Precordial chest punch: meaning, when to do it, guidelines

By Cristiano Antonino On Jun 26, 2022

The precordial punch is a manual mechanical cardioversion technique, characterised by the administration of a punch to the sternum at heart level, used in extreme emergency conditions and in the absence of an electric defibrillator

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Cardioversion is a special procedure that is carried out in the medical field when a subject has an arrhythmia, i.e. an alteration of the normal cardiac rhythm (sinus rhythm), in order to restore it while avoiding dangerous complications that can even lead to the patient’s death.

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Cardioversion can be

spontaneous: when the arrhythmia stops spontaneously, within a few hours of its onset;

non-spontaneous: when the arrhythmia does NOT stop spontaneously, in which case medical personnel must intervene as soon as possible to restore sinus rhythm.

Non-spontaneous cardioversion can be carried out in three ways: pharmacological cardioversion, electrical cardioversion (with an external defibrillator or internal ICD) or, indeed, mechanical cardioversion using a precordial fist.

The mechanical energy imparted by the fist should convert into sufficient electrical energy to restore normal sinus rhythm.

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Precordial fist defibrillation: how to do it?

The operator stands at the side of the patient placed on a possibly hard surface and administers the precordial fist on the sternum at heart level.

Important:

after making the fist, immediately withdraw your hand (do not leave it resting on the patient’s chest): the blow must be “dry”;
the fist must be given with the ulnar part of the fist itself;
the fist must be impressed in the lower half of the sternum;
the force of the manoeuvre must be “important” but not violent, especially if the operator is particularly robust and/or the patient is particularly slender or “fragile” (e.g. children and the elderly);
the force of the fist is regulated and limited by starting the fist from a distance of approximately 20 centimetres from the chest;
the manoeuvre should be avoided if possible if there are significant wounds on the chest and/or there is a risk of injury to the spine;
the manoeuvre should not be repeated.

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Precordial fist defibrillation: when to do it?

This manoeuvre should only be performed in the event of cardiac arrest when a defibrillator is not available, i.e. in extreme emergency situations.

In rare cases, it has actually made it possible to convert ventricular fibrillation or ventricular tachycardia into an effective cardiac rhythm, but more frequently it is ineffective or can even cause an opposite conversion, ultimately leading to asystole, which further aggravates the situation, so it is extremely important to use this technique only if there are no other options.

In order to be performed, this technique should only be carried out if

it is within the first 10 to 30 seconds after the occurrence of the arrhythmic phenomenon, no longer;
you are certain that you do not have a defibrillator immediately available;
you know what you are doing: it should only be performed by appropriately trained healthcare professionals. NEVER UNDER ANY CIRCUMSTANCES WITH HEALTH CARE OPERATORS, or you may irreversibly worsen an otherwise solvable situation.

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