Article: Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016 Sep;109:33-39
Objective: To assess survival to hospital admission (primary outcome), and survival to hospital discharge and return of spontaneous circulation (ROSC) (secondary outcomes) after cardiac arrest with point-of-care ultrasound incorporated into ACLS.
Design: Non-randomized, prospective, protocol-driven, multicenter observational study
Inclusion Criteria: Patients presenting to ED with non-traumatic cardiac arrest who were found to be in asystole or PEA, and had ultrasound imaging performed during their resuscitation.
Exclusion Criteria: Resuscitation efforts lasting less than 5 minutes, or when resuscitation was not continued after initial ultrasound or if resuscitation was discontinued due to a do-not-resuscitate order.
Methods: Ultrasound was utilized during pauses in ACLS to assess for cardiac activity and to assess for etiologies such as pericardial effusion and pulmonary embolism. All clips were reviewed by a blinded single reviewer for study agreement.
Results: A total of 953 patients were enrolled in the study, with 793 included based upon the criteria above. 208 (26.2%) demonstrated ROSC, 114 (14.4%) demonstrated survival to hospital admission, and 13 (1.6%) demonstrated survival to hospital discharge. The study found that cardiac activity upon initial ultrasound was associated with higher ROSC and survival to hospital admission. Of the 263 patients with initial cardiac activity, 134 (51%), 76(28.9%), and 10 (3.8%) survived to ROSC, hospital admission, and hospital discharge respectively. Of the 530 without cardiac activity, only 76 (14.3%), 38 (7.2%), and 3 (0.6%) survived to ROSC, hospital admission, and hospital discharge respectively. Additionally, PEA was associated with increased survival at all time points and cardiac activity when compared to asystole.
Pericardial effusion was identified in 34 patients, 13 of which underwent attempted pericardiocentesis. Survival to hospital discharge in these patients was 15.4%. Additionally 2 of 15 patients receiving thrombolytics for suspected PE given right heart strain survived to hospital admission (13.3%), and one patient survived to hospital discharge (6.7%).
Location of arrest (home vs. ED) and length of resuscitation were not determined to be contributing factors to survival to discharge.
Takeaway: Point-of-care ultrasound is a useful tool in resuscitation for cardiac arrest. While initial cardiac activity can be a positive indicator of the patient’s survival, three patients in this study survived to discharge even without initial cardiac activity. It also is a great tool to determine secondary etiologies such as pericardial effusion and PE, which indicate alternative therapy to ACLS, and subsequently greater survival. However, this study is limited by the resuscitation team not being blinded to ultrasound results. This may have led to prolonged resuscitation efforts in patients with cardiac activity. Additionally, this study did not assess neurocognitive outcomes, which may contribute significantly to the quality of survival in those that survived to discharge.
Post by Joseph Terzian, MS4