# Can you break someone's ribs with CPR?



## paramedichopeful (Jul 8, 2009)

Ok, I hate to admit it but I watched one of those medical shows on TV tonight. In it there was a case where somebody died and was autopsied only to find that they had 2 broken ribs. Weird part about it? THERE WAS NO HEMORRHAGING!! In my Aid/CPR/AED class the rule of thumb was that if you have a broken rib, there is going to be hemorrhaging of some sort. Anyway, back to the story, the coroner ruled that the Paramedics broke the ribs when they gave the guy CPR! Is this even possible? I mean, I was always taught to get as good a compression as you can, but come on: breaking ribs? You gotta know where to stop.


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## DrankTheKoolaid (Jul 8, 2009)

*re*

fact is if you dont break at least part of the sternum away from the ribs then your probably not performing effective CPR.  It all really depends on the persons body though


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## Afflixion (Jul 8, 2009)

Fracturing ribs is quite normal during CPR. Especially on patients with osteoporosis. When I was going through school the cadre joked that "if you don't break ribs your doing it wrong!" The fact of the matter is pressing directly on the sternum repeatedly and pressing deep enough to get good perfusion ribs may be fractured.


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## TransportJockey (Jul 8, 2009)

Afflixion said:


> Fracturing ribs is quite normal during CPR. Especially on patients with osteoporosis. When I was going through school the cadre joked that "if you don't break ribs your doing it wrong!" The fact of the matter is pressing directly on the sternum repeatedly and pressing deep enough to get good perfusion ribs may be fractured.



I've heard a lot of older medics state that. And two of the times I've performed CPR, I've felt cracking and popping. The others I've been relieving people on compressions, so they probably did the breaking


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## Shishkabob (Jul 8, 2009)

Part of the cracking is ribs, but part of it is also the cartilage.


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## mikie (Jul 8, 2009)

*...from my first arrest*



jtpaintball70 said:


> I've heard a lot of older medics state that. And two of the times I've performed CPR, *I've felt cracking and popping*. The others I've been relieving people on compressions, so they probably did the breaking



That's a feeling I'll never forget!


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## medichopeful (Jul 9, 2009)

I remember from CPR class (which I took awhile ago) that you can also break the xiphoid process, which can puncture a lung if you do the CPR incorrectly (in other words, doing it too close to the stomach).


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## DrankTheKoolaid (Jul 9, 2009)

*re*

the reason we do compressions away from the xiphoid process, is the xiphoid process is an anchor point for the diaphragm.  You break that and away goes your interthoracic pressure


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## medichopeful (Jul 9, 2009)

Corky said:


> the reason we do compressions away from the xiphoid process, is the xiphoid process is an anchor point for the diaphragm.  You break that and away goes your interthoracic pressure



Alright, from someone out of the medical field, here is a dumb question:

Couldn't you also puncture a lung?  (Unless that is what you said in more fancy terms ^_^)


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## DrankTheKoolaid (Jul 9, 2009)

*re*

You mean with compression or with the broken off xiphoid process?  Compression sure it can and probably does happen, xiphoid process same i guess if someone was over zealous enough to make it happen


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## medichopeful (Jul 9, 2009)

Corky said:


> You mean with compression or with the broken off xiphoid process?  Compression sure it can and probably does happen, xiphoid process same i guess if someone was over zealous enough to make it happen



Yeah, I remember (at least I think I remember correctly) that if you do CPR too low (over the xiphoid process), you can break it off and it could puncture a lung.  I was just wondering if this was correct.


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## 46Young (Jul 9, 2009)

medichopeful said:


> Alright, from someone out of the medical field, here is a dumb question:
> 
> Couldn't you also puncture a lung?  (Unless that is what you said in more fancy terms ^_^)



That hapened when I was in medic school on a ride along. The medics had me do a needle decompression, then later another one on the other side. When we bagged, you would hear it all the way down into the abdomen. It was sick.


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## paramedichopeful (Jul 9, 2009)

the first time I did CPR I did hear a slight crack but I didn't think it was from the pt. Well at least now I know I'm getting good compressions


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## Ridryder911 (Jul 9, 2009)

46Young said:


> That hapened when I was in medic school on a ride along. The medics had me do a needle decompression, then later another one on the other side. When we bagged, you would hear it all the way down into the abdomen. It was sick.



I hop this was on a tauma patient, if not; then you had more problems than I would care to make public. The evidence of bi-lateral tension pnuemothorax in non-traumatic patients is almost never heard of. Myself and some students took care of a patient that Paramedics had performed bi-lateral decompression on a medical call. We researched the incidence and was rarely documented unless the patient had underlying disease process. Enough concern the Paramedic was disciplined and licensed reviewed. 

Also if you heard air into the abdomen area, you either did not have the airway opened properly that allow air into the stomach or an esophageal intubation occurred. The other cause would be diaphramatic puncture/tear, again if it was not a trauma patient I would look at some gross negligent concerns. 

Majority of the time it is NOT the ribs that break. Remember anatomy, cartilage is what attaches the sterum to the ribs and the bony portion does not begin to almost pre midclavicular. 

R/r 911


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## mycrofft (Jul 9, 2009)

*CPR is another example of zealous warnings gaining their own life.*

The xyphoid process extends below the diaphragm, more likely to puncture the liver if anything. Ther are rare people born with no detectable xyphoid who are doing just fine, thanks, not to mention people with xyphoids which point stright back into their torsos.
If you are low enough to "snap the xyphoid", then you aren't pumping air. Also, if the xyphoid were to "snap off", it would no longer be propelled forcefully down, would it?

CPR is a patient's last ditch chance at survival. A case can be made that the often cited upswing in MI survival after the inception of CPR training during the Sixties was due to the fact that it raised the consciousness of people to recognize a "code", start rescue breathing, and call the newly adopted "911" to activate the then-newly upgrading emergency response forces, and only marginally to the actual CPR touted widely as the cause for this "miracle".
(How many bystander-initiated CPR's cited as "successes" were really unnecessary, or actually owed their success to oxygenating a deficient cardiac state until rescue arrived versus actually acting as curbside heart-lung machines?).


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## medichopeful (Jul 9, 2009)

mycrofft said:


> The xyphoid process extends below the diaphragm, more likely to puncture the liver if anything. Ther are rare people born with no detectable xyphoid who are doing just fine, thanks, not to mention people with xyphoids which point stright back into their torsos.
> If you are low enough to "snap the xyphoid", then you aren't pumping air. Also, if the xyphoid were to "snap off", it would no longer be propelled forcefully down, would it?



Maybe it was the liver that they said it would puncture.  I know they said something could be injured.  But this was a few years ago, so I just might be remembering it wrong.

Yeah, I remember them saying that CPR over the xiphoid would do more harm than good.


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## DV_EMT (Jul 9, 2009)

I was taught that  most of the time, the cracking and popping that you hear upon doing compressions is the cartilage of the sternum. That being said, when my dad was doing CPR training when I was just a baby, he broke the CPR dummy.... so I suppose its possible.


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## Ridryder911 (Jul 9, 2009)

This should be old stuff for those that had any CPR training, as it has always been a test question(s) for AHA. Complications of CPR includes and Complications of possible fracture ribs/cartilage include: 

If one has improper hand placement or if the patients body cannot withstand the pressure the cartilage will break; simple as that. If one does not have proper hand placement and is to low there is a possibility of breaking off the xiphoid process from body of the sternum. Complications of this is lacerated liver/stomach. I never have seen total separation or the body separated from the manubrium of the sternum. 

Breaking of the cartilage(s) is a very common thing, but one should always check and verify hand placement and proper deepness and continue on. As the old saying they can live over cartilage separation but cannot live over the dead heart. 

R/r 911


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## ResTech (Jul 9, 2009)

> Weird part about it? THERE WAS NO HEMORRHAGING!! In my Aid/CPR/AED class the rule of thumb was that if you have a broken rib, there is going to be hemorrhaging of some sort.



The majority of times, rib fractures are from blunt trauma (ie fall, MVC, assault) and are not going to produce external hemorrhage. There is a good likely hood of internal hemorrhage... maybe the internal hemorrhage is what you are referring to.


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## 46Young (Jul 10, 2009)

Ridryder911 said:


> I hop this was on a tauma patient, if not; then you had more problems than I would care to make public. The evidence of bi-lateral tension pnuemothorax in non-traumatic patients is almost never heard of. Myself and some students took care of a patient that Paramedics had performed bi-lateral decompression on a medical call. We researched the incidence and was rarely documented unless the patient had underlying disease process. Enough concern the Paramedic was disciplined and licensed reviewed.
> 
> Also if you heard air into the abdomen area, you either did not have the airway opened properly that allow air into the stomach or an esophageal intubation occurred. The other cause would be diaphramatic puncture/tear, again if it was not a trauma patient I would look at some gross negligent concerns.
> 
> ...



It wasn't my tube, it was one of my first ride alongs, and I was just doing as instructed by my preceptors. They had me get a line, push epi/atropine, and do the decompressions only. This little old lady who just dropped dead in her bedroom was butchered beyond belief. Probably gross negligence like you said. I ended working with one of them per diem, and made sure I always teched when we were paired up. 

I wanted to crawl under the floorboards when the pt's daughter looked in to see what we were doing.


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## usafmedic45 (Jul 11, 2009)

> the reason we do compressions away from the xiphoid process, is the xiphoid process is an anchor point for the diaphragm. You break that and away goes your interthoracic pressure



Care to provide some evidence to support that claim?  I've never heard that and I used to work with a prof who did cardiac arrest research (not that the idea does not make sense from a mechanics of CPR standpoint, just that the chances are minimal of it actually happening.  

The PRIMARY reason you don't compress over the xiphoid is the risk of liver laceration.  Even with tremendous compressive trauma to the chest (such as plane crashes in the case of my study), it is very uncommon to see the rupture of a diaphragm solely at the anterior aspect.  More often it involves the dome (center) of the diaphragm or in less common cases where there is avulsion of the diaphragm from the chest wall it is normally seen at the posterior aspect.  This is possibly due to the differences in angle of connection between the anterior and posterior insertions of the diaphragm.  Also, where the xiphoid is at, there are several reinforcing structures that lessen the chances of an iatrogenic perforation.  

Here's an example of an injury to the diaphragm that demonstrates damage to the dome of the left leaflet of the diaphram:







In roughly five hundred cases of blunt chest trauma due to plane crashes- including cases where the body is fragmented- so far I have seen _two_ cases of isolated injury to the medial diaphragm.  Both of these cases involved avulsion of the sternum from the ribs and the heart was macerated (shredded).   I am not saying that it cannot happen, but just that it is a highly unlikely occurence and not the primary concern for xiphoid process motion during chest compressions. 



> Couldn't you also puncture a lung?


Yes, although most pulmonary complications of CPR are associated with the ventilation component which is one reason a couple of in-hospital research programs have reported (not sure if it has been published yet, speaking from conversations at the cardiac conference in Stavanger, Norway a couple of years back) a decrease in pneumothoraces with the decreased emphasis on ventilation during resuscitation. 



> Anyway, back to the story, the coroner ruled that the Paramedics broke the ribs when they gave the guy CPR!



It is not at all a rare event and sternal fractures are also seen as a not uncommon as a complication of CPR.  In fact, in my injury research we use autopsy data and there is a variable in the database to indicate whether CPR was performed to be able to see if there was any effect (since I am also are looking at correlations between certain superficial injuries and internal injuries as a side project and do not want resuscitation trauma to skew the data). 



> you can break it off and it could puncture a lung


That is less likely to do that than a rib fracture which is less likely than a pneumothorax due to excessive or overzealous ventilation.  As one of my pathologist friends likes to say, "The most common cause of pneumothorax in resuscitation is eager EMTs named Bubba". 



> The majority of times, rib fractures are from blunt trauma (ie fall, MVC, assault) and are not going to produce external hemorrhage. There is a good likely hood of internal hemorrhage... maybe the internal hemorrhage is what you are referring to.



They are talking about hemorrhage around the fractured ends of the ribs.  It looks like extreme bruising on the chest wall.   The only way you get significant "internal" hemorrhage in the sense of a hemothorax would be if you did serious damage to multiple intercostal vessels or took out one of the internal mammary arteries. 

Here is an example of what rib fractures look like at autopsy (looking from the interior surface of the chest, the xiphoid process can be seen in the middle at the bottom of the sternum):




The black/purple discoloration to the left of the upper arrows is the hemorrhage which is *usually* absent in post- or perimortem fractures.


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