Rationale for Open-Chest Cardiopulmonary Resuscitation

Abstract

Present national and international guidelines for resuscitation call for open-chest cardiopulmonary resuscitation (CPR) instead of standard external CPR under the following circumstances associated with pulselessness:1) chest already open;2) penetrating thoracic trauma;3) suspected intrathoracic hemorrhage;4) suspected pulmonary embolism (thoracotomy permits disruption or removal of emboli);5) deep hypothermia (open chest allows direct warming of the heart for defibrillation); and6) no palpable artificial pulse during standard external CPR basic life support, as is sometimes encountered in cases of barrel chest or spine deformities.We will present evidence in support of a 7th indication, that is when standard external CPR advanced life support efforts do not result in the prompt restoration of spontaneous circulation, as may be the case after prolonged unwitnessed cardiac arrest or in patients with severe myocardial disease.Historically, open-chest CPR has been used effectively to reverse cardiac arrest in laboratory animals since the 1980s and in patients since 1900. We conducted interviews with Drs. DelGuercio, Johnson, Stephenson and Leighninger (for Beck), who have had extensive experience with open-chest CPR. All confirmed personal experience of one of us (PS) with open-chest CPR in the 1950s, and anecdotal reports, that during direct cardiac massage, the heart usually regained color, spontaneous breathing returned, survivors had a very low incidence of neurologic deficit, and complications were almost non-existent. Stephenson's review of 1200 cases of open-chest CPR hospital-wide between 1900 and 1950 (1) report an overall recovery rate of 30%. However, after Kouwenhoven's report on closed-chest CPR in 1960 (2), open-chest CPR became a forgotten art.