CARDIAC ARREST ULTRASOUND

Transcription

1 ADIA AEST ULTASOUND Phillip Andrus, MD, FAEP Department of Emergency Medicine Division of Emergency Ultrasound Mount Sinai School of Medicine Point of are Ultrasound provides important diagnostic, procedural and prognostic guidance in the management of patients in cardiac arrest. To use ultrasound effectively to guide resuscitation, it is important to have a predefined strategy to incorporate insonation into the flow of ALS care. Diagnostic point of care ultrasound in ardiac Arrest VF/VT ultrasound plays a limited role. May be useful in differentiation fine ventricular fibrillation from asystole. PEA/Asystole ultrasound has greater utility. PEA/Asystole arrests have a much broader differential than VF/VT. Many causes of PEA/Asystole can be uncovered by ultrasound. ypovolemia Tension Pneumothorax ypoxia Tamponade (ardiac) + Ion (Acidosis) Toxins ypo/yperkalemia Thrombosis (PE) ypothermia Thrombosis (AS) Table 1. Differential Diagnosis of PEA/Asystole. The s and T s. US definable etiologies are bolded. A number of protocols have been designed for both cardiac arrest and the intimately related problem of unexplained hypotension.

2 Table 2. ardiac Arrest and ypotension US protocols Of these protocols, the one which includes only those elements we find essential and performable during a cardiac arrest is the US exam. With the current paradigm of minimally interrupted P, the views obtained need to be split between those that can be performed during chest compressions and those that must be done with a still chest i.e. during the rhythm or pulse check. The US exam can be tweaked to allow this separation as noted below in Figure 1. The US exam in ardiac Arrest esuscitation Patient in ardiac Arrest 1. Start P 2. Place on ardiac Monitor and check rhythm: PEA/Asystole VF/pVT Unshockable hythm Pathway 1. Epinephrine 1mg IV/IO every 3-5 min 2. US Exam (I MAP) Shockable hythm Pathway 1. Defibrillate 2. ontinue ALS () Subxyphoid Pericardial Effusion Pericardiocentesis D U I N G (I) IV (M) Morison's, FAST ollapse Free Fluid rystalloid Infusion onsider surgical consultation, P (A) Aorta > 4 cm onsider surgical consultation, (P) Lung Pneumothorax Decompression Y T M E K Ventricular Fibrillation epeat Subxyphoid V > LV size, Thrombus Myocardial ontractility / Pseudo-PEA ardiac Standstill & EtO2 <10 mmg Follow VF/pVT ALS Pathway onsider Thrombolysis onsider other causes: ypoxia Toxins Acidosis ypothermia yperkalemia Myocardial Infarction ypokalemia END ESUSITATION Figure 1. The US Exam in ardiac Arrest esuscitation. (see last page)

3 In addition to a formal, algorithmic approach to the integration of ultrasound into ALS, the ultrasound machine itself needs to be integrated into the team roles and positioning. As in trauma codes, when cardiac arrest team members have designated places and roles, resuscitation is run most efficiently. Figure 2. demonstrates the optimal placement of the team member assigned to sonography. Figure 2. ardiac arrest team positions and roles.

4 For efficiency, limit yourself to scanning with one multifunctional probe if for your cardiac arrest patients. This can be either a large curvilinear or a phased array transducer. Figure 3. urvilinear and Phased array transducers Prognostic utility of ultrasound in cardiac arrest ardiac standstill carries exceedingly poor prognostic value. Most studies have shown no survival when standstill is seen on intraarrest echo (Blaivas, Salen). Of those few cases where patients survived to admission, no cases of survival with good neurologic outcome have been published. Standstill can be documented as a video clip. Or with m-mode through the still heart. Figure 3. ardiac Standstill on M-Mode

5 eferences More at sinaiem.us Atkinson, P T, D J McAuley, J Kendall, O Abeyakoon, G eid, J onnolly, and D Lewis. "Abdominal and ardiac Evaluation with Sonography in Shock (AES): An Approach by Emergency Physicians for the Use of Ultrasound in Patients with Undifferentiated ypotension." Emergency medicine journal : EMJ 26, no. 2 (2009): doi: /emj Blaivas, M, and J Fox. "Outcome in ardiac Arrest Patients Found to ave ardiac Standstill on the Bedside Emergency Department Echocardiogram." Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 8, no. 6 (2001): Breitkreutz, aoul, Susanna Price, olger V Steiger, Florian Seeger, endrik Ilper, anns Ackermann, Marcus udolph, and others. "Focused Echocardiographic Evaluation in Life Support and Peri-esuscitation of Emergency Patients: A Prospective Trial." esuscitation 81, no. 11 (2010): doi: /j.resuscitation ernandez,, K Shuler, annan, Sonyika, A Likourezos, and J Marshall. ".A.U.S.E.: ardiac Arrest Ultra-Sound Exam--A Better Approach to Managing Patients in Primary Non-Arrhythmogenic ardiac Arrest." esuscitation 76, no. 2 (2008): Jones, A E, V S Tayal, D M Sullivan, and J A Kline. "andomized, ontrolled Trial of Immediate Versus Delayed Goal-Directed Ultrasound to Identify the ause of Nontraumatic ypotension in Emergency Department Patients*." ritical care medicine 32, no. 8 (2004): doi: /01.m Lichtenstein, Daniel A, and Gilbert A Mezière. "elevance of Lung Ultrasound in the Diagnosis of Acute espiratory Failure: The BLUE Protocol." hest 134, no. 1 (2008): doi: /chest ose, J S, A E Bair, D Mandavia, and D J Kinser. "The UP Ultrasound Protocol: A Novel Ultrasound Approach to the Empiric Evaluation of the Undifferentiated ypotensive Patient." The American journal of emergency medicine 19, no. 4 (2001):

6 Salen, Philip, Larry Melniker, arolyn hooljian, John S ose, Janet Alteveer, James eed, and Michael eller. "Does the Presence or Absence of Sonographically Identified ardiac Activity Predict esuscitation Outcomes of ardiac Arrest Patients?" The American journal of emergency medicine 23, no. 4 (2005): Weingart, Scott, Daniel Duque and Bret Nelson. "The US Exam - apid Ultrasound for Shock / ypotension." (accessed January 9, 2011).

7 The US exam in ardiac Arrest esuscitation Patient in ardiac Arrest 1. Start P 2. Place on ardiac Monitor and check rhythm: PEA/Asystole VF/pVT Unshockable hythm Pathway 1. Epinephrine 1mg IV/IO every 3-5 min 2. US Exam (I MAP) Shockable hythm Pathway 1. Defibrillate 2. ontinue ALS () Subxyphoid Pericardial Effusion Pericardiocentesis D U I N G (I) IV (M) Morison's, FAST ollapse Free Fluid rystalloid Infusion onsider surgical consultation, P (A) Aorta > 4 cm onsider surgical consultation, (P) Lung Pneumothorax Decompression Y T M E K Ventricular Fibrillation epeat Subxyphoid V > LV size, Thrombus Myocardial ontractility / Pseudo-PEA ardiac Standstill & EtO2 <10 mmg Follow VF/pVT ALS Pathway onsider Thrombolysis onsider other causes: ypoxia Acidosis yperkalemia ypokalemia Toxins ypothermia Myocardial Infarction END ESUSITATION