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Cardiac US

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The hypotensive patient

ECHO IN CARDIAC ARREST

There are several algorithms for the use of echo in cardiac arrest as well such as FEEL, COACHRED (1,2). In 2010, based on level IV evidence, the ARC Guideline 11.6 (2010) gave a Class B recommendation to the use of ultrasound in cardiac arrest. The 2020 AHA guidelines recommends the use of echo in cardiac arrest when a sonographer is available based on level 2B evidence (3). With time, more studies show the benefits of bedside echo for the diagnosis of reversible causes of cardiac arrest (4). 

The main things to consider when performing bedside echo in the arrested patient are:

1. Be mindful of the use of US gel (slippery for the cardiac compressions)

2. Do no interfere with CPR

3. Do not also try to run the resus (all your brain power should be used for echo diagnosis of the cause of hypotension). 

COACHRED algoritm for echo in cardiac arrest (2)

HOW TO PERFORM BEDSIDE ECHO IN A CARDIAC ARREST

The best sonographer available should perform the echo. 

With conventional CPR, the subxyphoid view is optimal. With an external compresison device, the PLAx is usually accessible. 

Set you machine to save 10 second prospective clips. During CPR try get on axis images and save clips as you go. During the pulse checks get as many on axis images in as many planes as possible. DO NOT try to make a diagnosis during the pulse check. In the hands off/ echo off time, review the clips you have saved and communicate your findings to the team leader. 

If unsure about the diagnosis, look for corroborating evidence with other forms of US or other cardiac views. 

The aim of echo in cardiac arrest is to look for 1. cardiac contractility, 2. reversible causes

REVERSIBLE CAUSES

Always keep the 4Hs and 4Ts in mind. Echo is probably best for the Ts. 

Ts seen on echo

1. Thrombus: dilated RV 1:1 with LV

2. Toxins: LV may be dilated

3. Tamponade: pericardial effusion

4. Tension pneumothorax: absent pleural sliding

CARDIAC ACTIVITY

Echo is able to easily differentiate true PEA (no cardiac activity on echo) from pseudo PEA (pulseless electrical activity with coordinated contractions). Patients with pseudoPEA have been shown to have higher levels of ROSC and survival post arrest (5). Be careful with you assessment, sometimes fluids and other intravenous therapies can cause fluttering of valves which may look like cardiac activity, 

Blaivas et al (6) showed that there was 0% chance of survival for patients with true PEA. However, since then Gaspari et al (7) has shown that ROSC is still possible in true PEA. Thus the current AHA guidelines' recommendation is not to rely solely on echo for the termination of resuscitation (8). 

PLAx: Pseudo-PEA: coordinated contraction of the IV septum and inferiolateral LV wall

PLAx: True PEA: note the valves move due to the passage of IV fluids but there is nor myocardial contraction

Subxyphoid: true PEA

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REFERENCES

1. Breitkreutz R, Price S, Steiger HV, Seeger FH, Ilper H, Ackermann H, Rudolph M, Uddin S, Weigand MA, Müller E, Walcher F; Emergency Ultrasound Working Group of the Johann Wolfgang Goethe-University Hospital, Frankfurt am Main. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation. 2010 Nov;81(11):1527-33. doi: 10.1016/j.resuscitation.2010.07.013. PMID: 20801576.

2. Finn TE, Ward JL, Wu CT, Giles A, Manivel V. COACHRED: A protocol for the safe and timely incorporation of focused echocardiography into the rhythm check during cardiopulmonary resuscitation. Emerg Med Australas. 2019 Dec;31(6):1115-1118. doi: 10.1111/1742-6723.13374. Epub 2019 Aug 27. PMID: 31456338.

3. Panchal AR, Bartos JA, Cabañas JG, et al. Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. doi: 10.1161/CIR.0000000000000916. Epub 2020 Oct 21. PMID: 33081529.CopyDownload .nbibFormat:

4. Tsou PY, Kurbedin J, Chen YS, Chou EH, Lee MG, Lee MC, Ma MH, Chen SC, Lee CC. Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Resuscitation. 2017 May;114:92-99. doi: 10.1016/j.resuscitation.2017.02.021. Epub 2017 Mar 2. PMID: 28263791.

5. Blyth L, Atkinson P, Gadd K, Lang E. Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review. Acad Emerg Med. 2012 Oct;19(10):1119-26. doi: 10.1111/j.1553-2712.2012.01456.x. Epub 2012 Oct 5. Erratum in: Acad Emerg Med. 2015 Jul;22(7):892. PMID: 23039118.

6. Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med. 2001 Jun;8(6):616-21. doi: 10.1111/j.1553-2712.2001.tb00174.x. PMID: 11388936.

7. Gaspari R, Weekes A, Adhikari S, et al Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016 Dec;109:33-39. doi: 10.1016/j.resuscitation.2016.09.018. Epub 2016 Sep 28. PMID: 27693280.

8. Soar J, Berg KM, Andersen LW, et al  Adult Advanced Life Support Collaborators. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2020 Nov;156:A80-A119. doi: 10.1016/j.resuscitation.2020.09.012. Epub 2020 Oct 21. PMID: 33099419; PMCID: PMC7576326.