ArticleLiterature Review

Echocardiography in cardiac arrest

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Abstract

Successful resuscitation requires potentially reversible causes to be diagnosed and reversed, and many of these can readily be diagnosed using echocardiography. Although members of the resuscitation team routinely use adjuncts to their clinical examination in order to differentiate these causes, the use of echocardiography is not yet considered standard. The purpose of this review is to discuss the potential for echocardiography to aid diagnosis and treatment during resuscitation, together with some of the perceived challenges that currently limit its widespread use. Many studies have demonstrated the value of echocardiography in the assessment of critically ill patients in the intensive care unit and emergency room settings, including more recently the use of focused echocardiography. This can be performed within the time frame allowed during the pulse check of the advanced life support (ALS) algorithm. ALS-compliant focused echocardiography can be taught to nonexpert practitioners such that high-quality cardiopulmonary resuscitation is not compromised while diagnosing/excluding some of the potential causes of cardiac arrest. Persistent and worsening haemodynamic instability are regarded as clear indications for echocardiography. The focused application of this well established technique within the ALS algorithm provides the resuscitation team with a potentially powerful diagnostic tool that can be used to diagnose/exclude some of the potentially treatable causes of cardiac arrest as well as to guide therapeutic interventions. The impact of routine periresuscitation echocardiography on patient outcomes both for in-hospital and prehospital care remains an exciting avenue for future research.

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... The treatment for these findings is directed toward reversing the electrical abnormality present by cardioversion, defibrillation, or pacing. [4][5][6] Pulseless electrical activity (PEA) and asystole are in the nonshockable category. These are classified as nonelectrical cardiac arrests, and direction of treatment should be aimed at determining a reversible cause. ...
... These are classified as nonelectrical cardiac arrests, and direction of treatment should be aimed at determining a reversible cause. 6 Proper identification of these rhythms can assist providers to determine a cause as well as how to promptly administer treatment. 6,7 While echocardiography may not be a current standard at all facilities, the American Heart Association has recommended point-ofcare ultrasound (POCUS) to evaluate for reversible causes of cardiac arrest. ...
... 6 Proper identification of these rhythms can assist providers to determine a cause as well as how to promptly administer treatment. 6,7 While echocardiography may not be a current standard at all facilities, the American Heart Association has recommended point-ofcare ultrasound (POCUS) to evaluate for reversible causes of cardiac arrest. 8 The aim of this review is to highlight the benefits of a focused echocardiography during cardiac arrest as well as the challenges. ...
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.
... cardiac tamponade, pulmonary embolism, hypovolaemia, pneumothorax) and identify pseudo-PEA. 373,[375][376][377][378][379][380][381][382] When available for use by trained clinicians, ultrasound may be of use in assisting with diagnosis and treatment of potentially reversible causes of cardiac arrest. The integration of ultrasound into advanced life support requires considerable training if interruptions to chest compressions are to be minimised. ...
... A sub-xiphoid probe position has been recommended. 375,381,383 Placement of the probe just before chest compressions are paused for a planned rhythm assessment enables a well-trained operator to obtain views within 10 s. ...
... 84,85 Echocardiography will typically reveal RV dilatation, dysfunction, and an underfilled left ventricle. 89 The management of thromboembolism depends on the procedure and patient. Therapeutic options range from supportive measures to anticoagulation, thrombolysis, operative thrombectomy, and ECMO. ...
... Patients undergoing procedures with high risk for gas embolism, such as posterior fossa craniotomy in the sitting position, should be monitored using right parasternal precordial Doppler 93 or transesophageal echocardiography. 20,21,89 Traumatic Cardiac Arrest POCA in the setting of trauma is associated with high mortality. 94 Traumatic cardiac arrest (TCA) may occur due to hemorrhage, vasodilatory hypotension, cardiac trauma (acute pericardial tamponade, ischemia, penetrating trauma), hypoxia, acidosis, electrolyte disturbance, nerve reflex, drug usage, anesthetic technique, and/or the procedure being performed. ...
Article
Cardiac arrest in the operating room and in the immediate postoperative period is a potentially catastrophic event that is almost always witnessed and is frequently anticipated. Perioperative crises and perioperative cardiac arrest, although often catastrophic, are frequently managed in a timely and directed manner because practitioners have a deep knowledge of the patient's medical condition and details of recent procedures. It is hoped that the approaches described here, along with approaches for the rapid identification and management of specific high-stakes clinical scenarios, will help anesthesiologists continue to improve patient outcomes.
... 1,2 In this context, the 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 interpretation of standard investigations such as ECG, echocardiography, and coronary angiography may not be straightforward, and nonspecific findings secondary to the cardiac arrest and subsequent resuscitation may act as confounders. [3][4][5] Cardiac magnetic resonance (CMR), in addition to accurately assessing ventricular function, allows the identification of myocardial tissue changes such as myocardial edema as evidenced by increased signal intensity on T2-weighted sequences and myocardial fibrosis by late gadolinium enhancement (LGE) on postcontrast sequences. 6 In the evaluation of patients who survived OHCA, the combination of sequences for myocardial edema and fibrosis has the potential to distinguish an acute and potentially reversible injury from a chronic and irreversible lesion. ...
... 12,13 In addition, features of the so-called "postresuscitation syndrome" may further confuse the clinical diagnosis. [3][4][5] This study was designed to evaluate the diagnostic yield and prognostic implication of early CMR study with a comprehensive protocol for tissue characterization, including T2-weighted sequences for myocardial edema and postgadolinium sequences for myocardial fibrosis in a cohort of 856 857 858 859 860 861 862 863 864 865 866 867 868 869 870 871 872 873 874 875 876 877 878 879 880 881 882 883 884 885 886 887 888 889 890 891 892 893 894 895 896 897 898 899 900 901 902 903 904 905 906 907 908 909 910 911 912 OHCA survivors with and without obstructive CAD at coronary angiography who underwent contrast-enhanced CMR within 1 week after the event. The main findings were as follows. ...
Article
Background: In patients who survived out-of-hospital cardiac arrest (OHCA) it is crucial to establish the underlying cause and its potential reversibility. Objective: We assessed the incremental diagnostic and prognostic role of early cardiac magnetic resonance (CMR) in survivors of OHCA. Methods: Among 139 consecutive OHCA patients, we enrolled 44 (median age 43 years; 84% males) patients who underwent coronary angiography and CMR ≤7 days after admission. The CMR protocol included T2-weighted sequences for myocardial edema and late gadolinium-enhancement (LGE) sequences for myocardial fibrosis. Results: Coronary angiography identified obstructive coronary artery disease (CAD) in 18/44 patients, in whom CMR confirmed the diagnosis of ischemic heart disease by demonstrating subendocardial or transmural LGE; the presence of myocardial edema allowed to differentiate between acute myocardial ischemia (N=12) and post-infarction myocardial scar (N=6). Among the remaining 26 patients without obstructive CAD, 19 (73%) showed at CMR dilated cardiomyopathy (N=5), myocarditis (N=4), mitral valve prolapse associated with LGE (N=3), ischemic scar (N=2), idiopathic non-ischemic scar (N=2), arrhythmogenic cardiomyopathy (N=1), hypertrophic cardiomyopathy (N=1) and Tako-Tsubo cardiomyopathy (N=1). In this subgroup, 6/26 (23%) had myocardial edema. During a mean follow-up of 36±17 months, all 18 patients with myocardial edema had an uneventful outcome while 9/26 (35%) without myocardial edema experienced sudden arrhythmic death (N=1), appropriate defibrillator interventions (N=5) and non-arrhythmic death (N=3) (p=0.006). Conclusions: In survivors of OHCA, early CMR with a comprehensive tissue characterization protocol provided additional diagnostic and prognostic value. The identification of myocardial edema was associated with a favorable long-term outcome.
... [10] Transthoracic echocardiography (TTE) is a bed-side real-time diagnostic tool used for post-ROSC patients, and the use of this tool in CA patients can be useful for prognostic judgement. [14,15] The aim of this study was to investigate the impact of initial post-ROSC myocardial dysfunction on mortality and neurological outcome. ...
... Factors associated with 7-day mortality the remaining 12 unrecovered patients died from multiple organ failure in the early stage of admission.According Palmer et al.[22], continued CPR has adverse impact on the left ventricle in a time dependent way at a later stage, and Xie et al.[23] also claimed the time-dependent adverse effects of defibrillation on the left ventricle. Separately, Chang et al.[14] suggested that LVEF level at 6 h after CA and isovolumic relaxation time are associated with patient survival rate.[15] In a study of cardiac index and neurological outcome, Torgersen et al.[24] reported a higher cardiac index in favorable neurological outcome group, compared with unfavorable neurological outcome group, suggesting the association between cardiac indexes and neurological outcome. ...
Article
Full-text available
Background The aim of this study was to investigate the relationships between left ventricular ejection fraction (LVEF) and mortality and neurologic outcomes with post-cardiac arrest syndrome (PCAS) after out-of-hospital cardiac arrest (OHCA). Methods Patients with PCAS after OHCA admitted to the intensive care unit between January 2014 and December 2015 were analyzed retrospectively. Results A total of 104 patients were enrolled in this study. The mean age was 54.4 ± 15.3 years, and 75 of the patients were male (72.1%). Arrest with a cardiac origin was found in 55 (52.9%). LVEF < 45%, 45-55%, and > 55% was measured in 39 (37.5%), 18 (17.3%), and 47 (45.2%) of patients, respectively. In multivariate analysis, severe LV dysfunction (LVEF < 45%) was significantly related to 7-day mortality (odds ratio 3.02, 95% Confidence Interval 1.01-9.0, p-value 0.047). Conclusions In this study, moderate to severe LVEF within 48 hours after return of spontaneous circulation was significantly related to 7-day short-term mortality in patients with PCAS after OHCA. Clinicians should actively treat myocardial dysfunction, and further studies are needed.
... As echocardiographic features of cardiac tamponade may not always be present during arrest states, the presence of a pericardial effusion should prompt consideration for pericardial drainage. 29 There is a generally low risk of complications associated with ultrasound-guided pericardiocentesis. 29 Further training of emergency physicians in ultrasound-guided pericardiocentesis should be considered. ...
... 29 There is a generally low risk of complications associated with ultrasound-guided pericardiocentesis. 29 Further training of emergency physicians in ultrasound-guided pericardiocentesis should be considered. Familiarisation with this procedure may increase the confidence of clinicians and likelihood of intervention. ...
Article
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INTRODUCTION: Ultrasonographic evaluation of patients in cardiac arrest is currently not protocolised in the advanced cardiac life support (ACLS) algorithm. Potentially reversible causes may be identified using bedside ultrasonography that is ubiquitous in most emergency departments (EDs). This study aimed to evaluate the incidence of sonographically detectable reversible causes of cardiac arrest by incorporating an ultrasonography protocol into the ACLS algorithm. Secondary objectives include rates of survival to hospital admission, hospital discharge, and 30-day mortality. MATERIALS AND METHODS: We conducted a prospective study using bedside ultrasonography to evaluate for potentially reversible causes in patients with cardiac arrest at the ED of National University Hospital, Singapore, regardless of the initial electrocardiogram rhythm. A standardised ultrasonography protocol was performed during the 10-second pulse check window. RESULTS: Between June 2015 and April 2016, 104 patients were recruited, corresponding to 65% of all out-of-hospital cardiac arrest patients conveyed to the ED. Median age was 71 years (interquartile range, 55 to 80) and 71 (68.3%) patients were male. The most common rhythm on arrival was asystole (45.2%). Four (3.8%) patients had ultrasonographic findings suggestive of massive pulmonary embolism while 1 received intravenous thrombolysis and survived until discharge. Pericardial effusion without tamponade was detected in 4 (3.8%) patients and 6 (5.8%) patients had intra-abdominal free fluid. Twenty (19.2%) patients survived until admission, 2 of whom (1.9%) survived to discharge and beyond 30 days. CONCLUSION: Bedside ultrasonography can be safely incorporated into the ACLS protocol. Detection of any reversible causes may alter management and improve survival in selected patients.
... 2,3 Cardiovascular evaluation after SCA based on ECG, echocardiogram, and coronary angiogram may be inconclusive. [4][5][6][7] Cardiac magnetic resonance (CMR) imaging has become the gold standard imaging technique not only for assessment of morphofunctional ventricular abnormalities but also for detection of myocardial lesions, owing to its unique ability to noninvasively characterize tissue composition. 8 Previous studies demonstrated that CMR is a key imaging test for diagnosing the substrate of SCA. ...
... and troponin elevation may lack specificity after SCA because they may be secondary to an anoxic injury (postresuscitation syndrome). 4,5 Other presumed reversible causes of CA, such as electrolyte abnormalities, may be either the cause or the consequence of SCA and associated resuscitation efforts. ...
Article
Background Sudden cardiac arrest (SCA) may be caused by an acute and reversible myocardial injury, a chronic and irreversible myocardial damage, or a primary ventricular arrhythmia. Cardiac magnetic resonance imaging may identify myocardial edema (ME), which denotes acute and reversible myocardial damage. We evaluated the arrhythmic outcome of SCA survivors during follow‐up and tested the prognostic role of ME. Methods and Results We included a consecutive series of 101 (71% men, median age 47 years) SCA survivors from 9 collaborative centers who underwent early (<1 month) cardiac magnetic resonance imaging and received an implantable cardioverter‐defibrillator (ICD). On T2‐weighted sequences, ME was found in 18 of 101 (18%) patients. According to cardiac magnetic resonance imaging findings, the arrhythmic SCA was ascribed to acute myocardial injury (either ischemic [n=10] or inflammatory [n=8]), to chronic structural heart diseases (ischemic heart disease [n=11], cardiomyopathy [n=20], or other [n=23]), or to primarily arrhythmic syndrome (n=29). During a follow‐up of 47 months (28 to 67 months), 24 of 101 (24%) patients received an appropriate ICD intervention. ME was associated with a significantly higher survival free from both any ICD interventions (log‐rank=0.04) and ICD shocks (log‐rank=0.03) and remained an independent predictor of better arrhythmic outcome after adjustment for left ventricular ejection fraction and late gadolinium enhancement. The risk of appropriate ICD intervention was unrelated to the type of underlying heart disease. Conclusions ME on early cardiac magnetic resonance imaging, which denotes an acute and transient arrhythmogenic substrate, predicted a favorable long‐term arrhythmic outcome of SCA survivors. These findings may have a substantial impact on future guidelines on the management of SCA survivors.
... 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. ...
... Echocardiographic findings are presented in Table 2. Type of POCUS study performed was majority 76% TEE, with 24% TTE. Median duration of POCUS study was 6 minutes (IQR: 2-13) in the thrombus group versus 7 minutes (IQR: [3][4][5][6][7][8][9][10][11][12] in the no thrombus group. ...
Article
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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.
... Aus diesem Grund ist die Wirksamkeit der Thrombolyse bei einem Kreislaufstillstand durch eine Lungenarterienembolie am aussichtsreichsten, wenn diese frühzeitig nach Kollaps verabreicht wird. Da die prähospitale Sicherung einer Lungenarterienembolie mitunter schwierig ist und die klinischen Zeichen oftmals nicht eindeutig sind, könnte eine prähospitale Echokardiographie eine diagnostische Möglichkeit sein[20,21].Die vorliegende Studie belegt jedoch, dass die systemische Thrombolyse nicht selten außerhalb des empfohlenen Protokolls als Ultima-Ratio-Rettungsmaßnahme in verzweifelten Situationen, wie einer erfolglosen Reanimation, bei jungen Patienten verabreicht wird.Auch die Tatsache, dass lediglich 52% der Patienten der Lysegruppe nach dem genannten Behandlungsprotokoll behandelt wurden, verdeutlicht die Probleme bei der Anwendung der Lysetherapie und deren Kotherapeutika im klinischen Alltag der Notfallmedizin.Ein Nichtdurchführen sämtlicher prähospital möglicher Maßnahmen, wie der systemischen Thrombolyse bei nicht erfolgreicher Reanimation, stellt v. a. unerfahrene Notärzte nicht selten vor ethisch-moralische Konflikte.Als Einschränkung der vorliegenden Studie müssen folgende Punkte bedacht werden: Zum einen ist das Studiendesign retrospektiv, zum anderen hängt die Entscheidung zur Fibrinolysetherapie weitestgehend von den örtlichen Gegebenheiten und der persönlichen Erfahrung des behandelnden Notarztes ab. Ferner muss die relativ geringe Anzahl der Patienten und das monozentrische Design erwähnt werden. ...
... 45 Within the current mechanical milieu (severe MVO), it is conceivable to see it as a chief additive cause of intractable CA. ALScompliant echocardiography 46 and intra-arrest betablockade 47 may be better delineated in the future and may have changed the course in this case. Until then, the goal of good functional outcome post CA and CPR remains a challenge, in particular with cases such as that described here. ...
Article
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Catecholamines are entrenched in the management of shock states. A paradigm shift has pervaded the critical care arena in recent years acknowledging their propensity to cause harm and fuel a ‘death-spiral’. We present the case of a 21-year-old male following a witnessed out-of-hospital cardiac arrest who received high-quality cardiopulmonary resuscitation and standard advanced life support for refractory ventricular fibrillation until return of spontaneous circulation after 70 min. Early post-admission echocardiography revealed severe diffuse sub-basal left ventricular hypertrophy with dynamic mid-cavity obstruction and akinetic apical pouching. Within this context, a decatecholaminised strategy comprising a beta-blocker was used to augment the left ventricular end-diastolic volume and attain cardiovascular stability.
... 143,144 Echocardiography of the patient with RV shock will typically reveal RV dilation and dysfunction, with an underfilled left ventricle. 145 The management of intraoperative or perioperative thromboembolism is highly dependent on the procedure and patient. Therapeutic options range from supportive measures only to anticoagulation to thrombolysis. ...
Article
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As noted in part 1 of this series, periprocedural cardiac arrest (PPCA) can differ greatly in etiology and treatment from what is described by the American Heart Association advanced cardiac life support algorithms, which were largely developed for use in out-of-hospital cardiac arrest and in-hospital cardiac arrest outside of the perioperative space. Specifically, there are several life-threatening causes of PPCA of which the management should be within the skill set of all anesthesiologists. However, previous research has demonstrated that continued review and training in the management of these scenarios is greatly needed and is also associated with improved delivery of care and outcomes during PPCA. There is a growing body of literature describing the incidence, causes, treatment, and outcomes of common causes of PPCA (eg, malignant hyperthermia, massive trauma, and local anesthetic systemic toxicity) and the need for a better awareness of these topics within the anesthesiology community at large. As noted in part 1 of this series, these events are always witnessed by a member of the perioperative team, frequently anticipated, and involve rescuer-providers with knowledge of the patient and the procedure they are undergoing or have had. Formulation of an appropriate differential diagnosis and rapid application of targeted interventions are critical for good patient outcome. Resuscitation algorithms that include the evaluation and management of common causes leading to cardiac in the perioperative setting are presented. Practicing anesthesiologists need a working knowledge of these algorithms to maximize good outcomes.
... It is crucial to identify and treat reversible causes of cardiac arrest during resuscitation in order to make decisions that reverse them and more efficiently achieve return of spontaneous circulation (ROSC) [1]. Bedside ultrasound (US) has emerged as an invaluable tool in the diagnosis and management of critically ill patients, including CA [2,3]. US may aid to diagnose reversible causes of CA, such as pericardial tamponade, tension pneumothorax, or hypovolemia; guide procedures and other management strategies for quality resuscitation; and reveal signs that can serve in clinical context as prognosticators for the ability to achieve ROSC and longer term recovery. ...
... Previous studies have demonstrated the feasibility of the application of ultrasound during in-hospital and out-of-hospital cardiopulmonary resuscitation (CPR) (9). Integrating it in current ALS algorithms is achievable while maintaining strict protocol adherence (10). ...
Article
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Background: Patients in cardiac arrest must receive algorithm-based management such as basic life support and advanced (cardiac) life support. International guidelines dictate diagnosing and treating any factor that may have caused the arrest or may be complicating the resuscitation. Ultrasound may be of potential value in this process and can be used in a prehospital setting. The objective is to evaluate the use of prehospital ultrasound during traumatic and non-traumatic CPR and determine its impact on prehospital treatment decisions in a Dutch helicopter emergency medical service (HEMS). Methods: We conducted an observational study in cardiac arrest patients, of any cause, in whom the Nijmegen HEMS performed CPR with concurrent echocardiography. The participating physicians had to adhere to Advanced Life Support protocols as per standard operating procedure. Simultaneous with the interruptions of chest compressions to allow for heart rhythm analysis, ultrasound-trained HEMS physicians performed echocardiography according to study protocol. The HEMS nurse and physician recorded patient data and data on impacted (supported or altered) patient treatment decisions. Results: From February 2014 through November 2016, we included 56 patients who underwent 102 ultrasound examinations. Sixty-two (61%) ultrasound examinations impacted 78 treatment decisions in 49 patients (88%). The impacted treatment was related to termination of CPR in 32 (57%), fluid management (14%), drugs selection and doses (14%), and choice of destination hospital (5%). Causes of cardiac arrest included trauma (48%), cardiac (21%), medical (14%), asphyxia (9%), and other (7%). Conclusion: Prehospital echocardiography has an impact on patient treatment and may be a useful tool to support decision-making during CPR in a Dutch HEMS.
... With this said, only time and continued investigation will tell if studying your patient's heart will tell you something useful about their head. Unfortunately, of the main potentially reversible underlying causes of CA, only three may be definitively diagnosed at the bedside using existing standard monitoring and point-of-care investigations: hypoxia, hypothermia, and hypo/hyperkalemia (2). The remaining causes require a combination of clinical assessment, a high index of suspicion, and additional investigations: severe hypovolemia, tamponade, pulmonary embolism (PE), coronary thrombosis, tension pneumothorax, and toxinrelated arrest. ...
... Ecografía dúplex transcraneal codificada en color La ecografía DTCC es una técnica poco conocida y por ende subutilizada en medicina intensiva para la evaluación de pacientes neurocríticos. Utilizando el mismo ecógrafo que se usa en la evaluación de los pacientes críticos, con el mismo transductor sectorial empleado para ecocardiografía (1)(2)(3)(4)(5) se obtienen las mismas ventanas de estudio que la técnica de ecografía convencional, con el agregado de imágenes bidimensionales de las distintas estructuras parenquimatosas cerebrales y la visualización por Doppler color de la vasculatura cerebral. Estas características descritas permiten determinar con mayor exactitud el vaso insonado y, por otra parte, realizar una corrección del ángulo de insonación, lo que se traduce en una medida más exacta de la velocidad del flujo. ...
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Libro de texto básico para la introducción de la ecografía junto al paciente en la residencia de Medicina Intensiva y Emergencias en Cuba
... Echocardiography in the setting of cardiopulmonary resuscitation (CPR) can provide information as to the cause of the sudden cardiac arrest (SCA), as well as indicators of futility [1][2][3]. In the first application, echocardiography can identify potentially reversible causes of arrest. ...
Article
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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.
... On the other hand, an inconclusive angiogram poses a diagnostic dilemma requiring further investigation, and to our knowledge this is the first study looking at the role and clinical impact of CMR in OHCA survivors with this angiographic finding. Identifying OHCA aetiology is often challenging in the acute setting, as clinical data are often lacking and ECG and echocardiographic interpretation might be affected by resuscitation manoeuvres or external defibrillation [27,29]. However, correct identification of the underlying cause, especially if reversible, plays a determinant role for appropriate treatment strategy and long-term prognosis. ...
Article
Background: Non-traumatic out of hospital cardiac arrest (OHCA) is the leading cause of death worldwide, mainly due to acute coronary syndromes. Urgent coronary angiography with view to revascularisation is recommended in patients with suspected acute coronary syndrome. Diagnosis and management of patients with inconclusive coronary angiogram (unobstructed coronaries or unidentified culprit lesion) is challenging. We sought to assess the role of Cardiovascular Magnetic Resonance (CMR) in the diagnosis and management of OHCA survivors with an inconclusive coronary angiogram. Methods and results: This is a retrospective multicentre CMR registry analysis of OHCA survivors with an inconclusive angiogram. Clinical, ECG and multi-modality imaging data were analysed. Clinical impact of CMR was defined as a change in diagnosis or management. Out of 174 OHCA survivors referred for CMR, 110 patients (63%, 84 male, median age 58) had an inconclusive angiogram. CMR identified a pathologic substrate in 76/110 patients (69%): ischemic heart disease was found in 45 (41%) and non-ischemic heart disease in 31 (28%). A structurally normal heart was found in 25 patients (23%) and non-specific findings in 9 (8%). As compared to trans-thoracic echocardiogram, CMR proved to be superior in identifying a pathologic substrate (69% vs 54%, p=0.018). The CMR study carried a clinical impact in 70% of patients, determining a change in diagnosis in 25%, in management in 29% and a change in both in 16%. Conclusions: CMR showed a promising role in the diagnostic work-up of OHCA survivors with inconclusive angiogram and its wider use should be considered.
... Treatment for PEA arrest includes high-quality cardiopulmonary resuscitation (CPR), as well as identification and treatment of reversible causes of arrest (4). Ultrasonography during PEA arrest can differentiate underlying abnormalities, such as ventricular failure, pulmonary embolism, hypovolemia, and cardiac tamponade (5)(6)(7)(8)(9)(10), and may alter management of critically ill patients in up to 78% of cases (10). Additionally, ultrasonography provides prognostic information, as in cardiac standstill, which is associated with almost no likelihood of return of spontaneous circulation (11)(12)(13)(14)(15). ...
... In addition to its usefulness for treating and evaluating patients in intensive care unit (ICU) settings 6 , 2D echocardiography has been reported to play a major role in vasopressor dose adjustments or fluid management during the treatment of patients with shock 7,8 . In patients with IHCA, 2D echocardiography has been shown to facilitate the rapid detection or exclusion of various aetiologies during the peri-resuscitative period and to help physicians identify targets for possible correction 9 . Furthermore, 2D echocardiography is useful for the diagnosis and treatment of post-arrest myocardial dysfunction (PAMD), a common condition affecting patients who achieve return of spontaneous circulation (ROSC) after IHCA 10-12 . ...
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This retrospective cohort study investigated the association between in-hospital survival and two-dimensional (2D) echocardiography within 24 hours after the return of spontaneous circulation (ROSC) in patients who underwent in-hospital cardiopulmonary resuscitation (ICPR) after in-hospital cardiopulmonary arrest (IHCA). The 2D-echo and non-2D-echo groups comprised eligible patients who underwent transthoracic 2D echocardiography performed by the cardiology team within 24 hours after ROSC and those who did not, respectively. After propensity score (PS) matching, 142 and 284 patients in the 2D-echo and non-2D-echo groups, respectively, were included. A logistic regression analysis showed that the likelihood of in-hospital survival was 2.35-fold higher in the 2D-echo group than in the non-2D-echo group (P < 0.001). Regarding IHCA aetiology, in-hospital survival after cardiac arrest of a cardiac cause was 2.51-fold more likely in the 2D-echo group than in the non-2D-echo group (P < 0.001), with no significant inter-group difference in survival after cardiac arrest of a non-cardiac cause (P = 0.120). In this study, 2D echocardiography performed within 24 hours after ROSC was associated with better in-hospital survival outcomes for patients who underwent ICPR for IHCA with a cardiac aetiology. Thus, 2D echocardiography may be performed within 24 hours after ROSC in patients experiencing IHCA to enable better treatment.
... In high-acuity fields such as anesthesiology, critical care, and emergency medicine, physicians are playing both roles with focused cardiac ultrasound (FOCUS), allowing them to assess and manage acutely ill patients in real time, including during cardiac arrest. 1,2 BACKGROUND While high-quality cardiopulmonary resuscitation (CPR) remains the backbone of resuscitation, the American Heart Association 3 and Society of Critical Care Medicine (SCCM) 4 suggest that FOCUS can be useful in identifying cardiac motion and potentially reversible causes of cardiac arrest in patients with pulseless electrical activity (PEA). Incorporating FOCUS into advanced life support (ALS) requires a protocol to limit evaluations to the 10-second maximum pause for the pulse/rhythm check. ...
Article
When incorporated into the 10-second pulse/rhythm check of the advanced life support (ALS) protocol, focused cardiac ultrasound is a useful adjunct to cardiopulmonary resuscitation. In this case series, we demonstrated the feasibility of echocardiographic assessment using subcostal-only view in ALS (EASy-ALS) performed by anesthesiology residents during the periresuscitative period after structured training. Residents obtained diagnostic quality images in 100% of the self-reported cases, which enabled them to identify cardiac motion and potentially reversible causes of hemodynamic instability. Implementation of EASy-ALS into practice requires system-wide changes in cardiac arrest management for consistency, quality, and further evaluation of patient outcomes.
... Low-frequency phased array transducers are commonly employed in transthoracic echocardiography (TTE) (1,14,(33)(34)(35). Low frequency probes focus at 12-16 cm. ...
... In those who underwent CT after TH, cerebral edema and hypoxic encephalopathy were associated with a poor outcome. Current resuscitation guidelines recognize echocardiography as a valuable diagnostic tool in the early identification of the precipitating cause of CA, 11,19 which is why it was performed in all except one of our patients in the after-arrest setting. However the exam was a point-of-care focused study, with non-standard echocardiographic views, in patients under mechanical ventilation and inotropic support. ...
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Therapeutic hypothermia (TH) is recommended for patients with return of spontaneous circulation (ROSC) after cardiac arrest (CA). There is still uncertainty about management, target temperature and duration of TH. In the present study we aim to describe the initial experience of a non-tertiary care center with TH after CA and to determine predictors of mortality.
... In those who underwent CT after TH, cerebral edema and hypoxic encephalopathy were associated with a poor outcome. Current resuscitation guidelines recognize echocardiography as a valuable diagnostic tool in the early identification of the precipitating cause of CA, 11,19 which is why it was performed in all except one of our patients in the after-arrest setting. However the exam was a point-of-care focused study, with non-standard echocardiographic views, in patients under mechanical ventilation and inotropic support. ...
Article
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Introduction and objectives: Therapeutic hypothermia (TH) is recommended for patients with return of spontaneous circulation (ROSC) after cardiac arrest (CA). There is still uncertainty about management, target temperature and duration of TH. In the present study we aim to describe the initial experience of a non-tertiary care center with TH after CA and to determine predictors of mortality. Methods: During the period 2011-2014, out of 2279 patients hospitalized in the intensive care unit, 82 had a diagnosis of CA with ROSC. We determined predictors of mortality and neurological outcome in comatose patients with ROSC after CA treated by TH. Results: A total of 15 patients were included, mean age 47.3±14 years, 10 (67.0%) male. CA occurred out-of-hospital (n=11; 73.3%) or in-hospital (n=4; 26.7%), in initial shockable (n=10; 66.7%) or non-shockable (n=5, 33.3%) rhythm. The mean time from CA to ROSC (CA-ROSC) was 44.7±36.5 min. All patients met the 24-hour TH target temperature of 33°C. The mean neuron-specific enolase (NSE) level was 93.7±109.0 μg/l. Seven patients (46.7%) were discharged with good cerebral performance and eight (53.3%) died. Patients who survived had lower median age (p=0.032), shorter CA-ROSC (p=0.048), lower NSE levels (p=0.020) and initial ventricular fibrillation rhythm (p=NS). Conclusions: The effectiveness of TH appears to be related to younger age, shockable initial rhythm and shorter CA-ROSC time. This results indicates some lines of inquiry that should be developed in appropriate prospective studies. The role of biomarkers as predictors of prognosis is an open question, with NSE potentially playing an important role.
Chapter
The techniques and equipment used to provide advanced life support (ALS) as part of cardiopulmonary resuscitation (CPR) have evolved considerably over the last 10 years. The guidelines for the resuscitation of adults and children are updated every 5 years and these include detailed recommendations on the indications and the techniques for which resuscitation equipment is used. Some of the equipment used during resuscitation will leave characteristic marks or injuries and if these are identified during autopsy it is important that pathologists are able to attribute them to the resuscitation procedure. It is important for all involved in death investigation to be aware and up to date with current resuscitation procedures and equipment to be able to assess whether the resuscitation provided was in keeping with current guidelines, consider whether if it deviated from guidelines it could have caused or contributed to the death and to be able to distinguish between marks and injuries caused by resuscitation and those that were not. This chapter provides a guide to those involved in death investigation to allow them to consider these aspects of the death.
Article
Objectives: The aim of this study was to test the hypothesis that the right ventricle is more dilated during resuscitation from cardiac arrest caused by pulmonary embolism, compared with hypoxia and primary arrhythmia. Design: Twenty-four pigs were anesthetized and cardiac arrest was induced using three different methods. Pigs were resuscitated after 7 minutes of untreated cardiac arrest. Ultrasonographic images were obtained and the right ventricular diameter was measured. Setting: University hospital animal laboratory. Subjects: Female crossbred Landrace/Yorkshire/Duroc pigs (27-32 kg). Interventions: Pigs were randomly assigned to cardiac arrest induced by pulmonary embolism, hypoxia, or primary arrhythmia. Measurements and main results: There was no difference at baseline. During induction of cardiac arrest, the right ventricle dilated in all groups (p < 0.01 for all). The primary endpoint was right ventricle diameter at the third rhythm analysis: 32 mm (95% CI, 29-36) for pulmonary embolism which was significantly larger than both hypoxia: 23 mm (95% CI, 20-27) and primary arrhythmia: 25 mm (95% CI, 22-28)-the absolute difference was 7-9 mm. Physicians with basic training in focused cardiac ultrasonography were able to detect a difference in right ventricle diameter of approximately 10 mm with a sensitivity of 79% (95% CI, 64-94) and a specificity of 68% (95% CI, 56-80). Conclusions: The right ventricle was more dilated during resuscitation when cardiac arrest was caused by pulmonary embolism compared with hypoxia and primary arrhythmia. However, the right ventricle was dilated, irrespective of the cause of arrest, and diagnostic accuracy by physicians with basic training in focused cardiac ultrasonography was modest. These findings challenge the paradigm that right ventricular dilatation on ultrasound during cardiopulmonary resuscitation is particularly associated with pulmonary embolism.
Article
Objectives: Dilation of the right ventricle during cardiac arrest and resuscitation may be inherent to cardiac arrest rather than being associated with certain causes of arrest such as pulmonary embolism. This study aimed to compare right ventricle diameter during resuscitation from cardiac arrest caused by hypovolemia, hyperkalemia, or primary arrhythmia (i.e., ventricular fibrillation). Design: Thirty pigs were anesthetized and then randomized to cardiac arrest induced by three diffrent methods. Seven minutes of untreated arrest was followed by resuscitation. Cardiac ultrasonographic images were obtained during induction of cardiac arrest, untreated cardiac arrest, and resuscitation. The right ventricle diameter was measured. Primary endpoint was the right ventricular diameter at the third rhythm analysis. Setting: University hospital animal laboratory. Subjects: Female crossbred Landrace/Yorkshire/Duroc pigs (27-32 kg). Interventions: Pigs were randomly assigned to cardiac arrest caused by either hypovolemia, hyperkalemia, or primary arrhythmia. Measurements and main results: At the third rhythm analysis during resuscitation, the right ventricle diameter was 32 mm (95% CI, 29-35) in the hypovolemia group, 29 mm (95% CI, 26-32) in the hyperkalemia group, and 25 mm (95% CI, 22-28) in the primary arrhythmia group. This was larger than baseline for all groups (p = 0.03). When comparing groups at the third rhythm analysis, the right ventricle was larger for hypovolemia than for primary arrhythmia (p < 0.001). Conclusions: The right ventricle was dilated during resuscitation from cardiac arrest caused by hypovolemia, hyperkalemia, and primary arrhythmia. These findings indicate that right ventricle dilation may be inherent to cardiac arrest, rather than being associated with certain causes of arrest. This contradicts a widespread clinical assumption that in hypovolemic cardiac arrest, the ventricles are collapsed rather than dilated.
Article
Introduction: Advanced life support (ALS) guidelines recommend ultrasound to identify reversible causes of cardiac arrest. Right ventricular (RV) dilatation during cardiac arrest is commonly interpreted as a sign of pulmonary embolism. The RV is thus a focus of clinical ultrasound examination. Importantly, in animal studies ventricular fibrillation and hypoxia results in RV dilatation. Tension pneumothorax (tPTX) is another reversible cause of cardiac arrest, however, the impact on RV diameter remains unknown. Aim: To investigate RV diameter evaluated by ultrasound in cardiac arrest caused by tPTX or hypoxia. Methods: Pigs were randomized to cardiac arrest by either tPTX (n = 9) or hypoxia (n = 9) and subsequently resuscitated. Tension pneumothorax was induced by injection of air into the pleural cavity. Hypoxia was induced by reducing tidal volume. Ultrasound images of the RV were obtained throughout the study. Tension pneumothorax was decompressed after the seventh rhythm analysis. The primary endpoint was RV diameter after the third rhythm analysis. Results: At cardiac arrest the RV diameter was 17 mm (95% CI: 13; 21) in the tPTX group and 36 mm (95% CI: 33; 40) in the hypoxia group (P < 0.01, n = 9 for both). At third rhythm analysis RV diameter was smaller in the tPTX group: 12 mm (95% CI: 7; 16) vs. hypoxia group: 28 mm (25; 32) (P < 0.01). After decompression no difference existed between groups: tPTX 29 mm (95% CI: 23; 34) vs. hypoxia 29 mm (95% CI: 20; 38). Conclusion: The RV diameter is smaller during cardiopulmonary resuscitation in cardiac arrest caused by tPTX when compared with hypoxia. The difference disappears after tPTX decompression.
Article
The German recommendations on emergency echocardiography set up and propose standards for ultrasound equipment, execution, documentation, data storage, interpretation of the results as well as education and training of physicians performing echocardiography in the emergency setting. Emergency echocardiography is defined as a comprehensive diagnostic procedure performed by cardiologists or physicians who are able to independently perform echocardiography and its documentation and to interpret the results unaided. In contrast, focused sonography of the heart is an informative, focused diagnostic measure in emergencies which does not adequately conform to the quality standards of emergency echocardiography. The recommendations describe the echocardiographic approach and procedure in cardiovascular diseases, such as acute myocardial infarction, pulmonary embolism, pericardial tamponade, acute heart valve diseases, endocarditis, aortic dissection, thoracic trauma, shock and heart failure considering the most important cardiac structures. © Deutsche Gesellschaft für Kardiologie - Herz- und Kreislaufforschung e.V. Published by Springer-Verlag - all rights reserved 2013.
Chapter
Whilst conventional (‘quantitative’) transthoracic echocardiography (TTE) performed by an echocardiography laboratory remains a useful diagnostic tool for non-invasive cardiac assessment, limited availability, cost, and a time-delay between request and result restrict its use. However, increased availability, portability and imaging capability of TTE equipment has enabled treating physicians to perform their own ‘focused TTE’ as an aid to initial clinical assessment at the ‘point-of-care’ when required. Initially embraced by critical care and emergency physicians for rapid assessment of shock, anaesthetists are increasingly using focused TTE for perioperative cardiac assessment. An abbreviated ‘qualitative’ study enables convenient separation of significant from non-significant cardiac pathology and helps identify the causes for persistent hypotension, such altered preload, afterload, pump or valve failure, tamponade or pulmonary hypertension. When incorporated into routine initial patient assessment of patients at increased cardiac risk presenting to the preoperative clinic before non-cardiac surgery, focused TTE changes the diagnosis and management in approximately 50 % of patients. Identification of previously unknown cardiac disease alerts the anaesthetist to increased perioperative risk, prompting an escalation in preoperative work-up, perioperative haemodynamic monitoring and management and increased use of postoperative intensive or high dependency care. Conversely, reassuring TTE enables a step-down in care, preventing unnecessary surgical delay for investigations or referral, and circumventing the need for invasive monitoring during or after surgery. Focused TTE may assist anaesthetists assess and manage the increasing number of patients presenting to surgery with increased age and increasingly complex co-morbidities admitted on the day of surgery.
Article
Idiopathic ventricular fibrillation is a rare cause of sudden cardiac arrest and a diagnosis by exclusion. Unraveling the mechanism of ventricular fibrillation is important for targeted management, and potentially for initiating family screening. Sudden cardiac arrest survivors undergo extensive clinical testing, with a growing role for multimodality imaging, before diagnosing “‘idiopathic” ventricular fibrillation. Multimodality imaging, considered as using multiple imaging modalities as diagnostics, is important for revealing structural myocardial abnormalities in patients with cardiac arrest. This review focuses on combining imaging modalities (echocardiography, cardiac magnetic resonance and computed tomography) and the electrocardiographic characterization of sudden cardiac arrest survivors and discusses the surplus value of multimodality imaging in the diagnostic routing of these patients. We focus on novel insights obtained through electrostructural and/or electromechanical imaging in apparently idiopathic ventricular fibrillation patients, with special attention to non-invasive electrocardiographic imaging.
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Libro de texto para el programa de ecografía clínica que será insertado en el curriculo de la residencia en Medicina Intensiva y Emergencias en Cuba. El libro describe en forma práctica la realización de la ecografía clínica junto a la cama del paciente realizada por el médico de asistencia. Cada capítulo está ilustrado con fotografías editadas tomadas durante la realización de las ecografías. Al final de cada capítulo se señalan referencias bibliográficas para la profundización en los temas abordados.
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Since cardiac ultrasound was introduced into medical practice around the middle twentieth century, transthoracic echocardiography has developed to become a highly sophisticated and widely performed cardiac imaging modality in the diagnosis of heart disease1. This evolution from an emerging technique with limited application, into a complex modality capable of detailed cardiac assessment has been driven by technological innovations that have both refined ‘standard’ two dimensional and Doppler imaging and led to the development of new diagnostic techniques. Accordingly, the adult transthoracic echocardiogram has evolved to become a comprehensive assessment of complex cardiac anatomy, function and haemodynamics. This guideline protocol from the British Society of Echocardiography aims to outline the minimum dataset required to confirm normal cardiac structure and function when performing a comprehensive standard adult echocardiogram and is structured according to the recommended sequence of acquisition. It is recommended that this structured approach to image acquisition and measurement protocol forms the basis of every standard adult transthoracic echocardiogram. However, when pathology is detected and further analysis becomes necessary, views and measurements in addition to the minimum dataset are required and should be taken with reference to the appropriate British Society of Echocardiography imaging protocol. It is anticipated that the recommendations made within this guideline will help standardise the local, regional and national practice of echocardiography, in addition to minimising the inter and intra-observer variation associated with echocardiographic measurement and interpretation.
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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.
Chapter
Ultrasound technology has developed in recent years and has had an emerging and important role within the field of cardiology. Cardiac patients and those who have had cardiac surgery represent unique challenges. Some examples of the role of ultrasound include regional nerve blocks and fluid assessment. This book chapter summarizes the role of ultrasound in cardiac patients and those who have had cardiac surgery.
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Point of Care Ultrasound (POCUS) is a valuable bedside diagnostic tool for a variety of expeditious clinical assessments or as guidance for a multitude of acute care procedures. Varying aspects of nearly all organ systems can be evaluated using POCUS and with the increasing availability of affordable ultrasound systems over the past decade, many now refer to POCUS as the 21st-century stethoscope. With the current available and growing evidence for the clinical value of POCUS, its utility across the perioperative arena adds enormous benefit to clinical decision-making. Cardiothoracic anesthesiologists have routinely used portable ultrasound systems for nearly as long as the technology has been available, making POCUS applications a natural extension of existing cardiothoracic anesthesia practice. This narrative review presents a broad discussion of the utility of POCUS for the cardiothoracic anesthesiologist in varying perioperative contexts, including the preoperative clinic, the operating room (OR), intensive care unit (ICU), and others. Furthermore, POCUS-related education, competence, and certification is addressed.
Article
Introduction Though point-of-care ultrasound (POCUS) is recognized as a useful diagnostic and prognostic intervention during cardiac arrest (CA), critics advise caution. The purpose of this survey study was to determine the barriers to POCUS during CA in the Emergency Department (ED). Methods Two survey instruments were distributed to emergency medicine (EM) attending and resident physicians at three academic centers in the South Florida. The surveys assessed demographics, experience, proficiency, attitudes and barriers. Descriptive and inferential statistics along with Item Response Theory Logistic Model and the Friedman Test with Wilcoxon Signed Rank tests were used to profile responses and rank barriers. Results 206 EM physicians were invited to participate in the survey, and 187 (91%) responded. 59% of attending physicians and 47% of resident physicians reported that POCUS is performed in all their cases of CA. 5% of attending physicians and 0% of resident physicians reported never performing POCUS during CA. The top-ranked departmental barrier for attending physicians was “No structured curriculum to educate physicians on POCUS.” The top-ranked personal barriers were “I do not feel comfortable with my POCUS skills” and “I do not have sufficient time to dedicate to learning POCUS.” The top-ranked barriers for resident physicians were “Time to retrieve and operate the machine” and “Chaotic milieu.” Conclusions While our study demonstrates that most attending and resident physicians utilize POCUS in CA, barriers to high-quality implementation exist. Top attending physician barriers relate to POCUS education, while the top resident physician barriers relate to logistics and the machines. Interventions to overcome these barriers might lead to optimization of POCUS performance during CA in the ED.
Chapter
Cardiac ultrasound has evolved substantially since the 1970s. Its high quality images provide useful information on cardiac morphology, physiology and functionality that complimenting standard physical examination in many acute care settings including the perioperative period. Transthoracic echocardiography (TTE) is a cardiac ultrasound modality with comparable diagnostic and monitoring capabilities to and yet less invasive than the transesophageal echocardiography (TEE). This chapter will discuss the feasibility and impact of TTE use in the perioperative setting, the TTE expertise pyramid, various focused TTE protocols and a “TTE Toolbox” proposed by the authors.
Article
Introduction: Cardiac arrest management primarily focuses on optimal chest compressions and early defibrillation for shockable cardiac rhythms. Non-shockable rhythms such as pulseless electrical activity (PEA) and asystole present challenges in management. Point-of-care ultrasound (POCUS) in cardiac arrest is promising. Objectives: This review provides a focused assessment of POCUS in cardiac arrest, with an overview of transthoracic (TTE) and transesophageal echocardiogram (TEE), uses in arrest, and literature support. Discussion: Cardiac arrest can be distinguished between shockable and non-shockable rhythms, with management varying based on the rhythm. POCUS provides a diagnostic and prognostic tool in the emergency department (ED), which may improve accuracy in clinical decision-making. Several protocols incorporate POCUS based on different cardiac views. TTE includes parasternal long axis, parasternal short axis, apical 4-chamber, and subxiphoid views, which may be used in cardiac arrest for diagnosis of underlying cause and potential prognostication. TEE is conducted by inserting the probe into the esophagus of intubated patients, with several studies evaluating its use in cardiac arrest. It is associated with few adverse effects, while allowing continued compressions (and evaluation of those compressions) and not interrupting resuscitation efforts. Conclusions: POCUS is a valuable diagnostic and prognostic tool in cardiac arrest, with recent literature supporting its diagnostic ability. TTE can guide resuscitation efforts dependent on the rhythm, though TTE should not interrupt other resuscitation measures. TEE can be useful during arrest, but further studies based in the ED are needed.
Article
Diagnostic ultrasonography was first utilized in the 1940s. The past 70+ years have seen an explosion in both ultrasound technology and availability of ultrasound technology to more and more clinicians. As ultrasound technology and availability have grown, the utility of ultrasound technology in the clinical setting as only been limited by clinicians' imagination. Due to its lack of radiation, non-invasive nature, and gentle learning curve, medical ultrasonography is now a tremendously useful Point of Care technology in the clinical arena. What follows is a discussion of Point of Care Ultrasound (PoCUS) and how it can be incorporated in the daily practice of any regional anesthesiology. While most regional anesthesiologists usually focus on the interventional aspects of ultrasonography (i.e. nerve blocks), our discussion will center on the diagnostic value of ultrasonography-especially concerning assessment of cardiac physiology and pathophysiology, gastric anatomy, airway anatomy, and intracranial pathophysiology. After reading and reviewing this chapter, the learner will have the knowledge to start training themselves in a variety of PoCUS exams that will allow rapid diagnosis of normal and abnormal patient conditions. Once an accurate diagnosis is established, the anesthesiologist and his/her team can then confidently optimize an anesthetic pain, prevent harm, and/or treat a patient condition. In this day and age, the ability to rapidly establish an accurate diagnosis cannot be overstated-especially in a critical situation. It is the authors' sincerest hope that the following discussion will help regional anesthesiologist to become even better and well-rounded clinical leaders.
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Since 2006, physicians of the Nijmegen Helicopter Emergency Medical Service (HEMS) in the Netherlands have been using a portable ultrasound device to reliably detect or rule out potentially life-threatening conditions in critically ill and trauma patients. Significant abnormalities are pneumothorax, hemothorax, intraperitoneal free fluid, and cardiac tamponade. In 12-21% of patients who underwent an ultrasound examination, the outcomes impacted treatment decisions. During prehospital resuscitation in which the HEMS was involved, the global cardiac function and the presence or absence of pericardial fluid can be assessed by ultrasound. These outcomes impacted treatment decisions in 88% of patients. Since 2014, there has been fruitful collaboration between the anesthesiology department and the Radboudumc Emergency Department on the subject of ultrasound-guided locoregional anesthesia. Since then, emergency physicians are effectively performing ultrasound-guided femoral blocks on patients with femoral neck fractures.
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Ultrasonography is a modern diagnostic tool both in intensive care and emergency medicine. Small, portable and simple ultrasound devices have been introduced due to technological advances. The image quality, size, and weight of portable ultrasound devices are improving. Prehospital point-of-care ultrasonog-raphy may have an impact on the decision making in prioritizing initial treatment. First aid at the scene of the accident and transporting the patient to the hospital is a key element, which in the case of appropriate diagnostics allows you to fight life-threatening injuries. The intention of using ultrasound protocols is to shorten and simplify the ultrasound examination allowing to eliminate or find complications of an injury as soon as possible. The protocols used include elements of ultrasonography and echocardiography of the lung tissue, abdominal cavity, pelvis, large vessels or the eyeball. The intention of the authors of the article was to present to the reader the basic ultrasound protocols applicable to patients in emergency situations.
Article
Objective: We sought to identify the impact of echocardiographic right ventricular (RV) systolic dysfunction on mortality in adults with cardiac arrest (CA). Methods: The study population included 147 adults hospitalized with CA who underwent both echocardiogram and coronary angiogram at an academic tertiary medical center. The primary outcome of interest was all-cause in-hospital mortality. Results: Of the 147 patients studied, 20 (13.6%) had evidence of RV systolic dysfunction while 127 (86.4%) did not. Patients with RV dysfunction had higher rates of prior surgical and percutaneous coronary revascularization. They also had higher rates of mechanical ventilation, therapeutic hypothermia, vasopressor and inotrope use, and a trend towards higher rates of mechanical support. Coronary angiogram revealed higher rates of multivessel disease, right coronary artery intervention, and glycoprotein IIb-IIIa inhibitor use in those with RV dysfunction, alongside with lower echocardiographic left ventricular ejection fraction. In-hospital mortality rates were higher in adults with RV dysfunction compared to those without (55% vs 11%, p < 0.001). In multivariate analysis, RV dysfunction was the strongest independent predictor of higher mortality [odds ratio 4.71, 95% confidence interval 1.27-17.50]. Conclusions: In this observational contemporary study, RV dysfunction was independently associated with higher mortality in adults with CA undergoing coronary angiogram. RV dysfunction may be useful for risk stratification and management in this high-mortality population.
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.
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Non-thrombotic PE does not represent a distinct clinical syndrome. It may be due to a variety of embolic materials and result in a wide spectrum of clinical presentations, making the diagnosis difficult. With the exception of severe air and fat embolism, the haemodynamic consequences of non-thrombotic emboli are usually mild. Treatment is mostly supportive but may differ according to the type of embolic material and clinical severity.
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We describe a training programme for non-specialists in focused echocardiography in the periresuscitation setting which represents an entry level in echocardiography training (FEEL) for emergency and critical care medicine physicians. A prospective observational study based upon the development of a periresuscitation echocardiography training programme developed for novice practitioners (N=15 courses). The programme enables novice echocardiographers to be able to perform a focused echocardiogram in an ALS-compliant manner, and interpret the findings in the context of the clinical scenario. It is based on the concept of blended learning, incorporating a combination of e-learning, web-based teaching and reading selected literature, and attendance at a course. The course comprises 4-hours of theory and 4-hours of hands-on training. Periresuscitation echocardiography, performed safely, within the competence of practitioners in an ALS-compliant manner is a potentially valuable skill to be acquired by physicians caring for the critically ill, regardless of the environment in which they work, or their level of seniority. This newly-developed blended learning periresuscitation echocardiography programme (FEEL) may serve as entry level in peri-resuscitation echocardiography for both emergency physicians and critical care practitioners.
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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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This study assessed the clinical features, timing of presentation, and echocardiographic characteristics associated with clinically significant pericardial effusions after cardiothoracic surgery. The outcomes of echocardiographically (echo-) guided pericardiocentesis for the management of these effusions were evaluated. From the prospective Mayo Clinic Registry of Echo-guided Pericardiocentesis (February 1979 to June 1998), 245 procedures performed for clinically significant postoperative effusions were identified. Clinical features, effusion causes, echocardiographic findings, and management outcomes were studied and analyzed. Cross-referencing the registry with the Mayo Clinic surgical database provided an estimate of the incidence of significant postoperative effusions and the number of cases in which primary surgical management was chosen instead of pericardiocentesis. Use of anticoagulant therapy was considered a significant contributing factor in 86% and 65% of early effusions (< or =7 days after surgery) and late effusions (>7 days after surgery), respectively. Postpericardiotomy syndrome was an important factor in the development of late effusions (34%). Common presenting symptoms included malaise (90%), dyspnea (65%), and chest pain (33%). Tachycardia, fever, elevated jugular venous pressure, hypotension, and pulsus paradoxus were found in 53%, 40%, 39%, 27%, and 17% of cases, respectively. Transthoracic echocardiography permitted rapid diagnosis and hemodynamic assessment of all effusions except for three cases that required transesophageal echocardiography for confirmation. Echo-guided pericardiocentesis was successful in 97% of all cases and in 96% of all loculated effusions. Major complications (2%), including chamber lacerations (n = 2) and pneumothoraces (n = 3), were successfully treated by surgical repair and chest tube reexpansion, respectively. Median follow-up duration for the study population was 3.8 years (range, 190 days to 16.4 years). The use of extended catheter drainage was associated with reduction in recurrence for early and late postoperative effusions by 46% and 50%, respectively. The symptoms and physical findings of clinically significant postoperative pericardial effusions are frequently nonspecific and may be inadequate for a decision regarding intervention. Echocardiography can quickly confirm the presence of an effusion, and pericardiocentesis under echocardiographic guidance is safe and effective. The use of a pericardial catheter for extended drainage is associated with lower recurrence rates, and the majority of patients so treated do not require further intervention.
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The advanced trauma life support course teaches that if only the patient's carotid pulse is palpable, the systolic blood pressure is 60-70 mm Hg; if carotid and femoral pulses are palpable, the systolic blood pressure is 70-80 mm Hg; and if the radial pulse is also palpable, the systolic blood pressure is more than 80 mm Hg.1 The only study to examine the accuracy of this model used non-invasive blood pressure measurements, which have a tendency to underestimate systemic arterial blood pressure during hypotension.2 No reliable data are therefore available to support the advanced trauma life support guidelines on which clinical decisions are made. We assessed whether the guidelines accurately predict systolic blood pressure by palpation of radial, femoral, and carotid pulses in hypovolaemic patients …
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The use and potential benefits of the focused trauma ultrasound examination in the accident and emergency setting has been increasingly recognised in recent years.1 We report a case re-emphasising the benefits of immediate access to skilled ultrasound examination in the critically ill non-trauma patient. A 25 year old woman presented to our accident and emergency department with a three hour history of retrosternal pleuritic chest pain and dyspnoea. She was previously completely well, was a non-smoker and her only medication was a levonorgestrel-based second generation oral contraceptive. Initial clinical examination revealed moderate obesity, tachypnoea (oxygen saturation of 94% on air) and a tachycardia of 110 bpm. There were no other abnormal clinical signs and no evidence of lower limb venous thrombosis. 12-lead ECG showed an “S1Q3T3” pattern. After initial assessment she was accompanied to the toilet, where she collapsed with no palpable cardiac output. She was immediately transferred to the resuscitation room. Appropriate cardiopulmonary resuscitation was started and electromechanical dissociation was noted. A presumptive diagnosis of massive pulmonary embolism was made. …
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In 50 patients treated from January 1998 through March 2002 for pericardial effusion and tamponade, we retrospectively investigated the efficacy of percutaneous placement of an indwelling pericardial catheter guided by 2-dimensional echocardiography and fluoroscopy. We also investigated causation. In 80% of the patients, we were able to determine specific causes through clinical, serologic, and cytologic investigation: cancer in 15 patients, chronic renal failure in 11, systemic lupus erythematosus in 2 rheumatoid arthritis in 2, Dressler syndrome in 2, tuberculosis in 1, blunt chest trauma in 1, purulent pericarditis in 1, and probably viral pericarditis in 5. No specific cause could be determined in 10 patients (20%). We did not observe any complication due to the procedure. Two patients died during hospitalization. After hospitalization, 9 patients with metastatic cancer died within 3 months. A 2nd percutaneous drainage procedure was required in 2 cancer patients. Recurrence of pericardial effusion and tamponade and the requirement of pericardiectomy occurred in 2 patients with perfusion of unknown cause and in 1 patient with perfusion due to rheumatoid arthritis. Histologic examination of pericardial tissue in patients with idiopathic disease showed fibrinous pericarditis but no causal factor. In the group with idiopathic pericardial effusion, 2 patients with multiple mediastinal lymphadenopathy underwent mediastinal exploration; biopsy revealed nonspecific lymphadenitis and fibrinous pericarditis. In patients with large pericardial effusions and tamponade, the specific cause was in most cases already known or obtained by initial clinical and laboratory investigation. Sufficient cardiac decompression was achieved by percutaneous pigtail catheter drainage.
Article
Objective: To determine whether emergency physicians (EPs) with goal-directed training can use echocardiography to accurately assess left ventricular function (LVF) in hypotensive emergency department (ED) patients. Methods: Prospective, observational study at an urban teaching ED with >100,000 visits/year. Four EP investigators with prior ultrasound experience underwent focused echocardiography training. A convenience sample of 51 adult patients with symptomatic hypotension was enrolled. Exclusion criteria were a history of trauma, chest compressions, or electrocardiogram diagnostic of acute myocardial infarction. A five-view transthoracic echocardiogram was recorded by an EP investigator who estimated ejection fraction (EF) and categorized LVF as normal, depressed, or severely depressed. A blinded cardiologist reviewed all 51 studies for EF, categorization of function, and quality of the study. Twenty randomly selected studies were reviewed by a second cardiologist to determine interobserver variability. Results: Comparison of EP vs. primary cardiologist estimate of EF yielded a Pearson's correlation coefficient R = 0.86. This compared favorably with interobserver correlation between cardiologists (R = 0.84). In categorization of LVF, the weighted agreement between EPs and the primary cardiologist was 84%, with a weighted kappa of 0.61 (p < 0.001). Echocardiographic quality was rated by the primary cardiologist as good in 33%, moderate in 43%, and poor in 22%. The EF was significantly lower in patients with a cardiac cause of hypotension vs. other patients (25 ± 10% vs. 48 ± 17%, p < 0.001). Conclusions: Emergency physicians with focused training in echocardiography can accurately determine LVF in hypotensive patients.
Article
Objective: To assess echocardiographic observations during in hospital cardiopulmonary resuscitation (CPR) and the utility of this information in the management of cardiac arrest. Design: Echocardiographic system brought to the hospital site of cardiac arrest and applied to patients in conjunction with conventional CPR. Setting: Large community-hospital with portable echocardiographic system and an alerted cardiology team skilled in this technique. Measurements and main results: Mechanical asystole was initially observed in 18 (90%) of 20 cardiac arrest patients during CPR, including four patients with severe bradyarrhythmia as the arrest rhythm. The return of ventricular contractions in four of these 18 patients a short time after starting CPR prompted positive inotropic therapy. Ventricular wall motion was noted in two patients with severe bradyarrhythmia (pseudo-electromechanical dissociation) and the causes of cardiac arrest identified as massive pulmonary embolism and hypovolemia, respectively. A gel-like, coalescent echo contrast within the cardiac chambers was observed 20 to 30 mins after CPR in ten patients with unrelenting cardiac arrest and uniformly associated with an adverse outcome. Six patients survived resuscitation but only two patients survived to hospital discharge. Conclusions: An echocardiographic examination is feasible during CPR and may offer useful information in the management of the individual patients with cardiac arrest. It may depict the proximate cause of cardiac arrest, e.g., pulmonary embolism, cardiac tamponade, or hypovolemia, and signal the return of ventricular contractions in patients with initially absent mechanical activity. The appearance of intracardiac coalescent echo contrast in our patients with unrelenting cardiac arrest was associated with a failed outcome. The role of echocardiographic imaging in the setting of advanced cardiac life support requires further study.
Article
Un critère hémodynamique statique est un paramètre sensé représenter ou évaluer la précharge cardiaque. Il s'agit par exemple des pressions de remplissage droite et gauche (PVC, PAPO), des dimensions ventriculaires (volume et surface télédiastoliques droites et gauches), d'indices dérivés du cathétérisme transpulmonaire (volume télédiastolique global, volume sanguin intrathoracique), d'indices Doppler comme le temps d'éjection mesuré et monitoré par le Doppler œsophagien. Certains de ces critères (PVC, PAPO, volume télédiastolique VD) sont mesurables de façon invasive par cathétérisme mais aussi appréciables de façon non invasive par échocardiographie. Il s'avère globalement que ces critères ne permettent pas de prédire de façon fiable la réponse à une expansion volémique, ou que pour certains des études manquent encore pour en apprécier la fiabilité. Cet état de fait relève de plusieurs limites : des limites d'ordre technique, inhérentes aux pièges et à la sensibilité des méthodes de mesure ; mais aussi des limites physiologiques qui se traduisent par le fait qu'une mesure statique peut mal apprécier la précharge ventriculaire mais surtout la réserve de précharge qui dépend entre autres de la compliance des cavités ventriculaires. Cet article fait le point sur les principales limites de chacun de ces indices, permettant de comprendre l'importance des indices dits dynamiques qui sont présentés dans le même numéro.
Article
Objective: To measure the ability of cardiac sonography and capnography to predict survival of cardiac arrest patients in the emergency department (ED). Methods: Nonconsecutive cardiac arrest patients prospectively underwent either cardiac ultrasonography alone or in conjunction with capnography during cardiopulmonary resuscitation at two community hospital EDs with emergency medicine residency programs. Cardiac ultrasonography was carried out using the subxiphoid view during pauses for central pulse evaluation and end-tidal carbon dioxide (ETCO2) levels were monitored by a mainstream capnograph. A post-resuscitation data collection form was completed by each of the participating clinicians in order to assess their impressions of the facility of performance and benefit of cardiac sonography during nontraumatic cardiac resuscitation. Results: One hundred two patients were enrolled over a 12-month period. All patients underwent cardiac sonographic evaluation, ranging from one to five scans, during the cardiac resuscitation. Fifty-three patients also had capnography measurements recorded. The presence of sonographically identified cardiac activity at any point during the resuscitation was associated with survival to hospital admission, 11/41 or 27%, in contrast to those without cardiac activity, 2/61 or 3% (p < 0.001). Higher median ETCO2 levels, 35 torr, were associated with improved chances of survival than the median ETCO2 levels for nonsurvivors, 13.7 torr (p < 0.01). The multivariate logistic regression model, which evaluated the combination of cardiac ultrasonography and capnography, was able to correctly classify 92.4% of the subjects; however, of the two diagnostic tests, only capnography was a significant predictor of survival. The stepwise logistic regression model, summarized by the area under the receiver operator curve of 0.9, furthermore demonstrated that capnography is an outstanding predictor of survival. Conclusions: Both the sonographic detection of cardiac activity and ETCO2 levels higher than 16 torr were significantly associated with survival from ED resuscitation; however, logistic regression analysis demonstrated that prediction of survival using capnography was not enhanced by the addition of cardiac sonography.
Article
In 59 critically ill patients the diameter of the inferior vena cava, measured by ultrasonography, was compared with the central venous pressure (CVP). Fifty five patients were mechanically ventilated. The correlation was significant (r = 0,78). Moreover, for each patient, the changes of these two parameters, induced by volume expansion, change in PEEP level or disconnection from the ventilator, correlated. Like CVP, the diameter of inferior vena cava, obtained by a non invasive ultrasonic measure, might be used as a diagnostic aid in acute circulatory failure. The conditions for a good measurement are detailed.
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
Numerous studies have demonstrated the value of echocardiography in the assessment of critically ill patients in the Intensive Care Unit (ICU) and Emergency Room (ER). We seek to encourage expansion of echocardiography in these areas. However it is important to establish training programmes, standards of knowledge and skills, assessment methods and quality assurance if echocardiography is to be offered with confidence in these clinical areas. We have undertaken discussion with the many groups with a relevant interest in critical echocardiography and developed a consensus on proposals for the appropriate provision of training in echocardiography for the ICU, ER, and increasingly the medical high dependency and admissions wards.
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
The inferior vena cava diameter and its respiratory response are used to estimate right atrial pressures in spontaneously breathing patients but its value in patients receiving mechanical ventilation is unvalidated. Forty-nine patients undergoing mechanical ventilation were prospectively evaluated in the intensive or coronary care units with two-dimensional echocardiography of the inferior vena cava and simultaneous measurements of mean right atrial pressures by central venous or pulmonary artery catheter. Correlation between inferior vena cava diameter at expiration and mean right atrial pressure was only 0.58. The correlation between inspiratory change in inferior vena cava diameter and mean right atrial pressure was poor (r = 0.13). Despite these correlations, an inferior vena cava diameter of < or = 12 mm predicted a right atrial pressure of 10 mm Hg or less 100% of the time, but sensitivity was only 25%. An inferior vena cava diameter > 12 mm had no predictive value for right atrial pressure.
Article
To evaluate a simple noninvasive means of estimating right atrial (RA) pressure, the respiratory motion of the inferior vena cava (IVC) was analyzed by 2-dimensional echocardiography in 83 patients. Expiratory and inspiratory IVC diameters and percent collapse (caval index) were measured in subcostal views within 2 cm of the right atrium. Parameters were correlated with RA pressure by flotation catheter within 24 hours of the echocardiogram (38 were simultaneous). Correlations between RA pressure (range 0 to 28 mm Hg), expiratory and inspiratory diameters and caval index were 0.48, 0.71 and 0.75, respectively. Of 48 patients with caval indexes less than 50%, 41 (89%) had RA pressure greater than or equal to 10 mm Hg (mean +/- standard deviation, 15 +/- 6), while 30 of 35 patients (86%) with caval indexes greater than or equal to 50% had RA pressure less than 10 mm Hg (mean 6 +/- 5). Sensitivity and specificity for discrimination of RA pressure greater than or equal to or less than 10 mm Hg were maximized at the 50% level of collapse. Thus, IVC respiratory collapse on echocardiography is easily imaged and can be used to estimate RA pressure. A caval index greater than or equal to 50% indicates RA pressure less than 10 mm Hg, and caval indexes less than 50% indicate RA pressure greater than or equal to 10 Hg.
Article
Cardiac ultrasound quickly provides both anatomic and physiologic assessment of the heart at the bedside, permitting rapid diagnosis and triage of patients presenting to the emergency department with chest pain, hypotension, or dyspnea. The identification and quantification of left ventricular dysfunction by ultrasound allows effective determination of prognosis and, thus, may supplant the ECG in patient triage. Transesophageal echocardiography definitively identifies the presence of thoracic aortic dissections, and this information may be obtained more immediately than by other imaging methods. Emergency physicians should have, at a minimum, sufficient knowledge of echocardiography to know when it is applicable to a patient problem. It may be feasible for noncardiologists to gain sufficient proficiency in echocardiography to use the technique as a screening procedure in the emergency department setting.
Article
A retrospective chart review identified 46 consecutive patients who underwent catheter drainage of the pericardium over 3 years. Cardiac tamponade was present in the majority of patients, and the underlying cause was tumour metastasis in 72%. Pericardial catheterization was accomplished by the Seldinger technique using the subxiphoid approach. Catheter insertion was successful in 42 of the 46 patients, and in only 1 was there a serious complication. The mean duration of catheter drainage was 3 days. The pericardial space was successfully drained in all but one patient, who subsequently required surgery. Intrapericardial chemotherapy was administered in 27 patients. There was no instance of catheter-associated sepsis. Supraventricular arrhythmias occurred in 19% of patients, but all were managed medically. There were no late complications attributable to the period of drainage. The authors conclude that catheter drainage of the pericardium is a safe and effective means of providing definitive drainage of the pericardial space.
Article
Electromechanical dissociation (EMD) has been described as "organized electrical depolarization of the heart without synchronous myocardial fiber shortening and, therefore, without cardiac output." However, little evidence demonstrating this description exists. We wished to determine whether mechanical activity is present during EMD. Twenty-two patients presenting with, or subsequently developing EMD in the emergency department from April 1986 to January 1987 were studied. Echocardiograms were performed during five-second pauses in CPR, using the subxiphoid approach. Nineteen patients (86%) had synchronous myocardial wall motion. In two others, there was a rhythmic change in the echocardiographic density of the myocardium, without visible chamber narrowing. In one there was no visible myocardial response associated with the QRS complex. One or more cardiac valves were visualized in 17 patients. Of these, valvular motion was seen in 15 (88%), but only four exhibited visible valve closure. In our study population, the majority of patients in EMD had myocardial wall and valve motion. Thus, the term "electromechanical dissociation" may be a misnomer.
Article
Pericardiocentesis guided by 2-dimensional echocardiography has been used at the Mayo Clinic since April 1980. The 2-dimensional examination localizes the pericardial fluid. Particular note is made of the place on the body wall closest to the fluid. An entry track that permits puncture of the pericardial sac without damage to any vital structure is then selected for the pericardiocentesis needle. Between April 1980 and March 1984, 132 consecutive pericardiocenteses in 117 patients were done by this technique. The volume of fluid obtained ranged from 75 to 1,700 ml (mean 650). Seventy percent of the taps were done for therapy, 21% for diagnosis, and 9% for both therapy and diagnosis. A Teflon-sheathed "intracath" needle was used to complete 80% of the pericardiocenteses. In the other 20%, a large catheter was secondarily introduced and connected to a closed drainage system. There were no deaths related to the procedure. One symptomatic pneumothorax occurred. There were 3 minor complications. Two-dimensional echocardiographic imaging of the heart and pericardial fluid permits a safe and effective means of performing pericardiocentesis.
Article
Transesophageal echocardiography is increasingly used intraoperatively as a monitor of ventricular function and volume. Although obliteration of the left ventricular (LV) cavity at end-systole is interpreted as indicative of intraoperative hypovolemia, this relation has not been demonstrated directly. We continuously monitored the LV short axis by using transesophageal echocardiography and determined the relation between acute changes in LV area and hemodynamic variables in 139 patients undergoing elective coronary artery bypass graft surgery. The end-diastolic areas (EDA) and end-systolic areas were calculated during the control state (after anesthetic induction) and during LV end-systolic cavity obliteration. Thirty-nine of 139 patients had episodes of LV cavity obliteration. Mean LV end-systolic area decreased significantly from the control to obliterated state (7.29 +/- 2.56 to 4.00 +/- 1.46 cm2, P = 0.0001). The corresponding mean LV EDA also significantly decreased from the control to obliterated state (18.18 +/- 4.36 to 12.92 +/- 3.74 cm2, P = 0.0001). Mean ejection fraction area increased from 0.609 +/- 0.095 (control) to 0.692 +/- 0.083 (obliteration) (P < 0.0001). Of these 39 episodes, 31 (80%) were associated with a greater than 10% decrease in EDA relative to the initial value after induction of anesthesia and tracheal intubation; 4 (10%) with increases in ejection fraction area only; and an additional 4 (10%) with no substantial change in either the EDA or ejection fraction area. Overall, LV cavity obliteration was not associated with hemodynamic changes. Our study demonstrates that LV cavity obliteration is rarely preceded by any acute alteration in hemodynamic parameters. Although end-systolic cavity obliteration detected by intraoperative transesophageal echocardiography is frequently associated with decreases in EDA, not every instance of end-systolic cavity obliteration is indicative of decreased left ventricular filling.
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
Percutaneous pericardiocentesis was introduced during the 19th century and became a preferred technique for the management of pericardial effusion by the early 20th century. Until the era of two-dimensional echocardiographically guided pericardiocentesis, however, the procedure was essentially "blind," and serious complications were comparatively common, an outcome that resulted in an increased preference for surgical solutions. Because two-dimensional echocardiography facilitates direct visualization of cardiac structures and adjacent vital organs, percutaneous pericardiocentesis can be performed with minimal risk. Since its inception in 1979 (19 years ago), the echocardiographically guided pericardiocentesis technique has continued to evolve. Important procedural adaptations and modifications that optimize safety, simplicity, and patient comfort and minimize the recurrence of effusion have been defined and incorporated. This technique has been proved to be safe and effective. A detailed step-by-step description of the procedure and the necessary precautions to optimize success and safety is presented herein.
Article
Abnormalities in right ventricular regional and global function can occur in the setting of acute pulmonary embolism. Treatment of acute pulmonary embolism with thrombolysis is associated with significant improvement in regional and global right ventricular function.
Article
The purpose of the current study was to evaluate the CPR techniques of emergency healthcare professionals (emergency medical technicians, firemen, emergency first responders, CPR instructors). Skills were evaluated using a Laerdal Skillmeter Manikin, which provided a computerized printout of the quantifiable data during the CPR sequence. All of the 66 subjects in the study had completed a recertification course within the last 2 years (mean = 0.86 +/- 0.18, 95% CI). The sequence was videotaped for later viewing and for correlating the errors with the data. In addition, the participants were required to fill in a questionnaire. The most frequently occurring errors were observed in landmarking, overcompression, palpating a carotid pulse and insufficient ventilation. Although 98.5% of participants made an attempt to landmark their position for compression on the sternum, 35.9% of the total compressions performed by all subjects were incorrectly positioned on the patient's chest. Overcompression of the patient's chest accounted for 55.3% of incorrect compressions. Although 94% of participants attempted to verify a carotid pulse, only 45% were able to feel it and therefore stop performing cardiac massage. Of the total ventilations, 49% were below the American Heart Association (AHA) recommended minimum (800 ml). The results of this study showed a high rate of errors occurring in the CPR provided by emergency healthcare professionals.
Article
[Cummins RO, Hazinski MF: Cardiopulmonary resuscitation techniques and instruction: When does evidence justify revision? Ann Emerg Med December 1999;34:780-784.]
Article
The conventional surgical pericardiotomy and blind needle-puncture pericardiocentesis using a subxiphoid approach have been reported to have only moderate success rates and to be associated with unacceptably high rates of morbidity and mortality. More recently, echocardiographically guided pericardiocentesis was reported to improve considerably the likelihood of success and the safety of this procedure. To evaluate the efficacy and safety of echocardiographically guided pericardiocentesis in the authors' institution. A series of consecutive patients who underwent percutaneous pericardiocentesis at the Hamilton General Hospital, Hamilton, Ontario, from June 1994 to December 1998. Forty-one patients underwent a total of 46 echocardiographically guided pericardiocentesis procedures. The procedure was successful in 100% of attempts. Clinical complications occurred in two (5%) patients: one patient with known coagulopathy developed hemothorax and one patient developed purulent pericarditis several days after the procedure. There were no deaths, and no patient required urgent referral for surgical management. Echocardiographically guided pericardiocentesis is safe and effective, and is the method of choice for therapeutic and diagnostic drainage of pericardial effusions. While echocardiographically guided pericardiocentesis was described originally at centres with large volumes of patients with clinically significant pericardial effusions and with extensive experience in using this technique, similar high success and low complication rates were attained at an institution with relatively low numbers of patients requiring pericardial drainage.
Article
To measure the ability of cardiac sonography and capnography to predict survival of cardiac arrest patients in the emergency department (ED). Nonconsecutive cardiac arrest patients prospectively underwent either cardiac ultrasonography alone or in conjunction with capnography during cardiopulmonary resuscitation at two community hospital EDs with emergency medicine residency programs. Cardiac ultrasonography was carried out using the subxiphoid view during pauses for central pulse evaluation and end-tidal carbon dioxide (ETCO(2)) levels were monitored by a mainstream capnograph. A post-resuscitation data collection form was completed by each of the participating clinicians in order to assess their impressions of the facility of performance and benefit of cardiac sonography during nontraumatic cardiac resuscitation. One hundred two patients were enrolled over a 12-month period. All patients underwent cardiac sonographic evaluation, ranging from one to five scans, during the cardiac resuscitation. Fifty-three patients also had capnography measurements recorded. The presence of sonographically identified cardiac activity at any point during the resuscitation was associated with survival to hospital admission, 11/41 or 27%, in contrast to those without cardiac activity, 2/61 or 3% (p < 0.001). Higher median ETCO(2) levels, 35 torr, were associated with improved chances of survival than the median ETCO(2) levels for nonsurvivors, 13.7 torr (p < 0.01). The multivariate logistic regression model, which evaluated the combination of cardiac ultrasonography and capnography, was able to correctly classify 92.4% of the subjects; however, of the two diagnostic tests, only capnography was a significant predictor of survival. The stepwise logistic regression model, summarized by the area under the receiver operator curve of 0.9, furthermore demonstrated that capnography is an outstanding predictor of survival. Both the sonographic detection of cardiac activity and ETCO(2) levels higher than 16 torr were significantly associated with survival from ED resuscitation; however, logistic regression analysis demonstrated that prediction of survival using capnography was not enhanced by the addition of cardiac sonography.
Article
To determine whether emergency physicians (EPs) with goal-directed training can use echocardiography to accurately assess left ventricular function (LVF) in hypotensive emergency department (ED) patients. Prospective, observational study at an urban teaching ED with >100,000 visits/year. Four EP investigators with prior ultrasound experience underwent focused echocardiography training. A convenience sample of 51 adult patients with symptomatic hypotension was enrolled. Exclusion criteria were a history of trauma, chest compressions, or electrocardiogram diagnostic of acute myocardial infarction. A five-view transthoracic echocardiogram was recorded by an EP investigator who estimated ejection fraction (EF) and categorized LVF as normal, depressed, or severely depressed. A blinded cardiologist reviewed all 51 studies for EF, categorization of function, and quality of the study. Twenty randomly selected studies were reviewed by a second cardiologist to determine interobserver variability. Comparison of EP vs. primary cardiologist estimate of EF yielded a Pearson's correlation coefficient R = 0.86. This compared favorably with interobserver correlation between cardiologists (R = 0.84). In categorization of LVF, the weighted agreement between EPs and the primary cardiologist was 84%, with a weighted kappa of 0.61 (p < 0.001). Echocardiographic quality was rated by the primary cardiologist as good in 33%, moderate in 43%, and poor in 22%. The EF was significantly lower in patients with a cardiac cause of hypotension vs. other patients (25 +/- 10% vs. 48 +/- 17%, p < 0.001). Emergency physicians with focused training in echocardiography can accurately determine LVF in hypotensive patients.