Internal Cardiac Massage Research Articles

Modernization of Cardiac Advanced Life Support: Role and Value of Cardiothoracic Anesthesiologist Intensivist in Post–Cardiac Surgery Arrest Resuscitation

Cardiac arrest in the post-operative cardiac surgery patient requires a unique set of management skills that deviates from traditional cardiopulmonary resuscitation and Advanced Cardiovascular Life Support (ACLS). Cardiac Advanced Life Support (CALS) was first proposed in 2005 to address these intricacies. The hallmark of CALS is early chest reopening and internal cardiac massage within five minutes of the cardiac arrest in patients unresponsive to basic life support. Since the introduction of CALS, the landscape of cardiac surgery has continued to evolve.Cardiac intensivists encounter more patients who undergo cardiac surgical procedures performed via minimally invasive techniques such as lateral thoracotomy or mini sternotomy, in which an initial bedside sternotomy for cardiac massage is not applicable. Given the heterogeneous nature of the patient population in the cardiothoracic intensive care unit (CTICU), personnel must expeditiously identify the most appropriate rescue strategy. As such, we have proposed a modified CALS approach to (1) adapt to a newer generation of cardiac surgery patients and (2) incorporate advanced resuscitative techniques. These include rescue-focused cardiac ultrasound to aid in the early identification of underlying pathology and guide resuscitation and early institution of extracorporeal cardiopulmonary resuscitation (ECPR) instead of chest re-opening. While these therapies are not immediately available in all cardiac surgery centers, we hope this creates a framework to revise guidelines to include these recommendations to improve outcomes and how cardiac anesthesiologist intensivists' evolving role can aid resuscitation.

Nurses' roles and responsibilities in cardiac advanced life support: A single-site eDelphi study.

Nurses are often the first responders to in-hospital cardiac arrest in postoperative cardiac surgical patients. Poor clarity about role expectations and responsibilities can hinder nurses' performance during cardiac advanced life support (CALS) procedures. To seek expert consensus on nurses' roles and responsibilities in CALS for patients in postoperative cardiac surgical patients. A two-round modified eDelphi survey. Delphi items were informed by guideline literature, an audit of resuscitation records and expert interviews. Panellists, drawn from a single site of a large tertiary health service in metropolitan Melbourne, included nurses, doctors and surgeons familiar with the management of cardiac arrest in post-operative cardiac surgical patients. The two rounds of the modified eDelphi generated 55 responses. A consensus of >80% agreement was reached for 24 of the 41 statements in Round 2. All items related to nurses' roles and responsibilities during nurses pre- and post-arrest phases reached consensus. In contrast, only 29% (n= 4/14) of items related to peri-arrest, and 36% of those related to nurse scope of practise in CALS arrest (n= 4/11) reached consensus. The study's aim was only partially achieved. Findings indicate high agreement about nurses' roles and responsibilities before and immediately after a cardiac arrest, but limited clarity about nurses' roles when implementing the CALS protocol, such as resternotomy and internal cardiac massage. There is an urgent need to address uncertainty about nurses' roles and scope of practice in CALS, which is essential to the recognition of nurses' contribution to the cardiac specialty workforce. Uncertainty about nurses 'roles and responsibilities when implementing the CALS protocol may hinder their performance to their full scope of practice, leading to poor patient outcomes.

The Australasian ANZSCTS/ANZICS guidelines on cardiothoracic advanced life support (CALS-ANZ)

Every year, more than 15 000 patients undergo cardiac surgery in Australia and NewZealand. 1 The overall incidence of cardiac arrest after cardiac surgery is between 0.7% and5.2%. 2, 3, 4, 5, 6 Most cardiac arrests occur within 24 hours of surgery, with up to 50% occurring in the first 3 hours following intensive care unit (ICU)admission. 2, 7 Compared with other in-hospital cardiac arrests, survival in this patient population is high (75% v 39%). 2, 8 The reasons for this include the high degree of cardiac monitoring; a high proportion of reversible causes, such as pericardial tamponade or haemorrhage, and the effects of internal cardiacmassage. 9, 10, 11 The application of standard advanced life support protocols in post-surgical cardiothoracic patients may lead to avoidable adverse events, and hence, specific resuscitation protocols have been developed and established in Europe and NorthAmerica. 12

Multivessel coronary artery vasospasm masquerading as surgical coronary atherosclerotic disease

We report a case of a 39-year-old lady presenting with worsening angina. This is a case report study. Clinical case data was retrieved from hospital paper and electronic records. Invasive coronary angiography revealed disease in the left main stem, proximal left anterior descending (LAD) artery and circumflex artery. The patient proceeded to on-pump coronary artery bypass grafting. Intraoperatively, there were multiple unsuccessful attempts to wean off cardiopulmonary bypass. An on-table angiogram-which initially triggered asystole requiring internal cardiac massage and institution of venoarterial extracorporeal membrane oxygenation (ECMO)- showed no native coronary artery disease. Instead, this angiogram revealed severe vasospasm with narrowing in the grafts and distal LAD. The patient received calcium channel blockers and bilateral thoracic sympathectomies to suppress any further coronary vasospasm. She was subsequently successfully weaned off ECMO. This case reveals the life-threatening nature and diagnostic dilemma posed by severe multivessel coronary vasospasm. We also highlight the novel role of thoracic sympathectomy for definitive management of refractory vasospastic angina.

Heart rupture repair during huge mediastinal mass resection \u2013 case report

BackgroundVentricular rupture is rarely described in the literature outside the context of myocardial infarction, infection or neoplasm. It is associated with a high mortality rate due to late presentation and delayed surgical intervention, which involves sutureless or sutured techniques. Comprehensive literature review failed to identify any case of intra-operative right ventricular heart rupture followed by myocardial repair and a complete recovery after a prolonged intensive care unit (ICU) stay.Case presentationA 57-year-old previously healthy gentleman presented complaining of a new onset shortness of breath for 2 months. A large mediastinal mass was found on chest imaging and biopsy revealed a thymoma. Patient received a neoadjuvant Cisplatin/Doxorubicin/Cyclophosphamide (CAP) regimen chemotherapy then sternotomy and thymectomy en bloc with anterior pericardium. Post-thymectomy, the patient continued to be hypotensive in recovery despite aggressive fluid resuscitation. He was sent back to theatre, aggressive fluid resuscitation continued, surgical site exploration was done by reopening the sternum, and the bleeding source was identified and controlled, but intraoperative asystole developed. During internal cardiac massage, the right ventricle ruptured with a 3 cm defect which was successfully repaired using a pericardial patch without a bypass machine due to unavailability at our cancer center. The patient remained dependent on mechanical ventilation through tracheostomy for a total of 2 months due to bilateral phrenic nerve paralysis, was discharged from ICU to the surgical floor 66 days after the operation and weaned off ventilator support after 85 days, adequate respiratory and physical rehabilitation followed. Patient is doing very well now with excellent performance, and free of tumor recurrence 30 months after surgery.ConclusionRight ventricular rupture is rarely described outside the context of myocardial infarction and valvular heart disease. Tumor proximity to the heart and neoadjuvant cardiotoxic chemotherapy are the proposed causes for precipitating the cardiac rupture in our case. Post-surgical patients who receive early physical rehabilitation and respiratory physiotherapy have improved survival and outcome.

Low versus standard-blood-flow reperfusion strategy in a pig model of refractory cardiac arrest resuscitated with Extra Corporeal Membrane Oxygenation

ObjectiveThis study was designed to assess the effect of two veno-arterial ExtraCorporeal Membrane Oxygenation (ECMO) blood-flow strategies in an experimental model of Extracorporeal Cardio-Pulmonary Resuscitation (ECPR) on macrocirculatory, metabolic and microcirculatory parameters in the first six hours of ECMO initiation. MethodsCardiac arrest was induced in 18 pigs by surgical ligature of the left descending coronary artery followed by a low-flow time of 40 min using internal cardiac massage. ECPR was initiated in normothermia with an ECMO blood flow of 30–35 ml.kg−1. min−1 (low-blood-flow group, LBF) or 65–70 ml.kg−1. min-1 (standard-blood-flow group, SBF), with the same mean arterial pressure target of 65 mmHg adjusted with norepinephrine. Macrocirculatory and metabolic parameters were assessed by lactate clearance and carotid blood flow. Microcirculatory parameters were assessed by sublingual microcirculation with Sidestream Dark Field (SDF) imaging and peripheral Near-InfraRed Spectrometry (NIRS). Inflammatory cytokine levels were measured with a multicomplexed ELISA-based array platform. ResultsThere were no between-group differences at baseline and at ECMO initiation (H0). Lactate clearance at H6 was lower in LBF compared to SBF (6.67[-10.43-18.78] vs. 47.41[19.54–70.69] %, p = 0.04). Carotid blood flow was significantly lower (p<0.005) during the last four hours despite similar mean arterial pressure levels. For microvascular parameters, SDF and NIRS parameters were transitorily impaired at H3 in LBF. IL-6 cytokine level was significantly higher in LBF at the end of the experiment. ConclusionIn an experimental porcine model of refractory cardiac arrest treated by ECMO, a low-blood-flow strategy during the first six hours of resuscitation was associated with lower lactate clearance and lower cerebral blood flow with no benefits on ischemia-reperfusion parameters.

Resuscitation thoracotomy

Resuscitation thoracotomy is a rarely performed procedure whose use, in France, remains marginal. It has five specific goals that correspond point-by-point to the causes of traumatic cardiac arrest: decompression of pericardial tamponade, control of cardiac hemorrhage, performance of internal cardiac massage, cross-clamping of the descending thoracic aorta, and control of lung injuries and other intra-thoracic hemorrhage. This approach is part of an overall Damage Control strategy, with a targeted operating time of less than 60minutes. It is indicated for patients with cardiac arrest after penetrating thoracic trauma if the duration of cardio-pulmonary ressuscitation (CPR) is <15minutes, or <10minutes in case of closed trauma, and for patients with refractory shock with systolic blood pressure <65mm Hg. The overall survival rate is 12% with a 12% incidence of neurological sequelae. Survival in case of penetrating trauma is 10%, but as high as 20% in case of stab wounds, and only 6% in case of closed trauma. As long as the above-mentioned indications are observed, resuscitation thoracotomy is fully justified in the event of an afflux of injured victims of terrorist attacks.

The effect of thoracoscopy upon the repair of pectus excavatum

The Nuss procedure is the most commonly performed operation to correct pectus excavatum (PE). Thoracoscopic assistance has been anecdotally noted to improve the safety of this operative approach. This study aimed to compare complications and clinical outcomes before and after the introduction of thoracoscopy in a single-center. A retrospective review was performed of all patients who underwent the Nuss procedure at The Royal Children's Hospital over an 11-year period (2005-2015), collecting data on all intra-operative and post-operative outcomes. A total of 217 Nuss procedures were performed (122 non-thoracoscopic pectus repairs, 95 thoracoscopic pectus repairs). Median patient age was 14.9years, with the majority male (185/217, 84.3%). Patient demographics (age, gender, defect severity) and postoperative recovery were comparable between the two groups. Major complications included cardiac arrest requiring internal cardiac massage, hemothorax, pneumothorax, empyema, bar displacement and infection. The overall major complication rate was low (19/217, 8.8%); however, there was a significant reduction in major complications in the thoracoscopic pectus repair group (13.1% versus 3.2%, p=0.02). Thoracoscopic vision during the Nuss procedure reduces the risk of major complications. Treatment study - Level III (Retrospective comparative study).

Implementation of a Simulation-Based Cardiac Surgery Advanced Life Support Course

BackgroundNurses rarely have the opportunity to gain experience with the low-volume high-risk event of cardiac arrest and emergent bedside resternotomy in the cardiothoracic surgery patient. MethodNonprobability sample consisted of 33 intensive and progressive care nurses at a cardiovascular specialty hospital. Five- to eight-hour cardiac surgery advance life support courses with didactic content and four simulated patient scenarios were held. Team time to internal cardiac massage (TICM) was recorded with all patient scenarios. Participants completed the Student Satisfaction and Self-Confidence in Leaning survey postcourse. ResultsAll teams demonstrated improvements in TICM from initial scenario to final scenario with a mean time of 441.8 seconds for initial scenario and 237.8 seconds for final scenario. Student Satisfaction and Self-Confidence in Leaning survey results indicated participants were satisfied with simulated scenario practice and self-confident in their learning. ConclusionTICM results support that teams improved their performance with the emergent resternotomy, and participants expressed satisfaction and self-confidence in learning.

FAST RIB RETRACTOR FOR INTERNAL CARDIAC MASSAGE IN DOGS – THE VENTURA RETRACTOR

Cardiorespiratory arrest is a common affection in small animal practice. Thus, internal cardiac massage has not been addressed with adequate instruments for its realization, which implies slower thoracic inlet through the use of Finochietto retractor. In this way, the aim of this article was to disclose the project of a rib retractor that could decrease the thoracic opening time, properly allowing internal cardiac massage. Ten canine corpses, with corporal mass between tree and 60 kg, were employed, with non-related to thoracic injuries causa mortis. Mechanical efficiency calculation was also accomplished. The Ventura Retractor was capable of decreasing the thoracic opening time, making it easier to execute, thanks to its simple and mechanically efficient design, which can concur to outliving.

Establishing Benchmarks for Resuscitation of Traumatic Circulatory Arrest: Success-to-Rescue and Survival among 1,708 Patients

Attempts are made with emergency department thoracotomy (EDT) to salvage trauma patients who present to the hospital in extremis. The EDT allows for relief of cardiac tamponade, internal cardiac massage, and proximal hemorrhage control. Minimally invasive techniques, such as endovascular hemorrhage control (EHC) are available, but their noninferiority to EDT remains unproven. Before adopting EHC, it is important to evaluate the current outcomes of EDT. We hypothesized that EDT survival has improved during the last 4 decades, and outcomes stratified by pre-hospital CPR and injury patterns will provide benchmarks for success-to-rescue and survival outcomes for patients in extremis. Consecutive trauma patients undergoing EDT from 1975 to 2014 were prospectively observed as part of quality improvement. Predicted probabilities of survival were adjusted for pre-hospital CPR, mechanism of injury, injury pattern, patient demographics, and time period of EDT using logistic regression. Success-to-rescue was defined as return of spontaneous circulation with blood pressure permissive for transfer to the operating room. There were 1,708 EDTs included, with an overall 419 (24%) success-to-rescue patients and 106 survivors (6%), and 1,394 (79%) of these patients had pre-hospital CPR and 900 (54%) had penetrating wounds. The most common injury patterns were chest (29%), multisystem with head (27%), and multisystem without head (21%). Penetrating injury was associated with higher survival than blunt trauma (9% vs 3% p < 0.001). Success-to-rescue increased from 22% in 1975 to 1979 to 35% over the final 5 years (p < 0.001); survival increased from 5% to 14% (p < 0.001). Outcomes of EDT have improved over the past 40 years. In the last 5 years, STR was 35% and overall survival was 14%. These prospective observational data provide benchmarks to define the role of EHC as an alternative approach for patients arriving in extremis.

Does internal cardiac massage play a role in ROSC after prolonged CPR ? : Our experience in a tertiary care hospital

AbstractCardiopulmonary resuscitation (CPR) is a life-saving skill involving chest compressions &amp; ventilation to pump oxygenated blood through the vital organs of the body. Among different techniques and devices for chest compression, no single method has been definitively shown to produce the best outcome and hence, direct comparisons between them are not possible. Internal cardiac massage is the manual squeezing of the heart through a surgical incision into the chest cavity, when the chest is already open for cardiac surgery. Unlike the usual cardiac arrest scenarios, internal cardiac massage is employed mostly in cardiothoracic surgical patients and will have more chance for survival and favorable neurologic outcomes across all durations of CPR. We describe two cases of return of spontaneous circulation (ROSC) after prolonged CPR with internal cardiac massage performed in hospital setting.

Use of Resuscitative Endovascular Balloon Occlusion of the Aorta in a Highly Lethal Model of Noncompressible Torso Hemorrhage

Noncompressible torso hemorrhage is a leading cause of death in trauma, with many patients dying before definitive hemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct than can be used to expand the window of salvage in patients with end-stage hemorrhagic shock. The aim of this study was to evaluate the effect of continuous and intermittent REBOA (iREBOA) on mortality using a highly lethal porcine model of noncompressible torso hemorrhage. Male splenectomized pigs (70-90 kg) underwent a laparoscopic liver injury (80% resection of left lobe) followed by a 10-min free-bleed period. Animals were then divided into three groups (n = 8) for a 60-min intervention phase (n = 8): continuous occlusion (cREBOA), iREBOA, or no occlusion (nREBOA). Groups then underwent whole blood resuscitation, damage control surgery, and further critical care. Endpoints were mortality and hemodynamic and circulating measures of shock and resuscitation. Systolic blood pressure (in mmHg) at the end of the free-bleed period for cREBOA, iREBOA, and nREBOA was 31 ± 14, 48 ± 28, and 28 ± 17, respectively (P = 0.125). Following the start of the intervention phase, systolic blood pressure was higher in the iREBOA and cREBOA groups compared with the nREBOA (85 ± 37 and 96 ± 20 vs. 42 ± 4; P < 0.001). Overall mortality for the cREBOA, iREBOA, and nREBOA groups was 25.0%, 37.5%, and 100.0% (P = 0.001). Resuscitative endovascular balloon occlusion of the aorta can temporize exsanguinating hemorrhage and restore life-sustaining perfusion, bridging critical physiology to definitive hemorrhage control. Prospective observational studies of REBOA as a hemorrhage control adjunct should be undertaken in appropriate groups of human trauma patients.

When should cardiopulmonary bypass be used in the setting of severe hypothermic cardiac arrest?

A best evidence topic was written according to a structured protocol. The question addressed was regarding the indication and timing of the use of cardiopulmonary bypass (CPB), following severe hypothermic cardiac arrest. A total of 284 papers were found using the reported searches, of which nine represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were survival, rewarming speed, incidence of arrhythmia during rewarming, resolution of full neurological function, long-term neurological function, evidence of damage on neurological imaging and venous metabolic parameters in hypothermic patients. The most recent of the best evidence studies, a retrospective comparative study of 68 patients, demonstrated CPB rewarming to be far superior to conventional methods of rewarming, with mortality rates of 15.8 and 53.3%, respectively. Another study of similar size, comparing CPB with extracorporeal membrane oxygenation (ECMO) for rewarming, revealed superior survival rates with ECMO, 75 vs 34%. A systematic review of 68 patients demonstrated an overall survival of 60%, and 80% of survivors returning to a previous level of activity. Two smaller observational studies reported survival rates of 73.1 and 45.5%, respectively. A retrospective study analysing long-term neurological outcomes of survivors reported normal history and physical examination in 93.3%, normal neurovascular ultrasound in 100%, normal neuropsychological findings in 93.3% and normal brain magnetic resonance imaging in 86.7%. A small comparative study demonstrated a significant survival benefit when CPB was preceded with emergency thoracotomy, internal cardiac massage and warm mediastinal irrigation compared with CPB alone. We conclude that, following deep hypothermic circulatory arrest, the urgent use of cardiopulmonary bypass is widely indicated for rewarming where it has been shown to provide good survival and neurological outcomes far superior in comparison with conventional methods of rewarming.

Insulin Facilitates the Recovery of Myocardial Contractility and Conduction during Cardiac Compression in Rabbits with Bupivacaine-Induced Cardiovascular Collapse

Bupivacaine inhibits cardiac conduction and contractility. Insulin enhances cardiac repolarization and myocardial contractility. We hypothesizes that insulin therapy would be effective in resuscitating bupivacaine-induced cardiac toxicity in rabbits. Twelve rabbits were tracheally intubated and midline sternotomy was performed under general anesthesia. Cardiovascular collapse (CVC) was induced by an IV bolus injection of bupivacaine 10 mg/kg. The rabbits were treated with either saline (control) or insulin injection, administered as a 2 U/kg bolus. Internal cardiac massage was performed until the return of spontaneous circulation (ROSC) and the time to the return of sinus rhythm (ROSR) was also noted in both groups. Arterial blood pressure, and electrocardiography were continuously monitored for 30 min and plasma bupivacaine concentrations at every 5 min. The ROSC, ROSR and normalization of QRS duration were attained faster in the insulin-treated group than in the control group. At the ROSC, there was a significant difference in bupivacaine concentration between two groups. Insulin facilitates the return of myocardial contractility and conduction from bupivacaine-induced CVC in rabbits. However, recovery of cardiac conduction is dependent mainly on the change of plasma bupivacaine concentrations.

Re: Guideline for resuscitation in cardiac arrest after cardiac surgery

Dr Dunning et al. [1] published guidelines for resuscitation of patients suffering cardiac arrest after cardiac surgery; hoping that this document would be helpful when the International Liaison Committee on Resuscitation (ILCOR) guidelines are updated in 2010. In creating these guidelines, efforts were made to obtain as wide a range of opinions as possible from the cardiothoracic surgical community and beyond; including topic reviews open to online comments for 2 months, which were published together with these reviews. However, none of these e-comments was referenced; some of which [2] contributed to these guidelines in that discussion included new concepts brought to the authors’ attention through these e-comments. It was suggested that abdominal-only (AO) cardiopulmonary resuscitation (CPR) (or AO-CPR) can immediately be appliedduring theperformanceof a sternotomy, resternotomy or thoracostomy, thereby allowing uninterrupted CPR [2]. However, aspointedout in these guidelines, further research is necessary before AO-CPR during resternotomy can be recommended for routine use. Some of this research is already underway in humans. Two case reports of AO-CPR during resternotomy were recently brought to my attention; which, according to the authors, resulted after reading my e-comment [2] cited above. They described two patients in whom AO-CPR was used; in patient 1, the generated systolic blood pressures measured from the radial artery were the same as conventional CPR and, in patient 2, were the same as internal cardiacmassage. They are currently considering using a protocol of primary abdominal CPR for all their cardiac surgery patients; however, consensus and training have not been achieved as yet. Themost recent animal study of AO-CPR [3], not referenced by these guidelines, indicates that AO-CPR provides far superior compression-induced ventilation (an adequate breath for each compression/decompression cycle) and equivalent, if not better, haemodynamics when compared to chest-only (CO) CPR (or CO-CPR) and standard CPR. In addition to the aforementioned potential/theoretical advantages of AO-CPR, another advantage is the likelihood that CPR does not have to be interrupted to perform endotracheal intubation. Intubating the patient with a Boussignac multichannel endotracheal tube would allow the delivery of constant-flow insufflation of 100% oxygen (CFIO) [4]. CFIO has been reported to be an efficient ventilatory method (with greater oxygenation when compared to the group of intubated patients that were mechanically ventilated) during continuous CO-CPR for cardiac arrest in humans [4]. Continuous CO-CPR ensures maximal haemodynamic efficiency [5]. Perhaps use of a Boussignac tube should be advocated in all cardiac surgery patients that are to remain intubated after surgery. The recommendation made in these guidelines that if the patient is not intubated then the second person to attend the arrest should administer 100% oxygen with a bag/valve/mask with two breaths every 30 compressions optimises neither ventilation/oxygenation nor circulation. On the other hand, immediate use of a Boussignac tube along with uninterrupted AO-CPR could allow the ‘ultimate’ optimisation of both ventilation/oxygenation and circulation because of its already superior ventilation and haemodynamics. Perhaps nurses caring for cardiac surgery patients that are not already intubated should be required to be proficient in endotracheal intubation.

Prehospital Emergency Thoracotomy: When to Do It?

Traumatic injuries still constitute one of the leading causes of death in all age groups. Emergency thoracotomy is a procedure carried out in patients presenting in extremis. The primary goals are the control of massive hemorrhage, the release of cardiac tamponade, the internal or open cardiac massage, the prevention or control of air embolism, the control of bronchopleural fistulae and the cross-clamping of descending aorta. Although the usefulness of prehospital emergency thoracotomy remains controversial and specific guidelines are lacking, when faced with no alternative, it can be a lifesaving procedure. A comprehensive search for relevant studies was performed from 1975 to the present. An algorithm is proposed to assist physicians in deciding when to perform on scene thoracotomy.

A New Internal Cardiac Massage Technique

Classical internal cardiac massage mostly can increase systolic blood pressure to maintain sufficient brain and systemic organ perfusion but diastolic blood pressure commonly remains below 10 mmHg. To be able to increase the diastolic blood pressure sufficiently, the surgeon grabs the distal part of the ascending aorta between the thumb and index finger of the left hand and squeezes it during the diastolic time period to increase the diastolic pressure. Ascending aorta is released during ventricular squeezing, and subsequently ascending aorta is squeezed during the ventricular relaxation.

Surgical Challenges for Urgent Approach in Penetrating Heart Injuries

The aim of this clinical study is to assess the characteristics of penetrating heart injury and its surgical challenges for urgent surgical approach. Seventeen patients suffering from penetrating heart wounds were evaluated retrospectively in the department of cardiovascular surgery between 1996 and 2004. All patients were male, with ages ranging from 19 to 36 years, with a mean age of 23.6 +/- 5 years. Median sternotomy, left anterior thoracotomy, and right anterior thoracotomy were performed to control the bleeding or to reach the heart for internal cardiac massage in 5, 11 and, 1 control, respectively. The right ventricle was the most commonly injured chamber (64.7%, n = 12), followed by left ventricle (17.7%, n = 4), and right atrium (17.6%, n = 3); a left atrial injury was not seen. Mortality rate was 29% (5 cases), and 12 controls were discharged without any complications. Although the most important factor affecting mortality in penetrating heart injuries is rapid transport, an urgent approach applied by a specialist team can decrease potential mortality and morbidity rates.

Additional specialist training for cardiac intensive care staff on cardiac arrests is urgently needed

The European Resuscitation Council guidelines of December 2005 [1] have called for the training of ‘non-surgical medical staff to re-open the sternotomy’ in cases of cardiac arrest. We have commenced a course to teach these skills and a range of additional skills for the care of the critically ill patient in the cardiac intensive care unit (ICU) [2–3]. We do not however have a clear idea of the current level of skills possessed by cardiac ICU nurses in our region and we therefore conducted a three-centre survey to elucidate this more clearly. A survey was conducted in three cardiac ICUs. Two shifts at each centre were selected to ensure high compliance. The survey asked the respondent to rank their confidence in a range of clinical skills required in either a medical or in a cardiothoracic cardiac arrest. Sixty-one nursing staff were questioned: 48 staff nurses, 12 sisters and one matron. Mean (range) number of years in the cardiac ICU was 5.5 (1–20) years, and number of chest re-openings that they had attended was 9 (0–50+). Of the nurses, 79% were happy to perform external defibrillation, 81% did not know how to perform internal defibrillation, and 40% did not know how to connect up the internal defibrillators. Thirty-nine percent of nurses would not be confident to drape the patient while maintaining good sterility and only 30% had ever put on a sterile gown and gloves to assist at a chest reopening. Sixty-nine percent would not feel confident to pass the correct instruments to a surgeon from a thoracotomy set and 71% did not know how to set-up an intra-aortic balloon pump machine. Ninety-two percent would not be confident to re-open the sternotomy incision even if clinically required, 86% would not know how to remove the sternal wires, and 84% of staff members would not be able to perform internal cardiac massage. While 85% had received Basic or Advanced Cardiac Life Support training, only four nurses had ever received any formal training for cardiac arrests in patients following cardiac surgery; 96% of nurse would go on such a course if available. Our survey has identified critical gaps in the skill base of our cardiothoracic nursing staff. We advocate programmes of formal training in all UK cardiothoracic ICUs to address this deficiency.