Don’t kill your patient with a probe! Welcome to UltraSound in Cardiac Arrest for (not so) Dummies!

8 Mar

A 2017 study about US and cardiac arrest aroused the debate about using POCUS during cardiac arrest . The authors concluded that:

“The use of POCUS during cardiac arrest resuscitation was associated with significantly increased duration of pulse checks, nearly doubling the 10-s maximum duration recommended in current guidelines.”

THE QUESTION

Is POCUS an unuseful loose of time and a potential KILLER when used on patients in Cardiac Arrest?

licence-to-kill

In my personal experience (and in the EMS where I work) we tried to give an answer to this question formulating a structured approach to use ultrasound during a code. The objective is to have vital information from the probe without delays or interruption in chest compressions. 

THE RATIONALE

In WHICH cardiac arrest using POCUS really worths the price?

For sure PEA and Asistoly are the the most relevant conditions to use a probe, on the contrary in defibrillating rhythms, defibrillation and anti-arythmic therapy is a priority, and no useful information can come from ultrasound.

So look at the monitor, if there is a defibrillating rhythm continue with classical ALS approach.

Use a probe only if Asystoly or a PEA are present.

WHEN we use the probe?

The right moment is during the 10 seconds pause indicated from guidelines to asses the rhythm.

Look at the monitor screen for rhythm check and place the probe on the patient for no longer than 10 seconds.

WHERE we place the probe.

  1. SubCOSTAL view of the heart for heart beating
  2. SubCOSTAL view of the heart pericardial effusion and VD>VS
  3. Left CHEST view for lung sliding
  4. Right CHEST view for lung slinging

WHAT  we can identify with ultrasound during Cardiac Arrest.

First thing is there any cardiac activity?

We no more check the pulse, but rely on indirect signs of cardiac arrest when starting chest compressions, but at the beginning of the code and during the reanimation, cardiac activity is a game changing information.

Second thing is does exists any reversible cause of Cardiac Arrest?

Addressing and treating those can really change the outcome of the patient. 

Pulmonary Embolism

Cardiac Tamponade

Tension Pneumo

Hypovolemia

 

Infogram ECOALS

The method

During the 10 sec pause asses the rhythm and place the probe .

During the following 2 min CPR think and address, when indicated, the reversible causes.

infogram-ecoals12.jpg

THE SCHEDULE

infogram-ecoals4.jpg

IMG_2597

 

 

 

 

HEART BEATING

 

 

 

infogram-ecoals11-e1520247725886.jpg

If heart is beating and the rhythm is Asystoly think to an equipment problem or to a very fine VF.

 

If the heart is beating and we have a PEA this is not a true PEA but a pseudo PEA so we have to treat this patient as a profound shock patient (POCUS differential diagnosis for shock) more than CA patient.

 

If heart is not beating, any rhythm, we look for reversible cause of CA.

 

infogram-ecoals5.jpg

IMG_2597

PERICARDIAL EFFUSION 

 

VD>VS

 

 

 

Infogram ECOALS1

If pericardial effusion is present think at CARDIAC TAMPONADE

If VD>VS think at PULMONARY EMBOLISM 

If no one of that are present go to the following step 

 

infogram-ecoals2-e1520249512473.jpg

IMG_2597

 

Lung Sliding

 

 

 

 

Infogram ECOALS1

If lung sliding is absent  think at a selective intubation of the right main bronchus or at a PNX. If lung sliding is present go to the following step.

 

infogram-ecoals6.jpg

IMG_2597Lung Sliding

 

 

 

Infogram ECOALS1

If lung sliding is absent  think at a PNX.

Can we scan more during 2 min CPR?

We can

Left flank and look for free fluid.

img_2601.jpg

Right flank and look for free fluid.

img_2600.jpg

If there is free fluid in the abdomen think and treat HYPOVOLEMIA.

ob_291b8c_attention-logo-red-and-gold-color

REMEMBER! At any time during the code, if EtCO2 rises or a coordinated electric activity is present 

NO PULSE CHECK

carotideo2.jpghorrifiedface-650x488

USE ULTRASOUND TO IDENTIFY A BEATING HEART

TRUST THE PROBE NOT YOUR FINGERS

ProbeOK

If no reversible cause are detected, and the patient is still in non defibrillating rhythm, check the heart and the EtCO2.

If heart is not beating and EtCO2 level is less than 10 mmHg. during good quality chest compressions, consider to call the code.

 

USninja1

 

 

 

 

 

 

 

4 Risposte to “Don’t kill your patient with a probe! Welcome to UltraSound in Cardiac Arrest for (not so) Dummies!”

  1. Franco Benedetti 8 marzo 2018 a 4:30 PM #

    Veramente un passo avanti nell’approccio dell’arresto cardiaco .
    Sarebbe bello poterlo inserire in un algoritmo…

    • medest118 8 marzo 2018 a 4:53 PM #

      Mei corsi di ecografia preospedaliera qui al 118 di Firenze lo stiamo già diffondendo come pratica clinica. Purtroppo non tutti i mezzi sono dotati di ecografo (per ora solo le automediche) e non tutti hanno una pratica tale da renderli esperti in ecografia POC. Ma ci stiamo lavorando….

      • Franco Benedetti 8 marzo 2018 a 6:08 PM #

        Grazie Mario
        L’uso dell’eco nell’extraospedaliero nel triveneto è ancora cosa rara,nel fvg poi è in dotazione solo in due postazioni .La riduzione delle dimensioni e,forse,dei costi ,credo ne possa facilitare la diffusione.
        Usarlo mi aiuta nella diagnosi e nelle procedure.
        Ad ogni modo anche solo leggendo si intravede il futuro…ed il tuo articolo è l’avanguardia.

      • medest118 8 marzo 2018 a 6:24 PM #

        Grazie e spero a breve di scrivere qualcosa sull’utilizzo in prepspedaliero dell’eco in altri percorsi diagnostici tempo dipendenti cone la dispnea ed il dolore toracico traendo spunto come sempre dalla nostra pratica clinica quotidiana. A presto.

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