Bedside echocardiography for prognosis of emergency department cardiac arrest?
Date First Published:
June 9, 2010
Last Updated:
October 23, 2011
Report by:
Daniel S. Dallon, MD, Resident Physician (Grand Rapids Medical Education Partners/Michigan State University)
Search checked by:
Jeffery S. Jones, MD, Grand Rapids Medical Education Partners/Michigan State University
Three-Part Question:
In [adults in cardiac arrest] does [Emergency Physician performed bedside transthoracic echocardiography] have [accurate prognostic accuracy]?
Clinical Scenario:
A 62 year old male emergency patient arrives in cardiac arrest. During resuscitation he is found to have pulseless electrical activity (PEA). Several rounds of ACLS are performed with no improvement in the patient's condition. You wonder if a rapid bedside cardiac ultrasound (echocardiography) would be of any prognostic or diagnostic utility.
Search Strategy:
Ovid Medline(R) 1950 to August 2011
Search Details:
((exp ultrasonography OR exp echocardiography) AND (exp cardiopulmonary resuscitation OR exp heart arrest OR cardiac arrest)). Limited to English and human.
Outcome:
457 papers were found of which six were considered relevant to the three-part question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Rapid cardiac ultrasound of inpatients suffering PEA arrest performed by nonexpert sonographers Niendorff DF, Rassias AJ, Palac R, et al. 2005, USA | 17 consecutive patients suffering 18 PEA arrests over a 6 month period at a major academic hospital. Bedside echocardiography was attempted in 7 arrests and completed in 5 | Prospective feasibility study | Evaluate performance and reliability of Ultrasound assessment as an integrated part of the ACLS PEA arrest protocol | In four of five cases the nonexpert interpretation was confirmed | Extremely small sample size. Low compliance with study protocol. No follow up on cause of PEA arrest. Non-Emergency Physicians with limited ultrasound training. |
| Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardogram Blaivas M, Fox JCl. 2001, USA | Convenience sample of 169 adult non-traumatic patients arriving to a single ED over a 20-month period receiving ongoing CPR. Rapid bedside echocardiogram was performed during pulse check pauses. No patients with cardiac standstill on arrival (136) survived to leave the ED. 100% of patients presenting with asystole (65) had cardiac standstill on initial ECHO. | Prospective observational study | Survival of patients with cardiac motion at arrival to the ED. | 20 patients (12/67% with PEA, 8/53% with VF) survived to leave the ED. 13 patients (6/33% in PEA, 7/47% in VF) died despite cardiac activity on arrival. | Small convenience sample (800 eligible pts during study). No follow-up of survivors. 'Survival' included only to hospital admission. |
| Survival of patients in asystole on arrival to the ED. | No patients (65) in asystole on arrival survived. 100% had cardiac standstill on ultrasound. | ||||
| Survival of patients arriving to the ED with cardiac standstill. | No patients (136) arriving with cardiac standstill on ultrasound survived to leave the ED. | ||||
| Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Salen P, Melniker L, Chooljian C, et al. 2005, USA | Convenience sample of 70 adult non-traumatic patients arriving to four EDs over a 12-month period in either PEA or asystole. Rapid bedside echocardiogram was performed during pulse check pauses by Emergency Physicians. | Prospective observational study | Survival of patients arriving with cardiac standstill | No patients with cardiac standstill on arrival (59/70) survived to leave the hospital | Convenience sample. Small sample size. Resuscitation teams were not blinded to US results. Most patients arrived with cardiac standstill. 17 of 70 subjects did not get sequential US exams. |
| Return of spontaneous circulation | 0 of 59 patients with cardiac standstill had ROSC. 8/11 patients in PEA with cardiac motion had ROSC. | ||||
| Survival to hospital discharge | Only 1/8 patients survived to hospital discharge | ||||
| Can Cardiac Sonography and Capnography Be Used Independently and in Combination to Predict Resuscitation Outcomes? Salen P, O'Connor R, Sierzenski P, et al. 2001, USA | 102 nonconsecutive adult pulseless non-traumatic patients presenting to 2 community EDs over a 12 month period. All received a subxiphoid cardiac ultrasound during CPR pauses. 53 also had capnography levels recorded. | Prospective clinical observational study | Survival to hospital admission | 27% (11/41) of patients with cardiac motion survived to admission vs. 3% (2/61) of patients with cardiac standstill. | Convenience sample. No quantification of cardiac contractility. Only measured survival to admission. Small sample size. Resuscitation team not blinded to ultrasound results. |
| Usefulness of US in management of cardiac arrest | 96% of EPs felt US was helpful. | ||||
| Presence of pericardial effusion | 4% (4/102) of patients had a pericardial effusion | ||||
| Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states Tayal VS, Kline JA. 2003, USA | Twenty adult patients arriving at the ED in non-traumatic hemodynamic collapse over an 18 month period at a level 1 trauma center. | Prospective observational study | Cardiac standstill | 8/20 (40%) were in cardiac standstill | Not randomized. Small sample size. Selection bias (higher pre-test probability of pericardial effusion). Resuscitation team not blinded to ultrasound results Patients not necessarily in cardiac arrest, inclusion criteria included patients with hypotension |
| Survival | None of the 8 in cardiac standstill survived | ||||
| Pericardial Effusion | 8/12 (69%) of patients with cardiac activity had pericardial effusions. Bedside Echo diagnosed tamponade in 3 cases. | ||||
| An evaluation of echo in life support (ELS): is it feasible? What does it add? Hayhurst C, Lebus C, Atkinson PR, et al. 2011, UK | Convenience sample of 56 patients in cardiac arrest recruited over a 29-month period from two hospitals. Six patients excluded because scans were performed outside the cardiac arrest period | Prospective feasibility study | Return of spontaneous circulation | Ventricular wall movement present in 20 cases, 11 had ROSC. 1 Patients without VWM had ROSC | Small study |
| Survival to ED discharge | Four patients with VWM and one patient without VWM survived to ED discharge |
Author Commentary:
Cardiac standstill on bedside echocardiography performed during cardiac arrest is an extremely poor prognostic indicator. Only 0.9% of patients with cardiac standstill across all six studies (3/320) survived to hospital admission. One study, Niendorff DF et al, demonstrated that non-emergency physicians with minimal ultrasound experience might carry out inadequate examinations and/or misinterpret the results. However, in the other four studies where this was examined, for all studying emergency physicians in EDs with formal ultrasound training programmes, there was excellent correlation between EP and radiologist interpretations and quick and reliable assessments of cardiac activity were obtained. Several cases of tamponade were identified at the bedside and emergent drainage permitted survival to hospital admission. Few physicians felt that the sonography interfered with, or delayed, resuscitation. All the studies had small sample sizes and the resuscitation teams were not blinded to the ultrasound results. However, the results were highly consistent between studies and cardiac standstill was almost universally associated with failed resuscitations.
Bottom Line:
Cardiac standstill seen on physician-performed bedside echocardiography during cardiac arrest virtually predicts unsuccessful resuscitation. Even physicians with minimal training can reliably differentiate cardiac standstill from contractile myocardium. Experienced EP sonographers can also use bedside echocardiography to accurately diagnose reversible causes of cardiac arrest (ie, pericardial effusion, hypovolaemia, right heart strain, etc) and therefore potentially improve their patient's prognosis by treating the underlying process.
References:
- Niendorff DF, Rassias AJ, Palac R, et al. . Rapid cardiac ultrasound of inpatients suffering PEA arrest performed by nonexpert sonographers
- Blaivas M, Fox JCl.. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardogram
- 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?
- Salen P, O'Connor R, Sierzenski P, et al. . Can Cardiac Sonography and Capnography Be Used Independently and in Combination to Predict Resuscitation Outcomes?
- Tayal VS, Kline JA.. Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states
- Hayhurst C, Lebus C, Atkinson PR, et al. . An evaluation of echo in life support (ELS): is it feasible? What does it add?