Variability in Interpretation of Cardiac Standstill Among Physician Sonographers

Cardiac Point-Of-Care Ultrasound: An Emergency Medicine Review

Cardiac point-of-care ultrasound (POCUS) can make critical diagnoses and monitor the response to interventions. In contrast with consultative echocardiography, cardiac POCUS serves to answer a specific clinical question. This imaging modality can be used to evaluate for left ventricular systolic and diastolic dysfunction, pericardial effusion and tamponade, acute and chronic right ventricular dysfunction, valvular dysfunction, and cardiac activity in cardiac arrest.

Utility of Point-of-Care Ultrasound During Prone Positioning Cardiopulmonary Resuscitation

This report describes a 34-year-old male admitted to the medical intensive care unit (ICU) who sustained cardiac arrest while in prone positioning. Prone position CPR was initiated, and the utilization of point-of-care ultrasound (POCUS) during CPR was necessary to assess compression quality. Specifically, the popliteal was observed using POCUS to gauge the adequacy of compressions and subsequent perfusion during prone position CPR. This approach provides insight into assessing the effectiveness of chest compressions in a challenging prone position, potentially improving outcomes in similar cases. Further research and application of POCUS in this context may enhance the quality of CPR and patient care during cardiac arrest events in prone positioning.

Updates on the clinical integration of point-of-care ultrasound in pediatric emergency medicine

PURPOSE OF REVIEW

There is expanding evidence for point-of-care ultrasound (POCUS) use in pediatric emergency medicine - this review highlights the benefits and challenges in the clinical integration of high-yield POCUS applications. Specifically, it will delve into POCUS applications during resuscitations, controversies of Focused Assessment with Sonography for Trauma (FAST) in pediatric trauma, POCUS-guided procedures, and examples of clinical pathways where POCUS can expedite definitive care.

RECENT FINDINGS

POCUS can enhance diagnostic accuracy and aid in management of pediatric patients in shock and help identify reversible causes during cardiac arrest. The use of the FAST in pediatric blunt abdominal trauma remains nuanced - its proper use requires an integration with clinical findings and an appreciation of its limitations. POCUS has been shown to enhance safety and efficacy of procedures such as nerve blocks, incision & drainage, and intravenous access. Integrating POCUS into pathways for conditions such as intussusception and testicular torsion expedites downstream care.

SUMMARY

POCUS enhances diagnostic efficiency and management in pediatric patients arriving at the ED with undifferentiated shock, cardiac arrest, or trauma. Additionally, POCUS improves procedural success and safety, and is integral to clinical pathways for expediting definitive care for various pediatric emergencies. Future research should continue to focus on the impact of POCUS on patient outcomes, ensuring user competency, and the expansion of POCUS into diverse settings.

Use of point-of-care ultrasound during cardiac arrest in the intensive care unit: A cross-sectional survey

BACKGROUND

There is growing interest in the use of point-of-care ultrasound during cardiac arrest, but few studies document its use in the intensive care unit.

OBJECTIVE

We hypothesised this may reflect a low prevalence of use of point-of-care ultrasound during cardiac arrest or negative attitudes towards its use. We aimed to determine the self-reported prevalence, attitudes towards, and barriers to use of point-of-care ultrasound during cardiac arrest in the intensive care unit.

METHODS

We conducted a web-based survey over 3 months (08/08/2022-06/11/2022), of intensive care unit consultants and registrars in Victoria, Australia. Descriptive and mixed-methods analyses of Likert-type and free-text answers were performed.

RESULTS

The response rate was 91/398 (22.8%), split evenly between consultants and registrars. There was a broad range of clinical and ultrasound experience. Only 22.4% (22/91) of respondents reported using point-of-care ultrasound 75-100% of the time during their management of cardiac arrest. Respondents rated the value they place in point-of-care ultrasound during cardiac arrest 3 (interquartile range: 3-4) and that of a "skilled operator" 4 ((interquartile range; 4-5) on a 5-point scale. Free-text analysis suggested exclusion of "tamponade" (40/80 [50%] comments) as the most valuable use-case and "skill" as a personal barrier (20/73 [27.4%] comments). Personal and departmental barriers were not rated highly, although registrars perceived "lack of a structured training program" as a barrier. Respondents were equivocal in the value they gave point-of-care ultrasound during cardiac arrest but saw greater value when conducted by a skilled operator.

CONCLUSIONS

Point-of-care ultrasound was reported to be infrequently used in cardiac arrest, mostly due to self-perceived skill and lack of a structured training program.

Can absence of cardiac activity on point-of-care echocardiography predict death in out-of-hospital cardiac arrest? A systematic review and meta-analysis

AIM

The purpose of this systematic review and meta-analysis was to evaluate the accuracy of the absence of cardiac motion on point-of-care echocardiography (PCE) in predicting termination of resuscitation (TOR), short-term death (STD), and long-term death (LTD), in adult patients with cardiac arrest of all etiologies in out-of-hospital and emergency department setting.

METHODS

A systematic review and meta-analysis was conducted based on PRISMA guidelines. A literature search in Medline, EMBASE, Cochrane, WHO registry, and ClinicalTrials.gov was performed from inspection to August 2022. Risk of bias was evaluated using QUADAS-2 tool. Meta-analysis was divided into medical cardiac arrest (MCA) and traumatic cardiac arrest (TCA). Sensitivity and specificity were calculated using bivariate random-effects, and heterogeneity was analyzed using I2 statistic.

RESULTS

A total of 27 studies (3657 patients) were included in systematic review. There was a substantial variation in methodologies across the studies, with notable difference in inclusion criteria, PCE timing, and cardiac activity definition. In MCA (15 studies, 2239 patients), the absence of cardiac activity on PCE had a sensitivity of 72% [95% CI 62-80%] and specificity of 80% [95% CI 58-92%] to predict LTD. Although the low numbers of studies in TCA preluded meta-analysis, all patients who lacked cardiac activity on PCE eventually died.

CONCLUSIONS

The absence of cardiac motion on PCE for MCA predicts higher likelihood of death but does not have sufficient accuracy to be used as a stand-alone tool to terminate resuscitation. In TCA, the absence of cardiac activity is associated with 100% mortality rate, but low number of patients requires further studies to validate this finding. Future work would benefit from a standardized protocol for PCE timing and agreement on cardiac activity definition.

POCUS literature primer: key papers on POCUS in cardiac arrest and shock

OBJECTIVE

The objective of this study is to identify the top five most influential papers published on the use of point-of-care ultrasound (POCUS) in cardiac arrest and the top five most influential papers on the use of POCUS in shock in adult patients.

METHODS

An expert panel of 14 members was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. The members of the panel are ultrasound fellowship trained or equivalent, are engaged in POCUS research, and are leaders in POCUS locally and nationally in Canada. A modified Delphi process was used, consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers for the use of POCUS in cardiac arrest and shock.

RESULTS

The panel identified 39 relevant papers on POCUS in cardiac arrest and 42 relevant papers on POCUS in shock. All panel members participated in all three rounds of the modified Delphi process, and we ultimately identified the top five most influential papers on POCUS in cardiac arrest and also on POCUS in shock. Studies include descriptions and analysis of safe POCUS protocols that add value from a diagnostic and prognostic perspective in both populations during resuscitation.

CONCLUSION

We have developed a reading list of the top five influential papers on the use of POCUS in cardiac arrest and shock to better inform residents, fellows, clinicians, and researchers on integrating and studying POCUS in a more evidence-based manner.

Interpretation of Cardiac Standstill in Children Using Point-of-Care Ultrasound

STUDY OBJECTIVE

This study aimed to determine the level of agreement among pediatric emergency medicine (PEM) physicians in whether various point-of-care ultrasound (POCUS) video clips represent cardiac standstill in children and to highlight the factors that may be associated with the lack of agreement.

METHODS

A single, online, cross-sectional, convenience sample survey was administered to PEM attendings and fellows with variable ultrasound experience. PEM attendings with an experience of 25 cardiac POCUS scans or more were the primary subgroup based on ultrasound proficiency set by the American College of Emergency Physicians. The survey contained 11 unique, 6-second video clips of cardiac POCUS performed during pulseless arrest in pediatric patients and asked the respondent if the video clip represented a cardiac standstill. The level of interobserver agreement was determined using the Krippendorff's α (Kα) coefficient across the subgroups.

RESULTS

A total of 263 PEM attendings and fellows completed the survey (9.9% response rate). Of the 263 total responses, 110 responses were from the primary subgroup of experienced PEM attendings with at least 25 previously seen cardiac POCUS scans. Across all video clips, PEM attendings with 25 scans or more had an acceptable agreement (Kα=0.740; 95% CI 0.735 to 0.745). The agreement was the highest for video clips wherein the wall motion corresponded to the valve motion. However, the agreement fell to unacceptable levels (Kα=0.304; 95% CI 0.287 to 0.321) across video clips wherein the wall motion occurred without the valve motion.

CONCLUSION

There is an overall acceptable interobserver agreement when interpreting cardiac standstill among PEM attendings with an experience of at least 25 previously reported cardiac POCUS scans. However, factors that may influence the lack of agreement include discordances between the wall and valve motion, suboptimal views, and the lack of a formal reference standard. More specific consensus reference standards of pediatric cardiac standstill may help to improve interobserver agreement moving forward and should include more specific details regarding the wall and valve motion.

Death and Ultrasound Evidence of the Akinetic Heart in Pediatric Cardiac Arrest

Point-of-care ultrasound (POCUS) is an expanding noninvasive diagnostic modality used for the management of patients in multiple intensive care and pediatric specialties. POCUS is used to assess cardiac activity and pathology, pulmonary disease, intravascular volume status, intra-abdominal processes, procedural guidance including vascular access, lumbar puncture, thoracentesis, paracentesis, and pericardiocentesis. POCUS has also been used to determine anterograde flow following circulatory arrest when organ donation after circulatory death is being considered. Published guidelines exist from multiple medical societies including the recent guidelines for the use of POCUS in neonatology for diagnostic and procedural purposes.

Cardiac POCUS in Pediatric Emergency Medicine: A Narrative Review

PURPOSE OF THIS REVIEW

The cardiac point of care ultrasound (POCUS) is among the most impactful examinations in the evaluation of an ill child. This paper will review the English-language literature on cardiac POCUS in the pediatric emergency department (PED), the adult emergency literature with relevance to pediatric emergency, and other pediatric cardiac studies outside pediatric emergency with relevance to PED detection of potentially emergent pediatric cardiac pathology.

RECENT FINDINGS

Pediatric emergency physicians can reliably detect decreased left-sided systolic function and pericardial effusion using POCUS. Case reports show that pediatric emergency physicians have detected right-sided outflow tract obstruction, aortic root dilatation, and congenital cardiac disease using POCUS. Training for pediatric cardiac POCUS competency is feasible, and cardiac POCUS does not increase the burden on cardiology resources to the PED.

SUMMARY

While cardiac pathology in children is relatively rare, pediatric cardiac POCUS can incorporate a broad curriculum beyond systolic function and the presence of pericardial fluid. Further research should assess pediatric emergency physician performance in the identification of a broader range of cardiac pathology.

Determining Intraosseous Needle Placement Using Point-of-Care Ultrasound in a Swine (Sus scrofa) Model

OBJECTIVE

Intraosseous (IO) access is critical in resuscitation, providing rapid access when peripheral vascular attempts fail. Unfortunately, misplacement commonly occurs, leading to possible fluid extravasation and tissue necrosis. Current research exploring the utility of bedside ultrasound in confirming IO line placement is limited by small sample sizes of skeletally immature subjects or geriatric cadaveric models. The objective of this study was to investigate the potential value of ultrasound confirming IO needle placement in a live tissue model with bone densities approximated to the young adult medical or trauma patient.

MATERIALS AND METHODS

In this randomized, blinded prospective study, IO devices were placed into the bilateral humeri of 36 sedated adult swine (N = 72) with bone densities approximating that of a 20-39-year-old adult. Of the 72 lines, 53 were randomized to the IO space ("correct") and 19 into the subcutaneous tissue ("incorrect"). Four emergency physicians with variable ultrasound experience and blinded to needle location independently assessed correct or incorrect needle placements based on the presence of an intramedullary "flare" on color power Doppler (CPD) during a saline flush. Participants adjusted the ultrasound beam trajectory and recorded assessments up to three times, totaling 204 separate observations.

RESULTS

Overall, sensitivity for placement confirmation was 72% (95% CI: 64%-79%). Specificity was 79% (95% CI: 66%-89%). First assessment and final assessment results were similar. More experienced sonographers demonstrated greater success in identifying inaccurate placements with a specificity of 86% (95% CI: 63%-96%).

CONCLUSION

Within the context of this study, point-of-care ultrasound with CPD did not reliably confirm IO line placement. However, more accurate assessments of functional and malpositioned catheters were noted in sonographers with greater than 4 years of experience. Future study into experienced sonographers' use of CPD to confirm IO catheter placement is needed.

Focused Ultrasonography in Cardiac Arrest

Rapid diagnostic tools available to the emergency physician caring for cardiac arrest patients are limited. Focused ultrasound (US), and in particular, focused echocardiography, is a useful tool in the evaluation of patients in cardiac arrest. It can help identify possible causes of cardiac arrest like tamponade and pulmonary embolism, which can guide therapy. US can also yield prognostic information, with lack of cardiac activity being highly specific for failure to achieve return of spontaneous circulation. US may also be used to aid in procedural guidance. Recently, focused transesophageal echocardiography has been used in the emergency department setting.

Agreement on Interpretation of Point-of-Care Ultrasonography for Cardiac Tamponade Among Emergency Physicians

STUDY OBJECTIVE

Cardiac tamponade is an impending calamitous disorder that emergency physicians need to consider and diagnose rapidly. A pericardial effusion with right atrial systolic collapse (earliest sign) or right ventricular diastolic collapse (most specific sign) and a plethoric inferior vena cava are indicators of cardiac tamponade physiology and may be identified with point-of-care ultrasonography (POCUS). The goal of this study is to assess the agreement among emergency physicians with varying levels of sonographic training and expertise in interpreting echocardiographic signs of cardiac tamponade in adult patients.  Methods: Emergency physicians at different levels of training as sonographers were surveyed at didactic conferences at three major academic medical centers in northern New Jersey. Two cardiologists were also included in the study for comparison. Survey respondents were shown 15, 20-second video clips of patients who had presented to the emergency department (ED) with or without significant pericardial effusions and were asked to rate whether tamponade physiology was present or not. Data were collected anonymously on Google Forms (Google LLC, Mountain View, CA) and included self-reported levels of POCUS expertise and level of training. Data were analyzed using Fleiss' kappa (k). All patients had an echocardiogram performed by the department of cardiology within 24 hours of the POCUS, and the results are presented in the paper.  Results: There were 97 participant raters, including attendings, fellows, and resident physicians specializing in adult emergency medicine and two cardiologists. There was a fair degree of inter-rater agreement among all participants in interpreting whether tamponade physiology was present or not. This low level of agreement persisted across self-reported training levels and self-reported POCUS expertise, even at the expert level in both emergency medicine and cardiology specialties.

CONCLUSION

According to the results of our study, there appears to be a low level of agreement in the interpretation of cardiac tamponade in adult patients. The lack of agreement persisted across specialties, self-reported training levels, and self-reported ultrasonographic expertise. This low level of agreement seen among both specialists indicates that emergency physicians are not limited in their ability to determine cardiac tamponade on POCUS. This highlights the technical nature of POCUS clips and strengthens the importance of physical exam findings when diagnosing cardiac tamponade in emergency department patients. Further research utilizing POCUS for the diagnosis of tamponade is warranted.

A highly predictive cardiac positron emission tomography (PET) risk score for 90-day and one-year major adverse cardiac events and revascularization

BACKGROUND

With the increase in cardiac PET/CT availability and utilization, the development of a PET/CT-based major adverse cardiovascular events, including death, myocardial infarction (MI), and revascularization (MACE-Revasc) risk assessment score is needed. Here we develop a highly predictive PET/CT-based risk score for 90-day and one-year MACE-Revasc.

METHODS AND RESULTS

11,552 patients had a PET/CT from 2015 to 2017 and were studied for the training and development set. PET/CT from 2018 was used to validate the derived scores (n = 5049). Patients were on average 65 years old, half were male, and a quarter had a prior MI or revascularization. Baseline characteristics and PET/CT results were used to derive the MACE-Revasc risk models, resulting in models with 5 and 8 weighted factors. The PET/CT 90-day MACE-Revasc risk score trended toward outperforming ischemic burden alone [P = .07 with an area under the curve (AUC) 0.85 vs 0.83]. The PET/CT one-year MACE-Revasc score was better than the use of ischemic burden alone (P < .0001, AUC 0.80 vs 0.76). Both PET/CT MACE-Revasc risk scores outperformed risk prediction by cardiologists.

CONCLUSION

The derived PET/CT 90-day and one-year MACE-Revasc risk scores were highly predictive and outperformed ischemic burden and cardiologist assessment. These scores are easy to calculate, lending to straightforward clinical implementation and should be further tested for clinical usefulness.

Transesophageal Echocardiography in Patients in Cardiac Arrest: The Heart and Beyond

Point of care ultrasound involves different ultrasound modalities and is useful to assist management in emergent clinical situations such as cardiac arrest. The use of point of care ultrasound in cardiac arrest has mainly been described using transthoracic echocardiography as a diagnostic and as a prognostic tool. However, cardiac evaluation using transthoracic echocardiography might be challenging because of patient-related or technical factors. Furthermore, its use during pulse check pauses has been associated with delays in chest compression resumption. Transesophageal echocardiography (TEE) overcomes these limitations by providing reliable and continuous imaging of the heart without interfering with cardiopulmonary resuscitation. In this narrative review we describe the role of TEE during cardiopulmonary resuscitation in 4 different applications: (1) chest compression quality feedback; (2) rhythm characterization; (3) diagnosis of reversible causes; and (4) procedural guidance. Considering its limitations, we propose an algorithm for the integration of TEE in patients with cardiac arrest with a focus on these 4 applications and extend its use to extracardiac applications.

Point-of-Care Ultrasound Compression of the Carotid Artery for Pulse Determination in Cardiopulmonary Resuscitation

AIM

To identify whether a novel pulse check technique, carotid artery compression using an ultrasound probe, can reduce pulse check times compared to manual palpation (MP).

METHODS

This prospective study was conducted in an emergency department between February and December 2021. A physician applied point-of-care ultrasound-carotid artery compression (POCUS-CAC) and assessed the carotid artery compressibility and pulsatility by probe compression during rhythm check time. Another clinician performed MP of the femoral artery. The primary outcome was the difference in the average time for pulse assessment between POCUS-CAC and MP. The secondary outcomes included the time difference in each pulse check between methods, the proportion of times greater than 5 s and 10 s, and the prediction of return of spontaneous circulation (ROSC) during ongoing chest compression.

RESULTS

25 cardiac arrest patients and 155 pulse checks were analyzed. The median (interquartile range) average time to carotid pulse identification per patient using POCUS-CAC was 1.62 (1.14-2.14) s compared to 3.50 (2.99-4.99) s with MP. In all 155 pulse checks, the POCUS-CAC time to determine ROSC was significantly shortened to 0.44 times the MP time (P < 0.001). The POCUS-CAC approach never exceeded 10 s, and the number of patients who required more than 5 s was significantly lower (5 vs. 37, P < 0.001). Under continuous chest compression, six pulse checks predicted the ROSC.

CONCLUSIONS

We found that emergency physicians could quickly determine pulses by applying simple POCUS compression of the carotid artery in cardiac arrest patients.

Focused echocardiography, end-tidal carbon dioxide, arterial blood pressure or near-infrared spectroscopy monitoring during paediatric cardiopulmonary resuscitation: A scoping review

AIM

To evaluate the individual use and predictive value of focused echocardiography, end-tidal carbon dioxide (EtCO2), invasive arterial blood pressure (BP) and near-infrared spectroscopy (NIRS) during cardiopulmonary resuscitation (CPR) in children.

METHODS

This scoping review was undertaken as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) and based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for scoping reviews. PubMed, MEDLINE, CINAHL and EMBASE were searched from the last ILCOR reviews until September 2020. We included all published studies evaluating the effect of echocardiography, EtCO2, BP or NIRS guided CPR on clinical outcomes and quality of CPR.

RESULTS

We identified eight observational studies, including 288 children. Two case series reported the use of echocardiography, one in detecting pulmonary emboli, the second in cardiac standstill, where contractility was regained with the use of extracorporeal membrane oxygenation. The two studies describing EtCO2 were ambivalent regarding the association between mean values and any outcomes. Mean diastolic BP was associated with increased survival and favourable neurological outcome, but not with new substantive morbidity in two studies describing an overlapping population. NIRS values reflected changes in EtCO2 and cerebral blood volume index in two studies, with lower values in patients who did not achieve return of circulation.

CONCLUSION

Although there seems some beneficial effect of these intra-arrest variables, higher quality paediatric studies are needed to evaluate whether echocardiography, EtCO2, BP or NIRS guided CPR could improve outcomes.

Barriers to point-of-care ultrasound utilization during cardiac arrest in the emergency department: a regional survey of emergency physicians

INTRODUCTION

Though point-of-care ultrasound (POCUS) is recognized as a useful diagnostic and prognostic intervention during cardiac arrest (CA), critics advise caution. The purpose of this survey study was to determine the barriers to POCUS during CA in the Emergency Department (ED).

METHODS

Two survey instruments were distributed to emergency medicine (EM) attending and resident physicians at three academic centers in the South Florida. The surveys assessed demographics, experience, proficiency, attitudes and barriers. Descriptive and inferential statistics along with Item Response Theory Logistic Model and the Friedman Test with Wilcoxon Signed Rank tests were used to profile responses and rank barriers.

RESULTS

206 EM physicians were invited to participate in the survey, and 187 (91%) responded. 59% of attending physicians and 47% of resident physicians reported that POCUS is performed in all their cases of CA. 5% of attending physicians and 0% of resident physicians reported never performing POCUS during CA. The top-ranked departmental barrier for attending physicians was "No structured curriculum to educate physicians on POCUS." The top-ranked personal barriers were "I do not feel comfortable with my POCUS skills" and "I do not have sufficient time to dedicate to learning POCUS." The top-ranked barriers for resident physicians were "Time to retrieve and operate the machine" and "Chaotic milieu."

CONCLUSIONS

While our study demonstrates that most attending and resident physicians utilize POCUS in CA, barriers to high-quality implementation exist. Top attending physician barriers relate to POCUS education, while the top resident physician barriers relate to logistics and the machines. Interventions to overcome these barriers might lead to optimization of POCUS performance during CA in the ED.

Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.

Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.

Checking the pulse in the 21st century: Interobserver reliability of carotid pulse detection by point-of-care ultrasound

INTRODUCTION

Detection of a pulse is crucial to decision-making in the care of patients who are in cardiac arrest, however, the current standard of manual pulse palpation is unreliable. An emerging alternative is the use of point-of-care ultrasound (POCUS) for direct assessment of the carotid pulse. The primary objective of this study is to determine the interobserver reliability for physician interpretation of pre-recorded point-of-care ultrasound pulse-check clips for patients who are in cardiac arrest.

METHODS

We conducted a web-based survey of residents and physicians working in an academic center. Participants were shown a tutorial demonstrating POCUS detection of the carotid pulse and then asked to interpret 15 carotid pulse ultrasound clips from patients who were in cardiac arrest. The primary outcome was interobserver reliability for carotid pulse assessment. Secondary outcomes included interobserver reliability stratified by physician role and POCUS experience, median tutorial and median pulse assessment duration. Interobserver reliability was determined by Krippendorff's ⍺.

RESULTS

68 participants completed the study, with a response rate of 75%. There was high interobserver reliability for pulse assessment amongst all study participants (⍺ = 0.874, 95% CI 0.869 to 0.879). All sub-groups had ⍺ greater than 0.8. Median tutorial duration was 35 s (IQR 29). Median pulse assessment duration was 6 s (IQR 5) with 76% of assessments completed within 10 s.

CONCLUSION

Interpretation of the carotid pulse by POCUS showed high interobserver reliability. Further work must be done to determine the performance of POCUS pulse assessment in real-time for patients who are in cardiac arrest.

Assessing the validity of two-dimensional carotid ultrasound to detect the presence and absence of a pulse

BACKGROUND

Traditional assessment of return of cardiac output in cardiac arrest by manual palpation has poor accuracy. Point of care ultrasound of a major artery has been suggested as an alternative. We conducted a diagnostic accuracy study of two-dimensional carotid ultrasound to detect the presence or absence of a pulse, using cardiopulmonary bypass patients for pulse and pulseless states.

METHODS

A cross-sectional multi-patient, multi-reader repeated measures diagnostic study was conducted. For patients undergoing routine cardiopulmonary bypass, a portable ultrasound was used to record four 10-s videos the common carotid artery, three aimed for a pulse in high (>90 mmHg), medium (70-90 mmHg) and low (<70 mmHg) systolic blood pressure (SBP) ranges, and a pulseless video was recorded on cardiopulmonary bypass. Critical care physicians viewed the videos and were asked to nominate within 10 s if a pulse was present. True pulse-status was determined via the arterial-line waveform.

RESULTS

Twenty-three patients had all four videos collected. Median patient age was 64 (IQR 14), sixteen were male (70%) and median BMI was 27. The median SBP in high-, medium- and low-SBP groups were 120 mmHg, 83 mmHg and 69 mmHg respectively. Forty-six physicians reviewed a subset of 24 videos. Overall sensitivity was 0.91 (95% confidence interval 0.89-0.93) and specificity 0.90 (95% CI 0.86-0.93). Sensitivity was highest in the high-SBP group (0.96, 95% CI 0.93-0.98) and lowest in the low-SBP group (0.83, 95% CI 0.78-0.87).

CONCLUSION

2D ultrasound of the common carotid artery is both sensitive and specific for detection of the presence or absence of a pulse.

Point-of-care cardiac ultrasound during cardiac arrest: a reliable tool for termination of resuscitation?

PURPOSE OF REVIEW

Point-of-care ultrasound (POCUS) is commonly used during cardiac arrest to screen for potential causes and to inform termination of resuscitation. However, unique biases and limitations in diagnostic and prognostic test accuracy studies lead to potential for misinterpretation. The present review highlights recent evidence regarding POCUS in cardiac arrest, guides the incorporation of POCUS into clinical management, and outlines how to improve the certainty of evidence.

RECENT FINDINGS

Multiple frameworks organize and direct POCUS during cardiac arrest. Although many are proofs of concept, several have been prospectively evaluated. Indirect evidence from undifferentiated shock suggests that POCUS offers better specificity than sensitivity as a diagnostic aid. The prognostic accuracy of POCUS during cardiac arrest to predict subsequent clinical outcomes is better characterized, but subject to unique biases and confounding. Low certainty direct evidence suggests that POCUS offers better specificity than sensitivity as a prognostic aid.

SUMMARY

POCUS findings might indicate a particular diagnosis or encourage the continuation of resuscitation, but absence of the same is not sufficient in isolation to exclude a particular diagnosis or cease resuscitation. Until the evidence to support POCUS during cardiac arrest is more certain, it is best characterized as a diagnostic and prognostic adjunct.

Prognostication with point-of-care echocardiography during cardiac arrest: A systematic review

AIM

To conduct a prognostic factor systematic review on point-of-care echocardiography during cardiac arrest to predict clinical outcomes in adults with non-traumatic cardiac arrest in any setting.

METHODS

We conducted this review per PRISMA guidelines and registered with PROSPERO (ID pending). We searched Medline, EMBASE, Web of Science, CINAHL, and the Cochrane Library on September 6, 2019. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using the Quality in Prognosis Studies (QUIPS) template. We estimated prognostic test performance (sensitivity and specificity) and measures of association (odds ratio). Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology evaluated the certainty of evidence.

RESULTS

In total, 15 studies were included. We found wide variation across studies in the definition of 'cardiac motion' and timing of sonographic assessment. Most studies were hindered by high risks of bias from prognostic factor measurement, outcome measurement, and lack of adjustment for other prognostic factors. Ultimately, heterogeneity and risk of bias precluded meta-analyses. We tabulated ranges of prognostic test performance and measures of association for 5 different combinations of definitions of 'cardiac motion' and sonographic timing, as well as other miscellaneous sonographic findings. Overall certainty of this evidence is very low.

CONCLUSIONS

The evidence for using point-of-care echocardiography as a prognostic tool for clinical outcomes during cardiac arrest is of very low certainty and is hampered by multiple risks of bias. No sonographic finding had sufficient and/or consistent sensitivity for any clinical outcome to be used as sole criterion to terminate resuscitation.

Impact of Point-of-Care Ultrasound in the Emergency Department on Care Processes and Outcomes in Critically Ill Nontraumatic Patients

Supplemental Digital Content is available in the text.

Outcomes data on point-of-care ultrasound (POCUS) in critically ill patients are lacking. This study examines the association between POCUS in the emergency department and outcomes in critically ill patients.

Critical care echocardiography and outcomes in the critically ill

PURPOSE OF REVIEW

Critical care echocardiography offers a comprehensive assessment of cardiac anatomy and function performed by the intensivist at point of care. This has resulted in widespread use of critical care echocardiography in ICUs leading to the question if this increased usage has resulted in improved patient outcomes.

RECENT FINDINGS

Recent studies have evaluated the role of critical care echocardiography in the ICU with an emphasis on establishing accurate diagnosis and measurement of haemodynamic variables. There are no prospective randomized controlled trials that have examined the effect of critical care echocardiography on patient outcomes SUMMARY: Although the effect of critical care echocardiography on patient outcomes has not yet been established, its value as a diagnostic tool has been well demonstrated. We can only assume that its diagnostic capability leads to an improvement in patient outcomes.

In-Hospital Cardiac Arrest: A Review

IMPORTANCE

In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with other high-risk cardiovascular conditions, such as stroke, myocardial infarction, and out-of-hospital cardiac arrest.

OBSERVATIONS

In-hospital cardiac arrest occurs in over 290 000 adults each year in the United States. Cohort data from the United States indicate that the mean age of patients with in-hospital cardiac arrest is 66 years, 58% are men, and the presenting rhythm is most often (81%) nonshockable (ie, asystole or pulseless electrical activity). The cause of the cardiac arrest is most often cardiac (50%-60%), followed by respiratory insufficiency (15%-40%). Efforts to prevent in-hospital cardiac arrest require both a system for identifying deteriorating patients and an appropriate interventional response (eg, rapid response teams). The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation, when applicable, and immediate attention to potentially reversible causes, such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. Post-cardiac arrest care is focused on identification and treatment of the underlying cause, hemodynamic and respiratory support, and potentially employing neuroprotective strategies (eg, targeted temperature management). Although multiple individual factors are associated with outcomes (eg, age, initial rhythm, duration of the cardiac arrest), a multifaceted approach considering both potential for neurological recovery and ongoing multiorgan failure is warranted for prognostication and clinical decision-making in the post-cardiac arrest period. Withdrawal of care in the absence of definite prognostic signs both during and after cardiac arrest should be avoided. Hospitals are encouraged to participate in national quality-improvement initiatives.

CONCLUSIONS AND RELEVANCE

An estimated 290 000 in-hospital cardiac arrests occur each year in the United States. However, there is limited evidence to support clinical decision making. An increased awareness with regard to optimizing clinical care and new research might improve outcomes.

Interpretation errors in focused cardiac ultrasound by novice pediatric emergency medicine fellow sonologists

Background

Focused cardiac ultrasound (FOCUS) is a core competency for pediatric emergency medicine (PEM) fellows. The objectives of this study were (1) to evaluate test characteristics of PEM-fellow-performed FOCUS for pericardial effusion and diminished cardiac function and (2) to assess image interpretation independent of image acquisition.

Methods

PEM fellows performed and interpreted FOCUS on patients who also received cardiology service echocardiograms, the reference standard. Subsequently, eight different PEM fellows remotely interpreted a subset of the PEM-acquired and cardiology-acquired echocardiograms.

Results

Eight PEM fellows performed 54 FOCUS exams, of which two had pericardial effusion and four had diminished function. PEM fellow FOCUS had a sensitivity of 50.0% (95% CI 9.19–90.8) and specificity of 100.0% (95% CI 91.1–100.0) for detecting diminished function, and sensitivity of 50.0% (95% CI 2.67–97.33) and specificity of 98.1% (95% CI 88.42–99.9) for detecting pericardial effusions. When PEM fellows remotely interpreted 15 echocardiograms, the sensitivity was 81.3% (95% CI 70.7–88.8) and specificity 75% (95% CI 67.0–81.0) for detecting diminished function, and sensitivity of 76.3% (95% CI 65.0–85.0) and specificity 94.4% (95% CI 89.0–97.0) for detecting pericardial effusion. There were no differences in sensitivity and specificity of PEM fellows’ interpretation of FOCUS studies compared to their interpretation of cardiology echocardiograms. Interrater reliability for interpretation of remote images (kappa) was 0.66 (95% CI 0.59–0.73) for effusion and 0.31 (95% CI 0.24–0.38) for function among the fellows.

Conclusion

Novice PEM fellow sonologists (a physician who performs and interprets ultrasound) in the majority of instances were able to acquire and remotely interpret FOCUS images with limited training. However, they made real-time interpretation errors and likely need further training to incorporate real-time image acquisition and interpretation into their practice.

Electronic supplementary material

The online version of this article (10.1186/s13089-018-0113-4) contains supplementary material, which is available to authorized users.