POCUS� in �CARDIAC ARREST

DO HONG ANH

Fellow in EM & Critical US, UiTM, MY

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Introduction

• Running an effective & evidence-based cardiac arrest (CA) resuscitation is a core skill for not only EP/intensivist but also all clinicians working in acute care setting
• Resuscitation of patient in CA can be difficult for even the most seasoned clinician
• Integration of POCUS into care for this group of critical ill pts can offer a reduction in cognitive burden during this demanding period
• A simplified clinical POCUS pathway to decrease duration of CPR pauses when using POCUS is needed�����

International consensus on the use of POCUS in CPR�Bedside US in cardiac standstill: a clinical review �Hussein et al. Ultrasound J (2019) �

Outline

• Objectives:
• Identify reversible causes of CA
• Procedure guidance
• During Pulse check
• Technical aspect
• Tactic improving POCUS in CA without having prolonged pulse check

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Objectives 1: Identify reversible causes of CA�

POCUS can give information about 4 of the “T’s” & 1 of the “H’s.” – T1: TAMPONADE

- A moderate or large effusion during CA requires pericardiocentesis.

-Consider imaging aorta looking for dissection

Looking for aorta dissecting

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T2: Tension pneumothorax�

• Clinicians may not see lung sliding in patients with CA.
• Lung sliding
• Clinical context
• Look for B-lines in lungs during compressions.
• Shifting heart
• Plump IVC

True PEA wo cardiac activity vs Pseudo-PEA �w cardiac activity

 Patient initially thought to be a PEA arrest. She had a narrow complex rhythm on monitor but no palpable pulse assessed by 1 dr & 1 nurse.

True PEA OR Pseudo-PEA

Ddx only by POCUS

🡪Reversible causes: find 4 Ts & H

T3: Thrombosis-Myocardial Infarction (MI)

• Typically ECG is used to make Dx but can be challenging to obtain in CA
• POCUS assessment in MI is useful in patients who are peri-arrest or have some cardiac activity.
• Look for regional wall motion abnormality (RWMA), which is a focal absence of contraction of a wall of the heart.

RWMA/MI

T4: Thrombosis-Pulmonary Embolism (PE)

• RV dilation can be seen with PE, but can also be seen in CA without PE
• If there is RV strain in peri-arrest patient, PE is more likely.
• If there is a clot visualized in transit, PE is the likely cause of CA
• In cases where you are unsure, look for presence or absence of a DVT

RV can be dilated after CA of almost any cause�Algaar. Crit Care 2017

RV DILATATION during Arrest confirm no PE

RV dilatation during arrest & ROCS

DVT detected & failed thrombolysis�Confirmed PE

PEA w asystole : RV dilatation; & McConnell’s sign & Clot in transit in ROCS�

T5: Internal trauma

• Perform a FAST exam looking for free fluid in abdomen.
• The cause will depend on clinical scenario, but can also be an indication of ruptured ectopic pregnancy (in a young woman) or ruptured aortic AAA

Internal trauma & pregnancy�

Aortic Dissection : Low back pain admit ED & then PEA & nearly arrest�

1 H: Hypovolemia

• On POCUS there would be a small LV IVC
• Need additional views: Lung & Heart

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IVC collapse: trick

Additional views: Lung & Heart

Outline

• Objectives:
• Identify reversible causes of CA
• Procedure guidance
• During Pulse check
• Technical aspect
• Tactic improving POCUS in CA without having prolonged pulse check

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Useful for procedural guidance:

• Large bore vascular access in the femoral vein (such as an introducer or dialysis catheter or IV resuscitation)
• Arterial access to help assess for peripheral perfusion during rhythm checks.
• US-guided pericardiocentesis

Outline

• Objectives:
• Identify reversible causes of CA
• Procedure guidance
• During Pulse check for cardiac activity
• Technical aspect
• Tactic improving POCUS in CA without having prolonged pulse check

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Cardiac standstill: asystole

Restart CPR

M‑mode of the heart in asystole �

VF vs Asystole

Outline

• Objectives:
• Identify reversible causes of CA
• Procedure guidance
• During Pulse check for cardiac activity
• Technical aspect
• Tactic improving POCUS in CA without having prolonged pulse check

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Take Home Points�POCUS not makes delay in chest compression but human!�

• 1. Performing US NOT properly during arrest poses risk for delay in chest compressions.
• 2. This doesn’t mean stop doing it, just do it judiciously & quickly.

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POCUS position

Scanning region in CA�

Colors indicate timing of scan:

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Blue: 

During Chest Compressions

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Red: 

During Pulse Check

Protocol for POCUS use in CA (ACEP)

Tactics for improving POCUS use without having prolonged rhythm checks(ACEP now sep 2023)�

1. Prepare 15 s before pulse check : Charge defib;

Put a cardiac probe in the hand closest to pt & put gel on probe. Hold a rag in the other hand

2. During pulse check Obtain subxiphoid view.

Have a person count down from 10 to 0.

At 2 seconds, take probe off & wipe gel away with a rag.

If you cannot get a cardiac window within 8 s, assume no cardiac activity & resume compressions

3. Separate obtaining images from interpreting images: Record images & review after compressions restarted

11. Prior pulse check: place linear probe in inguinal canal & look for pulsation of FA

POCUS in CA resuscitation- Tool to reduce CPR pause.

ACEP now Sep 2023- Nagdev et al

2. Prior pulse check: press PW & �indicator place in the center of FA

3. Pulse check start: freeze image & measure PSV (max) � PSV > 20 cm/s ≈ SBP >60 mmHg�

Take home messages

• Incorporating POCUS into resus of CA pts is an important skill for all clinicians working in acute care setting
• A protocolized & simple techniques to reduce CPR pauses
• POCUS also allows clinicians to Dx reversible causes rapidly & define endpoints for resus
• Compliance with tactics for improving POCUS use without having prolonged rhythm checks
• Use POCUS finding & clinical context for prognostic CA pt
• This POCUS adjustment to resus protocol is one way to improve the care of our sickest patients.