Sonography in Cardiac Arrest

Transcription

1 Sonography in Cardiac Arrest Real-time Assessment and Evaluation with Sonography - Outcomes Network (REASON) Dr. Paul Atkinson MB MA FRCEM Professor and Research Program Director Emergency Medicine Dalhousie University Saint John Regional Hospital Saint John, NB on behalf of Dr. Romolo Gaspari and the REASON Study Group

2 Thank you to the REASON network and clinicians at each site who have contributed. Study Investigators: Michael Woo - Canada PI Louise Rang - Canada Paul Atkinson - Canada Srikar Adhikari - Regional PI Vicki Noble - Regional PI Jason Nomura - Regional PI Christopher Raio - Regional PI Daniel Theodoro - Regional PI Anthony Weekes - Regional PI David Blehar Samuel Brown Bear Caffery Ashley Crimmins Samuel Lam Romolo Gaspari - Study PI Michael Lanspa Margaret Lewis Otto Liebmann Alexander Limkakeng Fernando Lopez Elke Platz Michelle Mendoza Hal Minnigan Christopher Moore Joseph Novik Will Scruggs Daniel Shogilev Paul Sierzenski Marsia Vermeulen

3 2015 Province of New Brunswick National Institutes of Health. REASON 1 Trial: Sonography in Cardiac Arrest. Available at: No Financial Disclosures I have no conflict of interests

4 Ultrasound the new stethoscope N Engl J Med 2011; 364:

5 Feasibility

6 New York Times 2012

7 no cardiac activity = stop New York Times 2012

8 Duration of resuscitation efforts and subsequent survival after in-hospital cardiac arrest Goldberger et al. Lancet. 2012;

9 (n= a few)

10 (n= a few) +(n= a few) +(n= a few)

11 Blyth et al. AEM 2012

12 Methods Multicenter Prospective Observational Trial Adults with atraumatic PEA or Asystole (in the ED) undergoing resuscitation PoCUS at start & end of resuscitation Primary Outcome - ROSC REDCap Database

13 Power Calculation 80% power, 1 sided alpha 0.05 : 761 patients Assuming: US will identify patients without ROSC 1% misclassification rate 20 % ROSC 25% exclusion rate Sasson et al. JAMA. 2008

14 Group Comparisons initial activity Lilliefors Test - Normality Mann-Whitney U test, Fisher Exact

15 Saint John Kingston Ottawa May November 2014, 18 Sites

16 Initial Database 1087 Excluded Included Vfib/Vtach Arrest Missing Data No US performed

17 Patient Characteristics Age - 63yo Male - 62% OOCHA - 84% Length of resus - 18 min

18 Patient Characteristics Initial activity on US % ROSC % Hospital Admission % Survival to Hospital DC - 1.5%

19 Cardiac Rhythm PEA 40% 49% 52% Asystole 35% 47% 28% VF/VT 14% 0% Other (SR/Paced) 4% 4% 20% Initial Rhythm Start of Resuscitation Final Rhythm

20 Timing During Resuscitation 5 (0-12) 25 (18-35) 0 (0-1) 4 (2-7) 14 (9-21) (median time in min (IQR))

21 Timing by Initial US results p<0.001 p< Cardiac Arrest CPR/ EMS ED Arrival ACLS Started US#1 ACLS Completed (median time in minutes)

22 Survival % US + US % % 8.2% 8 pts 4 pts 0 Initial ROSC Hospital Admission Hospital Discharge

23 ROSC: 47.4% vs. ROSC 14.5% p<0.001

24 Survive to admission: 27.6% vs. ROSC 8.2% p<0.001

25 Sensitivity 63.2% ROSC + ROSC - (56% to 70%) Specificity 77.8% US % to 81% LR US (2.37 to 3.43) LR (0.39 to 0.57)

26 Sensitivity 63.9% (54% to 72%) Specificity 72.9% (69% to 76%) survival to admission Death US LR (1.97 to 2.83) LR US (0.39 to 0.63)

27 Survival to Discharge For Hospital Discharge (total 12 survivors) Similar test characteristics Sensitivity 66.7% (35% to 90%) Specificity 67.7% (64% to 71%) LR LR- 0.49

28 Asystole PEA In ED In ED US+ US- US+ US ROSC Hospital Admission p=ns % 10% 55% 21% % 6% 33% 11% p=0.0001

29 Influence on Outcomes ROSC Survival to admission Survival to discharge Presenting Rhythm (PEA) 2.12 ( ) 1.62 ( ) ( ) ED Rhythm (PEA) 4.24 ( ) 3.90 ( ) 4.91 ( ) Downtime (<5min) 1.82 ( ) 2.03 ( ) 3.03 ( ) Ultrasound (+activity) 6.12 ( ) 4.54 ( ) 4.06 ( ) Age (<50) 0.90 ( ) 1.05 ( ) 2.05 ( ) Location of arrest (in ED) 3.08 ( ) 1.45 ( ) 3.41 ( ) OR (95%CI)

30 Do US findings affect resus efforts? - Patients started on IV continuous drip pressors

31 Survival to hospital discharge rates are low.

32 Survival to hospital discharge rates are low. 1.5% overall, 0.5% if no cardiac activity on US

33 US activity is associated with ROSC in PEA, but not in asystole

34 US activity is associated with ROSC in PEA, but not in asystole PEA with cardiac activity had the highest likelihood of survival to hospital admission

35 US is not a reliable independent test to predict cardiac arrest outcome in ED patients, overall, or even in PEA

36 US is not a reliable independent test to predict cardiac arrest outcome in ED patients, overall, or even in PEA LR+ve ; LR-ve

37 Patients with cardiac activity on US had more use of IV pressor support Survival in this group was higher

38 Patients with cardiac activity on US had more use of IV pressor support Survival in this group was higher?association vs causation

39 References 1. Heart and Stroke Foundation of Canada. Statistics. Available at: c.ikiqlcmwjte/b /k.34a8/statistics.htm# heartdisease. Accessed Jul 18, American College of Emergency Physicians. ACEP policy statement: emergency ultrasound guidelines. Ann Emerg Med. 2009; 53: Atkinson PR, McAuley DJ, Kendall RJ, et al. Abdomi- nal and cardiac evaluation with sonography in shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J. 2009; 26: Canadian Association of Emergency Physicians, Emergency Department Targeted Ultrasound Inter- est Group. Emergency department targeted ultra- sound: 2006 update. CJEM. 2006;8: College of Emergency Medicine. Emergency Medi- cine Ultrasound Level 1 Training. Available at: asp?id=3409. Accessed Jul 17, Aichinger G, Zechner PM, Prause G, et al. Cardiac movement identified on prehospital echocardiogra- phy predicts outcome in cardiac arrest patients. Prehosp Emerg Care. 2012; 16: Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bed- side emergency department echocardiogram. Acad Emerg Med. 2001; 8: Labovitz AJ, Noble VE, Bierig M, et al. Focused car- diac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiog- raphy and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010; 23: Moher D, Liberati A, Tetzlaff J, Altman D. Preferred reporting items for systematic reviews and meta- analyses: the PRISMA statement. BMJ. 2009; 339: b Whiting PF, Weswood ME, Rutjes AW, Reitsma JB, Bossuyt PN, Kleijnen J. Evaluation of QUADAS, a tool for the quality assessment of diagnostic accu- racy studies. BMC Med Res Methodol. 2006; 6:e Breitkreutz R, Price S, Steiger HV, et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospec- tive trial. Resuscitation. 2010; 81: Hayhurst C, Lebus C, Atkinson PR, et al. An evalua- tion of echo in life support (ELS): is it feasible? What does it add? Emerg Med J. 2011; 28: Salen P, O Connor R, Sierzenski P, et al. Can cardiac sonography and capnography be used indepen- dently and in combination to predict resuscitation outcomes? Acad Emerg Med. 2001; 8: Salen P, Melniker L, Chooljian C, et al. Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Am J Emerg Med. 2005; 23: Schuster KM, Lofthouse R, Moore C, Lui F, Kaplan LJ, Davis KA. Pulseless electrical activity, focused abdominal sonography for trauma, and cardiac contractile activity as predictors of survival after trauma. J Trauma. 2009; 67: Tayal VS, Kline JA. Emergency echocardiography to detect pericardial effusion in patients in PEA and near-pea states. Resuscitation. 2003; 59: Niendorff DF, Rassias AJ, Palac R, Beach ML, Costa S, Greenberg M. Rapid cardiac ultrasound of inpa- tients suffering PEA arrest performed by nonexpert sonographers. Resuscitation. 2005; 67: Dallon DS, Jones JS. Bedside echocardiography for prognosis of emergency department cardiac arrest. Emerg Med J. 2011; 28: National Institutes of Health. REASON 1 Trial: Sonography in Cardiac Arrest. Available at: Accessed May 25, 2015.

40 REASON Study Group

41 survival to DC death Sensitivity 66.7% (35% to 90%) Specificity 67.7% US % to 71% LR US (1.37 to 3.12) LR (0.22 to 1.10)

42 PEA Survival - ROSC Sensitivity 74.85% (67.46% to 81.31%) ROSC +ve ROSC -ve Specificity % (53.93% to 66.47%) US +ve Positive Likelihood Ratio 1.89 (1.58 to 2.25) Negative Likelihood Ratio 0.42 US -ve (0.31 to 0.55)

43 PEA Survival Admission Sensitivity 76.6% (67% to 85%) Survival to Admit Death Specificity 53.2 % (48% to 59%) US LR (1.39 to 1.92) LR US (0.30 to 0.64)

44 US+ US- In ED Downtime <5 min Downtime >5 min Downtime <5 min Downtime >5 min ROSC % 50% 20% 12% Hospital Admit % 27% 13% 5% p=0.0001