Diagnostic Test Accuracy of Point-of-Care Ultrasound During Cardiopulmonary Resuscitation to Indicate the Etiology of Cardiac Arrest: A Systematic Review

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.

Early point-of-care echocardiography as a predictive factor for absence of return of spontaneous circulatory in out-of-hospital cardiac arrests: A multicentre observational study

INTRODUCTION

Early assessment of the prognosis of a patient in cardiac arrest during cardiopulmonary resuscitation is highly challenging. This study aims to evaluate the predictive outcome value of early point-of-care ultrasound (POCUS) in out-of-hospital settings.

METHODS

This observational, prospective, multicentre study's primary endpoint was the positive predictive value (PPV) of POCUS cardiac standstill within the first 12 min of advanced life support (ALS) initiation in determining the absence of return of spontaneous circulation (ROSC). A multivariate logistic regression model was constructed with adjustments for known predictive variables typically used in termination of resuscitation (TOR) rules.

RESULTS

A total of 293 patients were analysed, with a mean age of 66.6 ± 14.6 years, and a majority were men (75.8%). POCUS was performed on average 7.9 ± 2.6 min after ALS initiation. Among patients with cardiac standstill (72.4%), 16.0% achieved ROSC compared with 48.2% in those with visible cardiac motions. The PPV of early POCUS cardiac standstill for the absence of ROSC was 84.0%, 95% CI [78.3-88.6]. In multivariable analysis, only POCUS cardiac standstill (adjusted odds ratio [aOR] 3.89, 95% CI [1.86-8.17]) and end-tidal CO2 (ETCO2) value ≤37 mmHg (aOR 4.27, 95% CI [2.21-8.25]) were associated with the absence of ROSC.

CONCLUSION

Early POCUS cardiac standstill during CPR for out-of-hospital cardiac arrest was a reliable predictor of the absence of ROSC. However, its presence alone was not sufficient to determine the termination of resuscitation efforts.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03494153. Registered March 29, 2018.

Guidance for performance, utilization, and education of cardiac and lung point-of-care ultrasonography from the Japanese Society of Echocardiography

In recent years, bedside ultrasound examinations have been used in many clinical departments and are called point-of-care ultrasound (POCUS). Regarding POCUS in the cardiac field, a protocol called focus (focused) cardiac ultrasound (FoCUS) has been developed in Europe and the United States, is being used clinically, and an educational syllabus has been created. According to them, FoCUS is defined as a point-of-care cardiac ultrasound examination using standardized limited sections and protocols. FoCUS is primarily intended to be performed by non-cardiologists, and in order to avoid making mistakes in judgment, it is important to be familiar with its limitations and it is necessary to understand pathological conditions that can only be diagnosed using conventional comprehensive echocardiography. The Japanese Society of Echocardiography has edited this clinical guideline because we believe that FoCUS should be used effectively and appropriately in Japan, and that appropriate education is essential to popularize FoCUS in Japan. Furthermore, lung POCUS has recently come into clinical use. Lung POCUS is useful for the diagnosis and follow-up of heart failure when used in conjunction with FoCUS, and is especially useful in primary care where chest X-rays are not available. The working group that created this manual agreed that it is desirable to educate patients about lung POCUS in conjunction with FoCUS, so we decided to include the basic techniques of lung POCUS and how to use them in this manuscript.

Advanced life support interventions during intra-operative cardiac arrest among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists

BACKGROUND

Few existing resuscitation guidelines include specific reference to intra-operative cardiac arrest, but its optimal treatment is likely to require some adaptation of standard protocols.

METHODS

We analysed data from the 7th National Audit Project of the Royal College of Anaesthetists to determine the incidence and outcome from intra-operative cardiac arrest and to summarise the advanced life support interventions reported as being used by anaesthetists.

RESULTS

In the baseline survey, > 50% of anaesthetists responded that they would start chest compressions when the non-invasive systolic pressure was < 40-50 mmHg. Of the 881 registry patients, 548 were adult patients (aged > 18 years) having non-obstetric procedures under the care of an anaesthetist, and who had arrested during anaesthesia (from induction to emergence). Sustained return of spontaneous circulation was achieved in 425 (78%) patients and 338 (62%) were alive at the time of reporting. In the 365 patients with pulseless electrical activity or bradycardia, adrenaline was given as a 1 mg bolus in 237 (65%). A precordial thump was used in 14 (3%) patients, and although this was associated with return of spontaneous circulation at the next rhythm check in almost three-quarters of patients, in only one of these was the initial rhythm shockable. Calcium (gluconate or chloride) and 8.4% sodium bicarbonate were given to 51 (9%) and 25 (5%) patients, but there were specific indications for these treatments in less than half of the patients. A thrombolytic drug was given to 5 (1%) patients, and extracorporeal cardiopulmonary resuscitation was used in 9 (2%) of which eight occurred during cardiac procedures.

CONCLUSIONS

The specific characteristics of intra-operative cardiac arrest imply that its optimal treatment requires modifications to standard advanced life support guidelines.

Bedside-focused transthoracic echocardiography in acute atraumatic thoracic aortic syndrome: a systematic review and meta-analysis of diagnostic accuracy

The objective of this review is to assess the diagnostic accuracy of bedside-focused transthoracic echocardiography (TTE) in acute atraumatic thoracic aortic syndrome in adults. We performed a systematic review and meta-analysis of publications that described the use of bedside-focused TTE on adults presenting to the emergency care setting with suspected atraumatic thoracic aortic syndrome. Studies were identified using keyword and Medical Subject Heading searches on databases and grey literature, followed by abstract screening and study selection by two independent reviewers. Sixteen studies over six decades were included in the meta-analysis (n = 4569 patients). The prevalence of Type A thoracic aortic dissection was 11% (range 1.4-45.7%) and Type B dissection was 7% (range 1.8-30.55%). Type A dissection through direct visualisation of an intimal flap on TTE (i.e. direct sign) pooled sensitivity and specificity were 89% [95% confidence interval (CI), 82-94%] and 92% (95% CI, 88-95%) respectively. For Type B dissection, the pooled sensitivity was 65% (95% CI, 45-80%) and specificity was 100% (95% CI, 0.69-100%). TTE indirect signs for dissection showed a pooled sensitivity of 64% (95% CI, 5.2-98.2%) and specificity of 94% (95% CI, 92-96.1%) for aortic valve regurgitation, a pooled sensitivity of 92% (95% CI 54-99.2%) and specificity of 87% (95% CI, 62-97%) for thoracic aortic aneurysm and a pooled sensitivity of 39% (95% CI 33.8-45%) and a specificity of 94% (95% CI, 92-95%) for pericardial effusion. In this systematic review and meta-analysis, bedside-focused TTE has a good specificity for Type A and B dissection, but poor sensitivity for Type B, and unclear for intramural haematoma and penetrating aortic ulcer.

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.

Application of the TiPS65 score for out-of-hospital cardiac arrest patients with initial non-shockable rhythm treated with ECPR

Background

The TiPS65 score is a validated scoring system used to predict neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients with shockable rhythm treated with extracorporeal cardiopulmonary resuscitation (ECPR). This study aimed to assess the predictive performance of the TiPS65 score in OHCA patients with initial non-shockable rhythm treated with ECPR.

Methods

This was a secondary analysis using the JAAM-OHCA registry, a multicenter prospective cohort study. The study included adult OHCA patients with initial non-shockable rhythm who underwent ECPR. The TiPS65 score assigned one point to each of four variables: time to hospital ≤25 minutes, pH value ≥7.0 on initial blood gas assessment, shockable on hospital arrival, and age younger than 65 years. Based on the sum score, the predictive performance for 1-month survival and favorable neurological outcomes, defined as the Cerebral Performance Category 1 or 2, was evaluated.

Results

Among 57,754 patients in the registry, 370 were included in the analysis. The overall one-month survival and favorable neurological outcome were 11.1% (41/370) and 4.2% (15/370), respectively. The 1-month survival rates based on the TiPS65 score were as follows: 11.2% (12/107) for 0 points, 9.3% (14/150) for 1 point, 10.0% (9/90) for 2 points, and 26.1% (6/23) for ≥3 points. Similarly, the 1-month favorable neurological outcomes were: 5.6% (6/107) for 0 points, 2.7% (4/150) for 1 point, 4.4% (4/90) for 2 points, and 4.3% (1/23) for ≥3 points. The area under the curve was 0.535 (95% CI: 0.437-0.630) for 1-month survival and 0.530 (95% CI: 0.372-0.683) for 1-month neurological outcome.

Conclusion

This study demonstrates that the TiPS65 score has limited prognostic performance among OHCA patients with initial non-shockable rhythm treated with ECPR. Further research is warranted to develop a predictive tool specifically focused on OHCA with initial non-shockable rhythm to aid in determining candidates for ECPR.

Termination of Cardiopulmonary Resuscitation in Mountain Rescue: A Scoping Review and ICAR MedCom 2023 Recommendations

Lugnet, Viktor, Miles McDonough, Les Gordon, Mercedes Galindez, Nicolas Mena Reyes, Alison Sheets, Ken Zafren, and Peter Paal. Termination of cardiopulmonary resuscitation in mountain rescue: a scoping review and ICAR MedCom 2023 recommendations. High Alt Med Biol. 24:274-286, 2023. Background: In 2012, the International Commission for Mountain Emergency Medicine (ICAR MedCom) published recommendations for termination of cardiopulmonary resuscitation (CPR) in mountain rescue. New developments have necessitated an update. This is the 2023 update for termination of CPR in mountain rescue. Methods: For this scoping review, we searched the PubMed and Cochrane libraries, updated the recommendations, and obtained consensus approval within the writing group and the ICAR MedCom. Results: We screened a total of 9,102 articles, of which 120 articles met the inclusion criteria. We developed 17 recommendations graded according to the strength of recommendation and level of evidence. Conclusions: Most of the recommendations from 2012 are still valid. We made minor changes regarding the safety of rescuers and responses to primary or traumatic cardiac arrest. The criteria for termination of CPR remain unchanged. The principal changes include updated recommendations for mechanical chest compression, point of care ultrasound (POCUS), extracorporeal life support (ECLS) for hypothermia, the effects of water temperature in drowning, and the use of burial times in avalanche rescue.

The effect of point-of-care ultrasound on length of stay and mortality in patients with chest pain/dyspnea

PURPOSE

This study aims to investigate the effects of point-of-care ultrasound (PoCUS) on length of stay (LOS) and mortality in hemodynamically stable patients with chest pain/dyspnea.

MATERIALS AND METHODS

The prospective study was conducted from June 2020 to May 2021. A convenience sample of adult non-traumatic patients with chest pain/dyspnea was included and evaluated by PoCUS. The primary outcome was the relationship between the door-to-PoCUS time and LOS/mortality categorized by the ST-segment elevation (STE) and non-STE on the initial electrocardiogram. The diagnostic accuracy of PoCUS was computed, compared to the final diagnosis.

RESULTS

A total of 465 patients were included. 3 of 18 patients with STE had unexpected cardiac tamponade and 1 had myocarditis with pulmonary edema. PoCUS had a minimal effect on LOS and mortality in patients with STE. In the non-STE group, the shorter door-to-PoCUS time was associated with a shorter LOS (coefficient, 1.26±0.47, p=0.008). After categorizing the timing of PoCUS as 30, 60, 90, and 120 minutes, PoCUS had a positive effect, especially when performed within 90 minutes of arrival, on LOS of less than 360 minutes (OR, 2.42, 95% CI, 1.61-3.64) and patient survival (OR, 3.32, 95% CI, 1.14-9.71). The overall diagnostic performance of PoCUS was 96.6% (95% CI, 94.9-98.2%), but lower efficacy occurred in pulmonary embolism and myocardial infarction.

CONCLUSION

The use of PoCUS was associated with a shorter LOS and less mortality in patients with non-STE, especially when performed within 90 minutes of arrival. Although the effect on patients with STE was minimal, PoCUS played a role in discovering unexpected diagnoses.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Establishing the international research priorities for pediatric emergency medicine point-of-care ultrasound: A modified Delphi study

BACKGROUND

The Pediatric Emergency Medicine (PEM) Point-of-care Ultrasound (POCUS) Network (P2Network) was established in 2014 to provide a platform for international collaboration among experts, including multicenter research. The objective of this study was to use expert consensus to identify and prioritize PEM POCUS topics, to inform future collaborative multicenter research.

METHODS

Online surveys were administered in a two-stage, modified Delphi study. A steering committee of 16 PEM POCUS experts was identified within the P2Network, with representation from the United States, Canada, Italy, and Australia. We solicited the participation of international PEM POCUS experts through professional society mailing lists, research networks, social media, and "word of mouth." After each round, responses were refined by the steering committee before being reissued to participants to determine the ranking of all the research questions based on means and to identify the high-level consensus topics. The final stage was a modified Hanlon process of prioritization round (HPP), which emphasized relevance, impact, and feasibility.

RESULTS

Fifty-four eligible participants (16.6%) provided 191 items to Survey 1 (Round 1). These were refined and consolidated into 52 research questions by the steering committee. These were issued for rating in Survey 2 (Round 2), which had 45 participants. At the completion of Round 2, all questions were ranked with six research questions reaching high-level consensus. Thirty-one research questions with mean ratings above neutral were selected for the HPP round. Highly ranked topics included clinical applications of POCUS to evaluate and manage children with shock, cardiac arrest, thoracoabdominal trauma, suspected cardiac failure, atraumatic limp, and intussusception.

CONCLUSIONS

This consensus study has established a research agenda to inform future international multicenter PEM POCUS trials. This study has highlighted the ongoing need for high-quality evidence for PEM POCUS applications to guide clinical practice.

Risen Alive: The Lazarus Phenomenon

The Lazarus phenomenon described as delayed return of spontaneous circulation (ROSC) after cessation of CPR is rare, though underreported. We present the case of a 25-year-old woman who visited our hospital for persistent vomiting and weight loss for the last six months following bariatric surgery. On the 16^th day of admission, the patient experienced cardiac arrest (code blue). The patient underwent 73 min of continuous cardiopulmonary resuscitation (CPR); however, no responses were observed, which led to an announcement of death. Fifty minutes later, the family members noticed subtle eye movements that necessitated resumption of the advanced cardiac life support protocol and resuscitation. The patient survived; however, she developed significant neurological deficits secondary to prolonged anoxic brain injury. She was discharged after a ten-week stay in the hospital but did not achieve full neurologic, cognitive, and motor recovery. Patients should be observed and monitored after the cessation of CPR before confirming death.