Lay Rescuers & the "Precordial Thump"

[DeepSeaDan]

Greetings Good Physicians,

Was speaking with a physician acquaintance at the gym the other day, & we were discussing the frequency of incidences involving cardiac dysrhythmias in folks who were engaged in cardio training on one of the many cardio machines. He related that he had, on two occasions, delivered a "pre-cordial thump" to folks who had taken a spinner while working on machines near where he was exercising. In each instance, the patient responded immediately & positively to the treatment.

To my knowledge, the "thump" technique has long since disappeared from lay-rescuer training algorhythms ( I remember learning it many years ago ), but my discussion with the good Doctor got me thinking about the efficacy of the immediate application of the thump for witnessed arrests ( post assessment of course, though that would take away from the "immediacy" of the technique ) as applied by the general public. My Doctor friend felt it best for lay-rescuers to simply start cpr & use a defib. a.s.a.p. which is, of course, the current standard for lay-rescuer response. But might not a "thump," delivered once prior to the application of compressions, be of value??

Thanks for your thoughts in advance...

Regards,
DSD
ITLS-BLS Inst.
Red Cross EMR Inst.

 

[Duke Dive Medicine]

Dan,

Per the AHA:

A precordial thump has been reported to convert ventricular tachyarrhythmias in 1 study with concurrent controls,³⁹ single-patient case reports, and small case series.^{40,–,44} However, 2 larger case series found that the precordial thump was ineffective in 79 (98.8%) of 80 cases⁴⁵ and in 153 (98.7%) of 155 cases of malignant ventricular arrhythmias.⁴⁶ Case reports and case series^{47,–,49} have documented complications associated with precordial thump including sternal fracture, osteomyelitis, stroke, and triggering of malignant arrhythmias in adults and children.
The precordial thump should not be used for unwitnessed out-of-hospital cardiac arrest (Class III, LOE C). The precordial thump may be considered for patients with witnessed, monitored, unstable ventricular tachycardia including pulseless VT if a defibrillator is not immediately ready for use (Class IIb, LOE C), but it should not delay CPR and shock delivery. There is insufficient evidence to recommend for or against the use of the precordial thump for witnessed onset of asystole.

Note that the conditions for use include witnessed, monitored arrest, that is, the patient is already on a monitor and the cardiac rhythm can be interpreted. It would not be appropriate for lay rescuer use on an unmonitored patient. The full Circulation article can be found here:


Part 7: CPR Techniques and Devices

For what it's worth, the one time I used it I converted an ICU patient out of torsades de pointes with one thump.

Best regards,
DDM

 

[DeepSeaDan]

Dan,

Per the AHA:

A precordial thump has been reported to convert ventricular tachyarrhythmias in 1 study with concurrent controls,³⁹ single-patient case reports, and small case series.^{40,–,44} However, 2 larger case series found that the precordial thump was ineffective in 79 (98.8%) of 80 cases⁴⁵ and in 153 (98.7%) of 155 cases of malignant ventricular arrhythmias.⁴⁶ Case reports and case series^{47,–,49} have documented complications associated with precordial thump including sternal fracture, osteomyelitis, stroke, and triggering of malignant arrhythmias in adults and children.
The precordial thump should not be used for unwitnessed out-of-hospital cardiac arrest (Class III, LOE C). The precordial thump may be considered for patients with witnessed, monitored, unstable ventricular tachycardia including pulseless VT if a defibrillator is not immediately ready for use (Class IIb, LOE C), but it should not delay CPR and shock delivery. There is insufficient evidence to recommend for or against the use of the precordial thump for witnessed onset of asystole.

Note that the conditions for use include witnessed, monitored arrest, that is, the patient is already on a monitor and the cardiac rhythm can be interpreted. It would not be appropriate for lay rescuer use on an unmonitored patient. The full Circulation article can be found here:


Part 7: CPR Techniques and Devices

For what it's worth, the one time I used it I converted an ICU patient out of torsades de pointes with one thump.

Best regards,
DDM

Thanks DDM, that sums it up nicely.

Best,
DSD

 

[TSandM]

Be very careful with diving accidents, because some of those patients may be hypothermic. Significant hypothermia makes the myocardium irritable, and those are precisely the cases where a precordial thump could convert a benign rhythm with a pulse too weak for the lay rescuer to feel, to a malignant dysrhythmia.

 

[DandyDon]

I think we used to see that one at the start of one of the TV doctor shows in the 60s...?

 

[DeepSeaDan]

I think we used to see that one at the start of one of the TV doctor shows in the 60s...?

Dr. Ben Casey, perhaps??

If you want to see it fervently applied, watch that scene in "The Exorcist" when priest #2 ( name escapes me ) tries to revive #1 priest ( Max Von Sydow, I believe ), after he succumbs to the exertions of Demon-ousting.

Best,
DSD

---------- Post added February 14th, 2014 at 11:33 AM ----------

Be very careful with diving accidents, because some of those patients may be hypothermic. Significant hypothermia makes the myocardium irritable, and those are precisely the cases where a precordial thump could convert a benign rhythm with a pulse too weak for the lay rescuer to feel, to a malignant dysrhythmia.

Yes indeed.

DDM has convinced me to stick with "pump n' zap" as opposed to "thump/pump n' zap" - we field techs. will leave any act of thumping to you good Doctors!

Regards,
DSD