‘The American Journal of Forensic Medline and Pathol uy 0-85, 190, 1190 Raven Press Li, New York Anterior Thoracic Wall Trauma in Elderly Homicide Victims The ‘*CPR Defense” Kris Sperry, M.. During the course of medicolegal postmortem examina- tions, forensic pathologists often encounter the sequelae of cardiopulmonary resuscitation (CPR) that was admin- istered by medical and paramedical personnel. A wide variety of CPR-related injuries have been described since the institution nearly 30 years ago of this now common: place emergency technique. The forensic pathologist must be aware of both typical and unusual CPR-related trauma patterns in order to differentiate between injury produced during emergency therapy procedures and in- Jury sustained through other mechanisms (for example, during an assault or an accident). This article describes ‘wo recent separate and unrelated incidents in which an elderly woman was murdered. In each instance. bony injuries of the anterior thoracic wall structures were identified during the autopsy. Defense attorneys in each ise attempted to use these injuries as proof that their ‘accused clients had performed external cardiac massage ‘on their victims, thus indicating that the homicides had ‘not been intentional. and that the perpetrators showed remorse. These cases are presented, with a discussion of the typical features of CPR-related thoracic wall trauma as compared with willfully inflicted injury. Key Words: Chest wall injuries—Homicide—Cardiopul- monary resuscitation. From the Department of Pathology. Office of the Medical Investigator for the State of New Mexico. University of New Mexico School of Medicine, Albuquerque. New Mexico, Assist- ant Professor. ‘Address correspondence and reprint requests to Kris Sperry. M.D., Department of Pathology. Office of the Medical Investi- galor for the State of New Mexico, University of New Mexico School of Medicine, Albuquerque, NM 87131, U.S.A. 50 Closed-chest cardiac massage as a form of emer- gency resuscitation for cardiac arrest victims was first popularized nearly 30 years ago, and has grad: ually become extremely commonplace in medical care (1). In addition to physicians, nurses, emer- gency medical technicians, and other paramedic: personnel, uncounted thousands of lay individuals have learned the basics of cardiac massage, which, in tandem with external respiratory support, form the cornerstones of cardiopulmonary resuscitation (CPR). As these techniques have evolved and be- come perfected, sporadic reports have slowly sur- faced that have documented a multiplicity of inju- ries that can be inadvertently inflicted upon a cardiac arrest victim during resuscitative efforts. Virtually any abdominal and thoracic organ can be injured in this way and, were it not for the under~ lying disease process that has led to the sudden cardiac arrest in the first place, some of these iatrogenic injuries would, in and of themselve: prove fatal (2). Some of the most common thoraci injuries produced by CPR are fractures of the ribs and sternum, Forensic pathologists encounter the direct results of CPR-induced trauma more frequently than do ‘most other physicians. During medicolegal autop- sies, it is vital to document resuscitative injuries and to differentiate them from injuries that were sustained through other mechanisms, Very ageres- sive external cardiac massage may produce exten- sive injuries, especially in elderly individuals. whose ribs and sternum may be weakened by osteoporosis or other metabolic conditions. Internal injuries of the heart. lungs, great vessels, liver, and upper gastrointestinal tract are all potentiated in older persons whose bony thoracic wall structures, have less than normal resilience. Resuscitative trauma must be correctly categorized by the pathol-THE CPR DEFENSE SI ogist to ensure that lawyers and other physicians who review the autopsy report will not misinterpret such findings as being related to other traumatic mechanisms or, perhaps more importantly. as being the actual cause of death Because CPR techniques are now widely taught and recognized by nonmedical persons, forensic pathologists may be called upon during court testi- ‘mony to differentiate CPR injuries from other types of trauma. In two recent, unrelated instances in which elderly women had been brutally murdered autopsy examinations disclosed various degrees of ‘anterior chest wall trauma. Defense attorneys rep- resenting the accused individuals attempted to use these injuries as tacit proof that their clients had attempted to perform external cardiac massage af- ter finding their victims unresponsive, thus indi ing that the accused did not in fact intend to commit murder and also felt remorse for the rapes that they did commit. The specific findings of each case are as follows. CASE REPORTS Case 1 The body of an 80-year-old woman was discov- cred in the burned remnants of her bedroom. The fire did not spread beyond the bedroom, and the victim was supine, lying within the bedsprings at the foot of the bed. As she was burned beyond visual recognition, antemortem radiographs were obtained and the body was sent for autopsy. pri- marily to establish a positive identification. The death was initially attributed to an accidental fire caused by the victim smoking cigarettes in bed. ‘At the initial examination, her hands were found to be tied behind her back with a partially charred shirt (Fig. 1). The carboxyhemoglobin saturation level was <5%. Internal injuries included cervical soft tissue hemorrhage, a cornual fracture of the right thyroid cartilage, and a fracture with associ- ated hemorrhage between the sixth and seventh cervical vertebrae. The introitus and proximal va~ gina exhibited numerous mucosal hemorrhages, in- dicative of forcible penetration, The right fourth and fifth ribs were fractured anterolaterally, with a small amount of muscular bleeding around the fourth rib fracture, and the left fifth rib was also fractured anteriorly (Fig. 2). The cause of death was certified as strangulation with an associated fracture of the neck. A suspect was caught 2 days after discovery of the woman’s body. This man had been convicted 8 years earlier for the forcible rape and attempted FIG. 1. Case 1, The victim's hands are bound behind her back by a partially charred shir, tied in a double overhand knot. murder of an elderly woman who had survived only because he had been scared away by a car that had pulled into the driveway. The man had been paroled from a penitentiary only 19 days before raping and murdering his latest victim, and had set @ fire in the bedroom in an attempt to cover the crime, He was charged with capital murder. During the trial, one of the defense lawyers focused upon the chest wall injuries that had been described during the autopsy. As anterior and lat- erally placed rib fractures have been associated with external cardiac compression attempts. the attorney postulated that the assailant had become remorseful and had attempted to perform resusci- tative maneuvers after his victim stopped moving. The pathologist testified that, although such injuries of the anterior chest wall are known and recognized CPR complications, the sternum was not involved, nor were other injuries present that would be con- sistent with external compression attempts, espe- ally by an untrained and inexperienced individual. The defendant was a very large and strong man, and, the victim had had osteoporotic alterations of the axial skeleton to the degree where any ugeressive CPR efforts would have probably caused much more extensive central thoracic injury. There was ro expert testimony by the defense either to sub- stuntiate the allegation of CPR administration or to contradict the pathologist. The jury convicted the accused man of first- degree murder and, during the sentencing phase, unanimously agreed that the death penalty be im- posed in this case. The sentence was later com- muted to life imprisonment without parole by the state governor, shortly before he left office. An J Forensic Me Pathol Val 11, No. 1 (032 K. SPERRY FIG. 2. The location and distribution of the chest wall injuries in both cases are graphically depicted. The injuries in case 1 (left) include fractures of the right fourth and fitth ribs, and the left fith rib. The injuries in case 2 (right) include fractures of the right first through ninth ribs, left first through seventh ribs, and two stemal fractures. Case 2 ‘An 89-year-old woman was found. sprawled within the living room of her small house (Fig. 3). She was unclad, and had defecated: handprints smeared in feces were on her body and on the surrounding rug. The house had been ransacked, and a screen on the bedroom window torn out FIG. 3. Case 2. The victim was found sprawled on her back. Her chest injuries were most likely caused during the assault while she was in this position, ‘Am I Forensic Med Path, Va. 11, Xo. 1 10H) The autopsy disclosed a small fracture of the left thyroid cartilage cornua. The chest was extensively injured. both externally and internally. A cluster of contusions was localized over the upper left chest wall, extending onto the clavicular region and the anterior shoulder (Fig. 4). After reflection of the anterior thoracic skin and soft tissues, extensive : ie * e FIG. 4. Case 2. Several contusions are clustered over the Upper anterior left shoulder and clavicular region. These: are not in a typical location for CPR-related injuries, and most likely resulted from direct blows to this area,THE CPR DEFENSE 53 hemorrhage was seen investing the pectoralis re~ gions, intercostal musculature, and parasternal muscles bilaterally. The sternum had two frac tures—between the insertion points of the first and second ribs, and between the third and fourth costosternal joints—with extensive localized hem- orrhage. Copious hemorrhage was apparent in the underlying anterior mediastinal tissues. The left first through seventh ribs were fractured anterolaterally, with severe accompanying soft tis sue and intercostal hemorrhage. The right first through ninth ribs were similarly fractured antero- laterally, in a line, with slightly less accompanying soft tissue and muscular hemorrhage than on the left (Fig. 2). Hemorrhage dissected beneath the apical parietal pleura bilaterally. A few contusions were localized on the anterolateral right and left visceral pleural surfaces, beneath the fractured ribs. ‘The vulvar tissues were hemorrhagic and lacerated, which indicated a violent sexual assault Following a series of fortuitous circumstances. a suspect was arrested whose fingerprints were found both at the scene and on an item of lugeage that he had stolen from the murdered woman. He was charged with capital murder and brought to trial. The defense focused upon two separate issues Firstly. the defendant alleged that he and the dead woman had engaged in a long-term sexual relation- ship, despite a difference of ~60 years between their ages. This was effectively refuted by the extensive vulvar injuries, which proved that the victim had been sexually inactive for many years and had also resisted a violent rape. The second major defensive issues revolved around the severe anterior thoracic wall soft tissue and bony injuries. ‘The defendant alleged that he had not intended to kill the elderly woman, but had accidentally stran- gled her during attempts to keep her quiet. When he realized that she was dead, he began performing external cardiac massage to try to revive her. Thus, the severe chest injuries were unintended sequelae that had complicated his resuscitative efforts. The pathologist who performed the autopsy tes- tified that all of the injuries had clearly occurred while the victim was alive, as the massive associ- ated hemorrhage proved a functional cardiac output when the trauma was inflicted. The extent and severity of the injuries were clearly in excess of even very aggressive CPR. creating essentially a flail chest, which directly led to the victim's death through respiratory insufficiency. The externally visible chest injuries, which included the contusions located on the upper left shoulder and clavicular region, were also not resuscitative in origin, Nu- merous defensive injuries. primarily coalescent contusions on both hands and arms, also served to indicate that the victim had been sexually assaulted The defense retained a specialist in emergency medicine, who testified that the thoracic injuries were all unquestionably related to CPR attempts Upon cross examination, however, he was unable to state what degree of thoracic injury would be expected during external cardiac massage, as com- pared with what injury would be excessive or inconsistent. He also had no familiarity with au- topsy findings in CPR-related trauma. Despite this testimony, the jury convicted the defendant of first-degree murder, and subsequently gave him the death penalty. DISCUSSION Aggressive external cardiac massage techniques fare meant to maintain corporeal blood circulation specifically to the brain, in instances where the heart is either asystolic or has a rhythm that is inadequate 10 provide sufficient blood flow. ‘Through repetitive compressions. coupled with pu monary insufflation to provide oxygen and carbon dioxide exchange. life may be maintained and hy- poxia averted until either electrical or pharmaco- logic means restore a functional cardiac rhythm. Firm, forcible compressions are necessary to sus- tain blood flow. and the force required to achieve adequate tissue perfusion has the potential to cause untoward complications. Additionally, improper hand placement during compression can unexpect- edly damage both thoracic and abdominal organs The elderly are at increased risk for thoracic wall complications, because they do not have the bony resiliency of younger individuals, and their bones may be even more brittle through the development of osteoporosis or other metabolic disorders. Rib and sternum fractures are the most common complications associated with external cardiac mas- sage (3-6). However, the actual incidence of rib and sternal fracture reported in the medical literature has been quite variable, occurring in from 16% to as high as 80% of all patients undergoing CPR (7.8). A few studies have not only examined the presence of rib fractures, but grouped the injuries based on the numbers of ribs involved. These figures are partic ularly valuable in differentiating iatrogenic injury during CPR from intentionally inflicted trauma Patterson et al. (3) examined 379 consecutive nec- ropsies (excluding infants) in which resuscitation was performed, finding fractures of 1-4 ribs in only 32 cases (8.4%). and fractures of five or more ribs in ‘Am Forensic Med Pathol, Vol, 11 No, 1090S4 K. SPERRY only 10 cases (2.6%). Sternal fractures were de- tected in only five cases (1.3%). In an earlier series, Himmethoch et al. (6) detected 2-8 rib fractures in 16 (31%) of 52 autopsied cases, and eight fractures in another two cases (3.8%). ‘The most commonly fractured ribs during exter- nal cardiac compression are those in the middle of the chest, which articulate with the midsternal region. This is the location that is typically forcibly compressed by the individual performing the CPR manipulations, and characteristically may include any or all of the third through seventh ribs, unilat- erally or bilaterally. Fractures of other ribs are certainly possible, depending upon both abnormal hand placement during compressive activity and the force that is exerted by the person doing the com- pressions, Thus. hand positioning too high might injure the upper anterior ribs, placement too far laterally may cause unilateral fractures well away from the midline, and positioning too low may even spare the ribs while injuring the liver. spleen, or segments of hollow viscus. Distinct localization of specific CPR complications away from the central thoracic region can indicate abnormal hand place- ment. This information is valuable in the clinical setting, as medical and paramedical personnel should be notified of atypically located injuries in order to correct faulty and improper resuscitative technique. In the first case outlined here, the thoracic wall injuries were relatively few and separated. Given the violent nature of the assault, these injuries are ot unexpected as the sequelae of forcible rape in an elderly woman, and are perhaps even more readily explained because the victim's hands were bound behind her back. Although the defense attor- neys suggested a CPR defense. they did not explore it extensively or offer further expert testimony to support this allegation The second case exhibited much greater chest wall injury. The severity of the injuries was far in excess of even extensive known complications of external cardiac massage. and included bilateral first-rib fractures, a total of 16 rib fractures, and a double sternal fracture. The rib fractures were widely separated, in anterolateral distributions, rather than in parasternal locations as would be expected in more typical CPR-related trauma. These findings made it much more likely that the injuries were sustained during @ violent assault, while the assailant was perhaps positioned with his knees on the victim’s chest, with the full force of his weight bearing down upon the broad diameter of the chest wall while simultaneously restraining her. Am J Forensic Med Patil, Vol HI, No 1 1900 ‘This would result in a broadly applied force, which could easily have caused the multitude of injuries. The contusions on the upper left shoulder region, well away from even the most unconventional site of CPR administration, indicated that blows had been struck upon this site. The location, distribu- tion, and severity of the injuries formed the basis whereby the pathologist testified that the injuries inflicted upon the elderly woman dramatically ex- ceeded those commonly associated with external cardiac massage, and were in greatest probability caused by a violent assault. Despite expert testi- mony to the contrary, the jury agreed with the pathologist's opinions. CONCLUSIONS, ‘As new techniques evolve within the spectrum of medical therapy. complications involving their use are inevitable. It is imperative that the forensic pathologist become familiar with patterns of tissue alteration that may be the inadvertent sequelae of therapeutic maneuvers, so as to avoid misidentifi- cation of the actual origin of such injuries, In most instances, the trauma inflicted during CPR is re: recognized. although some of the more unusual complications may confuse even experienced pi thologists. Liver lacerations, splenic and pancreatic injury, cardiac rupture, pneumothorax. aortic laceration, and systemic fat embolism (2) are all conditions that have been directly related to both properly and improperly performed external cardiac massage. and, in different settings, may each be distinctly certified as a cause of death. Most of the time, however, the body of a person who has required CPR will exhibit a medical condition, injury. or combination thereof that adequately explains a sud- den cessation of vital functions, enabling the med- ical examiner to segregate CPR-related injuries properly and consider them evidence of therapy. Furthermore, as CPR is usually administered by medical and paramedical personnel, the pathologist may readily consult with these caregivers to accu- rately delineate the scope of the therapy provided, ‘as well as their perceptions about possible injuries that were caused during their ministrations. How difficult is it to differentiate actual, inten- tionally inflicted traumatic thoracic or abdominal injuries from the sequelae of medical therapy when itis alleged that an accused perpetrator of a violent crime attempted resuscitative actions? Defense at- torneys are aware that external cardiac massage is common knowledge among large groups of non-medical individuals through training courses that disseminate this information and by the dramatic situations portrayed on medical-themed television shows. Itis not unreasonable to expect that a clever attorney might depict chest injuries, and even intra- abdominal trauma, as being the result of an abortive attempt at resuscitation, and thereby dissemble their actual importance to the jury. Fortunately. three factors in this approach oper- ate against the success of such obfuscatory strate- gies. Firstly. the trained and experienced forensic pathologist should. in the majority of cases. be able to distinguish between CPR-induced trauma and other injury patterns. This testimony will obviously carry a great deal of weight, especially if communi- cated with certainty. Secondly, the nature of violent assaults that can cause thoracic and abdominal injuries is such that there are generally other inju- ries in other parts of the body that substantiate the excessive degrees of force that have been applied. Finally, it is ultimately up to the jury to either believe or discount allegations of resuscitative as- sistance performed by the perpetrator of a violent assault. Logically, even if the injuries are consistent with such claims, the fact that the assault itself preceded any such real or imaginary assistance is inherent proof that a crime has been committed. The concept of the cracked egg. that “you take your victim as you find him or her,"” must apply to these situations, and allegations of external cardiac massage are somewhat irrelevant when held in 55 comparison to the underlying issues of lethal violent injury. In the two cases presented here. the juries clearly did not consider purported cardiac resusci- tation as a viable and legitimate explanation for the injuries suffered by the two victims, nor did they view CPR as sufficiently mitigating to decrease the severity of the crime. It is to be hoped that this approach will continue in the future. when cardio- pulmonary resuscitation is inevitably again brought forth as an explanation for severe thoracic or ab- dominal injuries in homicidal assault victims. REFERENCES 1. Kouwenhoven WD, Jude JR, Knickerbocker GG. Closed: chest eardiae massage. JAMA™1960:173: 1064-7. ‘Atcheson SG, Fred HL. Complications of cardiac resuscita tion. Am Heart J 19TS:89:263-5, 3, Patterson RH, Burns WA. Jannotta FS. Complications of external cardise resuscitation: & retrospective review sand Survey of the literature, Med Ann DC 1974:43:389-95 4. Nagel EL. Fine EG. Krischer JP. Davis JH. Complications of CPR. Crit Cure Med 1981:9:424, 5, Bedell SE, Fulton EJ. 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