Cardiac & Resuscitation, Columns, Patient Care

Use of the Poised-Finger Technique

Review of: Grayson SK, LeGros WL, Pace R, et al: “A New Approach to Arrhythmia Suppression: Use of the ‘poised finger’ technique in management of cardiac arrhythmias.” Journal of Interventional Cardiology. 54(8):678-681, 2007.

The Science
To evaluate the efficacy of the “poised-finger technique” in suppressing cardiac arrhythmias.

METHODS: Prospective observational study of patients suffering symptomatic cardiac arrhythmias in the out-of-hospital setting during a one-year study period. The setting was a rural ambulance service transporting to a community hospital, rural-health clinic and convalescent home. On odd days, patients received the “poised finger” arrhythmia suppression technique and on even days received conventional pharmacological and/or electrical intervention according to current American Heart Association ACLS guidelines. Paramedics were instructed to hold their index finger as close as possible to the PRINT button on a standard Medtronic/Physio Control LP12 at the first indication of cardiac arrhythmias. Paramedics were asked to record their observations.

RESULTS: Seventeen patients were excluded from the study because the paramedics were able to actually make physical contact with the PRINT button and record a strip. Of the 194 patients included in the study group, 38 (19.6%) exhibited atrial fibrillation with rapid ventricular rate and 156 patients (80.4%) had another narrow complex tachycardia of greater than 150 beats per minute. A total of 134 patients were included in the control group, of which 107 (79.9%) exhibited a supraventricular tachycardia of greater than 150 beats per minute, and 27 (21.1%) patients exhibited wide complex tachycardia. Arrhythmia suppression was defined as reduction of heart rate to the point that the paramedic noted “nothing cool” to see on the monitor. Of the 194 patients in the study group, 178 patients (91.8%) sustained a measurable decrease in ectopic beats, and 165 patients (85.1%) achieved full arrhythmia suppression as defined in the study parameters. In the control group, 54 patients (40.3%) exhibited a measurable decrease in ectopic beats, with only 23 patients (17.2%) achieving full arrhythmia suppression as defined in the study parameters. 68 patients (50.7%) received adenosine, 14 patients (10.4%) received diltiazem, 40 patients (29.9%) received amiodarone and 12 patients (9.6%) received synchronized cardioversion or defibrillation. Of the treatment methods used in the control group, the electrical interventions were by far the most effective, achieving arrhythmia suppression 78% of the time. Six of the 12 patients had a post shock rhythm of asystole.

CONCLUSION: The “poised-finger” technique is markedly better than the antiarrhythmic therapy currently in use. EMS systems should review their current practice of arrhythmia treatment accordingly.

The Street
I believe the authors of this study best can describe what this means to you.

In an informal interview following the release of the study, author Richard Pace was ebullient in discussing the results of his research. “This just proves what we’ve known all along — that the act of reaching for the PRINT button on the monitor makes the arrhythmia go away. Finally, we’re applying the principle of EBM to the practice of paramedicine, finding out what really works as opposed to just blithely accepting the next wonder drug that hits the market. Amiodarone, schmamiodarone! I got yer antiarrhythmic right here, baby!” Pace crowed, one finger held aloft in a gesture of triumph.

When asked to give his prediction as to whether the poised-finger technique should be adopted as an EMS Best Practice, Pace answered, “Absolutely,” wagging his finger for emphasis. “I predict that PFT will become the standard of care for life-threatening arrhythmias. It’s safe, it’s effective and it’s cheap. All you gotta do is extend your booger hooker toward that PRINT button, and people magically get better. Hey, the abstract doesn’t tell the whole story. Read the entire study and you’ll see. Our numbers would be even better if Grayson hadn’t shocked all those people. Of the 12 people who got the therapeutic electrocution, he was the medic for 10 of them. I think those patients could have benefited from PFT as well, but what are ya gonna do? The guy loves to shock people.”

“We need to do more research,” Pace went on to say. “One thing we discovered was that the effectiveness of PFT tends to increase in direct relation to the proximity of the fingertip to the PRINT button. Our best results were obtained with the index finger poised about one inch from the button, but it’s difficult to hold that posture in the back of a moving ambulance, especially the way LeGros drives. We also discovered that positioning yourself more than arm’s reach from the SHOCK button on the monitor triples the likelihood of a lethal arrhythmia, but that’s the subject of a whole other study.”