Chapter 43. Open Cardiac Massage

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.1–11

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.

The efficacy of cardiac massage can be established by measuring the cardiac output, coronary perfusion pressure, and cerebral perfusion pressure. Del Guercio et al. showed that 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 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 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 42).

The preparation and positioning of the patient is exactly the same as that for a thoracotomy. A thoracotomy must first be performed (Figure 43-1). Refer to Chapter 42 for the complete details of a 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.

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 heart be grasped incorrectly. The pressure from open cardiac massage is distributed over a larger area if the pericardium remains intact. The heart will move within the pericardial sac, prevent the fingers from compressing one spot for a prolonged time, and may decrease the chance of myocardial rupture.

Several important principles must be kept in mind prior to performing open cardiac massage. The heart must be angled not more than 20° to 30° into the left hemithorax (Figure 43-2A). Angulation of more than 30° may crimp the pulmonary veins and vena cava closed and thus minimize cardiac output. The compressive forces should be applied perpendicular to the interventricular septum. Your hands should be placed directly behind and in front of the heart. The left anterior descending artery can be used as a landmark, as it runs above the interventricular septum. Do not place the fingers over the coronary arteries so that their flow is occluded. The fingertips should never be used to compress the heart, as they may rupture the myocardium. Use only the palm, volar surfaces of the fingers, and pads of the fingers to perform cardiac compressions. The fingers should always be held tightly together to form a flat surface. This allows the force of compression to be spread out and not concentrated over one finger. Each compression of the heart must be followed by complete relaxation of the heart. It is during this relaxation phase (i.e., diastole) that the cardiac chambers fill with blood and the coronary arteries perfuse the myocardium.

Three techniques have been described to perform open cardiac massage (Figures 43-2 & 43-3). These include one-handed massage with sternal compression, one-handed compression, and two-handed compression. Two-handed compression has been shown to be consistently superior to the other two techniques in generating cardiac output.5

One-Handed Massage with Sternal Compressions

Tightly adduct the fingers of the dominant hand to make a flat surface. Insert the hand into the thoracotomy incision and against the posterior surface of the heart (Figures 43-2A & B). Angle the heart 20° to 30° into the left hemithorax. Compress the heart against the sternum, beginning with the heel of the hand, then the palm, then fingers in sequence. This method is difficult to perform in children because of the plasticity of the sternum.6

One-Handed Compressions

Tightly adduct the fingers of the dominant hand to make a flat surface. Insert the hand into the thoracotomy incision and against the anterior surface of the heart (Figure 43-2C). Place the thumb against the posterior surface of the heart. The apex of the heart will lie in the palm of the hand (Figure 43-2C). Angle the heart 20° to 30° into the left hemithorax. Appose the thumb and fingers to compress the heart. This is not the preferred method, as the thumb can place significant pressure on the left ventricle and possibly cause it to rupture.

Two-Handed Compressions

This is the technique of choice in children. The child's sternum, the costochondral tissues, and the ribs are mostly cartilage. Thus, the sternum is very pliable. This makes the one-handed massage with sternal compression technique not very effective. The one-handed compression technique can rupture the thin myocardial walls.

Tightly adduct the fingers and cup the left hand. Insert the left hand into the thoracotomy incision and against the anterior surface of the heart (Figure 43-3A). Tightly adduct the fingers of the right hand to make a flat surface. Insert the right hand into the thoracotomy incision and against the posterior surface of the heart (Figure 43-3A). Angle the heart 20° to 30° into the left hemithorax. Appose the hands to compress the heart (Figure 43-3B). Compressions should ideally begin with the heel of the hands and progress toward the fingers.

Compressions should begin at a rate appropriate for the patient's age as specified by the American Heart Association (Pediatric Advanced Life Support and Advanced Cardiac Life Support). Ideally, compress the heart at a rate of at least 100 times a minute if possible. This compression rate is based on consensus and not clinical research. Assess the effectiveness of the cardiac compressions by noting a palpable carotid pulse. A radial or femoral arterial line can be placed to monitor the effectiveness of the compressions. The arterial line allows for repeated blood and blood gas sampling. The arterial line will also allow the Emergency Physician to ensure that the heart is completely relaxed between compressions.

If a spontaneous cardiac rhythm and a peripheral pulse return, cover the thoracotomy incision with sterile saline-moistened gauze and a simple dressing. Administer intravenous antibiotics whose spectrum covers skin flora. The patient must be taken emergently to the Operating Room by a Trauma Surgeon or Cardiothoracic Surgeon for definitive treatment and closure of the chest wall.

The major complication of open cardiac massage is myocardial rupture or perforation. This can occur from compression of the heart against a jagged and fractured rib or sternum. Incorrect technique with too vigorous a massage can result in perforation of the ischemic myocardium by the fingertips. Other complications include decreased cardiac output with compressions if the heart is angled more than 30° into the left hemithorax and kinks shut the vena cava or pulmonary veins. Infection is possible if the patient survives. Parenteral antibiotics should be administered to prevent infection and sepsis. The complications associated with the thoracotomy and the pericardiotomy are discussed in Chapter 42. The quality of life of survivors can be poor to normal.8

Open cardiac massage is a more efficient way of maintaining circulation than closed chest massage. Cardiac compressions can be performed with one or two hands, depending on physician preference. The two-handed technique is preferred, as it generates greater cardiac output than the one-handed techniques. Once a cardiac rhythm and blood pressure are restored, definitive treatment for injuries must be provided expeditiously by a Surgeon in the Operating Room.