménez-Herrera6, Alberto Ameijide7, Christer Axelsson8, Alfredo Bardají3,5,9 Objective. To determine the incidence of serious rib cage damage (SRD) and serious visceral damage (SVD) Authors’ affiliation: 1Emergency Medical System secondary to cardiopulmonary resuscitation (CPR) and to explore associated factors. of Catalonia, L’Hospitalet de Methods. We analyzed data from the prospective registry of cases of sudden death in Tarragona, Spain (the ReCaPTa Llobregat, Barcelona, Spain. 2Emergency Department, Hospital study). Cases were collected from multiple surveillance sources. In this study we included the cases of autopsied Universitari Sant Joan de Reus, nonsurvivors after attempted manual CPR between April 2014 and May 2016. A specific protocol to detect injuries Reus, Tarragona, Spain. 3Institut d’Investigació Sanitaria secondary to CPR was used during the autopsies. Pere Virgili, Tarragona, Spain. Results. We analyzed 109 cases. The mean age at death was 63 years and 32.1% were women. SRD were found in 4Institut de Medicina Legal y Forense de Catalunya, Tarragona, 63.3% and SVD in 14.7%. The group with SRD were significantly older (63 vs 59 years, P=.031) and included higher Spain. percentages of persons with a chest circumference over 101 cm (56.5 vs 30%, P=.016) and a waist circumference 5Universitat Rovira i Virgili, over 100 cm (62.3 vs 37.5%, P=.017). A multivariable analysis confirmed chest circumference over 101 cm as the Tarragona, Spain. 6Department of Nursing, Rovira only risk factor for SRD (odds ratio [OR], 2.45; 95% CI, 1.03–5.84) and female sex as the only risk factor for SVD (OR, i Virgili University, Tarragona, 5.02; 95% CI, 1.18–21.25). Spain. 7Biostatistics Unit, Fundació Lliga Conclusion. Women and any patient with a chest circumference greater than 101 cm are at greater risk for serious per a la Investigació i Prevenció injuries related to CPR. del Càncer, Reus, Tarragona, Spain. Keywords: Cardiopulmonary resuscitation. Rib fractures. Thoracic injuries. 8University of Borås, Borås, Västra Götaland, Sweden. 9Cardiology Department, Joan XXIII University Hospital, Incidencia y variables asociadas a lesiones graves secundarias a reanimación Tarragona, Spain. cardiopulmonar Corresponding author: Youcef Azeli Objetivo. Determinar la incidencia de lesiones torácicas óseas graves (LTOG) y de lesiones viscerales graves (LVG) se- Sistema d’Emergències Mèdiques cundarias a reanimación cardiopulmonar (RCP) y estudiar las variables asociadas a ellas. de Catalunya 112 Reus, Carrer dels Pagesos, 2 Método. Se analizaron los datos del proyecto ReCaPTa, estudio prospectivo de la muerte súbita, con varias fuentes de 43204 Reus, Tarragona, Spain información. Se incluyeron los pacientes no supervivientes a un intento de RCP manual, entre abril de 2014 y mayo E-mail: de 2016, en los que se aplicó un protocolo autópsico específico para el estudio de las lesiones secundarias a la RCP. [email protected] Resultados. Se analizaron 109 sujetos, con una mediana de edad de 63 años y un 32,1% de mujeres. El 63,3% pre- Article information: sentaron LTOG y el 14,7%, LVG. El grupo con LTOG fue de mayor edad (63 vs 59 años, p = 0,031) y se asoció a una Received: 11-5-2019 mayor proporción de pacientes con un perímetro torácico > 101 cm (56,5 vs 30%, p = 0,016) y con un perímetro Accepted: 27-7-2019 Online: 12-9-2019 abdominal > 100 cm (62,3 vs 37,5%, p = 0,017). En un análisis multivariado el perímetro torácico > 101 cm fue el único factor de riesgo para LTOG (OR 2,45; IC 95% 1,03-5,84) y el sexo femenino fue el único factor de riesgo para Editor in charge: LVG (OR 5,02; IC 95% 1,18-21,25). Guillermo Burillo Putze Conclusión. Los pacientes con un perímetro torácico mayor de 101 cm y las mujeres presentan un riesgo superior de lesiones graves debidas a la RCP. Palabras clave: Reanimación cardiopulmonar. Fracturas costales. Lesiones torácicas. Introduction the best possible balance between the benefit of increa- sed CC depth and the risk of causing harm to the pa- The survival rate of out-of-hospital cardiac arrest is tient6. Although maximum survival has been found to low1. The quality of chest compressions (CC), with an be associated with patients receiving CC between 40.3 adequate depth and frequency to allow the sternum and 55.3 mm7, the latest guidelines of the European to return to its position, is key to optimizing cardiac Resuscitation Council (ERC) support the recommenda- output during cardiopulmonary resuscitation (CPR)2. tions of the International Liaison Committee on Chest injuries secondary to CC are common and Resuscitation, which state that a compression depth of may be accompanied by visceral lesions3. The duration approximately 5 cm, but not more than 6 cm, is reaso- of CPR, female sex, age and depth of compression are nable for a medium sized adult8. the main known associated variables4,5. In the last deca- The objective of this study was to determine the in- de, resuscitation guidelines have attempted to establish cidence of serious rib cage damage (SRD) and severe 327 Azeli Y, et al. Emergencias 2019;31:327-334 visceral damage (SVD) in a prospective series of pa- mild ribcage damage (MRD). SVD was considered as tients who did not survive CPR with manual CC, and to any of the following lesions: hemopericardium, epicar- study the factors associated with them. dial contusion, dissection or hematoma of the thoracic aorta, pneumothorax, hemothorax, hepatic laceration, hepatic subcapsular hematoma, spleen injury, pulmo- Method nary hematoma. Any injury that could interfere with the cardiovascular or respiratory system or with ex- Design and stage sanguination of more than 800 ml14 was considered a life-threatening injury14. The Tarragona Clinical Pathological Register (ReCaPTa) is a prospective study of sudden cardiac Statistical analysis death carried out in the Camp de Tarragona Health Region (Catalonia, Spain), which has a population of The continuous variables are described with me- 511,622 inhabitants. This register is based on several dian and interquartile ranges and the categorical ones sources of information: data from all out-of-hospital with number of cases and percentages. The Student’s cardiac arrests attended by the Sistema d’Emergències T or Mann-Whitney’s U and the chi-square were used Mèdiques de Catalunya (SEM), data from autopsies to compare the subgroups according to severity. A performed by the Forensic Pathology Service, data ROC curve (Figures 1 and 2) was performed in order from survivors admitted to hospitals in the area, as to obtain a threshold value of the thoracic and abdo- well as the medical history of patients, through the minal perimeters that would allow predicting SRD primary care (PC) clinical history. The study was with the greatest possible sensitivity and specificity. approved by the ethical committee of the Joan XXIII Based on this value, the thoracic perimeter was cate- University Hospital (CI 65/2014) and its design has gorized as greater or less than 101 cm and the abdo- been previously published9. minal perimeter as greater or less than 100 cm. A bi- Patients treated by SEM who did not survive a ma- nary logistic regression model was constructed to nual CPR attempt between April 2014 and May 2016 assess the effect of various risk factors on SRD and and who died in situ were included in this paper. SVD. The odds ratio (OR) and confidence interval were Excluded were people under 18 years of age, trauma- initially calculated in a univariate analysis and subse- tic deaths, patients treated with a mechanical chest quently variables showing a p < 0.05 and variables compressor and those transferred to the hospital. All such as age and sex were included in a stepwise mul- patients were treated according to SEM protocols, tivariate analysis, regardless of their significance. The who followed the recommendations of the ERC resus- statistical package R and the software SPSS v23 were citation guidelines in force during the study period10. used. Clinical and autopsy variables Data on the SEM support were collected by the 1.0 team that cared for the patient and the variables in- cluded in the Utstein11 register were recorded. A team of PC researchers collected the medical history of the 0.8 patient. In Spain, according to the law, a forensic au- topsy is required for all violent deaths where there is no known cause of death. This includes all natural and unexpected deaths occurring in the out-of-hospital se- 0.6 tting. All subjects were autopsied according to a speci- y fic protocol12 by forensic doctors from the Institute of Forensic and Legal Medicine of Catalonia in Tarragona. Sensitivit 0.4 In addition to anthropometric variables such as wei- ght, height, and thoracic and abdominal perimeter, AUC: 0.591 (IC 95%: 0.454-0.728) the depth of the compression point was measured. For this purpose, the sternum was measured between 0.2 the sternal notch and the base of the xiphoid appen- dix and the compression point was located in the mi- ddle of the lower half of the sternum. The depth of 0.0 this point was measured in relation to the anterior 0.0 0.2 0.4 0.6 0.8 1.0 pectoral plane. Specificity SRD was defined as the presence of a sternal fractu- Figure 1. ROC curve for thoracic perimeter and severe thora- re or more than 6 unilateral rib fractures or more than cic bone injury. The chest circumference value of 101 has a 4 rib fractures if one of them was bilateral13. Patients sensitivity of 0.599 and a specificity of 0.652.
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