Extracorporeal circulation

Although technically more demanding, extracorporeal circulation is the most effective hemodynamic intervention for cardiac resuscitation available at present. However, it requires even more skill and greater complexity of instrumentation than balloon occlusion. Both arterial and venous cannulas are required, typically by percutaneous or surgical cannulation of the femoral artery and vein with an extracorporeal circuit from the patient to the membrane oxygenator and back to the patient using a centrifugal pump.

Extracorporeal circulation allows successful restoration of spontaneous circulation after 15 to 20 min of untreated cardiac arrest. Coronary perfusion pressure is almost immediately restored to normal levels. If applied sufficiently rapidly to victims who fail conventional methods, there may be an impressive improvement in outcome. The technique is confined to patients who sustain in-hospital cardiac arrest, particularly in operating room environments.

Complications include bleeding and vascular injury from cannulation. Open-chest cardiac massage

Open-chest cardiac massage was first employed more than 120 years ago, and was the primary intervention after in-hospital cardiac arrest during the 1940s and 1950s. In the 1960s, however, non-invasive external precordial compression came into predominant use. Open-chest cardiac massage is now utilized only in settings of cardiac arrest caused by penetrating chest trauma, cardiac arrest after thoracotomy, or in victims who have major bony deformities of the chest that preclude successful chest compression.

An anterolateral thoracotomy is performed through the fourth or fifth intercostal space. After the chest is opened, the rescuer's open right hand, with the palm facing anteriorly, is advanced posteriorly behind the left ventricle. The palm of the hand compresses the heart against the posterior sternal surface at a frequency of 60/min. When compression is released the heart fills passively.

Open-chest cardiac massage is unequivocally more effective than external chest compression for increasing cardiac output, coronary perfusion, initial resuscitability, and survival. In fact, the aorta distal to the left subclavian can be cross-clamped to provide increased coronary and cerebral perfusion. However, complications from this procedure are significantly greater than those associated with external precordial compression. Traumatic injury to the heart, lungs, and surrounding tissues can occur. Thus, except in cases of penetrating torso trauma, no improvement in outcome has been demonstrated with open-chest cardiac massage.

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