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Successful use of percussion pacing in a pre-hospital p-wave asystole and ventricular standstill

02 August 2017
Volume 7 · Issue 2

Abstract

Background:

The use of percussion pacing (PP) using a clenched fist as an external cardiac pacemaker is not scientifically supported. However, European Guidelines for resuscitation 2015 recommend PP as an initial intervention for haemodynamically unstable patients with bradyarrhythmias or p-wave asystole. We describe a case where paramedics witnessed a patient developing p-wave asystole with ventricular standstill, and treated the patient successfully with PP until transcutaneous pacing was established.

Case presentation:

An 87-year-old man with a previous history of bifascicular heart block collapsed in his private residence in Denmark. Initially conscious and clinically unstable when assessed by Emergency Medical Services (EMS), his condition quickly deteriorated and lost consciousness. PP was initiated resulting in electric capture in shape of broad QRS complexes on the ECG tracing corresponding with palpable carotid pulses and rise in consciousness. The successful intervention lasted for 20 seconds until transcutaneous pacing was commenced and further treatment was established. The patient survived to hospital admission.

Conclusions:

Although current research has not been able to establish a scientific base for the use of PP in extreme bradycardia and p-wave asystole, several case reports have been published. We contribute to these with our description of an 87-year-old man who benefited from this easy to use and probably life-saving intervention. To our best knowledge, this is the first case report of Danish paramedics intervening with PP.

Unstable emergency patients might experience different cardiac arrhythmias. A rarely seen arrhythmia is the p-wave asystole also mentioned ventricular asystole, ventricular standstill or third-degree atrioventricular block with no ventricular escape rhythm. Here, atrial depolarisation is being displayed on the ECG as the only cardiac activity resulting in a patient with no palpable pulses and no consciousness. Left untreated, this arrhythmia will result in cardiac arrest within seconds. Of 2333 patients with non-shockable rhythm cardiac arrest, 6,13% have been described to have p-wave asystole as their initial rhythm (Hulleman et al, 2016). European Guidelines for resuscitation 2015 recommends percussion pacing (PP) as an initial intervention for haemodynamically unstable patients with p-wave asystole or bradyarrhythmias until other means of cardiac pacing are commenced (Soar et al, 2015: 110, 116). The intervention is not scientifically supported and only case reports and reviews of case reports have been published. Our case report contributes to these describing a patient with syncope witnessed by EMS, presenting with p-wave asystole and ventricular standstill, treated successfully with PP and thereof palpable carotid pulses and rise in consciousness.

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