Open-chest message is a form of resuscitation for cardiac arrest. Theoretically, an Open chest message produces survival benefits over a closed chest massage. There are no randomized controlled trials.
Table of Contents
The first open-chest massage
The open-chest message of a chloroform-induced cardiac arrest in 1874 was possibly the first reported in the literature. By the turn of the century, cardiac surgeons widely employed this procedure, especially for resuscitation of in-hospital cardiac arrests.
open-chest message -present scenario
From the mid-1960s, the open-chest message was entirely reserved for acute trauma circumstances or arrests during or after thoracotomy.
The most common reasons for thoracotomy and sternotomy are Lobectomy, Pneumonectomy, CABG, and valve surgeries. Both lobectomy and pneumonectomy are widely used To treat lung cancer. An open chest message is the best option when such patients develop cardiac arrest. This is the most common situation where the role of an open-chest message is justifiable.
The open-chest approach was usually regarded as old-fashioned for the rest of the arrests.
Closed chest massage shortfalls
The favorable effects of the Closed-chest message are attributable to the physical compression of the heart between the sternum and the vertebrae. During Closed chest compression, the heart has little to do with circulation. Because the heart chambers do not fill and the valves do not move during Closed-chest messages, different explanations for blood flow production have emerged. Blood flow during closed-chest compression is mostly caused by phasic changes in intrathoracic pressure rather than extrathoracic vascular pressure.
When basic life support was prolonged for a significant period (> 15 minutes) before applying advanced life support (particularly defibrillation), success rates were extremely low, frequently falling between 0% and 2% with closed chest massages.
The most crucial and successful response is prompt defibrillation during CPR. Epinephrine injection is almost surely effective, and endotracheal intubation is almost certainly effective. Although therapeutic medicines such as antiarrhythmics and catecholamines other than epinephrine are used occasionally, their overall influence on survival rates is negligible.
Prolonged closed-chest massage may decrease neurologic outcomes compared to open-chest massage.
In general, the open-chest technique results in a blood-flow volume that is two to three times that of the closed-chest technique, as well as a higher rate of life and a higher degree of neurologic recovery.
The open-chest approach appears to give significantly more coronary and cerebral blood flow than the closed-chest procedure.
Another advantage of open-chest massage is that it avoids many of the difficulties associated with closed-chest massage. After closed-chest massage, rib fractures, pulmonary and myocardial contusions, and visceral (mainly hepatic and splenic) lacerations are common. The open-chest method eliminates the majority of these difficulties.
Open-chest heart massage-Advantages over closed
Increased cardiac output
Immediate diagnosis and treatment of PericardialTamponade, Occult hypovolemia, Tension pneumothorax
Direct defibrillation
Aortic compression (or cross-clamping)
Direct mediastinal warming for severe hypothermia
Direct aspiration of intracardial air
Direct myocardial pacing
Verification or refutation of apparent electromechanical dissociation
The aorta may be constricted or clamped with the chest open to divert blood flow to the heart and brain, as is routinely done in the trauma setting.
open-chest heart massage-Indications
Failure to establish adequate cardiac output with closed-chest cardiac massage for any reason
Atypical anatomy
Suspected cardiac tamponade
Suspected occult hypovolemia
Refractory ventricular fibrillation
Hypothermic cardiac arrest
Massive air embolism
Recent sternotomy.
The open cardiac massage increases blood flow (doubled cardiac output) and generally improves hemodynamics. It also enables the prompt diagnosis and treatment of all common reversible causes of cardiac arrest.
Electromechanical dissociation
pericardial tamponade
Electromechanical dissociation is a common symptom of pericardial tamponade. This is instantly discovered after thoracotomy and eased in seconds under direct view, clearly a benefit over the blind pericardiocentesis through the chest wall during conventional CPR.
pneumothorax
Opening the chest relieves tension pneumothorax, another usually undiagnosed cause of cardiac arrest.
occult hypovolemia
Opening the chest and feeling the fullness of the heart chambers allows prompt detection of occult hypovolemia from any cause (e.g., unreported trauma, ruptured aneurysm, severe dehydration).
myocardium rupture
Finally, the open-chest method may enable the early detection of cardiorrhexis (myocardium rupture) or other untreatable diseases, allowing for the early conclusion of extended and futile resuscitation efforts.
Heartbeat can also be determined instantly. Cases that appear to be ventricular fibrillation based on ECG are frequently discovered to be asystole, and occasionally the opposite is discovered. Direct defibrillation of the heart muscle can be used to treat rare cases of refractory ventricular fibrillation that cannot be defibrillated through the chest wall.
Air embolism
Air embolism can cause cardiac arrest, especially during dialysis or the placement of central venous lines.
The open-chest approach might theoretically be used to assist the aspiration of air from the right atrium in such cases.
Severe hypothermia
Severe hypothermia in the presence of cardiac arrest is already a recognized indication for thoracotomy and open chest massage.
How to perform or do open chest massages?
The emergency thoracotomy is the same as the one performed routinely in some cases of penetrating trauma. Any physician may be trained to execute this treatment safely and efficiently.
An incision is created in the fourth or fifth intercostal space. It is then extended laterally from the sternal border to the midaxillary line. The muscle layer is separated bluntly, and the chest cavity is opened with rib spreaders to expose the heart and major vessels. Aside from rib spreaders, no other additional equipment is necessary. Simple pressure can compress the aorta against the vertebral column; cross-clamping may be challenging. The heart is massaged from apex to base, and enough time is allowed for the chambers to fill.
Conclusion
The cardiac output is significantly boosted by emergency thoracotomy and open-chest massage over external chest compression. Any suitably trained emergency physician or surgeon using standard instruments in a usually equipped institution can perform the technique quickly.
