Focused Cardiac Ultrasound and the Periresuscitative Period: A Case Series of Resident-Performed Echocardiographic Assessment Using Subcostal-Only View in Advanced Life Support

Introduction: Survival from non-shockable cardiac arrest is unlikely unless a reversible cause is identified and treated. Guidelines state that ultrasound has the potential to identify reversible causes. Currently, ultrasonographic findings from patients with spontaneous circulation are extrapolated to patients in cardiac arrest. While right ventricular (RV) dilation is a finding normally associated with pulmonary embolism (PE), porcine studies have shown that RV dilation is also seen in ventricular fibrillation (VF) and severe hypoxia. No studies have investigated how causes of cardiac arrest affect RV size during resuscitation. Hypothesis: The RV diameter is larger during resuscitation of cardiac arrest caused by PE when compared to hypoxia and VF. Methods: Pigs were anesthetized and randomized to cardiac arrest induced by VF, hypoxia, or PE. Advanced life support (ALS) was preceded by 7 minutes of untreated cardiac arrest. Cardiac ultrasound images of the RV from a subcostal 5-chamber view were obtained during induction of cardiac arrest and ALS. The RV diameter was measured two centimeters from the aortic valve at end diastole. RV diameter at 3rd rhythm analysis was the primary endpoint. Based on pilot studies a sample size of 8 animals in each group was needed. Results: Eight animals were included in each group. RV diameter was not statistically different at baseline (mean (95%CI)) in VF: 19.8 (18.0-21.5) mm, hypoxia: 19.8 (16.6-22.9) mm, and PE: 21.8 (19.2-24.3) mm. During induction of cardiac arrest the RV diameter increased to 29.6 (27.3-31.9) mm in the hypoxia group and 38.0 (33.4-42.6) mm in the PE group (difference to baseline and between groups, both p<0.01). Induction of VF caused an immediate increase in the RV diameter to 25.0 (21.2-28.8) mm (difference to baseline p<0.01). At 3rd rhythm analysis, RV diameter was 32.4 (28.6-36.2) mm in the PE group, which was significantly larger than both the hypoxia group at 23.3 (19.5-27.0) mm and the VF group at 24.9 (22.2-27.5) mm (difference between groups p<0.01). Conclusions: Cardiac arrest due to VF, hypoxia, and PE all caused an increase in RV diameter. During resuscitation the RV was larger in PE compared to VF and hypoxia. Cardiac ultrasound thus has the potential to detect PE during resuscitation.

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Patients Who Refuse Transportation by Ambulance: A Case Series

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00037808 ◽

1997 ◽

Vol 12 (4) ◽

pp. 45-50 ◽

Cited By ~ 8

Author(s):

John E. Hipskind ◽

JM Gren ◽

DJ Barr

Keyword(s):

Medical Information ◽

Life Support ◽

Motor Vehicle ◽

Demographic Data ◽

Vital Signs ◽

Case Series ◽

Advanced Life Support ◽

Care Program ◽

Motor Vehicle Crash ◽

Discharge Instructions

AbstractIntroduction:Patients refusing hospital transportation occurs in 5% to 25% of out-of-hospital calls. Little is known about these calls. This study was needed to determine the demographics, inherent risks, and timing of refused calls.Methods:This was a prospective review of all run sheets of patients who refused transportation were collected for a two month period. Demographic data and medical information was collected. Each run was placed into one of three categories of need for transport and further evaluation: 1) minimal; 2) moderate; and 3) definite. The Greater Elgin Area Mobile Intensive Care Program (GEA-MICP) based at Sherman Hospital in Elgin, Illinois, was the setting. The GEA-MICP is an Emergency Medical Services (EMS) system comprised of 17 advanced life support (ALS) ambulance agencies servicing northeastern Illinois. Study subjects were all patients who refused transportation to a hospital by ALS ambulance during July 1993 and February 1994. Paramedics were required to complete a run sheet for all calls.Results:Overall, 30% (683 of2,270) of all runs resulted in refusal of transportation. Patients who most commonly refused transportation were asymptomatic, 11–40 years old and involved in a motor vehicle crash. They usually had no past medical history, normal vital signs, and a normal mental status. Patients generally signed for their own release after evaluation. The average time to arrival was 4.2 minutes and average time spent on scene by paramedics was 18.4 minutes. Of the patients, 72% were judged to have minimal need, 25% were felt to have a moderate need, and 3% were felt to definitely need transport to a hospital for further evaluation and/or treatment.Conclusion:There are many cases when EMS are activated, but transportation is refused. Most refusals occur after paramedic evaluation. Providing paramedics with primary care training and protocols would standardize care given to patients and provide a mechanism for discharge instructions and follow-up for those who chose not to be transported to a hospital. Patients judged to require further treatment had unique characteristics. These data may be useful in identifying potentially sicker patients allowing a concentrated effort to transport this subset of patients to a hospital.

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Feasibility of focused cardiac ultrasound during cardiac arrest in the emergency department

Cardiovascular Ultrasound ◽

10.1186/s12947-021-00252-3 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Jessica R. Balderston ◽

Alan X. You ◽

David P. Evans ◽

Lindsay A. Taylor ◽

Zachary M. Gertz

Keyword(s):

Emergency Department ◽

Cardiac Arrest ◽

Image Quality ◽

Life Support ◽

Clinical Care ◽

Advanced Cardiac Life Support ◽

Spontaneous Circulation ◽

Cardiac Ultrasound ◽

Focused Cardiac Ultrasound ◽

And Gender

Abstract Background Focused cardiac ultrasound (FOCUS) can aid in evaluation and management of patients with cardiac arrest, but image quality in this population has been questioned. Our goal was to determine how often adequate imaging can be obtained in cardiac arrest patients. Methods We conducted a prospective cohort study to examine the utility of FOCUS in cardiac arrest. All patients who presented to the Emergency Department (ED) in cardiac arrest or who had cardiac arrest while in the ED over 6 months were prospectively identified. FOCUS images were obtained as part of routine clinical care. Patients with images obtained were paired with age- and gender-matched controls who underwent FOCUS for another indication during the study period. Image quality was scored by two blinded reviewers using a 0–4 scale, with a score of ≥ 2 considered adequate. Results There were 137 consecutive cardiac arrests, 121 out-of-hospital and 16 in-hospital, during the study period. FOCUS images were recorded in 126 (92%), who were included in the analysis. The average age was 58 years, and 45% were female. Ninety-seven studies (77%) were obtained during advanced cardiac life support while 29 (23%) were obtained after return of spontaneous circulation. The controls were appropriately matched. Of the cardiac arrest studies, 106 (84%) were rated adequate, compared to 116 (92%) in controls (p = 0.08). When compared to control FOCUS studies, the scores given to studies of cardiac arrest patients were lower (p = 0.001). Conclusions FOCUS can reliably be used during cardiac arrest to obtain images adequate to answer clinical questions and guide therapies.

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Adverse Events during Interfacility Transfers by Ground Advanced Life Support Services

Prehospital and Disaster Medicine ◽

10.1017/s1049023x0004084x ◽

1994 ◽

Vol 9 (1) ◽

pp. 50-53 ◽

Cited By ~ 6

Author(s):

Richard Wuerz ◽

Steve Meador

Keyword(s):

Cardiac Arrest ◽

Adverse Events ◽

Life Support ◽

Case Series ◽

Advanced Life Support ◽

Hospital Staff ◽

Retrospective Case ◽

Medication Therapy ◽

Patient Deterioration ◽

Acute Care Facilities

AbstractObjective:To identify risk factors for adverse events that occur during interfacility transfers by advanced life support (ALS).Design:A four-year, retrospective, case series.Setting:Three ALS units in a rural/suburban emergency medical services (EMS) system.Participants:351 transports to or from twelve acute care facilities; two patients records could not be located.Interventions:Patients were classified by illness/injury, transporting staff, and ongoing therapy; these were correlated with frequency of ALS intervention and patient deterioration.Results:During the study period, the number of transfers as a percentage of total calls (1.1%–5.2%) rose consistently. There were 11 illness/injury categories; the largest was cardiac (44%, 154 patients). Hospital staff accompanied the patient in 15% (52). Advanced life support (ALS) therapy was required in 4.9% (17): one monitored cardiac arrest was defibrillated successfully, 13 patients required unanticipated medication therapy, and three were noted to have clinical deterioration en route. The upper 95% confidence limit for cardiac arrest is 12.9/1,000 transfers or 20.8/1,000 hours. Patient deterioration and the need for ALS intervention were associated with the presence of medication infusions (p <.O5), but not with hospital staff (p >.40).Conclusions:Interfacility transfers of a heterogeneous group of patients in this series involve a low risk of cardiac arrest. Patients with medication infusions are at higher risk of deterioration and more frequently require ALS intervention en route. The presence of hospital staff had no measurable effect. These findings have implications for the development of ALS transfer protocols.

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Cardiac arrest

Focused Intensive Care Ultrasound ◽

10.1093/med/9780198749080.003.0021 ◽

2019 ◽

pp. 185-192

Author(s):

Gajen Sunthar Kanaganayagam ◽

Andrew Constantine ◽

Susanna Price

Keyword(s):

Cardiac Arrest ◽

Coronary Artery ◽

Cardiopulmonary Resuscitation ◽

Pulmonary Embolus ◽

Cardiac Rhythm ◽

Life Support ◽

Tension Pneumothorax ◽

Advanced Life Support ◽

Cardiac Ultrasound ◽

Coronary Artery Thrombosis

This chapter will present how advanced life support-compliant focused cardiac ultrasound can help confirm the cardiac rhythm, diagnose reversible causes, and predict favourable outcomes during cardiopulmonary resuscitation. It will describe how to recognize severe hypovolaemia, cardiac tamponade, coronary artery thrombosis, massive pulmonary embolus, and tension pneumothorax, and when to intervene. It will conclude by introducing how echo can assist clinical management during post-resuscitation care.

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The Cardiac Surgery Advanced Life Support Course (CALS): Delivering Significant Improvements in Emergency Cardiothoracic Care

Yearbook of Critical Care Medicine ◽

10.1016/s0734-3299(08)70318-6 ◽

2007 ◽

Vol 2007 ◽

pp. 147-148

Author(s):

E.A. Martinez

Keyword(s):

Cardiac Surgery ◽

Life Support ◽

Advanced Life Support

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Recommended Guidelines for Uniform Reporting of Pediatric Advanced Life Support: The Pediatric Utstein Style

Circulation ◽

10.1161/01.cir.92.7.2006 ◽

1995 ◽

Vol 92 (7) ◽

pp. 2006-2020 ◽

Cited By ~ 72

Author(s):

Arno Zaritsky ◽

Vinay Nadkarni ◽

Mary Fran Hazinski ◽

George Foltin ◽

Linda Quan ◽

...

Keyword(s):

Life Support ◽

Advanced Life Support ◽

Recommended Guidelines ◽

Utstein Style

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Evaluating pediatric advanced life support in emergency medical services with a performance and safety scoring tool

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2021.06.061 ◽

2021 ◽

Author(s):

Nathan Bahr ◽

Garth Meckler ◽

Matthew Hansen ◽

Jeanne-Marie Guise

Keyword(s):

Emergency Medical Services ◽

Life Support ◽

Advanced Life Support ◽

Medical Services ◽

Emergency Medical ◽

Scoring Tool ◽

A Performance

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One clot after another in COVID-19 patient: diagnostic utility of handheld echocardiogram

Oxford Medical Case Reports ◽

10.1093/omcr/omaa141 ◽

2021 ◽

Vol 2021 (2) ◽

Author(s):

Gini Priyadharshini Jeyashanmugaraja ◽

Evgeny Shloknik ◽

Deborah Tosin Akanya ◽

Kristin Stawiarski ◽

Christopher Winterbottom ◽

...

Keyword(s):

Right Ventricular ◽

Care Setting ◽

Pressure Overload ◽

Massive Pulmonary Embolism ◽

Cardiac Ultrasound ◽

Ventricular Dilation ◽

Severe Respiratory Distress ◽

Systemic Thrombolysis ◽

Focused Cardiac Ultrasound ◽

Right Ventricular Dilation

ABSTRACT A 63-year-old woman was admitted with severe respiratory distress requiring mechanical ventilation and shock requiring vasopressor support. She was found to have COVID-19 pneumonia. Focused cardiac ultrasound performed for evaluation of shock was significant for right ventricular dilation and dysfunction with signs of right ventricular pressure overload. Given worsening shock and hypoxemia systemic thrombolysis was administered for presumed massive pulmonary embolism with remarkable improvement of hemodynamics and respiratory failure. In next 24 h patient’s neurologic status deteriorated to the point of unresponsiveness. Emergent computed tomography showed multiple ischemic infarcts concerning for embolic etiology. Focused cardiac ultrasound with agitated saline showed large right to left shunt due to a patent foramen ovale. This was confirmed by transesophageal echocardiogram, 5 months later. This case highlights strengths of focused cardiac ultrasound in critical care setting and in patients with COVID-19 when access to other imaging modalities can be limited.

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