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Three Part Question

In [adults with cardiac arrest from ventricular fibrillation or pulseless ventricular tachycardia] is the [precordial thump better than BLS alone] at [restoring spontaneous circulation]?

Clinical Scenario

A 72 year old male presents to the emergency department with pulseless ventricular tachycardia. You wonder if a precordial thump is effective in restoring the heart to a sinus rhythm?

Search Strategy

Ovid MEDLINE® 1946 to January Week 2 2016:
[(precordial thump.mp.) OR (pre-cordial thump.mp.)]. Limit to humans and English language.

Cochrane Database of Systematic Reviews: Issue 1 of 12, January 2016: ‘pre-cordial thump in Title, Abstract, Keywords’ OR ‘precordial thump in Title, Abstract, Keywords’ 0 results.

Search Outcome

Forty-seven papers were identified, of which five were relevant to the clinical question. However, two studies were excluded because they enrolled only patients undergoing electrophysiology studies who had a malignant ventricular tachyarrhythmia induced. The remaining three papers are summarised in the table

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Nehme Z et al 2013 Australia	Adult patients who suffered a monitored VF/VT of presumed cardiac etiology. Cases were excluded if the arrest occurred after arrival at hospital, or a 'do not resuscitate' directive was documented	Retrospective cohort study with information gathered from the prehospital Cardiac Arrest Registry	Impact of first shock/thump on return of ROSC	16.5% of patients observed a PT-induced rhythm change, including 5 cases of ROSC and 10 rhythm deteriorations 4.9% were ROSC vs 57.8% in the defibrillation group	Retrospective study; there was no standardized definition as to how a precordial thump is performed, rhythm deterioration following precordial thump occurred in 10% of patients
			Survival to hospital discharge	There was no significance difference in these two groups 70% in defibrillation vs 71% in PT group
Pellis T et al 2008 Italy	144 out-of-hospital patients with cardiac arrest had immediate precordial thump immediately after monitor attached	Observational study	Effects on heart rhythm	Precordial thump had no effect on heart rhythm in 138 patients	No control group Inclusion in the study cohort was dependent upon whether or not the EMS providers elected to try a thump prior to proceeding with standard ACLS (219 patients were excluded as a result)
			Return of spontaneous circulation	PT caused ROSC in 3 patients with asystolic cardiac arrest
			Hospital discharge	Survival of the PT induced ROSC was no different than the PT unresponsive ROSC patients
			Presence of adverse effects	No adverse effects observed
Miller J et al 1984 USA	50 pulseless, non-breathing patients (27 VT, 23 VF) who received precordial thumps during ACLS resuscitation	Observational study	Effects on heart rhythm	15 had a change in rhythm None had a change in rhythm	Observational study only Insufficient data provided to determine how long after arrest the patients received the precordial thump VF/VT were not the initial rhythms in 20 of the 50 patients
			Return of spontaneous circulation	3 patients with VT were thumped into a perfusable rhythm (SVT)
			Adverse effects	12 patients with VT were thumped into more detrimental rhythms such as asystole and VF.

Comment(s)

In a precordial thump, a provider delivers a single sharp blow to the middle of a person's sternum with the ulnar aspect of a clenched fist. The intent is to interrupt a potentially fatal rhythm. Traditionally, the precordial thump was considered in those with witnessed, monitored, unstable ventricular tachycardia (including pulseless VT) if a defibrillator was not immediately ready for use. At one time, the technique was taught as part of standard CPR training. These recommendations were based largely on anecdotal reports of successful ‘thump version’ of asystole, VF and VT. The potential complications include sternal fracture, osteomyelitis, stroke and rhythm deterioration in adults and children.

Editor Comment

ACLS, advanced cardiac life support; EMS, Emergency Medical Service; PT, precordial thump; SVT, supraventricular tachycardia.

Clinical Bottom Line

Using the precordial thump in out-of-hospital cardiac arrest rarely results in immediate return of spontaneous circulation and is more commonly associated with rhythm deterioration.

References

1. Nehme Z, Andrew E, Bernard SA et al. Treatment of monitored out-of-hospital ventricular fibrillation and pulseless ventricular tachycardia utilising the precordial thump. Resuscitation 2013; 84: 1691-1696.
2. 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 2009; 80: 17-23.
3. Miller J, Tresch D, Horwitz L et al. The precordial thump. Ann Emerg Med 1984;13:791-794.