practical procedures resuscitation skills – part five Precordial thump phil Jevon, pGce, Bsc, rN, is tachycardia, asystole and resuscitation officer/clinical skills complete heart block where a lead, Manor Hospital, Walsall. precordial thump was delivered. The results were as follows: The precordial thump is a blow to l Ninety-one (49%) reverted to the lower half of the patient’s normal sinus rhythm; sternum using the lateral aspect l Seventy-seven (41%) had no of a closed fist. It can successfully change in rhythm; resuscitate the patient when l Nineteen (10%) were worse; given promptly following a l Overall, 90% of patients were cardiac arrest caused by either better or no change and Fig 1. check carotic pulse ventricular fibrillation (VF) or 10% were worse. ventricular tachycardia (VT) (Resuscitation Council (UK), 2006). Procedure This article describes the On discovering a collapsed procedure for delivering a unconscious patient: precordial thump. l Call out for help and activate the emergency buzzer; Mechanism of action l Lie the patient flat; The rationale for delivering a l Look, listen and feel for no precordial thump is that it longer than 10 seconds to generates a mechanical energy, determine if the patient is which is converted to electrical breathing normally (an occasional energy, which then may be gasp, slow, laboured or noisy sufficient to achieve successful breathing is abnormal) or has other cardioversion (Kohl et al, 2005). signs of life (Resuscitation Council Following the onset of VF, the (UK), 2006). If trained and threshold for successful experienced in assessing ill defibrillation rises steeply after a patients, a simultaneous Fig 2. check monitor few seconds. In all reported carotid pulse check is also cases of successful use of the recommended (Resuscitation precordial thump for VF, it was Council (UK), 2006) (Fig 1); delivered within 10 seconds l If cardiac arrest is confirmed, (Resuscitation Council (UK), 2006). that is no signs of life (no This demonstrates the importance breathing, coughing, movement of witnessing the collapse. and no palpable carotid pulse), send colleagues to alert the Indications cardiac arrest team and bring the A precordial thump should be resuscitation equipment, including considered if cardiac arrest is the defibrillator (Resuscitation confirmed rapidly following a Council (UK), 2006); witnessed and monitored (ECG) l Interpret the ECG rhythm on the sudden collapse (VF or VT) if the monitor (Fig 2); defibrillator is not immediately l If VF or VT is confirmed, at hand (Resuscitation Council consider delivering a precordial (UK), 2006). thump immediately if cardiac arrest was witnessed but the Efficacy defibrillator is not immediately Fig 3. position clenched fist 20cm directly above sternum A research study (American Heart at hand (Resuscitation Council Association, 2006) looked at 187 (UK), 2006); episodes of VF, VT, supraventricular l Tightly clench your fist (the SPL 28 NT 18 July 2006 Vol 102 No 29 www.nursingtimes.net keywords n Procedures n Resuscitation n Precordial thump dominant hand is usually used); REferences l Position your fist approximately 20cm directly above the patient’s Adam, S., Osborne, S. (2005) sternum (Fig 3); Critical Care Nursing Science and l Using the ulnar edge of the fist, Practice (2nd ed). Oxford: Oxford deliver a sharp blow to the lower University Press. half of the sternum (Resuscitation American Heart Association (2006) Council (UK), 2006) (Fig 4). An Worksheet BLS – Alternative effective but not excessive force Methods of CPR Including Cough can be generated by swinging the CPR and Precordial Thump. fist from the elbow (Adam and www.americanheart.org. Osborne, 2005); l Immediately retract your fist to Caldwell, G. et al (1985) Simple create an impulse-like stimulus mechanical methods for (Nolan et al, 2005) (Fig 5); cardioversion: defence of the precordial thump and cough version. l Prepare to start cardiopulmonary British Medical Journal; 291: resuscitation (30 compressions: 627–630. Fig 4. deliver sharp blow to lower half of sternum two ventilations) (Resuscitation Council (UK), 2006) (Fig 6). If the Kohl, P. et al (2005) Antiarrhythmic precordial thump successfully effects of acute mechanical terminates VF or VT, it is probable stimulation. In: Kohl, P. et al (eds) that the patient will regain Cardiac Mechano-electric Feedback consciousness very quickly, and Arrhythmias From Pipette to sometimes almost spontaneously; Patient. Philadelphia, PA: Elsevier therefore, cardiopulmonary Saunders. resuscitation will not be required. Krijne, R. (1984) Rate acceleration of ventricular tachycardia after a Complications precordial chest thump. American There are isolated cases reported Journal of Cardiology; 53: 964–965. in the literature of a precordial thump converting a pulse producing Nolan, J. et al (2005) European rhythm to a non-pulse producing Resuscitation Council Guidelines for rhythm (Krijne, 1984), although Resuscitation 2005: Section 4. Adult this is a very rare phenomenon advanced life support. Resuscitation; (Resuscitation Council (UK), 2006). 675S: S39–S86. There is also a risk of damaging Fig 5. immediately retract fist Resuscitation Council (UK) (2006) the ribcage, particularly if the Advanced Life Support (5th ed). precordial thump is incorrectly London: Resuscitation Council (UK). delivered. Nevertheless, the potential benefit of the precordial thump greatly outweighs its risks proFessioNal (Caldwell et al, 1985). respoNsiBilities All nurses who carry out clinical Training procedures must have received Precordial thump should only be approved training, undertaken delivered by healthcare supervised practice and practitioners trained in its use demonstrated competence in (Resuscitation Council (UK), 2006). the clinical area. The onus is It is also necessary to have some also on the individual to ensure ECG interpretation skills as that knowledge and skills are confirmation of VF or VT is now a maintained from both a prerequisite for delivering a theoretical and a practical precordial thump (previous perspective. Nurses should also guidelines have recommended undertake this role in Fig 6. start cardiopulmonary resuscitation considering it in either a accordance with an witnessed or monitored cardiac organisation’s protocols, arrest). The local resuscitation policies and guidelines. policy should be followed. n NT 18 July 2006 Vol 102 No 29 www.nursingtimes.net 29 34 NT 24 May 2005 Vol 101 No 21 www.nursingtimes.net.