Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: A prospective trial

doi:10.1016/j.resuscitation.2010.07.013

Resuscitation

Volume 81, Issue 11, November 2010, Pages 1527-1533

https://doi.org/10.1016/j.resuscitation.2010.07.013 Get rights and content

Abstract

Purpose of the study

Focused ultrasound is increasingly used in the emergency setting, with an ALS-compliant focused echocardiography algorithm proposed as an adjunct in peri-resuscitation care (FEEL). The purpose of this study was to evaluate the feasibility of FEEL in pre-hospital resuscitation, the incidence of potentially treatable conditions detected, and the influence on patient management.

Patients, materials and methods

A prospective observational study in a pre-hospital emergency setting in patients actively undergoing cardio-pulmonary resuscitation or in a shock state. The FEEL protocol was applied by trained emergency doctors, following which a standardised report sheet was completed, including echo findings and any echo-directed change in management. These reports were then analysed independently.

Results

A total of 230 patients were included, with 204 undergoing a FEEL examination during ongoing cardiac arrest (100) and in a shock state (104). Images of diagnostic quality were obtained in 96%. In 35% of those with an ECG diagnosis of asystole, and 58% of those with PEA, coordinated cardiac motion was detected, and associated with increased survival. Echocardiographic findings altered management in 78% of cases.

Conclusions

Application of ALS-compliant echocardiography in pre-hospital care is feasible, and alters diagnosis and management in a significant number of patients. Further research into its effect on patient outcomes is warranted.

Introduction

Pulselessness or severe shock of unknown origin is generally initially managed according to Basic and Advanced Life Support guidelines.1, 2, 3 Emergency echocardiography has been proposed as a basic diagnostic tool for the haemodynamically unstable critically ill patient, for acute severe dyspnoea, and during cardio-pulmonary resuscitation.4, 5, 6, 7, 8 Further, early echocardiography is now recommended in guidelines relating to the diagnosis of suspected pulmonary embolism or pericardial effusion.9, 10 Focused echocardiographic evaluation in life support (FEEL) has been developed to be used by cardiologists and non-cardiologists alike, as an adjunct to resuscitation in an ALS-compliant manner.11, 12, 13 The aim is to use FEEL to diagnose/exclude some of the potentially treatable causes of cardiac arrest, including tamponade, massive pulmonary embolism, severe ventricular dysfunction, and hypovolaemia as well as fine ventricular fibrillation missed by surface ECGs thereby optimizing peri-resuscitation care. Hence the use of FEEL is to improve resuscitative efforts but not to terminate resuscitation. The purpose of this study was to evaluate the feasibility of FEEL in pre-hospital resuscitation, the incidence of potentially treatable conditions detected, and the influence on patient management.

Section snippets

Study design

Ethical approval was obtained from the Institutional Ethics Committee for Human Studies, University Hospital, Frankfurt am Main, Germany. A prospective observational study with data acquisition controlled using STARD criteria for diagnostic trials and abbreviated Utstein-style data sets was performed.14, 15

Study setting

Patients were enrolled between August 2002 and December 2007. Four emergency medical systems (EMS) were involved: Frankfurt (urban), Darmstadt (urban and rural) and Raststatt (suburban). The

Results

A total of 230 patients (male 141, female 84; age: 65 ± 19 years) were enrolled in the study (Fig. 1). CPR was required in 100 patients and performed according to the ALS guidelines. Peri-resuscitation echocardiography was performed in all of these cases according to the FEEL protocol. Echocardiography was used in an additional 104 cases where the patient was judged to be in a peri-resuscitation state (but not currently requiring CPR). In 26 cases ultrasound was used additionally for abdominal or

Discussion

The concept of ALS-compliant echocardiography using the FEEL algorithm is gaining acceptance.11, 12, 13, 36 This study demonstrates that FEEL can be performed in the pre-hospital setting, resulting in the diagnosis of a significant number of potentially treatable underlying conditions and subsequent alteration in patient management.

The use of echocardiography or ultrasound by novice practitioners has been shown to be feasible in the emergency setting, with success in obtaining images and

Conclusion

Out-of hospital echocardiography using FEEL is feasible, and can be performed by EPs. The findings of this study call into question some of the peri-arrest diagnoses that are made, and demonstrate that echocardiography can be used in the pre-hospital setting to diagnose many of the potentially reversible causes of cardiac arrest, not identifiable by any other means, thereby changing patient management. The potential to improve patient outcome, and the implications upon fine-tuning the

Conflict of interest

There are no conflicts of interest to declare.

Author contributions

RB, FHS, FW designed the study. HVS, FS reviewed results for the study protocol. EM, FHS and FW performed data collection. RB, HS, HI, HA, EM, FW analysed the data. RB, MAW, SU and SP prepared and revised the manuscript. RB, HVS, EM and FW take responsibility of the results and the paper as a whole.

Acknowledgements

We are obliged to the participating EP and patients, the Frankfurt Fire Department (Prof. R. Ries) and chief of pre-hospital EMS of the city of Frankfurt am Main (Prof. Leo Latasch). Following colleagues were generously participating in data acquisition or advised in planning or execution of the study: U. Hannemann, M. Goebel, S. Kortüm, D. Oberndörfer, Th. Weber, K. Rimbach, C. Byhahn, S. Fichtlscherer. We thank I. Marzi, B. Zwißler and P. Kessler for continuous support.

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Live stream of prehospital point-of-care ultrasound during cardiopulmonary resuscitation – A feasibility trial
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Current resuscitation guidelines recommend that skilled persons could use ultrasound to detect reversible causes during cardiopulmonary resuscitation (CPR) where the examination can be safely integrated into the Advanced Life Support (ALS) algorithm. However, in a prehospital setting performing and rapidly interpreting ultrasound can be challenging for physicians. Implementing remote, expert-guided, and real-time transmissions of ultrasound examinations offers the opportunity for tele-support, even during an out-of-hospital cardiac arrest (OHCA). The aim of this feasibility study was to evaluate the impact of tele-supported ultrasound in ALS on hands-off time during an OHCA.
In an urban setting, physicians performed point-of-care ultrasound (POCUS) on patients during OHCA using a portable device, either with tele-support (n = 30) or without tele-support (n = 12). Where tele-support was used, the ultrasound image was transmitted via a remote real-time connection to an on-call specialist in anaesthesia and intensive care medicine with an advanced level of critical care ultrasound expertise. The primary safety endpoint of this study was to evaluate whether POCUS can be safely integrated into the algorithm, and to provide an analysis of hands-off time before, during, and after POCUS during OHCA.
In all 42 cases it was possible to perform POCUS during regular rhythm analyses, and no additional hands-off time was required. In 40 of these 42 cases, the physicians were able to perform POCUS during a single regular rhythm analysis, with two periods required only in two cases. The median hands-off time during these rhythm analyses for POCUS with tele-support was 10 (8–13) seconds, and 11 (9–14) seconds for POCUS without tele-support. Furthermore, as a result of POCUS, in a quarter of all cases the physician on scene altered their diagnosis of the primary suspected cause of cardiac arrest, leading to a change in treatment strategy.
This feasibility study demonstrated that POCUS with tele-support can be safely performed during OHCA in an urban environment.
Trial Registration (before patient enrolment): ClinicalTrials.gov, NCT04817475.
Should I Stay or Should I Go: Exploring the Role of Point-of-Care Ultrasound During Pediatric Cardiopulmonary Resuscitation Termination
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Interpretation of Cardiac Standstill in Children Using Point-of-Care Ultrasound
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This study aimed to determine the level of agreement among pediatric emergency medicine (PEM) physicians in whether various point-of-care ultrasound (POCUS) video clips represent cardiac standstill in children and to highlight the factors that may be associated with the lack of agreement.
A single, online, cross-sectional, convenience sample survey was administered to PEM attendings and fellows with variable ultrasound experience. PEM attendings with an experience of 25 cardiac POCUS scans or more were the primary subgroup based on ultrasound proficiency set by the American College of Emergency Physicians. The survey contained 11 unique, 6-second video clips of cardiac POCUS performed during pulseless arrest in pediatric patients and asked the respondent if the video clip represented a cardiac standstill. The level of interobserver agreement was determined using the Krippendorff’s α (Kα) coefficient across the subgroups.
A total of 263 PEM attendings and fellows completed the survey (9.9% response rate). Of the 263 total responses, 110 responses were from the primary subgroup of experienced PEM attendings with at least 25 previously seen cardiac POCUS scans. Across all video clips, PEM attendings with 25 scans or more had an acceptable agreement (Kα=0.740; 95% CI 0.735 to 0.745). The agreement was the highest for video clips wherein the wall motion corresponded to the valve motion. However, the agreement fell to unacceptable levels (Kα=0.304; 95% CI 0.287 to 0.321) across video clips wherein the wall motion occurred without the valve motion.
There is an overall acceptable interobserver agreement when interpreting cardiac standstill among PEM attendings with an experience of at least 25 previously reported cardiac POCUS scans. However, factors that may influence the lack of agreement include discordances between the wall and valve motion, suboptimal views, and the lack of a formal reference standard. More specific consensus reference standards of pediatric cardiac standstill may help to improve interobserver agreement moving forward and should include more specific details regarding the wall and valve motion.
Pro: Does Every Anesthesiologist Need to Learn Point-of-Care Ultrasound?
2023, Journal of Cardiothoracic and Vascular Anesthesia
Focused Ultrasonography in Cardiac Arrest
2023, Emergency Medicine Clinics of North America
Managing Cardiac Arrest Using Ultrasound
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^☆: A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.07.013.

^☆☆: The study was presented in part during the 9th Congress of the European Resuscitation Council in Budapest/Hungary, 8th September 2004.

¹: www.notfallsono.de.

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Clinical paperFocused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: A prospective trial☆,☆☆

Abstract

Purpose of the study

Patients, materials and methods

Results

Conclusions

Introduction

Section snippets

Study design

Study setting

Results

Discussion

Conclusion

Conflict of interest

Author contributions

Acknowledgements

Resuscitation

Resuscitation

Resuscitation

Ann Emerg Med

J Am Soc Echocardiogr

Resuscitation

Am J Emerg Med

Resuscitation

Ann Emerg Med

Resuscitation

Chest

Ann Emerg Med

Resuscitation

Resuscitation

Chest

Resuscitation

Resuscitation

American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 7.2: Management of Cardiac Arrest

Circulation

Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients

Crit Care Med

Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes?

Acad Emerg Med

Clinical paper
Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: A prospective trial☆,☆☆