# Precordial Thumps



## Ethanol4all (Jul 23, 2007)

Hey, I'm a newly licensed SoCal EMT-B...... and I never really heard of it in class .....but are Precordial Thumps CPR protocol? and are they proven to actually work?


----------



## EMT007 (Jul 23, 2007)

Nope definitely not.


----------



## SwissEMT (Jul 23, 2007)

I've heard of a three stories where they worked.


----------



## Ridryder911 (Jul 23, 2007)

PreCordial Thumps, produce 0.4 joules of electrical shock. They have proven to work *very* effective in certain conditions and settings. AHA has removed PCT due to the advantage of having AED, and defibrillators that can deliver enough joules to convert rhythms such as V-Tach an V-Fib. It was removed because idiots was performing it incorrectly and as well patients were not being monitored prior. It is *NOT* part of the Basic or general Health Provider BLS criteria. 

It can be used when the patient is on ECG monitor and defibrillation is not imminently available. Now these days is unusual to have a patient monitored and not have some form of defib readily available. Most ACLS courses no longer even address PCT or "fist pacing" (Which is repeatedly PCT), for brady rhythms until a pace maker can be placed. Yes, they worked and was used until better technology was available. 

R/r 911


----------



## Airwaygoddess (Jul 23, 2007)

"RAMPART, THIS IS SQUAD 51 !"


----------



## Summit (Jul 23, 2007)

Do you think there are there wilderness applications for PCT in unmonitored patients in situations where neither AED nor monitor is going to show up in the next 30 min or 2hrs?


----------



## firecoins (Jul 23, 2007)

yes, it can be used in that situation


----------



## Ridryder911 (Jul 23, 2007)

Actually, it used to be recommended that an witnessed cardiac arrest receive a PCT while getting an monitor/defib ready. If they are truly pulseless, what is it going to hurt?

Now with said, * I am not responsible for breaking protocols, injuries sustained, etc... etc..

R/r 911


----------



## BossyCow (Jul 23, 2007)

Ridryder911 said:


> Actually, it used to be recommended that an witnessed cardiac arrest receive a PCT while getting an monitor/defib ready. If they are truly pulseless, what is it going to hurt?
> 
> Now with said, * I am not responsible for breaking protocols, injuries sustained, etc... etc..
> 
> R/r 911



Okay Rid... just since its you with your focus on spelling and grammar..... 

did you mean 'a witnessed cardiac arrest' or 'an unwitnessed cardiac arrest'.


----------



## Ridryder911 (Jul 23, 2007)

lol... A witnessed arrest.. spell check got me! 

R/r 911


----------



## Anomalous (Jul 25, 2007)

Ridryder911 said:


> "fist pacing"
> 
> R/r 911




Never heard that one before.  Nice.


----------



## TKO (Jul 25, 2007)

We use them here in BC, Canada, but not all provinces do.  Saskatchewan didn't, for example.

My protocols say that I precordial thump a witnessed arrest.  Logic there is that it may resuscitate the pt since they've only been down a few seconds.  Then we move to CPR and defibrillations.  An unwitnessed arrest requires us to move our *** and get CPR underway and since an undeterminable amount of time has passed it is going to be pretty much a futile effort anyway.  But if you know the pt and they owe you money, well, you may as well give 'em one anyway.


----------



## VentMedic (Jul 25, 2007)

> Originally Posted by Ridryder911
> "fist pacing"






Anomalous said:


> Never heard that one before.  Nice.



This is also known as Percussion Pacing.

It was popular in the 1970s and is still studied according to articles appearing in several European Medical Journals.

http://www.americanheart.org/downloadable/heart/1104859986186a.fistpacing.CE.12Dec04Final.pdf


----------



## DT4EMS (Jul 26, 2007)

I have tried the Precordial Thump  a couple of times over the years. Both were during witnessed arrests. On one, a 74 y/o male on a side street, while I was off-duty. He left the hospital and lived for about 6 more months.

The precordial thump and fist pacing were a part of my medic school training.

As a side note............. the cough was talked about back then too.


----------



## KEVD18 (Jul 26, 2007)

Summit said:


> Do you think there are there wilderness applications for PCT in unmonitored patients in situations where neither AED nor monitor is going to show up in the next 30 min or 2hrs?



in this scenario, do anything that comes into your mind. they are dead, and are more than likely going to stay dead.

(not responsible for the actions of persons who heed my advice)


----------



## Jon (Jul 28, 2007)

I've talked about it with some "old-heads"... and my understanding was that it was still on the AHA's curriculum, at least until the last revision.

If I wittnessed a cardiac arrest, ESPICIALLY if I am off-duty... I might thump the patient... on duty... well - I don't know... it would be against my protocol... but if they were dead, and now aren't... should they really complain?


----------



## Aileana (Jul 28, 2007)

If you witness the arrest, there's no harm done if you try a PT. It may or may not work, but it only takes a few seconds to attempt. I wouldn't try this, however, if in school you were not taught the proper technique, as commodio cordis (sp?) can occur if done wrong. I personally would not attempt it as of now, since I have not been trained in it, but situations do change...


----------



## Arkymedic (Aug 14, 2007)

Ethanol4all said:


> Hey, I'm a newly licensed SoCal EMT-B...... and I never really heard of it in class .....but are Precordial Thumps CPR protocol? and are they proven to actually work?



I have seen it work once in the ER with a witnessed arrest.


----------



## Arkymedic (Aug 14, 2007)

VentMedic said:


> This is also known as Percussion Pacing.
> 
> It was popular in the 1970s and is still studied according to articles appearing in several European Medical Journals.
> 
> http://www.americanheart.org/downloadable/heart/1104859986186a.fistpacing.CE.12Dec04Final.pdf



You beat me to it. I was going to ask if it was the same as percussion lol.


----------



## Gbro (Sep 2, 2007)

I have used PCT on 2 patients. That is 2 where it made a difference. Both walked away from the hospital. 
1st one the unit was squawking "No shock indicated" w/ flat line.
When we rolled pt for long board i saw v-fib gave pt. a thump and she converted. Enroute she went int V-Fib 3 more times and i thumped her each time. When she would revert the skin color changed almost immediately, and upon converting with the thump Pt's color would change back just as fast.
Pt got a pacer and is still alive today. 20 + years!

2nd was in a seniors complex across the st. from my residence.
Late at night Pt called for self, and i respond directly there w/pass keys. When i got into  apartment pt. was in agonal breathing, Pulsless.
I started CPR and after 1 min, I gave pt a thump and got pulse back. 
She lived 3-4 years.
The very next afternoon we were paged to a chocking adult male 80 years old.
When i got on scene, pt had lost con. and was just being lowered to floor by LEO's. We had intercept agreements by now, so one was enroute 14 miles.

After 6-7 procedures (BB, FS CC) another EMT?CPR instructor arrived and took his turn. Then i stopped everything, I had 2 assistants lift PT. to a sitting position by the arms, Butt off the floor, then I did the abdominal thrust as hard as i could about 8 times. I am 6' 4" and 250lbs, and i was squeezing for all i was worth and then some. He started to crock like a seal, and we started CPR w/ Hi flo O2, and transported. Met the intercept and pt was bagged to Hosp. Received last rites, and next day woke. No injury, No pain!
was home after one more day. His wish was "He wanted that big guy to be a pallbearer when the time came. It was 3 years and i was honored.
What a day that was for me. 2 saves in under 24 hrs. (rural service-380 annual runs).


----------



## stonez (Sep 3, 2007)

We were taught that we can use PCT on witnessed arrest.


----------



## Geri709 (Sep 3, 2007)

*Pct*

I thought that was out of most protocols nowadays??  I am wrong. :unsure:


----------



## Ridryder911 (Sep 3, 2007)

PCT can be used if the patient is currently being monitored on a ECG and a witness V-fib, V-tach and there is a time delay of electrical defibrillation, cardioversion, per AHA. It is not taught as much since most monitors have defib attached or there is AED type devices within range. 

R/r 911


----------



## Gbro (Sep 3, 2007)

Taught, to deliver PCT

Back when, the proper procedure for delivering a PCT was to align the lower arm with the mid-line of chest, Elbow about nose area, and then a crashing blow down on the sternum with a closed fist.
Dose that sound familiar to anyone??

I have never done it that way, I felt the procedure took into account those in the medical field would probably be much smaller and weaker than i am.

I fold my fingers, and with an open palm, wrist flexed back, From the pt's side i bring arm down rapidly, and at the same time snap my wrist down, making contact with the sternum with my 2nd knuckle's.
More of a snapping action. 
Practice it on a box or something that gives a little.
Ribs are broken in a PCT, my procedure is more in line with the sternum, and it has worked for me.
I wouldn't hesitate to thump someone that went down in my presence and i had no monitor handy, Not only that, but think about the time it takes to apply pads, power up(can be done simultaneously), analyze rhythm, indicate shock advised, Charge up, check for clear. then the button can be pushed. The thump can be done in just about the time it takes to push the Dad-Burn-Button, with analyzing done simultaneously!
Just think about that...

Where did that come from you ask;
Years ago my wife and i were transporting a cardiac to the twin city's 225 miles, and that was before ALS in our area. We did have a RN on board, actually 2 as the Mrs. is also an RN, but only an EMT on the ambulance. 
The pt. went into V-Tach over 40 times during that trip, and was converted with PCT's each time.
The pt. was really beat up upon arriving at the U of M, saying please don't hit me again.


----------



## chico.medic (Sep 6, 2007)

I just "thumped" a guy the other day that I witnessed go into V-Fib.  Didn't work, but was worth a shot while w/ were getting the fast patches out.  He converted  after defibrillation.


----------



## Gbro (Sep 6, 2007)

Amen to that;
were you watching the monitor when you delivered the thump?
The times i have done it with a monitor, the wave was very large, recording the thump. 
Sure would like to get one on a strip, but not at the expense of the pt.


----------



## Ridryder911 (Sep 6, 2007)

Couple of things, PCT *should NOT* be administered to a non *monitored* patient. Remember, this would be the same as defib someone at 4 joules of electricity, without a monitor! Would you shock somone without a monitor, or AED type of device?

If you are breaking ribs or producing so much force to do such, you are incorrectly performing it. This is the reason it was * removed* from the CPR and general ACLS courses more than twenty years ago. Yes, it is performed by measuring from nose (elbow) to about 6 inches upward, from mid sternum, with a quick thump. If used it should be * only performed once* and *used only* when a defibrillator is not readily available. It has * never* been thought as a replacement for cardioversion, or electrical therapy. By performing PCT, one * better* have a license and certification in advanced cardiac care, as it is * NOT * taught or recommended in lesser levels. 

It has been proven it is more beneficial to * perform CPR* for one minute, if the monitor is not readily available or unable to immediate charge for defib. (As per 2005 ACLS Standards).

Let's not get away from the current National Standards, which most EMS and EMT's treatment is based upon. 

R/r 911


----------



## Gbro (Sep 6, 2007)

Rid said;


> Would you shock somone without a monitor, or AED type of device?



Were you thinking about the Dog's shock collar?, Uncle John's electric fence, or deputy Marks Tazer?
If you are asking if i would thump without a monitor, I think you know the answer to that one.
Would i delay or omit any thing to do this, again i think you know the answer.
Will i sleep well knowing i did everything possible, Thats a yes.
One must remember, when i am 30-50 min out, most wouldn't/Might not do anything. I am not in that circle.


----------



## chico.medic (Sep 7, 2007)

Gbro said:


> Amen to that;
> were you watching the monitor when you delivered the thump?



I was a little pre-occupied with concentrating on my target, whilst holding onto the ceiling railing with my other hand because my partner, Mario Andretti, was in front, rocketing my Ford Econovan-350 around a corner, into opposing traffic at 90 MPH.  Not sure if it made a "bump" on the monitor.  (Maybe he wasn't in V-Fib after all, and it was just artifact from the EMT driving! :unsure 

All I know is the before/after looked the same and it returned to an organized sinus rhythm-- w/ those tombstones we all know and love-- after I delivered 200J of Edison Medicine, (My LEMSA hasn't adopted the new ACLS yet).


----------



## Gbro (Sep 7, 2007)

Holly Molly;
I sure hope you were doing a touch of exaggerating on that speed issue.

Our protocol demands that we pull over and stop to analyze(AED) rhythm & shock. 
There are known cases of slowing down to do this. 
With our roads its a common thing for the AED to give us a "Check Pt." message, I usually tell the pt., that it should say "Check Road", 

Most defibs (if not all) will print out several seconds of pre- print time tracings.(i know there is better terminology for that ,Hey it's 0540).




> Couple of things, PCT should NOT be administered to a non monitored patient.



Hypothetical Situation;
   You are hunting with (Dad, Granddad, Whom-ever) and they may or mayn't have MI, HX.
 They code on you, right in front of you, or someone else at the hunting shack. You are right there,but may not see the event unfold. You assess and maybe give a quick PCT and rescue breath, (although this person would almost certainly be in agonal breathing). start chest compressions, assess after 1 min, deliver PCT,resume CPR.
Help is being summoned, 30-60 min away, 
"IS" there anyone, "ANYONE" that wouldn't feel right delivering one or more PCT"s?.

Now if you are within 4-10 min of ALS this need not be considered.


----------



## PArescueEMT (Sep 7, 2007)

Gbro said:


> Hypothetical Situation;
> You are hunting with (Dad, Granddad, Whom-ever) and they may or mayn't have MI, HX.
> They code on you, right in front of you, or someone else at the hunting shack. You are right there,but may not see the event unfold. You assess and maybe give a quick PCT and rescue breath, (although this person would almost certainly be in agonal breathing). start chest compressions, assess after 1 min, deliver PCT,resume CPR.
> Help is being summoned, 30-60 min away,
> ...



i'm lucky enough that the local fire co for my hunting grounds left a first in bag at my property. I have taught most of the people up there how to use the equipment. This all came from a drowning i responded on my dirt bike to a few properties over. I DID thump x2 since the ambulance was 30mins out. and the kid flew after 2 shocks with ROSC. It's not really something you think about in the heat of the moment... to quote and old Nike slogan, you "just do it"


----------



## Ridryder911 (Sep 7, 2007)

One needs to remember the point of a PCT. It is used only to help terminate V-fib or V-tach, that's it. If you are not able to see that, then you really do not know what you have, as well PCT on a patient with a rythm may actually cause v-fib (vulnarable period). Yes, it can be dangerous and lethal! So one needs to be *very* cautious and as well, it should be in your standard protocols. If it is not, then *one should not perform it!*. 

There is a reason, they no longer actively teach it or recognize it as a standard of care. 

R/r 911


----------



## chico.medic (Sep 8, 2007)

Gbro said:


> Holly Molly;
> I sure hope you were doing a touch of exaggerating on that speed issue.


I thought there was sufficient sarcasm in that post, indicating I was only kidding.  Maybe not.


----------



## EMTmetzger (Sep 12, 2007)

what are Precordial Thumps?


----------



## Ridryder911 (Sep 12, 2007)

EMTmetzger said:


> what are Precordial Thumps?



Google can answer ...


----------



## Aileana (Sep 12, 2007)

ridryder 911 said:


> One needs to remember the point of a PCT. It is used only to help terminate V-fib or V-tach, that's it. If you are not able to see that, then you really do not know what you have, as well PCT on a patient with a rythm may actually cause v-fib (vulnarable period). Yes, it can be dangerous and lethal! So one needs to be *very* cautious and as well, it should be in your standard protocols. If it is not, then *one should not perform it!*.
> 
> There is a reason, they no longer actively teach it or recognize it as a standard of care.
> 
> R/r 911



wow, I did not realize that PCT's can cause v-fib! Thanks for that information, It'll definately change how I view this issue. How much do protocols vary regarding PCT's typically?


----------



## Gbro (Sep 12, 2007)

With our service, 
  I asked the Medical director, He said he has no problem with using PCT's, 
No protocol, use with a monitored pt. witnessed arrest, V-fib or V-tach.

So Rid, 
When you stated;


> as well PCT on a patient with a rythm may actually cause v-fib (vulnarable period). Yes, it can be dangerous and lethal!



What is this "Vulnerable period" you are cautioning about,    PVC's? as "V-Fib" is quite lethal in and of itself.


----------



## Ridryder911 (Sep 12, 2007)

Vulnerable period is the point of where the cells are responsive to stimulus after refractory period of depolarizing the cells. It is between the R & mid T wave on the ECG. 

This is where when "cardioversion" occurs and where someone is cardioverting the patient. The ECG senses the upward "R" wave (one will see a "blip" bright point on the monitor oscilloscope in synch mode) and the defib will automatically "fire" on this area. It would be difficult to perform such maneuver without a automatic sensing device. In other words, when someone is "cardioverting" the defib is synchronizing with the monitor (hence synchronized cardioversion), the operator only holds the button down and allows to the defib to fire. Also why it is so dangerous of not "waving" charge paddles around in a sych mode. Any artifact resembling a R wave can cause discharge. 

The same concern of the "R on T" wave PVC. Again, firing on the "vulnerable period" which can cause v-fib.... 

So in theory, without monitoring and thumping randomly, one could produce the "joules" on that location causing v-fib... 

Again, it has been proven not to be very effective, especially in comparison to electrical therapy or Edison medicine. 

R/r 911


----------



## Gbro (Sep 12, 2007)

So;
Even though the school of thought is to deliver only 1 PCT(PT), There are talks about multiple thumps.

Like;


> The mean tachycardia rate amounted to 145/min (range from 102 to 222/min) in successfully treated patients. Bursts of rapid precordial thumps were more effective than single precordial thumps


. 

That quote if found here;
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=2087859&dopt=AbstractPlus


I just like the idea of giving something more than one shot. 
(can be hard to do with a flintlock rifle)


----------



## doc5242 (Sep 12, 2007)

PCT from a bls provider...?? can you spell lawsuit and loss of card for being out side the scope of practice?.. not a good idea, in my experience, and from what i have seen, they do not work and are ineffective.


----------



## Ridryder911 (Sep 12, 2007)

If your going to cite material, be sure to include the remainder and as well to understand scientific readings and studies. 

......_ In 17 of the 37 cases of ventricular tachycardia. The mean tachycardia rate was significantly higher (176/min, range from 120 to 250/min) than in successfully treated cases. Altogether, ventricular tachycardias with heart rate less than or equal to 160/min were terminated by mechanical stimulation in 17 of 22 cases, and ventricular tachycardias with heart rate greater than 160/min only in *3 of 15 cases*. Ventricular fibrillation (n = 3) or ventricular flutter (n = 7) *was not *interrupted in any case by precordial thumps. In patients with ventricular tachycardia, mechanical stimulation extends the therapeutic possibilities. The rate of success is higher, the lower the tachycardia rate. The tachycardia rate is the only predictive parameter for therapeutic success...._

We need to be careful here, we are comparing apples to oranges. First, this is an * old* study and as well, other methods have been proven to be more effective and less harmful to patients. The article was in regards of termination of ventricular tachycardia versus ventricular fibrillation in scientific controlled setting. As well, the study does not describe if the V-Tach could had not been terminated with pharmacology agents such as Lidocaine or another antiarrhythmic. 

I believe we are beating a dead horse... (no pun intended) PCT is * only to be performed and administered by approved by ACLS personal on cardiac monitored patients* when electrical therapy is prolonged. Immediate electrical defibrillation has been proven to be more effective than PCT, as well as synchronized electrical cardioversion is far better than PCT for those in symptomatic ventricular tachycardia (chest pain, hypotension) etc.

R/r 911


----------



## DisasterMedTech (Oct 17, 2007)

Rid-

Am I reading correctly that you say a pre-cordal will deliver .4 jules, as in less than half a jule. I thought I remembered being taught that it was 4 jules and I cant find a source to confirm.

Please advise.  Thank you, sir.


----------



## Paramajik (Oct 18, 2007)

Check AMLS... ~5J.  Even for the EMT-B.  If its me punch me in the sternum as hard as you like and as many times as you like.  My wife wont sue you.  Im worth more dead than i am alive!  hahahaha


----------



## Aileana (Oct 18, 2007)

In the region I am doing my ride-alongs, from what I understand neither BLS nor ALS providers administer PCT's...


----------



## DisasterMedTech (Nov 3, 2007)

Ridryder911 said:


> Couple of things, PCT *should NOT* be administered to a non *monitored* patient. Remember, this would be the same as defib someone at 4 joules of electricity, without a monitor! Would you shock somone without a monitor, or AED type of device?
> 
> If you are breaking ribs or producing so much force to do such, you are incorrectly performing it. This is the reason it was * removed* from the CPR and general ACLS courses more than twenty years ago. Yes, it is performed by measuring from nose (elbow) to about 6 inches upward, from mid sternum, with a quick thump. If used it should be * only performed once* and *used only* when a defibrillator is not readily available. It has * never* been thought as a replacement for cardioversion, or electrical therapy. By performing PCT, one * better* have a license and certification in advanced cardiac care, as it is * NOT * taught or recommended in lesser levels.
> 
> ...



I know this is an old thread, but I was re-reading and found what you have said here to be quite confusing. First you say that PCT has been removed from CPR and ACLS curriculum. Then you say a person better have ACLS if they are going to do it. Which is it? Im confused. What good would it do for a person to have ACLS if PCT has been removed?


----------



## Ridryder911 (Nov 3, 2007)

PCT has been removed from the general education to common ACLS (yes, there are different ACLS courses as well as in-depthness). It can be taught, as it is still a procedure according to emergency cardiac care committee (ECC) which makes recommendations for ACLS . The same as "anal sweep" to cause vagal stimulation is technically in the ACLS program however; usually never discussed often. The same as intubation is no longer taught or tested in the standard ACLS course. This does not mean one cannot teach it, or use it, however; it is no longer part of the standard. There is now a separate course in advanced airway.

There are multiple procedures and procedures that are involved in ACLS, however; are not usually taught or in the AHA ACLS health care provider standardized course. Remember ACLS is NOT just a course, rather a methodology of treatment and involves multiple arenas that are briefly discussed in a regular ACLS course. 

R/r 911


----------



## enjoynz (Nov 4, 2007)

Just shows you the differences between Countries.
We are taught right at the start of our Ambulance training, at the first level, to do a PCT on the Pt at a Witnessed Cardiac Arrest ONLY.
Our Station Officer had a pt a couple of months ago arrest on him, and did the PCT with good results, so it does work.
We don't have the same issues with law suits, etc that you deal with over there. We do still have to adhere to protocols and answer to the Ambulance Service, should something go wrong on a call.
We also have a protocol here, that after 20 mins CPR (Unless the PT has arrested secondary to hypothermia), the job is called if there is no result (ROSC) within that time frame, of course that does vary at times.

Cheers Enjoynz


----------



## FFPARAMEDIC08 (Dec 2, 2007)

If you witness the arrest, what can it hurt? Might as well try it..


----------

