What is the proper procedure for cardiopulmonary resuscitation (CPR) on a patient with an open chest?

Open-Chest CPR: Technique and Indications

Open-chest CPR is strongly indicated when cardiac arrest occurs during surgery with the chest already open or in the early postoperative period after cardiothoracic surgery, and should be performed via thoracotomy through the 5th left intercostal space with direct cardiac compression using thumb and fingers or palm against the sternum. 1

Technique

Direct cardiac compression is performed by accessing the heart through a thoracotomy (typically the 5th left intercostal space) and compressing using either:

• Thumb and fingers technique 1
• Palm and extended fingers against the sternum 1

This technique generates superior forward blood flow and coronary perfusion pressure compared to closed-chest compressions. 1

Primary Indications (Class IIa - Should Be Used)

Open-chest CPR should be performed when: 1

• Cardiac arrest develops during surgery when the chest or abdomen is already open
• Cardiac arrest occurs in the early postoperative period after cardiothoracic surgery

Post-Cardiac Surgery Arrest Protocol

For witnessed VF/VT arrest: 2

• Perform immediate defibrillation
• If unsuccessful within 1 minute, initiate CPR (external if chest closed, open if chest open)

For asystolic or bradycardic arrest with pacing wires in place: 2, 3

• Attempt immediate pacing
• If unsuccessful within 1 minute, initiate CPR

Early resternotomy is reasonable when performed by experienced providers in an appropriately staffed and equipped ICU, as good outcomes have been observed with rapid resternotomy protocols. 1, 2 The Society of Thoracic Surgeons recommends resternotomy be a standard part of resuscitation protocols for at least 10 days after surgery. 1

Secondary Indications (Class IIb - May Be Considered)

Resuscitative thoracotomy to facilitate open-chest CPR may be considered in very select circumstances: 1

• Adults and children with out-of-hospital cardiac arrest from penetrating trauma
• Short transport times to a trauma facility
• Small case series have reported survivors with mild or no neurological deficit after blunt or penetrating trauma 1

Hemodynamic Superiority

Open-chest CPR demonstrates superior hemodynamics compared to external compressions: 1

• Two small studies in cardiac surgery patients showed improved hemodynamic effects
• Improved coronary perfusion pressure and return of spontaneous circulation (ROSC) documented in both in-hospital (following cardiac surgery) and out-of-hospital environments 1

Critical Timing Considerations

The timing of open-chest CPR initiation is crucial for outcome. Animal studies suggest that if open-chest cardiac massage is delayed more than 20 minutes from cardiac arrest onset, little to no successful outcome can be expected. 4 This underscores the importance of early decision-making in appropriate clinical scenarios.

Common Pitfalls and Caveats

Resternotomy performed outside the ICU results in poor outcomes, so this intervention should only be attempted in appropriately equipped settings with experienced providers. 1

External chest compressions remain necessary when open-chest CPR is not immediately available, despite potential risk of cardiac damage, as the certain death without perfusion outweighs the risk of compression injury. 1

Rapidly identify and correct mechanical causes including tamponade, pneumothorax, valve dysfunction, graft occlusion, or bleeding, as these may be the underlying etiology requiring surgical intervention. 2

Refractory Cases

For patients refractory to standard resuscitation procedures, mechanical circulatory support including ECMO or cardiopulmonary bypass may improve outcomes when the suspected etiology is potentially reversible during a limited period of mechanical support. 1, 2

Evidence Quality

While no prospective randomized trials exist comparing open-chest to conventional CPR, 1 the consistent demonstration of improved coronary perfusion pressure and ROSC across multiple case series, combined with basic physiologic principles, supports its use in the specific clinical scenarios outlined above. The 2020 AHA Guidelines 1 reaffirm the 2010 recommendations 1 with additional support from the Society of Thoracic Surgeons.