Ultrasound is a vital modality during cardiac arrest, but unless you have thought through exactly how you are going to use it, then it can be haphazard and potentially even harmful!
Today, we bring on Mike Prats of the Ultrasound Gel Podcast to discuss his Ultrasound Hierarchy of Needs in Cardiac Arrest.
Do no harm
Avoid Delays
Ultrasound is not the primary focus. Prioritize good care. Only one piece of information during the arrest.
Do not need every rhythm check!
Tips:
- Pre-pause imaging -in a pre/post protocol implementation it saved about 15 seconds
- Adjust clip time to 6 seconds or less, save only 1 clip
- Do not interpret in real time, get back on chest
- Person leading should not be doing ultrasound
- Use a real timer
- Most experienced sonographer if possible
- Consider TEE
- Protocol (such as CASA)
PLAX vs SUX?
Parasternal better quality and maybe slightly faster (but this was on ED patients NOT in arrest)
Diagnostic
Same as a non-arresting echo but even more focused
REASON data on pericardiocentesis → higher survival (15.4% vs 1.3% overall survival)
- Pericardial Effusion
- PE (RV dilation is tricky)
- Fine Vfib
- Maybe hypovolemia, hemorrhagic
- Pseudo-PEA
Could throw in pneumothorax and rest of RUSH if you want
Prognostic
REASON study was first good study
- Some patients without cardiac activity did get ROSC
Quantitative LV function in PEA (also from REASON data) – maybe it is a spectrum
Caution in variability of interpretation
*What is a good definition? REASON definition:
visible [coordinated] movement of the myocardium, excluding movement of blood within the cardiac chambers or isolated valve movement.
Pulse checks
The EMCrit Way: POCUS pulses–if you get one, have a team member palpating for a palpable pulse while you throw doppler over the artery:
Femoral Pulse Wave Doppler
Find the femoral artery
Put the gate in the center of the artery
PSV > 20 cm/sec is correlated with ROSC with SBP>60 mmHG [10.1016/j.resuscitation.2023.109695]
Tailoring resuscitation
TEE data for frequency of changing locations (53%), Teran 2019
Prehospital guiding compressions
Catena 2019 Resuscitation TEE LVOT Opening (100% of survivors had open LVOT vs 8% of nonsurvivors had open LVOT. 19 patients, retrospective)
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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What are people’s trigger to stop chest compressions and perform a rhythm check? I ask this because blindly performing rhythm checks say every 2 minutes is the wrong thing to do and adds to the chest compression fraction. Also, some monitors are able to see the native rhythm through chest compression artifact. In regards to pulse checks, hopefully people aren’t blindly performing these either. At a minimum an organized rhythm should be in place. Thoughts? Concensus?
I agree with your points and I think there are many factors to take into consideration when determining when to do a rhythm check. Suspected etiology, duration of resuscitation, changes in end tidal CO2, recent interventions that might lead to improvement (defibrillation, antiarrhythmics, procedure, etc). There is little reason to check a pulse unless there is a potentially perfusing rhythm (or you have reason to distrust your monitor).
Hi Scott and Mike, Really interesting. Question: does all of this apply to ‘asystole’ as well? I understand we have to look for cardiac activity in PEA to differentiatie pseudo PEA / true PEA. In the case of pseudo PEA (PREM) we consider it as a deep low flow / shock state and we treat it accordingly ( stop chest compressions – switch to low dose vasopressor /fluids etc).We use US for looking further for treatable causes. In the case of true PEA(PRES)we use US for looking further for treatable causes. So I understand we have to do this in… Read more »
Frank, thanks for the message on Ultrasound GEL. Will reply to you here and copy to your message. A lot of the literature on this topic groups PEA and asystole together but I understand your concern that asystole generally portends less likely ROSC and traditionally less actionable causes. Two things I would say. 1/ First confirm this is true asystole. Best way is to look at the heart with ultrasound. Fine vfib has been discovered when it was thought to be asystole. 2/ For my practice, even asystole deserves at least one look for causes of the arrest that I… Read more »
Mike beat me to it. Agree with all of that. In addition, there is a big difference for me between asystole after 40 minutes of an EMS code and asystole as the first rhythm in a witnessed arrest in front of me in terms of how aggressive I am going to be.