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Forensic imaging findings by post-mortem

computed tomography after manual versus
mechanical chest compression

Article in Journal of Forensic Radiology and Imaging · September 2015

DOI: 10.1016/j.jofri.2015.08.001

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 Journal of Forensic Radiology and Imaging 3 (2015) 167–173

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Journal of Forensic Radiology and Imaging

journal homepage: www.elsevier.com/locate/jofri

Forensic imaging findings by post-mortem computed tomography after

manual versus mechanical chest compression
Rilana Baumeister a,n, Ulrike Held b, Michael J Thali a, Patricia M Flach a, Steffen Ross a
a
University of Zurich, Institute of Forensic Medicine, Forensic Medicine and Imaging, Winterthurerstrasse 190/52, CH-8057 Zurich, Switzerland
b
Horten Centre for Patient Oriented Research and Knowledge Transfer, University Hospital Zurich, Switzerland

art ic l e i nf o a b s t r a c t

Article history: Objectives: The aim of this study was to compare the injuries observed after cardiopulmonary re-
Received 3 June 2015 suscitation (1 CPR) by means of standard or assisted chest compression by the Lund University Cardio-
Received in revised form pulmonary Assist System (2 LUCAS™2) device visualized by post-mortem computed tomography
20 July 2015
(3 PMCT).
Accepted 6 August 2015
Materials and methods: A retrospective study was conducted that included 44 cases delivered to our
Available online 8 August 2015
institution following CPR before death. All bodies underwent PMCT. The case group was divided into two
Keywords: groups: one group that underwent manual and one group that underwent mechanical CPR with the
Forensic imaging LUCAS™2 device. The main traumatic findings associated with CPR were reported, and a statistical
Post-mortem computed tomography evaluation was performed.
(PMCT)
Results: The LUCAS group comprised 24 cases, the manual group 20 cases. Rib fractures were the most
Cardiopulmonary resuscitation (CPR)
frequent injury in both groups. A mean of 10.38 rib fractures per case was observed in the LUCAS group,
CPR-related injuries
Manual CPR
and 10.40 fractures were observed in the manual group (p¼ 0.999). Subcutaneous pre-sternal hemato-
Mechanical chest compression mas were described in 15/24 patients in the LUCAS group and in 6/20 patients in the manual group. The
LUCAS™2 frequency of sternal factures was similar in both groups. A few trauma injuries to internal organs (i.e.,
Virtopsy retrosternal, perihepatic, and retroperitoneal hematomas and lung contusion) were recorded in both
groups.
Conclusion: PMCT is useful for evaluating injuries related to CPR. LUCAS™2-CPR has a greater association
with subcutaneous pre-sternal hematomas than standard CPR. There is no further significant difference
in the incidence of injuries between mechanical and manual chest compression. From a forensic point of
view, it is important to identify CPR-related injuries.
& 2015 Elsevier Ltd. All rights reserved.

1. Introduction 2002. The LUCAS™2 (the 2nd-generation device, Fig. 1) is a fully

Cardiopulmonary resuscitation (CPR) is well known and has
been applied for more than 50 years as a treatment in cases of
cardiac arrest through the establishment of a basic circulation
through continuous manual chest compression. Mechanical chest
compression devices are increasingly used during CPR because
they ensure continuous compressions over long time periods. They
can be used during transportation and advanced resuscitation
techniques or procedures, such as percutaneous interventions [1–
4].
The most widely used device is the Lund University Cardio-
pulmonary Assist System (LUCAS™), which was introduced in
Abbreviations: 1 CPR, cardiopulmonary resuscitation; 2 LUCAS™2, Lund University
Cardiopulmonary Assist System, 2nd-generation; 3 PMCT, Post-mortem computed
tomography
n
Corresponding author.
E-mail address: rilana.baumeister@irm.uzh.ch (R. Baumeister).
pneumatic automatic device that is equipped with a drag for
compression and a suction cup for active decompression and
needs to be properly placed on the central breast region. The drag
piece and suction cup are maintained on top of a plastic ring that
surrounds the body for fixation.
Although the device has known advantages, it has been noted
that the assisted CPR is associated with more rib fractures than
standard CPR (for example 78.8% versus 64.6%, p¼ 0.021), but
there are no further differences in CPR-related injuries [4,5]. Yang
et al. [6] detected rib fractures in general and buckle fractures in
particular as a common finding after CPR. Buckle rib fractures are
incomplete fractures involving the inner cortex alone. After man-
ual chest compressions, sternum fractures and injuries to the
trachea were the most frequent findings, much rarer findings were
lesions of the pleura, pericardium, myocardium, and abdominal
organs (1% or less) [4,5,7].
Although there have been many studies on the incidence of or
factors related to complications of CPR, most of them are based

http://dx.doi.org/10.1016/j.jofri.2015.08.001
2212-4780/& 2015 Elsevier Ltd. All rights reserved.
168 R. Baumeister et al. / Journal of Forensic Radiology and Imaging 3 (2015) 167–173
Fig. 1. Appearance of LUCAS™2 device. (Published with permission of Physio-
Control).
only on autopsy or X-ray findings on plain films [8], clinical data
and ante-mortem computed tomography (CT) results, or different
findings during autopsy compared with post-mortem CT (PMCT)
[7]. To our knowledge, there is no study that has compared PMCT
findings between manual and mechanical CPR-related injuries.
Virtual autopsy (Virtopsy) is an emerging technique that was
developed to supplement traditional forensic autopsy. Virtopsy
can be performed using various imaging techniques, such as
computed tomography and magnetic resonance imaging. Virtopsy
CT consists of a whole-body, non-contrast CT scan obtained after
death. It is useful in trauma cases, as it can provide an overview of
injuries sustained by the victim [9]. Sometimes, the scan is per-
formed without further autopsy; therefore, CPR-related injuries in
PMCT should be defined.
The aim of this study was to compare injuries observed after
CPR by means of manual or mechanical-assisted chest compres-
sion visualized by PMCT.
2. Materials and methods
2.1. Study population
We reviewed retrospective data from our institute (Institute of
Forensic Medicine, University of Zurich) from January 2011 to
February 2015. The inclusion criteria were cases deceased after
cardiac arrest with CPR attempt by means of LUCAS™2 (Chest
Compression System, Physio-Control/Jolife AB, Lund, Sweden)
(n ¼24) or manual (n ¼20) cardiopulmonary resuscitation. The
exclusion criteria were age under 16 years, too much signs of de-
composition and thoracic-abdominal trauma, such as trauma
caused by motor accidents. All patients received a whole-body
PMCT scan; some received additional post-mortem imaging to
clarify organ lesions. No further autopsy, as the gold standard,
followed.
2.2. Study protocol
The whole-body PMCT scan was performed using a dual-source
CT scanner (Flash Definition, Siemens, Forchheim, Germany). The
scan parameters for the torso were as follows: tube voltage,
120 kVp; 400 ref mAs using automatic dose modulation software
(CARE dose 4D, Siemens, Forchheim, Germany); slice thickness,
1.0 mm; increment, 0.6 mm; and image reconstruction with soft
tissue and bone kernels. Image review was conducted using a PACS
workstation (IDS 7, Sectra AB, Linköping, Sweden). Axial, coronal,
and sagittal reformatted series were available.
Two image readers (radiologists with 0.5 and 9 years of ex-
perience in PMCT) assessed the following information in a con-
sensus reading of the available PMCT data set: acute rib fractures
and buckle fractures, along with fracture type and location;
pneumothorax; lung contusion; retro- and pre-sternal hemor-
rhage; sternal fracture; hemothorax; hemopericardium; pathology
of the heart and main vessels in the thorax and abdomen; and
perihepatic, perisplenic and retroperitoneal hemorrhage. The
findings were documented in a Microsoft Excel 2010 spreadsheet.
Demographic data, such as sex, age, and cause of death, were
collected for every case. For this type of study, an ethics committee
and formal consent were not required.
2.3. Statistical analysis
Descriptive statistics were used for the comparison of deceased
patients between the manual and LUCAS groups. Categorical
variables were summarized by numbers within each group, and
continuous variables were summarized using the median and in-
terquartile range. Stacked bar plots were used for graphical display
of the cause of death variable. We used chi-square tests to assess
statistical significance between groups for the categorical variables
and the Wilcoxon test for the continuous variables. We used the
statistic program R Core Team (2015. R: A language and environ-
ment for statistical computing; R Foundation for Statistical Com-
puting, Vienna, Austria). A p value o 0.05 was considered
significant.
3. Results
Of the 44 cases included, 20 (45.5%) had received manual CPR,
and 24 (54.5%) had been treated with the LUCAS™2 device. There
was no difference in age or sex between the two groups. The de-
mographic data of the corpses that were included in the study are
presented in Table 1. Because this was a retrospective analysis,
information on the duration of CPR was not always available. The
causes of death are detailed in Fig. 2.
Injuries were found in 19/20 cases in the manual group and in
24/24 cases in the LUCAS group (p¼ 0.455). Both groups showed
similar pathology distributions. The frequency of injuries is sum-
marized in Table 2.
There was one ruptured heart infarction and one aortic
Table 1
Demographic data of the patients included in the study.
Manual LUCAS (n ¼24) p-value
(n¼20)
Age (years: median, interquartile 57.5 (47.8– 63.5 (46.8– 0.517
range) 75.3) 75.8)
Sex (male) 15 (75) 19 (79.2) 0.999
 R. Baumeister et al. / Journal of Forensic Radiology and Imaging 3 (2015) 167–173 169

Fig. 2. Statistical visualization. Causes of death in the study population. Subarachn.¼ Subarachniodal; hemorrh.¼ hemorrhage; Intracerebr. ¼ Intracerebral.

Table 2
Number of injuries detected by PMCT.

Injury Manual (20) n LUCAS (24) n (%) p-value

(%)

Subcutaneous pre-sternal 6 (30) 15 (62.5) 0.040

hematoma
Sternal fracture 12 (60) 17 (70.8) 0.532
Rib fracture 18 (90) 22 (91.7) 0.999
Rib fractureZ 3 right 12 (60) 16 (66.7) 0.757
Rib fractureZ 3 left 12 (60) 18 (75) 0.342
Location
none 0 (0) 2 (8.3)
Parasternal 17 (85) 21 (87.5)
Lateral 1 (5) 0 (0)
Posterior 0 (0) 1 (4.2) 0.886
Pneumothorax 3 (15) 7 (29) 0.450
Hemothorax 3 (15) 7 (29) 0.450
Lung contusion 7 (35) 10 (42) 0.888
Hemopericardium 0 (0n) 5 (22.7n) 0.056n
Retrosternal bleeding 9 (45) 13 (54.2) 0.763 Fig. 3. CPR-related injuries. Axial PMCT of the thorax, lung window, a small
Ruptured heart /great vessels/ 4 (20) 2 (8.3) 0.387 pneumothorax (asterisk) due to a CPR-related rib fracture with a corresponding
dissection contusion of the lung/middle lobe (arrows).
Perihepatic bleeding 1 (5) 4 (16.7) 0.356
Perisplenic bleeding 0 (0) 5 (20.8) 0.053
Retroperitoneal bleeding 2 (10) 1 (4.2) 0.583 LUCAS group. Hemo-pericardium was noted in 0/17 cases in the
Pathology 19 (95) 24 (100) 0.455
manual group and in 5/22 cases in the LUCAS group (p¼ 0.056).
n
Subtraction of 3 cases in the manual group and 2 cases in the LUCAS group Intrathoracal injuries are shown in Fig. 3. Perisplenic bleeding was
because hemopericardium was caused by non-CPR-related pathologies. present only in the LUCAS group (5/24, p¼ 0.053). Fig. 4 shows that
sternal fracture, retrosternal bleeding, and subcutaneous pre-
dissection type A in the LUCAS group. Two cases of aortic dissec- sternal hematoma, they were not associated with each other in
tion type A were noted in the manual group, as well as a perfo- either group (manual, p ¼0.999; LUCAS, p ¼0.417).
rated atrial electrode, which caused hemopericardium. Injuries, The classification of the rib fractures into buckle fractures or
mentioned in this paragraph, were considered to be the primary complete fractures without and with dislocation is shown in Fig. 5.
cause of cardiac arrest and were not treatment-related injuries. The sum of the rib fractures and the differentiation between them
Therefore, we subtracted 3 cases in the manual and 2 cases in the were not significantly different (Fig. 6). A mean of 10.38 rib
170 R. Baumeister et al. / Journal of Forensic Radiology and Imaging 3 (2015) 167–173
Fig. 4. CPR-related injuries. a Axial PMCT of the thorax, soft tissue window and picture detail in bone window, subcutaneous, pre-sternal hematoma (ellipse), and fracture of
the sternum (arrow). b Axial PMCT of the thorax, soft tissue window, a retrosternal hematoma (asterisk).
fractures per case was observed in the LUCAS group, while 10.40
fractures per case were observed in the manual group (p ¼0.999).
Only one case in each group showed additional posterior (LUCAS)
or lateral (manual) rib fractures.
4. Discussion
No difference between the two methods of chest compressions
in CPR were found with respect to the incidence of injuries, with
the exception of significantly more subcutaneous pre-sternal he-
matomas found in the LUCAS group (15/24, 62.5%). These results
were consistent with findings noted by Smekal et al. [5]. Lardi et al.
[4] detected significantly more cutaneous anterior chest lesions in
the LUCAS group (two LUCAS groups, 18 and 13 of 26 and 20, both
p o0.001), which is comparable to our finding (15 of 24, p ¼0.040).
The LUCAS™2 device is adapted to the body during CPR even in
the decompression interval; thus, there is always a low pressure
on the pre-sternal skin and, accordingly, the subcutaneous fat.
Rib fractures are the most common complications of chest
compression during CPR in this study, Kashiwagi et al. confirm this
[8]. In contrast to Lardi et al. [4] (3.1, 6.6, 6.4, p ¼0.007, p ¼0.017),
we did not detect a difference in manual or mechanical CPR-re-
lated average nuber of rib fractures (10.40 versus 10.38, p ¼0.999)
detected by PMCT.
The classification that we used, namely, dividing each rib into
thirds, was reproducible on PMCT. The disadvantage of this clas-
sification may be illustrated by the following example: below the
seventh rib level, the anterior one-third of the ribs is situated
laterally or posterolaterally in the chest wall [6]. Very few rib
fractures are located in the middle or posterior one-third of the
ribs, here we observe only one case in each group.This classifica-
tion could be useful pathologically as an indicator for evaluating
the probability of non-CPR-related rib fractures with PMCT.
Conducting PMCT prior to any manipulation of the deceased is
an ideal way to evaluate the occurrence of previous CPR by the
detection of patterned (symmetrical and continuous) complete
and incomplete rib injury, including buckle fractures [6]. Schulze
et al. [10] stated that PMCT has a rather low sensitivity for rib
fracture detection when validated against autopsy; however, par-
tial rib fractures often remain undetected at autopsy and are better
detected by PMCT.
While paravertebral rib fractures are common in blunt trauma,
posterior thoracic fractures are exceptional after CPR, a fact that
has forensic implications [11]. However, Pinto et al. [12] detected a
high number of posterior rib fractures (430%, p o0.000) resulting
s
from mechanically assisted CPR with AutoPulse . Additionally,
they observed more traumatic injuries after manual CPR. On the
contrary, Baubin et al. [13] detected an increased frequency of
thorax injury with mechanical CPR. Smekal et al. [14] observed no
difference in autopsy-detected injuries after LUCAS™2-CPR com-
pared with manual CPR. These findings are similar to our results.
 R. Baumeister et al. / Journal of Forensic Radiology and Imaging 3 (2015) 167–173
Fig. 5. Classification of the rib fractures. Axial PMCT of the right thorax, bone window. a Dislocated rib fracture (arrow). b Complete rib fracture without dislocation (arrow). c
Buckle fracture (arrow).
Even rarer were CPR-related lesions of the pleura, pericardium,
and myocardium (o1%). Perforations of the abdominal organs
were also rare (1%) and are mainly due to fractured ribs and/or a
fractured sternal bone, as the external forces exerted during CPR
are transferred through the unstable thorax to the visceral organs,
which may lead to ruptures and perforations [7]. Spoormans et al.
[15] discovered 67 case reports of gastric perforation after CPR.
Sajith et al. [16] described only one case of gastric perforation after
CPR using the LUCAS™2 device. Mutsaers et al. [17] reported un-
expected bleeding due to a dislocated gallbladder after CPR, but
the type of CPR performed is not known. According to the litera-
ture findings, these complications are rare, and they arise more
frequently if external CPR is performed with active compression–
s
decompression devices such as the Cardio Pump [18]. Patholo-
gists of the University Hospital of Lund have suggested an increase
in the number and severity of injuries associated with mechanical
CPR; unfortunately, they did not report the statistics [1,19]. The
differences in perisplenic hemorrhage and hemopericardium be-
tween the groups in this study as detected by PMCT were not
statistically significant. However, it is remarkable that no case in
the manual group had perisplenic blood or hemopericardium,
while a fifth of the LUCAS group displayed this pathology.
Because of the lack of autopsy, as the gold standard, there is a
missing proof of some findings such as perisplenic hemorrhage or
171
retrosternal bleeding for example. Nevertheless, in these days and
in our institute PMCT without further autopsy is more and more
common for forensic case solving management. Therefore, the
approach of this study is an option.
Even though we excluded trauma patients, we still had to deal
with trauma-related injuries, e.g., lung contusion. In some cases, it
was difficult to distinguish between lung contusion, infarction,
atelectasis, and infiltrate. Treugut et al. [20] detected that the time
of trauma with associated lung opacity/pathology was the most
useful characteristic with which to discriminate between the
pathologies; however, we did not have sufficient information on
this variable. Another trauma-related injury is pneumothorax,
which primarily occurs when rib fractures are detected or is due to
emphysema, sharp force injuries, spontaneous, barotrauma or ia-
trogen causes [21–23]. However, in PMCT, pneumothorax is de-
tected in decomposed bodies without any of the above-mentioned
causes.
Cases in the LUCAS group were first reanimated manually.
Therefore, it was not simple to distinguish pathologies related to
manual or mechanical CPR. Moreover, in all studies, including
prospective studies, involving human bodies resuscitated by me-
chanical devices, it is difficult to obtain a group of mechanical CPR
cases that can be compared with manual CPR cases. For evident
ethical reasons, corpses frequently underwent previous manual
172 R. Baumeister et al. / Journal of Forensic Radiology and Imaging 3 (2015) 167–173
Fig. 6. Boxplots comparing rib fractures. Classification of rib fractures and the sum of the rib fractures.
chest compressions before devices were applied. Resuscitation
cannot be delayed for scientific purposes. Human cadavers were
investigated for CPR-associated lesions. Such studies permitted
analysis of the injuries that were directly related to the use of
mechanical CPR devices without any bias due to manual com-
pressions; however, porcine model studies [2,22,23] have allowed
the comparison of manual CPR with active compression–decom-
pression-CPR (ACD-CPR) only. The authors observed more trau-
matic injuries associated with manual CPR in their animal model.
Based on these considerations, it is possible to hypothesize that
human studies tend to overestimate device-related trauma in-
juries in assisted CPR.
The influence of sex on CPR-related injuries is unclear. Women
have a higher prevalence of osteoporosis and are typically older
than men at the time of attempted resuscitation. Similarly, Kri-
scher et al. [24] found no statistically significant correlation be-
tween sex and the incidence of rib fractures. In a study by Baubin
et al. [13], age and female gender were found to be related to
higher rates of rib and sternal fractures, respectively.
Age may have an important impact on the occurrence of frac-
tures during chest compression. One proposed explanation may be
the loss of cortical bone mass caused by skeletal demineralization
(osteoporosis), which allows the rib(s) to fracture when less ki-
netic force is applied to the thorax relative to the force required in
younger patients [25]. Resuscitation-related injuries of the thorax
wall are rarely observed in children because the infantile chest is
of higher elasticity than that in older people, while resuscitation
measures are altogether rarer during infancy. If infantile bone in-
juries are present, they must be differentiated from trauma caused
by repetitive child abuse and/or battering [26]. Mortality is in-
creased in older patients sustaining rib fractures [27,28]. Flagel
et al. [25] detected an increased number of rib fractures correlated
directly with increasing pulmonary morbidity and mortality.
Nevertheless, most studies, including the present study, have
not identified instantly life-threatening injuries due to any type of
CPR. The risk of complications from CPR never outweighs the
benefit of the return of spontaneous circulation. Rib or sternal
fractures themselves are not fatal; however, there are a few as-
sociated complications, such as bilateral pneumothorax and he-
mopericardium, which can be fatal. These injuries are easy to
detect with PMCT [8]. With regard to hemopericardium, in this
study, there were 7 cases (7/24, 29.2%) in the LUCAS group, and
two of these cases were caused by a ruptured myocardial infarc-
tion and a type A aortic dissection; however, 22.7% (5/22) of the
hemopericardium cases due to other causes still remained.
Knowledge of CPR-related injuries is important for managing
treatment after the return of spontaneous circulation. After CPR,
physicians should be aware of rare complications, such as hemo-
pericardium, abdominal injury of the liver, spleen, and stomach, or
injury to the great vessels, in unstable patients [1].
 R. Baumeister et al. / Journal of Forensic Radiology and Imaging 3 (2015) 167–173
5. Conclusion
PMCT is useful for evaluating injuries related to CPR. LUCAS™2-
CPR had a greater association with subcutaneous pre-sternal he-
matoma than standard CPR. There was no further significant dif-
ference in the incidence of injuries between mechanical and
manual chest compression. Rib fractures were common findings.
From a forensic point of view, the detection of pathologies related
to CPR by PMCT is possible, especially if the rib fractures follow a
specific pattern.
Conflicts of interest
None declared.
Acknowledgements
None.
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