Cardiopulmonary resuscitation (CPR) complications encountered in forensic autopsy cases.

BACKGROUND: Cardiopulmonary resuscitation (CPR) provides a significant increase in survival rate, even if performed by bystanders. However, bystanders may refrain from performing CPR for fear of eventual malpractice litigation. Currently lack Guidelines specifying whether a particular CPR-related complication is in all likelihood unavoidable or not. To fulfill this gap a great number of studies is required to be published in the most relevant leading academic literature. This paper aims at making a contribution to addressing such a challenge. METHODS: A retrospective observational study based on forensic autopsy material aiming at recording injuries resulting from the application of CPR. The severity of injuries was forensically evaluated. RESULTS: Out of 88 cases autopsied, only 26.7% had rib fractures (only 20% of which were located in the 6 lower ribs), 17.4% had sternal fractures (85.7% of which were detected in the body of the sternum and 14.3% in the manubrium). The ratio of sternal fractures to rib fractures is similar to the ratio cited in other studies reported in the literature (2:3, approximately). The number of fractures was 7.86 (4.11 on the right side and 4.75 on the left side). 16% of the cases were found to be mild, 48% were moderate, and 35% of the cases were severe. When a physician was present, a (not statistically significant) trend towards more severe complications was found. CONCLUSION: The findings are in accordance with other similar studies reported in the literature referring to the classic external CPR. This study offers a proposal aiming at making a contribution to develop Guidelines specifying whether a particular CPR-related complication is in all likelihood unavoidable or not.

Current treatment and outcomes of traumatic sternal fractures-a systematic review.

PURPOSE: Traumatic sternal fractures are rare injuries. The most common mechanism of injury is direct blunt trauma to the anterior chest wall. Most (> 95%) sternal fractures are treated conservatively. Surgical fixation is indicated in case of fracture instability, displacement or non-union. However, limited research has been performed on treatment outcomes. This study aimed to provide an overview of the current treatment practices and outcomes of traumatic sternal fractures and dislocations. METHODS: A systematic review of literature published from 1990 to June 2017 was conducted. Original studies on traumatic sternal fractures, reporting sternal healing or sternal stability were included. Studies on non-traumatic sternal fractures or not reporting sternal healing outcomes, as well as case reports (n = 1), were excluded. RESULTS: Sixteen studies were included in this review, which reported treatment outcomes for 191 patients. Most included studies were case series of poor quality. All patients showed sternal healing and 98% reported pain relief. Treatment complications occurred in 2% of patients. CONCLUSIONS: Treatment of traumatic sternal fractures and dislocations is an underexposed topic. Although all patients in this review displayed sternal healing, results should be interpreted with caution since most included studies were of poor quality.

Minor Trauma, Major Discovery: The Ultrasound Identification of a Sternal Fracture Missed by Computed Tomography in an Older Patient Presenting With Acute Chest Pain.

This case report presents the diagnostic difficulties encountered by a 96-year-old woman with osteoporosis who experienced acute chest pain following minor trauma, eventually diagnosed with a sternal fracture. It highlights the nuanced presentation and diagnostic challenges associated with sternal fractures in older patients. Despite the prevalent use of chest radiography and computed tomography in acute trauma assessments, this case emphasizes their limitations, as both modalities initially failed to detect the sternal fracture. The successful identification of the fracture using ultrasound (US) underscores the utility of this modality in detecting subtle yet clinically significant injuries. This report advocates for a high index of suspicion for sternal fractures in older patients presenting with chest pain after minor trauma and suggests that US is a valuable, less invasive diagnostic tool. By illuminating the potential for minor trauma to cause major injury and the critical role of US in diagnosis, this case provides valuable insights into the management of sternal fractures in the geriatric population, urging clinicians to consider atypical presentations in diagnostic evaluations.

Factors Associated with Cardiac/Pericardial Injury among Blunt Injury Patients: A Nationwide Study in Japan.

The lack of established diagnostic criteria makes diagnosing blunt cardiac injury difficult. We investigated the factors associated with blunt cardiac injury using the Japan Trauma Data Bank (JTDB) in a multicenter observational study of blunt trauma patients conducted between 2004 and 2018. The primary outcome was the incidence of blunt cardiac/pericardial injury. Multivariable logistic regression analysis was used to identify factors independently associated with blunt cardiac injuries. Of the 228,513 patients, 1002 (0.4%) had blunt cardiac injury. Hypotension on hospital arrival (adjusted odds ratio (AOR) 4.536, 95% confidence interval (CI) 3.802-5.412), thoracic aortic injury (AOR 2.722, 95% CI 1.947-3.806), pulmonary contusion (AOR 2.532, 95% CI 2.204-2.909), rib fracture (AOR 1.362, 95% CI 1.147-1.618), sternal fracture (AOR 3.319, 95% CI 2.696-4.085). and hemothorax/pneumothorax (AOR 1.689, 95% CI 1.423-2.006)) was positively associated with blunt cardiac injury. Regarding the types of patients, car drivers had a higher rate of blunt cardiac injury compared to other types of patients. Driving a car, hypotension on hospital arrival, thoracic aortic injury, pulmonary contusion, rib fracture, sternal fracture, and hemothorax/pneumothorax were positively associated with blunt cardiac injury.

POCUS Diagnosis of Sternal Fractures in Children without Direct Trauma-A Case Series.

Sternal fractures in children are rare and tend to be caused by high-energy injury. However, sternal fractures may also be caused by minor and indirect trauma and might therefore not be as rare as previously stated. Ultrasound examination is the method of choice for the diagnosis of sternal fractures. We present three cases of sternal fractures not caused by direct trauma that were presented to our A&E department within a period of only 62 days. All of them exhibited localized tenderness, but none had an associated injury. Children presenting to the A&E unit with musculoskeletal thorax pain should be screened by POCUS for sternal fractures, even if they do not report any direct trauma to the thorax.

Blunt Cardiac Injury in Patients With Sternal Fractures.

Background Blunt cardiac injury (BCI) is a possible consequence of sternal fractures (SF). There is a scarcity of studies addressing BCI in patients with different types of SF and with pre-existing cardiac conditions. The goal of this study was to delineate diagnostic patterns of BCI in different cohorts of SF patients. Methods This retrospective cohort study included 380 blunt trauma patients admitted to two level 1 trauma centers between January 2015 and March 2020 with radiologically confirmed SF. Electrocardiography, cardiac enzymes and echocardiography were evaluated for BCI diagnosis. Analyzed variables included: age, comorbidities, injury severity score, Glasgow coma score, type of SF (isolated, combined, displaced), incidence of traumatic brain injury, co-injuries, retrosternal hematoma, intensive care unit admissions, hospital lengths of stay, and mortality. Results In 380 SF patients there were 250 (66%) females and 130 (34%) males and the mean age was 63 years old. Electrocardiography was done in all patients, cardiac enzymes in 234 (62%) and echocardiography in 181 (48%). BCI was diagnosed in 19 (5%) of patients, all having combined SF. BCI patients had higher injury severity score (mean 18.4) and 14 (74%) had pulmonary co-injuries. Multivariable analysis confirmed pulmonary co-injuries as a statistically significant predictor of BCI (p<0.001). BCI patients compared to no BCI patients had all three tests (electrocardiography, cardiac enzymes and echocardiography) performed statistically more often (90% vs 36%, p<0.001). SF patients with pre-injury cardiac comorbidities had similar incidence of BCI as without cardiac comorbidities (5% vs 6%, p=0.6). In SF patients with traumatic brain injury, cardiac enzymes (troponin, creatine kinase) were elevated significantly more often compared to patients without traumatic brain injury (58% vs 38%, p=0.02). SF displacement or retrosternal hematoma presence were not associated with BCI. Mortality in SF patients with BCI versus without was not statistically different (16 vs 9%, p=0.4). Conclusions Blunt cardiac injury is rare in patients with SF. Higher degree of BCI suspicion must be applied in combined SF patients, especially those with pulmonary co-injuries. Cardiac comorbidities did not affect the rate of BCI. Echocardiography for BCI diagnosis is essential in SF patients with traumatic brain injury, as cardiac enzymes may be less informative, however is less important in isolated SF patients. Performing all three diagnostic tests in combined SF patients improves the accuracy of BCI diagnosis.

Traumatic Sternal Fractures can be Safely Treated Conservatively - A 13-Year Retrospective Cohort Study.

Background: Traumatic sternal fractures are rare injuries with little evidence supporting the best treatment strategy. This study assessed treatment outcomes from our level-I trauma centre. Methods: A retrospective cohort study was conducted, including all sternal fracture patients admitted to our level-I trauma centre between 2007 and 2019. Patients with sternal fractures due to cardiopulmonary resuscitation, patients <16 years, patients who died during initial hospital stay, and patients lost to follow-up were excluded from analysis. Results: In 13 years, 355 patients with traumatic sternal fractures were admitted, corresponding to 2% of all trauma patients. 262 patients were included in analysis. Mean age was 52 years and 71% of patients were male. Mean ISS was 19 (range 4-66). The majority of sternal fractures was located in the sternal body. Six patients (2%) underwent primary sternal fixation. Treatment failure occurred in three patients (1%) and was significantly higher in the surgical treatment group (p=0.001). There was no difference in treatment failure between patients with and without concomitant spinal fractures. Conclusions: Conservative treatment is safe and effective for traumatic sternal fractures. Surgical treatment should be reserved for rare cases, such as imminent respiratory failure or debilitating symptomatic non-union.

Anatomical variations of the sternal angle and anomalies of adult human sterna from the Galloway osteological collection at Makerere University Anatomy Department.

BACKGROUND: Anatomical variations of the sternal angle and anomalies of the sternum are unique happenings of major clinical significance. It is known that misplaced sternal angles may lead to inaccurate counting of ribs and create challenges with intercostal nerve blocks and needle thoracostomies. Sternal foramina may pose a great hazard during sternal puncture, due to inadvertent cardiac or great vessel injury. These sternal variations and anomalies are rarely reported among Africans. The aim of this study was to determine the anatomical variations of the sternal angle and anomalies of the sternum among adult dry human sterna at the Galloway osteological collection, Makerere University, Uganda. MATERIALS AND METHODS: This was a descriptive cross sectional study in which quantitative and qualitative data were collected. The study examined 85 adult human sterna at the Department of Anatomy, Makerere University. Univariate and bivariate analyses were done using SPSS 21.0 for Windows. RESULTS: Over 40% (36/85) of the specimens had variations in size, location and fusion of the sternal angle. There was no significant difference in the mean size of the sternal angle in males at 163.4 ± 6.7o compared with 165.0 ± 6.4o in females (p = 0.481). Of the 85 specimens examined, only 21 (24.7%) had a xiphoid process. The most frequent sternal anomalies were bifid xiphoid process 42.9% (9/21) and sternal foramen 12.9% (11/85). CONCLUSIONS: Sternal variations and anomalies are prevalent in the Galloway osteological collection and there is need for increased awareness of these findings as they may determine the accuracy of clinical and other procedures in the thoracic region.

Treatment of middle-super thoracic fractures associated with the sternum fracture.

To analyze the characteristics and treatment of middle-super thoracic fractures associated with the sternum fracture, twenty six patients with middle-super thoracic fractures associated with the sternum fracture were retrospectively reviewed. The intimate information of patients including age, gender, cause of injury, site of the sternal fracture, level and type of thoracic vertebral fracture, spinal cord injury and associated injuries were included in the analysis. There were 12 compressed fractures, 11 fracture-dislocations, two burst fracture and one burst-dislocation in this study. Six patients had a complete lesion of the spinal cord, nine sustained a neurologically incomplete injury and 11 were neurologically intact. Nine patients were treated non-operatively and 17 were underwent surgery. All patients were followed up for 8~99 months. Our results showed that road traffic accidents (RTA) and fall were the dominated in the causes. All six patients with a complete paralytic lesion were not recovered with any significant function. Four out of eleven neurologically intact patients had local pain although ten of them remained normal function and one patient turn up tardive paralysis. One of nine patients with incomplete paraplegia returned to normal and four recovered with some function. These study suggested that the sternum is one of the important parts in constructing thoracic cage and plays an important role in maintain the stabilization of the thoracic vertebra. Because of the unique anatomy and biomechanics of the thoracic cage, the classification commonly applied to thoracic vertebra fractures is not suitable for middle-super thoracic fractures associated with the sternum fracture. Middle-super thoracic fractures associated with the sternum fracture was marked by violent force, severe fractures of spine, severe injuries of spinal cord and high incidence of associated injuries. These cases confirm the existence and clinical relevance of the fourth column of the thoracic spine and its role for spinal stability in the patient with middle-super thoracic fracture.

Management of isolated sternal fractures using a practical algorithm.

BACKGROUND: The implementation of seat belt legislation has led to an increase in the frequency of isolated sternal fractures (ISFs) in motor vehicle crash. AIMS: We reviewed retrospectively the medical records of our tertiary center in order to find out the frequency of ISFs, review our experience in their management, and define the mean length of hospitalization. MATERIALS AND METHODS: From January 2008 to April 2012, 64 patients were admitted to the accident and emergency department of the University Hospital of Larissa, Greece, suffering from sternal fractures (SFs). Of these 64 patients, 45 had sustained ISF, while the remaining 19 had SF and additional injuries (intrathoracic and extrathoracic). The files of these 45 patients were further investigating as concerning the mechanism of injury, hospitalization days, morbidity, and mortality. RESULTS: All the patients had been involved in motor vehicle crashes and most of them were wearing seat belts during the accident (91%). The hospital length of stay (LOS) was 1.85 ± 1.67. All the patients had upon admission chest radiograms, serial electrocardiographs (ECGs), echocardiograms, and cardiac enzyme levels. Two patients had abnormal ECG and abnormal cardiac enzymes which contributed in prolonged hospitalization. However, there was no incidence of cardiac complications or deaths. CONCLUSIONS: ISFs, with normal electrocardiogram, cardiac enzymes, and chest X-ray in the absence of complications, require no further investigation.