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CLOSED-CHEST CARDIAC MASSAGE W. B. Kouwenhoven, Dr. Ing., James R. Jude, M.D. and G. Guy Knickerbocker, M.S.E., Baltimore When cardiac arrest occurs, either as standstillor as ventricular fibrillation, the circulation mustbe restored promptly; otherwise anoxia will result Cardiac resuscitation after cardiac arrestin irreversible damage. There are two techniques or ventricular fibrillation has been limited bythat may be used to meet the emergency: one is to the need for open thoracotomy and directopen the chest and massage the heart directly and cardiac massage. As a result of exhaustivethe other is to accomplish the same end by a new animal experimentation a method of externalmethod of closed-chest cardiac massage. The latter transthoracic cardiac massage has been de-method is described in this communication. The veloped. Immediate resuscitative measuresclosed-chest alternating current defibrillator that can now be initiated to give not only mouthx=req--was developed in our laboratories has proved to be to-nose artificial respiration but also ade-an effective and reliable means of arresting ven¬ quate cardiac massage without thoracotomy.tricular fibrillation. Its counter-shock must be sent The use of this technique on 20 patients hasthrough the chest promptly, or else cardiac anoxia given an over-all permanent survival rate ofwill have developed to such a degree that the heart 70%. Anyone, anywhere, can now initiatewill no longer be able to resume forceable contrac¬ cardiac resuscitative procedures. All that istions without assistance. Our experience has indi¬ needed are two hands.cated that external defibrillation is not likely to befollowed by the return of spontaneous heart action,unless the counter-shock is applied within less thanthree minutes after the onset of ventricular fibrilla¬ one-half minutes after the onset of induced ven¬tion. tricular fibrillation. They reported that this time A study was undertaken of means of extending limitation might be extended to as long as eightthis time limitation without opening the chest. A minutes by rhythmical application of pressure onmethod was sought that would provide adequate the thorax in the region of the heart. In tests whichcirculation to maintain the tone of the heart and the lasted 10 to 15 minutes 19 animals survived and 17nourishment of the central nervous system. This died. These authors, however, gave no specificmethod was to be at once readily applicable, safe information as to the method of application of theto use, and requiring a minimum of gadgets. pressure. Rainer and Bullough7 treated cardiac One of the first attempts at enhancing circulation arrest in children by lowering the head about 10in the arrested heart was a closed-chest method degrees, placing one arm underneath the patientsreported by Boehm in 1878. Working with cats, 2 knees, and flexing the legs and buttocks against thehe grasped the chest in his hands at the area of chest. They reported eight successful resuscitations in patients ranging from 8 weeks to 13 years in age.greatest expansion and applied rhythmic pressure.His results were quite striking in some series of Stout 8 in 1957 reported the successful use of thistests. Tournade and co-workers reported that by 3 method in one adult.an abrupt compression of the thorax of a dog in Experimentcardiac arrest blood pressures of 60 to 100 mm. Hg With dogs used as the experimental animal, car¬could be produced. No survival studies were given.Killick and Eve reported that the rocking tech¬ 4 diac arrest in the form of ventricular fibrillation was induced. In the initial experiments more thannique of artificial respiration, by which a patient is 100 dogs, weighing from 5 to 24 kg. (11 to 52tilted about 60 degrees in each direction from thehorizontal plane, will produce a change in the lb.), were used in testing various methods of mov¬blood pressure at the atrium from 38 to 76 mm. Hg. ing blood by massaging the intact chest. A safe andEve 5 hypothesized that this change will produce effective method of "massaging the heart" withoutsufficient blood flow to nourish the heart and the thoracotomy was developed. Adequate circulation for periods as long as 30 minutes was easily main¬brain. In 1947 Gurvich and Yuniev 6 found that a tained with the dog in ventricular fibrillation. Acapacitor discharge sent through the chest of a dog closed-chest defibrillating shock would result inwould be followed by a resumption of the cardiac the immediate return of normal sinus rhythm infunction if applied not later than one or one and such animals. In fig. 1 are shown sections taken from the re¬ Lecturer in Surgery (Dr. Kouwenhoven), Resident Surgeon (Dr.Jude), and Assistant in Surgery (Mr. Knickerbocker), Johns Hopkins cording of the variations in blood flow, blood pres¬University School of Medicine. sure, and electrocardiogram of a dog whose heart Downloaded from www.jama.com by guest on November 10, 2010
was in ventricular fibrillation for eight minutes. slightly to permit full expansion of the chest. TheSimultaneously recorded on a four-channel recorder operator should be so positioned that he can usewere the blood flow in a carotid artery, the instan¬ his body weight in applying the pressure. Sufficienttaneous and average pressures in a femoral artery, pressure should be used to move the sternum 3 orand the cardiogram. The tracings in the first column 4 cm. toward the vertebral column.of figure 1 are the normal values of these respective Closed-chest cardiac massage provides some ven¬phenomena immediately before fibrillation was in¬ tilation of the lungs, and if there is only one personduced by a 110-volt shock. The second column present in a case of arrest, attention should beshows the build-up of blood flow and pressures thattook place when closed-chest cardiac massage wasstarted, one minute after the onset of fibrillation.The third column is a record of what took placeabout seven minutes later. Note that vigorousfibrillation has been maintained throughout theentire period. The fourth and last column showsthe immediate return of normal sinus rhythm whenthe closed chest defibrillator shock was given. Theelectrocardiograph was temporarily disconnectedwhen the counter shock was applied. Method—The method of closed-chest cardiacmassage developed during these animal studies issimple to apply; it is one that needs no com¬plex equipment. Only the human hand is required.The principle of the method as applied to man isreadily seen by consideration of the anatomy of thebony thorax and its contained organs. The heart islimited anteriorly by the sternum and posteriorly by the vertebral bodies. Its lateral movement isrestricted by the pericardium. Pressure on thesternum compresses the heart between it and thespine, forcing out blood. Relaxation of the pressure allows the heart to fill. The thoracic cage in uncon¬scious and anesthetized adults is surprisingly mo¬bile. The method of application is shown in figure2. With the patient in a supine position, preferablyon a rigid support, the heel of one hand with the Fig 2.—Position of hands during massage of adult. concentrated the massage. If there are two or on more persons one should massage the present, heart while the other gives mouth-to-nose respira¬ tion. ClinicalApplication.—About nine months prior to time of at Johns Hopkins Hospital, clin¬ writing, ical application of closed-chest cardiac massage was Fig. 1 .—Record of blood flow, pressures, and electrocardio¬ successfully illustrated in a case of cardiac arrest.gram of dog whose heart was in ventricular fibrillation for Initially, it was felt that the method might be usefuleight minutes. I: normal initial values; II: start of closed- in treating arrest in children, whose ribs are knownchest massage; III: seventh minute of massage; IV: closed- to be flexible, but that it would not be effective inchest defibrillation. adults. This latter assumption was proved to be in¬ correct, since the chest of an unconscious adult wasother on top of it is placed on the sternum just found to be remarkably flexible.cephalad to the xiphoid. Firm pressure is applied During the 10 months prior to writing this meth¬vertically downward about 60 times per minute. At od alone has been applied on 20 patients aged fromthe end of each pressure stroke the hands are lifted 2 months to 80 years. In 13 of these patients artifi- Downloaded from www.jama.com by guest on November 10, 2010
cial respiration was applied simultaneously with the Nov. 17,1959, the patient was again returned to themassage; the duration of the massage varied from operating room for a left mastoidectomy, afterless than 1 minute to 65 minutes. In seven cases preoperative medication with 60 mg. of pentobarbi-records were obtained of either the blood pressure tal and 0.25 mg. of scopolamine. The patientor of the electrical activity of the heart (by electro¬ was yomiting continuously on arrival in the anes¬cardiogram) during the episode. Systolic pressures thesia room, and his pulse was irregular. The induc¬ tion of anesthesia stormy because of the pa¬ was tients nausea. He given open-drop anesthesia wasmm Hg with fluothane and intubation was performed with 120- ease. At this point his pulse suddenly disappeared, 80- as did the blood pressure and apical beat. Closed- 40- AJVJVJUVÀjy. chest cardiac massage was carried out for one minute and the patient responded with a good return of pulse, blood pressure, and respirations. Fig. 3.—Blood pressure produced in an adult by closed-chest cardiac massage. The operation was canceled, and the patient re¬ turned to the ward. He had no further difficultiesduring massage ranged from 60 to 100 mm. Hg. and no central nervous system damage.Figure 3 shows the blood pressures recorded on an Case 3.—An 80-year-old woman was admittedadult. The hearts of 3 of the 20 patients treated with a large tumor of the thyroid and had awere in ventricular fibrillation, and all were de- tracheostomy with biopsy of the thyroid on Nov. 5,fibrillated by a closed-chest A. C. deffbrillator 1959. The diagnosis was papillary adenocarcinomashock. All 20 patients were resuscitated and, at time of the thyroid. She was returned to the operatingof writing, 14 of them are alive without central room three days later for a definitive procedurenervous system damage and without undergoing after premedication with 100 mg. of pentobarbitalthoracotomy. and 0.5 mg. of atropine. She was given anesthesia Report of Cases with thiopental sodium and fluothane. Succinylcho- line in divided doses was also given. Intubation Four cases of cardiac standstill and one case of was performed through the tracheostomy. A fewventricular fibrillation are reported below. minutes thereafter the blood pressure became un¬ Case L—A 35-year-old woman was admitted in obtainable and the administration of fluothane wasJuly, 1959, through the emergency room, with acute immediately stopped. There was no apical or peri¬cholecystitis. After premedieation with 8 mg. of mor¬phine sulfate, 0.4 mg. of atropine, and 100 mg. of pheral pulse. External cardiac massage was begunpentobarbital (Nembutal), she was taken, one and immediately and carried out for a period of twoone-half hours later, to the operating room where minutes. Mephentermine (Wyamine), 30 mg., andanesthesia was induced with thiopental sodium and phenylephrine (Neo-Synephrine) hydrochloride, 1succinylcholine. Intubation was attempted, but diffi¬ mg., were given intravenously. A good pulse andculty was encountered, with inability to ventilate thepatient. She became pulseless and cyanotic and herrespirations disappeared. External cardiac massagewas instituted, without artificial respiration. Aftertwo minutes a strong transthoracic pulse developed,together with spontaneous shallow respirations.Blood pressure returned to 130/80 mm. Hg andpulse to 100 beats per minute. Intubation pro¬ceeded thereafter, with some difficulty but no fur¬ther cardiac problems. The patient underwent acholecystectomy for acute hydrops of the gallblad¬der and had anuneventful recovery. She was dis¬charged five days later without neurological signsor symptoms and has been entirely normal on sub¬sequent follow-up examinations. Case 2.—A 9-year-old boy with chronic mastoidi-tis was admitted and on Nov. 5, 1959, had a mas- Fig. 4 (case 5).—First defibrillation shock, followed bytoidectomy. Postoperatively the patient was very standstill and return of fibrillation.cyanotic. Respirations stopped in the recovery roombut a weak heart beat was obtainable. The child blood pressure returned about 90 seconds after thewas given mouth-to-mouth respiration and cardiacassistance with external cardiac massage for about beginning of massage. The operation was com¬ pleted without difficulty and the patient had no30 seconds. He responded to this with good return sign of central nervous system damage in the post¬of all functions and had no further difficulty. On operative period. Downloaded from www.jama.com by guest on November 10, 2010
Case 4.—A 12-year-old boy developed sudden Summary cardiac arrest Jan. 22, 1960, while undergoing on Closed-chest cardiac massage has been proved to an excision of a verrucus linearis of the scalp. be effective in cases of cardiac arrest. It has pro¬ Under thiopental and fluothane anesthesia the vided circulation adequate to maintain the heart patient became anoxic, with an irregular pulse fol¬ and the central nervous system, and it has provided lowed by arrest. Local infiltration with epinephrine- saline solution may have contributed. The pupils an opportunity to bring a defibrillator to the scene dilated and the patient was pulseless and without respiration for at least one minute before external massage was begun. After one minute of massage a good pulse and pressure returned. The operation was completed without difficulty. Postoperatively the patient had transitory blindness and bilateral Babinski reflex. Nystagmus was also present. Over 36 hours the neurological findings returned to normal. The remainder of the postoperative course was uneventful. Case 5.—A 45-year-old man was brought to the emergency room of the hospital with excruciating substernal chest pains radiating down both arms on Jan. 6, 1960. He was conscious when admitted. While removing his clothing, preparatory to exami¬ nation, he fell to the floor. His respirations ceased, and there were no heart sounds and no pulse. Thehouse officer immediately began closed-chest car¬diac massage. An electrocardiogram was taken andshowed the heart to be in ventricular fibrillation.The patient began to breathe spontaneously. Tenminutes after the start of external massage artificial Fig. 6 (case 5).—Cardiogram taken two hours after de-respiration by endotracheal tube was first begun. fibrillation, showing anterior myocardial infarction.External heart massage and artificial respirationwere continued for 20 minutes, while a closed-chest if necessary. Supportive drug treatment and otherA. C. defibrillator was being brought to the emer¬ measures may be given. The necessity for a thora¬gency room. cotomy is eliminated. The real value of the method Two defibrillator shocks were given; the first lies in the fact that it can be used wherever the(fig. 4) temporarily arrested the fibrillation. After emergency arises, whether that is in or out of thethe second shock (fig. 5) the heart resumed natural hospital.beats. An electrocardiographic tracing (fig. 6) taken This study was supported by a grant from the Nationaltwo hours later showed an anterior myocardial Heart Institute, National Institutes of Health.infarction. Subsequent tracings confirmed the diag¬ Referencesnosis. 1. Kouwenhoven, W. B.; Milnor, W. R.; Knickerbocker, G. G.; and Chestnut, W. R.: Closed Chest Defibrillation of Heart, Surgery 42:550-561 (Sept.) 1957. 2. Boehm, R.: V. Arbeiten aus dem pharmakologischen Institute der Universitl=a"tDorpat: 13. Ueber Wiederbelebung nach Vergiftungen und Asphyxie, Arch. exper. Path. u. Phar- makol. 8:68-101, 1878. 3. Tournade, A.; Rocchisani, L.; and Mely, G.: Etude expl=erimentaledes effets circulatoires quentrainent la respira- tion artificielle et la compression saccadl=eedu thorax chez le chien Compt. rend. Soc. de biol. 117:1123-1126, 1934. 4. Killick, E. M., and Eve, F. C.: Physiological Investiga- tion of Rocking Method of Artificial Respiration, Lancet 2:740-742 (Sept. 30) 1933. 5. Eve, F. C.: Artificial Circulation Produced by Rocking: Its Use in Drowning and Anaesthetic Emergencies, Brit. M. J. Fig. 5 (case 5).—Second defibrillation shock, followed by 2:295-296 (Aug. 23) 1947.natural beats. 6. Gurvich, H. L., and Yuniev, G. S.: Restoration of Heart Rhythm During Fibrillation by Condenser Discharge, Am. The patient had no sign of central nervous system Rev. Soviet Med. 4:252-256 (Feb.) 1947.damage, except amnesia for the period of cardiac 7. Rainer, E. H., and Bullough, J.: Respiratory and Car- diac Arrest During Anesthesia in Children, Brit. M. J. 2:massage plus two hours. He has followed, without 1024-1028 (Nov. 2) 1957.incident, the usual course of treatment fer myo¬ 8. Stout, H. A.: Cardiac Arrest: Massage Without Incision,cardial infarction. J. Oklahoma M. Assoc. 3:112-114 (March) 1957. Downloaded from www.jama.com by guest on November 10, 2010