Tuesday, May 10, 2011

The Precordial Thump

We found this heart-shaped stone while excavating to electrify the barn we built to care for animals. The barn was dedicated to Daniel and my father.

Many years ago, when I was first in the process of becoming a registered nurse, we were taught something called the "precordial thump". The pre-cordial thump, in the seventies, was to be used during a witnessed cardiac arrest, prior to CPR (Cardiopulmonary resuscitation.) Pretty much, it was used only one time. (delivered to a midpoint as measured from the notch at the top of the chest to the bottom of the xiphoid process at the end of the sternum,essentially midsternally) This could be effective if the person is experiencing a rhythm which is incompatible with continuing life, but is not actually in a cardiac standstill just yet. I have done the precordial thump several times, when it was acceptable practice, and been successful a couple of times. It does not take much force to deliver correctly.
This was set aside though, sometime in the 1980s, and then, with the advent of AEDs (automatic emergency defibrillators) which are now found in more schools, government and or public buildings, we never heard it mentioned.
When we found Daniel in cardiac arrest, part of me wanted to do a precordial thump, but this was not the time to get creative. I did everything as was the standard in 2008, when his arrest occured. He did not actually meet the criteria for even a 1970s precordial thump because he was behind the door when the arrest occured,(so it is not strictly witnessed) and because he was likely in full arrest by the time we got beyond the bathroom door. Still, the mother in me rethinks whether one precordial thump would have made a difference.
Interestingly, ACLS (Advanced Cardiac Life Support) standards now permit a precordial thump in certain circumstances. Apparently, on a cardiac monitored patient, or one who who has a rhythm indicating ventricular tachycardia, it may be delivered if a defibrillator is not readily available. Since it is only effective in a very short window of time, it should not preclude CPR or defibrillation if this is available. It seems that what I did was correct in 2008, but that the precordial thump has some narrow uses once again, in the ACLS of 2010. Apparently, of patients who experience a life threatening rhythm and are about to descend into a full cardiac arrest, as many as 25% of them can be returned to a productive rhythm by the precordial thump. It should be attempted only once. There is no evidence that a precordial thump will do anything at all for a patient in a full cardiac arrest (who is pulseless).Even though I wish I had tried this on Daniel, he was in full arrest when I got beyond the bathroom door,assessed breathlessness and pulselessness and began CPR.
It's still strange that two and a half years following his passing, I still rethink those awful moments for things that could have been done differently, hopefully altering the outcome.
Of course, I recommend that every parent, every able person over about thirteen becomes certified in CPR. My eldest son Adam saved an attorney who had a full cardiac arrest at a shopping mall, a few months before Daniel's passing. Adam had been certified to do CPR at college a couple of years earlier.

This is an interesting blog entry on the use of precordial thump written by a physician.


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