Use of open chest cardiopulmonary resuscitation after failure of standard closed chest CPR: illustrative cases.

Compared to standard closed chest CPR, open chest cardiac massage improves vital organ perfusion and survival in animal models of medical cardiac arrest. Yet its use is essentially limited to the treatment of traumatic arrest. Three cases of medical cardiac arrest are presented in which open chest compression was used after failure of external chest compression. These cases illustrate the range of potential outcomes and how this therapy can be optimally applied. Approaches we have used to prevent application of futile intensive therapy in patients unlikely to be neurologically intact survivors are described. Replacement of open chest CPR by closed chest CPR as the standard of care for the in-hospital cardiac arrest was not justified by experimental data. The circumstances of refractory cardiac arrest make it unlikely that well controlled human studies will be able to demonstrate the superiority of open chest CPR in selected patients. The decision to use this therapy will likely remain within the art of medicine.