Question 17.1

College Answer

a)
1) enable rapid diagnosis of potentially treatable causes of cardiac arrest e.g. PE, tamponade, hypovolaemia
2) guide interventions undertaken during cardiac arrest e.g. guide needle placement for
pericardiocentesis
3) assess response to therapy e.g. IVC diameter post fluid bolus in hypovolaemia

b)
Subcostal view (below the xiphoid sternum) – can be done without interfering with CPR.

Discussion

Which is the most appropriate view? Plainly the subcostal view; it would be insane to interfere with CPR by trying to shove the probe on the chest.

Rationale for the use of TTE during an arrest

• Cardiac arrest is caused by numerous aetiologies, of which only a few can be diagnosed by virtue of rhythm analysis or history and examination.
• Many of the "non-shockable" causes of cardiac arrest can be identified or confirmed by TTE, including the following:
  • Cardiac tamponade (RV collapse in systole, large effusion)
  • Massive PE (RV diltation, empty LV, D-shaped septum)
  • Hypovolemia (empty chambers, collapsed IVC)
  • Tension pneumothorax (chest US rather than cardiac echo)
• Other basic tools of assessment are already in routine use (eg. SpO₂ monitoring and EtCO₂ monitoring)

Advantages of intra-arrest TTE

• Non-invasive
• More effective in determining cardiac activity than palpation of central pulses
• May be effective in identifying a shockable rhythm when the ECG is impossible or unhelpful
• Allows US guidance of remedial procedures, eg. pericardiocentesis
• Allows real-time monitoring of the effectiveness of fluid resuscitation
• Allows the identification of regional wall motion abnormalities during periods of ROSC, which might result in an earlier decision to proceed with angiography
• Non-experts can be easily trained to perform brief focused TTE.

Disadvantages of intra-arrest TTE

• Intrudes upon team attention (it is another screen to mindlessly watch)
• Takes focus off resuscitation
• Requires significant skill to perform
• Images may be of poor quality in many circumstances
• Uninformative images may be misinterpreted and inaccurate management decisions could be made.
• So far, there has been no evidence of improved outcome
• It may result in an unacceptable interruption to CPR. in't Veld et al (2017) and Clattenburg et al (2018) found that the use of ultrasound prolonged off-the-chest pauses from an average of 11 seconds to 17 seconds, with the additional six seconds being wasted on image acquisition. Most interestingly, the ultrasonography pause was longer when the operator was also leading the arrest. 

Evidence and consensus guidelines regarding intra-arrest TTE

• Memtsoudis et al (2006) - 22 of non-cardiac surgical patients who had an unexpected cardiac arrest; the use of TOE in the operating theatre was evaluated. Of the 22, 18 had major changes made to their management on the basis of TOE findings. In-hospital survival was 32%.
• Blyth et al (2012) - meta-analysis of TTE as predictor of survival in cardiac arrest. 11 papers with a total of 558 patients were included. Intra-arrest TTE which demonstrated cardiac inactivity was strongly associated with the inability to restore spontaneous circulation. There was also a small, nonzero chance of ROSC with a motionless heart: 2.4% of patients with a motionless left ventricular wall would go on to achieve ROSC.. Pooled sensitivity was 91% and specificity was 80%. Research such as this is frustrated by unclear methodology: was the TTE performed in the first minute of CPR, or in the fortieth minute? Most people would agree that there is a difference in the way you would interpret the findings.
• Anderson et al (2014) - swine model of cardiac arrest; ultrasound-guided compressions improved coronary perfusion pressure, because the rescuers were able to see how well (or poorly) they were compressing the left ventricle.
• Flato et al (2015) - observational cohort of 49 ICU patients. TTE changed management in 51% and there was a surprising number of "pulseless" patients who actually had cardiac activity on TTE. These patients actually had a much better rate of ROSC (~70%) in comparison to the truly pulseless patients who had no cardiac motility (who had ROSC rates of around 20%). The authors concluded that intra-arrest TTE can identify potentially salvageable patients.

Support for this practice among published  guidelines

• ARC Guideline 11.6 (2010) gives a Class B recommendation to the use of ultrasound in cardiac arrest, but on the basis of weak (Level IV) evidence.
• Intensive Care Society recommends "Focused Intensive Care Echo"(FICE) to be among the basic competencies for intensivists.
• ASEP/ASE consensus statement (2010)  recommends FOCUS ( focused cardiac ultrasound ) in a complimentary diagnostic role.
• ILCOR (2015) demur making any recommendation, saying that it "may be considered" as an adjunct only where "a qualified sonographer is present and use of ultrasound does not interfere" with CPR.

Price, Susanna, Shahana Uddin, and Tom Quinn. "Echocardiography in cardiac arrest." Current opinion in critical care 16.3 (2010): 211-215.
Zafiropoulos, Andreas, et al. "Critical Care Echo Rounds: Echo in cardiac arrest." Echo Research and Practice 1.2 (2014): D15-D21.

Flato, Uri Adrian Prync, et al. "Echocardiography for prognostication during the resuscitation of intensive care unit patients with non-shockable rhythm cardiac arrest." Resuscitation 92 (2015): 1-6.

Anderson, Kenton L., et al. "Ultrasound Guided Chest Compressions Over the Left Ventricle During Cardiopulmonary Resuscitation Increases Coronary Perfusion Pressure and Return of Spontaneous Circulation in a Swine Model of Traumatic Cardiac Arrest." Circulation 130.Suppl 2 (2014): A15853-A15853.
Memtsoudis, Stavros G., et al. "The usefulness of transesophageal echocardiography during intraoperative cardiac arrest in noncardiac surgery." Anesthesia & Analgesia 102.6 (2006): 1653-1657.

Blyth, Lacey, et al. "Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review." Academic Emergency Medicine 19.10 (2012): 1119-1126.

Labovitz, Arthur J., et al. "Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians." Journal of the American Society of Echocardiography 23.12 (2010):

in't Veld, Maite A. Huis, et al. "Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions." Resuscitation 119 (2017): 95-98.

Clattenburg, Eben J., et al. "Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: a prospective cohort study." Resuscitation 122 (2018): 65-68.

Michels, Guido, and Roman Pfister. "Point-of-care ultrasound use in patients with cardiac arrest: More harmful than useful?." Resuscitation 124 (2018): e21.

Atkinson, Paul R., et al. "Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? A Study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators." Cureus 11.4 (2019).