Effectiveness of the precordial thump in restoring heart rhythm following out-of-hospital cardiac arrest
Date First Published:
August 12, 2014
Last Updated:
February 10, 2017
Report by:
James Smith MD, Senior EM Resident (Grand Rapids Medical Education Partners)
Search checked by:
Bryan Judge MD, Grand Rapids Medical Education Partners
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:
Search Details:
[(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.
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.
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):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Treatment of monitored out-of-hospital ventricular fibrillation and pulseless ventricular tachycardia utilising the precordial thump. Nehme Z, Andrew E, Bernard SA 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 | ||||
| Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: a prospective study. Pellis T, Kette F, Lovisa D 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 | ||||
| The precordial thump. Miller J, Tresch D, Horwitz L 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. |
Author Commentary:
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.
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:
- Nehme Z, Andrew E, Bernard SA et al.. Treatment of monitored out-of-hospital ventricular fibrillation and pulseless ventricular tachycardia utilising the precordial thump.
- Pellis T, Kette F, Lovisa D et al.. Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: a prospective study.
- Miller J, Tresch D, Horwitz L et al.. The precordial thump.