To Thump or Not To Thump

The value of the precordial thump

 

 
 
 

Keith Wesley, MD, FACEP | | Friday, May 8, 2009


Review of: Pellis T, Kette F, Lovisa D, et al. "Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: A prospective study." Resuscitation. 80(1):17-23, 2009.

The Science

The authors of this study prospectively reviewed the effect, if any, of the precordial thump (PT) on out-of-hospital cardiac arrest victims in a rural system in Italy. The EMTs weren't specifically trained in the delivery of the PT, but their protocol was amended to have them deliver it upon arrival at the scene if no prior treatment had been performed or if they witnessed the patient arrest.

The authors reviewed 144 cases. The initial rhythm was ventricular fibrillation (V Fib) in 23 cases and ventricular tachycardia (V Tach) in 1 (16.7%), pulseless electrical activity (PEA) in 42 (29.2%), and asystole in 78 (54.2%). They felt the relatively low fraction of tachyarrhythmias observed here may be related to the long response time (mean less than nine minutes, which is not untypical for rural areas).

In the unwitnessed arrests, only two patients had changes in their rhythm associated with PT. One was in PEA that converted to asystole, and no return of spontaneous circulation (ROSC) was achieved. The second was in V Tach and converted to PEA without ROSC.

PT was performed three times in witnessed arrests, and all three had ROSC. In all three cases the patients developed asystole, and PT resulted in the spontaneous return of a pulse. They subsequently received pacemakers.

In no instance did the performance of PT delay the delivery of defibrillation, and the authors concluded that "PT can make a contribution to overall ROSC and survival, in particular in witnessed early asystolic cardiac arrest. PT had neither positive nor detrimental effects in non-EMS-witnessed cardiac arrests, and it was ineffective in tachyarrhythmic cardiac arrest and pulseless electrical activity."

The Street

The debate continues to rage regarding the value of the precordial thump. This study is interesting and enlightening for two reasons. First, studies have shown the maneuver generates very little electrical energy. This study confirms the amount of energy certainly isn't enough to terminate V Fib. However, there are several problems using this study alone to condemn PT. The very low number of patients in V Tach is concerning. It's far fewer than what is generally reported in most U.S. systems. This is most likely a reflection of long response times in this system. The energy required to terminate fresh V Tach is much less than V Fib, and PT continues to be employed in the cardiovascular lab. So there still may be a place for its use. If you can do it without delaying care and the arrest is relatively fresh, there may be benefit.

Second, the fact that the cases where PT worked were on patients in asystole is astounding. Not only is this a remarkable finding, but one that would have otherwise generated several case reports. Most providers have been taught that PT is only for V Fib/V Tach and that a patient who goes into asystole gets CPR, pharmacology and pacing.

I don't think this study definitively answers the question of whether to abandon PT, but it certainly raises some interesting questions about its use in witnessed arrest from asystole.




Connect: Have a thought or feedback about this? Add your comment now
Related Topics: Cardiac and Circulation, Research

 
What's Your Take? Comment Now ...

Featured Careers & Jobs in EMS

 

 

 

 

 

 

 

 

 

Get JEMS in Your Inbox

 

Fire EMS Blogs


Blogger Browser

Today's Featured Posts

 

EMS Airway Clinic

The Evolution of Civilian High Threat Medical Guidelines

How mass killing events have proven a need for new guidelines.
More >

Multimedia Thumb

Ebola Changes How North Carolina EMS Responds to Calls

Concern about virus spread leads to new protocols.
Watch It >


Multimedia Thumb

Oklahoma Hospitals Prepare for Ebola Cases

Training and preparation are keys for metro hospitals.
Watch It >


Multimedia Thumb

EMS in Nevada Prepares for the Unexpected

Protocols and PPE protect AMR personnel.
Watch It >


Multimedia Thumb

D.C. Fire and EMS Brace for Possible Ebola Patients

Union leader shares concern over precautions.
Watch It >


Multimedia Thumb

Life Link III Trauma Tactics Conference in Minnesota

Conference was designed to enhance the skills of providers of all levels, covering rescue and prehospital situations, to transport and in-hospital treatment.
More >


Multimedia Thumb

EMS Tailgating

Rigs converted for football.
More >


Multimedia Thumb

CDC Ebola Training for Clinicians

Students learn the complexities of working in bulky suits.
More >


Multimedia Thumb

Field Bridge Xpress ePCR on iPad, Android, Kindle Fire

Sneak peek of customizable run forms & more.
Watch It >


Multimedia Thumb

The AmbuBus®, Bus Stretcher Conversion Kit - EMS Today 2013

AmbuBus®, Bus Stretcher all-hazards preparedness & response tool
Watch It >


Multimedia Thumb

Braun Ambulances' EZ Door Forward

Helps to create a safer ambulance module.
Watch It >


More Product Videos >