A Nursing Old Wives’ Tale: Effective CPR Always Results In Extensive Rib Fractures

Written by Paul M. Dohse, LPN, ADN, CDP.

In nurse training, there is a heavy emphasis on fact-based care or “best practice.” However, once nurses are working the floor, little additional research or study takes place, and seemingly, fact-based care, in many cases, is replaced with opinion, ideology, and in more recent times, politics. Nurses at all levels should confirm anything that is not common information with research. Nurses need to discern between research evidence and opinion. In our day, even medical authorities like the CDC have been found wanting because of conflicts of interest.

A dominate narrative among nurses in our day concerns code status for the elderly. Since their bones are fragile due to old age, the elderly shouldn’t have a Full Code status because effective CPR will break all of the bones in their rib cage causing great harm and further reducing their low quality of life. One of the primary factors for this assessment is that old age is synonymous with a “low quality of life.” Nurses routinely exhibit frustration regarding older patients that are full code. In many cases, nurses consider full code to be abuse and putting nurses in a position where they are forced to do harm. The horror stories shared among nurses about performing CPR on the elderly abound. Of course, you are expected to always assume the CPR was done properly.

What is the first overt problem with this view? Answer: the proverbial slippery slope greased with subjectivism. What is old? Is it ok for someone in their 60’s being full code? 70s? 80s? 90s? What is too old to be on Full Code status? Should a 20-year-old with Osteogenesis be full code? Should a 40-year-old with Osteoporosis or Osteomalacia be full code? It is alarming that this mentality among nurses is in vogue when you consider the small dose of critical thinking required to expose it as poor nurse judgement. Furthermore, if you want to invoke a deer-in-the-headlights look in a nurse, merely ask her/him to define “quality of life.” Though the term is tossed about routinely in healthcare circles, it is mostly undefined and enslaved to subjective opinion.

So, what are the facts? Most CPR trainers and specialists reject the idea that fractured or broken ribs are synonymous with effective CPR. Training dummies have colored lights that indicate the right amount of pressure to apply during CPR, and it is far from being a violent thrusting. Most CPR trainers describe sternum and ribcage fractures to be rare or “uncommon” as a result of CPR (https://www.cprlittlerock.org/rib-fractures-during-cpr-causes-complications-and-mitigation). Soreness in the chest area and ribs is common.

In a study reported by the National Library of Medicine, “A retrospective observational study based on forensic autopsy material aiming at recording injuries resulting from the application of CPR. The severity of injuries was forensically evaluated.” (https://pmc.ncbi.nlm.nih.gov/articles/PMC6396442/). The study involved 88 individuals who received CPR from “In 96.6% of the cases…specialized staff (medical, paramedical or both), and in 2% of the cases it was performed by both specialists and laypersons.” Results pertinent to this post follow:

• The bodies were those of 53 males and 35 females. At the time of death the age range was 18–87 years.
• out of 88 cases, only 26.1% had rib fractures…17.4% were accompanied with sternal fractures. Most of them were located in the body of the sternum…
• A history of osteoporosis was only found in one case; however, no CPR-related injuries were identified.
• All cases with sternal fractures referred to a single fracture.
• Statistical analysis showed independence between gender and rib or sternal fractures…Similarly, no correlation between age and rib or sternal fractures was found…
• None of the identified CPR-related injuries was lethal. The severity of injuries was evaluated in the aforementioned cases and it was found that 16% of them were mild, 48% were moderate, and 35% of the cases were severe. 
• The major finding of this study were that the incidence of rib and sternal fractures and of soft tissue injuries caused by CPR is consistent with the corresponding rates of other studies… 

Conclusion

Age is just one factor that contributes to bone density. Lifestyle, diet, and diseases are other contributing factors that wouldn’t exclude the use of CPR. There are no fact-based studies that recommend the exclusion of CPR because of age. Furthermore, age is not synonymous with so-called, “quality of life,” whatever that is.