Point-of-care Ultrasound in Cardiac Arrest

Modernization of Cardiac Advanced Life Support: Role and Value of Cardiothoracic Anesthesiologist Intensivist in Post-Cardiac Surgery Arrest Resuscitation

Cardiac arrest in the postoperative cardiac surgery patient requires a unique set of management skills that deviates from traditional cardiopulmonary resuscitation and Advanced Cardiovascular Life Support (ACLS). Cardiac Advanced Life Support (CALS) was first proposed in 2005 to address these intricacies. The hallmark of CALS is early chest reopening and internal cardiac massage within 5 minutes of the cardiac arrest in patients unresponsive to basic life support. Since the introduction of CALS, the landscape of cardiac surgery has continued to evolve. Cardiac intensivists encounter more patients who undergo cardiac surgical procedures performed via minimally invasive techniques such as lateral thoracotomy or mini sternotomy, in which an initial bedside sternotomy for cardiac massage is not applicable. Given the heterogeneous nature of the patient population in the cardiothoracic intensive care unit, personnel must expeditiously identify the most appropriate rescue strategy. As such, we have proposed a modified CALS approach to (1) adapt to a newer generation of cardiac surgery patients and (2) incorporate advanced resuscitative techniques. These include rescue-focused cardiac ultrasound to aid in the early identification of underlying pathology and guide resuscitation and early institution of extracorporeal cardiopulmonary resuscitation instead of chest reopening. While these therapies are not immediately available in all cardiac surgery centers, we hope this creates a framework to revise guidelines to include these recommendations to improve outcomes and how cardiac anesthesiologist intensivists' evolving role can aid resuscitation.

Role of Point-of-Care Ultrasound (POCUS) in Cardiac Arrest: A Case Report

Acute pulmonary embolism (PE) is a significant cause of cardiac arrests, with subsequent high mortality worldwide. Early recognition of acute PE allows earlier diagnosis, stabilization, and risk stratification, which are crucial in deciding the most adequate treatment option. However, diagnosis is sometimes difficult due to nonspecific clinical presentation. We report a case of successful cardiopulmonary resuscitation with the identification of this reversible cause of cardiac arrest using point-of-care ultrasound in cardiopulmonary arrest (POCUS-CA), thus allowing appropriate prompt life-saving treatment.

Pioneering Use of Extracorporeal Life Support in Intraoperative Cardiac Arrest in Dubai: A Case Report

We describe, to our knowledge, the first use in Dubai of extracorporeal life support (ECLS) in a patient who suffered intraoperative cardiac arrest due to presumed cardiac channelopathy. A 40-year-old patient presented for open myomectomy surgery. She had no other medical problems apart from obesity. The patient denied any family history of surgery or anesthesia-related complications. Her initial electrocardiogram (ECG) and laboratory results were within reference limits. Intraoperatively, the patient suffered sudden cardiac arrest, from which she was resuscitated. Point-of-care cardiac ultrasound and intensive care unit (ICU)-performed echocardiography revealed severely reduced left ventricular contractility. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and intra-aortic balloon pump were utilized in the immediate postoperative period. Although the patient's heart sustained more than 300 DC shocks, it recovered. Family members revealed that the patient's brother and sister had died in their 20s from sudden cardiac death. Another sister had been resuscitated a few years ago from intraoperative cardiac arrest, too. The case illustrates the importance of the patient's disclosure of relevant information. It supports the notion that ECLS can be used in the immediate postoperative period if surgical hemostasis is achieved. Controversies, such as the use of heparinization and the risk of bleeding, transthoracic echocardiography (TTE) versus transesophageal echocardiography (TEE), timely insertion of intracardiac defibrillator, and genetic screening, are discussed. A learning point is that clinicians do not work in a vacuum. Organizational leadership can greatly impact outcomes, creating conditions for safer patient care.

Causes of Perioperative Cardiac Arrest: Mnemonic, Classification, Monitoring, and Actions

Perioperative cardiac arrest (POCA) is a catastrophic complication that requires immediate recognition and correction of the underlying cause to improve patient outcomes. While the hypoxia, hypovolemia, hydrogen ions (acidosis), hypo-/hyperkalemia, and hypothermia (Hs) and toxins, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary), and thrombosis (coronary) (Ts) mnemonic is a valuable tool for rapid differential diagnosis, it does not cover all possible causes leading to POCA. To address this limitation, we propose using the preload-contractility-afterload-rate and rhythm (PCARR) construct to categorize POCA, which is comprehensive, systemic, and physiologically logical. We provide evidence for each component in the PCARR construct and emphasize that it complements the Hs and Ts mnemonic rather than replacing it. Furthermore, we discuss the significance of utilizing monitored variables such as electrocardiography, pulse oxygen saturation, end-tidal carbon dioxide, and blood pressure to identify clues to the underlying cause of POCA. To aid in investigating POCA causes, we suggest the Anesthetic care, Surgery, Echocardiography, Relevant Check and History (A-SERCH) list of actions. We recommend combining the Hs and Ts mnemonic, the PCARR construct, monitoring, and the A-SERCH list of actions in a rational manner to investigate POCA causes. These proposals require real-world testing to assess their feasibility.

The Promise of Artificial Intelligence-Assisted Point-of-Care Ultrasonography in Perioperative Care

The role of point-of-care ultrasonography in the perioperative setting has expanded rapidly over recent years. Revolutionizing this technology further is integrating artificial intelligence to assist clinicians in optimizing images, identifying anomalies, performing automated measurements and calculations, and facilitating diagnoses. Artificial intelligence can increase point-of-care ultrasonography efficiency and accuracy, making it an even more valuable point-of-care tool. Given this topic's importance and ever-changing landscape, this review discusses the latest trends to serve as an introduction and update in this area.

Point-of-Care Ultrasound (POCUS) in Adult Cardiac Arrest: Clinical Review

Point-of-Care Ultrasound (POCUS) is a rapid and valuable diagnostic tool available in emergency and intensive care units. In the context of cardiac arrest, POCUS application can help assess cardiac activity, identify causes of arrest that could be reversible (such as pericardial effusion or pneumothorax), guide interventions like central line placement or pericardiocentesis, and provide real-time feedback on the effectiveness of resuscitation efforts, among other critical applications. Its use, in addition to cardiovascular life support maneuvers, is advocated by all resuscitation guidelines. The purpose of this narrative review is to summarize the key applications of POCUS in cardiac arrest, highlighting, among others, its prognostic, diagnostic, and forensic potential. We conducted an extensive literature review utilizing PubMed by employing key search terms regarding ultrasound and its use in cardiac arrest. Apart from its numerous advantages, its limitations and challenges such as the potential for interruption of chest compressions during image acquisition and operator proficiency should be considered as well and are discussed herein.

Ultrasound technology assisted colloidal nanocrystal synthesis and biomedical applications

Non-invasive and high spatiotemporal resolution mythologies for the diagnosis and treatment of disease in clinical medicine promote the development of modern medicine. Ultrasound (US) technology provides a non-invasive, real-time, and cost-effective clinical imaging modality, which plays a significant role in chemical synthesis and clinical translation, especially in in vivo imaging and cancer therapy. On the one hand, the US treatment is usually accompanied by cavitation, leading to high temperature and pressure, so-called "hot spot", playing a significant role in sonochemical-based colloidal synthesis. Compared with the classical nucleation synthetic method, the sonochemical synthesis strategy presents high efficiency for the fabrication of colloidal nanocrystals due to its fast nucleation and growth procedure. On the other hand, the US is attractive for in vivo and medical treatment, with applications increasing with the development of novel contrast agents, such as the micro and nano bubbles, which are widely used in neuromodulation, with which the US can breach the blood-brain barrier temporarily and safely, opening a new door to neuromodulation and therapy. In terms of cancer treatment, sonodynamic therapy and US-assisted synergetic therapy show great effects against cancer and sonodynamic immunotherapy present unparalleled potentiality compared with other synergetic therapies. Further development of ultrasound technology can revolutionize both chemical synthesis and clinical translation by improving efficiency, precision, and accessibility while reducing environmental impact and enhancing patient care. In this paper, we review the US-assisted sonochemical synthesis and biological applications, to promote the next generation US technology-assisted applications.

Current and Future Role of Ultrasonography in the Cardiac Intensive Care Unit

The contemporary practice of ultrasonography in the cardiac intensive care unit integrates the principles of echocardiography with whole-body imaging to create a more expansive paradigm of critical care ultrasonography (CCUS). This article will review the use of CCUS for diagnostic assessment, monitoring, therapeutic guidance, and prognosis.

Live stream of prehospital point-of-care ultrasound during cardiopulmonary resuscitation - A feasibility trial

BACKGROUND

Current resuscitation guidelines recommend that skilled persons could use ultrasound to detect reversible causes during cardiopulmonary resuscitation (CPR) where the examination can be safely integrated into the Advanced Life Support (ALS) algorithm. However, in a prehospital setting performing and rapidly interpreting ultrasound can be challenging for physicians. Implementing remote, expert-guided, and real-time transmissions of ultrasound examinations offers the opportunity for tele-support, even during an out-of-hospital cardiac arrest (OHCA). The aim of this feasibility study was to evaluate the impact of tele-supported ultrasound in ALS on hands-off time during an OHCA.

METHODS

In an urban setting, physicians performed point-of-care ultrasound (POCUS) on patients during OHCA using a portable device, either with tele-support (n = 30) or without tele-support (n = 12). Where tele-support was used, the ultrasound image was transmitted via a remote real-time connection to an on-call specialist in anaesthesia and intensive care medicine with an advanced level of critical care ultrasound expertise. The primary safety endpoint of this study was to evaluate whether POCUS can be safely integrated into the algorithm, and to provide an analysis of hands-off time before, during, and after POCUS during OHCA.

RESULTS

In all 42 cases it was possible to perform POCUS during regular rhythm analyses, and no additional hands-off time was required. In 40 of these 42 cases, the physicians were able to perform POCUS during a single regular rhythm analysis, with two periods required only in two cases. The median hands-off time during these rhythm analyses for POCUS with tele-support was 10 (8-13) seconds, and 11 (9-14) seconds for POCUS without tele-support. Furthermore, as a result of POCUS, in a quarter of all cases the physician on scene altered their diagnosis of the primary suspected cause of cardiac arrest, leading to a change in treatment strategy.

CONCLUSIONS

This feasibility study demonstrated that POCUS with tele-support can be safely performed during OHCA in an urban environment. Trial Registration (before patient enrolment): ClinicalTrials.gov, NCT04817475.

Feasibility of resuscitative transesophageal echocardiography at out-of-hospital emergency scenes of cardiac arrest

Guidelines recommend the use of ultrasound in cardiac arrest. Transthoracic echocardiography, has issues with image quality and by increasing hands-off times during resuscitation. We assessed the feasibility of transesophageal echocardiography (TEE), which does not have both problems, at out-of-hospital cardiac arrest (OHCA) emergency scenes. Included were 10 adults with non-traumatic OHCA in Vienna, Austria. An expert in emergency ultrasound was dispatched to the scenes in addition to the resuscitation team. Feasibility was defined as the ability to collect specific items of information by TEE within 10 min. Descriptive statistics were compiled and hands-off times were compared to a historical control group. TEE examinations were feasible in 9 of 10 cases and prompted changes in clinical management in 2 cases (cardiac tamponade: n = 1; right ventricular dilatation: n = 1). Their mean time requirement was 5.1 ± 1.7 (2.8-8.0) min, and image quality was invariably rated as excellent or good during both compressions and pauses. No TEE-related complications, or interferences with activities of advanced life support were observed. The hands-off times during resuscitation were comparable to a historical control group not involving ultrasound (P = 0.24). Given these feasibility results, we expect that TEE can be used routinely at OHCA emergency scenes.

The forgotten cohort-lessons learned from prehospital trauma death: a retrospective cohort study

BACKGROUND

Trauma related deaths remain a relevant public health problem, in particular in the younger male population. A significant number of these deaths occur prehospitally without transfer to a hospital. These patients, sometimes termed "the forgotten cohort", are usually not included in clinical registries, resulting in a lack of information about prehospitally trauma deaths. The aim of the present study was to compare patients who died prehospital with those who sustained life-threatening injuries in order to analyze and potentially improve prehospital strategies.

METHODS

This cohort study included all primary operations carried out by Switzerland's largest helicopter emergency medical service (HEMS) between January 1, 2011, and December 31, 2021. We included all adult trauma patients with life-threatening or fatal conditions. The outcome of this study is the vital status of the patient at the end of mission, i.e. fatal or life-threatening. Injury, rescue characteristics, and interventions of the forgotten trauma cohort, defined as patients with a fatal injury (NACA score of VII), were compared with life-threatening injuries (NACA score V and VI).

RESULTS

Of 110,331 HEMS missions, 5534 primary operations were finally analyzed, including 5191 (93.8%) life-threatening and 343 (6.2%) fatal injuries. More than two-thirds of patients (n = 3772, 68.2%) had a traumatic brain injury without a significant difference between the two groups (p > 0.05). Thoracic trauma (44.6% vs. 28.7%, p < 0.001) and abdominal trauma (22.2% vs. 16.1%, p = 0.004) were more frequent in fatal missions whereas pelvic trauma was similar between the two groups (13.4% vs. 12.9%, p = 0.788). Pneumothorax decompression rate (17.2% vs. 3.7%, p < 0.001) was higher in the forgotten cohort group and measures for bleeding control (15.2% vs. 42.7%, p < 0.001) and pelvic belt application (2.9% vs. 13.1% p < 0.001) were more common in the life-threating injury group.

CONCLUSION

Chest decompression rates and measures for early hemorrhage control are areas for potential improvement in prehospital care.

Critical Care Echocardiography

Ultrasonography is increasingly applied in the critical care setting. With advancements in technology, ultrasonography has become easier to use, with smaller machines, and more fundamental to patient assessment. Ultrasonography is a hands-on tool that brings real-time, dynamic information to the bedside. Patients in the critical care setting often have unstable hemodynamics or a tenuous respiratory status; thus, the use of ultrasonography to augment the assessment greatly improves patient safety. This article explores how to differentiate the etiology of shock with the adjunct of critical care echocardiography. In addition, the article examines how various ultrasonography techniques can be used to diagnose other life-threatening cardiac conditions, such as pulmonary embolism or cardiac tamponade, and the role of echocardiography in cardiopulmonary resuscitation. Critical care providers can add echocardiography and the information it provides to their repertoire to improve diagnosis, treatment, and patient outcomes.

Comparison the efficacy of amiodarone and lidocaine for cardiac arrest: A network meta-analysis

BACKGROUND

There is no evidence that antiarrhythmic drugs can improve long-term survival or survival with favorable neurological outcomes in cardiac arrest patients. We did this network meta-analysis to comprehensively compare the efficacy of various antiarrhythmic drugs for cardiac arrest patients.

METHODS

We searched studies from inception until Nov 11, 2022 through PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP Database, and Wanfang database. All studies comparing different antiarrhythmic drugs for cardiac arrest were included in this meta-analysis. Outcomes were survival to hospital discharge in cardiac arrest, survival to hospital admission/24 h and favorable neurological outcome. This network meta-analysis was performed by R software.

RESULTS

Finally, a total of 9 studies (10,980 patients) were finally included in this network meta-analysis. Amiodarone (odd ratio [OR] 2.28, 95% credibility interval [CrI] 1.61-3.27) and lidocaine (OR 1.53, 95% CrI 1.05-2.25) was superior than placebo in terms of the survival to hospital admission/24 h with statistically significant. Amiodarone (OR 2.19, 95% CrI 1.54-3.14) and lidocaine (OR 1.58, 95% CrI 1.09-2.32) was superior than placebo in terms of the survival to hospital discharge with statistically significant. Amiodarone (OR 2.43, 95% CrI 1.61-3.68) and lidocaine (OR 1.62, 95% CrI 1.04-2.53) was superior than placebo in terms of the favorable neurological outcome with statistically significant. The surface under the cumulative ranking (SUCRA) shows that amiodarone ranked first (SUCRA, 99.6%), lidocaine ranked second (SUCRA, 49.6%), placebo ranked the last (SUCRA, 0.86%). Inverted funnel plot is essentially symmetrical, it is possible that this study has a small sample effect or a small publication bias.

CONCLUSIONS

Amiodarone had the best effect on both survival to hospital admission, discharge and more favorable neurological outcome. Thus, amiodarone should be listed as first line drug for cardiac arrest. However, the quality of available evidence limits the formation of powerful conclusions regarding the comparative efficacy or safety of amiodarone or lidocaine used to treat cardiac arrest. Higher-quality randomized controlled trials are required for further research in future.

Current status of point of care ultrasonography for the perioperative care of trauma patients

PURPOSE OF REVIEW

The incorporation of point of care ultrasound into the field of anesthesiology and perioperative medicine is growing at rapid pace. The benefits of this modality align with the acuity of patient care and decision-making in anesthetic care of a trauma patient.

RECENT FINDINGS

Cardiac ultrasound can be used to diagnose cardiac tamponade or investigate the inferior vena cava to assess volume status in patients who may suffer from hemorrhagic shock. Thoracic ultrasound may be used to rapidly identify pneumothorax or hemothorax in a patient suffering chest wall trauma. In addition, investigators are exploring the utility of ultrasonography in traumatic airway management and elevated intracranial pressure. In addition, the utility of gastric ultrasound on trauma patients is briefly discussed.

SUMMARY

Incorporation of point of care ultrasound techniques into the practice of trauma anesthesiology is important for noninvasive, mobile and expeditious assessment of trauma patients. In addition, further large-scale studies are needed to investigate how point of care ultrasound impacts outcomes in trauma patients.

Point-of-care ultrasound for critically-ill patients: A mini-review of key diagnostic features and protocols

Point-of-care ultrasonography (POCUS) for managing critically ill patients is increasingly performed by intensivists or emergency physicians. Results of needs surveys among intensivists reveal emphasis on basic cardiac, lung and abdominal ultrasound, which are the commonest POCUS modalities in the intensive care unit. We therefore aim to describe the key diagnostic features of basic cardiac, lung and abdominal ultrasound as practised by intensivists or emergency physicians in terms of accuracy (sensitivity, specificity), clinical utility and limitations. We also aim to explore POCUS protocols that integrate basic cardiac, lung and abdominal ultrasound, and highlight areas for future research.