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Focused echocardiographic evaluation in resuscitation management:

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  • 1. Focused echocardiographic evaluationFocused echocardiographic evaluation in resuscitation management:in resuscitation management: Concept of an advanced life support–Concept of an advanced life support– conformed algorithmconformed algorithm Raoul Breitkreutz, MD; Felix Walcher, MD, PhD; Florian H. Seeger,Raoul Breitkreutz, MD; Felix Walcher, MD, PhD; Florian H. Seeger, MDMD Critical Care Medicine, May 2007; 35(5) Suppl:S150-S161Critical Care Medicine, May 2007; 35(5) Suppl:S150-S161 Presented by R1 鄭鴻志 Supervised by VS 沈修年 本檔僅供內部教學使用 檔案內所使用之照片之版權仍屬於原期刊 公開使用時 , 須獲得原期刊之同意授權
  • 2. IntroductionIntroduction  In emergency and critical care medicine, the old and new American and EuropeanIn emergency and critical care medicine, the old and new American and European resuscitation guidelines of theresuscitation guidelines of the American Heart AssociationAmerican Heart Association,, European Resuscitation CouncilEuropean Resuscitation Council,, and theand the InternationalInternational Liaison Committee on ResuscitationLiaison Committee on Resuscitation recommended identifying andrecommended identifying and treatingtreating correctable causescorrectable causes of cardiopulmonary arrest.of cardiopulmonary arrest.  Patients must be treated using algorithm-based management such as basic lifePatients must be treated using algorithm-based management such as basic life support (BLS) and advanced life support (ALS).support (BLS) and advanced life support (ALS).  TimeTime is an essential component for successful cardiopulmonary resuscitationis an essential component for successful cardiopulmonary resuscitation (CPR).(CPR).  Any diagnostic procedures and interventions? to identify the underlying cause?Any diagnostic procedures and interventions? to identify the underlying cause?
  • 3. IntroductionIntroduction  Myocardial function during CPRMyocardial function during CPR is stillis still underdiagnosedunderdiagnosed in mostin most cases.cases.  Potentially treatable causes of sudden cardiac arrest:Potentially treatable causes of sudden cardiac arrest:  pericardial tamponadepericardial tamponade,,  cardiogenic shockcardiogenic shock,,  myocardial insufficiencymyocardial insufficiency (resulting from coronary or pulmonary(resulting from coronary or pulmonary artery thrombosis),artery thrombosis),  hypovolemiahypovolemia,,  should be detected or excluded as soon as possibleshould be detected or excluded as soon as possible !!!! In emergency rooms,In emergency rooms, the immediate application ofthe immediate application of sonographysonography could result in improved patient outcome.could result in improved patient outcome. In emergency rooms,In emergency rooms, the immediate application ofthe immediate application of sonographysonography could result in improved patient outcome.could result in improved patient outcome. EchocardiographyEchocardiography
  • 4. IntroductionIntroduction  TheThe new 2005new 2005 American Heart Association/European Resuscitation Council/American Heart Association/European Resuscitation Council/ International Liaison Committee on Resuscitation guidelinesInternational Liaison Committee on Resuscitation guidelines set narrowset narrow time intervalstime intervals for echocardiographic examination, due tofor echocardiographic examination, due to  potential detrimental effectspotential detrimental effects  the requirement ofthe requirement of rebuilding coronary perfusion pressurerebuilding coronary perfusion pressure..  Pauses in chest compression were recommended to bePauses in chest compression were recommended to be “brief“brief interruptions”interruptions” for adult ALS and of afor adult ALS and of a maximum of 10 secsmaximum of 10 secs forfor pediatric ALS to reduce the duration ofpediatric ALS to reduce the duration of no-flow intervals (NFIs).no-flow intervals (NFIs).  Thereby limiting potentialThereby limiting potential transthoracic ultrasound examinationstransthoracic ultrasound examinations..
  • 5. IntroductionIntroduction  A major challenge isA major challenge is recognizing return of spontaneous circulationrecognizing return of spontaneous circulation whenwhen no central pulseno central pulse is palpable.is palpable.  Even health professionals are insecure and take too long in detecting aEven health professionals are insecure and take too long in detecting a carotid pulse or respiratory effort.carotid pulse or respiratory effort.  Peripheral oxygen saturation with pulse curve or noninvasive blood pressurePeripheral oxygen saturation with pulse curve or noninvasive blood pressure measurement, are unreliable in severe hypotension or shock, and it can takemeasurement, are unreliable in severe hypotension or shock, and it can take 10 secs to obtain such a critical result.10 secs to obtain such a critical result.  Consequently, a structured process for aConsequently, a structured process for a focused echocardiographicfocused echocardiographic examinationexamination and forand for recognition of relevant pathologyrecognition of relevant pathology duringduring resuscitation management is mandatory.resuscitation management is mandatory. Focused echocardiographic evaluation in resuscitation (FEER)Focused echocardiographic evaluation in resuscitation (FEER)
  • 6. Algorithm of FEERAlgorithm of FEER
  • 7. Focused EchocardiographicFocused Echocardiographic Evaluation in ResuscitationEvaluation in Resuscitation  The FEER examination is aThe FEER examination is a ten-stepten-step procedure (Table 1).procedure (Table 1).  prevent any increase in the duration of the NFI and to reduce unwantedprevent any increase in the duration of the NFI and to reduce unwanted interruptions.interruptions.  fourfour distinct phasesdistinct phases..  Preparation Parallel to CPR.Preparation Parallel to CPR.  Obtaining an Echocardiogram Within Approximately a 5-secObtaining an Echocardiogram Within Approximately a 5-sec Pause of CPRPause of CPR  Evaluation of the Echocardiogram While Continuing CPR.Evaluation of the Echocardiogram While Continuing CPR.  Results, Follow-Up Information, and ConsequencesResults, Follow-Up Information, and Consequences
  • 8. FEER ExaminationFEER Examination 1.1. 2.2. 3. 4.4.
  • 9. Indications of EchocardiographyIndications of Echocardiography
  • 10. FEER examination starts with theFEER examination starts with the subcostalsubcostal window.window. If this option fails, it uses theIf this option fails, it uses the parasternalparasternal window,window, long-axislong-axis, or, or short-axisshort-axis view andview and only later theonly later the apical four-chamberapical four-chamber view if there is insufficient visualization.view if there is insufficient visualization. subcostalsubcostalsubcostalsubcostal parasternalparasternal long axislong axis parasternalparasternal long axislong axis short axis,LVshort axis,LVshort axis,LVshort axis,LVshort axis,short axis, aortaaorta short axis,short axis, aortaaorta four chamberfour chamberfour chamberfour chamber Echocardiography in FEEREchocardiography in FEER
  • 11. Observational TrialObservational Trial • We analyzed typical phases and interruption intervals during BLS/ALS to identify relevant timeWe analyzed typical phases and interruption intervals during BLS/ALS to identify relevant time windows for dummy echocardiography (DUE)windows for dummy echocardiography (DUE) • 1818 groups of paramedics performed a two-rescuer CPR scenario.groups of paramedics performed a two-rescuer CPR scenario. • A third person was allowed to use any interruption to apply DUE without disturbing CPRA third person was allowed to use any interruption to apply DUE without disturbing CPR workflow.workflow. • ““Old” BLS/ALS algorithmOld” BLS/ALS algorithm was analyzed. (studies beganwas analyzed. (studies began before November 2005before November 2005)) • BLS/ALS-related interruptions were (numbers are seconds ±SD):BLS/ALS-related interruptions were (numbers are seconds ±SD): • 1)1) BLSBLS:: 3434 ± 3;± 3; • 2)2) two breaths, 15 chest compressionstwo breaths, 15 chest compressions (CPR cycle):(CPR cycle): 2323 ±12;±12; • 3)3) applying electrocardiography and analysisapplying electrocardiography and analysis:: 3535 ± 8;± 8; • 4)4) parallel airway managementparallel airway management:: 224224 ±67;±67; • 5)5) rhythm analysis and three defibrillationsrhythm analysis and three defibrillations:: 4040 ±5.±5. • Results:Results: no differencesno differences in thein the number and duration of NFIs (no flow intervals)number and duration of NFIs (no flow intervals) with orwith or without dummy-echocardiography between the groups (Fig. 3).without dummy-echocardiography between the groups (Fig. 3).
  • 12. Duration & Number of No-flow-intervalsDuration & Number of No-flow-intervals in BLS/ALS-Training with or without FEERin BLS/ALS-Training with or without FEER Comparison of duration of no-flow intervals during ALSComparison of duration of no-flow intervals during ALS training according to thetraining according to the European ResuscitationEuropean Resuscitation Council (Council (ERCERC) 2001) 2001 ((upper two horizontal barsupper two horizontal bars)) andand ERC 2005ERC 2005 ((lower barlower bar) guidelines.) guidelines. ALS: advanced life support BLS: basic life support. black separations of the bar: no-flow intervals A randomized interruption with dummy-echocardiographyA randomized interruption with dummy-echocardiography ((DUEDUE)) did notdid not induce a prolongationinduce a prolongation ofof distinct phases or the duration or numberdistinct phases or the duration or number of no-flow intervals.of no-flow intervals.
  • 13. Observational TrialObservational Trial • AimAim: to test the: to test the capability of FEERcapability of FEER to differentiate PEA statesto differentiate PEA states • Participant:Participant: trained EP/INTtrained EP/INT • Out-of hospital CPR:Out-of hospital CPR: 7777 cases (men, n=54; women, n=23; age, 67±18 yrs) were includedcases (men, n=54; women, n=23; age, 67±18 yrs) were included in the FEER protocol.in the FEER protocol. • Suspected PEASuspected PEA  3030 / 77/ 77 cases.cases. • 1919 of 30of 30 suspected PEAsuspected PEA  cardiac wall movement(+),cardiac wall movement(+), • correctable causes such as pericardial tamponade (n=3), poor ventricular function (n=14),correctable causes such as pericardial tamponade (n=3), poor ventricular function (n=14), and hypovolemia (n=2) were noted or treated.and hypovolemia (n=2) were noted or treated. • In 13 of 19 true pseudo-PEA cases, patients survived to hospital admission.In 13 of 19 true pseudo-PEA cases, patients survived to hospital admission. • 1111 of 30of 30 PEA casesPEA cases  true cardiac standstill on echocardiogramtrue cardiac standstill on echocardiogram  died.died. • In addition to differentiating PEA states, FEER has the ability toIn addition to differentiating PEA states, FEER has the ability to identify a pseudo-PEAidentify a pseudo-PEA statestate, allowing the, allowing the continuation of CPR and further treatmentcontinuation of CPR and further treatment of theof the underlying disorder on the scene if possible.underlying disorder on the scene if possible.
  • 14. Educational Basis ofEducational Basis of ALS-Conformed EchocardiographyALS-Conformed Echocardiography  PeriodPeriod: 1-day course program on focused echocardiography: 1-day course program on focused echocardiography  TraineesTrainees: EP/INT without previous knowledge in transthoracic echocardiography: EP/INT without previous knowledge in transthoracic echocardiography  To answer a series of questionsTo answer a series of questions  AA precourse testprecourse test within the first hands-on training sessionwithin the first hands-on training session  Received theoretical and practical training with selected lectures as an intervention.Received theoretical and practical training with selected lectures as an intervention.  AA postcourse examinationpostcourse examination within the second hands-on training session was completedwithin the second hands-on training session was completed (Fig. 4).(Fig. 4).
  • 15. aa,, Significant decrease of time consumption (mean, SD) of trainees within the two hands-on trainingSignificant decrease of time consumption (mean, SD) of trainees within the two hands-on training sessions (sessions (left four barsleft four bars) and compared with the instructors () and compared with the instructors (black barsblack bars). The success rates, as). The success rates, as percentages of successful trials by all trainees, are given as numbers in thepercentages of successful trials by all trainees, are given as numbers in the barsbars.. bb,, Recognition skills tested by movie clips in a 5-inch screen with a maximum length of 5 secs.Recognition skills tested by movie clips in a 5-inch screen with a maximum length of 5 secs. The pairs ofThe pairs of barsbars with the same pattern depict the pretest (with the same pattern depict the pretest (leftleft) and posttest () and posttest (rightright)) percentagespercentages of correct answers per question/pathology.of correct answers per question/pathology. Results of the training course on theResults of the training course on the FEERFEER examinationexamination for emergency physicians and intensivistsfor emergency physicians and intensivists
  • 16. Results of the training course on theResults of the training course on the FEERFEER examinationexamination for emergency physicians and intensivistsfor emergency physicians and intensivists c, Improvement of practical skills to learn the FEER examination. Pairs of bars with the same pattern show pretest (left) and posttest (right) percentages of correct trials checked by objective structured clinical examination (from the left): information, preparation and testing, count-down announcement, correct interruption, pulse check, positioning of the probe parallel to cardiopulmonary resuscitation, control to continuing cardiopulmonary resuscitation, and follow-up information. d, Theoretical gain in 32 participants (mean, SD), measured by multiple-choice (MC) questionnaires.
  • 17. Physiologic pericardial fluidPhysiologic pericardial fluid Anterior fat padAnterior fat pad Small effusionSmall effusion Massive effusionMassive effusion
  • 18. Echocardiographic findingsEchocardiographic findings
  • 19. LV/RV: left or right ventricular cavum, FP: anterior fat pad.LV/RV: left or right ventricular cavum, FP: anterior fat pad. the pericardium (the pericardium (PP) follows the epicardium () follows the epicardium (EE) in waveforms) in waveforms and that E/P are tight together.and that E/P are tight together. Normal wall motion (subcostal window, long axis).Normal wall motion (subcostal window, long axis). M-mode in emergency echocardiographyM-mode in emergency echocardiography
  • 20. M-mode in emergency echocardiographyM-mode in emergency echocardiography Parasternal window, long axisParasternal window, long axis P and E are separated by the PEP and E are separated by the PE P is found as a flat lineP is found as a flat line Pericardial effusion (Pericardial effusion (PEPE)) LV is clearly identified withLV is clearly identified with unseparated posterior E and Punseparated posterior E and P Pleural effusion (Pleural effusion (Pl-EPl-E)) regular electrocardiographic rhythmregular electrocardiographic rhythm without wall motionwithout wall motion True PEATrue PEA no regular electrocardiographicno regular electrocardiographic rhythm or wall motionrhythm or wall motion Cardiac standstillCardiac standstill
  • 21. Normal findingNormal finding Enlarged RVEnlarged RV Normal findingNormal finding Paradoxical septal wall motionParadoxical septal wall motion (D sign) – acute cor pulmonale(D sign) – acute cor pulmonale
  • 22. DiscussionDiscussion Ultrasound imagingUltrasound imaging enhances the physician’s ability to evaluate, diagnose, andenhances the physician’s ability to evaluate, diagnose, and treat emergency department patients.treat emergency department patients. The most prominent thesis of this review is that the most used standard careThe most prominent thesis of this review is that the most used standard care interventionsinterventions do notdo not give enough direct information of cardiac responses in CPR andgive enough direct information of cardiac responses in CPR and PEA states.PEA states. The lack of aThe lack of a standardized emergency echocardiographystandardized emergency echocardiography in the periresuscitationin the periresuscitation complex is acomplex is a significant gapsignificant gap in our health system.in our health system.
  • 23. DiscussionDiscussion In our prehospital observational trial, we unexpectedly encountered several cases withIn our prehospital observational trial, we unexpectedly encountered several cases with hypotension because of ahypotension because of a pericardial effusionpericardial effusion oror tamponadetamponade.. One of these cases illustrated the need for emergency echocardiography.One of these cases illustrated the need for emergency echocardiography. A 14-yr-old child who was well 6 wks after open heart surgery suddenly deteriorated,A 14-yr-old child who was well 6 wks after open heart surgery suddenly deteriorated, with agitation and hypotension progressing to unconsciousness.with agitation and hypotension progressing to unconsciousness. The trained EP used FEER to diagnosis a massive pericardial effusion.The trained EP used FEER to diagnosis a massive pericardial effusion. On transportation to the pediatric intensive care unit, there was a cardiac arrest withOn transportation to the pediatric intensive care unit, there was a cardiac arrest with a PEA state.a PEA state. With the foreknowledge of the pericardial effusion, the EP decided to performWith the foreknowledge of the pericardial effusion, the EP decided to perform pericardiocentesispericardiocentesis beforebefore starting chest compressions.starting chest compressions. The child survived and now attends the same school class without neurologic deficit.The child survived and now attends the same school class without neurologic deficit. We believe that without detecting the pericardial fluid by echocardiography, the childWe believe that without detecting the pericardial fluid by echocardiography, the child probably would have died.probably would have died.
  • 24. The next challenge for the American Heart Association/European ResuscitationThe next challenge for the American Heart Association/European Resuscitation Council/International Liaison Committee on Resuscitation guidelines may includeCouncil/International Liaison Committee on Resuscitation guidelines may include reinforcing methodsreinforcing methods to identify treatable causes of arrest during resuscitation.to identify treatable causes of arrest during resuscitation. Unfortunately, theUnfortunately, the suggestion of echocardiography use disappeared insuggestion of echocardiography use disappeared in 20052005, except in special circumstances, in which the practitioner should “actively seek, except in special circumstances, in which the practitioner should “actively seek and exclude reversible causes of cardiac arrest” .and exclude reversible causes of cardiac arrest” . Such circumstances: postcardiac surgery p’ts and mainly relate to in-hospital care in theSuch circumstances: postcardiac surgery p’ts and mainly relate to in-hospital care in the immediate postsurgical phase.immediate postsurgical phase. InIn blunt or penetrating trauma,blunt or penetrating trauma, “ultrasound is a valuable tool in the evaluation“ultrasound is a valuable tool in the evaluation ofof possible cardiac tamponadepossible cardiac tamponade” .” . New technical solutions onNew technical solutions on mobile ultrasoundmobile ultrasound (weighing 2 kg of weight) are readily(weighing 2 kg of weight) are readily available for rescue teams of theavailable for rescue teams of the emergency departmentemergency department,, intensive care unitintensive care unit, or, or prehospital trauma supportprehospital trauma support at the patient’s bedside.at the patient’s bedside. DiscussionDiscussion
  • 25. Emergency echocardiography, based on mobile techniques, may be used in aEmergency echocardiography, based on mobile techniques, may be used in a qualitative approach as aqualitative approach as a “third eye”“third eye” in resuscitation.in resuscitation. We should consider its limitations and should implement these tools not only asWe should consider its limitations and should implement these tools not only as aa guide forguide for terminating resuscitation effortsterminating resuscitation efforts, but rather as a guide for, but rather as a guide for improving effectiveness of resuscitationimproving effectiveness of resuscitation.. With theWith the simple use of ALS-conformed echocardiographysimple use of ALS-conformed echocardiography, some of the, some of the diagnostic gaps in emergency and critical care medicine can be closed.diagnostic gaps in emergency and critical care medicine can be closed. A focusedA focused 6-hr echocardiographic training6-hr echocardiographic training course significantly improved EPcourse significantly improved EP residents’ written and practical examinations in a prospective, observational,residents’ written and practical examinations in a prospective, observational, educational study for goal-directed echocardiography performance andeducational study for goal-directed echocardiography performance and interpretation.interpretation. ~ Jones et al.~ Jones et al. DiscussionDiscussion
  • 26. Summary and ConclusionsSummary and Conclusions  Because of theBecause of the diagnostic pressure during CPRdiagnostic pressure during CPR to identify andto identify and treat reversible causes, there is a demand for a structured process whentreat reversible causes, there is a demand for a structured process when using echocardiography.using echocardiography.  The simple FEER examination mainly enables an ALS-conformed algorithm toThe simple FEER examination mainly enables an ALS-conformed algorithm to assess myocardial wall motionassess myocardial wall motion with the educated eye parallel towith the educated eye parallel to brief pauses of CPR within a few seconds.brief pauses of CPR within a few seconds.  FEER mayFEER may differentiate PEAdifferentiate PEA andand identify pericardial effusionidentify pericardial effusion without a major prolongation of the NFIs.without a major prolongation of the NFIs.  It is suggested as an extension to standard advanced cardiac life supportIt is suggested as an extension to standard advanced cardiac life support interventions.interventions.  Educational training for the FEER examination is essential by theoreticalEducational training for the FEER examination is essential by theoretical and practical means and can be learned in anand practical means and can be learned in an 8-hr8-hr course bycourse by non-non- expertexpert sonographers.sonographers.
  • 27. Thanks for your attention !!Thanks for your attention !!