Timing of focused cardiac ultrasound during advanced life support – A prospective clinical study

Point-of-care ultrasound induced changes in management of unselected patients in the emergency department - a prospective single-blinded observational trial

Background

Point-of-Care ultrasound (POCUS) changes the management in specific groups of patients in the Emergency Department (ED). It seems intuitive that POCUS holds an unexploited potential on a wide variety of patients. However, little is known about the effect of ultrasound on the broad spectrum of unselected patients in the ED. This study aimed to identify the effect on the clinical management if POCUS was applied on unselected patients. Secondarily the study aimed to identify predictors of ultrasound changing management.

Methods

This study was a blinded observational single center trial. A basic whole body POCUS protocol was performed in extension to the physical examination. The blinded treating physicians were interviewed about the presumptive diagnosis and plan for the patient. Subsequently the physicians were unblinded to the POCUS results and asked to choose between five options regarding the benefit from POCUS results.

Results

A total of 403 patients were enrolled in this study. The treating physicians regarded POCUS examinations influence on the diagnostic workup or treatment as following: 1) No new information: 249 (61.8%), 2) No further action: 45 (11.2%), 3) Further diagnostic workup needed: 52 (12.9%), 4) Presumptive diagnosis confirmed 38 (9.4%), and 5) Immediate treatment needed: 19 (4.7%). Predictors of beneficial ultrasound were: (a) triage > 1, (b) patient comorbidities (cardiac disease, hypertension or lung disease), or (c) patients presenting with abdominal pain, dyspnea, or syncope.

Conclusion

POCUS was found to be potentially beneficial in 27.0% of all patients. High triage score, known cardiac disease, hypertension, pulmonary diseases, a clinical presentation with abdominal pain, dyspnea, or syncope are predictors of this. Future research should focus on patient-important outcomes when applying POCUS on these patients.

Trial registration

The trail was registered prior to patient inclusion with the Danish Data Protection Agency (https://www.datatilsynet.dk/ Case no: 1–16–02-603-14) and Clinical Trials (www.clinicaltrials.gov/ Protocol ID: DNVK1305018).

COACHRED: A protocol for the safe and timely incorporation of focused echocardiography into the rhythm check during cardiopulmonary resuscitation

Focused echocardiography may be a useful tool in cardiopulmonary resuscitation for prognostication, to identify certain reversible causes of cardiac arrest, and to guide further management and procedures. Nonetheless, many clinicians have reservations regarding its widespread adoption due to evidence that it leads to prolonged interruption of cardiac compressions. Furthermore, the lack of a clear protocol for the inclusion of focused echocardiography into the rhythm check can lead to confusion in teams not familiar with incorporating the modality, as well as safety concerns for the echosonographer during delivery of a shock. We propose the protocol COACHRED to guide the use of focused echocardiography during rhythm check in a safe and timely manner. This approach incorporates the best strategies identified to date that minimise interruptions to chest compressions. We demonstrate that, in a simulation environment, it is achievable to incorporate focused echocardiography into the rhythm check while keeping the interruption to chest compressions within the timeframe prescribed by international guidelines.