Open heart massage is a resuscitation technique reserved for emergency situations in which the chest is exposed. This is why it is also called direct cardiac massage. It is performed only when the heart has stopped and there is no other alternative to resuscitation.
In this type of emergency situation, the patient’s life is in danger. If a piercing trauma has occurred, the heart will be located with some blades to access it. Conversely, if there is a penetrating wound but it does not allow full access to the heart, an emergency thoracostomy is required.
Thoracostomy is a medical technique for accessing the contents of the chest cavity. To do this, an incision is made using the intercostal spaces. Thoracostomy is usually performed on the most lateral part of one of the two hemithoraxes and is a small cut.
This is because it is usually practiced with the aim of draining the contents of the pleural cavity, whether liquid (as in the case of a pleural effusion) or airborne (in pneumothorax).
However, when a thoracostomy is performed for the purpose of performing open heart massage, the size of the incision must be larger. Also, a more medial location to the sternum is chosen. This facilitates access to the heart.
You have to be careful and not break any ribs when lifting the rib cage. If one of the ribs is fractured, it can puncture the organs located in the mediastinum. Special attention should be paid to the lungs to avoid respiratory distress syndrome.
How is internal heart massage performed?
First, the patient must be stabilized in a horizontal plane. The area where the thoracostomy is to be performed must then be thoroughly disinfected. Normally this step is omitted because in the vast majority of cases where internal cardiac massage is performed, the chest is already open, so no further incisions need to be made.
The next step is to stabilize the rib cage with paddles, i.e., Ribs that interfere with access to the heart are elevated. Immediately afterwards, it is necessary to ensure that the cardiac tamponade has been resolved and proceed as soon as possible to perform internal cardiac massage with both hands.
It is important that the massage is bimanual as various studies have shown that it improves the survival rate. This technique is the one that generates the best possible cardiac output and reduces it the number of complications. Among them, cardiac perforation by pressing with one hand.
What are the indications for internal heart massage?
The main indication is cardiac arrest due to perforating trauma. This technique can only be performed by experienced medical personnel as the risk of infection and complications is high. It should be remembered that this involves manipulating the heart with the entire chest exposed, therefore antiseptic measures must be taken to the extreme and any bleeding that is occurring must be controlled.
Also, you have to consider performing the massage when there is hypotension with a systolic pressure below 70 mmHg that is unresponsive to volume injection. This is an early sign of tamponade, in which the heart isn’t working properly.
you always have to perform internal cardiac massage as a last resort. In other words, less aggressive resuscitation techniques, such as conventional cardiopulmonary resuscitation, administration of inotropic drugs (adrenaline) to activate the sympathetic nervous system, etc. should be performed first.
The practice of minimally invasive thoracostomy is controversial within the medical community. Some doctors favor using a puncture wound to access the heart. While others are more cautious and believe that internal cardiac compression should be reserved for open trauma that completely exposes the contents of the chest cavity.
Nonetheless, in this type of situation the patient is in critical condition. Therefore, survival is not ideal as it is very difficult to stabilize such complex injuries. Despite everything, statistics show better results than a few years ago thanks to the early start of resuscitation.
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