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Should Percussion Pacing Have a Role in Perioperative Advanced Cardiac Life Support?: A Case Report

Giordano, Chris MD; Miller, Jordan MD; Keidan, Ilan MD

doi: 10.1213/XAA.0000000000000670
Case Reports

Percussion pacing involves using one’s fist to repeatedly strike a patient’s left sternal border in a rhythmic manner. The resulting increase in ventricular pressure can trigger myocardial depolarization and subsequent contraction. We describe the successful treatment of acute preoperative symptomatic sinus bradycardia with percussion pacing in a 63-year-old patient scheduled for placement of a gastric feeding tube after trauma involving spinal cord injury. Although no longer included in current advanced cardiovascular life support guidelines, percussion pacing may be a suitable alternative to chest compressions in multitrauma cases where the force of compressions could cause further complications.

From the Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida.

Accepted for publication September 25, 2017.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Chris Giordano, MD, Department of Anesthesiology, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100254, Gainesville, FL 32610. Address e-mail to

Anesthesiologists frequently encounter bradycardic reflexes perioperatively, and their management under exceptional circumstances can differ from current advanced cardiovascular life support (ACLS) guidelines. The approach to acute bradycardia in the perioperative setting has been recognized as a separate entity, and a separate algorithm from the traditional ACLS algorithm has subsequently been generated.1 In the 2005 Consensus of the International Liaison Committee on Resuscitation, percussion (fist) pacing was recommended as a possible intervention,2 but this was removed in the 2015 Consensus for lack of strong scientific evidence. We describe a multitrauma patient with severe symptomatic sinus bradycardia in the operating room during which percussion pacing was used as a rescue mode in the time between onset of symptoms and drug administration effect while pacing equipment was mobilized. We suggest that there are circumstances in which this rescue maneuver should be reconsidered in the perioperative bradycardia algorithms. The patient’s next of kin provided written permission for publication of this report.

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A 63-year-old man, who had sustained multiple long bone fractures, rib fractures, and a complete T6 spinal cord injury from a motor vehicle accident 10 days before, presented to the operating room for gastric feeding tube placement. This patient had sustained a pulseless electrical activity arrest at the time of his accident, which required endotracheal intubation and cardiopulmonary resuscitation that resulted in the immediate return of circulation. He was treated with and weaned off from an epinephrine infusion for his initial hypotension from spinal shock. Seven days after admission, a tracheostomy was placed in anticipation of a lengthy recovery process; by other accounts, the patient was recovering well. In the preceding 48 hours, he was hemodynamically stable and with no cardiac arrhythmias. He received a few doses of midazolam and fentanyl for sedation and pain control, and gastric feeds had been held in preparation for the insertion of a feeding tube. All preoperative laboratory values were within normal limits except for mild hyperglycemia (serum glucose concentration, 175 mg/dL) and anemia (hemoglobin, 7.1 g/L). The patient was transported uneventfully to the operating room while mechanically ventilated with pressure-controlled mode at the rate of 12 breaths/min. During transport, the patient was continuously monitored with pulse oximetry, invasive arterial blood pressure, electrocardiography, and capnography. Before transfer to the operating room table, the patient’s pulse oximeter read 100%, and he had a blood pressure of 91/61 mm Hg, heart rate of 94 beats/min, electrocardiogram showing normal sinus rhythm, and end-tidal CO2 of 35 mm Hg. We administered 50 mg of intravenous ketamine to facilitate the transfer. Despite an unremarkable transfer and connection to the anesthesia machine, severe sinus bradycardia with a heart rate of 20 beats/min became evident, along with hypotension (mean arterial pressure of 33 mm Hg) and a decrease in end-tidal CO2 to 15 mm Hg. We administered 1 mg atropine and called for a transcutaneous pacemaker to be delivered to the operating room. After 1 minute, we noticed no response to the administered atropine and elected to initiate percussion pacing. Each fist percussion resulted in ventricular depolarization indicated by a wide complex QRS on the electrocardiogram, which was accompanied by a waveform on plethysmography, an arterial pressure of 80/50 mm Hg, and an end-tidal CO2 concentration of approximately 35 mm Hg. Based on the success of our percussion pacing, we continued the percussions at a rate of 70/min while we waited for the pacemaker to arrive. After approximately 120 seconds, we briefly interrupted our percussion pacing to better appreciate a faster underlying sinus rhythm that had emerged on the electrocardiogram. This new narrow complex electrocardiographic waveform appeared approximately 2 minutes after initiating percussion pacing and corresponded with an additional arterial line waveform that maintained blood pressure levels close to 80/50 mm Hg. We waited for the next 30 seconds to see if this cardiac electrical activity provided a consistent rate and rhythm and a hemodynamically stable blood pressure. Upon confirming that our patient maintained these hemodynamics, which were similar to his preoperative baseline blood pressure of 90/50 mm Hg and sinus rhythm of 90 beats/min, we terminated our percussion pacing intervention. The pacemaker arrived about 2–3 minutes after the termination of percussion pacing, and we decided to apply external pacing pads on the patient in the event of another symptomatic bradycardia. Surgery was completed uneventfully without any other cardiac or hemodynamic perturbations.

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Vagally mediated reflex bradycardia is frequently encountered in the perioperative period. The patient’s bradycardia could have been a result of several factors, but we believe his complete spinal cord injury was likely a predominant cause. Other possible causes included the administration of ketamine in a critically ill patient, which may have led to myocardial depression or transfer from the stretcher to the operating table, which may have produced a vasovagal response. Vagally mediated bradycardia has been reported in ophthalmologic, testicular, and laparoscopic surgery, as well as procedures such as laryngoscopy, percutaneous liver biopsy, and electroconvulsive therapy.3 While ACLS4 and ACLS in the perioperative setting1 differ in the initial approach, differential diagnosis, and treatment, neither includes percussion pacing in the treatment algorithm. The main difference in the approach to bradycardia is that ACLS in the perioperative setting advises the clinician to consider situations that are unique to patients receiving anesthesia by, for example, observing the surgical field or checking for auto-positive end-expiratory pressure, gas or air embolism, or local anesthetic toxicity. Percussion pacing consists of serial rhythmic downward blows with a closed fist over the left lower edge of the sternum with a rate of approximately 50–70 percussions/min (Figure). This force causes an abrupt rise in left ventricular pressure, which leads to myocardial stretch, myocardial cell membrane deformation, and subsequent ion channel activation and depolarization.5 The mechanically applied force must be strong enough to generate electrical stimuli, triggering myocardial contractions and thus a corresponding arterial pulsation. In its 2005 Consensus, the International Liaison Committee on Resuscitation suggested percussion (fist) pacing as a therapeutic option: “Fist pacing may be considered in hemodynamically unstable bradyarrhythmias until an electrical pacemaker (transcutaneous or transvenous) is available.”2 Despite several animal studies, case reports, and a case series suggesting the efficacy of this potentially life-saving maneuver,6–9 the updated cardiopulmonary resuscitation guidelines no longer recommend this technique.



In our case, we initially considered managing the patient’s bradycardia with chest compressions as opposed to percussion pacing. Our decision to use percussion pacing emerged from a concern that adequate chest compressions could exacerbate the patient’s numerous underlying rib fractures and possibly cause further trauma. Cardiac chest compressions are associated with a 20%–90% incidence of chest wall injury,10 and in patients with preexisting rib fractures, this intervention has been associated with higher risk of pulmonary complications. Besides exacerbating preexisting injuries, numerous articles have cited the causation of new injuries, including flail chest, liver lacerations, right ventricular rupture, diaphragmatic laceration, aortic dissection, new rib and sternal fractures, and tension pneumothoraces.10,11 While there are no specific reports or data that cite the potential injuries of percussion pacing, one can infer that musculoskeletal injuries, vascular injuries, and even cardiac trauma are possible. As percussion pacing requires less force than chest compressions, we thought these complications were less likely to occur. The potential to elicit an R-on-T phenomenon that could cause ventricular fibrillation is of notable concern in percussion pacing.5

Reports on the use of this technique in the perioperative period are limited, and its use in cases of vagally mediated bradycardia under anesthesia is even less commonly mentioned in the literature. It has been suggested in cases of unstable bradycardia or asystole as a bridge to medication administration or application of pacing equipment.2,5 One report has described percussion pacing during acute bradycardia caused by a high spinal anesthetic,12 and another study described its utility to treat an oculocardiac reflex that occurred during strabismus repair surgery.13 We believed our patient’s exceptional circumstances—namely the multiple rib fractures that could have likely been worsened by chest percussion—warranted the use of this technique while medicines were being circulated and equipment delivered. Ultimately, we believe that our percussion pacing maintained cardiac output (as indicated by our invasively measured blood pressure and capnography), allowed the administered atropine to circulate, and provided time for the transcutaneous pacemaker to be delivered. Furthermore, it avoided complications that may have resulted from chest compressions by reducing the amount of applied force necessary.

This case demonstrates the utility of percussion pacing as an adjunct to medical management for severe sinus bradycardia in a multitrauma patient including multiple rib fractures. While this practice is not mentioned in the recent ACLS guidelines, we suggest that it should be considered during ACLS in the perioperative setting.

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Name: Chris Giordano, MD.

Contribution: This author helped draft and edit the manuscript.

Name: Jordan Miller, MD.

Contribution: This author helped draft and edit the manuscript.

Name: Ilan Keidan, MD.

Contribution: This author helped draft and edit the manuscript.

This manuscript was handled by: Hans-Joachim Priebe, MD, FRCA, FCAI.

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