Closed-Chest Cardiac Massage

Introduction

Closed chest cardiac massage, introduced in the year 1960, helped to save the lives of countless patients who had cardiac arrest. Cardiopulmonary resuscitation (CPR) is done in a patient with cardiac arrest, and the basic component of CPR is chest compressions. Closed chest cardiac massages are indicated for patients with cardiac arrest.

What Is Closed-Chest Cardiac Massage?

Closed chest cardiac massage, also known as cardiac massage, is called chest compressions or cardiac compression. This method includes the manual application of rhythmic pressure to the chest and mouth-to-mouth respiration. A two-hand technique where pressure is given to the heart from the apex upward, approximately 100 beats per minute.

The procedure is mainly done to restore the blood flow to the brain and decrease the chance of ischemic injury and cardiac arrest. The procedure is continued till a normal heartbeat is restored or till the patient has reached the hospital. Cardiac massage can be given at the rate of 100 to 120 compressions in a minute, similar to cardiopulmonary resuscitation (CPR). Chest compressions can be initiated without any physician's order. The success of cardiac compression is determined by the quality of the compressions, and everyone needs to familiarize themselves with this procedure.

What Are the Indications and Contraindications for Cardiac Compression?

• Indicated in all patients with cardiac arrest.

• No need for any doctor's order to initiate.

• An unresponsive patient without a pulse and normal breathing is the indication to begin a cardiac massage.

• There are certain situations that contraindicate chest compressions. A valid do not resuscitate (DNR) order is the only absolute contraindication.

What Is the Physiology of Chest Compressions?

Chest compressions initiate the blood flow to the brain and heart; it may be small, but are important to bring back cardiac functioning. Two hypotheses suggest the mechanism of blood flow following cardiac compression.

1. The external cardiac massage model is one hypothesis, which says that cardiac compression compresses the heart between the sternum and thoracic spine. This causes the ejection of blood into the systemic and pulmonary circulation, and the backward flow is minimal.

2. The thoracic pump model says that the global intra-thoracic pressure is increased in cardiac compressions, with equivalent pressure increase in the heart, vena cava, and aorta. This increase in pressure initiates the blood flow.

It is made clear that the cardiac massage and the action of the thoracic pump initiate the blood flow back. The most susceptible organ to reduced blood flow is the brain, followed by the myocardium, the second most susceptible organ.

How to Perform a Closed-Chest Cardiac Massage?

This technique is used in patients with sudden cardiac arrest, mainly done to start the heart beating. Mainly focusing on restoring heart function.

In this technique, both the ventilation and circulation are restored, which are necessary to sustain life.

Massaging the heart can restore and maintain circulation. This method can be performed anywhere, using two hands.

• Manual application of rhythmic pressure to the lower sternum and mouth-to-mouth respiration for ventilation of lungs.

• In a patient with cardiac arrest, tight clothing has to be removed; the patient should be placed in a supine position, on a firm surface, like a floor.

• Tilt the patient's head to the back, ensuring a patent airway.

• External cardiac massage should be done once if there are no signs of life.

Outside the Hospital:

• Ensure a patent airway, and ventilate the lungs.

• Start cardiac massage. In the lower sternum, apply pressure for 60 to 80 minutes.

• Pressure should not be applied to the ribs.

• Use the head of the hand to apply pressure.

• Pushing the sternum posteriorly by 1 to 1.5 inches causes compression of the heart between the thoracic vertebral column.

• These compressions cause the blood to force into the pulmonary and systemic circulation.

• On releasing the pressure from the chest, the chest expands, and the heart is refilled with venous blood.

• Use of an S-tube for mouth-to-mouth breathing. If only one person is attending to the patient, interrupt the massaging every 30 minutes and ventilate the lungs two to three times.

• Call for help; when another person is there, call for an ambulance.

• Breathe regularly into the patient's mouth, 12 to 14 times per minute, with the nose of the patient closed.

• If not resumed after a few minutes, consider giving an intracardiac injection of epinephrine (0.5 mg).

• Continue the cardiac massage till reaching the hospital.

• In adult men and women, while performing cardiac massage, the heel of the hand should be placed on the sternum just above the xiphoid process of the sternum. Place both hands with one above the other hand.

• In children in age up to nine or ten, only one hand is to be placed for applying pressure. In children, the rib cage is flexible.

• In infants, use only two fingertips of one hand to give pressure. This prevents giving excess pressure on internal organs.

When to Stop the Chest Compression?

The chest compression technique can be stopped when there is a return of spontaneous circulation (ROSC). Normal breathing patients in an unconscious state can be in the recovery position.

If the patient is unresponsive and ROSC, a decision should be made in correlation with clinical assessment and made by a physician. Some factors to be considered are:

• Duration of chest compression.

• Duration of cardiac arrest.

• Time taken to initiate the chest compression.

• Age of the patient.

• Comorbidities

• Initial arrest rhythm.

• Other reversible causes of cardiac arrest.

In most cases, prolonged cardiac massage will not succeed if no ROSC happens within half an hour, but exceptions are also there.

What Are the Complications of Chest Compressions?

• Life-threatening complications occur rarely.

• Hypotension following returning of blood circulation is noted and can lead to cardiogenic shock and abdominal injury.

• A rib fracture is another complication frequently reported.

• Following the return of spontaneous circulation, the patient should also be evaluated for resuscitation-related injuries.

Conclusion

Closed chest cardiac massages or chest compressions are the early and emergency help needed by a patient with cardiac arrest. The technique can be performed by anyone to save the life of the patient. Everybody should be made aware of this technique to face an emergency, as it can save a valuable life.