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. Open cardiac massage is considered a heroic procedure in the Emergency Department that can be lifesaving if performed on the appropriate patient.1-12
Open cardiac massage was routinely performed before the introduction of closed chest CPR. This technique was primarily performed in hospitals by Surgeons. Most of the patients were surgical, and open cardiac massage had a high success rate. After the development of closed chest CPR in the early 1960s, there was a dramatic decline in open cardiac massage in the mid-to-late 1960s and 1970s. The exceptions were cardiac arrests due to trauma or in the Operating Room.
ANATOMY AND PATHOPHYSIOLOGY
The efficacy of cardiac massage can be established by measuring the cardiac output, coronary perfusion pressure, and cerebral perfusion pressure. A higher cardiac index can be achieved 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.4,10 Open cardiac massage can generate near normal cerebral blood flow and improve cardiac perfusion pressure.
Open cardiac massage is indicated if absent or inadequate cardiac activity is noted after a thoracotomy for penetrating trauma, a thoracotomy to decompress a pericardial tamponade (spontaneous, postsurgical, or from an aortic dissection), or a cardiac arrest after recent chest surgery.7,9,11 Other possible indications include abnormal chest wall anatomy that prevents closed chest CPR, hypothermic cardiac arrest, refractory ventricular fibrillation, massive air embolism, and if standard CPR is not effective.
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 thoracotomy and pericardiotomy to 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. Refer to Chapter ...