Columns, Commentary, Patient Care

Does Point-of-Care Ultrasound Have an Effect on Chest Compression Interruptions?

Issue 3 and Volume 43.

 

The Research

Clattenburg EJ, Wroe P, Brown S, et al. Point-of-care ultrasound use in patients with cardiac arrest is associated with prolonged cardiopulmonary resuscitation pauses: A prospective cohort study. Resuscitation. 2018;122:65–68.

The Science

This study reports the length of chest compression interruptions that occurred when point-of-care-ultrasound (POCUS) was performed to detect cardiac motion during cardiac arrest resuscitation.

Over a period of six months, 24 of the 84 arrests resuscitated in the ED were video recorded. The length of compression interruptions was compared when POCUS was or wasn’t performed. The average interruption was 17 seconds when POCUS was performed, vs. 11 seconds when it wasn’t. POCUS performed by a fellow trained in ultrasound resulted in compression interruptions that were, on average, 4.1 seconds shorter than those performed by non-trained fellows. Interruptions were 6.1 seconds longer when POCUS was performed by the physician leading the resuscitation.

Medic Wesley Comments

Ultrasound during cardiac arrest sounds like a great idea in a controlled hospital setting with personnel specifically trained to provide the procedure.POCUS has also become a valuable tool in the trauma setting. Certainly, it can help to locate critical injuries requiring immediate attention.

However, the idea that it could or might be added to the prehospital protocol for patients in pulseless electrical activity (PEA) just isn’t plausible with current staffing, training and equipment budgets. Would the results actually be timely enough to limit compression pauses to acceptable gaps? I don’t think so.

Although it would likely be more valuable in trauma patients, it’s sometimes best to do what we can in the field to stabilize and transport in a timely fashion.

Further, as with any skill, this would require frequent in-hospital training and clinical time that just isn’t available to prehospital providers.

Let’s add the cost of equipment to the whole equation. It’s simply not in the budget for the majority of services.

Make no mistake; I’m all about new skills and education. The lessons learned from this study are valuable to the providers in the street when dealing with PEA cardiac arrest.

However, I don’t see the training opportunities, reimbursement, or staffing changes allowing for prehospital POCUS in the near future.

Doc Wesley Comments

Interruptions in chest compression greater than 10 seconds are associated with lower rates of successful resuscitation. That’s why the American Heart Association strongly recommends limiting compression interruptions to less than that.1

Ultrasound, especially for trauma, is one of the most impactful procedures an emergency medicine physician can perform. It can rapidly detect the presence of injury to the thorax or abdomen—but it’s usually performed on a patient with a pulse.

As it relates to this study, PEA is the result of a large variety of causes which, in most cases, creates severe shock, which is noted by the presence of heart contractions in the absence of a pulse.

Ultrasound in PEA cardiac arrest is used to detect clinically significant contraction of the heart thus guiding treatment.

This study documents that it takes a significant length of time to use ultrasound while performing CPR. Additionally, the level of training in the procedure correlates with the length of chest compression interruptions. It raises questions about the viability of extending this technology to the prehospital arena.

Perhaps it’s possible to train EMS providers to use ultrasound for trauma, but can we train them to the level of emergency medicine fellows? I have serious reservations.

Perhaps it would be more appropriate to place the PEA arrest victim on mechanical CPR, secure the airway, administer epinephrine every 5 minutes and transport them to the ED where a larger team can continue resuscitation and use ultrasound in the most efficient manner.

However, if a service decides to implement POCUS, they should appreciate the fact that these authors noted that compression interruptions were longer when the physician leading the resuscitation also performed the ultrasound procedure.

Therefore, it may be more effective to train a small group of providers to their best ability and then deploy them to the cardiac arrest scene, so that performance of POCUS is done as efficiently as possible.

Reference

1. Kleinman ME, Goldberger ZD, Swor RA, et al. Part 5: Adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S414–S435.