Article

Echocardiography for prognostication during the resuscitation of intensive care unit patients with non-shockable rhythm cardiac arrest

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Abstract

Transthoracic echocardiography (TTE) during cardiopulmonary arrest (CPA) has been studied in victims of cardiac arrests. Our objective was to evaluate the feasibility and usefulness of TTE in victims of cardiac arrest with non-shockable rhythms hospitalized in intensive care units (ICUs). This prospective and observational cohort study evaluated ICU patients with CPA in asystole or pulseless electrical activity (PEA). Intensivists performed TTE during intervals of up to 10seconds as established in the treatment protocol. Myocardial contractility was defined as intrinsic movement of the myocardium coordinated with cardiac valve movement. PEA without contractility was classified as electromechanical dissociation (EMD), and with contractility as pseudo-EMD. The images, the rates of return of spontaneous circulation (ROSC) and the survival upon hospital discharge and after 180 days were evaluated. A total of 49 patients were included. Image quality was considered adequate in all cases and contributed to the diagnosis of CPA in 51.0% of the patients. Of the 49 patients included, 17 (34.7%) were in asystole and 32 (65.3%) in PEA, among which 5 (10.2%) were in EMD and 27 (55.1%) in pseudo-EMD. The rates of ROSC were 70.4% for those in pseudo-EMD, 20.0% for those in EMD, and 23.5% for those in asystole. Survival upon hospital discharge and after 180 days occurred only in patients in pseudo-EMD (22.2% and 14.8%, respectively). TTE conducted during cardiopulmonary resuscitation in ICU patients can be performed without interfering with care protocols and can contribute to the differential diagnosis of CPA and to the identification of a subgroup of patients with better prognosis. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

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... 15 Four studies contained evidence of efforts to avoid confounding from self-fulfilling prophecy. 18,20,22,23 In Chardoli, et al., treating clinicians were blinded to sonographic results but made aware of other findings that could influence clinical treatment. 18 In Flato, et al., subjects without cardiac motion (median 12 cycles CPR) had longer durations of CPR than subjects with cardiac motion (median 6 cycles CPR), even though the treating team was not blinded to sonographic findings. ...
... 18 In Flato, et al., subjects without cardiac motion (median 12 cycles CPR) had longer durations of CPR than subjects with cardiac motion (median 6 cycles CPR), even though the treating team was not blinded to sonographic findings. 20 In both Kim et al. and Lien et al., all subjects received mandatory prespecified 30 min of CPR beyond sonographic assessment prior to termination of resuscitation. 22,23 The timing of sonographic assessment varied greatly between studies (Table 1 and Supplementary Appendix). ...
... for survival to 180 days. 20 Two observational studies of 229 IHCA and OHCA subjects reported ranges of sensitivity (0.67 to 1.00), specificity (0.51 to 0.89), and odds ratio (13.60 to 16.63) for survival to hospital discharge. 15,20 Two observational studies of 349 OHCA subjects reported ranges of ...
Article
Aim To conduct a prognostic factor systematic review on point-of-care echocardiography during cardiac arrest to predict clinical outcomes in adults with non-traumatic cardiac arrest in any setting. Methods We conducted this review per PRISMA guidelines and registered with PROSPERO (ID pending). We searched Medline, EMBASE, Web of Science, CINAHL, and the Cochrane Library on September 6, 2019. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using the Quality in Prognosis Studies (QUIPS) template. We estimated prognostic test performance (sensitivity and specificity) and measures of association (odds ratio). Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology evaluated the certainty of evidence. Results In total, 15 studies were included. We found wide variation across studies in the definition of ‘cardiac motion’ and timing of sonographic assessment. Most studies were hindered by high risks of bias from prognostic factor measurement, outcome measurement, and lack of adjustment for other prognostic factors. Ultimately, heterogeneity and risk of bias precluded meta-analyses. We tabulated ranges of prognostic test performance and measures of association for 5 different combinations of definitions of ‘cardiac motion’ and sonographic timing, as well as other miscellaneous sonographic findings. Overall certainty of this evidence is very low. Conclusions The evidence for using point-of-care echocardiography as a prognostic tool for clinical outcomes during cardiac arrest is of very low certainty and is hampered by multiple risks of bias. No sonographic finding had sufficient and/or consistent sensitivity for any clinical outcome to be used as sole criterion to terminate resuscitation.
... 14 Only 45% of physicians correctly diagnose a lack of pulse in cardiac arrest without differentiating between true PEA and pseudo-PEA. 3,14 The overall survival to discharge for PEA cardiac arrest is reportedly 13%. 5 The information reviewed did indicate that the determination of a "true" PEA scenario guided medical professionals to end resuscitative efforts sooner. 2,3,5,7,9,10,14 Identifying Reversible Causes Determining a cause of cardiac arrest is imperative to achieve successful return of spontaneous circulation (ROSC). ...
... 3,14 The overall survival to discharge for PEA cardiac arrest is reportedly 13%. 5 The information reviewed did indicate that the determination of a "true" PEA scenario guided medical professionals to end resuscitative efforts sooner. 2,3,5,7,9,10,14 Identifying Reversible Causes Determining a cause of cardiac arrest is imperative to achieve successful return of spontaneous circulation (ROSC). Echocardiography can attempt to elucidate a reversible cause of cardiac arrest and expedite treatment. ...
... One study indicated that the absence of cardiac activity harbors a significantly lower but not zero likelihood that a patient will experience return of spontaneous circulation. 5,7,14,15 Another study similarly concluded that finding any coordinated cardiac activity confers a better outcome and should potentially be regarded as an indication to continue resuscitation. 6 The results of a study that focused on trauma-related cardiac arrest produced a negative predictive value approaching 100% for survival. ...
Article
Cardiac arrest is the absence of a centrally palpable pulse and no respiratory effort in an unresponsive patient. This often-lethal medical condition affects hundreds of thousands of people in the United States alone every year. Immediate intervention is crucial to provide the patient with any chance of survival. Advanced cardiac life support (ACLS) is the cornerstone therapy for cardiac arrest. Increased awareness and proper identification of life-threatening arrhythmias is critical, as it may lead to prompt medical treatment and improved mortality. The use of focused echocardiography, during a cardiac arrest, has been a developing area of interest over the past several years. The specific aim of this literature review was to emphasize the role of a focused echocardiogram and the valuable information that can be provided during a cardiac arrest.
... Eleven 11-21 of the 20 studies were prospective and 13 5,[10][11][12]14,[16][17][18][19][22][23][24] were single centre. The settings include Europe (8), 5,[12][13][14][15]17,19,25 North America (6), 11,22,23,[26][27][28] Asia (3), 10,20,24 South America (2) 18,21 and Australia 16 and study dates range from 1987 to 2017. ...
... Eleven 11-21 of the 20 studies were prospective and 13 5,[10][11][12]14,[16][17][18][19][22][23][24] were single centre. The settings include Europe (8), 5,[12][13][14][15]17,19,25 North America (6), 11,22,23,[26][27][28] Asia (3), 10,20,24 South America (2) 18,21 and Australia 16 and study dates range from 1987 to 2017. The number of ICU admissions ranges from 112 to 362,074. ...
... Further information is available in the supplementary appendix (supplementary appendix, Table C). Smith et al. 11 2 2 Wallace et al. 22 2 2 3 Enohumah et al. 25 3 2 3 Yi et al. 10 2 2 3 Galhotra et al. 23 2 3 Maia et al. 12 2 1 Roessler et al. 13 3 2 Gershengorn et al. 26 3 1 3 Schmittinger et al. 14 2 2 Lee et al. 24 3 1 2 Efendijev et al. 15 3 2 3 Rozen et al. 16 3 2 3 Haerkens et al. 17 3 2 Flato et al. 18 2 1 Garcia Huertas et al. 19 3 1 Chanthawong et al. 20 2 2 3 Perman et al. 27 2 2 2 Miana et al. 21 2 1 3 Cook and Thomas 5 2 1 2 Quinn et al. 28 2 1 Three studies compared survival outcomes in patients who did and did not suffer ICU-CA. ...
Article
The incidence of cardiac arrest in the intensive care unit (ICU-CA) has not been widely reported. We undertook a systematic review and meta-analysis of studies reporting the outcome of cardiac arrest in adult, general intensive care units. The review was prospectively registered with PROSPERO (CRD42017079717). The search identified 7550 records, which included 20 relevant studies for qualitative analysis and 16 of these were included for quantitative analyses. The reported incidence of ICU-CA was 22.7 per 1000 admissions (95% CI: 17.4–29.6%) with survival to hospital discharge of 17% (95% CI: 9.5–28.5%). We estimate that at least 5446 patients in the UK have a cardiac arrest after ICU admission. There are limited data and significant variation in the incidence of ICU-CA and efforts to synthesise these are limited by inconsistent reporting. Further prospective studies with standardised process and outcome measures are required to define this important patient group.
... US has bolstered the clinical utility of categorizing electromechanical dissociation (EMD) into "true-EMD" vs. "pseudo-EMD." Pseudo-EMD is defined as the sonographic evidence of intrinsic and coordinated myocardial and valvular movement in the absence of a palpable pulse [11,48,49]. Several authors have noted that this observation of pseudo-EMD is associated with a better prognosis for ROSC as compared to true-EMD, which shows no contractile movement of the heart. ...
... Several authors have noted that this observation of pseudo-EMD is associated with a better prognosis for ROSC as compared to true-EMD, which shows no contractile movement of the heart. One such prospective observational study involving 49 intensive care unit (ICU) CA events showed pseudo-EMD to occur on US in 55% of PEA patients [48]. This study showed the rates of ROSC were 70% for those in pseudo-EMD compared to 20% for those in true EMD [48,50]. ...
... One such prospective observational study involving 49 intensive care unit (ICU) CA events showed pseudo-EMD to occur on US in 55% of PEA patients [48]. This study showed the rates of ROSC were 70% for those in pseudo-EMD compared to 20% for those in true EMD [48,50]. This US distinction could aid clinicians in their prognostication and decisions to continue or halt resuscitative efforts, with implications to resource utilization. ...
... There was very good agreement for abstracts (Cohen's kappa 0.92) and full agreement (Cohen's kappa 1.00) at the full article stage. Finally, 11 studies with 777 patients were eligible for the meta-analysis [11][12][13][14][15][16][17][18][19][20][21]. ...
... The characteristics of the included 11 studies are shown in Table 1. Seven of the eligible studies' objects were non-trauma patients [11,12,[16][17][18][19][20], and four studies enrolled both trauma and non-trauma patients [13][14][15]21]. The US evaluations in three studies were initiated out of hospital [11,13,17], while other studies' evaluations were performed in-hospital [12,[14][15][16][18][19][20][21]. ...
... Seven of the eligible studies' objects were non-trauma patients [11,12,[16][17][18][19][20], and four studies enrolled both trauma and non-trauma patients [13][14][15]21]. The US evaluations in three studies were initiated out of hospital [11,13,17], while other studies' evaluations were performed in-hospital [12,[14][15][16][18][19][20][21]. The US examinations were performed using various cardiac windows, including the subcostal, apical, and parasternal four chamber views, but there were three studies in which US images were acquired only in the subxiphoid view [11,14,21]. ...
Article
Full-text available
Background The prognosis of pulseless electrical activity is dismal. However, it is still challengable to decide when to terminate or continue resuscitation efforts. The aim of this study was to determine whether the use of bedside ultrasound (US) could predict the restoration of spontaneous circulation (ROSC) in patients with pulseless electrical activity (PEA) through the identification of cardiac activity. Methods This was a systematic review and meta-analysis of studies that used US to predict ROSC. A search of electronic databases (Cochrane Central, MEDLINE, EMBASE) was conducted up to June 2017, and the assessment of study quality was performed with the Newcastle-Ottawa Scale. Statistical analysis was performed with Review Manager 5.3 and Stata 12. Results Eleven studies that enrolled a total of 777 PEA patients were included. A total of 230 patients experienced ROSC. Of these, 188 had sonographically identified cardiac activity (pseudo-PEA). A meta-analysis showed that PEA patients with cardiac activity on US were more likely to obtain ROSC compared to those with cardiac standstill: risk ratio (RR) = 4.35 (95% confidence interval [CI], 2.20–8.63; p<0,00001) with significant statistical heterogeneity (I² = 60%). Subgroup analyses were conducted: US evaluation using only on the subxiphoid view: RR = 1.99 (95% CI, 0.79–5.02; p = 0.15); evaluation using various views: RR = 4.09 (95% CI,2.70–6.02; p<0.00001). Conclusions In cardiac arrest patients who present with PEA, bedside US has an important role in predicting ROSC. The presence of cardiac activity in PEA patients may encourage more aggressive resuscitation.
... In another study by Flato et al., it was seen that the rates of ROSC were 70% for the patients with pseudo-PEA and 20% for those with true PEA. Despite achieving ROSC, the patient with true PEA did not survive to hospital discharge, whereas 22% of the patients with pseudo-PEA survived to hospital discharge and 15% of them survived after 180 days [18]. A further study by Wu et al. demonstrated that although ROSC was achieved in some patients with pseudo-PEA and true PEA, only a few of the patients with pseudo-PEA survived to hospital discharge [19] ( Table 3). ...
... However, it is critical to differentiate pseudo-PEA from true PEA as the treatment strategies and prognoses for the two conditions are different. With regards to prognosis, pseudo-PEA is associated with higher rates of ROSC and survival to hospital discharge [17][18][19]. Identification of the underlying etiology of cardiac arrest can lead to expedited treatment of the severe shock state leading to pseudo-PEA [22]. Understanding the patient's prognosis will help guide the decision of terminating resuscitation efforts. ...
Article
Introduction: A great deal of the literature has focused specifically on true pulseless electrical activity (PEA), whereas there is a dearth of research regarding pseudo-PEA. This narrative review evaluates the diagnosis and management of patients in pseudo-PEA and discusses the impact on emerging patient outcomes. Discussion: Pseudo-PEA can be defined as evidence of cardiac activity without a detectable pulse. Distinguishing pseudo-PEA from true PEA is important for emergency physicians as the prognosis and management of these patients differ. POCUS is the tool most commonly used to diagnose pseudo-PEA and there are varying treatment strategies to manage these patients. Identifying patients in pseudo-PEA can help guide resuscitation decisions, and ultimately impact emergency response systems, patients, and families. Conclusions: The incidence of pseudo-PEA is increasing. Effective care of these patients begins with early diagnosis of this condition and immediate treatment to warrant the greatest chance of survival. There is a need for further prospective studies surrounding pseudo-PEA as evidenced by the lack of research in the current literature.
... In this regard, point-of-care ultrasound (POCUS) has been proposed as a powerful tool for recognizing such mechanism (s), as well as distinguishing a true from a false asystole, but a stable role in the CPR procedures is still debating. [1,[4][5][6][7] Among the right heart diseases, deep venous thrombosis and intracardiac thrombosis are the most common sources of pulmonary embolism, at times leading to CA as pulmonary arteries are massively thrombosed. [1,2,8] However, cardiac thrombus formation (TF) can also be the consequence of forward blood flow ceasing in patients with CA, and unawareness of this complication can undermine the efforts to ROSC. ...
... Fast-track examinations every 2 min upon the CPR timeline was found to predict ROSC in unshockable rhythm patients, with no significant time loss. [5,11] Based on the current knowledge and present findings, we have hypothesized a fast cardiac ultrasound protocol by skilled operators, to be performed at least after 3-4 cycles (6-8 min) of chest compressions, using the pause for rhythm check (5-15 s) to quickly attain a four-chamber apical or subcostal view and assess both ventricular function and potential complications, like TF [ Figure 2]. ...
Article
Current guidelines consider thrombosis as a potential (and reversible) cause of cardiorespiratory arrest (CA). However, cardiac thrombus formation (TF) is likely to be the consequence of the forward blood flow ceasing during cardiac standstill. We present the case of a young man who was hospitalized for infective endocarditis, complicated by multiorgan disease and sudden CA on the 5th day. Prompt cardiopulmonary resuscitation (CPR) warranted a return of spontaneous circulation in 16 min but, unexpectedly, a TF was recognized in the right atrium at echocardiography. The blood clot resolved with rapid administration of endovenous heparin and continued chest compressions. Even though cardiac ultrasound is not ready for a routine use during CPR, the present study confirms a key role in the management of CA patients.
... PEA without cardiac contractility was defined as electromechanical dissociation (EMD), and with cardiac contractility as pseudo-EMD. [10] It was reported that the rates of return of spontaneous circulation and the survival upon hospital discharge and after 6 months in patients with pseudo-EMD were higher than the patients with EMD. [10] Studies has shown that 10% to 35% of the CA patients have detectable cardiac contraction with POCUS and have a better prognosis than the patients without cardiac contraction. ...
... [10] It was reported that the rates of return of spontaneous circulation and the survival upon hospital discharge and after 6 months in patients with pseudo-EMD were higher than the patients with EMD. [10] Studies has shown that 10% to 35% of the CA patients have detectable cardiac contraction with POCUS and have a better prognosis than the patients without cardiac contraction. [6] However, the survivors of CA patients have a higher mortality due to irreversible damage of the brain, myocardium, and other vital organs. ...
Article
Full-text available
Rationale: Point-of-care ultrasound is widely used in patients with cardiac arrest, allowing for diagnosing, monitoring, and prognostication as well as assessing the effectiveness of the chest compressions. However, the detection of intraoperative cardiac arrest by Point-of-care ultrasound was rarely reported. Patient concerns: A 21-year-old male with Marfan syndrome which manifested Valsalva sinus aneurysms was admitted for aortic valve replacement. After endotracheal intubation, TEE transducer was inserted to evaluate the cardiac structure and function with different views. Severe aortic valve regurgitation was observed in the mid-esophageal aortic valve long and short axis view. Diagnosis: TEE showed that cardiac contraction was nearly stopped, the spontaneous echo contrast was obvious in the left ventricular and hardly any blood was pumped out from the heart despite the ECG showing normal sinus rhythm with HR 61 beats/min. Meanwhile, the IBP was dropped to 50/30 mm Hg. Interventions: Chest compressions were started immediately and epinephrine 100 μg was given intravenously. After 30 times of chest compressions, TEE showed that cardiac contractility increased and the stroke volume was improved in the TG SAX view. Outcomes: The patient was discharged 18 days later in a stable condition. Lessons: Continuous echocardiography monitoring may be of particular value in forewarning and detecting cardiac arrest in high-risk patients.
... Forest plots were prepared and performed with Review Manager Software 5.4 (The Cochrane Collaboration, Oxford, Copenhagen, Denmark). Turkey [27,36,41], 2 in Canada [22,24], and 1 in each of the following countries: Austria [23], Germany [26], Iran [28], Singapore [29], Brazil [31], United Kingdom [33], Republic of Korea [34], and Taiwan [35]. One study was also conducted as a multi-country trial. ...
... The 9 studies reported return of spontaneous circulation [22,24,28,31,32,34,36,41], in which pooled results of sensitivity and specificity were 0.238 (95% CI 0.214-0.264) and 0.507 (95% CI 0.458-0.557), ...
Article
Full-text available
Background: Echocardiography in the setting of resuscitation can provide information as to the cause of the cardiac arrest, as well as indicators of futility. This systematic review and meta-analysis were performed to determine the value of point-of-care ultrasonography (PoCUS) in the assessment of survival for adult patients with cardiac arrest. Methods: This meta-analysis was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, Web of Science, Cochrane have been searched from databases inception until March 2nd 2021. The search was limited to adult patients with cardiac arrest and without publication dates or country restrictions. Papers were chosen if they met the required criteria relating to the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of this diagnostic technique concerning resuscitation outcomes. Results: This systematic review identified 20 studies. Overall, for survival to hospital discharge, PoCUS was 6.2% sensitivity (95% confidence interval [CI] 4.7% to 8.0%) and 2.1% specific (95% CI 0.8–4.2%). PoCUS sensitivity and specificity for return of spontaneous circulation were 23.8% (95% CI 21.4–26.4%) and 50.7% (95% CI 45.8–55.7%) respectively, and for survival to admission 13.8% (95% CI 12.2–15.5%) and 20.1% (95% CI 16.2–24.3%), respectively. Conclusions: The results do not allow unambiguous recommendation of PoCUS as a predictor of resuscitation outcomes and further studies based on a large number of patients with full standardization of operators, their training and procedures performed were necessary.
... 3. Identifikacija potpunog odsustva srčanih kontrakcija. Kod pacijenata kod kojih se primenjuje KPR, potpuno odsustvo kontraktilnosti srca je važan pokazatelj koji ukazuje da napori u primeni mera resuscitacije neće biti zadovoljavajući 13,14,15,16 . ...
Article
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Aim: The aim of this paper is to show the concept of the treatment of the patients in cardiac arrest and the achievements and advantages of the use of ultrasound in cardiac arrest, comparing existing protocols for emergency care with the protocols we developed in the Resuscitation Council of Serbia and in cooperation with other national councils, the possibility of delayed application of ultrasound in order to further final diagostics and the establishment of therapeutic procedures as well as the use of ultrasound during transport and prolonged field care under out-of-hospital conditions (transport longer than 45 min) or work in the “remote area” in mountain areas. METHODOLOGY: The methodology of work reviewed literature (books, published articles) in the field of the application of ultrasound in emergency medicine. The bibliography database MEDLINE was used as a browser. THE RESULTS: According to the latest guidelines of the European Resuscitation Council, the use of ultrasound is recommended for the determination of reversible causes in cardiac arrest. Procedures that are carried out to determine reversible causes of cardiac arrest fall under red-eye procedures and these patients require urgent care. Ultrasonography has a place in diagnosing the following reversible causes of cardiac arrest: tension pneumothorax, hypoxemia, hypovolaemia, cardiac tamponade and pulmonary thromboembolism. Procedures that work in the yellow and green zone give the possibility of delayed application of ultrasound aiming for final diagnostics and establishment of therapeutic procedures. The use of ultrasound can be beneficial during transportation and prolonged field care in outhospital conditions (transport longer than 45 min) or work in the remote areas in mountains. One of the procedures in the yellow or green zone is the application of the FAST protocol. CONCLUSION: The use of ultrasound in emergency medicine, according to available literature, points to the benefit of implementing these diagnostic procedures in order to better and better manage critically ill patients. The education of the physiscians dealing with emergency medicine in the field of ultrasonography leads to a decrease in human resources and more efficient treatment of patients and to the possibility of implementing salvage (red procedures) in life-threatening conditions.
... In our study, the use of TTE during CPR was 71%. Many studies have investigated the role of TTE during CPR (18)(19)(20). Although no studies have proven that the use of TTE improves survival, it is clear that TTE has the potential to detect reversible causes of cardiac arrest. ...
Article
Full-text available
Objective: This study aimed to investigate the theoretical knowledge and clinical experience of cardiopulmonary resuscitation (CPR) among Turkish cardiologists according to the recommendations of the 2015 European Resuscitation Council (ERC) guidelines. Methods: A total of 120 cardiologists from 14 different medical centers (six university and eight research-education hospitals) in İstanbul were included in the study. The questionnaire consisting of 29 open-ended and multiple choice questions on CPR was used and validated based on the ERC guidelines published in 2015. The percentage of correct answers was calculated for each participant. Results: Of the 120 cardiologists included in this study, 108 (90%) accepted the participation, and the median percentage of correct answers for theoretical questions was 53% (38-72). The percentage of correct answers for interventional cardiologists (48%, n=52) was significantly higher [60% (50-66) vs. 46% (38-52), p<0.001]. Regarding the type of medical centers, no statictical difference was found in terms of theoretical knowledge on CPR [57% (50-72) university hospitals vs. 49% (41-57) research-education hospitals, p=0.160). Peri-arrest transthoracic echocardiography was used in 71% of cases. The ratio of participants who had received an advanced cardiac life support course in the preceding year was only 19% (n=20), and those participants had a significantly higher score regarding the CPR theoretical knowledge questions [68% (54-70) vs. 46% (38-51), p<0.001]. Conclusion: The theoretical knowledge of cardiologists on CPR is not satisfactory according to the 2015 ERC guidelines. An increased frequency of CPR training courses may improve this result.
... 3. Identifikacija potpunog odsustva srčanih kontrakcija. Kod pacijenata kod kojih se primenjuje KPR, potpuno odsustvo kontraktilnosti srca je važan pokazatelj koji ukazuje da napori u primeni mera resuscitacije neće biti zadovoljavajući13,14,15,16 .Ultrazvučnim pregledom se perikardialni izliv lako i na brz način identifikuje. Postavljanjem sonde u subksifoidni polažaj, prikazom četiri srčane šupljine, može se ustanoviti perikardijalna efuzija. ...
Article
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Aims This paper is analyzing the involvement and effectiveness of the witnesses in out-of-hospital cardiac arrest and compares the rate of ROSC and the survival in out-of-hospital cardiac arrest (OHCA) when the bystanders perform cardiopulmonary resuscutation (CPR) compared to the situation when they did not do anything. Methodology Data was collected during the three-year follow-up of OHCA through the EuReCa_Serbia which is part of the clinical trial of EuReCa_ONE - Clinical Trial NCT02236819.l. Statistic was done by SPSS. Results The chance to achieve ROSC is 1.6 times higher if the witness is absent (OR = 1.625, 95% CI = 1.256 - 2.103). A binary logistic analysis has indicated that independent predictors of the achievement of spontaneous circulation (ROSC) include gender and age, the time of the delivered first DC shock, and indicate that the chances to start CPR is 2.8 times higher if witnesses are present (OR = 2.771, 95% CI = 2.391-3.212), but the chance to achieve ROSC is 1.6 times higher if the witness is not present (OR = 1.625, 95% CI = 1.256 - 2.103). The analysis covered a total number of 4172 patients. In 2383 cases, the witness was present when collapse occurred, resuscitation was initiated in 1618 patients, and the ROSC was achieved at 323. Male gender have a 1.9 times higher chance to achieve the return of spontaneous circulation (OR = 1.981, 95% CI = 1.398 - 2.631). Conclusion According to the current opinion of majority “Any CPR is better than no CPR” needs to be critically analyzed, there are reasons to more deeply and carefully follow up the usefulness of the involvement bystander CPR with the opened possibility that our results indicate that such assistance might even be harmful.
... Ventricular Fibrillation (VF) and Pulseless Ventricular Tachycardia (pVT) are given as the most common electrophysiological mechanisms leading to SCA. Then there are successively: asystole (no mechanical heart activity) and Pulseless Electrical Activity (PEA) [6]. Hence, early recognition of the mechanism and causes of SCA as the foundation for out-of-hospital and hospital treatment becomes a priority. ...
Article
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INTRODUCTION: Systematic analysis of risk factors, causes of sudden death and patient survivability allows implementation of increasingly effective methods and procedures for emergency cardiac arrest (SCA). The conditions of the emergency room (ER) allow for initial medical imaging and laboratory diagnostics, which facilitate the assessment of critical parameters that may be a predictor of SCA. The aim of the study is to determine the survival level of patients with SCA that were staying in ER and to indicate the factors that increase the likelihood of SCA. MATERIAL AND METHODS: The study was conducted in 2018 based on medical records of SOR in 73 patients with sudden cardiac arrest in SOR. Descriptive statistics and data analysis were performed using parametric tests (Pearson test). The level of significance was determined for p
... The SysRev identified no RCTs and 15 relevant observational studies. [102][103][104][105][106][107][108][109][110][111][112][113][114][115][116] The overall certainty of evidence was rated as very low for all outcomes primarily due to risk of bias, inconsistency, and/or imprecision. There was a substantial risk of bias due to prognostic factor measurement, outcome measurement, adjustment for prognostic factors, or confounding. ...
Article
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This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
... The main findings of the present study are that LVMA was found to be preserved for a certain period after induction of CA in all experimental animals regardless of the induced electrical activity, two patterns of LVMA were identified in VF group animals and the pattern with LVMA of low frequency contractions (VFlow group) was associated with the longest time from CA induction to asystole to cessation of LVMA and microcirculation among the groups. The observed phenomenon of the presence of LVMA in all animals of the PEA group is consistent with clinical studies published previously (Breitkreutz et al. 2010, Flato et al. 2015. ...
Article
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We conducted an experimental study to evaluate the presence of coordinated left ventricular mechanical myocardial activity (LVMA) in two types of experimentally induced cardiac arrest: ventricular fibrillation (VF) and pulseless electrical activity (PEA). Twenty anesthetized domestic pigs were randomized 1:1 either to induction of VF or PEA. They were left in nonresuscitated cardiac arrest until the cessation of LVMA and microcirculation. Surface ECG, presence of LVMA by transthoracic echocardiography and sublingual microcirculation were recorded. One minute after induction of cardiac arrest, LVMA was identified in all experimental animals. In the PEA group, rate of LVMA was of 106+/-12/min. In the VF group, we identified two patterns of LVMA. Six animals exhibited contractions of high frequency (VF(high) group), four of low frequency (VF(low) group) (334+/-12 vs. 125+/-32/min., p<0.001). A time from cardiac arrest induction to asystole (19.2+/-7.2 vs. 7.3+/-2.2 vs. 8.3+/-5.5 min, p=0,003), cessation of LVMA (11.3+/-5.6 vs. 4.4+/-0.4 vs. 7.4+/-2.9 min, p=0.027) and cessation of microcirculation (25.3+/-12.6 vs. 13.4+/-2.4 vs. 23.2+/-8.7 min, p=0.050) was significantly longer in VF(low) group than in VF(high) and PEA group, respectively. Thus, LVMA is present in both VF and PEA type of induced cardiac arrest and moreover, VF may exhibit various patterns of LVMA.
... 30,61,62 There is an evidence that even highly-experienced echocardiographers require specific training in this regard. 30,31,[61][62][63][64] Trainees should be taught to record and store FoCUS examinations whenever possible and to issue the reports in a timely manner. 3 Stored data can then be used for documentation, case reviews and consultations, but also for quality control and medico-legal purposes. ...
Article
There is a growing trend of using ultrasound examination of the heart as a first-line diagnostic tool for initial patient evaluation in acute settings. Focus cardiac ultrasound (FoCUS) is a standardized but restricted cardiac ultrasound examination that may be undertaken by a range of medical professionals with diverse backgrounds. The intention of this core curriculum and syllabus is to define a unifying framework for educational and training processes/programmes that should result in competence in FoCUS for various medical professionals dealing with diagnostics and treatment of cardiovascular emergencies. The European Association of Cardiovascular Imaging prepared this document in close cooperation with representatives of the European Society of Anaesthesiology, the European Association of Cardiothoracic Anaesthesiology, the Acute Cardiovascular Care Association of the European Society of Cardiology and the World Interactive Network Focused On Critical Ultrasound. It aims to provide the key principles and represents a guide for teaching and training of FoCUS. We offer this document to the emergency and critical care community as a reference outline for teaching materials and courses related to FoCUS, for promoting teamwork and encouraging the development of the field.
... Ultrasound (US) exhibits the utmost value in such life-threatening conditions because of its non-invasive and readily accessible characteristics [1][2][3][4]. Recent studies demonstrated that US could be an integral part during resuscitation [1,3,5]. A number of US protocols such as CAUSE, RUSH, FEEL and SESAME were introduced in recent years [1,[6][7][8]; however, except FEEL, validation for these protocols in clinical practice is usually limited. ...
Article
Background: We previously developed a US-CAB protocol for evaluation of circulatory-airway-breathing status during cardiopulmonary resuscitation (CPR). This study aimed at validating its application in real CPR scenarios and the potential impact on CPR outcomes. Methods: The US-CAB protocol was implemented at the emergency department of National Taiwan University Hospital since January 2016. The US images, initiation time and operation duration of each US-CAB procedure, and relevant CPR information were recorded for analysis. Results: From January 2016 to March 2017, 177 cardiac arrest patients receiving US-CAB were included. The durations of US-C-A-B procedure were 9.0 ± 1.4, 7.5 ± 1.5, and 16.0 ± 1.9 seconds, respectively. Cardiac activity was identified in 47 cases (26.6%), with higher rates of return of spontaneous circulation (ROSC) (95.7% vs. 21.5%, p < 0.0001) and survival to hospital discharge (25.5% vs. 10.0%, p < 0.01). Detection of cardiac activity after 10 minutes of CPR exhibited 100% sensitivity, specificity, positive and negative predictive value for ROSC. Cardiac tamponade was noted in eight patients. ROSC was achieved in two (25.0%) after pericardiocentesis, and aortic dissection was diagnosed in one (12.5%). Confirmation of correct intubation was significantly faster by US than by capnography (7.4 ± 1.4 vs. 38.3 ± 110.2 seconds, p < 0.001). US detected 21 (11.9%) esophageal intubations and 3 (1.7%) one-lung intubations. All were promptly corrected. Conclusion: The US-CAB protocol is feasible in real CPR scenarios. It confers diagnostic value and prognostic implications which potentially impact the efficacy and outcomes of CPR. However, a future prospective multi-center study to validate its feasibility and indicate the need of structured training is mandated.
... Des valeurs seuils permettent de prédire la RACS et la survie à la sortie de l'hôpital (10 à 25 mmHg pour la PetCO 2 , 25 mmHg pour la pression artérielle diastolique). En cas d'activité électrique sans pouls (DEM), le constat d'une contraction ventriculaire résiduelle en échographie (« pseudo-DEM ») à l'initiation de la RCP serait de meilleur pronostic [90]. La mesure de la vélocité doppler carotidienne est accessible sans interruption de la RCP, mais son intérêt reste à démontrer [91]. ...
Article
Unexpected cardiac arrest is a rare event in the Intensive Care Unit (ICU). Despite immediate availability of advanced life support and trained staff, patients sufferfrom chronic diseases and organ failures that worsen the prognosis for cardiac arrest victims. Although the initial success rate of cardiopulmonary resuscitation may be high, most of the resuscitated patients die soon after restoration of spontaneous circulation. Studies report the percentage of patients surviving to hospital discharge to be about 15%. Factors associated with prognosis are divided into three groups: pre-arrest, intra-arrest, and post-arrest. Preexisting conditions associated with poor outcome are pneumonia, trauma, malignancy, renal insufficiency, organ failures, and comorbidities. Hypotension, sepsis and worsening of Acute Physiology Scores before arrest are more common among the non-survivors. Patients with ventricular tachycardia or fibrillation compared to non-shockable rhythms are more likely to survive. Even though spontaneous circulation is initially restored, the rate of patients discharged alive from hospital declines with the duration of cardiopulmonary resuscitation. However, cardiac arrest is frequently preceded by warning signs of clinical deterioration (hypoxia, hypovolemia, acidosis for instance) that can be identified and treated. Cautious anticipation, regular training, timely initiation of rescue, and selection of patients most likely to benefit from resuscitation are key steps to enhance prognosis and quality of life for cardiac arrest patients in the ICU.
... Huis in 't Veld et al did not attempt to associate imaging findings with outcome, but this has been done in several observational studies in the past, with multiple research groups reporting a strong association between cardiac standstill and mortality. [3,5,7,8,16] Some advocate using this to aid decision making, and in one prior work the only way in which POCUS findings altered treatment was in prompting the team to stop CPR when cardiac standstill was seen. [15] A systematic review however injects a note of caution, concluding that cardiac standstill "harbors a significantly lower (but not zero) likelihood that a patient will experience ROSC." [6] The authors of the review conclude that POCUS can inform prognosis but should not be used in isolation to make decisions on stopping CPR. ...
... Extracorporeal CPR (eCPR) should be considered to facilitate coronary angiography and PCI in coronary thrombosis A meta-analysis of eight studies (n = 568) with mixed non-traumatic and traumatic arrest patients [19] also showed a poor likelihood of ROSC and survival when no cardiac activity was detected, but a modest increase in ROSC and survival (LR 5) if cardiac contraction was present. Other studies showed similar results [5,20]. ...
Article
Point-of-care ultrasound (POCUS) is a widely used tool in critical care areas, allowing for the performance of accurate diagnoses and thus enhancing the decision-making process. Every major organ or system can be safely evaluated with POCUS. In that respect, the utility of POCUS in cardiac arrest is gaining interest. In this article, we will review the actual role of ultrasound in cardiac arrest and the main POCUS protocols focused to this scenario as well as discuss the potential role of POCUS in monitoring the efficacy of the chest compressions. Full text: http://rdcu.be/uCkQ
... Chardoli et al. found that 43% of the patients with pseudo-PEA achieved ROSC, whereas no patients with true PEA achieved ROSC (1). Flato et al. showed that 70% of the patients with pseudo-PEA achieved ROSC and 20% of those with true PEA and none of the patients with true PEA survived hospital discharge (20). Cardiac activity in the US had odd ratios of 6.86 for ROSC, 17.80 for survival to hospital admission, and 17.35 for survival to hospital discharge. ...
Article
Full-text available
Introduction: Ultrasonography (US) has been suggested as an integral part of resuscitation to identify potentially reversible causes of cardiac arrest (CA). This study aimed to evaluate the association between cardiac activity on ultrasonography during resuscitation and outcome of patients with non-shockable rhythms. Methods: We conducted a prospective, observational study on adult patients presenting with CA or experiencing CA in the emergency department (ED), and initial non-shockable rhythm. US examination of the sub-xiphoid region was performed during the 10-second interval of rhythm and pulse check and the association of US findings and patients' outcomes was evaluated. Results: 151 patients with the mean age of 65.32 ± 11.68 years were evaluated (76.2% male). 43 patients (28.5%) demonstrated cardiac activity on the initial US. The rate of asystole in initial rhythm was 58.9% (n=89). Return of spontaneous circulation (ROSC) was achieved in 36 (23.8%) patients, twenty (13.2%) survived to hospital admission and seven (4.6%) survived to hospital discharge. When the cardiac standstill duration increased to six minutes, no patient survived hospital discharge. Potentially reversible causes were detected in 15 cases (9.9%), and four of them survived to hospital discharge. Cardiac activity on first scan was associated with ROSC (OR: 6.86, 95%CI: 2.92-16.09; p < 0.001), survival to hospital admission (OR: 17.80, 95%CI: 3.95-80.17; p < 0.001), and survival to hospital discharge (OR: 17.35, 95%CI: 2.02-148.92; p = 0.001). Conclusion: In non-traumatic cardiac arrest patients with non-shockable rhythms, bedside US is of great importance in predicting ROSC. The presence of pulseless electrical activity (PEA) rhythm and cardiac activity on initial US were associated with ROSC, survival to hospital admission, and hospital discharge. When the cardiac standstill duration increased to six minutes, no patient survived hospital discharge.
... In a study with 49 patients in the intensive care unit, it was concluded that 34.7% were in asystole and 65.3% in pulseless electrical activity (PEA); the ROSC rates were lower in those with electromechanical dissociation. Ultrasound performed during cardiopulmonary resuscitation in intensive care unit (ICU) patients can be performed without interfering with care protocols and can contribute to the differential diagnosis of arrest and the identification of a subgroup of patients with a better prognosis [22]. Although the ROSC and the overall survival rate are low when the cardiac contraction was not observed there is no conclusive evidence to define a standard criterion for decision-making about not starting or stopping resuscitation efforts; since there are still a low number of patients who can come out of the arrest; especially those with witnessed arrest, early CPR, short downtime, or a potentially reversible cause [23,24]. ...
Article
Full-text available
The POCUS-CA (Point-of-care ultrasound in cardiac arrest) is a diagnostic tool in the Intensive Care Unit and Emergency Department setting. The literature indicates that in the patient in a cardiorespiratory arrest it can provide information of the etiology of the arrest in patients with non-defibrillable rhythms, assess the quality of compressions during cardiopulmonary resuscitation (CPR), and define prognosis of survival according to specific findings and, thus, assist the clinician in decision-making during resuscitation. This narrative review of the literature aims to expose the usefulness of ultrasound in the setting of cardiorespiratory arrest as a tool that allows making a rapid diagnosis and making decisions about reversible causes of this entity. More studies are needed to support the evidence to make ultrasound part of the resuscitation algorithms. Teamwork during cardiopulmonary resuscitation and the inclusion of ultrasound in a multidisciplinary approach is important to achieve a favorable clinical outcome.
... The role of POCUS echocardiography in current advanced cardiac life support (ACLS) algorithms is an area of ongoing debate. 8,[12][13][14][15] If intracardiac thrombus is associated with universally poor patient outcomes in cardiac arrest, incorporation of POCUS into ACLS algorithms could be made routine. It is unknown what implications this would have on current algorithms, and whether interventions may still be futile in this context. ...
Article
Full-text available
Background Point-of-care ultrasound (POCUS) has been previously studied in cardiac arrest, without definitive markers for futile resuscitation efforts identified. Intracardiac thrombus during cardiac arrest has not been systematically studied. Our objective was to describe the incidence of intracardiac thrombus and spontaneous echo contrast found during cardiac arrest. Methods A two hospital, retrospective, observational cohort study of 56 cardiac arrest patients who were assessed with POCUS (between January 1st, 2017 to April 30th, 2020). Eligible studies were reviewed for echocardiographic findings (e.g. presence of intracardiac thrombus or spontaneous echo contrast), baseline patient demographics, cardiac arrest-related data, and clinical outcomes. Primary outcome was in-hospital mortality. Results Fifty-six intra-arrest POCUS echocardiograms were identified (out of 738 out-of-hospital cardiac arrests). The median patient age was 63 years (interquartile range [IQR]: 51–72), with 25% female patients, and median Charlson Comorbidity Index score of 4 (IQR: 2–6). The incidence of intracardiac thrombus was 21 out of 56 patients (38%). Time-to-new thrombus formation during cardiac arrest was approximately 6 minutes (IQR: 2-–8). All patients with intracardiac thrombus during cardiac arrest had termination of resuscitation. Conclusions Intracardiac thrombus is potentially common during out-of-hospital cardiac arrests and was observed more frequently in those in whom termination of resuscitation was recommended. However, this is only hypothesis-generating at this time, and further study is required to determine if the presence of intracardiac thrombus may be used as a potential marker of resuscitation futility.
... "Pseudo-PEA", or "pulseless with a rhythm with echocardiographic motion (PREM)", which refers to patients with PEA but a beating heart under ultrasound, could be the cause. Studies reveal that patients with PREM had higher survival rates than those with PEA without echocardiographic motion; aggressive ALS treatment may increase their survival [41][42][43]. There are several reasonable explanations for early ALS team response time improving the rate of survival to hospital discharge and neurological outcome among OHCA patients. ...
Article
Full-text available
Background The association between out-of-hospital cardiac arrest patient survival and advanced life support response time remained controversial. We aimed to test the hypothesis that for adult, non-traumatic, out-of-hospital cardiac arrest patients, a shorter advanced life support response time is associated with a better chance of survival. We analyzed Utstein-based registry data on adult, non-traumatic, out-of-hospital cardiac arrest patients in Taipei from 2011 to 2015. Methods Patients without complete data, witnessed by emergency medical technicians, or with response times of ≥ 15 minutes, were excluded. We used logistic regression with an exposure of advanced life support response time. Primary and secondary outcomes were survival to hospital discharge and favorable neurological outcomes (cerebral performance category ≤ 2), respectively. Subgroup analyses were based on presenting rhythms of out-of-hospital cardiac arrest, bystander cardiopulmonary resuscitation, and witness status. Results A total of 4,278 cases were included in the final analysis. The median advanced life support response time was 9 minutes. For every minute delayed in advanced life support response time, the chance of survival to hospital discharge would reduce by 7% and chance of favorable neurological outcome by 9%. Subgroup analysis showed that a longer advanced life support response time was negatively associated with the chance of survival to hospital discharge among out-of-hospital cardiac arrest patients with shockable rhythm and pulse electrical activity groups. Conclusions In non-traumatic, adult, out-of-hospital cardiac arrest patients in Taipei, a longer advanced life support response time was associated with declining odds of survival to hospital discharge and favorable neurologic outcomes, especially in patients presenting with shockable rhythm and pulse electrical activity.
... Por otro lado, deben considerarse elementos relativos al desempeño en la RCP, como los dispositivos de retroalimentación para controlar la calidad de la misma, las compresiones torácicas mecánicas, las técnicas de soporte Correo electrónico: jlopezme@saludcastillayleon.es vital extracorpóreo (SVE) 7 , la ecocardiografía para descartar procesos reversibles y situaciones de «pseudo-PCR» en casos de actividad eléctrica sin pulso (AESP) 8 , así como el traslado al hospital de algunas víctimas con RCP en curso. ...
Chapter
Sudden cardiac arrest carries a grave prognosis. The management of cardiac arrest is algorithmic because providers typically have limited knowledge of the patient’s past medical history. Peri-resuscitation echocardiography provides an invaluable real-time bedside diagnostic tool that can identify some of the potentially reversible causes of cardiac arrest and can be regarded as analogous to pulse oximetry or ECG monitoring.
Article
Objective: To describe the prevalence, baseline characteristics and factors associated with survival in out-of-hospital cardiac arrest (OHCA) with initial non-shockable rhythm sub-grouped into pulseless electrical activity (PEA) and asystole as presenting rhythm. Methods: The Swedish Registry of Cardiopulmonary Resuscitation is a prospectively recorded nationwide registry of modified Utstein parameters, including all patients with attempted resuscitation after OHCA. Data between 1990-2016 were analyzed. Results: After exclusions, the study population consisted of 48,707 patients presenting with either PEA or asystole. The proportion of PEA increased from 12% to 22% during the study period with a fivefold increase in 30-day survival reaching 4.9%. Survival in asystole showed a modest increase from 0.6% to 1.3%. In the multivariable analysis, PEA was independently associated with survival at 30 days (OR 1.54, 95% CI 1.26-1.88). Conclusion: Between 1990 and 2016, the proportion of PEA as the first recorded rhythm doubled with a five-fold increase in 30-day survival, while survival among patients with asystole remained at low levels. PEA and asystole should be considered separate entities in clinical decision-making and be reported separately in observational studies and clinical trials.
Article
Recent technological advances in echocardiography, with progressive miniaturization of ultrasound machines, have led to the development of handheld ultrasound devices (HUD). These devices, no larger than some mobile phones, can be used to perform partial, focused exams as an extension to the physical examination. The European Association of Cardiovascular Imaging (EACVI) acknowledges that the dissemination of appropriate HUD use is inevitable and desirable, because of its potential impact on patient management. However, as a scientific society of cardiac imaging, our role is to provide guidance in order to optimize patient benefit and minimize drawbacks from inappropriate use of this technology. This document provides updated recommendations for the use of HUD, including nomenclature, appropriateness, indications, operators, clinical environments, data management and storage, educational needs, and training of potential users. It also addresses gaps in evidence, controversial issues, and future technological developments.
Article
Background: Transesophageal echocardiography (TEE) has been proposed as a modality to assess patients in the setting of cardiac arrest, both during resuscitation care and following return of spontaneous circulation (ROSC). In this study we aimed to assess the feasibility and clinical impact of TEE during the emergency department (ED) evaluation during out-of-hospital cardiac arrest (OHCA). Materials and methods: We conducted a prospective observational study consisting of a convenience sample of adult patients presenting to the ED of an urban university medical center with non-traumatic OHCA. TEE was performed by emergency physicians following intubation. Images and clinical data were analyzed. TEE was used intra-arrest in order to assist in diagnosis, assess cardiac activity and determine CPR quality by assessing area of maximal compression (AMC), using a 4 view protocol. Results: A total of 33 OHCA patients were enrolled over a one-year period, 21 patients (64%) presented with ongoing CPR and 12 (36%) presented with ROSC. The 4-view protocol was completed in 100% of the cases, with an average time from ED arrival to TEE of 12 min (min 3 max 30 SD 8.16). Fine ventricular fibrillation (VF) was recognized in 4 (12%) cases thought to be in asystole, leading to defibrillation, and 2 cases of pseudo-PEA were identified. Right ventricular (RV) dilation, was seen in 12 (57%) intraarrest cases. Intra-cardiac thrombus was found in one case, leading to thrombolysis. The AMC was identified over the aortic root or LVOT in 53% of cases. TEE was found to have diagnostic, therapeutic or prognostic clinical impact in 32 of the 33 cases (97%). Conclusions: TEE is feasible and clinically impactful during OHCA management. Resuscitative TEE may allow for characterization of cardiac activity, including identification of pseudo-PEA and fine VF, determination of reversible pathology, and optimization of CPR quality.
Article
Background: Each year, around 60 000 people in the UK experience an out-of-hospital cardiac arrest. The introduction of additional diagnostic tools such as focused cardiac ultrasound (FoCUS) aids assessment and management of patients at the point of care. The Resuscitation Council guidance recommends its use where possible. Method: A systematic literature search was undertaken of two databases, PubMed and Science Direct primarily to identify literature relevant to the use of ultrasound in medical cardiac arrests where the prevailing cardiac rhythm was non-shockable. Results: A total of 10 papers were included in the review out of 242 identified from the search. Across all papers, three themes were identified: prognostication, identification of reversible causes and true pulseless electrical activity (PEA) versus pseudo PEA. Conclusion: The evidence shows there is an association between cardiac activity identified with FoCUS and an increase in return of spontaneous circulation (ROSC) rates. The effect of FoCUS for improving survival is not statistically significant; however, there is a higher likelihood of survival because of its ability to aid decision making. Patients with cardiac motion identified by FoCUS had higher ROSC rates than those without. Although the data suggest that the presence of cardiac activity is highly associated with ROSC, there is little literature surrounding long-term outcomes of patients, so the ability of FoCUS to determine survival cannot be confirmed.
Article
Purpose: To explore correlations between the serum level of miRNA-21 expression and cardiac dysfunction severity after cardiopulmonary resuscitation (CPR) using ultrasonic cardiogram. Methods: Thirty-nine patients with cardiopulmonary arrest receiving successful CPR and forty-one healthy participants were recruited in the study. Reverse Transcription-Polymerase Chain Reaction (RT-PCR) and immunochemiluminometric assays was used to examine the serum miRNA-21 level and the concentration of cardiac troponins T and I, respectively. Indices of Electrocardiogram (ECG) and cardiac dysfunction measured by ultrasound of patients in the case group were used to assess cardiac function after CPR. Furthermore, the correlation between the serum level of miRNA-21 expression and severity of cardiac dysfunction was analyzed by Spearman correlation analysis. Results: As compared to the control group, the serum level of miRNA-21 expression, as well as cardiac troponin T and I levels in the case group were significantly higher (p = 0.000). The miRNA-21 expression level in the patients at IV grade of cardiac function were substantially higher than patients at III grade (p = 0.015). There was no significant difference in level of cardiac troponins T and I between patients at III grade and patients at IV grade (p > 0.05). Further, Spearman correlation analysis revealed that the level of miRNA-21 expression was negatively correlated with cardiac function index in the ultrasound imaging: E peak, E/A value, LVEF and LVEDD (r = 0.617, 0.535, 0.612, 0.573, P = 0.012, 0.009, 0.008, 0.011), but was positively correlated with the level of cardiac troponins T and I (r = 0.546,0.582, P = 0.006,0.007) and the severity of cardiac dysfunction (r = 0.859, p < 0.05). Conclusion: The level of miRNA-21 is higher after CPR is closely related to the severity of cardiac dysfunction that is measured by ultrasound, suggesting that it may serve as a potential biomarker.
Chapter
The concept of mean circulatory pressure (MCP) is based on a manufactured phenomenon which fails to account for the movement of blood after cardiac arrest. Direct observations of microvascular beds in experimental animals confirm vestigial movement of the blood in direction of the heart up to 30 min following the cessation of heart’s contractions. Observations on patients and dogs in deep hypothermic arrest confirm persistent movement of blood against the pressure gradient. The phenomenon of spontaneous return of circulation (SROC) after cardiac arrest and “failed” resuscitation is well-described in the literature. Further discussed are: interstitial pressure (IP) as a marker of the rate of fluid movement across the capillary membrane; negative interstitial pressure and its importance in the maintenance of constant intravascular volume, normal organ function, and facilitation of wound healing; historical development of the concepts of vis á fronte (force from the front) and vis a tergo (force from behind) in relation to heart and capillary actions. The introduction of mechanical respiration gradually obscured the importance of pulmonary microvascular beds for left ventricular filling. It marks the transition from the “hemocentric” view of circulation, where microvascular beds are seen as the principal source of blood propulsion, to a “cardiocentric” view where this role is ascribed to the heart.
Article
Background Target temperature management (TTM) is a recommended therapy for patients after cardiac arrest (PCA). The TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest (TIMECARD) registry was established for PCA who receive TTM therapy in Taiwan. We aim to determine the variables that may affect neurologic outcomes in PCA who undergo TTM. Methods We retrieved demographic variables, resuscitation variables, and cerebral performance category (CPC) scale score at hospital discharge from the TIMECARD registry. The primary outcome was a favorable neurologic outcome, defined as a CPC scale of 1 or 2 at discharge. A total of 540 PCA treated between January 2014 and September 2019 were identified from the registry. Univariate and multivariate analyses were performed to identify significant variables. Results The mortality rate was 58.1% (314/540). Favorable neurologic outcomes were noted in 117 patients (21.7%). The factors significantly influencing the neurologic outcome (p < 0.05) were the presence of an initial shockable rhythm or pulseless electric activity, a witnessed cardiac-arrest event, bystander cardiopulmonary resuscitation, a smaller total dose of epinephrine, the diastolic blood pressure value at return of spontaneous circulation, a pre-arrest CPC score of 1, coronary angiography, new-onset seizure, and new-onset serious infection. Older patients and those with premorbid diabetes mellitus, chronic kidney disease, malignancy, obstructive lung disease, or cerebrovascular accident were more likely to have an unfavorable neurologic outcome. Conclusions In the TIMECARD registry, some PCA baseline characteristics, cardiac arrest events, cardiopulmonary resuscitation characteristics, and post-arrest management characteristics were significantly associated with neurologic outcomes.
Article
Aim To identify whether a novel pulse check technique, carotid artery compression using an ultrasound probe, can reduce pulse check times compared to manual palpation (MP). Methods This prospective study was conducted in an emergency department between February and December 2021. A physician applied point-of-care ultrasound–carotid artery compression (POCUS-CAC) and assessed the carotid artery compressibility and pulsatility by probe compression during rhythm check time. Another clinician performed MP of the femoral artery. The primary outcome was the difference in the average time for pulse assessment between POCUS-CAC and MP. The secondary outcomes included the time difference in each pulse check between methods, the proportion of times greater than 5 s and 10 s, and the prediction of return of spontaneous circulation (ROSC) during ongoing chest compression. Results 25 cardiac arrest patients and 155 pulse checks were analyzed. The median (interquartile range) average time to carotid pulse identification per patient using POCUS-CAC was 1.62 (1.14–2.14) s compared to 3.50 (2.99–4.99) s with MP. In all 155 pulse checks, the POCUS-CAC time to determine ROSC was significantly shortened to 0.44 times the MP time (P < 0.001). The POCUS-CAC approach never exceeded 10 s, and the number of patients who required more than 5 s was significantly lower (5 vs. 37, P < 0.001). Under continuous chest compression, six pulse checks predicted the ROSC. Conclusions We found that emergency physicians could quickly determine pulses by applying simple POCUS compression of the carotid artery in cardiac arrest patients.
Preprint
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This trial is aimed at studying the utility and interventional outcomes of rescue transesophageal echocardiography (RescueTEE) to aid in diagnosis, change in management, and outcomes during CPR by using a point of care RescueTEE protocol in the evaluation of in-hospital cardiac arrest (IHCA). This is an interventional prospective convenience sampled partially blinded phase II clinical trial with primary outcomes of survival to hospital discharge (SHD) with RescueTEE image guided ACLS versus conventional ACLS.
Article
Full-text available
Pulseless electrical activity (PEA) is characterized by the disassociation of the mechanical and electrical activity of the heart and appears as the initial rhythm in 20–30% of out-of-hospital cardiac arrest (OHCA) cases. Predicting whether a patient in PEA will convert to return of spontaneous circulation (ROSC) is important because different therapeutic strategies are needed depending on the type of PEA. The aim of this study was to develop a machine learning model to differentiate PEA with unfavorable (unPEA) and favorable (faPEA) evolution to ROSC. An OHCA dataset of 1921 5s PEA signal segments from defibrillator files was used, 703 faPEA segments from 107 patients with ROSC and 1218 unPEA segments from 153 patients with no ROSC. The solution consisted of a signal-processing stage of the ECG and the thoracic impedance (TI) and the extraction of the TI circulation component (ICC), which is associated with ventricular wall movement. Then, a set of 17 features was obtained from the ECG and ICC signals, and a random forest classifier was used to differentiate faPEA from unPEA. All models were trained and tested using patientwise and stratified 10-fold cross-validation partitions. The best model showed a median (interquartile range) area under the curve (AUC) of 85.7(9.8)% and a balance accuracy of 78.8(9.8)%, improving the previously available solutions at more than four points in the AUC and three points in balanced accuracy. It was demonstrated that the evolution of PEA can be predicted using the ECG and TI signals, opening the possibility of targeted PEA treatment in OHCA.
Chapter
In the setting of a major incident, where many casualties are involved, patients requiring cardiopulmonary resuscitation (CPR) should not take priority over other patients who have better chances of survival. This however should take into consideration the teams’ ability of interpreting ECG recordings. In cardiac arrest, there is little doubt that the only interventions that improve the outcome are early initiation of bystander CPR, uninterrupted high-quality chest compressions and early defibrillation for the shockable rhythms. When resuscitation is initiated, the adult BLS/AED based on the 2015 ERC guidelines on resuscitation should be followed. When the team decides to change to the ALS treatment guidelines, it is expected that the team is trained according to the current guidelines and complies to local protocol policies. Every patient post-arrest who has not achieved sufficient level of consciousness needs sedation, intubation, and ventilation, and must be admitted to an Intensive Care Unit.
Chapter
The chapter discusses the issue of medical management of incidents caused by fire and toxic gas, hazardous material, chemicals, and irradiation. It presents the classification of injuries and the requirements for the medical care during decontamination of injured persons. It also presents decontamination patterns and maps and the necessary resources and equipment.
Article
This review explains the role of point-of-care ultrasound in cardiac arrest rhythm classification and the diagnosis of reversible causes, discusses available protocols for the application of ultrasound to Advanced Cardiac Life Support, and summarizes principles for its safe implementation.
Article
Full-text available
Aim Pseudo-pulseless electrical activity (pseudo-PEA) is a global hypotensive ischemic state with retained coordinated myocardial contractile activity and an organized ECG with no clinically detectable pulses. The role of standard external chest compressions (CPR) and its associated intrinsic hemodynamics remains unclear in the setting of pseudo-PEA. We undertook an experimental trial to compare epinephrine alone versus epinephrine with CPR in the treatment of pseudo-PEA. Methods Using a porcine model of hypoxic pseudo-PEA, we randomized 12 Yorkshire male swine to resuscitation with epinephrine only (control) (0.0015 mg/kg) versus epinephrine plus standard CPR (intervention). Animals who achieved return of spontaneous circulation (ROSC) were stabilized, fully recovered to hemodynamic and respiratory baseline, and rearrested up to 6 times. Primary outcome was ROSC defined as a sustained systolic blood pressure (SBP) of 60 mmHg for 2 min. Secondary outcomes included time to ROSC, coronary perfusion pressure (CoPP), and end-tidal carbon dioxide (ETCO2). Results Among 47 events of pseudo-PEA in 12 animals, we observed significantly higher proportion of ROSC when treatment included CPR (14/21 – 67%) compared to epinephrine alone (4/26 – 15%) (p = 0.0007). CoPP, aortic pressures and ETCO2 were significantly higher, and right atrial pressures were lower in the intervention group. Conclusions In a swine model of hypoxia-induced pseudo-PEA, epinephrine plus CPR was associated with improved intra-arrest hemodynamics and higher probability of ROSC. Thus, epinephrine plus CPR may be superior to epinephrine alone in the treatment of patients with pseudo-PEA.
Article
超音波装置の小型化とベッドサイドへの普及により,超音波検査は救急現場で積極的に利用されるようになった。医療従事者がベッドサイドで観察範囲を絞り,臨床決断と侵襲的手技の質向上のために実施する超音波検査はpoint–of–care ultrasonography(POCUS)と呼ばれる。その概念は世界中で広く共有されるようになったが,本邦ではfocused assessment with sonography for trauma(FAST)と超音波ガイド下中心静脈穿刺を除き,POCUSに関する正式な指針はこれまで存在しなかった。日本救急医学会Point–of–Care超音波推進委員会では,POCUSを用いた救急診療の質向上について議論を繰り返し,日本救急医学会からの認証を得て救急point–of–care超音波診療指針としてまとめた。この指針では,背景,救急科専門医の到達目標,その論文的根拠,領域横断的な活用について述べる。到達目標の主要項目には,超音波の基礎,上気道,胸部,心臓,腹部,深部静脈,ガイド下手技,症候別評価が含まれる。また将来主要項目になる可能性があるものは付加項目として広く言及した。この指針は救急科専門医にとっての超音波検査の概要と方向性を示すものであり,救急超音波教育のために利用できる。この指針をきっかけに,本邦の救急診療の現場で超音波検査が効果的に利用されることを願う。 Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision–making and improving the quality of invasive procedures is now called point–of–care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound–guided central venous cannulation. The Committee for the Promotion of Point–of–Care Ultrasonography in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the “Clinical Guidance for Emergency and Point–of–Care Ultrasonography” was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, upper airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound–guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.
Article
Purpose of review: Point-of-care ultrasound (POCUS) is commonly used during cardiac arrest to screen for potential causes and to inform termination of resuscitation. However, unique biases and limitations in diagnostic and prognostic test accuracy studies lead to potential for misinterpretation. The present review highlights recent evidence regarding POCUS in cardiac arrest, guides the incorporation of POCUS into clinical management, and outlines how to improve the certainty of evidence. Recent findings: Multiple frameworks organize and direct POCUS during cardiac arrest. Although many are proofs of concept, several have been prospectively evaluated. Indirect evidence from undifferentiated shock suggests that POCUS offers better specificity than sensitivity as a diagnostic aid. The prognostic accuracy of POCUS during cardiac arrest to predict subsequent clinical outcomes is better characterized, but subject to unique biases and confounding. Low certainty direct evidence suggests that POCUS offers better specificity than sensitivity as a prognostic aid. Summary: POCUS findings might indicate a particular diagnosis or encourage the continuation of resuscitation, but absence of the same is not sufficient in isolation to exclude a particular diagnosis or cease resuscitation. Until the evidence to support POCUS during cardiac arrest is more certain, it is best characterized as a diagnostic and prognostic adjunct.
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This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
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Background/Aim The relationship between echocardiographic findings of intra-arrest TEE and resuscitation outcomes was not clearly identified. We assessed echocardiographic findings observed in intra-arrest TEE and its relationship with resuscitation outcomes. Methods This retrospective observational study analysed adult patients with non-traumatic out-of-hospital cardiac arrest who underwent TEE during cardiopulmonary resuscitation in the emergency department. Patients were grouped according to the presence of specific TEE findings with cardiac arrest. Resuscitation outcomes were compared between groups. Results The study enrolled 158 patients (108 males, median age: 72.5 years), 40 (25.3%) patients (TEE positive group) had specific TEE findings including possible causes of cardiac arrest in 31 (19.6%) and the sequela of cardiac arrest in 9 (5.7%) while 118 (74.7%) patients (TEE negative group) had no specific TEE findings. In the TEE positive group, TEE identified possible causes of cardiac arrest including aortic dissection in 19 (61.3%), pulmonary embolism in 8 (25.8%), cardiac tamponade in 4 (12.9%), and the sequela of cardiac arrest including intracardiac thrombi in 5 (22.5%) patients. No patients in the TEE positive group and 7 patients (5.9%) in the TEE negative group survived to hospital discharge. Return of spontaneous circulation rates were 27.5% and 39.8% in the TEE positive and TEE negative groups, respectively (p = 0.16). Conclusion Intra-arrest TEE identifies specific findings related to causes of cardiac arrest. Presence of specific findings is associated with poor resuscitation outcomes.
Article
There are approximately 350,000 out-of-hospital cardiac arrests and 200,000 in-hospital cardiac arrests annually in the United States, with survival rates of approximately 5% to 10% and 24%, respectively. The critical factors that have an impact on cardiac arrest survival include prompt recognition and activation of prehospital care, early cardiopulmonary resuscitation, and rapid defibrillation. Advanced life support protocols are continually refined to optimize intracardiac arrest management and improve survival with favorable neurologic outcome. This article focuses on current treatment recommendations for adult nontraumatic cardiac arrest, with emphasis on the latest evidence and controversies regarding intracardiac arrest management.
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Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.
Article
Background: The role of echocardiographic indices of preload and contractility in predicting outcomes is unknown. We report the association of end diastolic area (EDA) and fractional area of change (FAC) with mortality in a cohort of trauma and burn patients. Methods: Data on 86 patients admitted to a tertiary care center between July 2013 and July 2015 were reviewed. The association between abnormal EDA and FAC and adverse clinical outcomes was tested using exact logistic regression analysis. Results: 31 patients had abnormal EDA (<10 cm(2)) and 13 had low FAC (<40%). Those with low FAC had higher blood pressure on admission, and lower urine output and higher lactic acid (p= < 0.01) on echocardiography day. Abnormal EDA was associated with in-hospital death (OR 4.20, 95% CI 1.45-12.17). Conclusions: Echocardiographic measurements can predict outcome in trauma and burn patients. Further studies are needed to confirm these findings.
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Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September, 2004, with methodologists, researchers, and journal editors to draft a che-cklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed explanation and elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE statement will contribute to improving the quality of reporting of observational studies.
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Background Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. Methods The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. Results During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. Conclusions This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.
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ACADEMIC EMERGENCY MEDICINE 2012; 19:1119–1126 © 2012 by the Society for Academic Emergency Medicine Objectives: The objective was to determine if focused transthoracic echocardiography (echo) can be used during resuscitation to predict the outcome of cardiac arrest. Methods: A literature search of diagnostic accuracy studies was conducted using MEDLINE via PubMed, EMBASE, CINAHL, and Cochrane Library databases. A hand search of references was performed and experts in the field were contacted. Studies were included for further appraisal and analysis only if the selection criteria and reference standards were met. The eligible studies were appraised and scored by two independent reviewers using a modified quality assessment tool for diagnostic accuracy studies (QUADAS) to select the papers included in the meta-analysis. Results: The initial search returned 2,538 unique papers, 11 of which were determined to be relevant after screening criteria were applied by two independent researchers. One additional study was identified after the initial search, totaling 12 studies to be included in our final analysis. The total number of patients in these studies was 568, all of whom had echo during resuscitation efforts to determine the presence or absence of kinetic cardiac activity and were followed up to determine return of spontaneous circulation (ROSC). Meta-analysis of the data showed that as a predictor of ROSC during cardiac arrest, echo had a pooled sensitivity of 91.6% (95% confidence interval [CI] = 84.6% to 96.1%), and specificity was 80.0% (95% CI = 76.1% to 83.6%). The positive likelihood ratio for ROSC was 4.26 (95% CI = 2.63 to 6.92), and negative likelihood ratio was 0.18 (95% CI = 0.10 to 0.31). Heterogeneity of the results (sensitivity) was nonsignificant (Cochran’s Q: χ2 = 10.63, p = 0.16, and I2 = 34.1%). Conclusions: Echocardiography performed during cardiac arrest that demonstrates an absence of cardiac activity harbors a significantly lower (but not zero) likelihood that a patient will experience ROSC. In selected patients with a higher likelihood of survival from cardiac arrest at presentation, based on established predictors of survival, echo should not be the sole basis for the decision to cease resuscitative efforts. Echo should continue to be used only as an adjunct to clinical assessment in predicting the outcome of resuscitation for cardiac arrest. Objetivos: Determinar si la ecocardiografía transtorácica dirigida (eco) puede ser utilizada durante la reanimación para predecir el resultado de la parada cardiaca. Métodos: Se realizó una búsqueda bibliográfica de los estudios de certeza diagnóstica en las bases de datos de MEDLINE via PubMed, EMBASE, CINAHL y Cochrane Library. Se realizó una búsqueda manual de las referencias y se contactó con los expertos en el campo. Se seleccionó estudios para posteriores evaluaciones y análisis sólo si cumplían los criterios de selección y los estándares de referencia. Los estudios elegidos fueron evaluados y puntuados por dos revisores independientes mediante una escala de valoración de calidad modificada para estudios de certeza diagnóstica (QUADAS) para seleccionar los artículos incluidos en el metanálisis. Resultados: La búsqueda inicial localizó 2.538 artículos, 11 de los cuales resultaron ser relevantes tras la aplicación de los criterios de despistaje por dos investigadores independientes. Se identificó un estudio adicional tras la búsqueda inicial, por lo que 12 estudios fueron incluidos en el análisis final. El número total de pacientes en estos estudios fue de 568, todos con una eco durante las maniobras de reanimación para determinar la presencia o ausencia de actividad cardiaca, y los pacientes fueron seguidos para determinar el retorno de la circulación espontánea (RCE). El metanálisis de los datos mostró que, como factor predictivo de RCE durante la parada cardiaca, la eco tuvo una sensibilidad agrupada del 91,6% (intervalo de confianza (IC) 95% = 84,6% a 96,1%), y una especificidad del 80,0% (IC 95% = 76,1% a 83,6%). El coeficiente de probabilidad positiva para un RCE fue 4,26 (IC 95% = 2,63 a 6,92), y el cociente de probabilidad negativa fue 0,18 (IC 95% = 0,10 a 0,31). La heterogeneidad de los resultados (sensibilidad) no fue significativa (Q de Cochran: ji-cuadrado = 10,63, p = 0,16; y ji-cuadrado = 34,1%). Conclusiones: La ecocardiografía realizada durante la parada cardiaca que demuestre una ausencia de actividad cardiaca abriga una probabilidad significativamente menor (pero no cero) que un paciente experimente un RCE. En aquellos pacientes seleccionados con una mayor probabilidad de supervivencia a la parada cardiaca al inicio, en base a los factores predictivos de supervivencia establecidos, la eco no debería ser el único parámetro para la toma de decisión de detener las maniobras. La eco debería continuar siendo usada sólo como un complemento a la valoración clínica en la predicción del resultado de reanimación de la parada cardiaca.
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The use of point of care echocardiography by non-cardiologist in acute care settings such as the emergency department (ED) or the intensive care unit (ICU) is very common. Unlike diagnostic echocardiography, the scope of such point of care exams is often restricted to address the clinical questions raised by the patient's differential diagnosis or chief complaint in order to inform immediate management decisions. In this article, an overview of the most common applications of this focused echocardiography in the ED and ICU is provided. This includes but is not limited to the evaluation of patients experiencing hypotension, cardiac arrest, cardiac trauma, chest pain and patients after cardiac surgery.
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Recent observations of increased discharge through fast-flowing outlet glaciers and ice streams motivate questions concerning the inland migration of regions of fast flow, which could increase drawdown of the ice-sheet interior. To investigate one process that could lead to inland migration we conduct experiments with a two-dimensional, full-stress, transient ice-flow model. An initial steady state is perturbed by initiating a jump in sliding speed over a fraction of the model domain. As a result, longitudinal-stress gradients increase frictional melting upstream from the slow-to-fast sliding transition, and a positive feedback between longitudinal-stress gradients, basal meltwater production and basal sliding causes the sliding transition to migrate upstream over time. The distance and speed of migration depend on the magnitude of the perturbation and on the degree of non-linearity assumed in the link between basal stress and basal sliding: larger perturbations and/or higher degrees of non-linearity lead to farther and faster upstream migration. Migration of the sliding transition causes the ice sheet to thin over time and this change in geometry limits the effects of the positive feedback, ultimately serving to impede continued upstream migration.
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The prognostic value of emergency echocardiography (EE) in the management of cardiac arrest patients has previously been studied in an in-hospital setting. These studies mainly included patients who underwent cardiopulmonary resuscitation (CPR) by emergency medicine technicians at the scene and who arrived at the emergency department (ED) still in a state of cardiac arrest. In most European countries, cardiac arrest patients are normally treated by physician-staffed emergency medical services (EMS) teams on scene. Transportation to the ED while undergoing CPR is uncommon. To evaluate the ability of EE to predict outcome in cardiac arrest patients when it is performed by ultrasound-inexperienced emergency physicians on scene. We performed a prospective, observational study of nonconsecutive, nontrauma, adult cardiac arrest patients who were treated by physician-staffed urban EMS teams on scene. Participating emergency physicians (EPs) received a two-hour course in EE during CPR. After initial procedures were accomplished, EE was performed during a rhythm and pulse check. A single subxiphoid, four-chamber view was required for study enrollment. We defined sonographic evidence of cardiac kinetic activity as any detected motion of the myocardium, ranging from visible ventricular fibrillation to coordinated ventricular contractions. The CPR had to be continued for at least 15 minutes after the initial echocardiography. No clinical decisions were made based on the results of EE. Forty-two patients were enrolled in the study. The heart could be visualized successfully in all patients. Five (11.9%) patients survived to hospital admission. Of the 32 patients who had cardiac standstill on initial EE, only one (3.1%) survived to hospital admission, whereas four out of 10 (40%) patients with cardiac movement on initial EE survived to hospital admission (p = 0.008). Neither asystole on initial electrocardiogram nor peak capnography value, age, bystander CPR, or downtime was a significant predictor of survival. Only cardiac movement was associated with survival, and cardiac standstill at any time during CPR resulted in a positive predictive value of 97.1% for death at the scene. Our results support the idea of focused echocardiography as an additional criterion in the evaluation of outcome in CPR patients and demonstrate its feasibility in the prehospital setting.
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Compact ultrasound technology has facilitated growth in point-of-care uses in many specialties. This review includes videos demonstrating the use of ultrasonography to guide central venous access, detect pneumothorax, detect evidence of hemorrhage after trauma, and screen for abdominal aortic aneurysm.
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Emergency physicians were trained to perform echo in life support (ELS)--that is, limited transthoracic echocardiography during advanced life support (ALS) management of cardiac arrest. Data were collected on the adequacy of views obtained and timing of the scan, as well as the clinical findings of pericardial effusion and ventricular wall motion. Any intervention performed as a result of the scan was also noted. ELS was performed on 50 patients during cardiac arrest. Adequate views were obtained in 47 (94%) scans, and 45 (90%) were obtained within the 10 s rhythm check. Twenty patients (40%) had ventricular wall motion (VWM), three (6%) had pericardial effusions and six patients (12%) had an intervention performed as a direct result of the scan. These included pericardiocentesis, thrombolysis and insertion of a chest drain. The presence of VWM had a positive predictive value of 55%. The absence of VWM resulted in a negative predictive value of 97% for predicting return of spontaneous circulation (ROSC). It is concluded that ELS is feasible and that the scan findings may guide further interventions.
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Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described. Obtaining competence in ICU echocardiography may be achieved in different ways – either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level – obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countrie's needs.
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Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case–control and cross-sectional studies. We convened a 2-day workshop in September 2004, with methodologists, researchers, and journal editors to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE Statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case–control, or cross-sectional studies. A detailed Explanation and Elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine and Epidemiology. We hope that the STROBE Statement will contribute to improving the quality of reporting of observational studies.
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Significant amount of data on the incidence and outcome of out-of-hospital and in-hospital cardiac arrest have been published. Cardiac arrest occurring in the intensive care unit has received less attention. To evaluate and summarize current knowledge of intensive care unit cardiac arrest including quality of data, and results focusing on incidence and patient outcome. Sources and methods: We conducted a literature search of the PubMed, CINAHL and Cochrane databases with the following search terms (Medical Subheadings): heart arrest AND intensive care unit OR critical care OR critical care nursing OR monitored bed OR monitored ward OR monitored patient. We included articles published from the 1st of January 1990 till 31st of December 2012. After exclusion of all duplicates and irrelevant articles we evaluated quality of studies using a predefined quality assessment score and summarized outcome data. The initial search yielded 794 articles of which 780 were excluded. Three papers were added after a manual search of the eligible studies' references. One paper was identified manually from the literature published after our initial search was completed, thus the final sample consisted of 18 papers. Of the studies included thirteen were retrospective, two based on prospective registries and three were focused prospective studies. All except two studies were from a single institution. Six studies reported the incidence of intensive care unit cardiac arrest, which varied from 5.6 to 78.1 cardiac arrests per 1000 intensive care unit admissions. The most frequently reported initial cardiac arrest rhythms were non-shockable. Patient outcome was variable with survival to hospital discharge being in the range of 0-79% and long-term survival ranging from 1-69%. Nine studies reported neurological status of survivors, which was mostly favorable, either no neurological sequelae or cerebral performance score mostly of 1-2. Studies focusing on post cardiac surgery patients reported the best long-term survival rates of 45-69%. At present data on intensive care unit cardiac arrest is quite limited and originates mostly from retrospective single center studies. The quality of data overall seems to be poor and thus focused prospective multi-center studies are needed.
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This is the first of a two-part series that reviews advanced critical care echocardiography (CCE) techniques designed for critical care physicians. In this section, we review training in basic and advanced CCE. This is followed by a review of Doppler principles, including pulsed wave, continuous wave, and color flow Doppler. Included are Doppler measurement techniques that are useful for assessing the patient with cardiopulmonary failure and the common pitfalls of Doppler. This section ends with a review of the quantitative and semiquantitative measurements of stroke volume, as well as problems with measurement of stroke volume in the ICU and its useful clinical applications. Video-based examples will help demonstrate the techniques that are described in the text.
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Ein Großteil der biomedizinischen Forschung ist beobachtend, und die Qualität der veröffentlichten Berichte über diese Forschung ist oft unzureichend. Dies behindert die Beurteilung der Stärken und Schwächen einer Studie und ihrer Übertragbarkeit. Die Strengthening the Reporting of Observational Studies in Epidemiology (STROBE-) Initiative hat Empfehlungen entwickelt, was in einem akkuraten und vollständigen Bericht einer Beobachtungsstudie enthalten sein sollte. Die Empfehlungen wurden von uns so definiert, dass sie 3 Hauptstudientypen abdecken: Kohorten-, Fallkontroll- und Querschnittsstudien. Im September 2004 veranstalteten wir einen zweitägigen Workshop mit Methodikern, Forschern und Herausgebern wissenschaftlicher Zeitschriften, um eine Checkliste zu entwerfen. Anschließend wurde der Entwurf bei mehreren Treffen der Koordinierungsgruppe und nach E-Mail-Diskussionen mit der erweiterten STROBE-Gruppe revidiert und dabei empirische Evidenz und methodologische Aspekte berücksichtigt. Das Ergebnis des Workshops und des anschließenden iterativen Prozesses aus Beratung und Revision war eine Checkliste von 22 Punkten (STROBE-Statement), die sich auf die Bereiche Titel, Abstract, Einleitung, Methoden, Ergebnisse und Diskussion eines Artikels beziehen. 18 der Punkte sind relevant für alle 3 Studiendesigns, während 4 der Punkte spezifisch für Kohorten-, Fallkontroll- und Querschnittsstudien sind. Ein ausführlicher Begleitartikel (Explanation and Elaboration) wurde separat veröffentlicht und ist auf den Webseiten von PLoS Medicine, Annals of Internal Medicine und Epidemiology frei zugänglich. Wir hoffen, dass das STROBE-Statement dazu beitragen kann, dass Beobachtungsstudien besser berichtet werden.
Article
Aim: To examine temporal trends in the epidemiology and outcomes of in-hospital cardiopulmonary resuscitation (CPR) recipients at a population level. Methods: Retrospective analysis of temporal trends in CPR incidence, survival to discharge, discharge disposition, hospital length of stay, and cost of hospitalization for CPR recipients (age ≥ 18 years) captured in the Nationwide Inpatient Sample (2000-2009) in the United States. Results: Between years 2000 and 2009, CPR incidence increased by 33.7%, from 1 case per 453 to 1 case per 339 hospitalized patients (annual percentage increase: 4.3%, 95% CI: 3.4-5.2%, p<0.001). Compared to CPR recipients in years 2000-2001, those in 2008-2009 were more often younger (age<65 years: 33.4% vs. 40.0%), non-white (29.3% vs. 36.4%), and higher comorbidity scores (score ≥ 4: 22.2% vs. 27.1%) (all p<0.001). Rates of neurologic compromise, mechanical ventilator, and feeding tube use increased by 37.7, 28.2, and 58.5%, respectively (all p<0.001). Adjusted rate of survival to discharge increased by 41.3% (20.6-29.1%, p<0.001). Compared to survivors in 2000, those discharged in 2009 were more often discharged to hospice (0.4% vs. 7.1%, p<0.001); a 35% decrease in discharge to home was noted (36.4% vs. 23.8%, p<0.001). Mean cost of hospitalization per day increased for both survivors ($2742-$3462, p=0.006) and decedents ($3159-$4212, p<0.001). Conclusions: The rate of in-hospital CPR in the U.S. increased, and CPR recipients have become younger and sicker over time. Survival to discharge has improved by 41.3%. Functional outcomes after in-hospital CPR appear to have worsened, with considerable clinical and economic implications.
Article
Patients presenting in cardiac arrest frequently have poor outcomes despite heroic resuscitative measures in the field. Many emergency medical systems have protocols in place to stop resuscitative measures in the field; however, further predictors need to be developed for cardiac arrest patients brought to the emergency department (ED). To examine the predictive value of cardiac standstill visualized on bedside ED echocardiograms during the initial presentations of patients receiving cardiopulmonary resuscitation (CPR). The study took place in a large urban community hospital with an emergency medicine residency program and a high volume of cardiac arrest patients. As part of routine care, all patients arriving with CPR in progress were subject to immediate and brief subxiphoid or parasternal cardiac ultrasound examination. This was followed by brief repeat ultrasound examination during the resuscitation when pulses were checked. A 2.5-MHz phased-array probe was used for imaging. Investigators filled out standardized data sheets. Examinations were taped for review. Statistical analysis included descriptive statistics, positive and negative predictive values, and likelihood ratios. One hundred sixty-nine patients were enrolled in the study. One hundred thirty-six patients had cardiac standstill on the initial echocardiogram. Of these, 71 patients had an identifiable rhythm on monitor. No patient with sonographically identified cardiac standstill survived to leave the ED regardless of his or her initial electrical rhythm. Cardiac standstill on echocardiogram resulted in a positive predictive value of 100% for death in the ED, with a negative predictive value of 58%. Patients presenting with cardiac standstill on bedside echocardiogram do not survive to leave the ED regardless of their electrical rhythms. This finding was uniform regardless of downtime. Although larger studies are needed, this may be an additional marker for cessation of resuscitative efforts.
Article
To evaluate the relationship between cause and outcome of in-hospital cardiac arrest. Retrospective analysis of resuscitation data, causes of cardiac arrest and outcome with a follow-up to 6 months of a cardiac arrest registry in an emergency department of a tertiary care hospital, covering a 17.5-year period. Of 1041 patients, 653 were male (63%), the median age was 64 years (IQR 53-73), 51% suffered cardiac arrest in the emergency department. The first recorded rhythm showed PEA in 432 (41%), ventricular fibrillation in 404 (39%) and asystole in 205 (20%) patients. Cardiac arrest of cardiac origin occurred in 63% of all patients, with 35% of them due to acute myocardial infarction. Non-cardiac causes were mostly due to pulmonary causes (15% of all patients). Aortic dissection/rupture, exsanguination, intoxication and adverse drug reactions, metabolic, cerebral, sepsis and accidental hypothermia each ranged between 1 and 4% of the cohort. Of all patients, 376 (36%) were discharged in good neurologic condition. Overall, patients with cardiac causes had a significantly better outcome than those with non-cardiac causes (44% vs. 23%, p<0.01). Patients with pulmonary causes survived in 24%. The other subgroups showed widely divergent survival results (3-65%). Patients who had suffered cardiac arrest in the emergency department had a better outcome then patients of the regular ward or radiology department. In hospital cardiac arrest is caused mainly by cardiac and pulmonary causes, outcome depends on the cause, with a big variability.
Article
In-hospital cardiopulmonary arrest (CPA) is an important issue, but data in Japan are limited. To investigate in-hospital CPA, we conducted a prospective multicenter observational registry of in-hospital CPA and resuscitation in Japan (J-RCPR). During January 2008 to December 2009, patients were registered from 12 participating hospitals. All patients, visitors and employees within the facility campus who experience a cardiopulmonary resuscitation event defined as either a pulseless or a pulse with inadequate perfusion requiring chest compressions and/or defibrillation of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) were registered. Data were collected in 6 major categories of variables: facility data, patient demographic data, pre-event data, event data, outcome data, and quality improvement data. Data for 491 adults were analyzed. The prevalence of pulseless VT/VF as first documented rhythm was 28.1%, asystole was 29.5% and pulseless electrical activity was 41.1%. Immediate causes of event were arrhythmia 30.6%, acute respiratory insufficiency 26.7%, and hypotension 15.7%. Return of spontaneous circulation was 64.7%; the proportion of survival 24h after CPA was 49.8%, the proportion of survival to hospital discharge was 27.8% and proportion of favorable neurological outcome at 30 days was 21.4%. This is the first report of the registry for in-hospital CPA in Japan and shows that the registry provides important observational data.
Article
The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.
Article
Focused ultrasound is increasingly used in the emergency setting, with an ALS-compliant focused echocardiography algorithm proposed as an adjunct in peri-resuscitation care (FEEL). The purpose of this study was to evaluate the feasibility of FEEL in pre-hospital resuscitation, the incidence of potentially treatable conditions detected, and the influence on patient management. A prospective observational study in a pre-hospital emergency setting in patients actively undergoing cardio-pulmonary resuscitation or in a shock state. The FEEL protocol was applied by trained emergency doctors, following which a standardised report sheet was completed, including echo findings and any echo-directed change in management. These reports were then analysed independently. A total of 230 patients were included, with 204 undergoing a FEEL examination during ongoing cardiac arrest (100) and in a shock state (104). Images of diagnostic quality were obtained in 96%. In 35% of those with an ECG diagnosis of asystole, and 58% of those with PEA, coordinated cardiac motion was detected, and associated with increased survival. Echocardiographic findings altered management in 78% of cases. Application of ALS-compliant echocardiography in pre-hospital care is feasible, and alters diagnosis and management in a significant number of patients. Further research into its effect on patient outcomes is warranted.
Article
Electrocardiographic artifacts on scope are frequently observed in pre-hospital settings. They can lead to misdiagnosis or inappropriate resuscitation treatments. Here we report a case of ventricular fibrillation by electrical injury masked by ECG artifacts, after the savage of a victim, due to persistent 50Hz domestic current and identified by trans-thoracic ultrasonography. No clinical randomized studies define precisely the benefit of such an examination. In cases where ECG analysis is impossible due to artifacts, ultrasonographic exam could be useful to identify ventricular fibrillation. This case underlines also the need for a correct device ECG analysis in any circumstances.
Article
To better define the reliability of left ventricular ejection fraction (LVEF) and left ventricular filling, as determined by either hand-carried ultrasound (HCU) or formal transthoracic echocardiography (TTE), in the critically ill surgical patient. Prospective cross-sectional study of 80 surgical intensive care unit patients with concomitant (<30 minutes apart) formal TTE and clinician-performed cardiac HCU. Visual estimates of LVEF and left ventricular filling ("underfilled" vs "normally filled") were recorded, both by clinicians performing HCU and fellowship-trained echocardiographers. Bland-Altman plot analysis of LVEF estimates revealed good interobserver agreement between HCU and formal TTE (% LVEF mean bias, -2.2; with 95% limits of agreement, +/-22.1). This was similar to agreement between independent echocardiography observers (% LVEF mean bias, 1.3; with 95% limits of agreement, +/-21.0). However, assessments of left ventricular filling demonstrated only fair to moderate interobserver agreement (kappa = 0.22-0.40). Of note, a greater percentage of the 5 standard acoustic windows were obtainable using formal TTE (72% vs 56%). Formal TTE offers no advantage over HCU for determination of LVEF in critically ill surgical patients, even though the former allows for a more complete examination. However, estimations of left ventricular filling only demonstrate fair to moderate interrater agreement and thus should be interpreted with care when used as markers of volume responsiveness.
Article
Assessing the neurological and disability status of cardiac arrest (CA) survivors is important for evaluating the outcomes of resuscitation interventions. The Cerebral Performance Category (CPC)--the standard outcome measurement after CA--has been criticized for its poorly defined, subjective criteria, lack of information regarding its psychometric properties, and poor relationships with long-term measures of disability and quality of life (QOL). This study examined the relationships among the CPC and measures of global disability and QOL at discharge from the hospital and at 1 month after CA. Twenty-one CA survivors participated in the study. A medical chart review was conducted at the time of discharge to determine CPC and Modified Rankin Scale (mRS) scores, while 1-month in-person interview was conducted to collect mRS and Health Utilities Index Mark 3 (HUI3) scores. Data collected during the interview were used to determine follow-up CPC scores. The strength of relationships among measures at discharge and 1 month ranged between fair to good. An examination of scatter plots revealed substantial variability and a wide distribution of chart review and 1-month mRS and HUI3 scores within each CPC category. CPC scores obtained through chart review were significantly better than the CPC 1-month scores, thus overestimating the participants' cognitive and disability status 1 month later. When compared to disability and quality of life measures, it is apparent that the CPC has limited ability to discriminate between mild and moderate brain injury. The validity of using the chart review method for obtaining scores is questionable.
Article
International guidelines for cardiopulmonary resuscitation (CPR) in adults advocate that cardiac arrest be recognized, within 5–10 s, by the absence of a pulse in the carotid arteries. However, validation of first responders' assessment of the carotid pulse has begun only recently. We aimed (1) to develop a methodology to study diagnostic accuracy in detecting the presence or absence of the carotid pulse in unresponsive patients, and (2) to evaluate diagnostic accuracy and time required by first responders to assess the carotid pulse.
Article
This study evaluated the ability of cardiac sonography performed by emergency physicians to predict resuscitation outcomes of cardiac arrest patients. A convenience sample of cardiac arrest patients prospectively underwent bedside cardiac sonography at 4 emergency medicine residency-affiliated EDs as part of the Sonography Outcomes Assessment Program. Cardiac arrest patients in pulseless electrical activity (PEA) and asystole underwent transthoracic cardiac ultrasound B-mode examinations during their resuscitations to assess for the presence or absence of cardiac kinetic activity. Several end points were analyzed as potential predictors of resuscitations: presenting cardiac rhythms, the presence of sonographically detected cardiac activity, prehospital resuscitation time intervals, and ED resuscitation time intervals. Of 70 enrolled subjects, 36 were in asystole and 34 in PEA. Patients presenting without evidence of cardiac kinetic activity did not have return of spontaneous circulation (ROSC) regardless of their cardiac rhythm, asystole, or PEA. Of the 34 subjects presenting with PEA, 11 had sonographic evidence of cardiac kinetic activity, 8 had ROSC with subsequent admission to the hospital, and 1 had survived to hospital discharge with scores of 1 on the Glasgow-Pittsburgh Cerebral Performance scale and 1 in the Overall Performance category. The presence of sonographically identified cardiac kinetic motion was associated with ROSC. Time interval durations of cardiac resuscitative efforts in the prehospital environment and in the ED were not accurate predictors of ROSC for this cohort. Cardiac kinetic activity, or lack thereof, identified by transthoracic B-mode ultrasound may aid physicians' decision making regarding the care of cardiac arrest patients with PEA or asystole.
Article
Emergency ultrasound is suggested to be an important tool in critical care medicine. Time-dependent scenarios occur during preresuscitation care, during cardiopulmonary resuscitation, and in postresuscitation care. Suspected myocardial insufficiency due to acute global, left, or right heart failure, pericardial tamponade, and hypovolemia should be identified. These diagnoses cannot be made with standard physical examination or the electrocardiogram. Furthermore, the differential diagnosis of pulseless electrical activity is best elucidated with echocardiography. Therefore, we developed an algorithm of focused echocardiographic evaluation in resuscitation management, a structured process of an advanced life support-conformed transthoracic echocardiography protocol to be applied to point-of-care diagnosis. The new 2005 American Heart Association/European Resuscitation Council/International Liaison Committee on Resuscitation guidelines recommended high-quality cardiopulmonary resuscitation with minimal interruptions to reduce the no-flow intervals. However, they also recommended identification and treatment of reversible causes or complicating factors. Therefore, clinicians must be trained to use echocardiography within the brief interruptions of advanced life support, taking into account practical and theoretical considerations. Focused echocardiographic evaluation in resuscitation management was evaluated by emergency physicians with respect to incorporation into the cardiopulmonary resuscitation process, performance, and physicians' ability to recognize characteristic pathology. The aim of the focused echocardiographic evaluation in resuscitation management examination is to improve the outcomes of cardiopulmonary resuscitation.
Article
full title: Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: An Utstein-style scientific statement - A scientific statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian Resuscitation Council, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, and the New Zealand Resuscitation Council); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research.
Article
Rapidly determining whether an unresponsive child is in cardiac arrest or in shock, and requiring cardiopulmonary resuscitation can be problematic. The pulse check in children has been shown to be unreliable, not only for laypersons, but also for healthcare providers. The recommendation for checking the pulse in unresponsive children has been eliminated for laypersons in the latest edition of the Emergency Cardiovascular Care guidelines. Thus the decision to initiate cardiopulmonary resuscitation in children, with the goal of delivering effective chest compressions, can be fraught with uncertainty. Despite the use of pediatric advanced life support guidelines developed by the American Heart Association and the American Academy of Pediatrics, management and decision making during resuscitation of children in cardiac arrest can be challenging. Outcomes for out-of-hospital pediatric cardiac arrest remain poor. The decision to end resuscitation in children, often an emotionally charged situation, can also be particularly difficult for physicians. Information from focused point-of-care echocardiography that allows for correlation with the presence or absence of a pulse and real time assessment of resuscitation may help direct and optimize the delivery of resuscitative interventions. We report our preliminary clinical observations of using focused point-of-care echocardiography to correlate with the pulse check during resuscitation in a series of pediatric cardiac arrests.
Point-of-care ultrasonography
  • Moore Cl Ja
Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011;364:749–57.
What changes in research ethics in Brazil: resolution no. 466/12 of the National Health Council
  • Pcr Novoa
Novoa PCR. What changes in research ethics in Brazil: resolution no. 466/12 of the National Health Council, vol. 12. São Paulo: Einstein; 2014. p. vii-x.
Pulse check no longer recommended for layperson CPR -American Heart Association releases new guidelines for emergency care
Pulse check no longer recommended for layperson CPR -American Heart Association releases new guidelines for emergency care. Nephrol Nurs J 2001;28:558-60.