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Ultrasound in cardiac arrest

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Ultrasound in cardiac arrest

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Ultrasound in cardiac arrest

  1. 1. UTILITY OF ECHO IN RESUS Sinéad Taylor Emergency Registrar Sir Charles Gairdner Hospital
  2. 2. Outline 1. Refresher on basic echocardiography views 2. Use of echocardiography in arrest and peri-arrest situations 1. Where does it fit in the ALS/ACLS algorithm? 2. Re-evaluating PEA 3. Finding a cause 4. When do we terminate CPR?
  3. 3. BASIC ECHO VIEWS
  4. 4. Echo Views 1. Parasternal long axis (PLAX) 2. Parasternal short axis (PSAX) 3. Apical view 4. Subcostal view
  5. 5. 1. Parasternal long axis view (PLAX)
  6. 6. 1. Parasternal long axis view (PLAX)
  7. 7. 2. Parasternal Short Axis View (PSAX) Mitral valve Mid-ventricular level Apex
  8. 8. 2. Parasternal Short Axis View (PSAX) Aortic valve level
  9. 9. 2. Parasternal Short Axis View (PSAX) Mitral valve level
  10. 10. 2. Parasternal Short Axis View (PSAX) Papillary muscle level
  11. 11. 3. Apical View
  12. 12. 3.1 Apical 4 Chamber View
  13. 13. 3.1 Apical 5 Chamber View
  14. 14. 4. Subcostal View Subcostal long axis Subcostal short axis
  15. 15. 4.1 Subcostal 4 Chamber View
  16. 16. 4.2 IVC
  17. 17. ECHO IN CARDIAC ARREST
  18. 18. What can an echo exam in cardiac arrest achieve? 1. Identify the cause of the arrest 1. Treatable vs. non-treatable 2. Can rapidly change management 2. Assess PEA – is the patient truly pulseless? 3. Early detection of myocardial activity and ROSC
  19. 19. Where does echo fit in the ACLS algorithm? • Challenges of echo during cardiac arrest: • Little space • Little time • Need to minimise interruptions to chest compressions/ACLS algorithm • How do we overcome these obstacles? • Pre-plan with ultrasound machine settings • FEEL protocol (Focused Echocardiographic Evaluation in Life Support)
  20. 20. 10 secs
  21. 21. PULSELESS ELECTRICAL ACTIVITY
  22. 22. Pulse Check • It’s one of the first things we’re taught when we learn basic CPR/first aid, but how useful is it? • Problems: • Takes time (sometimes even longer than 5 seconds in healthy people) • Accuracy can be as low as 78% • Lower in arrest – 45% of healthcare providers can’t accurately detect a central pulse! • No palpable pulse • (Semi) Organised electrical activity on monitor • Organised cardiac activity on echo Pseudo PEA
  23. 23. CAUSES OF ARREST
  24. 24. Causes of cardiorespiratory arrest 4 H’s • Hypoxia • Hypovolaemia • Hypo/hyperkalaemia/ metabolic disorders • Hypo/hyperthermia 4 T’s • Tension pneumothorax • Tamponade • Toxins • Thrombosis (pulmonary or cardiac)
  25. 25. Hypovolaemia Zafiropoulos A, Asrress K, Redwood S, Gillon S, Walker D. CRITICAL CARE ECHO ROUNDS: Echo in cardiac arrest. Echo Research and Practice. 2014;1(2):D15-D21.
  26. 26. Hypovolaemia – LV size and function
  27. 27. Hypovolaemia
  28. 28. Hypovolaemia - IVC
  29. 29. Hypovolaemia - IVC • To determine hypovolaemia, we look at 2 different IVC parameters: • Size • Collapsibility index • This then gives us an idea of right atrial pressure/CVP. • 𝐶𝐼 % = (𝐼𝑉𝐶𝐷 max − 𝐼𝑉𝐶𝐷 min) 𝑥100 𝐼𝑉𝐶𝐷 𝑚𝑎𝑥 • Probable non-fluid responders: • <50% collapsibility index • >2cm IVC diameter • Probable fluid responders (i.e., hypovolaemic) • >50% collapsibility index • <1cm IVC diameter
  30. 30. So they’re hypovolaemic… but why?
  31. 31. Splenic rupture
  32. 32. Large pleural effusion in the context of trauma
  33. 33. Tamponade • Remember… tamponade is a clinical diagnosis. • BUT if your patient is in cardiorespiratory arrest and you see the following features, think of tamponade: • RA collapse • RV collapse • IVC dilation • Swinging heart • Best views for tamponade: • Subcostal – good for cardiac arrest, and you can assess IVC • PLAX – is the fluid pericardial or a pleural effusion? • Apical 4CV – look for RA and RV collapse
  34. 34. Tamponade • How much fluid matters? • It’s more about how quickly the fluid builds up, rather than the absolute volume. • Correlate what you’re looking at on echo with the patient’s clinical and haemodynamic status.
  35. 35. Tamponade – RA wall collapse
  36. 36. Tamponade – RV wall collapse
  37. 37. Tamponade – swinging heart
  38. 38. Thrombosis - PE • Sensitivity of echo for detecting PEs of any severity – approx 60%. • However if your patient is unstable, an absence of echo evidence for RV overload/dysfunction can exclude a PE(*) • PE causing arrest • 2/3 pulmonary vascular bed obstructed •  sudden increase in afterload  dilation of right ventricle • On echo: • PLAX: Increase in RV diameter >30mm • A4CV: increase in area of RV as compared to LV to 90% • PSAX: D-shaped septum, paradoxical movement (*) Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galie` N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U et al. 2008 Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). European Heart Journal 29 2276–2315.
  39. 39. PE Echo features 1. Echo dense thrombus – in RA or RV, IVC or pulmonary artery 2. RV strain • Dilated RV • Poorly contracting RV • Reduced TAPSE • Hyperdynamic LV • RV free wall hypokinesis 3. RV overload • D-shaped ventricle • Dilated non-collapsing IVC
  40. 40. RV dilation
  41. 41. PE Echo features
  42. 42. The icing on the cake
  43. 43. The icing on the cake
  44. 44. Thrombosis: Cardiac • Assess for regional wall abnormalities
  45. 45. https://www.ultrasoundoftheweek.com/uotw-36-answer/ Global hypokinesis Wall motion abnormalities, worse in septal + apical segments
  46. 46. Cath lab: 100% ostial LAD lesion
  47. 47. WHEN DO WE STOP CPR?
  48. 48. References 1. Carbonatto G. Point of Care Ultrasound Module 6: Echo. Lecture presented at; 2018; Sydney University Medical School. 2. Beraud A, Burkett T. Introduction to transthoracic echocardiography [Internet]. Koninklijke Philips; 2015 [cited 15 August 2018]. Available from: http://viewer.zmags.com/publication/3c9e5062#/3c9e5062/1 3. ANZCOR Adult Cardiorespiratory Arrest Flowchart [Internet]. Australian Resuscitation Council. 2016 [cited 15 August 2018]. Available from: https://resus.org.au/guidelines/flowcharts-3/ 4. Zafiropoulos A, Asrress K, Redwood S, Gillon S, Walker D. CRITICAL CARE ECHO ROUNDS: Echo in cardiac arrest. Echo Research and Practice. 2014;1(2):D15-D21. 5. Neskovic A, Hagendorff A, Lancellotti P, Guarracino F, Varga A, Cosyns B et al. Emergency echocardiography: the European Association of Cardiovascular Imaging recommendations. European Heart Journal - Cardiovascular Imaging. 2012;14(1):1-11. 6. Breitkreutz R, Walcher F, Seeger F. Focused echocardiographic evaluation in resuscitation management: Concept of an advanced life support–conformed algorithm. Critical Care Medicine. 2007;35(Suppl):S150-S161. 7. 7. Bystrzycki A. Ultrasound Village: ED Basic Echo - where does it fit? [Internet]. 2017 [cited 15 August 2018]. Available from: https://www.youtube.com/watch?v=125wM8DrbNI 8. 8. Carbonatto G. Sepsis – Critical Care Sonography [Internet]. Criticalcare-sonography.com. 2016 [cited 15 August 2018]. Available from: https://www.criticalcare-sonography.com/2016/09/15/sepsis/ 9. UOTW #36 Answer - Ultrasound of the Week [Internet]. Ultrasound of the Week. 2015 [cited 15 August 2018]. Available from: https://www.ultrasoundoftheweek.com/uotw-36-answer/ 10. 10. Thavanathan R, Hoang R. Look Deep Inside Yourself: Echo in Cardiac Arrest - EMOttawa [Internet]. EMOttawa. 2017 [cited 15 August 2018]. Available from: https://emottawablog.com/2017/09/look-deep-inside-yourself-echo-in-cardiac-arrest/ 11. Tibballs, J., & Russell, P. (2017). Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation, 80(1), 61–64 12. Ochoa, F. J., Ramalle-Gómara, E., Carpintero, J. ., Garcı́a, A., & Saralegui, I. (1998). Competence of health professionals to check the carotid pulse. Resuscitation, 37(3), 173–175 13. 11. Long B, Alerhand S, Maliel K, Koyfman A. Echocardiography in cardiac arrest: An emergency medicine review. American Journal of Emergency Medicine. 2018;36:488-493. 14. 12. Blyth L, Atkinson P, Gadd K, Lang E. Bedside Focused Echocardiography as Predictor of Survival in Cardiac Arrest Patients: A Systematic Review. Academic Emergency Medicine. 2012;19(10):1119-1126.

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