ResUS in the Literature: Echo Integrated ACLS

Journal:  Chinese Journal of Traumatology

Title: Echocardiography integrated ACLS protocol versus conventional cardiopulmonary resuscitation in patients with pulseless electrical activity cardiac arrest.

Authors: Chardoli M, Heidari F, Rabiee H, Sharif-Alhoseini M, Shokoohi H, Rahimi-Movaghar V.

Date: 2012

Design: Prospective interventional study, patients presenting with PEA arrest were randomized into two groups.

• Group A, trained emergency physicians performed echocardiography.
• Group B underwent ACLS protocol without echocardiography

Measures: Evaluated cardiac activity, right ventricle dilation, left ventricle function, pericardial effusion/tamponade and IVC size. The presence or absence of mechanical ventricular activity (MVA) and evidence of PEA reversible causes were recorded. The return of spontaneous circulation (ROSC) and death were evaluated in both groups.

Results:

100 patients enrolled (50 in Group A, 50 in Group B)

The resuscitation outcomes for PEA arrest patients with/without cardiac activity on ResUS are described in Table 1

Importantly: The presence of  ventricular activity had 43% positive predictive value for ROSC. The absence of ventricular activity had 100% positive predictive value for death

The authors noted:
"ROSC was recorded in 17 (34%) and 14 (28%) patients in Groups A and B, respectively. However, resuscitation results did not indicate any significant difference between the two groups (P=0.52, power=0.06)"

Commentary: 

The only randomized trial of ResUS cited by AHA 2015 guidelines in support of ResUS during CPR.  ResUS "may be considered during the management of cardiac arrest, although its usefulness has not been well established (Class IIb, LOE C-EO)".

• This study demonstrates no survival benefit in patients receiving ResUS. 
• A qualified sonographer needs to be present 
• ResUS should not interfere with the standard treatment.
• No cardiac activity = death

Small number of cases, single center, More (large scale) studies are needed!

Posted by: A Adedipe, MD

ResUS Pearl: Confirmation of ETT Placement

POCUS can be used as an adjunct method for verification of proper endotracheal tube (ETT) placement, and can be used in real-time during or immediately following laryngoscopy.

Advantages

Helpful for emergency intubations where ETCO₂ has a higher error rate:

• Cardiac Arrest 
• Status Asthmaticus
• Pulmonary Edema
• Pulmonary Embolism 

Additionally, unlike ETCO₂ detectors, ultrasound can help confirm appropriate ETT depth.

Technique
Place a high frequency linear probe in the transverse position just cephalad to the suprasternal notch.

US Findings

Several different confirmatory findings have been described to determine ETT location, primarily relying on the exclusion of esophageal intubation. To date, there is no sonographic finding that is widely accepted amongst investigators.

References

American College of Emergency Physicians Board of Directors. Verification of Endotracheal Tube Placement. policy statement. Revised April 2009.

Favot, M. Ultrasound for Verification of Endotracheal Tube Location. Academic Life in Emergency Medicine.  March 2015.

Submitted by: A Hughes, MD

ResUS in the Literature: AHA Guidelines 2015

Ultrasound During Cardiac Arrest^{ALS 658}

Bedside cardiac and noncardiac ultrasound are frequently used as diagnostic and prognostic tools for critically ill patients.⁴⁴ Ultrasound may be applied to patients receiving CPR to help assess myocardial contractility and to help identify potentially treatable causes of cardiac arrest such as hypovolemia, pneumothorax, pulmonary thromboembolism, or pericardial tamponade.⁴⁵ However, it is unclear whether important clinical outcomes are affected by the routine use of ultrasound among patients experiencing cardiac arrest.

 

2015 Evidence Summary

One limited study with a small sample size was identified that specifically addressed the utility of ultrasound during cardiac arrest. This study evaluated bedside cardiac ultrasound use during ACLS among adult patients in pulseless electrical activity arrest and found no difference in the incidence of ROSC when ultrasound was used.⁴⁶

 

2015 Recommendations—Updated

Ultrasound (cardiac or noncardiac) may be considered during the management of cardiac arrest, although its usefulness has not been well established (Class IIb, LOE C-EO). If a qualified sonographer is present and use of ultrasound does not interfere with the standard cardiac arrest treatment protocol, then ultrasound may be considered as an adjunct to standard patient evaluation (Class IIb, LOE C-EO).

Clinical Assessment of Tracheal Tube Placement^{ALS 469}

 

Attempts at endotracheal intubation during CPR have been associated with unrecognized tube misplacement or displacement as well as prolonged interruptions in chest compression. Inadequate training, lack of experience, patient physiology (eg, low pulmonary blood flow, gastric contents in the trachea, airway obstruction), and patient movement may contribute to tube misplacement. After correct tube placement, tube displacement or obstruction may develop. In addition to auscultation of the lungs and stomach, several methods (eg, waveform capnography, CO2 detection devices, esophageal detector device, tracheal ultrasound, fiberoptic bronchoscopy) have been proposed to confirm successful tracheal intubation in adults during cardiac arrest.

 

2015 Evidence Summary

An ultrasound transducer can be placed transversely on the anterior neck above the suprasternal notch to identify endotracheal or esophageal intubation. In addition, ultrasound of the thoracic cavity can identify pleural movement as lung sliding. Unlike capnography, confirmation of ETT placement via ultrasonography is not dependent on adequate pulmonary blood flow and CO₂ in exhaled gas.^76–78 One small prospective study of experienced clinicians compared tracheal ultrasound to waveform capnography and auscultation during CPR and reported a positive predictive value for ultrasound of 98.8% and negative predictive value of 100%.⁷⁸ The usefulness of tracheal and pleural ultrasonography, like fiberoptic bronchoscopy, may be limited by abnormal anatomy, availability of equipment, and operator experience.

 

2015 Recommendations—Updated

Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an ETT (Class I, LOE C-LD). If continuous waveform capnometry is not available, a nonwaveform CO₂ detector, esophageal detector device, or ultrasound used by an experienced operator is a reasonable alternative (Class IIa, LOE C-LD).

Reference
Part 7: Adult Advanced Cardiovascular Life Support . 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015