By Kenn Ghaffarian DO & Kevin Flanagan DO
A 45-year-old male presents to the ED via EMS in cardiac arrest. Downtime is unknown. He has been in PEA since CPR began. He was intubated in the field and arrives with CPR in progress. As you approach the first pulse check, your senior resident asks if he should ultrasound the patient. You ponder briefly, because you remember reading a recent article about the negative impact of ultrasound in cardiac arrest because of possibly delaying timely care.
Point-of-care ultrasound (POCUS) has many potential roles in cardiac arrest. In addition to its procedural uses (arterial or central line placement, aid in confirmation of ET tube, identifying landmarks for cricothyrotomy), it can be diagnostic as well. POCUS can be used to eliminate many of the classic “H’s and T’s” of ACLS. In 2015, Littman, et al proposed a novel approach to PEA arrest;1 Narrow complex PEA likely represents a mechanical right ventricle issue such as tension pneumothorax, cardiac tamponade and pulmonary embolism, each of which can be evaluated for by POCUS.
POCUS may also have a prognostic role. In 2016, Gaspari et al showed 0.6% survival to hospital discharge if there was no cardiac activity on initial ultrasound compared to 3.8% patients with cardiac activity.2 This study involved out-of-hospital or in-ED cardiac arrest patients in asystole or PEA. On the other hand, variability between physician sonographers’ in their interpretation of cardiac standstill has been shown in another study.3
However, two recent articles were published demonstrating that POCUS during CPR led to increased time without compressions during pulse checks.4,5 POCUS added an additional six to eight seconds off the chest. This alone may give some clinicians pause on performing POCUS during CPR.
These authors view these findings in another light. We feel the above papers highlight the importance of being hypervigilant about the time spent on POCUS. We also have some suggestions (not evidence based) that may reduce the duration of interruptions during chest compressions.
You ask the senior resident to wait until the next pulse check/pause in compressions before attempting POCUS. You direct the resident to have the probe in hand with gel on the patient prior to holding compressions and you take a retrospective clip as the nurse counts down. You analyze the clip as compressions are going and note no cardiac activity, no pericardial effusion and no RV strain. You continue this pattern over the next few cycles with the same result. In addition, during compressions you have assessed for pneumothorax and free fluid in the abdomen and see no evidence of either. The code is called 25 minutes after patient arrival.