Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Open cardiac resuscitation Bradford Blakeman MD & William H. Wehrmacher MD To cite this article: Bradford Blakeman MD & William H. Wehrmacher MD (1990) Open cardiac resuscitation, Postgraduate Medicine, 87:1, 247-253, DOI: 10.1080/00325481.1990.11704536 To link to this article: http://dx.doi.org/10.1080/00325481.1990.11704536
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Monash University Library]
Date: 02 July 2016, At: 16:59
CME credit article
Open cardiac resuscitation A surgeon's viewpoint
Bradford Blakeman, MD
Downloaded by [Monash University Library] at 16:59 02 July 2016
Preview
able. The time required to establish circulatory support varies depending on the cause of cardiac arrest. About 30 to 60 minutes is needed for the patient with an occluded graft or massive bleeding. Cardiopulmonary bypass is often required, so a perfusion team should be available in Open cardiac resuscitation was be considered early and must be the operating room. first successfully performed in implemented only by personnel • Cardiac arrest during induc1898 by Tuffier, and for the next familiar with the technique. tion of anesthesia for open heart 62 years it was the only method ABSOLUTE INDICATIONs-surgery. This occasionally occurs used for cardiac massage. 1 In in the surgical suite, usually as a There are four absolute indicaresult of bradyarrhythmia or 1960, Kouwenhoven and associ- tions for open cardiac resuscitation: profound ischemia. The chest is ates popularized closed cardiac massage, which then became the • Cardiac arrest during the first quickly opened by a midsternal incision, and open cardiac masstandard method of resuscita72 hours after cardiotomy. This tion. 1•3 Although closed cardiac sage is performed by the surgeon. generally results from pump massage remains the method of The patient is then placed on failure or arrhythmia. Closed choice, interest in open cardiac cardiopulmonary bypass, and cardiac massage is performed resuscitation has been renewed. the surgeon proceeds with the while the patient is transported Reasons for this include imto the operating room. If an oper- operation. • Cardiac arrest following peneproved hemodynamics in animal ating room is not immediately trating chest injury. Open resusmodels with use of open cardiac available and attempts at carcitation is performed while the massage, frustration with results dioversion or defibrillation with patient is transported to the DC countershock fail, resuscitaof closed cardiac massage. and tion is begun at the bedside while operating room for repair of the the realization that postcardiotoinjury and sterile closure of the the operating room is being premy patients can be resuscitated chest. Cardiopulmonary bypass pared. The patient's chest is only by the open method. 1•9 should be available. opened through the site of the • Cardiac arrest following blunt previous sternotomy. The skin Indications chest injury. Open resuscitation stitches and wires holding the The indications for open cardiac is performed only if reasonable sternum can be cut in about 20 resuscitation can be categorized seconds. The wound is held open neurologic function was docuas either absolute or relative. In mented before the cardiac arrest. by a retractor. If the appropriate all cases, resuscitation must The procedure can be done either instruments are not readily accessible, closed cardiac massage at the site of trauma or in the William H. Wehrmacher, MD, was the emergency department. can be used until they are availEditorial Board coordinator for this article.
For many years, open cardiac massage was the preferred method of cardiac resuscitation. However, over the past three decades, closed cardiac massage bas been the more widely used method. In this article, Dr Blakeman describes the indications and techniques for open cardiac resuscitation and compares the relative merits of the open and closed methods.
continued
VOL 87~ 1/JANUARY 1990/POSTGRADUATE MEDICINE • OPEN CARDIAC RESUSCITATION
247
Downloaded by [Monash University Library] at 16:59 02 July 2016
Closed cardiac resuscitation may be ineffective in patients with severe emphysema or chest-wall deformity.
Figure 1. Site of anterolateral thoracotomy (dotted line). This approach may be used to open chest for open cardiac resuscitation.
RELATIVE INDICATIONs--The relative indications for open cardiac massage include the following: • Patients in whom closed cardiac massage has failed. • Patients in whom cardiac arrest was witnessed. This situation would probably apply only to the hospital setting, where properly trained personnel are available to implement treatment. • Patients with severe emphysema. Because such patients have a rigid chest, closed cardiac resuscitation may be ineffective. • Patients with chest-wall deformity (ie, pectus excavatum or pectus carinatum). Closed resuscitation may be ineffective because such patients have an abnormal sternum. Also, the heart could be perforated by the closed method.
Techniques When open cardiac resuscitation is indicated, the chest may be opened through a midsternal or an anterolateral incision in the left fourth intercostal space. Obviously, a midsternal incision is appropriate for a patient who has a cardiac arrest while awaiting cardiac surgery. The incision extends from the sternal notch to several inches below the xiphoid process. The sternum is split longitudinally with an electrical saw or osteotome, and a chest retractor is placed. If the patient had cardiac surgery recently, the physician needs only to cut the sutures and place a chest retractor. The pericardium is opened, and manual massage is started. A two-handed technique is used. Both ventricles are squeezed simultaneously, allowing the heart to fill passively between
each compression. A rate of 60 to 80 times per minute is sufficient. 4 While resuscitation is being performed, the surgical team prepares for cardiopulmonary bypass. Another approach to the heart is through an anterolateral thoracotomy (figure 1) at the fourth intercostal space. The incision is made two fingerbreadths below the nipple and extends from the sternum to the midaxillary line. The muscle is cut on the top surface of the rib to avoid the intercostal bundle. The incision should end 2 in. short of the sternum to prevent excessive bleeding from the internal mammary pedicle. A chest retractor is then placed. The pericardium is opened with a longitudinal incision above the phrenic nerve, extending from the diaphragm to the point where the pericardium fuses with the aorta. Cardiac massage is performed with the two-handed technique or with one hand placed behind the heart and compressing it against the sternum.
Open versus closed method The choice of open or closed cardiac resuscitation requires consideration of three issues: (1) the hemodynamics of each method as demonstrated in animal experiments, (2) the applicability of the method to the clinical situacontinued
248
OPEN CARDIAC RESUSCITATION • VOL 87 /I'K) 1/JANUARY 1990/POSTGRAOUATE MEDICINE
Downloaded by [Monash University Library] at 16:59 02 July 2016
Animal research to date clearly shows a marked improvement in hemodynamics with open cardiac massage when resuscitation extends beyond 2 minutes.
tion, and (3) the availability of open cardiac massage to the patient. Animal research to date clearly shows a marked improvement in hemodynamics with open cardiac massage when resuscitation extends beyond 2 minutes. 7-9 Normal electroencephalograms have been maintained for up to l hour, and carotid blood flow approximates normal clinical values. 7-9Cardiac output can be maintained at 70% of normal with open cardiac massage but at only 17% of normal with closed massage. 7-9 Cardiac blood flow can be doubled with the open method. 7 -9 Interestingly, when resuscitation is done for less than 2 minutes, the hemodynamic benefits of the two methods are indistinguishable. Beyond 2 minutes, the effectiveness of closed cardiac massage deteriorates.9 In clinical studies, the differences in effectiveness of the two methods are not as pronounced. Geehr and associates 10 found no statistical differences in survival rates in 49 patients with spontaneous cardiac arrest who were randomly assigned to receive either open or closed resuscitation. Beaver and associates 11 examined the efficiency of open resuscitation in a pediatric trauma setting and noted no significant improvement in survival
Bradford Blakeman, MD Dr Blakeman is assistant professor of thoracic and cardiovascular surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois. His particular interests are electrophysiology and pediatric cardiovascular surgery
rates with this method. In a trauma setting, Flynn reported a survival rate of 3.4% and Cogbill a rate of 3% with the open method. 4 Flynn did demonstrate a survival rate of 24% with the open method in patients with penetrating chest injury. 4 Other reports in the literature citing improved results with open cardiac massage are largely isolated case reports. Of note is the fact that open cardiac massage does not cause a prohibitive rate of infection. 12 Because the majority of cardiac arrests occur away from the · hospital, the expectation that trained personnel could implement open cardiac massage within 4 minutes is unreason-
able. It is easier and more costeffective to train technicians to implement closed cardiac massage, interpret electrocardiograms, and perform defibrillation when necessary. It is important to begin resuscitation early, and closed cardiac massage can be started at the scene of cardiac arrest. Use of the open method would delay the resuscitation. Use of the closed approach is unlikely to increase morbidity or mortality.
Summary and conclusion Open cardiac massage yields better hemodynamic results in the laboratory than does closed cardiac massage. However, continued
VOL 87/NO 1/JANUAAY 1990/POSTGAADUATE MEDICINE • OPEN CARDIAC RESUSCITATION
251
Downloaded by [Monash University Library] at 16:59 02 July 2016
reported survival rates with the two methods are similar, except in postcardiotomy patients and patients with penetrating injury. Implementation of resuscitation within several minutes of cardiac arrest is far more important than the specific method used. Closed cardiac massage can be instituted more universally and more quickly than open mas-
sage and thus should remain the mainstay of cardiac resuscitation. Open cardiac massage can be performed by trained surgical personnel in appropriate situations. Rill Address for correspondence: Bradford Blakeman, MD. Department of Thoracic and Cardiovascular Surgery. Loyola University Medical Center, Stritch School of Medicine, 2160 S First Ave, Maywood. 1L60153.
Refel'eDeell 1. J~ RE, Freeman SB. Hemodynamlcs of cardiac massage. Emerg Med CUn North Am 1983: I (3):
2. Crlley JM, Niemluul JT, Ra.boroagh JP. Cardio-
8.11artlettRL, StewartNJ Jr, RaJ'memdJ, eta!. Comparative study of three methods of resuscitation: closed-chest, open-chest manual. and direct mechanical ventricular assistance. Ann Emerg Med 1984:
pulmonary resuscitation research 1960-1984: discoverIes and advances. Ann Emerg Med 1984; 13(9 l't 2):
9. Blrcber Ill, Safar P. Manual open-chest cardtopul-
501-13
756-8 3. Roeenthal RE. Cardiopulmonary resuscitation: historical and future perspectives. Postgrad Med 1987;
13(9 pt 2):773-7
monary resuscitation. Ann Emerg Med 1984: 13 (9 pt 2):770-3
4. Grlabkln BA. Open-chest resuscitation. Crtt Care
JO. Geebr EC, Lewta FR. Aaerbach PS. Fallure of open-heart massage to Improve survival after prehospl· tal nontraumatlc cardiac arrest. (Letter) N Eng! J
5. Safar P. Resuscitation from cllnJcal death: pathophysiologic llmtts and therapeutic potenttals. Crtt Care Med 1988; 16( 10):923-41 6. Suclera AB, Kern KB, Ew)' GA. Time llmttatlons for open-chest cardiopulmonary resuscitation from cardiac arrest. Crtt Care Med 1985: 13( II ):897-8 7. Safar P. Recent advances tn cardtopulmonarycerebral resuscitation: a revtew. Ann Emerg Med 1984;
11. Beaver BL, Calambanl. PM, Bacl< JR, et al. Efficacy of emergency room thoracotomy tn pediatric trauma. J PedtatrSurg 1987:22(1):19-23 12. lllcKmnm RL,Jb&ovem GJ, Liebler GA. eta!. tnfectlous compUcatlons and cost-effectlveness of open resuscitation tn the surgical Intensive care unit after cardiac surgery. Ann Thorac Surg 1985;40(4): 388-92
81 (3):90-103 Nurs g 1988: 10(4):17-24
Med 1988:314(18):1189-90
13(9 pt 2):856-62
A REVIEWER'S COMMENT
As the author clearly states, open cardiac resuscitation is a highly specialized procedure that should be performed only by skilled surgical personnel. It is not a procedure that will be performed by a generalist under any circumstances. The author also states that there is little substantial cltntcal data to suggest that open cardiac resuscitation has advantages over closed heart massage.
VOL 87/NO 1/JANUARY 1990/POSTGRADUATE MEDICINE • OPEN CARDIAC RESUSCITATION
253
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Open cardiac resuscitation Bradford Blakeman MD & William H. Wehrmacher MD To cite this article: Bradford Blakeman MD & William H. Wehrmacher MD (1990) Open cardiac resuscitation, Postgraduate Medicine, 87:1, 247-253, DOI: 10.1080/00325481.1990.11704536 To link to this article: http://dx.doi.org/10.1080/00325481.1990.11704536
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Monash University Library]
Date: 02 July 2016, At: 16:59
CME credit article
Open cardiac resuscitation A surgeon's viewpoint
Bradford Blakeman, MD
Downloaded by [Monash University Library] at 16:59 02 July 2016
Preview
able. The time required to establish circulatory support varies depending on the cause of cardiac arrest. About 30 to 60 minutes is needed for the patient with an occluded graft or massive bleeding. Cardiopulmonary bypass is often required, so a perfusion team should be available in Open cardiac resuscitation was be considered early and must be the operating room. first successfully performed in implemented only by personnel • Cardiac arrest during induc1898 by Tuffier, and for the next familiar with the technique. tion of anesthesia for open heart 62 years it was the only method ABSOLUTE INDICATIONs-surgery. This occasionally occurs used for cardiac massage. 1 In in the surgical suite, usually as a There are four absolute indicaresult of bradyarrhythmia or 1960, Kouwenhoven and associ- tions for open cardiac resuscitation: profound ischemia. The chest is ates popularized closed cardiac massage, which then became the • Cardiac arrest during the first quickly opened by a midsternal incision, and open cardiac masstandard method of resuscita72 hours after cardiotomy. This tion. 1•3 Although closed cardiac sage is performed by the surgeon. generally results from pump massage remains the method of The patient is then placed on failure or arrhythmia. Closed choice, interest in open cardiac cardiopulmonary bypass, and cardiac massage is performed resuscitation has been renewed. the surgeon proceeds with the while the patient is transported Reasons for this include imto the operating room. If an oper- operation. • Cardiac arrest following peneproved hemodynamics in animal ating room is not immediately trating chest injury. Open resusmodels with use of open cardiac available and attempts at carcitation is performed while the massage, frustration with results dioversion or defibrillation with patient is transported to the DC countershock fail, resuscitaof closed cardiac massage. and tion is begun at the bedside while operating room for repair of the the realization that postcardiotoinjury and sterile closure of the the operating room is being premy patients can be resuscitated chest. Cardiopulmonary bypass pared. The patient's chest is only by the open method. 1•9 should be available. opened through the site of the • Cardiac arrest following blunt previous sternotomy. The skin Indications chest injury. Open resuscitation stitches and wires holding the The indications for open cardiac is performed only if reasonable sternum can be cut in about 20 resuscitation can be categorized seconds. The wound is held open neurologic function was docuas either absolute or relative. In mented before the cardiac arrest. by a retractor. If the appropriate all cases, resuscitation must The procedure can be done either instruments are not readily accessible, closed cardiac massage at the site of trauma or in the William H. Wehrmacher, MD, was the emergency department. can be used until they are availEditorial Board coordinator for this article.
For many years, open cardiac massage was the preferred method of cardiac resuscitation. However, over the past three decades, closed cardiac massage bas been the more widely used method. In this article, Dr Blakeman describes the indications and techniques for open cardiac resuscitation and compares the relative merits of the open and closed methods.
continued
VOL 87~ 1/JANUARY 1990/POSTGRADUATE MEDICINE • OPEN CARDIAC RESUSCITATION
247
Downloaded by [Monash University Library] at 16:59 02 July 2016
Closed cardiac resuscitation may be ineffective in patients with severe emphysema or chest-wall deformity.
Figure 1. Site of anterolateral thoracotomy (dotted line). This approach may be used to open chest for open cardiac resuscitation.
RELATIVE INDICATIONs--The relative indications for open cardiac massage include the following: • Patients in whom closed cardiac massage has failed. • Patients in whom cardiac arrest was witnessed. This situation would probably apply only to the hospital setting, where properly trained personnel are available to implement treatment. • Patients with severe emphysema. Because such patients have a rigid chest, closed cardiac resuscitation may be ineffective. • Patients with chest-wall deformity (ie, pectus excavatum or pectus carinatum). Closed resuscitation may be ineffective because such patients have an abnormal sternum. Also, the heart could be perforated by the closed method.
Techniques When open cardiac resuscitation is indicated, the chest may be opened through a midsternal or an anterolateral incision in the left fourth intercostal space. Obviously, a midsternal incision is appropriate for a patient who has a cardiac arrest while awaiting cardiac surgery. The incision extends from the sternal notch to several inches below the xiphoid process. The sternum is split longitudinally with an electrical saw or osteotome, and a chest retractor is placed. If the patient had cardiac surgery recently, the physician needs only to cut the sutures and place a chest retractor. The pericardium is opened, and manual massage is started. A two-handed technique is used. Both ventricles are squeezed simultaneously, allowing the heart to fill passively between
each compression. A rate of 60 to 80 times per minute is sufficient. 4 While resuscitation is being performed, the surgical team prepares for cardiopulmonary bypass. Another approach to the heart is through an anterolateral thoracotomy (figure 1) at the fourth intercostal space. The incision is made two fingerbreadths below the nipple and extends from the sternum to the midaxillary line. The muscle is cut on the top surface of the rib to avoid the intercostal bundle. The incision should end 2 in. short of the sternum to prevent excessive bleeding from the internal mammary pedicle. A chest retractor is then placed. The pericardium is opened with a longitudinal incision above the phrenic nerve, extending from the diaphragm to the point where the pericardium fuses with the aorta. Cardiac massage is performed with the two-handed technique or with one hand placed behind the heart and compressing it against the sternum.
Open versus closed method The choice of open or closed cardiac resuscitation requires consideration of three issues: (1) the hemodynamics of each method as demonstrated in animal experiments, (2) the applicability of the method to the clinical situacontinued
248
OPEN CARDIAC RESUSCITATION • VOL 87 /I'K) 1/JANUARY 1990/POSTGRAOUATE MEDICINE
Downloaded by [Monash University Library] at 16:59 02 July 2016
Animal research to date clearly shows a marked improvement in hemodynamics with open cardiac massage when resuscitation extends beyond 2 minutes.
tion, and (3) the availability of open cardiac massage to the patient. Animal research to date clearly shows a marked improvement in hemodynamics with open cardiac massage when resuscitation extends beyond 2 minutes. 7-9 Normal electroencephalograms have been maintained for up to l hour, and carotid blood flow approximates normal clinical values. 7-9Cardiac output can be maintained at 70% of normal with open cardiac massage but at only 17% of normal with closed massage. 7-9 Cardiac blood flow can be doubled with the open method. 7 -9 Interestingly, when resuscitation is done for less than 2 minutes, the hemodynamic benefits of the two methods are indistinguishable. Beyond 2 minutes, the effectiveness of closed cardiac massage deteriorates.9 In clinical studies, the differences in effectiveness of the two methods are not as pronounced. Geehr and associates 10 found no statistical differences in survival rates in 49 patients with spontaneous cardiac arrest who were randomly assigned to receive either open or closed resuscitation. Beaver and associates 11 examined the efficiency of open resuscitation in a pediatric trauma setting and noted no significant improvement in survival
Bradford Blakeman, MD Dr Blakeman is assistant professor of thoracic and cardiovascular surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois. His particular interests are electrophysiology and pediatric cardiovascular surgery
rates with this method. In a trauma setting, Flynn reported a survival rate of 3.4% and Cogbill a rate of 3% with the open method. 4 Flynn did demonstrate a survival rate of 24% with the open method in patients with penetrating chest injury. 4 Other reports in the literature citing improved results with open cardiac massage are largely isolated case reports. Of note is the fact that open cardiac massage does not cause a prohibitive rate of infection. 12 Because the majority of cardiac arrests occur away from the · hospital, the expectation that trained personnel could implement open cardiac massage within 4 minutes is unreason-
able. It is easier and more costeffective to train technicians to implement closed cardiac massage, interpret electrocardiograms, and perform defibrillation when necessary. It is important to begin resuscitation early, and closed cardiac massage can be started at the scene of cardiac arrest. Use of the open method would delay the resuscitation. Use of the closed approach is unlikely to increase morbidity or mortality.
Summary and conclusion Open cardiac massage yields better hemodynamic results in the laboratory than does closed cardiac massage. However, continued
VOL 87/NO 1/JANUAAY 1990/POSTGAADUATE MEDICINE • OPEN CARDIAC RESUSCITATION
251
Downloaded by [Monash University Library] at 16:59 02 July 2016
reported survival rates with the two methods are similar, except in postcardiotomy patients and patients with penetrating injury. Implementation of resuscitation within several minutes of cardiac arrest is far more important than the specific method used. Closed cardiac massage can be instituted more universally and more quickly than open mas-
sage and thus should remain the mainstay of cardiac resuscitation. Open cardiac massage can be performed by trained surgical personnel in appropriate situations. Rill Address for correspondence: Bradford Blakeman, MD. Department of Thoracic and Cardiovascular Surgery. Loyola University Medical Center, Stritch School of Medicine, 2160 S First Ave, Maywood. 1L60153.
Refel'eDeell 1. J~ RE, Freeman SB. Hemodynamlcs of cardiac massage. Emerg Med CUn North Am 1983: I (3):
2. Crlley JM, Niemluul JT, Ra.boroagh JP. Cardio-
8.11artlettRL, StewartNJ Jr, RaJ'memdJ, eta!. Comparative study of three methods of resuscitation: closed-chest, open-chest manual. and direct mechanical ventricular assistance. Ann Emerg Med 1984:
pulmonary resuscitation research 1960-1984: discoverIes and advances. Ann Emerg Med 1984; 13(9 l't 2):
9. Blrcber Ill, Safar P. Manual open-chest cardtopul-
501-13
756-8 3. Roeenthal RE. Cardiopulmonary resuscitation: historical and future perspectives. Postgrad Med 1987;
13(9 pt 2):773-7
monary resuscitation. Ann Emerg Med 1984: 13 (9 pt 2):770-3
4. Grlabkln BA. Open-chest resuscitation. Crtt Care
JO. Geebr EC, Lewta FR. Aaerbach PS. Fallure of open-heart massage to Improve survival after prehospl· tal nontraumatlc cardiac arrest. (Letter) N Eng! J
5. Safar P. Resuscitation from cllnJcal death: pathophysiologic llmtts and therapeutic potenttals. Crtt Care Med 1988; 16( 10):923-41 6. Suclera AB, Kern KB, Ew)' GA. Time llmttatlons for open-chest cardiopulmonary resuscitation from cardiac arrest. Crtt Care Med 1985: 13( II ):897-8 7. Safar P. Recent advances tn cardtopulmonarycerebral resuscitation: a revtew. Ann Emerg Med 1984;
11. Beaver BL, Calambanl. PM, Bacl< JR, et al. Efficacy of emergency room thoracotomy tn pediatric trauma. J PedtatrSurg 1987:22(1):19-23 12. lllcKmnm RL,Jb&ovem GJ, Liebler GA. eta!. tnfectlous compUcatlons and cost-effectlveness of open resuscitation tn the surgical Intensive care unit after cardiac surgery. Ann Thorac Surg 1985;40(4): 388-92
81 (3):90-103 Nurs g 1988: 10(4):17-24
Med 1988:314(18):1189-90
13(9 pt 2):856-62
A REVIEWER'S COMMENT
As the author clearly states, open cardiac resuscitation is a highly specialized procedure that should be performed only by skilled surgical personnel. It is not a procedure that will be performed by a generalist under any circumstances. The author also states that there is little substantial cltntcal data to suggest that open cardiac resuscitation has advantages over closed heart massage.
VOL 87/NO 1/JANUARY 1990/POSTGRADUATE MEDICINE • OPEN CARDIAC RESUSCITATION
253
