Echocardiography during cardiac arrest: Time to incorporate into ACLS?

Abstract

The use of echocardiography (echo) during cardiac arrest has been widely adopted amongst emergency and critical care clinicians over the past 20 years. 1. Long B. Alerhand S. Maliel K. Koyfman A. Echocardiography in cardiac arrest: an emergency medicine review. Am J Emerg Med. 2018; 36: 488-493 Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar It is possible to obtain transthoracic cardiac images in nearly all arrest patients without prolonging compression pause time. 2. Balderston J.R. You A.X. Evans D.P. Taylor L.A. Gertz Z.M. Feasibility of focused cardiac ultrasound during cardiac arrest in the emergency department. Cardiovasc Ultrasound. 2021; 19: 1-5 Crossref PubMed Scopus (5) Google Scholar , 3. Gaspari R.J. Harvey J. DiCroce C. et al. Echocardiographic pre-pause imaging and identifying the acoustic window during CPR, reduces CPR pause time during ACLS - a prospective cohort study. Resuscitation Plus. 2021; 6100094 Crossref PubMed Scopus (4) Google Scholar In a consensus statement from 2010, the American Society of Echocardiography and the American College of Emergency Physicians recommended focused cardiac ultrasound to assess patients in cardiac arrest, specifically to differentiate between asystole, pulseless electrical activity (PEA) and pseudo-PEA, a state where no pulse is palpated yet the patient has organized ventricular contractions on echo. 4. Labovitz A.J. Noble V.E. Bierig M. et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010; 23: 1225-1230 Abstract Full Text Full Text PDF PubMed Scopus (500) Google Scholar However, more recent consensus statements by both the American Heart Association and the European Resuscitation Council discouraged the use of echo for prognostication during cardiac arrest. 5. Berg K.M. Soar J. Andersen L.W. et al. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020; 142: S92-S139 Crossref PubMed Scopus (63) Google Scholar , 6. Soar J. Böttiger B.W. Carli P. et al. European Resuscitation Council guidelines 2021: adult advanced life support. Resuscitation. 2021; 161: 115-151 Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar Both cite a 2020 review in Resuscitation by Reynolds et al. that concludes that the evidence for the use of echo as a prognostic tool during cardiac arrest is limited and biased. 7. Reynolds J.C. Issa M.S. Nicholson T.C. et al. Prognostication with point-of-care echocardiography during cardiac arrest: a systematic review. Resuscitation. 2020; 152: 56-68 Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar So what does echo during cardiac arrest really add? Does it provide any additional prognostic information when combined with current modes of patient assessment such as electrocardiogram (ECG) and palpation of a pulse? Comparison of outcomes between pulseless electrical activity by electrocardiography and pulseless myocardial activity by echocardiography in out-of-hospital cardiac arrest; secondary analysis from a large, prospective studyResuscitationVol. 169PreviewBetween 350,000 and 400,000 cardiac arrest cases are managed in Emergency Departments annually in the United States.1 Survival to hospital discharge following out of hospital cardiac arrest has been reported between 3% and 22% and is influenced by many clinical, geographical and interventional factors.1,2 Echocardiography (echo) has been suggested as a tool to assist in cardiac arrest resuscitation.3,4 Initial suggestions that echo could prognosticate outcomes with a high degree of accuracy5–7 have not been supported with larger, better designed studies. Full-Text PDF