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THE UNIT: The Official Newsletter of the ACEP Critical Care Section - Summer 2016

Advanced Resuscitation in the Emergency Department


From the Editor

Joseph Tonna 2016It is with great excitement that we bring you this edition of “The Unit,” our ACEP Critical Care Section Newsletter, which focuses on advanced resuscitation in the emergency department. We have articles on emergency physician use of transesophageal echocardiography for intra-arrest management, on the use of mechanical cardiopulmonary resuscitation (CPR), a review of mechanical circulatory support for emergency physicians, and on the development of an emergency department eCPR program. We hope that you will find these pieces educational and fun.

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Resuscitative Transesophageal Echocardiography

Patrick Ockerse, MD  Echocardiography can be useful during CPR for multiple reasons. It can help identify reversible causes of cardiac arrest and evaluate for meaningful cardiac activity during pulse checks. Bedside transthoracic echocardiography (TTE) can be challenging to perform during CPR as there are significant difficulties unique to performing TTE during chest compressions. 

James Fair, MD

The current AHA guidelines recommend limiting interruptions in chest compressions, ideally decreasing pulse checks to less than 10 seconds.1 This is a narrow window in which to obtain adequate transthoracic imaging. Performing TTE during CPR is further complicated by competition for space on the patient’s chest during the resuscitation. External compressions, manually or by device, limit the parasternal views and the placement of defibrillator pads can hinder the apical view. Transesophageal echocardiography (TEE) during CPR is superior to TTE as it does not require access to the patient’s chest, allowing easier acquisition of images during both chest compressions and pulse checks. If available, TEE should be used to guide resuscitation during cardiac arrest.

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Mechanical CPR Devices: Increased Risk of Harm without Benefits

Mechanical cardiopulmonary resuscitation (CPR) devices have seen increased use in recent years. With the emphasis placed on the performance of uninterrupted high-quality CPR, it naturally follows that a mechanical device which is not subject to variation and fatigue from which human rescuers suffer would improve on manual CPR and increase survival. With this reasoning, their use has blossomed in the EMS Community.

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Extracorporeal Cardiopulmonary Resuscitation in the Emergency Department

Getting to write about the use of extracorporeal life support (ECLS) in the emergency department (ED) is a treat for me. Since fellowship, I have looked at ECLS as the type of therapy that would revolutionize medical care, akin to hemodialysis, antibiotics or surgery. Since that time, I have trained to learn about ECLS such that it could be used to improve the care and survival of patients from a variety of otherwise morbid or fatal conditions.

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The Rise of Mechanical Circulatory Support Devices; What and why Emergency Physicians should know about them

Felipe Teran-Merino, MDA 35 year old woman with no significant past medical history presents with 3 days of acutely worsening dyspnea. She just recovered from an upper respiratory infection, which left her with some residual cough. In the ED, she looks anxious and uncomfortable. She is tachypneic to 30/min, has sinus tachycardia to 130s, pulse oximetry shows saturation of 92% on a non-rebreather (NRB) mask placed by triage nurse, with crackles in both lung bases. Her blood pressure is 84/50 mmHg and her extremities are cold. Point of care (POC) lactate is 4,5. She has no risk factors for PE and her EKG shows no signs of ischemia. After initial evaluation you attempt non-invasive ventilation (NIV) to improve oxygenation, while you wait for labs and cardiology. Saturation improves, but pressure drops to systolic of 70 mmHg. You anticipate the need for intubation, but want to improve her acidemia and hypotension before proceeding. Infusion of norepinephrine and dobutamine is started but the patient continues to deteriorate. What else can you consider at this point?

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Mechanical CPR is a Necessary Adjunct to In-Hospital Cardiac Arrest Management

Michael Levy_2016Mechanical CPR (mCPR) has been around for decades, and the current devices are a sophisticated evolution of the earlier efforts. Although there was initial enthusiasm that the load distributing band (LDB) technology (Autopulse® Zoll Corporation) could provide a new type of CPR with superior perfusion,1 the best science suggests that LDBs provide equivalent outcomes to manual CPR in out of hospital cardiac arrest. The most recent large trial evaluating the LDB mCPR, the CIRC trial,2 showed that in the prehospital environment the device was equivalent to world class manual CPR. 

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Section Meeting at ACEP16

The ACEP Critical Care Medicine Section will be meeting in Las Vegas at ACEP16 on Monday, October 17th from 1 to 5 pm.  Featuring: 

ED-ECMO- Panel Discussion 
Rising Star Speakers
Social Hour immediately following the Section Meeting 

Come join the discussion!


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