Precordial Thump

DON’T YOU DIE ON ME, JOHNNY!!

Hollywood – ever scavenging for dramatic and at least obliquely true material – loves the precordial thump. The “thump” is basically a whomp on the chest when someone has had a heart attack. How cool. How many times in your life can you physically assault someone and then be regaled as a hero for it later? Kinda the Dr. Jekyll + Mr. Hyde amalgam of the medical world. Melt evil and goodness into one fantastic smashing fist on a dead man’s chest and viola…you saved a life.

Of course, you could just get sued for it. Or maybe prosecuted. The next time you’re in a bar fight, you might try the Precordial Thump defense (the bastard half-cousin of the Temporary Insanity defense). “Yeah, so I hit ‘im. So what? I thought he was dyin’. I was giving the jerk a precordial thump.”

“But he’s missing teeth.”

“Well, I aimed too high.”

Anyway, probably the thing that movies and T.V. most often get wrong is that CPR – especially with The Thump – pretty much never works. If it DOES work, it needs to have been successful reallyreallyreallyreally soon after the patient collapsed. Some people say 10 minutes. I think it’s actually more like 4. They may come around after 4 minutes, but they will have permanent brain damage of varying severity.

I’ve recently found myself sucked into the “Lost” T.V. show vortex (thanks to my wife, an ardent fan). I’m still working my way through the first season, which involves a bunch of people who are planwrecked on a South Pacific Island. Most annoying about the show is that there are in fact really crummy waves, which makes no sense to me, since I constantly dream of head-high barrels surrounding every S. Pac Island (all 10,000 of them) at all times. They might as well show me some great waves.

Anyway, there’s a doctor among the castaways and he helps out the sick people whenever he can. Often the medicine is realistic and/or simplistic enough to be enjoyable. But at one point he found one of his fellow castaways in a tree – hung by a bad guy. It took a few minutes just for the doc and his super-model gorgeous sidekick with eternally perfect makeup hair and lighting despite the remote island locale…to cut him down. Then the doc proceeds to pound this guy on the chest repeatedly for A LONG TIME. And (I shouldn’t be spoiling anything here since Season 1 was 4 years ago), he saved the guy. No brain damage. Talking by the end of the show.

Not realistic. For many reasons. Works for Hollywood, though. Bugged me, of course.

So here’s the deal. Thumps can be used when the heart needs electricity, which isn’t all the time. The most common type of heart rhythm that needs electricity is ventricular fibrillation, when the ventricles are trying to pump, but doing a bad job of it. They’re basically quivering. But they’re responding to electricity and doing what they can to get blood out into the body. The most likely heart rhythm after prolonged asphyxiation is going to be asystole. No heart beat at all. Dead. Flatline. You could plug that heart into a city power plant and it wouldn’t help.

Precordial thumps generate about 20 Joules of energy. It isn’t much more than the static zap you get from walking around a Sasquatch rug in your socks. By contrast, we give at least 200J of energy in defibrillation shocks. These days, we usually give even more than that. So the only time you can really hope for the thump to work is immediately following the heart attack. At that point, the heart may only need just need a little jump-start. The blood isn’t acidic yet, and everything is still kinda holding together. Even a few minutes later and El Thumpo will be nothing more than a weak legal defense to get out of a bar fight.

A more useful time to have used the thump may have been with the recent heart attack and death of Tim Russert, the journalist icon who collapsed in the sound studio while at work. His co-workers did everything they should have, including starting CPR and calling 911. And the paramedics tried real defibrillation unsuccessfully. But a thump may have helped because Russert’s collapse was witnessed, which means the small 20J jolt would have arrived almost immediately after his heart rhythm had switched. Also, the myocardium (heart muscle) usually goes into ventricular fibrillation first, then progresses to asystole a bit later. Russert was in Vfib when the paramedics arrived.

The thump probably won’t help anyone ever. In a thousand thumps, probably about 1/3 of a human actually benefitted from it. It’s more theory than realism and isn’t even taught in CPR or advanced CPR classes. But if you see someone drop, they have an open airway and they have no pulse…punching them in the chest might be justified. It probably won’t help, of course, and might get you sued or thrown in jail.

That said, if someone happens to film your medical heroics, you could always send the tape out to Southern California. Who knows…you might end up on T.V.

6 thoughts on “Precordial Thump

  1. That thumping always bugged me on Lost. I always attributed Charlies dumb reactions to that day, I just assumed he had a little brain damage after that.
    Also the same thing happens in J.J. Abrams other creation Mission Impossible 3.

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  2. secretwave101

    I’ve just finished Season 1 and I’ll say that in general the medical scenes are believable and interesting. I wonder if I’d have diagnosed Sawyer’s vision problem as adeptly, and I was really thinking Michael had appendicitis, not poisoning.

    Better doc, I guess. Incidentally, based on the neurosurgeons I work with, I’m not so sure they could pick that stuff up either. I think a family doc would have been a better character for the show. But, of course, I’m biased.

    Went to check out your site, and it looks great, but I ran away quickly since you’re talking about season 4!

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  3. Pingback: Precordial Thump « The ACUTE CARE Blog: Non-Urban Emergency Medicine

  4. I’m an ER RN. I’ve witnessed two precordial thumps…no luck. Fortunately, we had a biphasic defibrillator within reach when each “coded” on us. And both times it was the defibrillator that got the heart started again. But I do know of instances whereby a precordial thump has worked. Should I code, have the defibrillator ready!!

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  5. I am an ED and Critical Care RN of 20+ years..and in that time have successfully used a thump twice. Once I was standing at the bedside of the patient when they went into V fib, and the other time I was about 20 seconds away. I have also had it fail to work, but the general agreement among my fellow critical care nurses and I is: we all have had it work for us and/ or have seen it work…and we will continue to use it! (ONE thump. please!)

    Generally, the AHA (American Heart Association) has it right in their guidelines that a proffessional can use it if it dosn’t delay getting the other parts of ACLS (Advanced Cardiac Life Support) going.

    The only times I have heard of it working or seen it work (like the two cases in my own practice) are when it is delivered within SECONDS of the arrythmia happening. At 4 mins I would not bother with it. And using it in place of BLS / ACLS is pure Hollywood. But I always hate to see it discredited completely, or belittled, because it is truly dramatic and life saving when used properly.

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