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.
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
Open cardiac massage is indicated if absent or inadequate cardiac
activity is noted after a thoracotomy.
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.
No equipment is required to perform open cardiac massage other
than that needed to perform the thoracotomy and pericardiotomy (Chapter 31).
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.
The anterolateral thoracotomy.
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 ...