Focused echocardiographic evaluation iFocused echocardiographic evaluation in resuscitation management: n resuscitation management:

Concept of an advanced life support–coConcept of an advanced life support–conformed algorithmnformed algorithm

Focused echocardiographic evaluation iFocused echocardiographic evaluation in resuscitation management: n resuscitation management:

Concept of an advanced life support–coConcept of an advanced life support–conformed algorithmnformed algorithm

Raoul Breitkreutz, MD; Felix Walcher, MD, PhD; Florian H. Seeger, MRaoul Breitkreutz, MD; Felix Walcher, MD, PhD; Florian H. Seeger, MDDRaoul Breitkreutz, MD; Felix Walcher, MD, PhD; Florian H. Seeger, MRaoul Breitkreutz, MD; Felix Walcher, MD, PhD; Florian H. Seeger, MDD

Critical Care Medicine, May 2007; 35(5) Suppl:S150-S161Critical Care Medicine, May 2007; 35(5) Suppl:S150-S161 Critical Care Medicine, May 2007; 35(5) Suppl:S150-S161Critical Care Medicine, May 2007; 35(5) Suppl:S150-S161

Presented by R1 鄭鴻志Supervised by VS 沈修年Presented by R1 鄭鴻志Supervised by VS 沈修年

本檔僅供內部教學使用檔案內所使用之照片之版權仍屬於原期刊公開使用時 , 須獲得原期刊之同意授權

IntroductionIntroductionIntroductionIntroduction

In emergency and critical care medicine, the old and new American and In emergency and critical care medicine, the old and new American and European resuscitation guidelines of theEuropean resuscitation guidelines of the American Heart AssociationAmerican Heart Association, , European Resuscitation CouncilEuropean Resuscitation Council,, and theand the International International Liaison Committee on ResuscitationLiaison Committee on Resuscitation recommended identifying recommended identifying and treatingand treating correctable causescorrectable causes of cardiopulmonary arrest.of cardiopulmonary arrest.

Patients must be treated using algorithm-based management such as basic life Patients must be treated using algorithm-based management such as basic life support (BLS) and advanced life support (ALS).support (BLS) and advanced life support (ALS).

TimeTime is an essential component for successful cardiopulmonary resuscitation is an essential component for successful cardiopulmonary resuscitation (CPR). (CPR). Any diagnostic procedures and interventions? to identify the underlying cause?Any diagnostic procedures and interventions? to identify the underlying cause?

IntroductionIntroductionIntroductionIntroduction

Myocardial function during CPRMyocardial function during CPR is still is still underdiagnosedunderdiagnosed in most in most cases.cases.

Potentially treatable causes of sudden cardiac arrest: Potentially treatable causes of sudden cardiac arrest: pericardial tamponadepericardial tamponade, , cardiogenic shockcardiogenic shock, , myocardial insufficiencymyocardial insufficiency (resulting from coronary or pulmonary a(resulting from coronary or pulmonary a

rtery thrombosis),rtery thrombosis), hypovolemiahypovolemia,,

should be detected or excluded as soon as possibleshould be detected or excluded as soon as possible !!!!

In emergency rooms, In emergency rooms, the immediate application of the immediate application of sonographysonography could result in improved patient outcome. could result in improved patient outcome.

In emergency rooms, In emergency rooms, the immediate application of the immediate application of sonographysonography could result in improved patient outcome. could result in improved patient outcome.

EchocardiographyEchocardiographyEchocardiographyEchocardiography

IntroductionIntroductionIntroductionIntroduction

The The new 2005new 2005 American Heart Association/European Resuscitation Council/ In American Heart Association/European Resuscitation Council/ International Liaison Committee on Resuscitation guidelines ternational Liaison Committee on Resuscitation guidelines set narrow time set narrow time intervalsintervals for echocardiographic examination, due to for echocardiographic examination, due to

potential detrimental effectspotential detrimental effects the requirement of the requirement of rebuilding coronary perfusion pressurerebuilding coronary perfusion pressure..

Pauses in chest compression were recommended to be Pauses in chest compression were recommended to be “brief interruptio“brief interruptions”ns” for adult ALS and of a for adult ALS and of a maximum of 10 secsmaximum of 10 secs for pediatric ALS to redu for pediatric ALS to reduce the duration of ce the duration of no-flow intervals (NFIs).no-flow intervals (NFIs).

Thereby limiting potential Thereby limiting potential transthoracic ultrasound examinationstransthoracic ultrasound examinations. .

IntroductionIntroductionIntroductionIntroduction

A major challenge is A major challenge is recognizing return of spontaneous circulationrecognizing return of spontaneous circulation wh when en no central pulseno central pulse is palpable. is palpable.

Even health professionals are insecure and take too long in detecting a carotiEven health professionals are insecure and take too long in detecting a carotid pulse or respiratory effort. d pulse or respiratory effort.

Peripheral oxygen saturation with pulse curve or noninvasive blood pressure Peripheral oxygen saturation with pulse curve or noninvasive blood pressure measurement, are unreliable in severe hypotension or shock, and it can take 1measurement, are unreliable in severe hypotension or shock, and it can take 10 secs to obtain such a critical result. 0 secs to obtain such a critical result.

Consequently, a structured process for a Consequently, a structured process for a focused echocardiographic exafocused echocardiographic examinationmination and for and for recognition of relevant pathologyrecognition of relevant pathology during resuscitatio during resuscitation management is mandatory. n management is mandatory.

Focused echocardiographic evaluation in resuscitation (FEER)Focused echocardiographic evaluation in resuscitation (FEER)Focused echocardiographic evaluation in resuscitation (FEER)Focused echocardiographic evaluation in resuscitation (FEER)

Algorithm of FEERAlgorithm of FEERAlgorithm of FEERAlgorithm of FEER

Focused Echocardiographic EvFocused Echocardiographic Evaluation in Resuscitationaluation in Resuscitation

Focused Echocardiographic EvFocused Echocardiographic Evaluation in Resuscitationaluation in Resuscitation

The FEER examination is a The FEER examination is a ten-stepten-step procedure (Table 1).procedure (Table 1). prevent any increase in the duration of the NFI and to reduce unwanted prevent any increase in the duration of the NFI and to reduce unwanted

interruptions.interruptions. four four distinct phasesdistinct phases. .

Preparation Parallel to CPR.Preparation Parallel to CPR. Obtaining an Echocardiogram Within Approximately a 5-sec Obtaining an Echocardiogram Within Approximately a 5-sec

Pause of CPRPause of CPR Evaluation of the Echocardiogram While Continuing CPR. Evaluation of the Echocardiogram While Continuing CPR. Results, Follow-Up Information, and ConsequencesResults, Follow-Up Information, and Consequences

FEER ExaminationFEER ExaminationFEER ExaminationFEER Examination

1.1.1.1.

2.2.2.2.

3.3.

4.4.4.4.

Indications of EchocardiographyIndications of EchocardiographyIndications of EchocardiographyIndications of Echocardiography

FEER examination starts with theFEER examination starts with the subcostalsubcostal window. window. If this option fails, it uses the If this option fails, it uses the parasternalparasternal window,window, long-axislong-axis, or , or short-axisshort-axis view and view and only later the only later the apical four-chamberapical four-chamber view if there is insufficient visualization. view if there is insufficient visualization.

subcostal subcostal subcostal subcostal parasternal parasternal long axislong axis

parasternal parasternal long axislong axis short axis,LVshort axis,LVshort axis,LVshort axis,LVshort axis,short axis,

aortaaortashort axis,short axis,

aortaaortafour chamberfour chamberfour chamberfour chamber

Echocardiography in FEEREchocardiography in FEEREchocardiography in FEEREchocardiography in FEER

Observational TrialObservational TrialObservational TrialObservational Trial

• We analyzed typical phases and interruption intervals during BLS/ALS to identify relevant time winWe analyzed typical phases and interruption intervals during BLS/ALS to identify relevant time windows for dummy echocardiography (DUE) dows for dummy echocardiography (DUE)

• 1818 groups of paramedics performed a two-rescuer CPR scenario.groups of paramedics performed a two-rescuer CPR scenario.• A third person was allowed to use any interruption to apply DUE without disturbing CPR workflow. A third person was allowed to use any interruption to apply DUE without disturbing CPR workflow. • ““Old” BLS/ALS algorithmOld” BLS/ALS algorithm was analyzed. (studies began was analyzed. (studies began before November 2005before November 2005) ) • BLS/ALS-related interruptions were (numbers are seconds ±SD): BLS/ALS-related interruptions were (numbers are seconds ±SD):

• 1) 1) BLSBLS: : 3434 ± 3; ± 3;• 2) 2) two breaths, 15 chest compressionstwo breaths, 15 chest compressions (CPR cycle): (CPR cycle): 2323 ±12; ±12;• 3) 3) applying electrocardiography and analysisapplying electrocardiography and analysis: : 3535 ± 8; ± 8;• 4) 4) parallel airway managementparallel airway management: : 224224 ±67; ±67;• 5) 5) rhythm analysis and three defibrillationsrhythm analysis and three defibrillations:: 4040 ±5. ±5.

• Results: Results: no differencesno differences in the in the number and duration of NFIs (no flow intervals)number and duration of NFIs (no flow intervals) with or with or without dummy-echocardiography between the groups (Fig. 3).without dummy-echocardiography between the groups (Fig. 3).

Duration & Number of No-flow-intervals Duration & Number of No-flow-intervals in BLS/ALS-Training with or without FEERin BLS/ALS-Training with or without FEERDuration & Number of No-flow-intervals Duration & Number of No-flow-intervals in BLS/ALS-Training with or without FEERin BLS/ALS-Training with or without FEER

Comparison of duration of no-flow intervals during ALSComparison of duration of no-flow intervals during ALStraining according to the training according to the European ResuscitationEuropean ResuscitationCouncil (Council (ERCERC) 2001) 2001 ( (upper two horizontal barsupper two horizontal bars))and and ERC 2005ERC 2005 ( (lower barlower bar) guidelines. ) guidelines.

ALS: advanced life supportBLS: basic life support.black separations of the bar: no-flow intervals

A randomized interruption with dummy-echocardiographyA randomized interruption with dummy-echocardiography

((DUEDUE) ) did notdid not induce a prolongation induce a prolongation of ofdistinct phases or the duration or number distinct phases or the duration or number

of no-flow intervals. of no-flow intervals.

Observational TrialObservational TrialObservational TrialObservational Trial

• AimAim: to test the : to test the capability of FEERcapability of FEER to differentiate PEA states to differentiate PEA states • Participant:Participant: trained EP/INT trained EP/INT • Out-of hospital CPR:Out-of hospital CPR: 7777 cases (men, n=54; women, n=23; age, 67±18 yrs) were included i cases (men, n=54; women, n=23; age, 67±18 yrs) were included i

n the FEER protocol. n the FEER protocol. • Suspected PEA Suspected PEA 3030 / 77/ 77 cases. cases.

• 1919 of 30 of 30 suspected PEA suspected PEA cardiac wall movement(+), cardiac wall movement(+), • correctable causes such as pericardial tamponade (n=3), poor ventricular function (n=14), correctable causes such as pericardial tamponade (n=3), poor ventricular function (n=14),

and hypovolemia (n=2) were noted or treated. and hypovolemia (n=2) were noted or treated. • In 13 of 19 true pseudo-PEA cases, patients survived to hospital admission. In 13 of 19 true pseudo-PEA cases, patients survived to hospital admission.

• 1111 of 30 of 30 PEA cases PEA cases true cardiac standstill on echocardiogram true cardiac standstill on echocardiogram died. died.

• In addition to differentiating PEA states, FEER has the ability to In addition to differentiating PEA states, FEER has the ability to identify a pseudo-PEA staidentify a pseudo-PEA statete, allowing the , allowing the continuation of CPR and further treatmentcontinuation of CPR and further treatment of the of the

underlying disorder on the scene if possible. underlying disorder on the scene if possible.

Educational Basis of Educational Basis of ALS-Conformed EchocardiographyALS-Conformed Echocardiography

PeriodPeriod: 1-day course program on focused echocardiography: 1-day course program on focused echocardiography

TraineesTrainees: EP/INT without previous knowledge in transthoracic echocardiography: EP/INT without previous knowledge in transthoracic echocardiography To answer a series of questions To answer a series of questions

A A precourse testprecourse test within the first hands-on training session within the first hands-on training session

Received theoretical and practical training with selected lectures as an intervention.Received theoretical and practical training with selected lectures as an intervention. A A postcourse examinationpostcourse examination within the second hands-on training session was completed within the second hands-on training session was completed (Fig. 4).(Fig. 4).

aa,, Significant decrease of time consumption (mean, SD) of trainees within the two hands-on training Significant decrease of time consumption (mean, SD) of trainees within the two hands-on training sessions (sessions (left four barsleft four bars) and compared with the instructors () and compared with the instructors (black barsblack bars). The success rates, as ). The success rates, as percentages of successful trials by all trainees, are given as numbers in the percentages of successful trials by all trainees, are given as numbers in the barsbars. . bb,, Recognition skills tested by movie clips in a 5-inch screen with a maximum length of 5 secs. Recognition skills tested by movie clips in a 5-inch screen with a maximum length of 5 secs. The pairs of The pairs of bars bars with the same pattern depict the pretest (with the same pattern depict the pretest (leftleft) and posttest () and posttest (rightright) percentages ) percentages of correct answers per question/pathology.of correct answers per question/pathology.

Results of the training course on the Results of the training course on the FEERFEER examination examination for emergency physicians and intensivistsfor emergency physicians and intensivists

Results of the training course on the Results of the training course on the FEERFEER examination examination for emergency physicians and intensivistsfor emergency physicians and intensivists

c, Improvement of practical skills to learn the FEER examination. Pairs of bars with the same pattern show pretest (left) and posttest (right) percentages of correct trials checked by objective structured clinical examination (from the left): information, preparation and testing, count-down announcement, correct interruption, pulse check, positioning of the probe parallel to cardiopulmonary resuscitation, control to continuing cardiopulmonary resuscitation, and follow-up information. d, Theoretical gain in 32 participants (mean, SD), measured by multiple-choice (MC) questionnaires.

Physiologic pericardial fluidPhysiologic pericardial fluidPhysiologic pericardial fluidPhysiologic pericardial fluid Anterior fat padAnterior fat padAnterior fat padAnterior fat pad

Small effusionSmall effusionSmall effusionSmall effusionMassive effusionMassive effusionMassive effusionMassive effusion

Echocardiographic findingsEchocardiographic findingsEchocardiographic findingsEchocardiographic findings

LV/RV: left or right ventricular cavum, FP: anterior fat pad. LV/RV: left or right ventricular cavum, FP: anterior fat pad.

the pericardium (the pericardium (PP) follows the epicardium () follows the epicardium (EE) in waveforms ) in waveforms and that E/P are tight together.and that E/P are tight together.

the pericardium (the pericardium (PP) follows the epicardium () follows the epicardium (EE) in waveforms ) in waveforms and that E/P are tight together.and that E/P are tight together.

Normal wall motion (subcostal window, long axis).Normal wall motion (subcostal window, long axis). Normal wall motion (subcostal window, long axis).Normal wall motion (subcostal window, long axis).

M-mode in emergency echocardiographyM-mode in emergency echocardiography

M-mode in emergency echocardiographyM-mode in emergency echocardiography

Parasternal window, long axisParasternal window, long axis

P and E are separated by the PEP and E are separated by the PEP is found as a flat lineP is found as a flat line

P and E are separated by the PEP and E are separated by the PEP is found as a flat lineP is found as a flat line

Pericardial effusion (Pericardial effusion (PEPE))Pericardial effusion (Pericardial effusion (PEPE))

LV is clearly identified with LV is clearly identified with unseparated posterior E and Punseparated posterior E and P

Pleural effusion (Pleural effusion (Pl-EPl-E))Pleural effusion (Pleural effusion (Pl-EPl-E))

regular electrocardiographic rhythm regular electrocardiographic rhythm without wall motionwithout wall motion

True PEATrue PEA

no regular electrocardiographic no regular electrocardiographic rhythm or wall motionrhythm or wall motion

Cardiac standstillCardiac standstill

Normal findingNormal findingNormal findingNormal finding Enlarged RVEnlarged RVEnlarged RVEnlarged RV

Normal findingNormal findingNormal findingNormal finding

Paradoxical septal wall motionParadoxical septal wall motion(D sign) – acute cor pulmonale(D sign) – acute cor pulmonaleParadoxical septal wall motionParadoxical septal wall motion(D sign) – acute cor pulmonale(D sign) – acute cor pulmonale

DiscussionDiscussionUltrasound imagingUltrasound imaging enhances the physician’s ability to evaluate, diagnose, and t enhances the physician’s ability to evaluate, diagnose, and treat emergency department patients. reat emergency department patients.

The most prominent thesis of this review is that the most used standard care interventiThe most prominent thesis of this review is that the most used standard care interventions ons do notdo not give enough direct information of cardiac responses in CPR and PEA states. give enough direct information of cardiac responses in CPR and PEA states.

The lack of a The lack of a standardized emergency echocardiographystandardized emergency echocardiography in the periresuscitation compl in the periresuscitation complex is a ex is a significant gapsignificant gap in our health system. in our health system.

DiscussionDiscussionIn our prehospital observational trial, we unexpectedly encountered several cases with In our prehospital observational trial, we unexpectedly encountered several cases with hypotension because of a hypotension because of a pericardial effusionpericardial effusion or or tamponade tamponade. . One of these cases illustrated the need for emergency echocardiography. One of these cases illustrated the need for emergency echocardiography. A 14-yr-old child who was well 6 wks after open heart surgery suddenly deteriorated, wiA 14-yr-old child who was well 6 wks after open heart surgery suddenly deteriorated, with agitation and hypotension progressing to unconsciousness. th agitation and hypotension progressing to unconsciousness. The trained EP used FEER to diagnosis a massive pericardial effusion. The trained EP used FEER to diagnosis a massive pericardial effusion. On transportation to the pediatric intensive care unit, there was a cardiac arrest with a On transportation to the pediatric intensive care unit, there was a cardiac arrest with a PEA state. PEA state. With the foreknowledge of the pericardial effusion, the EP decided to perform pericardiWith the foreknowledge of the pericardial effusion, the EP decided to perform pericardiocentesis ocentesis before before starting chest compressions.starting chest compressions.The child survived and now attends the same school class without neurologic deficit.The child survived and now attends the same school class without neurologic deficit.We believe that without detecting the pericardial fluid by echocardiography, the child pWe believe that without detecting the pericardial fluid by echocardiography, the child probably would have died.robably would have died.

The next challenge for the American Heart Association/European Resuscitation Council/IThe next challenge for the American Heart Association/European Resuscitation Council/International Liaison Committee on Resuscitation guidelines may include nternational Liaison Committee on Resuscitation guidelines may include reinforcing reinforcing methodsmethods to identify treatable causes of arrest during resuscitation. to identify treatable causes of arrest during resuscitation.

Unfortunately, the Unfortunately, the suggestion of echocardiography use disappeared in 2suggestion of echocardiography use disappeared in 2005005, except in special circumstances, in which the practitioner should “actively seek an, except in special circumstances, in which the practitioner should “actively seek and exclude reversible causes of cardiac arrest” . d exclude reversible causes of cardiac arrest” .

Such circumstances: postcardiac surgery p’ts and mainly relate to in-hospital care in the immediSuch circumstances: postcardiac surgery p’ts and mainly relate to in-hospital care in the immediate postsurgical phase. ate postsurgical phase.

In In blunt or penetrating trauma,blunt or penetrating trauma, “ultrasound is a valuable tool in the evaluation “ultrasound is a valuable tool in the evaluation of of possible cardiac tamponadepossible cardiac tamponade” .” .

New technical solutions on New technical solutions on mobile ultrasoundmobile ultrasound (weighing 2 kg of weight) are readily (weighing 2 kg of weight) are readily available for rescue teams of the available for rescue teams of the emergency departmentemergency department, , intensive care unitintensive care unit, or , or prehospiprehospital trauma supporttal trauma support at the patient’s bedside. at the patient’s bedside.

DiscussionDiscussion

Emergency echocardiography, based on mobile techniques, may be used in a qualitaEmergency echocardiography, based on mobile techniques, may be used in a qualitative approach as a tive approach as a “third eye”“third eye” in resuscitation. in resuscitation.

We should consider its limitations and should implement these tools not only as We should consider its limitations and should implement these tools not only as a ga guide for uide for terminating resuscitation effortsterminating resuscitation efforts, but rather as a guide for , but rather as a guide for imprimproving effectiveness of resuscitationoving effectiveness of resuscitation..

With the With the simple use of ALS-conformed echocardiographysimple use of ALS-conformed echocardiography, some of the , some of the diagnostic gaps in emergency and critical care medicine can be closed.diagnostic gaps in emergency and critical care medicine can be closed.

A focusedA focused 6-hr echocardiographic training6-hr echocardiographic training course significantly improved EP course significantly improved EP residents’ written and practical examinations in a prospective, observational, educresidents’ written and practical examinations in a prospective, observational, educational study for goal-directed echocardiography performance and interpretation. ational study for goal-directed echocardiography performance and interpretation.

~ Jones et al.~ Jones et al.

DiscussionDiscussion

Summary and ConclusionsSummary and Conclusions

Because of the Because of the diagnostic pressure during CPRdiagnostic pressure during CPR to identify and treat to identify and treat reversible causes, there is a demand for a structured process when using ecreversible causes, there is a demand for a structured process when using echocardiography.hocardiography.

The simple FEER examination mainly enables an ALS-conformed algorithm tThe simple FEER examination mainly enables an ALS-conformed algorithm to o assess myocardial wall motionassess myocardial wall motion with the educated eye parallel to with the educated eye parallel to brief pauses of CPR within a few seconds. brief pauses of CPR within a few seconds.

FEER may FEER may differentiate PEAdifferentiate PEA and and identify pericardial effusionidentify pericardial effusion wi without a major prolongation of the NFIs.thout a major prolongation of the NFIs.

It is suggested as an extension to standard advanced cardiac life support intIt is suggested as an extension to standard advanced cardiac life support interventions. erventions.

Educational training for the FEER examination is essential by theoretical anEducational training for the FEER examination is essential by theoretical and practical means and can be learned in an d practical means and can be learned in an 8-hr8-hr course bycourse by non-expert non-expert s sonographers.onographers.

Thanks for your attention !!Thanks for your attention !!Thanks for your attention !!Thanks for your attention !!