Cardiac Arrest

How to Perform Closed-Chest Cardiac Massage

This article was originally published in the June 1961 issue of Consultant. Read the Editorial based on this article, written by Dr William J Brady, here.



James R. Jude, MD

Johns Hopkins Hospital



Jude JR. How to perform closed-chest cardiac massage. Consultant. 1961;1:4-7.


This article describes a technique that can be used to start hearts beating again in victims of sudden cardiac arrest. It is a technique we have used to restore functional cardiac activity and pre-arrest central-nervous-system status in 61 % of more than 100 patients whose hearts had abruptly stopped beating.


Both ventilation and circulation are necessary to sustain life, and both must be maintained by artificial methods when they are interrupted. Mouth-to-mouth respiration can be used to restore and maintain ventilation, and we now know that it is possible to massage the heart, to restore and maintain circulation, without opening the chest. This method makes it possible for the physician to attempt cardiac massage anywhere at all, using only his two hands.


Essentially, the method consists of closed-chest cardiac massage-manual application of rhythmic pressure to the patient’s lower sternum-and ventilation of the lungs by mouth-to-mouth respiration. Since death or irreparable damage to the brain may occur within 4 to 5 minutes, the wisest course is to act at once, without further examination, if cardiac arrest is even suspected. Removal of clothing, except for outer garments, and confirmatory diagnostic procedures are time-consuming and unnecessary. The patient should be placed supine on a firm surface such as the floor. The physician should make sure there is a patent airway by tilting the patient’s head back, and he should insufflate the lungs a few times. If this is not sufficient to return signs of life, then external cardiac massage should be initiated at once.


Outside the Hospital

Make sure there is a patent airway, and ventilate the patient’s lungs.

Ventilate lungs


Begin cardiac massage. Apply forceful pressure 60 to 80 times a minute on the lower sternum. Do not apply any pressure on the ribs with your fingers; use only the heel of the hand.

Begin cardiac massage


By pushing the lower sternum 1 to 1.5 inches posteriorly, you compress the heart between it and the thoracic vertebral column, and blood is forced into the pulmonary and systemic circulatory systems. When you release the pressure, the patient’s chest will expand, and his heart will refill with venous blood.

Compress the heart


Insert “S” tube, if available, to facilitate mouth-to-mouth breathing. If alone with the patient, you should interrupt massage every 30 seconds to ventilate his lungs 2 or 3 times.

Insert S tube


If a third person is present, have her call for an ambulance and alert the hospital that the patient is a cardiac arrest victim. Then tell her to breathe regularly (12 to 14 times per minute) into the patient's mouth while holding his nose closed. Give an intracardiac injection of epinephrine (0.5 mg) if heart action has not resumed after a few minutes.

Call ambulance


Continue massage and mouth-to-mouth breathing while patient is on the way to the hospital.

CPR hospital


CPR in children

CPR in the Hospital >>


In the Hospital

If respiration has not returned, intubate the trachea and begin positive pressure ventilation. Continue massage.

Continue cardiac massage


Apply external defibrillator if EKG shows patient’s heart to be in ventricular fibrillation. Since weak fibrillation is not easily converted to sinus rhythm, it may be necessary to inject dilute epinephrine directly into the heart to strengthen the ventricular fibrillation.



If a regular intravenous needle cannot be inserted, do a venous cutdown as soon as possible since continuous use of vasopressors may be necessary to maintain an adequate blood pressure.

IV vasopressors


Once you have started massage, the vital signs to look for indicating adequate circulation are spontaneous gasping respirations, palpable brachial, carotid or femoral pulses, and constriction of the pupils.

Check dilation



James R. Jude, MD, is Chief Resident in Surgery at The Johns Hopkins Hospital in Baltimore where he, William B. Kouwenhoven, DrIng., and G. Guy Knickerbocker, MSE, developed the technique of external cardiac massage. Dr. Jude received his medical training at the University of Minnesota Medical School. He has co-authored more than 20 scientific articles and has received several scholarships and awards, the most recent being the Mead-Johnson Award for Graduate Training in Surgery, 1959-1961. Dr. Jude’s special interest is thoracic and gastrointestinal surgery.