i have found some interesting articles supporting the use of echo during CPR and have seen ED attendings do this. have any guidelines reflected this? are there any major recent studies? the ones that i have found are from a couple of years ago. Thanx for your help.
echo during cardiac arrest
- Thread starter Sanchik
- Start date
- Joined
- Oct 11, 2008
- Messages
- 103
- Reaction score
- 0
We do it all the time, for us at least it comes down to PEA vs. Pulseless. The leads are always getting knocked off in a code and everyone is so jacked its hard to feel a pulse sometimes.
If you could do a quick EF I guess you could use it as a more sophisticated surrogate for measuring a pulse and deciding when to stop compressions.
But I've been at this for 6 months and don't know what I'm talking about.
If you could do a quick EF I guess you could use it as a more sophisticated surrogate for measuring a pulse and deciding when to stop compressions.
But I've been at this for 6 months and don't know what I'm talking about.
- Joined
- Nov 2, 2004
- Messages
- 4,485
- Reaction score
- 5,301
I've seen Darryl Macias talk about using it in undifferentiated hypotension, and this could be extended to codes, if you're quick.
Basically you can take a look at the heart to see if it's hyperdynamic (indicating hypovolemia), hypodynamic (indicating MI, or bad CHF), +/-effusion/tamponade, or a large RV (indicating PE), then a quick look at the belly to look for a AAA, a collasped IVC (which you could see in sepsis or other hypovolemic states) or a belly full of fluid.
It's a neat idea, and I like using it when someone rolls in hypotensive without much history. However this is only useful if you're quick, and shouldn't get in the way of more standard measures like IV, O2, monitor, EKG, or god forbid a physical exam.
In codes I usually will take a look to confirm PEA/exclude tamponade, but it's an adjunct. You need to be comfortable coding without one. As an old attending of mine used to say, "We called codes before we had ultrasounds."
Basically you can take a look at the heart to see if it's hyperdynamic (indicating hypovolemia), hypodynamic (indicating MI, or bad CHF), +/-effusion/tamponade, or a large RV (indicating PE), then a quick look at the belly to look for a AAA, a collasped IVC (which you could see in sepsis or other hypovolemic states) or a belly full of fluid.
It's a neat idea, and I like using it when someone rolls in hypotensive without much history. However this is only useful if you're quick, and shouldn't get in the way of more standard measures like IV, O2, monitor, EKG, or god forbid a physical exam.
In codes I usually will take a look to confirm PEA/exclude tamponade, but it's an adjunct. You need to be comfortable coding without one. As an old attending of mine used to say, "We called codes before we had ultrasounds."
- Joined
- Oct 20, 2003
- Messages
- 6,040
- Reaction score
- 23
To be clear on terminology, I don't use Echo in cardiac arrest. I use bedside ultrasound in codes to determine cardiac activity and to look for pericardial effusion/tamponade.
- Joined
- Sep 1, 2003
- Messages
- 534
- Reaction score
- 92
This is my take too. How many times have you continued working on a patient because the monitor didn't show a nice horizontal line (ie they're technically still in PEA)? I give a couple of rounds of epi-atropine and then check with the US, if they have no cardiac motion (except for maybe a flapping valve) I call it.
- Joined
- Mar 13, 2003
- Messages
- 62
- Reaction score
- 1
we use US during the majority of our codes. again to look for cardiac activity, effusion, tamponade. seeing lots of internal deflectors and blood sludging around can help in deciding its time to call it.
i also US most of my patients with hypotension (undifferentiated and when i know the underlying pathology). many of my fellow residents who scan alot also do this. usually we do a FAST, ECHO, and Aorta scan on these people and it takes maybe 5 minutes? (i havent actually watched the timer) it's really not that long, and gives you tons of information. looking at EPSS for EF estimates can help influence whether we start an inotrope sooner rather than later, m-mode on the IVC can show you a rough idea of full vs empty tank, etc. i usually see the pt/H&P, write orders, and while the nurses are getting things done i quickly scan
i also US most of my patients with hypotension (undifferentiated and when i know the underlying pathology). many of my fellow residents who scan alot also do this. usually we do a FAST, ECHO, and Aorta scan on these people and it takes maybe 5 minutes? (i havent actually watched the timer) it's really not that long, and gives you tons of information. looking at EPSS for EF estimates can help influence whether we start an inotrope sooner rather than later, m-mode on the IVC can show you a rough idea of full vs empty tank, etc. i usually see the pt/H&P, write orders, and while the nurses are getting things done i quickly scan
- Joined
- Jul 19, 2006
- Messages
- 31
- Reaction score
- 0
Here's a link to the article for people that haven't seen it:
http://www3.interscience.wiley.com/cgi-bin/fulltext/119825928/PDFSTART
Michael Blaivas MD 1 , *John Christian Fox MD 2
1 Department of Emergency Medicine, North Shore University ospital, Manhasset, NY 2 Department of Emergency Medicine, Christ Hospital and Medical Center, Oak Lawn, IL
Correspondence to RDMS, Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030. Fax: 516-562-3680; e-mail: [email protected]
Copyright 2001 Society for Academic Emergency Medicine
KEYWORDS
ultrasound emergency ultrasonography cardiac arrest outcome prediction emergency medicine
ABSTRACT
Abstract. 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). Objective: To examine the predictive value of cardiac standstill visualized on bedside ED echocardiograms during the initial presentations of patients receiving cardiopulmonary resuscitation (CPR). Methods: 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. Results: 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%. Conclusions: 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.
http://www3.interscience.wiley.com/cgi-bin/fulltext/119825928/PDFSTART
Michael Blaivas MD 1 , *John Christian Fox MD 2
1 Department of Emergency Medicine, North Shore University ospital, Manhasset, NY 2 Department of Emergency Medicine, Christ Hospital and Medical Center, Oak Lawn, IL
Correspondence to RDMS, Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030. Fax: 516-562-3680; e-mail: [email protected]
Copyright 2001 Society for Academic Emergency Medicine
KEYWORDS
ultrasound emergency ultrasonography cardiac arrest outcome prediction emergency medicine
ABSTRACT
Abstract. 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). Objective: To examine the predictive value of cardiac standstill visualized on bedside ED echocardiograms during the initial presentations of patients receiving cardiopulmonary resuscitation (CPR). Methods: 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. Results: 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%. Conclusions: 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.
- Joined
- Nov 24, 2002
- Messages
- 24,442
- Reaction score
- 18,068
End tidal CO2 less than 20, or no CO2 on qualitative measurement, and no cardiac activity on bedside ultrasound in an asystolic patient is prima facie evidence to stop resuscitative efforts in a euthermic patient.
If the paramedics have been flogging the patient, I do minimal interventions if these are true.
If the paramedics have been flogging the patient, I do minimal interventions if these are true.
- Joined
- Jul 25, 2003
- Messages
- 1,614
- Reaction score
- 6
I would just echo what's been said. In summary - if there is no coordinated cardiac activity on echo after prolonged resuscitation you can call it. Earlier in the code it can help identify reversible causes of arrest.
how many rounds of shock/cpr are you guys giving typically for vfib on monitor without pulse and no cardiac motion on u/s? and if you have some mild cardiac motion, but pt still not responding to shocks/meds/cpr and still without pulse but vfib on monitor how long are you guys going for?
- Joined
- Jul 17, 2008
- Messages
- 40
- Reaction score
- 0
Here is the C.A.U.S.E paper from Maimonides. Figure 8 shows a good algorithmic approach
http://emcrit.org/pdf/cause protocol.pdf
http://emcrit.org/pdf/cause protocol.pdf
http://emcrit.org/pdf/cause protocol.pdf
http://emcrit.org/pdf/cause protocol.pdf
