To thump or not to thump....

[123456yy]

so my fellow nurses and i had a very heated debate last night at work about precordial thumps. i have thumped patients and seen it work, i have thumped patients and seen it not work. several of my co-workers are of the opinion that the precordial thump has fallen out of favor and is no longer taught as part of the acls protocol. i have never heard that, but they say they're pretty sure. what i have heard is that most precordial thumps are not delivered with enough force to generate the energy necessary, and that's why they're not done as often. so i'm settling a debate. to thump, or not to thump, and why?:crash_com:lol_hitti

[Artemis2]

My favorite precordial thump:

The scene is a large, round, inner city, 10 bed ICU with curtains between the beds. The alarm goes off, heads snap up and turn. One nurse heads across the unit at at run , slides to the bedside, fist in the air and THUMP! It was pure poety in motion. I was a very green nurse and very impressed.

[JeanettePNP, MSN, RN, NP]

Those patients, however, did learn to bear-down and convert themselves after a while to avoid the inevitable thump.

Can you explain?

[kersti]

I have seen the thump work more than once- and I've had it not work. But if I'm standing right next to the bed- it's worth a shot before the crash cart comes rolling in!

[utahliz]

Quote:

Originally Posted by millkay

Those patients, however, did learn to bear-down and convert themselves after a while to avoid the inevitable thump.

Can you explain?

Intentional vasovagal maneuver.

[Mags4711, RN]

Quote:

Originally Posted by millkay

Those patients, however, did learn to bear-down and convert themselves after a while to avoid the inevitable thump.

Can you explain?

Intentional vasovagal maneuver.

Unfortunately that only works if a) you are still awake and alert and can do it and b)know you are in the rhythm immdeiately.

Though valsalvas work great.

[JeanettePNP, MSN, RN, NP]

:confused:I am lost...

How is it in the patient's control whether they go into cardiac arrest or not? Take pity and explain to a lowly pre-nursing student...

[JiffyGriff]

:confused:I am lost...

How is it in the patient's control whether they go into cardiac arrest or not? Take pity and explain to a lowly pre-nursing student...

They aren't in control of whether they go into cardiac arrest or not. What they are talking about is called the valsalva maneuver........I know it sounds crude but think about defecating......the pushing you do on the turtle head....that's the valsalva maneuver........you ever feel a little flushed or clammy sensation while doing that.....it's because your blood pressure and heart rate drop as a result of stimulating the vagal nerve.

Your heart is innervated (lined with nerves) from the the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system is in control of speeding up the heart and making it beat harder and the parasympathetic nervous system is in control of slowing it down or making it beat slower; the psns accomplishes this via the vagal nerve. Certain things cause the vagal nerve to be stimulated and in response, the heart is in effect given valium. These include but are not limited to coughing, gagging, intubation, slamming your head face first into freezing water, defecation, rectal stimulation, valsalva maneuver (bearing down), rectal temperatures, carotid massage, tracheal suctioning, etc..... You can figure out a lot of these things by knowing the areas of the body that the vagal nerve travels through.

Now, think about the heart rythm we are trying to slow down.....there are various ones......AT, PAT, SVT, VT, etc..... You don't need to know those right now.....all you need to know is that certain areas of the heart are going really, really fast because of overstimulation from the sympathetic nervous system........so in order to make it stop they use one of the methods above to stimulate the vagal nerve and make the parasympathetic nervous system take over and slow things down.

As to your original question: how are they in control of going into cardiac arrest.......they're not.......I think where you are confused on this is with V-tach........technically this is NOT cardiac arrest, it is just really, really fast ventricular contractions.......you can be symptomatic, or non-symptomatic....if you are non-symptomatic you can feel this happening and do something about it.......if you are symptomatic others will probably have to intervene for you. Asystole is cardiac arrest and does not apply to this because there is no sympathetic nervous system impulses in that situation.....parasympathetic stimulation would only make it worse. As far as V-Fib goes....others have to intervene because those patients are unresponsive......their hearts are not putting out any blood.

Hope all that helps make more sense of the subject.....if anything else needs clarified just let any of us know. :welcome:

Edit: In effect doing this could cause any of these really fast rythms from PROGRESSING to cardiac arrest or V-Fib.......they could become worse and stopping them early is preferred.......a lot of these patients that have these rythms know that they have them and are probably on medication for them......if they have breakthroughs of the rythms they have been taught the valsalva to convert the rhythm back to normal.

[JeanettePNP, MSN, RN, NP]

Wow, great explanation! Thanks so much for taking the time to type that all out.

[TopherSRN]

Jiffy, great post and not to take anything away from it, but doesn't intubation herald a sympatheitc response hence all the premedication. Also spent time shadowing a CRNA in CVOR and he made a point of explaining to me why he gave Tridil IVP to a severely hypertensive pt. before intubation. Sure enough as he dropped the tube her hemodynamics more than doubled (B/p 110, Hr 60s prior -> 240/140s after. He said intubation was one of the most sympathetic things you could do to someone.

[JiffyGriff]

Jiffy, great post and not to take anything away from it, but doesn't intubation herald a sympatheitc response hence all the premedication. Also spent time shadowing a CRNA in CVOR and he made a point of explaining to me why he gave Tridil IVP to a severely hypertensive pt. before intubation. Sure enough as he dropped the tube her hemodynamics more than doubled (B/p 110, Hr 60s prior -> 240/140s after. He said intubation was one of the most sympathetic things you could do to someone.

I'm sure that probably could happen.....but if it did I could see it being a response to not getting any O2 during the intubation......however the intubation procedure can cause gagging and stimulate the vagal nerve, if that happens things go down........if the intubation is difficult and taking some time and doesn't cause vagal stimulation on the patient then there is a lot of stress and when you get stress you get sympathetic responses...."flight or fight"....they are fighting. That's my best take on where that statement came from...... The vagal stimulation doesn't always happen, and I'm sure neither does the sympathetic response from stress, but both of them can. Don't take that as all out knowledge I'm really just taking a big guess on why he might have said that and why that happened to that patient......but the vagal response is a very real "possibility" with intubation.

Edit: Also, the only premedication I've seen prior to intubation is the sedation to keep them from realizing we are shoving a garden hose down their throat and antianxiety meds for people going to surgery, I've never heard of anyone premedicating to minimize a sympathetic response. Also with that particular patient you said that they were severely hypertensive, yet their preintubation bp was 110/60......if the bp was lowered that significantly from a very hypertensive state then I could see that bp rising very easily from a stress response....... I couldn't see that happening in a normotensive patient. What does everyone else think?

[dorimar, BSN, RN]

I have to agree with jiffy griff on that one. They can and do vagal during intubation. Usually right after they are tubed, they become hypotensive due the postive pressure in the thorax decreasing cardiac output, and from the sedation given for the intubation. I would think giving them a beta blocker would worsen any vagal stimulation or post intubation hypotension, but obvioulsy those with more education feel differently, and maybe with good reasons I don't know about.

I also have to add that precordial thump was not intended for asystoli, but Vfib. It was intended to simulate a shock, which interrupts the chaotic rhythm so sinus can take over. I have seen it work once years ago.

[HazelLPN, LPN]

Its involuntary for me....if I see it...I thump it. Its not 100% effective, but it seems to work far more than not. The sooner you can do it, the better.