# question about sternum/ribcage injury during CPR



## rechargeable (Aug 31, 2007)

I was only recently certified and still have no field experience. One always hears that chest compressions can and often do cause great chest injury. I've even heard that the sternum can become completely detached from the rest of the rib cage. This sounds pretty reasonable when I think about how frail someone like my grandmother is. 

So these questions are for those of you who have had the opportunity to perform many codes. What amount of chest damage have you personally seen happen to patients? Do healthy adult chests usually withstand the punishment without significantly breaking? Do elderly or pediatric chests usually break? Can a broken chest even recoil properly? Do you feel it when the chest becomes damaged, or does it happen without much evidence? Does damaging the chest mean that you're compressing too forcefully, or is it understood to be unavoidable?


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## Ridryder911 (Aug 31, 2007)

First, one needs to understand the anatomy of the thoracic rib cage. In reality, the ribs are attached per the way of cartiligous type material to the sternum. This allows for compressions to be performed and the "recoil" to occur (bones do not bend). When one discusses fractured ribs, this is usually what one is discussing is the broken cartilage, not a bone or real rib. 

Yes, a rib can actually fracture, due to incorrect hand position, and of course undue or great amount of compression, as well as pathogenic problems of the patient such as in the elderly, or osteoporosis, density, etc. 

To answer your question, one usually feels the cartilage break, as well as hear the "popping" sound. There might be a decreased amount in recoil action, but over all one can perform adequate compressions, and one can determine by checking for pulses with compressions. There is not much differential when this occurs. 

One needs to remember, that fractured ribs, detached sternum, etc. related injuries from CPR is to be expected, and hopefully reduced by correct hand position and performance, but; one can live with those type of injuries. One cannot live without coronary and cerebral circulation (no pulse). 

I have taken care of numerous patients post CPR; yes, they may complain of soreness, at least they are able to. 

R/r 911


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## VentMedic (Aug 31, 2007)

I also participate in several codes and care of post code patients each week. Of those that make it to ICU, I view their CXRs to check for problems of concern for ventilation. Rarely do I see gross fractures of ribs. On some of these patients the sounds of cartilage popping during compressions were quite noticable. I also know from working in a monitored area, it takes a great deal of compression pressure to acheive effective hemodynamics during CPR.  If you have the opportunity to take a chest trauma class later in your studies, you will learn about types of forces, angles and pressure that cause damage to the integrity of the chest and its contents. If you also get the opportunity to view an open chest cardiac surgery, you will see that the chest can be put through a lot even in the elderly and still come out okay.  

Infants and pediatrics have the best chest recoil. 

Good hand position and  proper postion of your body over the patient will give you and the patient the best advantage. I have seen more serious displaced rib fractures in hospital CPR because the performers were not able to get into proper body position initially. This can be due to the different types of air beds, rails, trapezes, and width of the bed.  Many of the special needs beds are difficult to get on with the patient to perform properly angled CPR. Bariatric beds can be particularly difficult. The patient may also be attached to many different pieces of equipment to disallow prompt movement into good position.  Sometimes you almost hope for the code to be on the floor or have an ambulance stretcher nearby even in the hospital setting.  

This is an article I saw recently in Cardiovascular Engineering. The actual article is not available yet online with out a subscription but here is a reference to that article and its contents:

http://www.sciencedaily.com/releases/2007/05/070531113247.htm

*CPR: More Rib Fractures, But Better Survival Rates*

Science Daily — New findings show that the majority of people untrained in how to perform cardiopulmonary resuscitation, and even many trained emergency personnel, do not push with enough force to properly administer CPR.

The research tested 104 adults untrained in CPR and 83 firefighters, trained in the procedure. The findings, to be published in the June issue of the journal Cardiovascular Engineering¹, showed that most of the untrained people simply do not apply enough force, said Leslie Geddes of Purdue University, one of the authors of the study.

The success rate for CPR ranges from 5 percent to 10 percent, depending on how quickly it is administered after a person's heart stops. "This is important because every minute lost in applying CPR results in a 10 percent decrease in successful resuscitation," Geddes said. "Time is the enemy. After 10 minutes, very few are resuscitated. The American Heart Association recommends pushing with enough force to compress the chest 1.5 to 2 inches, which requires 100 to 125 pounds of force.”

The research represents the first time such measurements have been recorded to quantify just how hard people push in a simulated CPR test. The findings showed that 60 percent of the CPR-trained rescue personnel pushed with more than 125 pounds, whereas more than 60 percent of those not trained in CPR failed to push with more than 125 pounds of force.


http://www.sciencedaily.com/releases/2007/05/070531113247.htm


> Pushing with more than 125 pounds increases the potential for rib fractures. Nevertheless, the chances of survival increase enormously.  New guidelines from the American Hearth Association recommend that rescuers performing CPR should "push harder and faster," Geddes said. "As a result of this recommendation, it's likely that the resuscitation rate will increase, but it's equally likely that the fracture rate will increase."


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## BossyCow (Aug 31, 2007)

This is a common question I get from layperson CPR students.  I think the idea of it is a lot more disconcerting than the actuality.  Generally when running a code, there are more things on your mind than 'Gee, I sure hope I'm not hurting them'.  I think best case scenario, having a pt. who is alive to complain about being sore about the ribs is great.  

I think the worst for me are trauma codes.  Very often the trauma to the thoracic area is so severe that it makes chest compressions ineffective and bagging sometimes durn near impossible.  I've yet to see anyone come out alive from one of those.  

I also remember a call, where the volly on BVM must have gotten a bit 'enthusiastic' on a CHF pt.  This was one of our frequent fliers with multiple health problems but a husband who refused to accept anything less than full code status.  Initially the bagging was difficult due to the fluid in the lungs but the new EMT doing the bagging went.. "Hey, it's much easier now" and we started seeing her pink up.  Later in the ER we found she had a pneumothorax which the doc said might have been caused by the bagging.


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## MedikErik (Aug 31, 2007)

I once had a patient with apparently very brittle bones... I wasn't going that hard and I was hearing 1,2,3,crack,5,6,7,pop,8,9,10,11,12,crunch,14,15... patient's chest was a little bruised when we got there... nurse asked if we'd used the thumper (this was before we had the AutoPulse), and I just had this sheepish look. 

Don't forget, if you don't do it hard enough you won't circulate enough blood (if you circulate any at all). I'd rather err on the side of a little too hard than a little too soft. I'd rather be in pain from broken ribs than in no pain because I'm dead, but that's just me.


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## rechargeable (Aug 31, 2007)

Thanks guys, that's all excellent information. Just wanted to know what sensations I should be prepared to accept as normal.


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## Jon (Aug 31, 2007)

I've done CPR on a "floating" sternum before... it just seems VERY wierd, becasue you loose a lot of recoil

Just remember:
If you are doing CPR, there are only 2 outcomes... in one, they are dead, and can't complain. In the other, YOU saved them with your CPR, so they better not complain.


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## KEVD18 (Aug 31, 2007)

sick people dont :censored::censored::censored::censored::censored:. if they live through it to bitcj, its because of you.


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## Aileana (Aug 31, 2007)

haha yep, if the pt. _can_ complain, they shouldn't be, since they're alive because of your actions. I've heard that it sounds kinda like crushing a bag of chips, but I am yet to perform CPR on an actual patient, so I can't verify if that is true.


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## rechargeable (Sep 1, 2007)

Very true.


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## DisasterMedTech (Oct 18, 2007)

2 Codes so far and the bag of chips analogy isnt far off. You'll be pumping away and then get the crunch and compressions become easier. Keep gettin' 'er done. Remember what the AHA says: Chances of surviving pulseless and breathless with no cardio-pulmonary assistance: 0%. Chances with: between 7-10%. Chances go up when you add defib to the mix and up again with cardioverting drugs.

Remember: once you start, you dont stop unless someone is performing another intervention or calls TOD. Until then, you go until you drop or are relieved by another responder. :excl:


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## NJN (Oct 22, 2007)

I've worked 1 code so far where i performed CPR and i didn't hear anything abnormal. Then again, my partner who was driving was siren happy and my other partner who was driving the medic's truck is also siren happy, + i was trying to listen to instructions from both medics at the same time.


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## VentMedic (Oct 22, 2007)

NJNewbie196 said:


> I've worked 1 code so far where i performed CPR and i didn't hear anything abnormal. Then again, my partner who was driving was *siren happy *and my other partner who was driving the medic's truck is also *siren happy*, + i was trying to listen to instructions from both medics at the same time.



So you have two vehicles both running lights and sirens, one of which is not transporting a patient?

And I take it you are standing while doing CPR?

And nobody can hear what is being said?

There's some good reading for you on this forum.

Live and learn. Key word is *live*.

Be Safe.


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## reaper (Oct 22, 2007)

Siren or not, you should still be able to hear. Unless you were on the hood?


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## NJN (Oct 22, 2007)

VentMedic said:


> So you have two vehicles both running lights and sirens, one of which is not transporting a patient?
> 
> And I take it you are standing while doing CPR?
> 
> And nobody can hear what is being said?



Well, what i meant is that i couldn't hear any crackeling or popping sounds. I could hear the medics fine. I also guess that i was focused on the task at hand to hear anything other than the medics.and i was kneeling on one knee next to the pt and backed up when we shocked. Another factor may have been is that this pt was quite young for a FDGBAD.


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## reaper (Oct 22, 2007)

You must be very tall? No way I could preform good CPR kneeling next to the stretcher.


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## NJN (Oct 22, 2007)

It was very uncomfortable but i had one knee on the cot and the other supporting me over the pt. I'm not too keen on the details as this was quite a while ago.


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