To thump, or not to thump
It has been a known fact that a cardiac arrest is a medical emergency that is potentially reversible if treated early, but however, with delayed or absent intervention, clinical death is inevitable.
In this report, I describe a case of successful cardiac resuscitation at my work place in the Intensive Care Unit, where an uncommon practice was performed and has helped save a patient’s life.
In the cardiac chain of survival (American Heart Association, 2011), it is emphasized that early access, recognition, cardiopulmonary resuscitation (CPR), defibrillation and advanced life support can improve chances of survival and recovery for such patients. But how about an early precordial thump?
I remember being briefly told in nursing school about the existence of a precordial thump as an early life saving measure of pulseless ventricular tachycardia (VT) and monitored ventricular fibrillation (VF) if no early access to a defibrillator is around. It is performed by a highly trained medical professional, witnessed, where he/she gives a single strike to a patient’s precordium with the fist, and that would cause an electrical depolarization to the heart of about 5 joules, which can regain a patient’s cardiac function. (NursingTimes.net)
In the 1980s, The American Heart Association recommended the precordial thump as the initial maneuver in treatment of VT and VF, based on a large report of successful attempts. (Miller J. et all 1984) However, as times progressed, precordial thumps have been deemphasized, and in my opinion, due to the large number, and easy accessibility to medical assistance and an automated external defibrillator, either in public or in hospitals, and also the increasing number of reported studies of failed attempts.
Mr. XYZ, a 60-year-old Chinese male has been admitted to our unit after going through a surgery for decortication of his right lung.
The patient, a taxi driver, had a medical history of hypertension, hyperlipidemia, and non-insulin dependent diabetes mellitus for the past 10 years. His regular daily medication includes aspirin, simvastatin and metformin. He was an ex-smoker and has quit 3 years ago.
On admission post surgery, he was sedated and intubated, his vital signs stable. A mediastinal and right pleural chest drain was attached to 80mmHg intermittent suction with moderate to minimal haemoserous fluid drainage.
He was successfully weaned off from sedation and then extubated 4 hours post surgery. Vital signs maintained stable and drainage from the chest tubes were minimum for the next 24 hours.
Mr. XYZ started mobilizing the next day with light breathing and physical exercises aided by the physiotherapist. He was sat on the chair for lunch and 2 hours later was assisted back to bed for rest. According to the nurse in charge, he fell asleep shortly after being back on bed.
About 30 minutes later, the monitor’s alarm sounded, and as I was nursing a patient directly across Mr. XYZ, I witnessed the incident. The monitor showed ventricular tachycardia (VT) and patient appeared to be unconscious. The nurse (a very experienced one) immediately assessed the patient for pulse and consciousness before quickly putting the patient down in supine position.
She then quickly checked for any interference between the patient and the monitoring devices before confirming the true arrhythmia and delivered a sharp precordial thump to the patient. And about a second later, Mr. XYZ’s cardiac rhythm was reverted back to sinus rhythm. Mr. XYZ was not aware of what has happened. Upon questioning, he said that he was asleep before being awoken by the strike on his chest. He did not mention of any chest pain/tightness or shortness or breath prior to the incident.
Vital signs were immediately measured, aside from a slightly compromised blood pressure (about 85/40mmHg), his heart rate, cardiac rhythm and oxygen saturation were normal. A 12-lead ECG was taken which suggested an ischemic heart, and further investigations such as an echocardiogram were performed, and confirmed a new onset of ischemic heart disease.
Mr. XYZ was then placed under ICU care for one more day before being transferred to the general ward with telemetry monitoring. No recurrence of arrhythmia was reported. He continued to receive follow-up by the cardiac team.
Deadly arrhythmias can occur to many around us, and can present itself as symptomatic or asymptomatic. It can happen frequently in the ICU settings where most patients are unstable haemodynamically, and especially if their cardiac function has been compromised.
According to Singapore Medical Journal Resuscitation guidelines (2011), upon recognition of a shockable rhythm, defibrillation was the first prescribed procedure, and if no monitoring device is around, cardiopulmonary resuscitation (CPR) was recommended as the initial step. There has been no mention of a precordial thump in the guidelines.
In a study in 2005, results of a precordial thump was founds to have a 60% success rate in a non-ischemic heart, and a 30% in ischemic heart. (Li, Kohl, Trayanova, 2005)
However in another study, it mentioned that a precordial thump was not successful in terminating a malignant arrhythmia as 99% of patients eventually required external defibrillation. (Amir et al., 2007)
Another study suggested that precordial thump can be combined with standard resuscitatory interventions to increase chance of survival. (Pellis et al., 2008)
Resuscitation of cardiac arrested patients can often not be successful. And a precordial thump remains controversial for such situations. In this clinical case study, I have mentioned a successful attempt in saving a patient’s life using such maneuver. However, other studies have proven that majority of such attempts has been unsuccessful. Although no adverse effect from a precordial thump has been reported in these studies, a precordial thump is still not a common practice in Singapore’s context, and no such training or education has been provided to nurses undertaking either basic, or advanced cardiac life support courses. Should we receive training and education about such a maneuver, such that it can be considered to be used as one of the resuscitatory resorts when an external defibrillator is not available? Or should this practice diminish in years to come as fewer and fewer of such an action is performed?
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