Precordial Thump Research Articles

Advanced life support interventions during intra-operative cardiac arrest among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists.

Few existing resuscitation guidelines include specific reference to intra-operative cardiac arrest, but its optimal treatment is likely to require some adaptation of standard protocols. We analysed data from the 7th National Audit Project of the Royal College of Anaesthetists to determine the incidence and outcome from intra-operative cardiac arrest and to summarise the advanced life support interventions reported as being used by anaesthetists. In the baseline survey, > 50% of anaesthetists responded that they would start chest compressions when the non-invasive systolic pressure was < 40-50 mmHg. Of the 881 registry patients, 548 were adult patients (aged > 18 years) having non-obstetric procedures under the care of an anaesthetist, and who had arrested during anaesthesia (from induction to emergence). Sustained return of spontaneous circulation was achieved in 425 (78%) patients and 338 (62%) were alive at the time of reporting. In the 365 patients with pulseless electrical activity or bradycardia, adrenaline was given as a 1 mg bolus in 237 (65%). A precordial thump was used in 14 (3%) patients, and although this was associated with return of spontaneous circulation at the next rhythm check in almost three-quarters of patients, in only one of these was the initial rhythm shockable. Calcium (gluconate or chloride) and 8.4% sodium bicarbonate were given to 51 (9%) and 25 (5%) patients, but there were specific indications for these treatments in less than half of the patients. A thrombolytic drug was given to 5 (1%) patients, and extracorporeal cardiopulmonary resuscitation was used in 9 (2%) of which eight occurred during cardiac procedures. The specific characteristics of intra-operative cardiac arrest imply that its optimal treatment requires modifications to standard advanced life support guidelines.

Computational modelling of mechano-electric feedback and its arrhythmogenic effects in human ventricular models

The current study aims to investigate the role of mechano-electric feedback (MEF) in healthy cardiac cycles and in cardiac arrhythmia using human ventricular models. The numerical formulation of stretch-activated channels (SACs) in terms of the fibre stretch of the myocardium is incorporated into the modified Hill model that describes the myocardium as an electro-visco-active material. Additionally, we propose models of SACs formulated in terms of the rate of stretch along fibre direction and the stretch along sheet direction. We analyze the effect of the three different models for SACs and different material properties on the regular cycles by using electrocardiogram and volume-time curves, and show that the each model of SACs has regionally different influences on the heart model. Moreover, we simulate ‘commotio cordis’ and ‘precordial thump’ and demonstrate that MEF plays a major role in the occurrence of fibrillation and defibrillation in the absence of the structural cardiac damage. Furthermore, we study the role of MEF in premature ventricular contraction when the blood pressure is disturbed.

AGITATED, ALTERED, AND ELONGATED: THE RISKS OF DIPHENHYDRAMINE OVERDOSE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Overdose has become a leading cause of injury-related death in the United States. Rapid recognition of a toxidrome is vital in determining management. CASE PRESENTATION: A young, unknown female was brought to the ED after being found agitated and combative. Evaluation was notable for tachycardia, mydriasis and diaphoresis. She received intramuscular diphenhydramine (DPH), haloperidol and lorazepam for agitation.She developed a wide QRS complex with polymorphic ventricular tachycardia (VT) concerning for Torsades de pointes, terminated by precordial thump. She was intubated for airway protection. Magnesium and sodium bicarbonate (NaHCO) pushes were administered for sustained monomorphic VT with return to sinus tachycardia. Electrocardiogram was significant for prolonged QTc of 607ms and QRS >150ms. Initial toxicology was negative for acetaminophen, salicylate and ethanol.NaHCO infusion with goal pH 7.5 to maintain a narrow QRS was started. She had persistently prolonged QT interval. Overdrive transcutaneous pacing was unsuccessful, so isoproterenol (IPN) infusion was started. NaHCO and IPN infusions were discontinued at 48 hours with no further arrhythmias. Extended toxicology screen was positive for DPH. On extubation, she endorsed consumption of >1.25g DPH. DISCUSSION: Classic anticholinergic symptoms of tachycardia, mydriasis and delirium are also the toxidrome for DPH overdose. Severe toxicity is observed after ingestion of >1.0g (1). Cardiac toxicity is exhibited as widening of QRS and QTc intervals (1-3). Similar to TCA overdose, QRS widening is manifested from blockade of the fast-closing myocardial sodium channels (2-3). Treatment for QRS widening with NaHCO is anecdotally recommended (2-3). In this case, bolus and infusion of NaHCO successfully shortened the patient's QRS duration. One case report suggested using lipid emulsion therapy(3); however, DPH intoxication was not suspected initially thereby limiting its use. Since presenting symptoms of DPH and anticholinergic toxicity overlap, physostigmine must be avoided due to QRS prolonging effects (2). This case reminds of cautious administration of the "B52" cocktail for agitated patients. The use of intravenous DPH, haloperidol and lorazepam can be used to calm acutely agitated or aggressive patients; yet, it should be avoided with unknown ingestions.Further, QT prolongation and polymorphic VT can result from DPH's ability to weakly block the delayed rectifier potassium channels (2). Traditionally resolving this includes overdrive pacing and magnesium supplementation, which were administered in this case. However, failed overdrive transcutaneous pacing led to IPN infusion to induce tachycardia-associated QTc shortening. CONCLUSIONS: High suspicion and familiarity with toxidromes can lead to early diagnosis and intervention for critically ill patients presenting with agitated altered mental status. REFERENCE #1: Radovanovic D, Meier PJ, Guirguis M, Lorent JP, Kupferschmidt H. Dose-dependent toxicity of diphenhydramine overdose. Hum Exp Toxicol. 2000 Sep;19(9):489-95. doi: 10.1191/096032700671040438 REFERENCE #2: Jang DH, Manini AF, Trueger NS, et al. Status epilepticus and wide-complex tachycardia secondary to diphenhydramine overdose. Clin Toxicol (Phila). 2010;48(9):945-948. doi:10.3109/15563650.2010.527850 REFERENCE #3: Abdi A, Rose E, Levine M. Diphenhydramine overdose with intraventricular conduction delay treated with hypertonic sodium bicarbonate and i.v. lipid emulsion. West J Emerg Med. 2014;15(7):855-858. doi:10.5811/westjem.2014.8.23407 DISCLOSURES: No relevant relationships by Joy Ayyoub, source=Web Response No relevant relationships by Lauren Catalano, source=Web Response No relevant relationships by Sydney Emerson, source=Web Response No relevant relationships by Shahrzad Zonoozi, source=Web Response

Prolonged Intraoperative Cardiac Arrest in a Young Patient with Successful Precordial Thump

Cardiac arrest during surgery is rare but is one of the most dreaded complications. Precordial thump (PT) had been used for a long time, but in the present day it has become obsolete. In regard to the witnessed onset of asystole, there is insufficient evidence to recommend for or against the use of the PT. This case report is of a 17-year-old male who presented to hospital with a congenital haemangioma on the right calf. He had no other significant medical conditions and was on no other medications. The patient history, clinical examination, and investigations were normal. He had undergone an operation 3 weeks previously where a section of his haemangioma was excised, and an appointment was made for excision of the remaining haemangioma. Anaesthesia induction and endotracheal intubation were smooth and uneventful. Following lifting and exsanguination of the patient’s leg by Esmarch bandage, he developed ventricular fibrillation and arrested with asystole. Cardiopulmonary resuscitation was performed, with no good response, for approximately 50 minutes. Lastly, a PT was performed, and the patient’s heart rate immediately returned. The operation was postponed. Postresuscitation care was conducted in an intensive care unit. The patient was later discharged without complications.

Prolonged Intraoperative Cardiac Arrest in a Young Patient with Successful Precordial Thump

Cardiac arrest during surgery is rare but is one of the most dreaded complications. Precordial thump (PT) had been used for a long time, but in the present day it has become obsolete. In regard to the witnessed onset of asystole, there is insufficient evidence to recommend for or against the use of the PT. This case report is of a 17-year-old male who presented to hospital with a congenital haemangioma on the right calf. He had no other significant medical conditions and was on no other medications. The patient history, clinical examination, and investigations were normal. He had undergone an operation 3 weeks previously where a section of his haemangioma was excised, and an appointment was made for excision of the remaining haemangioma. Anaesthesia induction and endotracheal intubation were smooth and uneventful. Following lifting and exsanguination of the patient’s leg by Esmarch bandage, he developed ventricular fibrillation and arrested with asystole. Cardiopulmonary resuscitation was performed, with no good response, for approximately 50 minutes. Lastly, a PT was performed, and the patient’s heart rate immediately returned. The operation was postponed. Postresuscitation care was conducted in an intensive care unit. The patient was later discharged without complications.

Prolonged Intraoperative Cardiac Arrest in a Young Patient with Successful Precordial Thump

Cardiac arrest during surgery is rare but is one of the most dreaded complications. Precordial thump (PT) had been used for a long time, but in the present day it has become obsolete. In regard to the witnessed onset of asystole, there is insufficient evidence to recommend for or against the use of the PT. This case report is of a 17-year-old male who presented to hospital with a congenital haemangioma on the right calf. He had no other significant medical conditions and was on no other medications. The patient history, clinical examination, and investigations were normal. He had undergone an operation 3 weeks previously where a section of his haemangioma was excised, and an appointment was made for excision of the remaining haemangioma. Anaesthesia induction and endotracheal intubation were smooth and uneventful. Following lifting and exsanguination of the patient’s leg by Esmarch bandage, he developed ventricular fibrillation and arrested with asystole. Cardiopulmonary resuscitation was performed, with no good response, for approximately 50 minutes. Lastly, a PT was performed, and the patient’s heart rate immediately returned. The operation was postponed. Postresuscitation care was conducted in an intensive care unit. The patient was later discharged without complications.

Effects of gadolinium on cardiac mechanosensitivity in whole isolated swine hearts

Mechanical stimulation can elicit electrical activation of the heart. This mechanosensitivity can start life-threatening arrhythmias (commotio cordis) or terminate them (precordial thump). Mechanosensitivity may also be involved in arrhythmogenesis in other settings. Stretch-activated ion channels (SACs) are thought to be important in mechanosensitivity and a number of agents that block them have been identified. Such agents could potentially be used as tools in experimental investigation of mechanosensitivity. However, studies using them in intact-heart preparations have yielded inconsistent results. In the present study, we used isolated, perfused hearts from 25–35 kg pigs and a computer-controlled device that repeatably delivered focal mechanical stimuli. The concentration-dependent ability of the SAC blocker gadolinium to suppress mechanical activation was assessed by the success rate of mechanical stimulation and by the delay between successful mechanical stimulation and electrical activation. In six hearts, perfusate was recirculated. In an additional six hearts, perfusate was not recirculated to prevent gadolinium from forming complexes with metabolic waste and possibly precipitating. Gadolinium did not suppress mechanically-induced activation. Although gadolinium has been shown to be an effective SAC blocker in isolated cells, using it to probe the role of mechanical stimulation in whole heart preparations should be done with great caution.

Effectiveness of precordial thump in the treatment of shockable rhythms

Effectiveness of precordial thump in the treatment of shockable rhythms

Correction

HomeCirculationVol. 128, No. 19Correction Free AccessCorrectionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCorrectionPDF/EPUBCorrection Originally published5 Nov 2013https://doi.org/10.1161/01.cir.0000436976.88168.0cCirculation. 2013;128:e393This article corrects the followingPart 5: Adult Basic Life SupportIn the article by Sayre et al, “Part 5: Adult Basic Life Support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations,” which published online October 18, 2010, and appeared with the October 19, 2010, issue of the journal (Circulation. 2010;122[suppl 2]:), a correction was needed:On page S302, left column, in the section “Firm Surface for Chest Compressions,” the paragraph under the heading “Treatment Recommendation” was replaced. The paragraph read,The precordial thump should not be used for unwitnessed out-of-hospital cardiac arrest. The precordial thump may be considered for patients with monitored, unstable ventricular tachycardia if a defibrillator is not immediately available. There is insufficient evidence to recommend for or against the use of the precordial thump for witnessed onset of asystole.The paragraph now reads,CPR should be performed on a firm surface when possible. Air-filled mattresses should be routinely deflated during CPR. There is insufficient evidence for or against the use of backboards during CPR. If a backboard is used, rescuers should minimize delay in initiation of chest compressions, minimize interruption in chest compressions, and take care to avoid dislodging catheters and tubes during backboard placement.The authors regret the error.This correction has been made to the current online version of the article, which is available at http://circ.ahajournals.org/content/122/16_suppl_2/S298. Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesPart 5: Adult Basic Life SupportMichael R. Sayre, et al. Circulation. 2010;122:S298-S324 November 5, 2013Vol 128, Issue 19 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/01.cir.0000436976.88168.0c Originally publishedNovember 5, 2013 PDF download Advertisement

Treatment of monitored out-of-hospital ventricular fibrillation and pulseless ventricular tachycardia utilising the precordial thump

BackgroundFew studies have described the value of the precordial thump (PT) as first-line treatment of monitored out-of-hospital cardiac arrest (OHCA) from ventricular fibrillation and pulseless ventricular tachycardia (VF/VT). MethodsPatient data was extracted from the Victorian Ambulance Cardiac Arrest Registry (VACAR) for all OHCA witnessed by paramedics between 2003 and 2011. Adult patients who suffered a monitored VF/VT of presumed cardiac aetiology were included. Cases were excluded if the arrest occurred after arrival at hospital, or a ‘do not resuscitate’ directive was documented. Patients were assigned into two groups according to the use of the PT or defibrillation as first-line treatment. The study outcomes were: impact of first shock/thump on return of spontaneous circulation (ROSC), overall ROSC, and survival to hospital discharge. ResultsA total of 434 cases met the eligibility criteria, of which first-line treatment involved a PT in 103 (23.7%) and immediate defibrillation in 325 (74.8%) cases. Patient characteristics did not differ significantly between groups. Seventeen patients (16.5%) observed a PT-induced rhythm change, including five cases of ROSC and 10 rhythm deteriorations. Immediate defibrillation resulted in significantly higher levels of immediate ROSC (57.8% vs. 4.9%, p<0.0001), without excess rhythm deteriorations (12.3% vs. 9.7%, p=0.48). Of the five successful PT attempts, three required defibrillation following re-arrest. Overall ROSC and survival to hospital discharge did not differ significantly between groups. ConclusionThe PT used as first-line treatment of monitored VF/VT rarely results in ROSC, and is more often associated with rhythm deterioration.

Off-patient assessment of pre-cordial impact mechanics among medical professionals in North-East Italy involved in emergency cardiac resuscitation

Pre-cordial thump (PT) relies on cardiac mechano-electric transduction to transform mechanically-delivered energy into an electrophysiologically relevant stimulus. Its use for emergency resuscitation has declined recent years, amidst concerns about effectiveness and side-effects. In addition, there is insufficient knowledge about bio-mechanical properties and mechanisms of PT. Using a PT-mechanics recorder, we measured PT off-patient among healthcare professionals (n = 58) in North-East Italy, and related this to retrospective information on self-reported PT outcomes. Impact-speed and peak-force were 4.7 ± 1.3 m s−1 (2.2–7.8 m s−1) and 394 ± 110 N (202–648 N), respectively. Average self-reported cardioversion rate by PT was 35%. No adverse events were stated. All but 3 of PT providers with self-reported cardioversion rates ≥50% had pre-impact fist-speeds of ≥3.7 m s−1. In comparison with previously-reported data from UK and US (n = 22 each), self-reported success-rates and pre-impact fist-speeds were more similar to US (PT-induced cardioversion rate 27.7%; fist-speed 4.17 ± 1.68 m s−1) than to UK participants (PT-induced cardioversion rate 13.3%; fist-speed 1.55 ± 0.68 m s−1). Small cohort-size, retrospective nature of data-gathering, and ‘self-selection bias’ (participants who have used PT on patients) limits the extent to which firm conclusions can be drawn. Observations are compatible, though, with the possibility that pre-impact fist-speed may affect success-rate of PT. Thus, where PT is used for acute resuscitation, it is delivered because it is immediately ‘at hand’. Negative side effects are rare or absent in witnessed cardiac arrest cases. Pre-impact fist-speed may be a determinant of outcome, and this could be trained using devices suitable for self-assessment.

Precordial Thump and Fist Pacing. ARC and NZRC Guideline 2010

Emergency Medicine AustralasiaVolume 23, Issue 3 p. 275-276 Precordial Thump and Fist Pacing. ARC and NZRC Guideline 2010 Australian Resuscitation Council, New Zealand Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation CouncilSearch for more papers by this author Australian Resuscitation Council, New Zealand Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation CouncilSearch for more papers by this author First published: 14 June 2011 https://doi.org/10.1111/j.1742-6723.2011.01422_11.xCitations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume23, Issue3June 2011Pages 275-276 RelatedInformation

Models of stretch-activated ventricular arrhythmias

One of the most important components of mechanoelectric coupling is stretch-activated channels, sarcolemmal channels that open upon mechanical stimuli. Uncovering the mechanisms by which stretch-activated channels contribute to ventricular arrhythmogenesis under a variety of pathologic conditions is hampered by the lack of experimental methodologies that can record the 3-dimensional electromechanical activity simultaneously at high spatiotemporal resolution. Computer modeling provides such an opportunity. The goal of this review is to illustrate the utility of sophisticated, physiologically realistic, whole heart computer simulations in determining the role of mechanoelectric coupling in ventricular arrhythmogenesis. We first present the various ways by which stretch-activated channels have been modeled and demonstrate how these channels affect cardiac electrophysiologic properties. Next, we use an electrophysiologic model of the rabbit ventricles to understand how so-called commotio cordis, the mechanical impact to the precordial region of the heart, can initiate ventricular tachycardia via the recruitment of stretch-activated channels. Using the same model, we also provide mechanistic insight into the termination of arrhythmias by precordial thump under normal and globally ischemic conditions. Lastly, we use a novel anatomically realistic dynamic 3-dimensional coupled electromechanical model of the rabbit ventricles to gain insight into the role of electromechanical dysfunction in arrhythmogenesis during acute regional ischemia.

Reanimation durch präkordialen Faustschlag

The case of 16-year-old, ASA I classified patient who suffered cardiac arrest during orthopedic surgery is reported. Return of spontaneous circulation was achieved with a precordial thump. The patient was discharged from hospital without any neurological deficits 10 days after the event.

Emergent precordial percussion revisited – pacing the heart in asystole

Precordial percussion is a technique by which a manual force is applied repeatedly to the chest of a patient experiencing an unstable bradycardic or asystolic rhythm. The force is used not to defibrillate the myocardium as is the case with the “precordial thump” in pulseless ventricular tachycardia/ventricular fibrillation but rather to initiate a current through the myocardium in the form of an essentially mechanically paced beat. In this review, we discuss the physiology and utility of precordial percussion, or precordial thump, in the emergency setting as a very temporary bridge to more effective and permanent pacing techniques.

Extracorporeal cardiac mechanical stimulation: precordial thump and precordial percussion

External cardiac mechanical stimulation is one of the fastest resuscitative manoeuvres possible in the emergency setting. Precordial thump (PT), initially reported for treatment of atrio-ventricular block, has been subsequently described to cardiovert also ventricular tachycardia (VT) and fibrillation (VF). PT efficacy, mechanics and mechanisms remain poorly characterized. Appropriate MESH and free terms were searched on PubMed, Embase and the Cochrane Library. Cross-referencing from articles and reviews, and forward search using SCOPUS and Google scholar have also been performed. Pre-set inclusion and exclusion criteria were applied to retrieved references on PT, which were then reviewed, summarized and interpreted. PT is not effective in treating VF, and of limited use for VT, although it has a very good safety profile (97% no changed/improved rhythm). If delivered, PT should be applied as early as possible after cardiac arrest, and cardio-pulmonary resuscitation (CPR) should begin with no delay if not effective. A relatively large fraction of reported positive outcomes (both for PT and the less forceful but serially applied precordial percussion) in witnessed asystole should be considered when critically reviewing present CPR recommendations. In addition, mechanisms, energy requirements and timing are analysed and discussed. The 2005 ALS guidelines recommend PT delivery only by healthcare professionals trained in the technique. The use of training aids should therefore be explored, regardless of whether they are based on stand-alone devices or integrated within resuscitation mannequins.

Cardiac arrest after submucosal infiltration with lignocaine 2%—epinephrine in nasal surgery: A case report

ABSTRACTA case of a 26-year-old ASA I physical status male undergoing septoplasty had an abrupt pulseless ventricular tachycardia following submucosal infiltration of lignocaine 2% with epinephrine 1: 200,000 combination. Ventricular tachycardia associated with unconsciousness and absent peripheral pulse was transient and easily reverted by precordial thump, but was recurrent. Ventricular tachycardia was replaced by ventricular bigeminy and subsequently by sinus tachycardia.

Postoperative exostosis of the xiphoid process: a contraindication for precordial thump

Postoperative exostosis of the xiphoid process: a contraindication for precordial thump

Precordial thump for cardiac arrest is effective for asystole but not for ventricular fibrillation

Precordial thump for cardiac arrest remains controversial. Although precordial blows can trigger ventricular fibrillation (VF) (i.e., commotio cordis), they paradoxically have been regarded as potential therapy for cardiac arrest. In commotio cordis, impact energy and resultant peak left ventricular (LV) pressure are important variables in VF initiation. The purpose of this study was to assess the relationship between LV pressures generated by thumps and their effectiveness in defibrillation of VF or resuscitation of asystole after defibrillation. After induction of VF, 10 swine each received 18 chest thumps; two sets of three thumps each with a clenched fist, a 30-mph lacrosse ball, and a 40-mph lacrosse ball. If asystole followed defibrillation, manual thumps were given to induce ventricular depolarizations until resumption of spontaneous rhythm. During VF, generated LV pressure (mmHg) was 263 +/- 52 with manual thumps, 392 +/- 179 with 30-mph ball thumps, and 616 +/- 182 with 40-mph ball thumps (P <.001). None of the 180 thumps terminated VF. All episodes required electrical defibrillation. During asystole, generated LV pressures were greater for thumps that induced ventricular depolarizations than for those that did not (111 +/- 27 mmHg vs 73 +/- 23 mmHg, P <.001). A significant association was observed between induction of ventricular depolarizations and thump-generated LV pressures (odds ratio 2.0 per 10 mmHg rise in LV pressure, 95% confidence interval 1.8-2.1). Despite generating high LV pressures, precordial thumps were not effective in terminating VF. Based on these data, precordial thump for VF in cardiac arrest victims cannot be recommended but for asystolic victims might be beneficial.

Defibrillation in clinical practice

To discuss recent data that may influence defibrillation in clinical practice and improve outcome after cardiac arrest from a shockable rhythm. Reducing the preshock pause (interval between stopping chest compressions and shock delivery) improves shock success. The preshock pause can be reduced by continuing chest compressions during defibrillator charging and using performance-integrated debriefing to improve the efficiency of the resuscitation team. The findings of a study documenting leakage current during elective cardioversion imply that the risk to healthcare personnel of accidental electrocution during defibrillation has probably been overstated. One study has shown that when more than one shock is required, a strategy of escalating defibrillation energies may be more effective than using a fixed energy. Findings from three recent studies suggest that the precordial thump is ineffective for terminating ventricular fibrillation or ventricular tachycardia. A defibrillation strategy that enables rhythm analysis to recognize ventricular fibrillation, defibrillator charging and optimally timed shock delivery with minimal or no interruptions to chest compressions should improve the chances of shock success. Performance debriefing of rescuers and recognizing that the risk to rescuers during defibrillation has been overstated should also help minimize interruptions to chest compressions for shock delivery.