Cardiac & Resuscitation, Columns, Patient Care

The Precordial Thump is an Outdated Practice

Issue 10 and Volume 39.

The Research
Nehme Z, Andrew E, Bernard SA, et al. Treatment of monitored out-of-hospital ventricular fibrillation and pulseless ventricular tachycardia utilizing the precordial thump. Resuscitation. 2013;84(12):1691–1696.

The EMS Science
This is a retrospective review of all cardiac arrests managed by the Victorian Ambulance Service in Melbourne, Australia, from 2003 to 2011. EMS providers followed the Australian Resuscitation Council guidelines that are essentially identical to those of the American Heart Association.

The researchers first extracted cases where the patient suffered a witnessed arrest while being monitored by EMS providers. They then divided the cases into patients who received a precordial thump (PT) before further resuscitation, thump first, and those who received defibrillation first, shock first. Their protocol allowed for the delivery of a PT initially when defibrillation wasn’t immediately available.

Of 424 monitored arrests, 71% (301) were ventricular fibrillation (VF) and 29% (123) were ventricular tachycardia (VT). A PT was administered to 103 patients—76 (73.8%) were in VF and 27 (26.2%) were in VT.

The thump first group was more likely to rearrest and only 16.5% (17) of them had a rhythm change as a result of the PT. There was no difference in the time to defibrillation for either group. However, the PT was significantly less likely to result in sustained return of spontaneous circulation (ROSC). There was no difference in initial ROSC, survival to hospital admission or discharged alive status between the two groups.

The researchers’ conclusion stated, “The PT used as first-line treatment of monitored VF/VT rarely results in ROSC, and is more often associated with rhythm deterioration.”

Early CPR, not a precordial thump, is key to cardiac arrest survival.

Early CPR, not a precordial thump, is key to cardiac arrest survival. Photo courtesy Courtney McCain

 

Doc Keith Wesley Comments
The precordial thump is second only to popping the tops off of the prefilled arrest medication with your thumbs as your partner contacts Rampart General for orders. It looked so dramatic; you could almost hear the medic willing the life back into the patient as they raised their fist into the air and slammed it down on the patient’s chest.

But did it work? Yes, sometimes. I’m sure there are some EMS dinosaurs out there who still swear by it. Heck, I’ve converted an awake VT with a joke that caused the patient to laugh so hard the VT stopped and sinus rhythm resumed, but that’s not science—that’s an anecdote.

Our care must be guided by scientific analysis and must be designed to provide the most good for the majority of cases. The reality is that VT and VF is best treated with defibrillation that results in depolarization of the entire myocardium. Asystole is the goal of defibrillation in order for one of the heart’s pacemaker sites to resume normal electrical stimulation.

Some will say that because there was no difference in ultimate survival of the patients, that there’s no harm in trying PT. Unfortunately, cardiac arrest survival is more complex than that. In this report, 83% of the PT patients required subsequent defibrillation. So in the end, it was defibrillation that converted almost all of the survivors.

Bottom line? PT should be relegated to the recesses of medical history along with rotating tourniquets and leeches.

Medic Karen Wesley Comments
The study states all patients were treated with a combination monitor/defibrillator, so I had a little trouble understanding how they could justify the use of PT instead of defibrillation. The study also said PT was used when defibrillation wasn’t immediately available or when extended extrication was necessary, but that seems to be a mixed message.