How to punch a dead man in the chest . . . and end up a hero!

If you don’t know CPR, you should learn. It’s cheap, easy, and may save someone’s life someday.

Having said that, did you know that CPR success stories – in general – are rare? In fact, the likelihood of someone having sudden cardiac arrest outside of a hospital, receiving CPR and walking out of the hospital at all (let alone with good neurologic function, i.e., the brain isn’t damaged) is actually pretty crappy.

According to a 2015 study by the AHA, the rate of ROSC (return of spontaneous circulation) and subsequent survival from the hospital in a patient who had sudden cardiac arrest and received CPR by emergency medical services prior to the hospital was only 10.6%. And, only 8.3% had good neurologic outcome.

Pretty crappy.

But wait! There’s more!

Of the patients who received bystander CPR, meaning a good samaritan like yourself happened to see someone go down and think, “hey, I think that guy just died, I’d better do CPR!” and actually did it, 31.4% survived!

Now, I don’t know about you but I’ll take a three-fold increase in my likelihood of surviving any day of the week. In fact, if anybody plans to spend much time around me, maybe I need to pay for all of you to learn CPR!

BUT WHAT IF I TOLD YOU THAT – FOR YEARS – DOCTORS WEREN’T RELYING SOLELY ON CHEST COMPRESSIONS AND MOUTH-TO-MOUTH TO ASSIST IN RESUSCITATION OF CARDIAC ARREST PATIENTS? WHAT IF I TOLD YOU THAT SOME DOCTORS, MYSELF INCLUDED, RELIED EVERY NOW AND THEN ON JUST A GOOD SOLID PUNCH TO THE CHEST OF A DEAD PERSON AS A MEANS TO MAKE THEIR DAY, I.E., GET THEM BACK?

 

In the 1970s, two doctors at Harvard – James E. Pennington and Bernard Lown – started studying the effect of “thumping” someone in the chest who had suffered sudden cardiac arrest. They were able to show that a forceful blow directly to the sternum could potentially get the heart out of an arrhythmia such as ventricular tachycardia (VT) and ventricular fibrillation (VF). Bear in mind, CPR wasn’t even officially endorsed by the AHA until 1963, so this was pretty groundbreaking stuff back then!

So, how is it done? It’s easy, as described below:

• If you witness an individual collapse and show no signs of life, first get help. Go yourself or ask someone to call 911 and to bring an automated external defibrillator (AED) if one is near.
• Assess the individual for responsiveness. (This isn’t where you get to punch them… that part’s coming!) Tap them on the chest firmly and ask, “Are you okay?”
• If there is no response, check to see if a patient is breathing and has a pulse. This is the look/listen/feel stage. Don’t take more than 10 seconds. if you find a pulse, great. If not, move on.
• If there is no pulse, then this is your moment! Clench your fist, hold it ulnar (pinky) side down (like you might bang it on a table whilst showing your boss who’s really boss in a meeting) about 8-10 inches above the person’s sternum, and deliver a sharp blow to the sternum. Immediately retract your fist almost like a whipping action to create a rebound of the chest as you remove the force.
• Start chest compressions at a rate of about 100-120 per minute.

There you have it: the process of punching someone a dead person in the chest and saving their life.

The discovery of this procedure – affectionately known as the “Precordial Thump” – was actually by mistake. Paramedics transporting a cardiac arrest patient hit a speed bump, and the jolt delivered to the patient’s chest in the back of the vehicle apparently saved the patient’s life! Funny how science is so non-technical when you get right down to it.

“So, Sam, I hear you had a major heart attack? Glad you’re doing well! What did the doctor say?”

“Not sure, Bill. I never saw one. Damned ambulance driver hit a telephone pole and I just woke up. Never did make it to the hospital.”

I’ve actually seen this done multiple times in the ED. I can remember once that the patient immediately awoke after a thump on the chest and a short (seconds) period of chest compressions. I know doctors who use this maneuver in their repertoire regularly when dealing with sudden cardiac arrest. I can’t say that it’s often this comes up for me, but for a handful of times. . .

Now, while this may seem like a cool party trick for your next office Christmas party, the truth is that it’s probably not all that effective, and may even be harmful. As it turns out, the survival rates still weren’t all that great, and there were reports of other injuries such as sternal fractures, cardiac contusions, etc.. Still, I know some physicians and EMS providers who would argue that this is still something to be tried when things are as bad as bad can be. After all, a common adage of the ED is that  you can’t kill a dead person. Still, the evidence is pretty clear that this technique isn’t really all that helpful, and probably only delays time to good bystander CPR, which is most definitely helpful.

In fact, in 2010, the American Heart Association released new guidelines stating that a precordial thump should not be used in unwitnessed cardiac arrest outside of the hospital, and should be considered only if there is a witnessed arrest into a (monitored) VT. In other words, if I’m your ER doc and we are talking while you’re on the telemetry monitor, and you pass out and I see your rhythm change to VT, I’ll probably punch you in the chest. Sorry and you’re welcome. But, if I’m out walking my dog and see you lying on the ground without a pulse, I’ll stick with good ole’ CPR, and would suggest you all do the same!