Revista Română de Anatomie funcţională şi clinică, macro- şi microscopică şi de Antropologie

Vol. XVI – Nr. 1 – 2017 CLINICAL ANATOMY

FORENSIC SIGNIFICANCE OF LESIONS INDUCED

BY CARDIOPULMONARY RESUSCITATION

Sofia David1,2, Carleta Teodorescu2, L. Teodorescu2, R. Dospinescu2,

A. Knieling1,2, Diana Bulgaru-Iliescu1,2
1. University of Medicine and Pharmacy “Grigore T. Popa”, Iasi, Romania
Discipline of Forensic Medicine
2. Institute of Forensic Medicine, Iasi, Romania

FORENSIC SIGNIFICANCE OF LESIONS INDUCED BY CARDIOPULMONARY RESUSCI-

TATION (Abstract): Cardiopulmonary resuscitation (CPR) is a lifesaving emergency procedure
generating various injuries. At necropsy examination, lesions produced by CPR maneuvers are
regularly encountered, unrelated to the primary death cause. The aim of the current study is to
examine traumatic injuries observed at forensic necropsy after CPR and to make the differential
diagnosis with those induced by violent acts or accidents. The authors performed a retrospective
study at the Institute of Forensic Medicine from Iasi, Romania on 49 cases (32 males, 17 females)
that benefited from CPR manoeuvres prior to death. Mean age was 47.3 years, 24 cases (48.98%)
presented cardiac arrest secondary to trauma and 41 (83.67%) in an extra-hospital environment.
CPR duration reported in 21 cases (42.86%) registered a mean value of 42 minutes. Additional
gestures like vein puncture were reported in 25 cases (51.02%) and surgical interventions in 5
cases (10.20%). All intra-thoracic structures can be injured directly or indirectly by chest compres-
sions. Rib fractures are among the most common complications associated with CPR and found
in one third of cases. Petechiae on the surface of the heart are observed mostly on the posterior
surface. Perivascular haemorrhagic infiltrations can also be noticed and are poorly described in
the literature. Intra-abdominal organs are less often the site of complications secondary to resus-
citation. In conclusion, injuries produced during CPR may be responsible for important artefacts
impeding the understanding of traumatic lesions observed during necropsy and related to the
primary death cause. A thorough knowledge of possible aspects is mandatory to the differential
diagnosis with other traumatic lesions. Keywords: CARDIOPULMONARY RESUSCITATION,
FORENSIC NECROPSY, TRAUMATIC LESIONS, DIFFERENTIAL DIAGNOSIS

INTRODUCTION pecially if technical errors are committed. Nec-

Cardiac arrest is an extreme medical emer-
gency, leading to irreversible brain damage and
death if proper measures to restore ventilation
and blood flow are not taken. Cardiopulmonary
resuscitation (CPR) is fundamental for increas-
ing the survival chance of these patients. In the
last decade, the interest of forensic pathologists
in the study of injuries caused by CPR has
augmented due to the emergence of resuscita-
tion guidelines containing specific recommen-
dations concerning the depth of chest compres-
sions, CPR duration, sequence of maneuvers.
Even if it is a lifesaving procedure, CPR is an
aggressive method causing various lesions es-
ropsy is still considered the gold standard for
study of CPR associated lesions despite exten-
sive usage of medical imaging techniques (com-
puted tomography, radiography) in the western
world.
At necropsy examination, CPR-related inju-
ries are commonly encountered, unrelated to
the primary death cause, and may mislead the
forensic examination. One of the objectives of
the recommendations made by the European
Resuscitation Council is to establish an appro-
priate balance between the benefit of CPR ma-
noeuvres and the risk of causing harm to the
patient (1). An observational study published

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 Forensic Significance of Lesions Induced by Cardiopulmonary Resuscitation
in 2013 found a higher incidence of iatrogenic
injuries provoked by manual CPR in patients
who received chest compressions at a compres-
sion depth greater than 6 cm (2). CPR injuries
may account for up to 20% of all injuries iden-
tified at forensic necropsy (3). Forensic pa-
thologists have to be able to make the differen-
tial diagnosis between injuries associated to
CPR and those generated by other traumas
related to violent acts, accidents, suicide or
homicide (4,5).
Although CPR can cause secondary life-
threatening lesions, such situations are extreme-
ly rare (3). Hemopericardium, hemothorax,
hemoperitoneum or other lesions produced dur-
ing CPR may be responsible for important ar-
tefacts impeding the understanding the trauma
observed during necropsy (6). In such situa-
tions, it is sometimes difficult for the forensic
pathologist to determine the exact cause of
death, particularly in cases where no other pa-
thology has been identified. It is therefore im-
portant, before starting any autopsy, to consult
all available data in order to understand discov-
ered lesions. Medical documents rarely contain
the exhaustive details of all CPR maneuvers
carried out. The reported data may also be er-
roneous, making it difficult to interpret certain
lesions (7,8). It is imperative for the forensic
pathologist to search and precisely identify all
the lesions secondary to CPR maneuvers in
order to determine their possible involvement
in the death process but, above all, not to con-
fuse them with the consequences of violent acts
causing death.
One of the difficulties encountered by foren-
sic pathologists when performing necropsies is
related to the fact that it is not always facile to
assert the exact origin of an observed lesion.
Sometimes it is difficult to identify all the in-
juries related to CPR maneuvers, even for rib
fractures whose incompleteness may alter find-
ings (9). For example, in a Swedish, multi-
center study conducted on 222 autopsies of
individuals with non-traumatic cardiac arrest
followed by CPR, it was impossible for the 40
forensic pathologists enrolled to affirm wheth-
er identified lesions were due to CPR maneu-
vers in 13.5% of cases (10).
Training of forensic pathology residents
should pay particular attention to teaching and
displaying all the lesions that can be produced
by resuscitation maneuvers. The realization of
a lesion mapping together with medical file
details would allow forensic pathologists to
avoid artifacts and misinterpretations. Thus, it
would be easier not to confuse them with inju-
ries induced by other factors such as acts of
willful or involuntary violence with completely
different legal implications. Initial errors of
interpretation are not uncommon. Prahlow and
McClain presented the case of an individual
presenting a circular wound of 9 mm that was
suspected to be the entrance point of a gunshot
but was finally found to be secondary to place-
ment of a thoracic drain (11).
The aim of the current study is to examine
traumatic injuries observed at forensic necrop-
sy after CPR and to make the differential diag-
nosis with those induced by violent acts or
accidents.
MATERIAL AND METHODS
The authors performed a retrospective study
at the Institute of Forensic Medicine from Iasi,
Romania on 49 cases (32 males and 17 females)
that benefited from CPR manoeuvres prior to
death and whose necropsies were performed
between January 2015-December 2016. Medi-
cal and police files provided by the authorities
were also analysed in order to interpret nec-
ropsy findings. Descriptive statistics (absolute
values, means, frequencies) were used to report
data.
RESULTS
The 49 cases had a mean age of 47.3 years.
24 cases (48.98%) presented cardiac arrest sec-
ondary to trauma (car accident, fall from height,
traumatic brain injury, strangulation, crushing,
stabbing, intoxications). Most cardiac arrests
(41 cases - 83.67%) occurred in an extra-hos-
pital environment.
CPR duration was reported in 21 cases
(42.86%) and registered a mean value of 42
minutes. Realisation of external cardiac mas-
sage was mentioned in the medical files of 26
cases (53.06%) and defibrillation in 7 cases
(14.29%). Additional gestures like vein punc-
ture were reported (directly or indirectly) in 20
cases (40.82%), surgical interventions in 5 cases
(10.20%), nasogastric tube insertion in one case
(2.04%), thoracic drain insertion (for pneumo-
thorax or pleural effusion) in 3 cases (6.12%).
Twenty cases (40.82%) were ventilated prior
to death with 15 tracheal intubations (30.61%).
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 Sofia David et al.
At the necropsy examination, no traces of
CPR manoeuvres were identified in 4 cases
(8.16%). In another 10 cases (20.41%) the pre­
sence of a puncture site was the only sign of
CPR. These aspects could be explained by the
presence of severe trauma that made impossible
to identify additional lesions.
Intubation injuries were frequently encoun-
tered. Lip lesions (ecchymoses, superficial ero-
sions) were observed in 4 cases (8.16%), dental
lesions (fractures, avulsions) in 2 cases (4.08%),
upper airways haemorrhagic infiltrates (vocal
chords, epiglottis) in 8 cases (16.33%).
In the thoracic region, presternal parch-
mented areas and ecchymoses were noted in 7
cases (14.29%). Rib fractures were among the
most frequent signs of CPR identified in 16
cases (32.65%) and associated to haemorrhag-
ic infiltrates corresponding to the fracture line.
Isolated haemorrhagic infiltrates corresponding
to anterior costal arches were observed in 2
cases (4.08%). Subjects that had important tho-
racic trauma (car accident, crushing, fall from
height) with potential of known rib fractures
were excluded from the analysis. A single case
presented a sternal fracture secondary to car-
diac massage. Generally, of the 26 cases with
known cardiac massage, 61.54% presented rib
fractures.
Intra-thoracic lesions related to cardiac mas-
sage were represented by perivascular haemor-
rhages (7 cases – 14.29%), cardiac petechiae
(6 cases – 12.24%, mostly located on the pos-
terior surface – 3 cases), and pulmonary contu-
sion (1 case – 2.04%).
Intra-abdominal organs were less often the
site of complications secondary to resuscita-
tion. Only 3 cases presented lesions of the di-
gestive or retroperitoneal structures that could
be attributed to CPR manoeuvres (haemorrhagic
gastritis – 2 cases, haemorrhagic infiltrate of
the retroperitoneum – 1 case).
Cutaneous lesions were visualised in most
cases. Even though venous punctures were re-
ported directly or indirectly in the medical files
of 20 cases (40.82%), typical lesions were noted
in 38 cases (77.55%). Other cutaneous lesions
that could be assimilated to CPR manoeuvres
were represented by ecchymoses and erosions
on the upper limbs due to movement of the body
and encountered in 8 cases (16.33%). Traces
left by defibrillator paddles were observed in 4
cases (8.16%). Fresh surgical incisions were
76
present in 5 cases (10.20%) and holes made by
thoracic drain insertions in 3 cases (6.12%).
Cutaneous lesions and rib fractures are
among the most obvious and easy to recognise
signs of CPR manoeuvres compared to intra-
thoracic and intra-abdominal organs lesions that
could erroneously be attributed to other trauma
related to the primary death cause.
DISCUSSIONS
The first elements suggestive for CPR ma-
noeuvres at external examination of the body
are represented by lesions of the lips, oral mu-
cosa and teeth but no current criterion makes
possible the differential diagnosis with non-
resuscitative trauma. The distribution and the
particular location of these lesions are impor-
tant key elements that help differentiating them
from those induced by a third-party interven-
tion.
Injuries to the oral mucosa may be induced
when securing airways, removing a foreign ob-
ject or by vomiting (12) and are capable of
causing bleeding that can be confused with
haemoptysis (4). Lips were injured in 8.1% of
cases and teeth in 1.1% of cases studied by
Krischer et al. (3). The laryngoscope in par-
ticular may remove or fracture the incisors (13).
Ecchymoses and erosions of the scalp, face
and neck are currently observed at external
examination of patients who have undergone
resuscitation (13,14). Even when these wounds
are mild and apparent ordinary, they are impor-
tant for the forensic pathologist who must dis-
tinguish them from those caused by an act of
violence. For example, the marks left by fingers
and nails on the face and neck during resuscita-
tion attempts are located at the base of the
mandible, around the mouth and between the
larynx and the maxilla, and are parallel to each
other while lesions produced during strangula-
tion are irregularly distributed in multiple di-
rections and cover a large area of the neck (12).
Ecchymoses of the nose may also be observed
as a consequence of mouth-to-mouth manoeu-
vres or application of a facial mask. Conjunc-
tival petechiae secondary to hypoxia and in-
creased capillary pressure can occur in up to
21% of cases and should be differentiated from
those appearing secondary to mechanical as-
phyxia (15).
Intubation is associated in about one third
of the cases with the lesions described above
 Forensic Significance of Lesions Induced by Cardiopulmonary Resuscitation
and with tracheo-laryngo-pharyngeal injuries.
A study of 705 autopsies, published in 1987 by
Krischer et al. found them (mucosa lesions,
lacerations, retropharyngeal haemorrhage, mus­
cular haemorrhagic infiltrates, tracheal rupture)
in 20.4% of cases (3). Severe tracheal lesions
could indicate an emergency context.
Other lesions involving cervical and diges-
tive structures (hyoid bone fractures, laryngeal
cartilages fractures, oesophageal perforations)
have been reported in the literature but were
not observed in our series. These are excep-
tional situations that must be known to forensic
pathologists (3). Hyoid bone and thyroid carti-
lage fractures are often associated with adjacent
soft tissue haemorrhage and it is important to
distinguish them from lesions produced during
strangulation (16). Haemorrhagic infiltrates
and fractures occurring in individuals surviving
resuscitation for a period of time are more in-
tense than those observed in death by strangu-
lation (17).
Thoracic ecchymoses and erosions are the
first elements that suggest the realisation of
thoracic compressions as part of CPR. Their
frequency is variable up to 2/3 of cases that
benefited from manual external cardiac mas-
sage (3). These lesions occur most frequently
on the anterior surface of the thorax near the
sternum. Presternal parchmented areas and ec-
chymoses appear secondary to electric defibril-
lation in up to 53.3% of cases (3) especially if
the electrodes are in direct contact with the skin
(without interposed conduction gel).
Rib fractures are also among the most fre-
quent complications found in about 1/3 of cases
(most cases with thoracic compressions) (18).
Clinical factors such as age and sex (greater
prevalence of osteoporosis in elderly women),
or the depth of chest compressions (more than
6 cm) are associated with their appearance (3,
4,7,19). The influence of other factors, such as
CPR duration, the experience of the person
performing cardiac compressions (medical per-
sonnel or witness) is still uncertain (13,20).
They are practically non-existent in children
and infants given the elasticity of the chest wall
at these ages (21). Most rib fractures occur
between the parasternal and anterior axillary
lines and involve the 2nd to the 6th (7th) rib
mostly on the left side when hands are cor-
rectly applied (21). Fractures of the 1rst, 8th and
12th rib are rare same as posterior arch fractures
thus imposing the pursuit of other causes (21).
Generally, there are encountered 5-8 rib fractures/
individual depending on the study (4, 7, 21).
Sternal fractures occur less often compared
to rib fractures, Black et al. discovering them
in 14% of cases (7). They seem to be related
especially to automatic chest compression de-
vices not used in our country.
Perivascular haemorrhagic infiltrations are
poorly described in the literature. However,
they are part of the frequently observed lesions
during necropsy when chest compressions have
been applied and mostly involve the ascending
aorta, superior vena cava and azygos vein but
may extend to the abdominal region in excep-
tional cases (3).
Petechiae on the surface of the heart, most-
ly on the posterior surface, are non-specific to
the CPR and no macroscopic criterion distin-
guishes them from those arising from mechan-
ical asphyxia (intentional or criminal) or agony
(22). Myocardial lesions (rupture) have also
been mentioned in the literature as being re-
lated to chest compressions especially in case
of increased cardiac pressure like in patients
with pulmonary embolism or thinned wall sec-
ondary to a myocardial infarction (23). Krischer
et al. observed some rare lesions such as endo-
cardial dilaceration, intraventricular haemor-
rhage, epicardial haemorrhage, subendocardial
contusion (3). His bundle and coronary arteries
lesions (intimal dilacerations) have been identi-
fied in 44% of cases on histological images (24).
All intra-thoracic structures (vessels, peri-
cardium, heart, lungs, diaphragm) can be injured
(contusion, rupture, perforation, dilaceration)
directly or indirectly by chest com­pressions.
The observed lesions can be directly attributed
to CPR only in the absence of trauma. Pulmo-
nary lesions are identified in 13% of cases
secondary to gastric content inhalation, emphy-
sema or contusion (3). Pulmonary oedema can-
not be directly considered a complication of
CPR but a consequence of prolonged manoeu-
vres. Pneumothorax, haemothorax (azygos vein
rupture) and subcutaneous emphysema can also
complicate chest compressions (25). Diaphrag-
matic lesions are rare same as vertebral fractures.
Intra-abdominal organs such as the liver,
spleen and stomach are less often the site of
complications secondary to resuscitation than
the structures mentioned above. However, due
to their anatomical location, secondary lesions
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 Sofia David et al.

(rupture, perforation, dilaceration) may be ob-
served directly related to chest compressions
or indirectly related, mainly through bone frac-
tures. An improper hand position could facili-
tate the occurrence of these type of injuries
(13). Krischer et al. identified liver lesions in
2.1% of cases (3) compared to 0.32% in an-
other study (26). Similarly, only 3 cases of
post-CPR splenic fracture have been indicated
in the literature (27).
Digestive lesions associated with ventilation
manoeuvres are most commonly observed in
emergency situations where malposition of the
intubation tube is frequent and may result in
oesophageal intubation. This can lead to oe-
sophageal and gastric lesions, sometimes as far
as gastric distension (29.1%) (3), even associ-
ated with pneumoperitoneum and subcutaneous
emphysema if CPR is continued (28). Signs like
cyanosis and abdominal distension indicate a
malposition of the tube (6). Such complications
can also occur during mouth-to-mouth respira-
tions or when using a facial mask (29). Gastric
distension may be complicated by lacerations
and bleeding (9-12%) especially in association
with chest compressions (4). Gastric ruptures
occur rarely and below the gastroesophageal
junction, parallel to the lesser curvature (28).
Ecchymoses, erosions and haemorrhagic in-
filtrations of the inner side of the upper limbs
occurring secondary to body manipulation dur-
ing resuscitation, are rarely mentioned in the
literature, probably due to the lack of repercus-
sions. On the other hand, they have particular
forensic implications because of their specific
location as they may suggest the intervention
of a third party potentially related to the pri-
mary cause of death. It is therefore important
to find precise anamnestic elements concerning
the gestures and manipulations performed dur-
ing resuscitation manoeuvres.
Puncture sites associated with ecchymoses
and underlying haemorrhagic infiltrations are
very often a sign of CPR especially if located
in specific anatomic regions (cubital fossa, dor-
sal hand). Nevertheless, no criterion, makes it
possible to distinguish these lesions from those
provoked by an act causing death (self-injection
or administration by a third party of toxic or
narcotic drugs). Nearly 80% of these lesions
are observed in individuals who have benefited
from intensive care manoeuvres. The precise
origin of each of these punctures must be strict-
ly checked in order not to omit any malicious
intervention by a third party or self-injection
(suicide, drug abuse) (3).
Buschmann et al. and Krischer et al. indi-
cate some other potential and rare lesions oc-
curring during CPR such as those involving the
recurrent nerves, piriform sinus, vocal cords
and arytenoid cartilages (3,6). Hyperextension
of the head during CPR may lead to fractures
of the cervical spine, or even dilacerations of
carotid intima (3,30). Mechanical ventilation is
a potential source of pulmonary barotrauma
which can be complicated by pneumothorax and
subcutaneous emphysema (31).
In common practice, when CPR has been
performed, the absence of any other explana-
tion for certain wounds discovered at necropsy
sometimes leads to the conclusion that CPR is
directly responsible for them. Anamnestic ele-
ments detailed in medical or police files are
essential and must be exhaustive in order to
ensure a certain link between lesions and CPR.
CONCLUSIONS
Injuries produced during CPR may be re-
sponsible for important artefacts impeding the
understanding of traumatic lesions observed
during necropsy and related to the primary
death cause. A thorough knowledge of possible
aspects is mandatory to the differential diagno-
sis with other traumatic lesions.

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Corresponding author

Sofia David
ddavid.sofia@yahoo.com

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