Complications of mechanical chest compression devices

Mechanical chest compression devices (MCCDs) are increasingly used during cardiopulmonary resuscitation (CPR) and they ensure continuous compressions of high quality, even during transportation [1] or during procedures such as percutaneous interventions [2]. Experimental trials have shown improved organ perfusion compared with manual chest compressions in pigs, [3, 4] but a pilot study in humans did not indicate improvement in early survival in out-of-hospital cardiac arrest [5]. Two larger, prospective clinical trials on outcome are ongoing: the LINC trial (NCT00609778) and the PARAMEDIC trial (ISRCTN08233942) [6].

Buschmann et al. described an association between manual chest compressions and various injuries. Rib and sternum fractures were reported frequently, as well as injury to the trachea. Much more rare were lesions of the pleura, pericardium and myocardium. Perforations of abdominal organs were also rare, with an incidence of less than 1 % [7].

Among the use of mechanical devices for CPR, injuries are more rare and less well described. In order to put together a complete list of these complications, we conducted a Medline search, which provided 1482 results. After screening on title and abstract, and thereafter on full text, 12 studies were selected. Table 1 presents an overview of the incidence of complications of CPR with the use of MCCDs. Injuries of the skin and fractures of sternum or ribs comprise a high incidence. Only a few case reports mention more serious injuries after mechanical chest compressions [8‐10].

It is debatable whether MCCDs lead to more serious injuries compared with manual compressions, because CPR may cause injury in any case. Smekal et al. compared lesions found at autopsy in patients who were resuscitated either manually or mechanically [11]. It should be noted that the mechanically resuscitated patients received manual compressions before the initiation of the device. Furthermore, a study on autopsy concerns the deceased patients and not the survivors. In this study, no differences in the incidence of injury between manual and mechanical groups were described, except for skin lesions, which were more common in mechanical CPR. Pathologists of the University Hospital of Lund suggest an increase in the number and severity of injuries with mechanical CPR. Unfortunately, they do not mention statistics [12].

In the described patient, the combination of difficult ventilation causing gastric air insufflations and the vigorous LUCAS device compressions most probably led to blowout injury of the stomach. In a review of all case reports of described gastric ruptures after CPR, Spoormans et al. discovered 67 case reports of gastric perforation after cardiopulmonary resuscitation (CPR) [13]. Common risk factors for this complication were bystander-provided basic life support (BLS), use of mask ventilation and difficult airway management. These factors are all associated with gastric distention due to air aspiration. This combined with the force provided by chest compressions may lead to perforation of the stomach. Thus far, Sajith et al. have described the only case of gastric perforation after CPR using the LUCAS device [14].

The risk of complications from CPR never outweighs the benefit of return of spontaneous circulation. Knowing the risks is important for treatment issues after ROSC, because both manual and mechanical CPR may lead to injuries. In unstable patients after CPR, physicians should be aware of rare complications such as abdominal injury of liver, spleen and stomach or injury to the great vessels.