Injuries Resulting From Resuscitation Procedures

  • Mario Darok
Part of the Forensic Pathology Reviews book series (FPR, volume 1)


Life-threatening situations deserve fast medical intervention but resuscitation procedures may have considerable effects on the patient’s health condition because (additional) trauma may occur. Additionally, these accidentally caused iatrogenic injuries might by themselves be life-threatening for the patient. The main injurious resuscitation measures include standard cardiopulmonary resuscitation (Std-CPR), active compression-decompression cardiopulmonary resuscitation (ACD-CPR), defibrillation, tracheotomy, coniotomy, tracheal intubation, puncture of veins or pericardium, and decompression of tension pneumothorax or mediastinal emphysema. In particular, injuries as a result of CPR are commonly encountered at autopsy and often not unexpected for the forensic pathologist. The most common cardiac resuscitation-related injuries are fractures of the ribs and sternum in 40-70% of cases. Above all, elderly patients are prone to such injuries. Trauma related to CPR is a rare complication in children. When encountering pediatric rib fractures, the forensic pathologist has to be aware of the differential diagnosis of child abuse since rib fractures, especially when of different ages and affecting multiple adjacent ribs, are a hallmark of nonaccidental injury in children. CPR may lead to severe injuries of internal organs. Main factors influencing frequency and severity of injuries resulting from resuscitation procedures include length of resuscitation time, age of the patient, and degree of qualification of the medical personnel. From the medicolegal point of view, complications and accidental iatrogenic injuries will never be completely avoidable but their possibility has to be taken into consideration throughout further medical treatment. An undetected injury may result in impairment or even death of the patient and the responsible physician runs the risk of being prosecuted. To give a correct opinion, especially in cases of questioned medical malpractice, it is essential that forensic medical experts are familiar with resuscitation-related injuries and are able to distinguish them from the sequels of a natural disease process or trauma that occurred prior to resuscitation procedures.

Key Words

Resuscitation iatrogenic injury medicolegal aspects adverse effect complication expert opinion 


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  1. 1.
    Horatz K, Spindler R (1966) Die Geschichte der Wiederbelebung. Munch Med Wochenschr 108, 985–988.PubMedGoogle Scholar
  2. 2.
    Darok M, Glenewinkel F, Fodor M, Buris L, Leinzinger EP (2000) Medical malpractice in the “90s”—a study of autopsy protocols from three European countries. Book of Proceedings of the 13th World Congress on Medical Law, Helsinki, pp. 195–199.Google Scholar
  3. 3.
    Saternus KS, Fuchs V (1982) Verletzungen der A. carotin communis durch Reanimationsmaßnahmen. Z Rechtsmed 88, 305–311.PubMedGoogle Scholar
  4. 4.
    Jaeger K, Ruschulte H, Osthaus A, Scheinichen S, Heine J (2000) Tracheal injury as a sequence of multiple attempts of endotracheal intubation in the course of a preclinical cardiopulmonary resuscitation. Resuscitation 43, 147–150.PubMedCrossRefGoogle Scholar
  5. 5.
    Maxeiner H (1988) Weichteilverletzungen am Kehlkopf bei notfallmäßiger Intubation. Anästh Intensivmed 29, 42–49.Google Scholar
  6. 6.
    Krause S, Donen N (1984) Gastric rupture during cardiopulmonary resuscitation. Can Anaesth Soc J 31, 319–322.PubMedCrossRefGoogle Scholar
  7. 7.
    Mills SA, Paulson D, Scott SM, Sethi G (1983) Tension pneumoperitoneum and gastric rupture following cardiopulmonary resuscitation. Ann Emerg Med 12, 94–95.PubMedCrossRefGoogle Scholar
  8. 8.
    Schvadron E, Moses Y, Weissberg D (1996) Gastric rupture complicating inadvertent intubation of the esophagus. Can J Surg 39, 487–489.PubMedGoogle Scholar
  9. 9.
    Eldor J, Ofek B, Abramowitz HB (1990) Perforation of oesophagus by tracheal tube during resuscitation. Anaesthesia 45, 70–71.PubMedCrossRefGoogle Scholar
  10. 10.
    Topsis J, Kinas HY, Kandall SR (1989) Esophageal perforation—a complication of neonatal resuscitation. Anesth Analg 69, 532–534.PubMedCrossRefGoogle Scholar
  11. 11.
    Kaloud H, Smolle-Jüttner FM, Prause G, List WF (1997) Latrogenic ruptures of the tracheobronchial tree. Chest 112, 774–778.PubMedCrossRefGoogle Scholar
  12. 12.
    Bauer H, Welsch KH (1976) Punktions-Techniken in der Notfallmedizin. Munch Med Wochenschr 118, 567–572.Google Scholar
  13. 13.
    Van Heurn LWE, Theunissen PHMH, Ramsay G, Brink PRG (1996) Pathologic changes of the trachea after percutaneous dilatational tracheotomy. Chest 109, 1466–1469.PubMedCrossRefGoogle Scholar
  14. 14.
    Malthauer RA, Telang H, Miller JD, McFadden S, Inculet RI (1998) Percutaneous tracheostomy. Chest 114, 1771–1772.CrossRefGoogle Scholar
  15. 15.
    Lignitz E, Mattig W (1989) Der iatrogene Schaden. Akademie-Verlag, BerlinGoogle Scholar
  16. 16.
    Pracht U, Schulz E (1987) Befunde nach erfolgloser kardiopulmonaler Reanimation. Notarzt 3, 187–189.Google Scholar
  17. 17.
    Hargarten KM, Aprahamian C, Mateer J (1988) Pneumoperitoneum as a complication of cardiopulmonary resuscitation. Am J Emerg Med 6, 358–361.PubMedCrossRefGoogle Scholar
  18. 18.
    Hartoko TJ, Demey HE, Rogers PE, Decoster HL, Nagler TM, Bossaert LL (1991) Pneumoperitoneum-a rare complication of cardiopulmonary resuscitation. Acta Anaesthesiol Scand 35, 235–237.PubMedCrossRefGoogle Scholar
  19. 19.
    Noffsinger AE, Blisard KS, Balko MG (1991) Cardiac laceration and pericardial tamponade due to cardiopulmonary resuscitation after myocardial infarction. J Forensic Sci 36, 1760–1764.PubMedGoogle Scholar
  20. 20.
    Umach P, Unterdorfer H (1980) Massive Organverletzungen durch Reanimationsmaßnahmen. Beitr Gerichtl Med 38, 29–32.PubMedGoogle Scholar
  21. 21.
    Norfleet RG, Smith GH (1990) Mallory-Weiss syndrome after cardiopulmonary resuscitation. J Clin Gastroenterol 12, 569–572.PubMedCrossRefGoogle Scholar
  22. 22.
    McGrath RB (1983) Gastroesophageal lacerations. A fatal complication of closed chest cardiopulmonary resuscitation. Chest 83, 571–572.PubMedCrossRefGoogle Scholar
  23. 23.
    Lawes EG, Baskett PJ (1987) Pulmonary aspiration during unsuccessful cardiopulmonary resuscitation. Intensive Care Med 13, 379–382.PubMedCrossRefGoogle Scholar
  24. 24.
    Adler SN, Klein RA, Pellecchia C, Lyon DT (1983) Massive hepatic hemorrhage associated with cardiopulmonary resuscitation. Arch Intern Med 143, 813–814.PubMedCrossRefGoogle Scholar
  25. 25.
    Hillman K, Albin M (1986) Pulmonary barotrauma during cardiopulmonary resuscitation. Crit Care Med 14, 606–609.PubMedCrossRefGoogle Scholar
  26. 26.
    Shulman D, Beilin B, Olshwang D (1987) Pulmonary barotrauma during cardiopulmonary resuscitation. Resuscitation 15, 201–207.PubMedCrossRefGoogle Scholar
  27. 27.
    Yamaki T, Ando S, Ohta K, Kubota T, Kawasaki K, Hirama M (1989) CT demonstration of massive cerebral air embolism from pulmonary barotrauma due to cardiopulmonary resuscitation. J Comput Assist Tomogr 13, 313–315.PubMedCrossRefGoogle Scholar
  28. 28.
    Guly UM, Robertson CE (1995) Active decompression improves the haemodynamic state during cardiopulmonary resuscitation. Br Heart J 73, 372–276.PubMedCrossRefGoogle Scholar
  29. 29.
    Rabl W, Baubin M, Broinger G, Scheithauer R (1996) Serious complications from active compression-decompression cardiopulmonary resuscitation. Int J Legal Med 109, 84–89.PubMedCrossRefGoogle Scholar
  30. 30.
    Rabl W, Baubin M, Haid C, Pfeiffer KP, Scheithauer R (1997) Review of active compression-decompression cardiopulmonary resuscitation (ACD-CPR). Analysis of iatrogenic complications and their biomechanical explanation. Forensic Sci Int 89, 175–183.PubMedCrossRefGoogle Scholar
  31. 31.
    Klintschar M, Darok M, Radner H (1998) Massive injury to the heart after attempted active compression-decompression cardiopulmonary resuscitation. Int J Legal Med 111, 93–96.PubMedCrossRefGoogle Scholar
  32. 32.
    Baubin M, Rabl W, Pfeiffer KP, Benzer A, Gilly H (1999) Chest injuries after active compression-decompression cardiopulmonary resuscitation ( ACD-CPR) in cadavers. Resuscitation 43, 9–15.PubMedCrossRefGoogle Scholar
  33. 33.
    Ellinger K, Luiz T, Denz C, Van Ackern K (1994) Randomisierte Anwendung der aktiven Kompression-Dekompressions-Technik ( ACD) im Rahmen der präklinischen Reanimation. Anesthesiol Intensivmed Notfallmed Schmerzther 29, 492–500.CrossRefGoogle Scholar
  34. 34.
    Minor RL Jr, Chandran PK, Williams CL (1990) Rhabdomyolysis and myoglobinuric renal failure following cardioversion and CPR for acute MI. Chest 97, 485–486.PubMedCrossRefGoogle Scholar
  35. 35.
    Krischer JP, Fine EG, Davis JH, Nagel EL (1987) Complications of cardiac resuscitation. Chest 92, 287–291.PubMedCrossRefGoogle Scholar
  36. 36.
    Saternus KS (1981) Direkte und indirekte Traumatisierung bei der Reanimation. Z Rechtsmed 86, 161–174.PubMedCrossRefGoogle Scholar
  37. 37.
    Saukko P (1980) Gerichtsmedizinische Gesichtspunkte für die Beurteilung von Schäden nach der äußeren Herzmassage. Zbl Rechtsmed 20, 8.Google Scholar
  38. 38.
    Kloss T, Puschel K, Wischhusen F, Welk I, Roewer N, Jungck E (1983) Reanimationsverletzungen. Anästh Intensivther Notfallmed 18, 199–203.PubMedCrossRefGoogle Scholar
  39. 39.
    Ryan MP, Young SJ, Wells DL (2003) Do resuscitation attempts in children who die, cause injury? Emerg Med J 20, 10–12.PubMedCrossRefGoogle Scholar
  40. 40.
    Price EA, Rush LR, Perper JA, Bell MD (2000) Cardiopulmonary resuscitation-related injuries and homicidal blunt abdominal trauma in children. Am J Forensic Med Pathol 21, 307–310.PubMedCrossRefGoogle Scholar
  41. 41.
    Zhu BL, Quan L, Ishida K, Taniguchi M, Oritani S, Kamikodai Y, et al. (2001) Fatal traumatic rupture of an aortic aneurysm of the sinus of Valsalva: an autopsy case. Forensic Sci Int 116, 77–80.PubMedCrossRefGoogle Scholar

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© Springer Science+Business Media New York 2004

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  • Mario Darok

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