1 Department of Anaesthesiology, Emergency and Intensive Care Medicine and 2 Department of Paediatric Cardiology and Paediatric Intensive Care Medicine, Georg-August-University, Robert-Koch-Strasse 40, 37099 Goettingen, Germany
3 Present address: Department of Anaesthesia and Critical Care, Royal Hospital for Sick Children, Edinburgh EH9 1LF, UK
* Corresponding author. E-mail: ceich{at}t-online.de
Accepted for publication April 24, 2005.
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Abstract |
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Keywords: anaesthesia, paediatric ; complications, cardiac arrest ; pacing, emergency ; pacing, percussion
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Introduction |
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Case report |
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Discussion |
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The physiology of percussion pacing is based on the physical phenomenon that the vital myocardium can respond to a mechanical stimulus with an electrical impulse (electrical coupling), visible as a broad QRS complex on ECG (Fig. 2). However, more crucial is the association with a subsequent myocardial contraction, capable of generating an appropriate stroke volume. This mechanical coupling is clinically well known from stimulation of the heart by surgical or catheter manipulation. In the setting of percussion pacing, a palpable central pulse, a good plethysmographic reading on the pulse oximeter and regained consciousness in a patient suffering a StokesAdams attack are regarded as reasonable signs of adequate perfusion.
Although occasional reports have shown that a single blow may terminate bradycardia, the majority of authors recommend rhythmically performed percussion pacing at a rate of 5070 beats min1.25 8 Because of the complete lack of paediatric data, it remains unclear whether a faster rate would be advisable in children.
Compared with the technique of precordial thumping, percussion pacing is applied with significantly less mechanical energy. To judge the appropriate force, it has been suggested to let the closed fist fall from approximately 2030 cm above the thorax.3 Case studies of percussion pacing under invasive monitoring have found that the right ventricular pressure must rise by at least 1015 mm Hg to generate an electrical impulse at the myocardium.3 The best anatomical site for percussion pacing seems to be the left lower sternal edge, presumably above the right ventricle.3 4 However, both site and force of the fist blows need to be titrated individually in each patient.
Chan and colleagues reported the case of an adult patient, monitored with a SwanGanz catheter, who suffered acute complete heart block with ventricular standstill.7 Initially they performed percussion pacing, followed by transcutaneous electrical pacing before transvenous electrical pacing could eventually be established. According to their comprehensive haemodynamic measurements, the three techniques showed similar effectiveness. Compared with a calculated cardiac output of 2030% of normal with optimally performed chest compressions during cardiopulmonary resuscitation, percussion-induced ventricular contractions generate a significantly higher cardiac output.5 7
Although electrical cardiac pacing is the treatment of choice for most patients with unstable bradyarrhythmias, percussion pacing can effectively provide short-term cardiocirculatory support before more advanced treatment is established or the bradycardia resolves, as seen in our patient. This neglected procedure is quick and easy to perform and may be indicated as a potentially life-saving technique in adults and in children.
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Acknowledgments |
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References |
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2 Zoll PM, Belgard AH, Weintraub MJ, Frank HA. External mechanical cardiac stimulation. N Engl J Med 1976; 294: 12746[ISI][Medline]
3 Zeh E, Rahner E. The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump. Z Kardiol 1978; 67: 299304[ISI][Medline]
4 Klumbies A, Paliege R, Volkmann H. Mechanical emergency stimulation in asystole and extreme bradycardia. Z Gesamte Inn Med 1988; 13: 34852
5 Iseri LT, Allen BJ, Baron K, Brodsky MA. Fist pacing, a forgotten procedure in bradyasystolic cardiac arrest. Am Heart J 1987; 113: 154550[CrossRef][ISI][Medline]
6 Wild JB, Grover JD. The fist as an external cardiac pacemaker. Lancet 1970; 29: 4367
7 Chan L, Reid C, Taylor B. Effect of three emergency pacing modalities on cardiac output in cardiac arrest due to ventricular asystole. Resuscitation 2002; 52: 1179[CrossRef][ISI][Medline]
8 Wirtzfeld A, Himmler FC, Forssmann B, et al. External mechanical cardiac stimulationMethods and possible applications. Z Kardiol 1979; 68: 5839[ISI][Medline]
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