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Emergency Ultrasound

Critical Care Case: Don’t Stop Believing (in ultrasound in cardiac arrest)

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.

  1. Have a timer. Assign a nurse/tech/med student to count down from 10 during each pause in compressions. At zero, the chest compressor restarts no matter what.
  2. Have a dedicated sonographer during the resuscitation who is also not running the code. This was shown to reduce the delay by 6 seconds.5
  3. Attempt looking for a cardiac window during chest compressions. Try the apical window if a mechanical compression device is being used. If there are no windows during CPR, have the probe with gel ready on the patients subxiphoid just prior to the pulse check.
  4. Have the most experienced provider perform the ultrasound. In the study by Clattenburg et al,5 ultrasound fellowship trained providers tended to have shorter CPR pauses. The more experienced provider will likely be able to find a sonographic window more efficiently.
  5. Obtain clips during the pauses and wait to analyze them during compressions. You may even preset your ultrasound machine to take 10 second retrospective clips prior to EMS arrival so that after you finish your POCUS/CPR pause, you hit the “clip” button and you will have recorded the prior 10 seconds.
  6. Use a protocol designed for ultrasound in cardiac arrest. This way you can approach every non-traumatic arrest in a systematic fashion. Cardiac Arrest Sonographic Assessment (CASA) is one example of such a protocol.6
  7. Get TEE (transesophageal echo). This is being done at more and more academic centers but is likely not feasible at most community sites yet. This allows you to have real-time ultrasound information during the entire arrest and you may even be able to modify your compressions to maximize LV compression.

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.

References

  1. Littmann L, Bustin DJ, Haley MW. A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity. Med Princ Pract. 2014;23:1-6.
  2. Gaspari R, Weekes A, Adhikari S, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016;109:33–39. https://doi.org/10.1016/j.resuscitation.2016.09.018
  3. Hu K, Gupta N, Teran F, et al. Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med. 2018;71(2):193–198. https://doi.org/10.1016/j.annemergmed.2017.07.476
  4. Huis in ’t Veld MA, Allison MG, Bostick DS, et al. Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions. Resuscitation. 2017;119:95-98. https://doi.org/10.1016/j.resuscitation.2017.07.021
  5. Clattenburg EJ, Wroe P, Brown S, et al. Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: A prospective cohort study. Resuscitation. 2018;122:65–68. https://doi.org/10.1016/j.resuscitation.2017.11.056
  6. Gardner KF, Clattenburg EJ, Wroe P, et al. The Cardiac Arrest Sonographic Assessment (CASA) exam – A standardized approach to the use of ultrasound in PEA. Am J Emerg Med. 2018;36(4):729-731. https://doi.org/10.1016/j.ajem.2017.08.052

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