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British Journal of Anaesthesia
BJA

Percussion pacing—an almost forgotten procedure for haemodynamically unstable bradycardias? A report of three case studies and review of the literature

  • C. Eich
    Correspondence
    Corresponding author: Department of Anaesthesiology, Emergency and Intensive Care Medicine, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
    Affiliations
    Department of Anaesthesiology, Emergency and Intensive Care Medicine, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
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  • A. Bleckmann
    Affiliations
    Department of Anaesthesiology, Emergency and Intensive Care Medicine, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
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  • S.K.W. Schwarz
    Affiliations
    Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, B.C., Canada V6Z 1Y6
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      More than 80 years after its first description by Eduard Schott, percussion (fist) pacing remains a little known procedure even though it represents an instantly available and easy to perform treatment for temporary emergency cardiac pacing in haemodynamically unstable bradycardias, including bradycardic pulseless electrical activity and complete heart block with ventricular asystole. Based on the Consensus on Science and Treatment Recommendations of the International Liaison Committee on Resuscitation, the European Resuscitation Council recently incorporated percussion pacing in its advanced life support guidelines (Nolan and colleagues, Resuscitation 67 (Suppl 1): S39–S86, 2005). Here, we briefly describe three of our own cases and present a review of the literature on percussion pacing with respect to the available evidence on its efficacy, its practical application, and clinical indications.

      Keywords

      ‘During the course of the 12th of May, out of the blue, attacks occurred that appeared extraordinarily threatening, resembled those of the type of Adam–Stokes’, lasted 1/2 to 1 minutes, and recurred approximately from hour to hour. Dr. Lenné, who was in charge of the ward to which the woman had been admitted, was able to relieve several attacks by massaging the heart, as it is customary during incidents in anaesthesia, and I had the opportunity to convince myself of the usefulness of this procedure. When the woman becomes deathly pale, and, lying passively supine, appears somewhat cyanotic and almost moribund, a single forceful blow with the fist upon the chest in the region of her heart is sufficient, and immediately afterwards one feels a forceful pulse beat of the radial, a wave of redness overcomes her face; subsequent pulse beats of the radial follow, the woman awakes and the state is completely resolved. Whether this represents a direct mechanical expulsion of the blood collected in the arrested heart during diastole, or a mechanical extrastimulus, trigger of an extrasystole, cannot be determined. Overall, the woman had a total of 15 attacks on the 12th of May, and never again since.’Eduard Schott (1920)
      • Schott E
      Über Ventrikelstillstand (Adams-Stokeśsche Anfälle) nebst Bemerkungen über andersartige Arhythymien passagerer Natur.
      In his publication from 1920, the physician Eduard Schott from Cologne, Germany first described mechanical stimulation of the heart, which he performed, repeatedly and successfully, in a patient with recurrent Adam–Stokes attacks caused by complete heart block (CHB).
      • Schott E
      Über Ventrikelstillstand (Adams-Stokeśsche Anfälle) nebst Bemerkungen über andersartige Arhythymien passagerer Natur.
      Although several case reports and case series have been published about this technique in the following decades, percussion (or fist) pacing seems to remain a ‘forgotten procedure’ in the management of symptomatic bradycardia or bradycardic circulatory arrest.
      • Iseri LT
      • Allen BJ
      • Baron K
      • Brodsky MA
      Fist pacing, a forgotten procedure in bradyasystolic cardiac arrest.
      Hence, more than 80 yr after its first description, percussion pacing is still relatively unknown and does not represent a standard component of the therapeutic repertoire of most medical professionals. This is remarkable inasmuch as percussion pacing represents an instantly available and easy to perform procedure for temporary emergency pacing of the heart in symptomatic bradycardias, including bradycardic pulseless electrical activity (PEA) and CHB with ventricular asystole. Here, we report a brief synopsis of three of our own case studies, followed by a narrative review of the literature, and appraisal regarding available levels of evidence in support of this procedure.

      Methods

      For the preparation of the worksheet of the International Liaison Committee on Resuscitation (ILCOR) on percussion pacing, we searched the databases of Medline (PubMed), EMBASE, and Cochrane Library for the following key words: ‘fist pacing’, ‘percussion pacing’, and ‘precordial percussion’. In addition, we cross-checked all references from previous publications dealing with that topic. We then reviewed the full-text articles from all retrieved references. In accordance with the data evaluation guidelines of the ILCOR process, all publications were classified according to their level of evidence (Table 1). Before the submission of this review, we performed an update of the above search procedure.
      Table 1Levels of evidence according to ILCOR 2005
      • International Liaison Committee on Resuscitation
      2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 1: Introduction.
      Level of evidenceDefinition
      Level 1Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects.
      Level 2Randomized clinical trials with smaller or less significant treatment effects.
      Level 3Prospective, controlled, non-randomized, cohort studies.
      Level 4Historic, non-randomized, cohort, or case–control studies.
      Level 5Case series: patients compiled in serial fashion, lacking a control group.
      Level 6Animal studies or mechanical model studies.
      Level 7Extrapolations from existing data collected for other purposes, theoretical analyses.
      Level 8Rational conjecture (common sense); common practices accepted before evidence-based guidelines.

      Case 1

      On postoperative day 6, after mechanical aortic valve replacement, a 78-yr-old female developed CHB. The intraoperatively inserted epicardial pacing wires had been removed shortly before. The patient was transferred immediately to the intensive care unit, where on admission she presented with marked haemodynamic instability and recurrent loss of consciousness consistent with classic Adams–Stokes attacks. During insertion of a venous sheath and a transvenous electrical pacemaker wire, percussion pacing was performed as a temporary intervention. The patient instantly regained consciousness, and continuous plethysmographic reading of the pulse oximeter showed good electromechanical coupling. However, each interruption of percussion pacing was associated with an immediate recurrence of loss of consciousness.

      Case 2

      Ten days after an aortocoronary bypass operation, a 65-yr-old female presented for surgical revision of her sternum. After induction of general anaesthesia, the patient suddenly developed CHB associated with marked haemodynamic instability. Immediately after onset, percussion pacing was initiated, resulting in rapid restoration of an adequate mean arterial pressure, shown by invasive arterial pressure monitoring. About 1 min after beginning of percussion pacing, the CHB resolved and a perfusing normal sinus rhythm resumed.

      Case 3

      A detailed account of case 3 has recently been reported.
      • Eich C
      • Bleckmann A
      • Paul T
      Percussion pacing in a three-year-old girl with complete heart block during cardiac catheterization.
      In brief, a 3-yr-old girl was undergoing percutaneous closure of a large secundum atrial septum defect under general anaesthesia. During the procedure, the occluder slipped off the septal rim and impacted in the right ventricular outflow tract. During a successful attempt to retrieve the occluder with a snare catheter, the septal leaflet of the tricuspid valve was injured, with subsequent CHB and ventricular asystole (Fig. 1). Percussion pacing was started instantly and generated an uninterrupted succession of QRS complexes over more than 3 min (Fig. 2). A good peripheral pulse was palpable and visible in a continuous plethysmography signal. While a transvenous pacemaker wire was inserted, i.v. adrenaline and atropine were administered. As CHB persisted, electrical pacing took over cardiac stimulation with good capture.
      Figure thumbnail gr1
      Fig 1CHB with ventricular asystole in a 3-yr-old girl during cardiac catheterization (reproduced from Eich and colleagues7 with permission).
      Figure thumbnail gr2
      Fig 2Wide QRS complexes with a rate of 80 min−1 in the same child under percussion pacing, indicated by ↓ (reproduced from Eich and colleagues7 with permission).

       Published literature on percussion pacing

      The above patients illustrate some of the clinical indications for temporary percussion pacing. Its feasibility and efficacy has been reported in case series [level of evidence (LOE), 5], single case reports, and animal studies (LOE 6; Tables Table 1, Table 2).
      • Albano A
      • Di Comite A
      • Tursi F
      Rhythmic percussion of the precordium with the closed fist as the first procedure in therapy of cardiac arrest.
      • Brandenburg JT
      • Medford O
      Successful treatment by a chest blow of cardiac arrest during myocardial infarction.
      • Chan L
      • Reid C
      • Taylor B
      Effect of three emergency pacing modalities on cardiac output in cardiac arrest due to ventricular asystole.
      • Chester WL
      Spinal anesthesia, complete heart block, and the precordial chest thump: an unusual complication and a unique resuscitation.
      • Don Michael TA
      • Lond MB
      • Stanford RL
      Precordial percussion in cardiac asystole.
      • Dowdle JR
      Ventricular standstill and cardiac percussion.
      • Iseri LT
      • Allen BJ
      • Baron K
      • Brodsky MA
      Fist pacing, a forgotten procedure in bradyasystolic cardiac arrest.
      • Klumbies A
      • Paliege R
      • Volkmann H
      Mechanical emergency stimulation in asystole and extreme bradycardia.
      • Paliege R
      • Volkmann H
      • Klumbies A
      The first as pace maker. Investigations about mechanical emergency pacing of the heart.
      • Scherf D
      • Bornemann C
      Thumping of the precordium in ventricular standstill.
      • Schott E
      Über Ventrikelstillstand (Adams-Stokeśsche Anfälle) nebst Bemerkungen über andersartige Arhythymien passagerer Natur.
      • Tucker KJ
      • Shaburihvili TS
      • Gedevanishvili AT
      Manual external (fist) pacing during high-degree atrioventricular block: a lifesaving intervention.
      • Weston CF
      Ventricular standstill and cardiac percussion.
      • Wild JB
      • Grover JD
      The fist an external cardiac pacemaker.
      • Wirtzfeld A
      • Himmler FC
      • Forssmann B
      • et al.
      External mechanical cardiac stimulation. Methods and possible applications.
      • Zeh E
      • Rahner E
      The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump.
      • Zoll PM
      • Belgard AH
      • Weintraub MJ
      • Frank HA
      External mechanical cardiac stimulation.
      • Zürcher KA
      Thump pacing and thump version.
      There are no publications on randomized (LOE 1 and 2), prospective (LOE 1–3), or cohort trials (LOE 4) on percussion pacing, and for obvious ethical reasons it seems unlikely that such studies will be conducted in the future.
      Table 2Summary of published literature on percussion pacing. CHB, complete heart block; AF, atrial fibrillation; RV, right ventricle; PEA, pulseless electrical activity
      PublicationPopulationRemarksLevel of evidence (Table 1)
      Case series
       Zoll and colleagues
      • Zoll PM
      • Belgard AH
      • Weintraub MJ
      • Frank HA
      External mechanical cardiac stimulation.
      10 PatientsSix patients with CHB, one with ventricular asystole, two with AF, one with sinus bradycardia5
       Zeh and Rahner
      • Zeh E
      • Rahner E
      The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump.
      50 PatientsVolunteers with (n = 31) and without (n = 19) electrical cardiac pacemaker; single and serial blows were applied; required pressure increase in RV 15–20 mm Hg5
       Klumbies and colleagues
      • Klumbies A
      • Paliege R
      • Volkmann H
      Mechanical emergency stimulation in asystole and extreme bradycardia.
      100 PatientsVentricular asystole and bradycardic PEA; recommended rate 50–70 min−15
      Case reports
       Schott
      • Schott E
      Über Ventrikelstillstand (Adams-Stokeśsche Anfälle) nebst Bemerkungen über andersartige Arhythymien passagerer Natur.
      1 PatientFirst report of fist pacing (CHB)
       Brandenburg
      • Brandenburg JT
      • Medford O
      Successful treatment by a chest blow of cardiac arrest during myocardial infarction.
      1 PatientVentricular asystole
       Scherf
      • Scherf D
      • Bornemann C
      Thumping of the precordium in ventricular standstill.
      11 PatientsFour patients with CHB, seven with ventricular asystole
       Don Michael and Stanford
      • Don Michael TA
      • Lond MB
      • Stanford RL
      Precordial percussion in cardiac asystole.
      1 PatientVentricular asystole
       Albano and colleagues
      • Albano A
      • Di Comite A
      • Tursi F
      Rhythmic percussion of the precordium with the closed fist as the first procedure in therapy of cardiac arrest.
      3 Patients
       Wild and Grover
      • Wild JB
      • Grover JD
      The fist an external cardiac pacemaker.
      3 PatientsTwo patients with ventricular asystole, one with CHB
       Zürcher
      • Zürcher KA
      Thump pacing and thump version.
      1 PatientVentricular asystole
       Iseri and colleagues
      • Iseri LT
      • Allen BJ
      • Baron K
      • Brodsky MA
      Fist pacing, a forgotten procedure in bradyasystolic cardiac arrest.
      4 PatientsThree patients with asystole, one with ventricular asystole
       Chester
      • Chester WL
      Spinal anesthesia, complete heart block, and the precordial chest thump: an unusual complication and a unique resuscitation.
      1 PatientVentricular asystole during spinal anaesthesia
       Tucker and colleagues
      • Tucker KJ
      • Shaburihvili TS
      • Gedevanishvili AT
      Manual external (fist) pacing during high-degree atrioventricular block: a lifesaving intervention.
      1 PatientVentricular asystole
       Dowdle
      • Dowdle JR
      Ventricular standstill and cardiac percussion.
      1 PatientVentricular asystole
       Weston
      • Weston CF
      Ventricular standstill and cardiac percussion.
      1 PatientVentricular asystole
       Chan and colleagues
      • Chan L
      • Reid C
      • Taylor B
      Effect of three emergency pacing modalities on cardiac output in cardiac arrest due to ventricular asystole.
      1 PatientComparison of three pacing modes in the same patient (percussion pacing, transcutaneous, and transvenous electrical pacing)
      Animal studies
       Scherf
      • Scherf D
      • Bornemann C
      Thumping of the precordium in ventricular standstill.
      MammalsSparse information about details of the animal study
       Zoll and colleagues
      • Zoll PM
      • Belgard AH
      • Weintraub MJ
      • Frank HA
      External mechanical cardiac stimulation.
      20 DogsExperimental CHB; transthoracic mechanical stimulation with an automated ‘cardiac thumper’6
       Wirtzfeld and colleagues
      • Wirtzfeld A
      • Himmler FC
      • Forssmann B
      • et al.
      External mechanical cardiac stimulation. Methods and possible applications.
      Rabbits and pigsCHB; transthoracic mechanical stimulation with an automated ‘cardiac thumper’6
       Iseri and colleagues
      • Iseri LT
      • Allen BJ
      • Baron K
      • Brodsky MA
      Fist pacing, a forgotten procedure in bradyasystolic cardiac arrest.
      4 dogsVentricular asystole6
      Two larger case series have reported on 50 and 100 patients, respectively.
      • Klumbies A
      • Paliege R
      • Volkmann H
      Mechanical emergency stimulation in asystole and extreme bradycardia.
      • Zeh E
      • Rahner E
      The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump.
      Zeh and Rahner
      • Zeh E
      • Rahner E
      The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump.
      found that mechanical transthoracic stimulation generated a reproducible cardiac rhythm in 31 patients after their implanted electrical pacemaker had been deactivated. Furthermore, these authors demonstrated successful over-stimulation of an intrinsic cardiac rhythm in 19 healthy volunteers. After preliminary investigations in 20 volunteers, Klumbies and colleagues
      • Paliege R
      • Volkmann H
      • Klumbies A
      The first as pace maker. Investigations about mechanical emergency pacing of the heart.
      described successful application of percussion pacing in 90 out of 100 patients with witnessed ventricular asystole or symptomatic bradycardia.
      • Klumbies A
      • Paliege R
      • Volkmann H
      Mechanical emergency stimulation in asystole and extreme bradycardia.
      In a 55-yr-old woman with CHB, Chan and colleagues
      • Chan L
      • Reid C
      • Taylor B
      Effect of three emergency pacing modalities on cardiac output in cardiac arrest due to ventricular asystole.
      compared the three different modes of emergency cardiac stimulation: percussion pacing, transcutaneous, and transvenous electrical pacing. Ventricular stroke volumes, calculated with the use of a previously inserted pulmonary artery catheter, were comparable for all three techniques. In a dog model with CHB, Iseri and colleagues
      • Iseri LT
      • Allen BJ
      • Baron K
      • Brodsky MA
      Fist pacing, a forgotten procedure in bradyasystolic cardiac arrest.
      compared percussion pacing and chest compression in terms of their effects on cardiac output (CO). CO under percussion pacing was approximately twice as high as that generated by chest compressions (60–77 vs 24–38% of control at baseline). Whereas the latter produces compressions of the heart with passive expulsion of blood, mechanical stimulation in percussion pacing generates an almost physiological situation with electrical impulses followed by myocardial contractions. ‘Percussion pacing’ and ‘fist pacing’ are used synonymously. Furthermore, some authors do not clearly differentiate between ‘percussion (fist) pacing’ and ‘precordial’, or ‘chest thumping’.

       Physiologic principles

      Percussion pacing is based on the physical phenomenon of energy transformation; mechanical energy applied to viable myocardium triggers an electrical impulse, after an all-or-none principle.
      • Scherf D
      • Bornemann C
      Thumping of the precordium in ventricular standstill.
      • Zeh E
      • Rahner E
      The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump.
      This is well known from mechanical manipulations during cardiac catheterization or cardiac surgery. Precordial thumping, which is more familiar to most health care providers and hence often confused with percussion pacing, produces a premature ventricular beat (PVB), capable of terminating early ventricular tachycardia, or ventricular fibrillation.
      • Klumbies A
      • Paliege R
      • Volkmann H
      Mechanical emergency stimulation in asystole and extreme bradycardia.
      In percussion pacing, rhythmically applied mechanical stimuli produce serial PVBs (electrical coupling), thus generating consecutive contractions of the myocardium with ventricular ejection (mechanical coupling).

       Practical application

      In some case reports, one single fist blow terminated symptomatic bradycardia.
      • Scherf D
      • Bornemann C
      Thumping of the precordium in ventricular standstill.
      • Schott E
      Über Ventrikelstillstand (Adams-Stokeśsche Anfälle) nebst Bemerkungen über andersartige Arhythymien passagerer Natur.
      • Zeh E
      • Rahner E
      The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump.
      However, most authors and also the ILCOR and the European Resuscitation Council (ERC) recommend serial blows with a rate of approximately 50–70 min−1.
      International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 4: Advanced life support
      • Nolan JP
      • Deakin CD
      • Soar J
      • Bottiger BW
      • Smith G
      • European Resuscitation Council
      European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support.
      • Zeh E
      • Rahner E
      The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump.
      Compared with precordial thumping, percussion pacing is performed with less force. To estimate the required mechanical energy, it is recommended to let the ulnar side of the fist fall from a height of approximately 20–30 cm above the chest (Fig. 3).
      • Zeh E
      • Rahner E
      The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump.
      Figure thumbnail gr3
      Fig 3Technique of percussion pacing. Serial blows with the ulnar side of the clenched fist from a height of approximately 20–30 cm above the chest to the lower left sternal edge.
      Because of its larger force, precordial thumps intended to terminate tachyarrhythmias are applied to the mid sternum,
      • Nolan JP
      • Deakin CD
      • Soar J
      • Bottiger BW
      • Smith G
      • European Resuscitation Council
      European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support.
      whereas for percussion pacing the lower left sternal edge is recommended, presumably above the right ventricle.
      • European Resuscitation Council
      Advanced life support.
      International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 4: Advanced life support
      • Nolan JP
      • Deakin CD
      • Soar J
      • Bottiger BW
      • Smith G
      • European Resuscitation Council
      European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support.
      • Zeh E
      • Rahner E
      The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump.
      Case studies by Zeh and Rahner
      • Zeh E
      • Rahner E
      The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump.
      in patients monitored with a pulmonary artery catheter indicate that an increase in right ventricular pressure of at least 15–20 mm Hg is necessary to generate an electrical impulse in the myocardium. However, most investigators emphasize that both site and force need to be individually optimized in each patient by means of efficacy control.
      • European Resuscitation Council
      Advanced life support.
      • Nolan JP
      • Deakin CD
      • Soar J
      • Bottiger BW
      • Smith G
      • European Resuscitation Council
      European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support.
      • Zeh E
      • Rahner E
      The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump.

       Confirmation of efficacy

      Similar to electrical pacing, the efficacy of percussion pacing must be controlled and reconfirmed continuously. Mechanical artifacts may render it difficult to identify percussion-generated QRS complexes (i.e. electrical coupling), if the ECG leads are attached to the chest or shoulders. Hence, it seems useful to attach the leads to the arms and legs, similar to the practice in cardiac catheterization (Fig. 2).
      A palpable central or peripheral pulse confirms mechanical coupling. It often is also visible on the pulse oximeter in a reliable plethysmographic reading. In some patients, an indwelling arterial catheter for invasive blood pressure monitoring, or even a pulmonary artery catheter may be available for reliable confirmation of the presence of a pulse with sufficient CO.
      • Chan L
      • Reid C
      • Taylor B
      Effect of three emergency pacing modalities on cardiac output in cardiac arrest due to ventricular asystole.
      Regaining of consciousness in patients suffering Adam–Stokes attacks is also regarded as a good clinical sign of restitution or improvement of systemic perfusion.
      • Eich C
      • Bleckmann A
      • Paul T
      Percussion pacing in a three-year-old girl with complete heart block during cardiac catheterization.
      • Klumbies A
      • Paliege R
      • Volkmann H
      Mechanical emergency stimulation in asystole and extreme bradycardia.
      • Schott E
      Über Ventrikelstillstand (Adams-Stokeśsche Anfälle) nebst Bemerkungen über andersartige Arhythymien passagerer Natur.

       Clinical indications

      Percussion pacing is generally indicated in all haemodynamically unstable bradyarrhythmias, in particular in CHB with or without ventricular escape rhythm (‘P wave asystole’). As in electrical cardiac pacing, the presence of atrial activity is regarded as a prerequisite for successful stimulation of the heart. Instantly started percussion pacing can bridge the time it takes to establish transcutaneous or transvenous electrical pacing. However, there are well-documented reports of longer periods of percussion pacing of up to 90 min.
      • Don Michael TA
      • Lond MB
      • Stanford RL
      Precordial percussion in cardiac asystole.
      • Dowdle JR
      Ventricular standstill and cardiac percussion.
      • Klumbies A
      • Paliege R
      • Volkmann H
      Mechanical emergency stimulation in asystole and extreme bradycardia.
      • Wild JB
      • Grover JD
      The fist an external cardiac pacemaker.
      In many patients with bradycardic circulatory arrest (PEA), percussion pacing can replace chest compressions until pharmacological or electrical intervention shows its effect. Particularly, in post-cardiac surgical patients, the avoidance of chest compressions may prevent the serious complication of an unstable sternum.

       Published guidelines and recommendations

      In its 2005 Consensus on Science And Treatment Recommendations (CoSTR), ILCOR explicitly describes percussion (fist) pacing as a therapeutic option.
      International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 4: Advanced life support
      Based on this statement, the ERC has recently incorporated percussion pacing in its 2005 guidelines for advanced life support (ALS),
      • Nolan JP
      • Deakin CD
      • Soar J
      • Bottiger BW
      • Smith G
      • European Resuscitation Council
      European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support.
      and continues to cover percussion pacing in its 2006 edition of the ALS Course Manual.
      • European Resuscitation Council
      Advanced life support.
      The 2005 ILCOR CoSTR states about percussion (fist) pacing: ‘Fist pacing may be considered in haemodynamically unstable bradyarrhythmias until an electrical pacemaker (transcutaneous or transvenous) is available’.
      International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 4: Advanced life support
      Percussion pacing consists of serial rhythmical blows with the closed fist over the left lower edge of the sternum with a rate of approximately 50–70 min − 1. The mechanically applied force must be strong enough to generate electrical stimuli triggering myocardial contractions with an arterial pulse. This must either be palpable or be recorded by appropriate cardiovascular monitoring (pulse oximetry or invasive arterial pressure measuring). If no cardiac stimulation can be achieved in bradycardic PEA, cardiopulmonary resuscitation (CPR) must be started immediately. Whereas there is a paucity of evidence (particularly, no Level 1 or 2 evidence) on percussion pacing, there exist numerous animal studies, case reports, and case series to report on its efficacy. However, partly because of the ERC’s recent incorporation of percussion pacing into their 2006 ALS manual, it is likely that this technique will receive more widespread publicity and clinical use.
      ‘In an experiment carried out upon a dove, after the heart had completely stopped moving and thereafter even the auricles had followed suit, I spent some time with my finger, moistened with saliva and warm, applied over the heart. When it had, by means of this fomentation, recovered – so to speak – its power to live, I saw the heart and its auricles move, and contract and relax, and – so to speak – be recalled from death to life.’William Harvey (1628)
      • Harvey W

      Acknowledgements

      The authors wish to thank Professor Volker Zimmermann, Department for Medical Ethics and History of Medicine at the Georg-August University of Göttingen for his support in obtaining the originals of the historic text sources and Dr Eva-Maria Jendrusch for her assistance with the photographs. Dr Schwarz is recipient of the 2006 Canadian Anesthesiologists’ Society (CAS) Research Award and the 2006 CAS/Abbott Laboratories Ltd Career Scientist Award in Anesthesia.

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        Effect of three emergency pacing modalities on cardiac output in cardiac arrest due to ventricular asystole.
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