Precordial Thump


Article Author:
Julia Hutchison


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Eugene Hu


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Sandeep Sekhon


Updated:
9/10/2019 10:03:04 PM

Introduction

Almost all fictional medical television shows feature a scene where a patient suddenly suffers from a cardiac arrest, and a heroic doctor thumps on their chest and seemingly miraculously saves them. The precordial thump, although frequently featured as successful in show business is less effective, and its use is more limited in real life. Currently, its use is recommended only for witnessed, monitored, unstable ventricular tachycardia when a defibrillator is not immediately available.[1] The technique is fast and easy to perform, and the first descriptions of the procedure date back to the 1920s.[2] The goal of precordial thump is to restore organized electrical cardiac activity and convert the patient from ventricular tachycardia to a more stable and organized rhythm. 

Anatomy

For a precordial thump to be effective, the healthcare professional must identify the proper anatomical landmarks to know where to deliver the thump and which part of their fist should make contact with the patient. The physician should make a closed fist and impact the patient with the ulnar side of their fist.[3] The ulnar side of the hand is the side of the fifth or little finger.  The fist should make contact with the bottom third of the patient’s sternum.[4] The sternum is a flat and plate-shaped bone of the anterior chest wall. It is comprised of three parts, which named superiorly to inferiorly are the manubrium, body, and xiphoid. The sternum protects the internal organs of the chest cavity, including the heart and lungs. The sternum connects to the ribs via cartilage and other chest wall bones to form the anterior chest cavity. It is identifiable on the anterior chest wall by palpating the U-shaped sternal notch, which is the apex and then palpating inferiorly until the encountering the pointy-shaped xiphoid.

Indications

Indication for a precordial thump is a patient with a witnessed cardiac arrest where a defibrillator is not immediately available with an unstable ventricular tachycardia observed on a monitor.[1] The ventricular tachycardia can be with or without a pulse. A precordial thump should not delay cardiac-pulmonary resuscitation, or defibrillation if available.[1]

Contraindications

If defibrillation is immediately available, it should be used preferentially over a precordial thump. There is not enough evidence to support the use of a precordial thump in asystole or unwitnessed cardiac arrest.[1] 

Equipment

Cardiac monitoring to confirm the presence of ventricular tachycardia is necessary. A clinician with a firmly clenched fist capable of delivering a firm blow is necessary. Usual equipment for cardiopulmonary resuscitation should be gathered by other personnel while performing the procedure, in case it is not successful.

Personnel

The technique is performable by an individual, but its success rates are low. If the procedure fails a healthcare team, including physicians, nurses, and technicians, will be needed to start cardiopulmonary resuscitation. If the procedure is successful, a multidisciplinary team will still be necessary to continue to stabilize and diagnose the underlying pathology in these patients. 

Preparation

In preparation for the precordial thump, the physician should make a firmly clenched fist and hold their arm approximately 20 centimeters above the patient. They should identify the correct anatomic landmarks to apply the blow in the proper location. Other team members should be gathering supplies and preparing for possible failure, which would necessitate advanced life support protocol or further stabilization efforts if successful. 

Technique

After observing unstable ventricular tachycardia on the monitor, and defibrillation is not immediately available, a firmly clenched fist at approximately 20 centimeters above the patient should swiftly strike the inferior third of the patient’s sternum. After making contact, the physician should immediately remove their hand to allow for chest recoil. The cardiac monitor should be observed for any change in rhythm, and proper advanced cardiac life support protocol followed after the blow. 

Complications

The precordial thump aims to terminate deadly arrhythmias. However, the thump can have the opposite effect and send the patient into a more unstable rhythm or asystole.[5] If blow delivery is not to the correct location, injury can occur from blunt trauma. Reports exist of sternal fractures, osteomyelitis, and thromboembolic stroke after precordial thumps.[1][6][7] An incorrectly placed, aggressive blow to the xiphoid can cause dislocation of the xiphoid with resultant injury to internal organs, for example, the liver, with resulting hemorrhage. There is also the potential for musculoskeletal injury to the medical professional performing the thump. 

Clinical Significance

Researchers have studied the precordial thump in multiple clinical settings. Results of studies looking at out of hospital cardiac arrests are mixed.[8] One more extensive study by Pellis et al., as well as several case reports, have documented the success of the precordial thump. Pellis et al. from 2009 found that precordial thump resulted in twenty-five percent of patients who regained circulation after witnessed cardiac arrest, and they did not find any adverse effects from preforming precordial thump.[2] However, Nheme et all from 2013 concluded that precordial thump was infrequently associated with the return of spontaneous circulation and more frequently resulted in deterioration of rhythm.[5] In this study, out of 434 cardiac arrests, there were 103 cases involving the use of the precordial thump and 325 cases using defibrillation.[5] Of the 103 patients who received precordial thump, five experienced return of spontaneous circulation (with 3 of the 5 experiencing repeat arrest warranting defibrillation).[5] Ten of the 103 patients who received precordial thump experienced rhythm deterioration.[5] Defibrillation was associated with 57.8% of the return of spontaneous circulation without significant rhythm deterioration versus 4.9% in the precordial thump group.[5] 

Hospital-based case series studies looking at the effectiveness of the precordial thump during electrophysiology testing have not had positive results. Amir et al. administered precordial thumps to patients who developed ventricular tachycardia during testing and found that, out of 80 patients, only one patient responded to precordial thump.[9] The other 79 patients required defibrillation.[9] The study concluded that a precordial thump is only potentially useful when no defibrillator is immediately available.[9] Another similar study from Haman et al. found that out of 155 patients with ventricular tachycardia, only two converted with a precordial thump, and the study concluded that the precordial thump had meager rates of success.[10]

Enhancing Healthcare Team Outcomes

A precordial thump is performable by a variety of healthcare professionals, including physicians in hospital settings or paramedics in prehospital settings. Following administration of a precordial thump, the healthcare team needs to prepare for the next steps of caring for the patient. If the precordial thump fails, the team needs to be ready to perform advanced cardiac life support. Intravenous or intraosseous access will need to be established to administer medications. The patient may need to be intubated. Defibrillator pads will need to be applied and shocks may need to be given. Cardiopulmonary resuscitation may need to be performed by experienced team members. The pharmacist will need to be available to verify medications that may be needed such as vasopressors. Following patient stabilization, the patient will likely need to be transferred to an intensive care unit if they are not already at this level of care. Precordial thump may be attempted in patients with an observed, monitored, unstable ventricular tachycardia when a defibrillator is not immediately available.[1] [level V]

Nursing will need to be prepared to help manage the patient in the event of both a successful or unsuccessful precordial thump. Intravenous access will be necessary, as well as vital signs. Nursing will need to be familiar with advanced life support techniques and protocols and assist the clinicians in performing the procedure as well as post-procedure monitoring. All healthcare team members should be aware of potential complications from the precordial thump and be watchful for signs of any adverse effect and communicate untoward complications to the team leader. [Level 5]

Nursing Monitoring

Nursing will need to monitor the patient's vital signs and cardiac rhythm. Patients who have been successfully resuscitated by precordial thump are at risk for recurrent arrhythmia and require close monitoring. The nurses should quickly report to the clinical team any changes in vital signs or development of malignant arrhythmia's and then make sure the crash cart is available.


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Precordial Thump - Questions

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A 25-year-old male with no past medical history is in the emergency department for evaluation of chest pain. He is connected to a cardiac monitor. The patient reports that he has been having intermittent chest pain for the past few months. He says that usually, he is very active, but last week he had two episodes of syncope while playing soccer. He states he had no prodrome of dizziness. He "just went out." His heart rate is 55 beats per minute, blood pressure is 120/60 mmHg, oxygen saturation is 99% on room air, and the temperature is 99.6 Fahrenheit. Electrocardiogram was obtained, which showed normal sinus rhythm and deep, narrow Q waves. Suddenly, the patient becomes unresponsive, and an abnormal rhythm is noted on the monitor. No defibrillator is present in the room. A clinician quickly applies a firm blow to the bottom third of his sternum. The patient regains consciousness, and his rhythm normalizes. Assuming the clinician performed the procedure appropriately, what was the most likely cardiac rhythm while the patient was unconscious?



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A 30-year-old female with no past medical history presents for evaluation of feeling dizzy. She reports that she recently went to urgent care for cold symptoms and nausea. She states that she was prescribed ondansetron for nausea and azithromycin for "bronchitis." Her cold symptoms have improved, but now she is experiencing intermittent dizziness, and yesterday, she almost passed out. Vital signs were obtained: her temperature is 98.7 F, respiratory rate is 16/min, blood pressure is 75/30 mmHg, and heart rate is 200/min. An ambulance is called, and the patient is placed on a gurney. Intravenous access is obtained. The patient is attached to an EKG machine, and a wide complex tachycardia is noted. A repeat blood pressure is requested, but the blood pressure cuff is unable to give a reading, and the patient states she thinks she is going to pass out again. What intervention may be attempted if a defibrillator is not available?



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A 65-year-old male with a history of hypertension, hyperlipidemia, tobacco use, and previous myocardial infarction presents to the emergency department with chest pain. He states the pain is "crushing" and feels like his last heart attack. On physical examination, his heart rate is 60/min, blood pressure is 150/90 mmHg, the respiratory rate is 20/min, and pulse oximetry is 89% on room air. The patient appears pale and diaphoretic. He is clutching the left side of his chest. The patient is connected to pads, and oxygen is administered. The EKG machine is left attached to the patient because it looks abnormal, and an ST-elevation myocardial infarction alert is activated. The patient suddenly becomes unresponsive and pulseless. A wide complex tachycardia is noted on the EKG machine. What would have been the best initial step in management if the patient had been outside of the healthcare setting?



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A 5-year-old male with a history of Brugada syndrome was transferred to the pediatric intensive care unit after a witnessed out of hospital cardiac arrest. The patient is currently intubated and sedated. Heart rate is 70 beats per minute, respiratory rate is 16/min, blood pressure is 120/60 mmHg, and the temperature is 98 F. The patient's mother reports that he had a syncopal event and that, when paramedics arrived, he suddenly stopped breathing. She states that one of the paramedics performed some procedure with one hand on her son's chest, which "brought him back to life." On examination, there is tenderness and crepitus over the patient's anterior chest wall. From what complication is the patient most likely suffering?



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A 70-year-old male with a history of diabetes and hypertension is recovering from a recent myocardial infarction. He states he was told that he has "a lot of scar tissue on his heart." His vital signs are taken, and his heart rhythm is monitored via telemetry. On arrival, his heart rate is 90/min, respiratory rate is 18/min, the temperature is 97.6 F, blood pressure is 170/90 mmHg, and oxygen saturation is 100% on room air. His heart has a regular rate and rhythm without murmurs. His chest is clear on auscultation. Blood glucose is 100 mg/dl. The patient begins walking on a treadmill when, suddenly, he collapses and falls off of the treadmill. Telemetry shows a wide complex tachycardia. A precordial thump is performed. The patient regains consciousness, and telemetry shows normal sinus rhythm. Assuming the procedure is done correctly, in which of the following places was contact made with the patient's chest wall?



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Precordial Thump - References

References

Cave DM,Gazmuri RJ,Otto CW,Nadkarni VM,Cheng A,Brooks SC,Daya M,Sutton RM,Branson R,Hazinski MF, Part 7: CPR techniques and devices: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;     [PubMed]
Müller GI,Ulmer HE,Bauer JA, Complications of chest thump for termination of supraventricular tachycardia in children. European journal of pediatrics. 1992 Jan;     [PubMed]
Nehme Z,Andrew E,Bernard SA,Smith K, Treatment of monitored out-of-hospital ventricular fibrillation and pulseless ventricular tachycardia utilising the precordial thump. Resuscitation. 2013 Dec;     [PubMed]
Pellis T,Kette F,Lovisa D,Franceschino E,Magagnin L,Mercante WP,Kohl P, Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: a prospective study. Resuscitation. 2009 Jan;     [PubMed]
Amir O,Schliamser JE,Nemer S,Arie M, Ineffectiveness of precordial thump for cardioversion of malignant ventricular tachyarrhythmias. Pacing and clinical electrophysiology : PACE. 2007 Feb;     [PubMed]
Haman L,Parizek P,Vojacek J, Precordial thump efficacy in termination of induced ventricular arrhythmias. Resuscitation. 2009 Jan;     [PubMed]
Ahmar W,Morley P,Marasco S,Chan W,Aggarwal A, Sternal fracture and osteomyelitis: an unusual complication of a precordial thump. Resuscitation. 2007 Dec;     [PubMed]
Zeh E,Rahner E, [The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump (author's transl)]. Zeitschrift fur Kardiologie. 1978 Apr;     [PubMed]
Miller J,Tresch D,Horwitz L,Thompson BM,Aprahamian C,Darin JC, The precordial thump. Annals of emergency medicine. 1984 Sep;     [PubMed]
Koster RW, Precordial thump: friend or enemy? Resuscitation. 2009 Jan;     [PubMed]

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