Open-Chest CPR: Technique and Indications

Primary Indications

The American Heart Association recommends open-chest CPR 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, 2
Open-chest CPR is indicated for cardiac arrest developing during surgery when the chest or abdomen is already open, with a Class IIa recommendation 1, 2, 4, 5
The Society of Thoracic Surgeons recommends resternotomy be a standard part of resuscitation protocols for at least 10 days after surgery, with good outcomes observed with rapid resternotomy protocols 8, 9, 10

Direct cardiac compression is performed by accessing the heart through a thoracotomy and compressing using either thumb and fingers technique or palm and extended fingers against the sternum, generating superior forward blood flow and coronary perfusion pressure compared to closed-chest compressions 1, 3

Resuscitative thoracotomy to facilitate open-chest CPR may be considered in very select circumstances, including adults and children with out-of-hospital cardiac arrest from penetrating trauma, with short transport times to a trauma facility 4, 5

Open-chest CPR demonstrates superior hemodynamics compared to external compressions, with improved coronary perfusion pressure and return of spontaneous circulation (ROSC) documented in both in-hospital and out-of-hospital environments 1, 3, 8, 9, 10

Early resternotomy is reasonable when performed by experienced providers in an appropriately staffed and equipped ICU, with good outcomes observed with rapid resternotomy protocols 8, 9, 10
External chest compressions remain necessary when open-chest CPR is not immediately available, despite potential risk of cardiac damage 9, 10
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 6

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 8, 9, 10, 6