Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review

Artificial intelligence-based evaluation of carotid artery compressibility via point-of-care ultrasound in determining the return of spontaneous circulation during cardiopulmonary resuscitation

AIM

This study introduces RealCAC-Net, an artificial intelligence (AI) system, to quantify carotid artery compressibility (CAC) and determine the return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation.

METHODS

A prospective study based on data from a South Korean emergency department from 2022 to 2023 investigated carotid artery compressibility in adult patients with cardiac arrest using a novel AI model, RealCAC-Net. The data comprised 11,958 training images from 161 cases and 15,080 test images from 134 cases. RealCAC-Net processes images in three steps: TransUNet-based segmentation, the carotid artery compressibility measurement algorithm for improved segmentation and CAC calculation, and CAC-based classification from 0 (indicating a circular shape) to 1 (indicating high compression). The accuracy of the ROSC classification model was tested using metrics such as the dice similarity coefficient, intersection-over-union, precision, recall, and F1 score.

RESULTS

RealCAC-Net, which applied the carotid artery compressibility measurement algorithm, performed better than the baseline model in cross-validation, with an average dice similarity coefficient of 0.90, an intersection-over-union of 0.84, and a classification accuracy of 0.96. The test set achieved a classification accuracy of 0.96 and an F1 score of 0.97, demonstrating its efficacy in accurately identifying ROSC in cardiac arrest situations.

CONCLUSIONS

RealCAC-Net enabled precise CAC quantification for ROSC determination during cardiopulmonary resuscitation. Future research should integrate this AI-enhanced ultrasound approach to revolutionize emergency care.

Post cardiac arrest left ventricular ejection fraction associated with survival to discharge

Background

Post cardiac arrest left ventricular ejection fraction (LVEF) is routinely assessed, but the implications of this are unknown. This study aimed to assess the association between post cardiac arrest LVEF and survival to hospital discharge.

Methods

In this retrospective cohort study, all in-hospital and out of hospital cardiac arrests at our tertiary care center between January 2012 and September 2015 were included. Baseline demographics, clinical data, characteristics of the arrest, and interventions performed were collected. Earliest post cardiac arrest echocardiograms were reviewed with LVEF documented. The primary outcome was survival to discharge.

Results

A total of 736 patients were included in the analysis (mean age 58 years, 44% female). 15% were out of hospital cardiac arrest (24% shockable rhythm). After adjusting for covariates, patients with LVEF < 30% had 36% lower odds of surviving to hospital discharge than those with LVEF ≥ 52% (p = 0.014). Shockable initial rhythm and targeted temperature management were associated with improved survival.

Conclusion

After a cardiac arrest, an initial LVEF < 30% is associated with significantly lower odds of survival to hospital discharge.

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.

Guidance for clinical practice using emergency and point-of-care ultrasonography

Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

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.

EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) LONG VERSION

AIMS

 To evaluate the evidence and produce a summary and recommendations for the most common heart and lung applications of point-of-care ultrasound (PoCUS).

METHODS

 We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendation were produced, including assignment of levels of evidence (LoE) and grading of the recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement regarding the summary and recommendation for each question (using a 5-point Likert scale), which was approved if a level of agreement of greater than 75 % was reached. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses.

FINDINGS AND RECOMMENDATIONS

 One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1). The remaining 9 questions achieved broad agreement with one assigned an LoE of 4 and weak GRADE recommendation (question 2), three achieving an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8), and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10).

CONCLUSION

 These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.

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.

Point-of-Care Resuscitative Echocardiography Diagnosis of Intracardiac Thrombus during cardiac arrest (PREDICT Study): A retrospective, observational cohort study

Background

Point-of-care ultrasound (POCUS) has been previously studied in cardiac arrest, without definitive markers for futile resuscitation efforts identified. Intracardiac thrombus during cardiac arrest has not been systematically studied. Our objective was to describe the incidence of intracardiac thrombus and spontaneous echo contrast found during cardiac arrest.

Methods

A two hospital, retrospective, observational cohort study of 56 cardiac arrest patients who were assessed with POCUS (between January 1st, 2017 to April 30th, 2020). Eligible studies were reviewed for echocardiographic findings (e.g. presence of intracardiac thrombus or spontaneous echo contrast), baseline patient demographics, cardiac arrest-related data, and clinical outcomes. Primary outcome was in-hospital mortality.

Results

Fifty-six intra-arrest POCUS echocardiograms were identified (out of 738 out-of-hospital cardiac arrests). The median patient age was 63 years (interquartile range [IQR]: 51–72), with 25% female patients, and median Charlson Comorbidity Index score of 4 (IQR: 2–6). The incidence of intracardiac thrombus was 21 out of 56 patients (38%). Time-to-new thrombus formation during cardiac arrest was approximately 6 minutes (IQR: 2-–8). All patients with intracardiac thrombus during cardiac arrest had termination of resuscitation.

Conclusions

Intracardiac thrombus is potentially common during out-of-hospital cardiac arrests and was observed more frequently in those in whom termination of resuscitation was recommended. However, this is only hypothesis-generating at this time, and further study is required to determine if the presence of intracardiac thrombus may be used as a potential marker of resuscitation futility.

Point-of-care ultrasound in cardiorespiratory arrest (POCUS-CA): narrative review article

The POCUS-CA (Point-of-care ultrasound in cardiac arrest) is a diagnostic tool in the Intensive Care Unit and Emergency Department setting. The literature indicates that in the patient in a cardiorespiratory arrest it can provide information of the etiology of the arrest in patients with non-defibrillable rhythms, assess the quality of compressions during cardiopulmonary resuscitation (CPR), and define prognosis of survival according to specific findings and, thus, assist the clinician in decision-making during resuscitation. This narrative review of the literature aims to expose the usefulness of ultrasound in the setting of cardiorespiratory arrest as a tool that allows making a rapid diagnosis and making decisions about reversible causes of this entity. More studies are needed to support the evidence to make ultrasound part of the resuscitation algorithms. Teamwork during cardiopulmonary resuscitation and the inclusion of ultrasound in a multidisciplinary approach is important to achieve a favorable clinical outcome.

Mortality in patients with hepatic gas on point-of-care ultrasound in cardiac arrest: Does location matter?

PURPOSE

Prior research has suggested an association of hepatic venous gas with mortality in cardiac arrest. As point of care ultrasound (POCUS) is frequently used in the context of resuscitation, we sought to evaluate if the presence of hepatic gas on POCUS had a similar mortality association.

METHODS

A retrospective review was conducted of patients who experienced nontraumatic cardiac arrest. Archived ultrasound images were independently reviewed to determine the presence of gas in the hepatic parenchyma and vasculature. Electronic medical records were then reviewed to collect remaining clinical data.

RESULTS

From 1 January 2017 through 16 June 2019, 87 patients met inclusion criteria. Among them, 68 (78.2%) patients died. Among those who died, 40 (58.8%) had hepatic gas, while 28 (41.2%) had none. Only a single survivor demonstrated hepatic venous gas (11%). While the difference in mortality with respect to presence of undifferentiated hepatic gas was not significant (P = .37), there was a significant difference with respect to the presence of venous gas (P = .004).

CONCLUSION

Our study demonstrated that the incidence of postarrest hepatic gas on POCUS was common, and that the presence of hepatic venous gas during cardiac resuscitation was associated with increased mortality, while hepatic parenchymal gas alone was not.

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.

Transesophageal echocardiography in patients with cardiac arrest: from high-quality chest compression to effective resuscitation

BACKGROUND

Survival after cardiac arrest depends on prompt and effective cardiopulmonary resuscitation (CPR). Transesophageal echocardiography (TEE) can be applied to evaluate the effectiveness of chest compression-decompression maneuvers in the setting of cardiac arrest undergoing CPR. The efficacy of chest compression can be continuously assessed by TEE that can improve the effectiveness of CPR guiding the rescuer to optimize or correct chest compression and decompression by directly examining the movements of the cardiac walls and valve leaflets.

PURPOSE

The review describes how to perform TEE in the emergency setting of cardiopulmonary arrest, its advantages, and limitations, and ultimately propose an echo-guided approach to CPR.

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.

A Shifting Paradigm: The Role of Focused Cardiac Ultrasound in Bedside Patient Assessment

Transthoracic echocardiography is the standard of care in anatomic and functional cardiovascular assessment; however, focused cardiac ultrasound (FoCUS) performed with portable ultrasound equipment is increasingly being used as an adjunct to comprehensive history and physical examination. FoCUS assessments, unlike formal echocardiography, are intended to assist physicians in answering explicit clinical questions with a narrow differential diagnosis in real time. Over the past decade, a growing body of literature has repeatedly shown the value that FoCUS adds to clinical evaluation. Specifically, FoCUS improves point-of-care diagnostic accuracy, which in turn modifies treatment plans, decreases time to diagnosis, and reduces resource utilization. Although less robust, there is also evidence showing improvement in clinical outcomes. Based on this evidence, clinicians, training programs, and clinical societies have embraced FoCUS as a tool to complement bedside patient evaluation. Herein, we review the evidence for FoCUS in clinical practice, specifically evaluating the diagnostic accuracy, the impact on clinical decision-making, and the effect on clinical outcomes.

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.

Bedside ultrasound in cardiac standstill: a clinical review

Patients with cardiac arrest present as a relatively frequent occurrence in the Emergency Department. Despite the advances in our understanding of the pathophysiology of cardiac arrest, managing the condition remains a stressful endeavor and currently implemented interventions, while beneficial, are still associated with a disappointingly low survivability. The majority of modern Advanced Life Support algorithms employ a standardized approach to best resuscitate the 'crashed' patient. However, management during resuscitation often encourages a 'one-size-fits-all' policy for most patients, with lesser attention drawn towards causality of the disease and factors that could alter resuscitative care. Life support providers are also often challenged by the limited bedside predictors of survival to guide the course and duration of resuscitation. Over the recent decades, point-of-care ultrasonography (PoCUS) has been gradually proving itself as a useful adjunct that could potentially bridge the gap in the recognition and evaluation of precipitants and end-points in resuscitation, thereby facilitating an improved approach to resuscitation of the arrested patient. Point-of-care ultrasound applications in the critical care field have tremendously evolved over the past four decades. Today, bedside ultrasound is a fundamental tool that is quick, safe, inexpensive and reproducible. Not only can it provide the physician with critical information on reversible causes of arrest, but it can also be used to predict survival. Of note is its utility in predicting worse survival outcomes in patients with cardiac standstill, i.e., no cardiac activity witnessed with ultrasound. Unfortunately, despite the increasing evidence surrounding ultrasound use in arrest, bedside ultrasound is still largely underutilized during the resuscitation process. This article reviews the current literature on cardiac standstill and the application of bedside ultrasound in cardiac arrests.

The Value of Focused Echocardiography During Cardiac Arrest

Cardiac arrest is the absence of a centrally palpable pulse and no respiratory effort in an unresponsive patient. This often-lethal medical condition affects hundreds of thousands of people in the United States alone every year. Immediate intervention is crucial to provide the patient with any chance of survival. Advanced cardiac life support (ACLS) is the cornerstone therapy for cardiac arrest. Increased awareness and proper identification of life-threatening arrhythmias is critical, as it may lead to prompt medical treatment and improved mortality. The use of focused echocardiography, during a cardiac arrest, has been a developing area of interest over the past several years. The specific aim of this literature review was to emphasize the role of a focused echocardiogram and the valuable information that can be provided during a cardiac arrest.

Do combined ultrasound and electrocardiogram-rhythm findings predict survival in emergency department cardiac arrest patients? The Second Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED2) study

Objectives

Point-of-care ultrasound (POCUS) is used increasingly during resuscitation. The aim of this study was to assess whether combining POCUS and electrocardiogram (ECG) rhythm findings better predicts outcomes during cardiopulmonary resuscitation in the emergency department (ED).

Methods

We completed a health records review on ED cardiac arrest patients who underwent POCUS. Primary outcome measurements included return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge.

Results

POCUS was performed on 180 patients; 45 patients (25.0%; 19.2%–31.8%) demonstrated cardiac activity on initial ECG, and 21 (11.7%; 7.7%–17.2%) had cardiac activity on initial POCUS; 47 patients (26.1%; 20.2%–33.0%) achieved ROSC, 18 (10.0%; 6.3%–15.3%) survived to admission, and 3 (1.7%; 0.3%–5.0%) survived to hospital discharge. As a predictor of failure to achieve ROSC, ECG had a sensitivity of 82.7% (95% CI 75.2%–88.7%) and a specificity of 46.8% (32.1%–61.9%). Overall, POCUS had a higher sensitivity of 96.2% (91.4%–98.8%) but a similar specificity of 34.0% (20.9%–49.3%). In patients with ECG-asystole, POCUS had a sensitivity of 98.18% (93.59%–99.78%) and a specificity of 16.00% (4.54%–36.08%). In patients with pulseless electrical activity, POCUS had a sensitivity of 86.96% (66.41%–97.22%) and a specificity of 54.55% (32.21%–75.61%). Similar patterns were seen for survival to admission and discharge. Only 0.8% (0.0–4.7%) of patients with ECG-asystole and standstill on POCUS survived to hospital discharge.

Conclusion

The absence of cardiac activity on POCUS, or on both ECG and POCUS together, better predicts negative outcomes in cardiac arrest than ECG alone. No test reliably predicted survival.

Cardiac Standstill With Intracardiac Clot Formation

This case describes and depicts cardiac standstill with thrombosed blood within the chambers of the heart. This was likely due to stasis of blood from a prolonged no-flow state. After viewing this ultrasound finding, the decision was made to halt resuscitative efforts in this case of a patient in cardiac arrest.

Early point-of-care focused echocardiographic asystole as a predictive factor for absence of return of spontaneous circulatory in out-of-hospital cardiac arrests: a study protocol for a prospective, multicentre observational study

INTRODUCTION

Management of out-of-hospital cardiac arrests (OHCAs) in France is performed by a particular prehospital system based on medicalisation of mobile intensive care units composed of an emergency physician and a nurse with all the required devices for advanced care. It follows the European recommendations which advocate for the use of early point-of-care focused echocardiography (EPOCE) in the prehospital setting. An ability of EPOCE may be to predict the absence of return of spontaneous circulation (ROSC) in cases of absence of cardiac motion. We thus intended to investigate this predictive value with a prospective multicentre study. This paper describes the study protocol, while the first patients were recruited in December 2018.

METHODS

ACE is a prospective multicentre (n=8) prognostic study. Briefly, as soon as OHCA is diagnosed and advanced life support (ALS) is initiated, EPOCE will be performed during the automated external defibrillator' analysis period. The physician will assess detectable motion within the heart and reversible causes of OHCA. However, as the prognostic value of absence of cardiac motion is not currently validated, the results of EPOCE will not be used to withdraw ALS, and the decision to withdraw life support will be done following the European Resuscitation Council recommendations during our study.

ANALYSIS

The primary endpoint is the positive predictive value of absence of cardiac motion for the absence of final ROSC. The secondary endpoints are predictive characteristics of EPOCE asystole on morbimortality 30 days after OHCA, description of reversible cause and analysis of the EPOCE technique.

ETHICS AND DISSEMINATION

ACE was approved by an ethical committee (2018-AO1491-54). While ACE is adapted to the French prehospital system, its results will be translatable to other organisations if inter-rater variability is not found.

TRIAL REGISTRATION NUMBER

NCT03494153.

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.

Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? A Study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators

Introduction This third study in the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) series examined potential relationships between point-of-care ultrasound (PoCUS) use and the length of resuscitation, the frequency of interventions, and clinical outcomes during cardiac arrest. Methods A health records review was completed for adult patients (>19 years, without a do not resuscitate (DNR) order) who presented to a tertiary emergency department in cardiac arrest between 2010 and 2014. Patients were grouped based on PoCUS use and findings for cardiac activity. Data were analyzed for length of resuscitation, frequency of interventions, return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and survival to hospital discharge (SHD). Results Of the 223 patients who met inclusion criteria, 180 (80.7%) received assessment by PoCUS during cardiac arrest management in the emergency department (ED). In the PoCUS group, 21 (11.6%) demonstrated cardiac activity and 159 (88.4%) did not. Patients with activity on PoCUS had longer mean resuscitation times (27.3; 95% confidence interval 17.7-37.0 min) than patients with no activity (11.51; 10.2-12.8 min) and patients who did not receive a PoCUS exam (14.36; 9.89-18.8 min). Patients with cardiac activity on PoCUS were more likely to receive endotracheal intubation (ET; 95.23%; 86.13-104.35%) and epinephrine (Epi; 100%; 100-100%) than patients with no activity (ET: 46.54%; 38.8-54.3%; Epi: 82.39%; 76.50-88.31%) and those with no PoCUS (ET: 65.11%; 50.87-79.36%; Epi: 81.39%; 69.76-93.03%). Those with no cardiac activity on PoCUS were much less likely to achieve ROSC (19.5%; 13.4-25.6), SHA (6.9%; 2.97-10.86%) and SHD (0.6%; -0.5-1.8%) compared to those with cardiac activity on PoCUS (ROSC; 76.19%; 57.97-94.4%), SHA (33.3%; 13.2-53.5%), SHD (9.5%; -3-22.07%), and those with no PoCUS (ROSC 39.5%; 24.9-54.1%; SHA 27.9%; 14.5- 41.3%, and SHD 6.9%; -0.6-14.59). Conclusions Emergency department cardiac arrest patients with cardiac activity on PoCUS received longer resuscitation with higher rates of intervention as compared to those with negative findings or when no PoCUS was performed. Patients with cardiac activity on PoCUS had improved clinical outcomes as compared with patients not receiving PoCUS, and patients with no activity on PoCUS.

Novel patterns of left ventricular mechanical activity during experimental cardiac arrest in pigs

We conducted an experimental study to evaluate the presence of coordinated left ventricular mechanical myocardial activity (LVMA) in two types of experimentally induced cardiac arrest: ventricular fibrillation (VF) and pulseless electrical activity (PEA). Twenty anesthetized domestic pigs were randomized 1:1 either to induction of VF or PEA. They were left in nonresuscitated cardiac arrest until the cessation of LVMA and microcirculation. Surface ECG, presence of LVMA by transthoracic echocardiography and sublingual microcirculation were recorded. One minute after induction of cardiac arrest, LVMA was identified in all experimental animals. In the PEA group, rate of LVMA was of 106+/-12/min. In the VF group, we identified two patterns of LVMA. Six animals exhibited contractions of high frequency (VFhigh group), four of low frequency (VFlow group) (334+/-12 vs. 125+/-32/min, p<0.001). A time from cardiac arrest induction to asystole (19.2+/-7.2 vs. 7.3+/-2.2 vs. 8.3+/-5.5 min, p=0.003), cessation of LVMA (11.3+/-5.6 vs. 4.4+/-0.4 vs. 7.4+/-2.9 min, p=0.027) and cessation of microcirculation (25.3+/-12.6 vs. 13.4+/-2.4 vs. 23.2+/-8.7 min, p=0.050) was significantly longer in VFlow group than in VFhigh and PEA group, respectively. Thus, LVMA is present in both VF and PEA type of induced cardiac arrest and moreover, VF may exhibit various patterns of LVMA.

In-hospital cardiac arrest: are we overlooking a key distinction?

PURPOSE OF REVIEW

To review the epidemiology, peri-arrest management, and research priorities related to in-hospital cardiac arrest (IHCA) and explore key distinctions between IHCA and out-of-hospital cardiac arrest (OHCA) as they pertain to the clinician and resuscitation scientist.

RECENT FINDINGS

IHCA is a common and highly morbid event amongst hospitalized patients in the United States. As compared with patients who experience an OHCA, patients who experience an IHCA tend to have more medical comorbidities, have a witnessed arrest, and be attended to by professional first responders. Further, providers resuscitating patients from IHCA commonly have access to tools and information not readily available to the OHCA responders. Despite these differences, society guidelines for the peri-arrest management of patients with IHCA are often based on data extrapolated from the OHCA population. To advance the care of patients with IHCA, clinicians and investigators should recognize the many important distinctions between OHCA and IHCA.

SUMMARY

IHCA is a unique disease entity with an epidemiology and natural history that are distinct from OHCA. In both research and clinical practice, physicians should recognize these distinctions so as to advance the care of IHCA victims.

Échographie et prise en charge de l’arrêt cardiaque

L’arrêt cardiorespiratoire (ACR) est une situation fréquente pour les structures d’urgences et de réanimation, et l’utilisation de l’échographie y est recommandée par les sociétés savantes. Elle doit impérativement se faire sans augmentation des temps d’interruption du massage cardiaque externe. Après formation, elle permet de détecter rapidement et facilement la présence d’une contractilité myocardique qui est un élément pronostique important pouvant aider dans la décision d’arrêter la RCP. Le recours à des protocoles bien établis avec des équipes entraînées permet d’éviter une interruption prolongée de la RCP. Cependant, aucune étude humaine de grande ampleur n’a permis de décrire de manière fiable pendant l’ACR la sémiologie échographique des causes curables que constituent l’hypovolémie, l’embolie pulmonaire, la tamponnade et le pneumothorax compressif.

Deployed military general internal physician’s toolkit: the recent past and near future

Introduction

The role of the military physician in Deployed Hospital Care involves the diagnosis and management of a wide variety of disease states. Broad clinical skills need to be complemented by judicious use of a limited array of investigations. No study has specifically quantified what investigations physicians use on operations.

Methods

A retrospective cross-sectional study was performed to ascertain what investigations were undertaken on all patients managed by the General Internal Medicine teams over a 14 month period during a recent enduring operation in Afghanistan. A record was also made of investigations that were unavailable but considered desirable by the treating physician in order to inform clinical or occupational decisions.

Results

676 patients were admitted during the study period. Blood tests were performed in 96% of patients, plain radiographs in 50%, CT in 12% and ultrasound in 12%. An ECG was performed in over half (57%) and a peak flow in 11%. The most desirable, but unavailable, investigations were cardiac monitoring and echocardiography (24% and 12% of patients, respectively).

Discussion

The data produced by this study both identified and quantified the investigations used by physicians during a mature operational deployment. This can be used in addition to accurate medical intelligence to inform and rationalise the diagnostic requirements for future operations as well as the provision of training. Technological advancements, particularly in weight and portability, are likely to enable more complex investigational modalities to be performed further forward on military deployments.

The predictive value of bedside ultrasound to restore spontaneous circulation in patients with pulseless electrical activity: A systematic review and meta-analysis

Background

The prognosis of pulseless electrical activity is dismal. However, it is still challengable to decide when to terminate or continue resuscitation efforts. The aim of this study was to determine whether the use of bedside ultrasound (US) could predict the restoration of spontaneous circulation (ROSC) in patients with pulseless electrical activity (PEA) through the identification of cardiac activity.

Methods

This was a systematic review and meta-analysis of studies that used US to predict ROSC. A search of electronic databases (Cochrane Central, MEDLINE, EMBASE) was conducted up to June 2017, and the assessment of study quality was performed with the Newcastle-Ottawa Scale. Statistical analysis was performed with Review Manager 5.3 and Stata 12.

Results

Eleven studies that enrolled a total of 777 PEA patients were included. A total of 230 patients experienced ROSC. Of these, 188 had sonographically identified cardiac activity (pseudo-PEA). A meta-analysis showed that PEA patients with cardiac activity on US were more likely to obtain ROSC compared to those with cardiac standstill: risk ratio (RR) = 4.35 (95% confidence interval [CI], 2.20–8.63; p<0,00001) with significant statistical heterogeneity (I² = 60%). Subgroup analyses were conducted: US evaluation using only on the subxiphoid view: RR = 1.99 (95% CI, 0.79–5.02; p = 0.15); evaluation using various views: RR = 4.09 (95% CI,2.70–6.02; p<0.00001).

Conclusions

In cardiac arrest patients who present with PEA, bedside US has an important role in predicting ROSC. The presence of cardiac activity in PEA patients may encourage more aggressive resuscitation.

Echocardiography in cardiac arrest: An emergency medicine review

INTRODUCTION

Cardiac arrest management primarily focuses on optimal chest compressions and early defibrillation for shockable cardiac rhythms. Non-shockable rhythms such as pulseless electrical activity (PEA) and asystole present challenges in management. Point-of-care ultrasound (POCUS) in cardiac arrest is promising.

OBJECTIVES

This review provides a focused assessment of POCUS in cardiac arrest, with an overview of transthoracic (TTE) and transesophageal echocardiogram (TEE), uses in arrest, and literature support.

DISCUSSION

Cardiac arrest can be distinguished between shockable and non-shockable rhythms, with management varying based on the rhythm. POCUS provides a diagnostic and prognostic tool in the emergency department (ED), which may improve accuracy in clinical decision-making. Several protocols incorporate POCUS based on different cardiac views. TTE includes parasternal long axis, parasternal short axis, apical 4-chamber, and subxiphoid views, which may be used in cardiac arrest for diagnosis of underlying cause and potential prognostication. TEE is conducted by inserting the probe into the esophagus of intubated patients, with several studies evaluating its use in cardiac arrest. It is associated with few adverse effects, while allowing continued compressions (and evaluation of those compressions) and not interrupting resuscitation efforts.

CONCLUSIONS

POCUS is a valuable diagnostic and prognostic tool in cardiac arrest, with recent literature supporting its diagnostic ability. TTE can guide resuscitation efforts dependent on the rhythm, though TTE should not interrupt other resuscitation measures. TEE can be useful during arrest, but further studies based in the ED are needed.

Variability in Interpretation of Cardiac Standstill Among Physician Sonographers

STUDY OBJECTIVE

Cardiac standstill on point-of-care ultrasonography has been widely studied as a marker of prognosis in cardiac arrest. Return of spontaneous circulation has been reported in as few as 0% and as many as 45% of patients with cardiac standstill. When explicitly documented, the definition of cardiac activity in these studies varied from any slight change in echogenicity of the myocardium to any kinetic cardiac activity. We hypothesize that the variability in research definitions of cardiac activity may affect interpretation of video clips of patients in cardiac arrest. The goal of this study is to assess the variability in interpretation of standstill among physician sonographers.

METHODS

We surveyed physician sonographers at 6 conferences held at 3 academic medical centers in the Greater New York area. Survey respondents were allotted 20 seconds per slide to determine whether each of 15 video clips of patients in cardiac arrest were standstill or not. Data were collected anonymously with radio frequency remotes.

RESULTS

There were 127 total participants, including faculty, fellows, and resident physicians specializing in emergency medicine, critical care, and cardiology. There was only moderate interrater agreement among all participants (α=0.47). This lack of agreement persisted across specialties, self-reported training levels, and self-reported ultrasonographic expertise.

CONCLUSION

According to the results of our study, there appears to be considerable variability in interpretation of cardiac standstill among physician sonographers. Consensus definitions of cardiac activity and standstill would improve the quality of cardiac arrest ultrasonographic research and standardize the use of this technology at the bedside.

Point-of-care ultrasound in cardiopulmonary resuscitation: a concise review

Point-of-care ultrasound (POCUS) is a widely used tool in critical care areas, allowing for the performance of accurate diagnoses and thus enhancing the decision-making process. Every major organ or system can be safely evaluated with POCUS. In that respect, the utility of POCUS in cardiac arrest is gaining interest. In this article, we will review the actual role of ultrasound in cardiac arrest and the main POCUS protocols focused to this scenario as well as discuss the potential role of POCUS in monitoring the efficacy of the chest compressions.

Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis

OBJECTIVE

We aim to summarize current evidence on the value of point-of-care (POC) focused echocardiography in the assessment of short-term survival in patients with cardiac arrest.

METHODS

PubMed and EMBASE were searched from inception to July 2016 for eligible studies that evaluated the utility of POC echocardiography in patients with cardiac arrest. Modified QUADAS was used to appraise the quality of included studies. A random-effect bivariate model and a hierarchical summary receiving operating curve were used to summarize the performance characteristics of focused echocardiography.

RESULTS

Initial search identified 961 citations of which 15 were included in our final analysis. A total of 1695 patients had POC echocardiography performed during resuscitation. Ultrasonography was mainly utilized to detect spontaneous cardiac movement (SCM) and identify reversible causes of cardiac arrest. Subcostal, apical and parasternal views were used to identify cardiac tamponade, pulmonary embolism, and pleural view for tension pneumothorax. Results of meta-analysis showed that SCM detected by focused echocardiography had a pooled sensitivity (0.95, 95%CI: 0.72-0.99) and specificity (0.80, 95%CI: 0.63-0.91) in predicting return of spontaneous circulation (ROSC) during cardiac arrest, with a positive likelihood ratio of 4.8 (95% CI: 2.5-9.4) and a negative likelihood ratio of 0.06 (95%CI: 0.01-0.39).

CONCLUSION

POC focused echocardiography can be used to identify reversible causes and predict short-term outcome in patients with cardiac arrest. In patients with a low pretest probability for ROSC, absence of SCM on echocardiography can predict a low likelihood of survival and guide the decision of resuscitation termination.

Precision Medicine With Point-of-Care Ultrasound: The Future of Personalized Pediatric Emergency Care

The Precision Medicine Initiative spearheaded by the National Institute of Health has pioneered a new model of health care focused on health care delivery that is tailored to an individual. Medical advances have already provided clinicians with the tools to better predict treatment outcomes based on the individual needs of each patient's disease process. Three-dimensional printing allows medical devices and implants to be custom made-to-order. Technological advances in preoperative imaging have augmented the ability for surgeons to plan a specific surgical approach for each patient. In a similar vein, point-of-care ultrasound offers the emergency care provider an opportunity to move beyond protocols and provide precise medical care tailored to the acute needs of each ill or injured emergent patient. In this article, we explore several cutting-edge applications of point-of-care ultrasound that can help providers develop a personalized approach to resuscitation and emergent procedures in pediatrics.

Ultrasonography in the emergency department

Point-of-care ultrasonography (POCUS) is a useful imaging technique for the emergency medicine (EM) physician. Because of its growing use in EM, this article will summarize the historical development, the scope of practice, and some evidence supporting the current applications of POCUS in the adult emergency department. Bedside ultrasonography in the emergency department shares clinical applications with critical care ultrasonography, including goal-directed echocardiography, echocardiography during cardiac arrest, thoracic ultrasonography, evaluation for deep vein thrombosis and pulmonary embolism, screening abdominal ultrasonography, ultrasonography in trauma, and guidance of procedures with ultrasonography. Some applications of POCUS unique to the emergency department include abdominal ultrasonography of the right upper quadrant and appendix, obstetric, testicular, soft tissue/musculoskeletal, and ocular ultrasonography. Ultrasonography has become an integral part of EM over the past two decades, and it is an important skill which positively influences patient outcomes.

Pre-hospital assessment with ultrasound in emergencies: implementation in the field

BACKGROUND

Point-of-care ultrasound (US) is a proven diagnostic imaging tool in the emergency department (ED). Modern US devices are now more compact, affordable and portable, which has led to increased usage in austere environments. However, studies supporting the use of US in the prehospital setting are limited. The primary outcome of this pilot study was to determine if paramedics could perform cardiac ultrasound in the field and obtain images that were adequate for interpretation. A secondary outcome was whether paramedics could correctly identify cardiac activity or the lack thereof in cardiac arrest patients.

METHODS

We performed a prospective educational study using a convenience sample of professional paramedics without ultrasound experience. Eligible paramedics participated in a 3-hour session on point-of-care US. The paramedics then used US during emergency calls and saved the scans for possible cardiac complaints including: chest pain, dyspnea, loss of consciousness, trauma, or cardiac arrest.

RESULTS

Four paramedics from two distinct fire stations enrolled a total of 19 unique patients, of whom 17 were deemed adequate for clinical decision making (89%, 95%CI 67%-99%). Paramedics accurately recorded 17 cases of cardiac activity (100%, 95%CI 84%-100%) and 2 cases of cardiac standstill (100%, 95%CI 22%-100%).

CONCLUSION

Our pilot study suggests that with minimal training, paramedics can use US to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill. Further large-scale clinical trials are needed to determine if prehospital US can be used to guide care for patients with cardiac complaints.

Improving Survival From Cardiac Arrest: A Review of Contemporary Practice and Challenges

Cardiac arrest is a common and lethal condition frequently encountered by emergency medicine providers. Resuscitation of persons after cardiac arrest remains challenging, and outcomes remain poor overall. Successful resuscitation hinges on timely, high-quality cardiopulmonary resuscitation. The optimal method of providing chest compressions and ventilator support during cardiac arrest remains uncertain. Prompt and effective defibrillation of ventricular arrhythmias is one of the few effective therapies available for treatment of cardiac arrest. Despite numerous studies during several decades, no specific drug delivered during cardiac arrest has been shown to improve neurologically intact survival after cardiac arrest. Extracorporeal circulation can rescue a minority of highly selected patients with refractory cardiac arrest. Current management of pulseless electrical activity is associated with poor outcomes, but it is hoped that a more targeted diagnostic approach based on electrocardiography and bedside cardiac ultrasonography may improve survival. The evolution of postresuscitation care appears to have improved cardiac arrest outcomes in patients who are successfully resuscitated. The initial approach to early stabilization includes standard measures, such as support of pulmonary function, hemodynamic stabilization, and rapid diagnostic assessment. Coronary angiography is often indicated because of the high frequency of unstable coronary artery disease in comatose survivors of cardiac arrest and should be performed early after resuscitation. Optimizing and standardizing our current approach to cardiac arrest resuscitation and postresuscitation care will be essential for developing strategies for improving survival after cardiac arrest.