Cardiac ultrasound

Monitoring the quality of cardiopulmonary resuscitation

PURPOSE OF REVIEW

Numerous recent reports have described limitations in the quality of cardiopulmonary resuscitation. Thus, there has been increasing interest in the techniques available to monitor quality. This review focuses on the major publications since the review published by the International Liaison Committee on Resuscitation in 2005. Some key articles published prior to this time period have also been included.

RECENT FINDINGS

A number of devices can monitor various components of the quality of cardiopulmonary resuscitation. End-tidal CO2 measurement assists in confirming placement of endotracheal tubes, correlates with cardiac output and detects the return of spontaneous circulation. Turbine flow-meters monitor respiratory rate and tidal volume. Transthoracic impedance monitoring measures respiratory rate, and may assist in confirmation of endotracheal tube placement. A new mechanical device (CPREzy) and a new defibrillator/monitor allow estimation of depth (and rate) of compressions. Ventricular-fibrillation waveform analysis may facilitate better timing of defibrillation. Echocardiography detects conditions that may impair the quality of cardiopulmonary resuscitation.

SUMMARY

Many options are available to monitor the quality of cardiopulmonary resuscitation. Some have significant limitations, and others are only readily available in hospital. The use of the information from this more intensive monitoring promises to improve outcomes of cardiopulmonary resuscitation.

Current issues with emergency cardiac ultrasound probe and image conventions

As emergency physicians (EPs) and other noncardiologists incorporate bedside ultrasound (US) and bedside echocardiography (echo) into their practice, confusion has resulted from the differing imaging conventions used by cardiac and general imaging. The author discusses the origin of these differences, current cardiac imaging conventions, and controversies in emergency medicine (EM) regarding adoption of imaging conventions. Also discussed in detail are specific echo windows and experience with different approaches. While there is no perfect solution to merging the differing conventions, it is important that those performing and teaching bedside US and echo have a thorough understanding of the issues involved, and adopt a consistent approach.

Identification and Resuscitation of the Trauma Patient in Shock

This article focuses on rapid diagnosis and treatment of the patient suffering from trauma-related shock, including early identification of patients at risk for occult hypoperfusion. Resuscitation strategies (delayed resuscitation, damage control resuscitation), end points of resuscitation, and the role of blood products and pro-coagulants for resuscitation are discussed.

Presentation and outcome of infective endocarditis in Spain: a retrospective study

OBJECTIVE

To analyze cases of infective endocarditis in patients who attended the Hospital General de Castellón, Spain, between 1999 and 2004.

METHODS

This was a retrospective study. Demographic and clinical characteristics were assessed, variation in presentation over time was analyzed, and factors influencing outcome were determined.

RESULTS

A total of 54 cases in 48 patients were included; 33 (61%) were in men. The median patient age was 62 years. Infective endocarditis occurred on a native valve in 36 cases (67%), a mechanical prosthetic valve in 12 (22%), and a pacemaker in six (11%). The mitral valve was the most commonly affected site. Transthoracic and/or transesophageal echocardiography showed a vegetation in 45 (83%) cases, moderate or severe valvular regurgitation in 27 (50%), and intracardiac destructive lesions in five (9%). The outcome in 15 (28%) cases was death, and multivariate analysis disclosed significantly increased risk of death associated with older age, lower serum albumin, and higher white blood cell count.

CONCLUSIONS

This study confirmed the protean nature of infective endocarditis, and identified several factors predictive of mortality including advanced age, low serum albumin, and high white blood cell count.

Red flag in the Emergency Department: Fracture and primary failure of a prosthetic valve

This case report concerns a patient with fracture and primary dysfunction of a prosthetic valve. A 40-year-old man presented to the Emergency Department with a chief complaint of breakthrough pleuritic back pain and shortness of breath. Past surgical history was significant only for an aortic valve replacement and mitral valve replacement performed 16 years prior. The transthoracic echocardiography raised suspicion of prosthesis malposition. The patient was taken to the operating room by cardiothoracic surgeons for valve replacement. Operative findings revealed that a prosthetic valve leaflet in the mitral position had broken off. Primary prosthetic valve failure should not be overlooked in the differential diagnosis of patients with valve replacement and a rapidly deteriorating clinical course. Emergency echocardiography is a guide to convenient diagnosis and management. Early surgical consultation and early reparative surgery might prevent unnecessary morbidity and mortality.