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Resuscitation 81 (2010) 1453–1454

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Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Editorial

Echocardiography during CPR: More studies needed

Transthoracic echocardiography (TTE) is a recognised non- Two studies in this issue of Resuscitation go towards help-
invasive tool used to guide interventions in critically ill patients. ing answer these questions.12,13 Firstly, the study by Breitkreutz
However, few studies have investigated the specific role of TTE and colleagues examines the feasibility and influence on patient
during cardiopulmonary resuscitation (CPR). Identification and management of using ALS-compliant focused echocardiography
treatment of reversible causes of cardiac arrest is a key component in pre-hospital resuscitation.12 In this prospective observational
of advanced life support (ALS).1 Transthoracic echocardiogra- study, 230 patients were recruited across four emergency medi-
phy has been used during cardiac arrest to identify pericardial cal services (EMS) in three cities in Germany. Each EMS included
tamponade, pulmonary embolus and severe hypovolaemia.2–7 paramedics and an emergency physician trained in ALS-compliant
Transthoracic echocardiography also has the potential to identify echocardiography. At the point of recruitment into the study,
cardiac ischaemia, aortic dissection, and pneumothorax. 100 patients were undergoing CPR and 104 were either severely
With rapidly improving portable ultrasound technology, the hypotensive, severely dyspnoeic, or tachycardic. In patients under-
use of echocardiography as a real-time diagnostic tool during going CPR, TTE was performed predominantly after tracheal
cardiac arrest, in both the in- and out-of-hospital setting has intubation and during interruptions in chest compression of less
become a reality. The recent European Resuscitation Council (ERC) than 10 s, coinciding with a rhythm or pulse check. All of the
Guidelines 2010, based on the International Liaison Committee on TTE examinations were self-reported by the emergency physician
Resuscitation (ILCOR) Consensus on Science and Treatment Rec- to have been performed in an ALS-compliant manner with 96%
ommendations, recognise the potential value of using ultrasound of patients having images of diagnostic quality. The TTE findings
in assisting diagnosis and treatment of potentially reversible causes were perceived by the treating emergency physician to warrant a
of cardiac arrest.1,8 The ERC guidelines state: ‘When available for change in management in 89% of patients undergoing CPR and 66%
use by trained clinicians, ultrasound may be of use in assisting with of severely hypotensive, tachycardic or dyspnoeic patients. These
diagnosis and treatment of potentially reversible causes of cardiac changes included pericardiocentesis, infusion of fluid or inotropes,
arrest. The integration of ultrasound into advanced life support and a change in destination hospital. There was no independent
requires considerable training if interruptions to chest compres- review of the accuracy of interpretation of the TTE images, either
sions are to be minimised. A sub-xiphoid [subcostal] probe position on scene or retrospectively by reviewing recordings of the images.
has been recommended. Placement of the probe just before chest It was also not possible to measure the effect TTE examinations
compressions are paused for a planned rhythm assessment enables had on patient management in a more objective way and the study
a well-trained operator to obtain views within 10 s.’ was not designed to assess improvement in outcomes. None the
Several ALS-compliant echocardiography protocols have been less, this study provides supporting evidence to show that TTE can
described and are comparable to the Focused Assessment with be performed in an ALS-compliant manner in the out-of-hospital
Sonography for Trauma (FAST) ultrasound algorithm used in setting and that TTE findings do impact on treatment decisions.
trauma resuscitation.7,9–11 However, none of the available echocar- Secondly, Price and colleagues describe the effectiveness
diography protocols have yet been evaluated in terms of improving of a standardised one-day training course designed to deliver
patient survival. As use of echocardiography during ALS increases, ALS-compliant algorithm TTE knowledge and skills.13 Acquiring
we should ask the following questions: independence in performing and interpreting TTE in the critically
ill and during CPR requires a lengthy commitment to practice and
supervision.1,14,15 The training course studied is designed to be the
first step in that process. In a simulated manikin scenario, all 41
(1) Does the use of TTE during ALS result in treatment changes that students selected at random from the course obtained a subcostal
improve survival of patients with cardiac arrest? view of diagnostic quality with acquisition in less than 10 s coincid-
(2) Does the introduction of TTE cause excessive interruptions to ing with pulse/rhythm checks during CPR in 86% of cases. Although
chest compressions during CPR that may be harmful? this finding does not conclude that novices can become proficient
(3) Is it feasible to train novices to an adequate technical standard and maintain the skills required to implement TTE meaningfully
to generate and interpret TTE images within a 10 s pause in during actual ALS, it does provide much needed data on the issue
chest compressions during actual CPR? of training in TTE for use during ALS.
(4) Will integrating TTE into the ALS algorithm prove a cost TTE during CPR is most likely to be beneficial for those cardiac
effective addition to resuscitation efforts, both in- and out-of- arrest victims in whom current ALS measures such as good-quality
hospital?

0300-9572/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2010.09.009
1454 Editorial / Resuscitation 81 (2010) 1453–1454

CPR and early defibrillation fail, and in whom echocardiography 5. Tsung JW, Blaivas M. Feasibility of correlating the pulse check with focused
identifies an easily treatable, reversible cause of cardiac arrest. point-of-care echocardiography during pediatric cardiac arrest: a case series.
Resuscitation 2008;77:264–9.
As a result, showing a survival benefit for the use of TTE during 6. Steiger HV, Rimbach K, Muller E, Breitkreutz R. Focused emergency echocardio-
ALS is likely to prove challenging. It is also worth recognising that graphy: lifesaving tool for a 14-year-old girl suffering out-of-hospital pulseless
TTE can provide prognostic information which is potentially useful electrical activity arrest because of cardiac tamponade. Eur J Emerg Med
2009;16:103–5.
in guiding decisions to discontinue resuscitation efforts and will 7. Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall JCAUSE.
also help to recognise the presence or absence of a spontaneous Cardiac arrest ultra-sound exam – a better approach to managing patients in
circulation.5,16–18 primary non-arrhythmogenic cardiac arrest. Resuscitation 2008;76:198–206.
8. Deakin CD, Morrison LJ, Morley PT, et al. International consensus on car-
Trans-thoracic echocardiography during ALS is a promising diopulmonary resuscitation and emergency cardiovascular care science with
advance in resuscitation care. However, further studies are needed treatment recommendations. Part 8: advanced life support. Resuscitation2010.
to help clarify the true value and practicality of TTE in cardiac arrest 9. Sloth E, Jakobsen CJ, Melsen NC, Ravn HB. The resuscitation guidelines
in force–time for improvement towards causal therapy? Resuscitation
patients. Before the routine use of TTE as part of the ALS algorithm
2007;74:198–9.
is justified, further insights into its effects on patient management 10. Jensen MB, Sloth E, Larsen KM, Schmidt MB. Transthoracic echocardiogra-
and outcomes as well as potential harm caused by interrupting phy for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol
chest compressions is needed. Echocardiography use during CPR 2004;21:700–7.
11. Breitkreutz R, Walcher F, Seeger FH. Focused echocardiographic evaluation in
appears to be useful in expert hands. However, the feasibility of resuscitation management: concept of an advanced life support-conformed
novice and basic level practitioners developing and maintaining algorithm. Crit Care Med 2007;35:S150–61.
independent ALS-compliant TTE skills needs to be further scruti- 12. Breitkreutz R, Price S, Steiger HV, et al. Focused echocardiographic evaluation in
life support and peri-resuscitation of emergency patients: A prospective trial.
nised. At a time when routine practices during ALS such as the use Resuscitation 2010;81:1527–33.
of drugs and tracheal intubation are under scrutiny, and large trials 13. Price S, Ilper H, Uddin S, et al. Peri-resuscitation echocardiography: training the
of mechanical chest compression devices are underway, it is essen- novice practitioner. Resuscitation 2010;81:1534–9.
14. Fox K. A position statement: echocardiography in the critically ill. J Intensive
tial that all new interventions such as echocardiography undergo Care Soc 2008;9:197–8.
these same rigorous levels of scrutiny before they become a part of 15. Price S, Via G, Sloth E, et al. Echocardiography practice, training and accreditation
standard ALS algorithms. in the intensive care: document for the World Interactive Network Focused on
Critical Ultrasound (WINFOCUS). Cardiovasc Ultrasound 2008;6:49.
16. Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac stand-
Conflicts of interest statement still on the bedside emergency department echocardiogram. Acad Emerg Med
2001;8:616–21.
17. Salen P, O’Connor R, Sierzenski P, et al. Can cardiac sonography and capnography
None. be used independently and in combination to predict resuscitation outcomes?
Acad Emerg Med 2001;8:610–5.
References 18. Salen P, Melniker L, Chooljian C, et al. Does the presence or absence of sono-
graphically identified cardiac activity predict resuscitation outcomes of cardiac
arrest patients? Am J Emerg Med 2005;23:459–62.
1. Deakin CD, Nolan JP, Soar J, et al. European resuscitation council guidelines
for resuscitation 2010. Section 4. Adult advanced life support. Resuscitation
2010;81. Rani Robson
2. Comess KA, DeRook FA, Russell ML, Tognazzi-Evans TA, Beach KW. The incidence
Cardiology, Southmead Hospital, North Bristol NHS
of pulmonary embolism in unexplained sudden cardiac arrest with pulseless
electrical activity. Am J Med 2000;109:351–6. Trust, Southmead Road, Bristol BS10 5NB, UK
3. MacCarthy P, Worrall A, McCarthy G, Davies J. The use of transthoracic echocar- E-mail address: ranirobson@gmail.com
diography to guide thrombolytic therapy during cardiac arrest due to massive
pulmonary embolism. Emerg Med J 2002;19:178–9.
4. Tayal VS, Kline JA. Emergency echocardiography to detect pericardial effusion 9 September 2010
in patients in PEA and near-PEA states. Resuscitation 2003;59:315–8.