klb48 Posted March 4, 2012 Share Posted March 4, 2012 I have a post-CABG patient who we had to take back to the OR for sternal wound dehiscence. Her sternum was almost necrotic so a sternectomy was done and she was closed with a muscle flap. I've never had a patient like this before and I was wondering about CPR. I tried to look up some things online and found mostly anecdotes from others about using a bedpan to distribute the pressure, or just not doing chest compressions at all. There doesn't seem to be any definitive answer, so I was just curious what you all thought. Anyone have experience with this? Link to comment Share on other sites More sharing options...
andersenpa Posted March 4, 2012 Share Posted March 4, 2012 Done it a few times. The best case scenario is where you have an a line, and you can see the arterial upstroke with each compression. If not you can have someone palpating the femoral or carotid to feel for a pulse while you compress. Either way, you will need to compress more lightly than you do with an intact sternum, but forceful enough that you give effective CPR. it's such a rare scenario and I've never seen any papers on it. That's why you probably will get slightly different answers from each person you ask. The debrided sternal edges can lacerate the RA or RV if compressed hard enough. It also depends on the survivability of the pt. If they are in multisystem failure and the likelihood of a good outcome is poor, then it is a low yield situation and why bother? However if it is a salvageable situation then the risk to their life exceeds the risk to their flap. Link to comment Share on other sites More sharing options...
CAAdmission Posted March 5, 2012 Share Posted March 5, 2012 If you need CPR after a sternectomy, you can be pretty sure God is punching your ticket home... Link to comment Share on other sites More sharing options...
whimsygirl Posted March 5, 2012 Share Posted March 5, 2012 I've done it using a clipboard over the sternum area. Several minutes of compressions (more than 20) and the patient survived. I bet I never forget that. Link to comment Share on other sites More sharing options...
klb48 Posted March 5, 2012 Author Share Posted March 5, 2012 Thanks for the advice everyone! I figured it doesn't happen all that often, that's why there isn't a ton of literature on it. Appreciate the input! Link to comment Share on other sites More sharing options...
DJ Bunnell MSHS PA-C Posted March 6, 2012 Share Posted March 6, 2012 I have run into issues where people are concerned about doing CPR at all on post median sternotomy patients. My advice is always that we are here to support perfusion. It is possible to do damage to an intact sternum with wires but does not make sense to spare the sternum and lose the patient. I agree that your patient with a sternectomy is a slightly different issue but I think that the focus on continuing to support perfusion even if that means CPR and to worry about the chest wall second still holds true. Good luck to you and your patient. Link to comment Share on other sites More sharing options...
CDHart Posted March 7, 2012 Share Posted March 7, 2012 I've done it a number of times (as a larger male RN I never got to pass meds in codes) and had good short term results. By that I mean we resuscitated the patient. I honestly have no idea what the long term damage generally is, we do check for broken wires but there may be an increased incidence of separation. The bottom line is who cares if the sternum is perfect in the coffin, if they need compressions, they need compressions. I do try to go the minimum depth to get a good BP/art line tracing though. Edit: I just noticed you were specifically talking post sternectomy and flap. D'oh. I'd second the bedpan/clipboard idea, that's one I haven't come across. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 7, 2012 Moderator Share Posted March 7, 2012 side effect of not doing something is far worse then any side effect of doing anthing... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 8, 2012 Moderator Share Posted March 8, 2012 wouldn't an agressive surgeon just open the chest and do direct cardiac massage in this situation? I've done it once on my trauma rotation on a thoracotomy pt post gsw. you need to do cpr as the alternative is certain death. sounds like a bad board question. on my ca state medic boards there was a question about someone in cardiac arrest with a knife in their back and how do you do cpr...(remove knife, cover site, do cpr)...other(wrong) options included doing cpr holding them up, etc Link to comment Share on other sites More sharing options...
andersenpa Posted March 8, 2012 Share Posted March 8, 2012 wouldn't an agressive surgeon just open the chest and do direct cardiac massage in this situation?I've done it once on my trauma rotation on a thoracotomy pt post gsw. you need to do cpr as the alternative is certain death. sounds like a bad board question. on my ca state medic boards there was a question about someone in cardiac arrest with a knife in their back and how do you do cpr...(remove knife, cover site, do cpr)...other(wrong) options included doing cpr holding them up, etc reopening a sternotomy is not a big deal Reopening a sternectomy with a muscle/omental flap is a huge deal You'd be cutting through a pedicled flap, and could destroy the viability of the tissue I don't know 100% but I'm thinking that cautious closed chest resuscitation would be just as effective as reopening a flapped chest and avoid the catastrophe of damaging the flap. Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted April 3, 2012 Share Posted April 3, 2012 To add to what others have said: pulseless patient with no DNR & no signs of long down time = CPR, independent of recent sternotomy, alternative is pt. staying dead. I've done those compressions and tried to back off a bit, ensuring good carotid pulses. No fun, but only chance of survival for pt. Link to comment Share on other sites More sharing options...
greg a Posted October 6, 2012 Share Posted October 6, 2012 side effect of not doing something is far worse then any side effect of doing anthing... Could not agree more .....as a sternectomy survivor (2007) it is shocking to come out of a coma to signs around the room "NO COMPRESSIONS" boy my hand was on that call button so fast to ask if I should get a tattoo version.NO need the muscle flap will harden in time I was told ....a year passed and then I was implanted with an ICD that has revived me a total of six times...... so I would say; 1) crash cart 2)clipboard/bedpan 3) direct light (almost as an infant) ......999) call the chaplain Link to comment Share on other sites More sharing options...
Guest JMPA Posted October 8, 2012 Share Posted October 8, 2012 If a patient/any patient needs CPR specifically compressions, then whether you do compressions with a palm, a foot, a clipboard, open chest, does not matter. You can not kill a dead patient. A clipboard offers no advantage over standard palm for sternal flap. Open chest does offer a little protection to the heart but exposes to other potential deadly consequences. The correct answer is just do it. Link to comment Share on other sites More sharing options...
greg a Posted October 8, 2012 Share Posted October 8, 2012 If a patient/any patient needs CPR specifically compressions, then whether you do compressions with a palm, a foot, a clipboard, open chest, does not matter. You can not kill a dead patient. A clipboard offers no advantage over standard palm for sternal flap. Open chest does offer a little protection to the heart but exposes to other potential deadly consequences. The correct answer is just do it. Your response is curious as what I posted is what my wife and I were told post the removal of my sternum and the fact that it was at the surgeon's request that thwe signs were posted in the ICCU and later in the step down It was explained to us that the conective tissues had been removed leaving only the bone as well as my sternum so a crash cart was needed or the flat object to evern the chest compressions. I am copying this to PM to you as I would really like to know the truth as I agree that doing nothing is the WRONG answer but want my wife to give correct info if she is with me at a time of distress. This is something that my medical team and I talked about at some length as I/we don't want someone to use an improper technique resulting in a rib doing fatal damage. Greg Link to comment Share on other sites More sharing options...
Guest JMPA Posted October 8, 2012 Share Posted October 8, 2012 If there was a sign saying "no compressions" then somebody felt that you should not be revived in the event of cardiac arrest requiring compressions. Cardiac compressions is the single most important factor for recusitation during cardiac arrest. Link to comment Share on other sites More sharing options...
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