To thump or not thump?

I wonder if the authors of the October 4th’s NEJM Journal Watch Alert saw the irony?

Firstly a review of a paper which examined the utility of the precordial thump for out of hospital cardiac events.

Nehme Z, Andrew E, Bernard SA, Smith K.  Treatment of monitored out-of-hospital ventricular fibrillation and pulseless ventricular tachycardia utilising the precordial thump. Resuscitation 2013 Aug 29

The author’s abstract (I’m too stingy to buy the complete paper) suggests that few studies have described the value of the precordial thump as first-line treatment of monitored out-of-hospital cardiac arrest from ventricular fibrillation and pulseless ventricular tachycardia.

Using data from the Victorian Ambulance Cardiac Arrest Registry  out-of-hospital cardiac arres witnessed by paramedics between 2003 and 2011. The study outcomes were: impact of first shock/thump on return of spontaneous circulation and more importantly, survival to hospital discharge.  434 cases met the eligibility criteria. Seventeen patients (16.5%) observed a precordial thump induced rhythm change, including five cases of return to spontaneous circulation and ten rhythm deterioration. Immediate defibrillation resulted in significantly higher levels of immediate  spontaneous circulation (57.8% vs. 4.9%, p<0.0001), without excess rhythm deteriorations (12.3% vs. 9.7%, p=0.48). Of the five successful precordial thump attempts, three required defibrillation following re-arrest. Overall  spontaneous circulation and survival to hospital discharge did not differ significantly between groups.

The authors concluded that the precordial thump when used as first-line treatment of monitored VF/VT rarely results in  spontaneous circulation and is more often associated with rhythm deterioration. In other words don’t thump, reach for the debrillator. Precordial thump delivers approximately 5 to10 joules of mechanical energy to the heart far less than defibrillation.

Australian Resuscitation Council Guidelines recommend a precordial thump for patients with monitored, pulseless ventricular tachycardia if a defibrillator is not immediately available. It is not recommended for ventricular fibrillation. There is insufficient evidence to recommend a precordial thump for witnessed onset of asystole caused by AV-conduction disturbance.  The precordial thump should not be used for unwitnessed cardiac arrest.  A precordial thump should not be used in patients with a recent sternotomy or recent chest trauma.  And of course, the precordial thump should not be used in the local pub even in self-defense.

The second review entitled, “Mortality from Blunt Traumatic Aortic Rupture” hopefully didn’t arise from over enthusiastic precordial thumps. Oh the bottom line on that study was that complete aortic transection was the only predictor of prehospital and overall mortality!

Whilst doing a web search I discovered a little note from Pub Med

“PubMed is open, however it is being maintained with minimal staffing due to the lapse in government funding. Information will be updated to the extent possible, and the agency will attempt to respond to urgent operational inquiries.”

Come on America get your act together…..