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The purpose of cardiopulmonary resuscitation (CPR) during cardiac arrest or hypovolemic shock is to provide adequate cardiac output. This can be done using either closed or open chest cardiac massage. Open cardiac massage may on rare occasions be performed in the Emergency Department. It is performed on patients who have had an emergent thoracotomy after penetrating chest trauma and have inadequate cardiac activity. It may also be performed, in rare instances, after a thoracotomy to decompress a pericardial tamponade in a medical patient.

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The efficacy of cardiac massage can be established by measuring the cardiac output, coronary perfusion pressure, and cerebral perfusion pressure. Guercio et al showed a higher cardiac index with open than with closed cardiac massage.1 A minimal coronary perfusion pressure of 15 mmHg must be maintained for return of spontaneous circulation. While not all patients with this pressure will have a return of spontaneous circulation, a pressure of less than 15 mmHg predicts a uniformly fatal outcome.2 While closed chest CPR generated only 1 to 9 mmHg of pressure, Boczar et al. found that their patients all had a coronary perfusion pressure of almost 20 mmHg throughout open chest massage.3 Open chest CPR produces improved cerebral perfusion and better neurologic recovery.4

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Open cardiac massage is indicated if absent or inadequate cardiac activity is noted after a thoracotomy.

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The only absolute contraindication to performing open cardiac massage is the presence of a palpable pulse. Open cardiac massage is ineffective if the patient has a pericardial tamponade. Perform a pericardiotomy and remove any clots from the pericardial sac. The heart may then begin to beat spontaneously. If not, repair any lacerations to the myocardium prior to performing cardiac compressions.

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No equipment is required to perform open cardiac massage other than that needed to perform the thoracotomy and pericardiotomy (Chapter 31).

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The preparation and positioning of the patient is exactly the same as that for a thoracotomy (Figure 32-1). A thoracotomy must first be performed (Figure 32-1). Refer to Chapter 31 for complete details on thoracotomy. A pericardiotomy should be performed only if absolutely necessary—that is, if blood is seen within the pericardial sac or cardiac tamponade is suspected. Remove any blood and clots from the pericardial sac, deliver the heart from the pericardial sac, and repair any myocardial lacerations.

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An intact pericardium is preferable if open cardiac massage is to be performed. It prevents the fingertips from inadvertently rupturing the atria or ventricles should the ...

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