BJA Advance Access originally published online on July 28, 2005
British Journal of Anaesthesia 2005 95(4):465-467; doi:10.1093/bja/aei209
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CASE REPORT |
Percussion pacing in a three-year-old girl with complete heart block during cardiac catheterization
1 Department of Anaesthesiology, Emergency and Intensive Care Medicine and 2 Department of Paediatric Cardiology and Paediatric Intensive Care Medicine, Georg-August-University, Robert-Koch-Strasse 40, 37099 Goettingen, Germany
3 Present address: Department of Anaesthesia and Critical Care, Royal Hospital for Sick Children, Edinburgh EH9 1LF, UK
* Corresponding author. E-mail: ceich{at}t-online.de
Accepted for publication April 24, 2005.
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Abstract |
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Complete heart block frequently requires emergency pacing to restore systemic perfusion. We report the case of a 3-yr-old girl undergoing interventional atrial septal defect closure who suffered from transient complete heart block with circulatory arrest. Transthoracic mechanical pacing for more than 3 min provided temporary support, sustaining an adequate cardiac output until sinus rhythm resumed.
Keywords: anaesthesia, paediatric; complications, cardiac arrest; pacing, emergency; pacing, percussion
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Introduction |
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Transcutaneous and transvenous electrical pacing modes are widely recognized as reliable emergency pacing techniques in bradyarrhythmic patients with critical systemic perfusion. Mechanical cardiac pacing, though easier and quicker to perform, seems to be less popular to most health care providers. In 1920 Schott1 published the case of a 60-yr-old woman in whom he successfully performed transthoracic mechanical pacing in complete atrioventricular (AV) block. Since then, several related case reports and series have followed, describing this technique as ‘percussion’ or ‘fist pacing’.2–7 However, to the best of our knowledge, this is the first successful reported use in a child.
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Case report |
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In December 2002, a 3-yr-old girl (body weight 15 kg) with a large atrial septal defect of secundum type (ASD II) underwent interventional cardiac catheterization under general anaesthesia. During the procedure the occluder accidentally slipped off the small rim of the ASD and impacted in the right ventricular outflow tract. The device was retrieved with a snare catheter, but during withdrawal the septal leaflet of the tricuspid valve was injured. Subsequently complete heart block occurred with ventricular asystole (Fig. 1).
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Transthoracic percussion pacing was commenced immediately by hitting the left lower edge of the sternum with the closed fist at a rate of approximately 80 beats min–1. This resulted in a succession of QRS complexes on the ECG (Fig. 2) which were associated with a clear plethysmographic signal on the pulse oximeter, indicating good mechanical coupling. Percussion-induced ventricular contractions were able to maintain an adequate cardiac output while atropine (0.3 mg) and epinephrine (0.15 mg) were administered i.v. Percussion pacing was continued for more than 3 min before complete heart block resolved and a sinus tachycardia ensued, providing haemodynamic stability. Later the same day the girl underwent surgical closure of the ASD and tricuspid valve repair. Repeated electrocardiograms during the following months showed no signs of residual AV block.
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Discussion |
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Acute bradyarrhythmias can be associated with critical and compromised myocardial and cerebral perfusion. Compared with pharmacological treatment, electrical pacing of the heart has been shown to be both effective and safe. This applies particularly to arrhythmias which show a rather unpredictable response to drug intervention, such as complete heart block with or without ventricular escape rhythm. Apart from the well-established electrical pacing modes (transvenous, transcutaneous), percussion pacing has been described as a particularly quick and easy to perform emergency procedure. For obvious ethical reasons, no prospective and controlled studies have been published on this topic. Thus, all available data on percussion pacing derive either from adult case reports or from a small number of animal studies.
The physiology of percussion pacing is based on the physical phenomenon that the vital myocardium can respond to a mechanical stimulus with an electrical impulse (electrical coupling), visible as a broad QRS complex on ECG (Fig. 2). However, more crucial is the association with a subsequent myocardial contraction, capable of generating an appropriate stroke volume. This mechanical coupling is clinically well known from stimulation of the heart by surgical or catheter manipulation. In the setting of percussion pacing, a palpable central pulse, a good plethysmographic reading on the pulse oximeter and regained consciousness in a patient suffering a Stokes–Adams attack are regarded as reasonable signs of adequate perfusion.
Although occasional reports have shown that a single blow may terminate bradycardia, the majority of authors recommend rhythmically performed percussion pacing at a rate of 50–70 beats min–1.2–5 8 Because of the complete lack of paediatric data, it remains unclear whether a faster rate would be advisable in children.
Compared with the technique of precordial thumping, percussion pacing is applied with significantly less mechanical energy. To judge the appropriate force, it has been suggested to let the closed fist fall from approximately 20–30 cm above the thorax.3 Case studies of percussion pacing under invasive monitoring have found that the right ventricular pressure must rise by at least 10–15 mm Hg to generate an electrical impulse at the myocardium.3 The best anatomical site for percussion pacing seems to be the left lower sternal edge, presumably above the right ventricle.3 4 However, both site and force of the fist blows need to be titrated individually in each patient.
Chan and colleagues reported the case of an adult patient, monitored with a Swan–Ganz catheter, who suffered acute complete heart block with ventricular standstill.7 Initially they performed percussion pacing, followed by transcutaneous electrical pacing before transvenous electrical pacing could eventually be established. According to their comprehensive haemodynamic measurements, the three techniques showed similar effectiveness. Compared with a calculated cardiac output of 20–30% of normal with optimally performed chest compressions during cardiopulmonary resuscitation, percussion-induced ventricular contractions generate a significantly higher cardiac output.5 7
Although electrical cardiac pacing is the treatment of choice for most patients with unstable bradyarrhythmias, percussion pacing can effectively provide short-term cardiocirculatory support before more advanced treatment is established or the bradycardia resolves, as seen in our patient. This neglected procedure is quick and easy to perform and may be indicated as a potentially life-saving technique in adults and in children.
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Acknowledgments |
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The authors wish to thank Dr David Simpson, Department of Anaesthesia and Critical Care, Royal Hospital for Sick Children, Edinburgh, UK, for his careful review of the manuscript.
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References |
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1 Schott E. Über Ventrikelstillstand (Adams-Stokes'sche Anfälle) nebst Bemerkungen über andersartige Arhythymien passagerer Natur. Deutsches Arch Klin Med 1920; 131: 211–29
2 Zoll PM, Belgard AH, Weintraub MJ, Frank HA. External mechanical cardiac stimulation. N Engl J Med 1976; 294: 1274–6[Web of Science][Medline]
3 Zeh E, Rahner E. The manual extrathoracal stimulation of the heart. Technique and effect of the precordial thump. Z Kardiol 1978; 67: 299–304[Web of Science][Medline]
4 Klumbies A, Paliege R, Volkmann H. Mechanical emergency stimulation in asystole and extreme bradycardia. Z Gesamte Inn Med 1988; 13: 348–52
5 Iseri LT, Allen BJ, Baron K, Brodsky MA. Fist pacing, a forgotten procedure in bradyasystolic cardiac arrest. Am Heart J 1987; 113: 1545–50[CrossRef][Web of Science][Medline]
6 Wild JB, Grover JD. The fist as an external cardiac pacemaker. Lancet 1970; 29: 436–7
7 Chan L, Reid C, Taylor B. Effect of three emergency pacing modalities on cardiac output in cardiac arrest due to ventricular asystole. Resuscitation 2002; 52: 117–9[CrossRef][Web of Science][Medline]
8 Wirtzfeld A, Himmler FC, Forssmann B, et al. External mechanical cardiac stimulation—Methods and possible applications. Z Kardiol 1979; 68: 583–9[Web of Science][Medline]
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  C. Eich, A. Bleckmann, and S. K. W. Schwarz Percussion pacing--an almost forgotten procedure for haemodynamically unstable bradycardias? A report of three case studies and review of the literature Br. J. Anaesth., April 1, 2007; 98(4): 429 - 433. [Abstract] [Full Text] [PDF]
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