Continuing Education Activity

Precordial thump is a potentially life-saving procedure for patients with witnessed, monitored, unstable ventricular tachycardia when a defibrillator is not immediately available. This activity reviews the indications, contraindications, and the role of the interprofessional team in managing patients who receive a precordial thump.

Objectives:

• Describe the potential complications that can arise during precordial thump.
• Summarize the technique in regards to precordial thump.
• Review the indications for precordial thump.
• Explain interprofessional team strategies for improving care coordination and communication to advance the use of precordial thump and improve outcomes.

Introduction

Almost all fictional medical television shows feature a scene where a patient suddenly suffers from a cardiac arrest, and a heroic doctor thumps on their chest and seemingly miraculously saves them. The precordial thump, although frequently featured as successful in show business is less effective, and its use is more limited in real life. Currently, its use is recommended only for witnessed, monitored, unstable ventricular tachycardia when a defibrillator is not immediately available.[1] The technique is fast and easy to perform, and the first descriptions of the procedure date back to the 1920s.[2] The goal of precordial thump is to restore organized electrical cardiac activity and convert the patient from ventricular tachycardia to a more stable and organized rhythm.

Anatomy and Physiology

For a precordial thump to be effective, the healthcare professional must identify the proper anatomical landmarks to know where to deliver the thump and which part of their fist should make contact with the patient. The provider should make a closed fist and impact the patient with the ulnar side of their fist.[3] The ulnar side of the hand is the side of the fifth or little finger. The fist should make contact with the bottom third of the patient’s sternum.[4] The sternum is a flat and plate-shaped bone of the anterior chest wall. It is comprised of three parts, which named superiorly to inferiorly are the manubrium, body, and xiphoid. The sternum protects the internal organs of the chest cavity, including the heart and lungs. The sternum connects to the ribs via cartilage and other chest wall bones to form the anterior chest cavity. It is identifiable on the anterior chest wall by palpating the U-shaped sternal notch, which is the apex and then palpating inferiorly until encountering the pointy-shaped xiphoid.

Indications

Indication for a precordial thump is a patient with a witnessed cardiac arrest where a defibrillator is not immediately available with an unstable ventricular tachycardia observed on a monitor.[1] The ventricular tachycardia can be with or without a pulse. A precordial thump should not delay cardiac-pulmonary resuscitation, or defibrillation if available.[1]

Contraindications

If defibrillation is immediately available, it should be used preferentially over a precordial thump. There is not enough evidence to support the use of a precordial thump in asystole or unwitnessed cardiac arrest.[1]

Equipment

Cardiac monitoring to confirm the presence of ventricular tachycardia is necessary. A provider with a firmly clenched fist capable of delivering a firm blow is necessary. Usual equipment for cardiopulmonary resuscitation should be gathered by other personnel while performing the procedure, in case it is not successful.

Personnel

The technique is performable by an individual, but its success rates are low. If the procedure fails a healthcare team, including physicians, nurses, and technicians, will be needed to start cardiopulmonary resuscitation. If the procedure is successful, an interprofessional team will still be necessary to continue to stabilize and diagnose the underlying pathology in these patients.

Preparation

In preparation for the precordial thump, the physician should make a firmly clenched fist and hold their arm approximately 20 centimeters above the patient. They should identify the correct anatomic landmarks to apply the blow in the proper location. Other team members should be gathering supplies and preparing for possible failure, which would necessitate advanced life support protocol or further stabilization efforts if successful.

Technique or Treatment

After observing unstable ventricular tachycardia on the monitor, and defibrillation is not immediately available, a firmly clenched fist at approximately 20 centimeters above the patient should swiftly strike the inferior third of the patient’s sternum. After making contact, the physician should immediately remove their hand to allow for chest recoil. The cardiac monitor should be observed for any change in rhythm, and proper advanced cardiac life support protocol followed after the blow.

Complications

The precordial thump aims to terminate deadly arrhythmias. However, this therapy can have the opposite effect and send the patient into a more unstable rhythm or asystole.[5] If the delivery of the thump is not to the correct location, injury can occur from blunt trauma. Reports exist of sternal fractures, osteomyelitis, and thromboembolic stroke after precordial thumps.[1][6][7] An incorrectly placed, aggressive blow to the xiphoid can cause dislocation of the xiphoid with resultant injury to internal organs, for example, the liver, with resulting hemorrhage. There is also the potential for musculoskeletal injury to the medical professional performing the thump.

Clinical Significance

Researchers have studied the precordial thump in multiple clinical settings. Results of studies looking at out-of-hospital cardiac arrests are mixed.[8] One more extensive study by Pellis et al., as well as several case reports, has documented the success of the precordial thump. Pellis et al. from 2009 found that precordial thump resulted in 25% of patients who regained circulation after witnessed cardiac arrest, and they did not find any adverse effects from performing precordial thump.[2] However, Nheme et all from 2013 concluded that precordial thump was infrequently associated with the return of spontaneous circulation and more frequently resulted in deterioration of rhythm.[5] In this study, out of 434 cardiac arrests, there were 103 cases involving the use of the precordial thump and 325 cases using defibrillation.[5] Of the 103 patients who received precordial thump, five experienced return of spontaneous circulation (with 3 of the 5 experiencing repeat arrest warranting defibrillation).[5] Ten of the 103 patients who received precordial thump experienced rhythm deterioration.[5] Defibrillation was associated with 57.8% of the return of spontaneous circulation without significant rhythm deterioration versus 4.9% in the precordial thump group.[5] 

Hospital-based case series studies looking at the effectiveness of the precordial thump during electrophysiology testing have not had positive results. Amir et al. administered precordial thumps to patients who developed ventricular tachycardia during testing and found that, out of 80 patients, only one patient responded to precordial thump.[9] The other 79 patients required defibrillation.[9] The study concluded that a precordial thump is only potentially useful when no defibrillator is immediately available.[9] Another similar study from Haman et al. found that out of 155 patients with ventricular tachycardia, only two converted with a precordial thump, and the study concluded that the precordial thump had meager rates of success.[10]

Enhancing Healthcare Team Outcomes

A precordial thump is performable by a variety of healthcare professionals, including physicians in hospital settings or paramedics in prehospital settings. Following the administration of a precordial thump, the healthcare team needs to prepare for the next steps of caring for the patient. If the precordial thump fails, the team needs to be ready to perform advanced cardiac life support. Intravenous or intraosseous access will need to be established to administer medications. The patient may need to be intubated. Defibrillator pads will need to be applied and shocks may need to be given. Cardiopulmonary resuscitation may need to be performed by experienced team members. The pharmacist will need to be available to verify medications that may be needed such as vasopressors. Following patient stabilization, the patient will likely need to be transferred to an intensive care unit if they are not already at this level of care. Precordial thump may be attempted in patients with an observed, monitored, unstable ventricular tachycardia when a defibrillator is not immediately available.[1] [level V]

Nursing staff will need to be prepared to help manage the patient in the event of both a successful or unsuccessful precordial thump. Intravenous access will be necessary, as well as vital signs. Nursing staff will need to be familiar with advanced life support techniques and protocols and assist the clinicians in performing the procedure as well as post-procedure monitoring. All healthcare team members should be aware of potential complications from the precordial thump and be watchful for signs of any adverse effect and communicate untoward complications to the team leader. [Level 5]

Nursing, Allied Health, and Interprofessional Team Monitoring

Nursing staff will need to monitor the patient's vital signs and cardiac rhythm. Patients who have been successfully resuscitated by precordial thump are at risk for recurrent arrhythmia and require close monitoring. The nurses should quickly report to the clinical team any changes in vital signs or development of malignant arrhythmias and then make sure the crash cart is available.