Sonography in Hypotension and Cardiac Arrest (SHoC): Rates of Abnormal Findings in Undifferentiated Hypotension and During Cardiac Arrest as a Basis for Consensus on a Hierarchical Point of Care Ultrasound Protocol

Abstract

Introduction

Point of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension. Current established protocols (RUSH and ACES) were developed by expert user opinion, rather than objective, prospective data. PoCUS also provides invaluable information during resuscitation efforts in cardiac arrest by determining presence/absence of cardiac activity and identifying reversible causes such as pericardial tamponade. There is no agreed guideline on how to safely and effectively incorporate PoCUS into the advanced cardiac life support (ACLS) algorithm. We wished to report disease incidence as a basis to develop a hierarchical approach to PoCUS in hypotension and during cardiac arrest.

Methods

We summarized the recorded incidence of PoCUS findings from the initial cohort during the interim analysis of two prospective studies. We propose that this will form the basis for developing a modified Delphi approach incorporating this data to obtain the input of a panel of international experts associated with five professional organizations led by the International Federation of Emergency Medicine (IFEM). The modified Delphi tool will be developed to reach an international consensus on how to integrate PoCUS for hypotensive emergency department patients as well as into cardiac arrest algorithms.

Results

Rates of abnormal PoCUS findings from 151 patients with undifferentiated hypotension included left ventricular dynamic changes (43%), IVC abnormalities (27%), pericardial effusion (16%), and pleural fluid (8%). Abdominal pathology was rare (fluid 5%, AAA 2%). During cardiac arrest there were no pericardial effusions, however abnormalities of ventricular contraction (45%) and valvular motion (39%) were common among the 43 patients included.

Conclusions

A prospectively collected disease incidence-based hierarchy of scanning can be developed based on the reported findings. This will inform an international consensus process towards the development of proposed SHoC protocols for hypotension and cardiac arrest, comprised of the stepwise clinical-indication based approach of Core, Supplementary, and Additional PoCUS views. We hope that such a protocol would be structured in a way that enables the clinician to only perform views that are clinically indicated, which limits exposure to the frequent incidental positive findings that accompany the current “one size fits all” standard protocols.

See full article at www.cureus.com

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Pediatric Emergency Medicine PoCUS Conference, 29th April 2016

Thanks to Dr Kirstin Weerdenburg, PEM Specialist at the IWK Hospital in Halifax, Nova Scotia, for sharing this invitation to the P2 Network Conference in Baltimore, Maryland on the 29th April 2016.

Information on P2|Network can be found on our website: www.p2network.com

Membership is free, and can be obtained by going to the website listed above, clicking on “Contact” in the upper right hand corner and entering your information under “Membership”.

Also, our annual P2|Network 2016 Conference is right around the corner, preceding the PAS conference. All PEM POCUS enthusiasts are welcome! Registration is now open! Register here: www.bit.ly/p2network2016 

Registration deadline is March 15, 2016.

Date and time: 

Friday, April 29, 2016

8AM – 5PM

Location: 

University of Maryland, Shock Trauma Auditorium

22 South Greene Street

Baltimore, Maryland USA

Hoping to see you there or as part of P2|Network in the future!

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eFAST – Recommended by NICE

The new NICE major trauma guidelines have recommended the use of eFAST as part of the assessment and management of Major Trauma. See the full recommendations here.

From: NICE guidelines [NG39] Published date:

1.3 Management of chest trauma in pre‑hospital settings

1.3.1 Use clinical assessment to diagnose pneumothorax for the purpose of triage or intervention.

1.3.2 Consider using eFAST (extended focused assessment with sonography for trauma) to augment clinical assessment only if a specialist team equipped with ultrasound is immediately available and onward transfer will not be delayed.

1.3.3 Be aware that a negative eFAST of the chest does not exclude a pneumothorax.

1.3.4 Only perform chest decompression in a patient with suspected tension pneumothorax if there is haemodynamic instability or severe respiratory compromise.

1.3.5 Use open thoracostomy instead of needle decompression if the expertise is available, followed by a chest drain via the thoracostomy in patients who are breathing spontaneously.

1.3.6 Observe patients after chest decompression for signs of recurrence of the tension pneumothorax.

1.3.7 In patients with an open pneumothorax:

  • cover the open pneumothorax with a simple occlusive dressing and
  • observe for the development of a tension pneumothorax.

These guidelines also recommend, where indicated, early endotracheal intubation using RSI within 45 minutes of the EMS call, and preferably at the scene of the incident. More evidence to support the case for Advanced Care Paramedics in New Brunswick?

Major_trauma__assessment_and_initial_management___recommendations___Guidance_and_guidelines___NICE

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ECCU 1 and ECCU IP School, Saint John, NB, 2016

ECCU Logo final

A few places remain open for both the ECCU 1 on 29th April 2016 and ECCU IP School 30th April 2016.

ECCU 1 Course (More Information) – Apply Here

ECCU IP School (More Information) – Apply Here

ECCU Dates this year

ECCU 1 – 29th April 2016

ECCU IP School – 30th April 2016

ECCU 2 Festival – 30th September – 1st October 2016

ECCU 1 – 25th November 2016

ECCU IP School – 26th November 2016

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Core PoCUS Applications – Recommended FOAMed Videos

Core Emergency Medicine PoCUS applications include:

  • PoCUS Physics
  • Abdominal Aorta
  • E-FAST
  • Core Cardiac
  • Early Pregnancy
  • Shock – IVC
  • Vascular Access

Free Open Access Medical Education (FOAMed) resources should be concise, clear and accessible. Here are some links to some great  – FOAMed – online PoCUS educational videos :



 

PoCUS Physics

From Vanderbilt’s Department of Emergency Medicine

Part 1

Part 2

 



Abdominal Aorta

From Mike Schick UC Davis EM

 



E-FAST

From Mike Schick UC Davis EM

Part 1

Part 2

 



Core Cardiac

From Mike Schick UC Davis EM

Basic Cardiac including intro to IVC


 

From EchoVTorials

Lets go window shopping / circle survey – guide to finding the best transthoracic cardiac views

 

Intro to Parasternal Views

 

Intro to Apical Views

 



 

Early Pregnancy / Obstetric (1st Trimester)

From EMUS Ottawa

Early pregnancy PoCUS rationale


 

From Sonosite Inc

IUP Part 1

IUP Part 2

Trans-Vaginal PoCUS

 



 

Shock – IVC

From Scott Weingart

IVC Ultrasound for Fluid Responsiveness


 

From Ultrasound Podcast.com

IVC Assessment with Respiratory Variation

 



 

Central Vascular Access

 

From Ultrasound Podcast.com

Internal Jugular Vein

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Resident Clinical Pearl – PoCUS for ETT Placement Confirmation

ETT Placement Confirmation During Cardiac Arrest: US for the Win!

Resident Clinical Pearl – November 2015

Kalen Leech-Porter, PGY 1, iFMEM, Saint John NB, Dalhousie University

Reviewed by: Dr Jay Mekwan and Dr David Lewis

 

The AHA has updated their guidelines for CPR and emergency cardiovascular care this year (2015)[i].  Previously, there were insufficient studies to warrant a recommendation for Point of Care Ultrasound (PoCUS) for ETT confirmation, however, a new study has emerged to suggest that PoCUS can be a useful adjunct for ETT placement confirmation.  A 96 patient observational study done on patients during cardiac arrest, found that PoCUS had a sensitivity of 98.9% and a specificity of 100%[ii].  ETT placement was determined by placing the ultrasound transducer transversely above the suprasternal notch to identify endotracheal or esophageal intubation.  It was determined during the study that in using this method ultrasound could be completed without interrupting chest compressions.

As the above study has yet to be replicated, end-tidal CO2 remains the gold standard for ETT placement confirmation (an observational, prospective study of 566 patients found colorimetric to be 95.6% sensitive, 99.8% specific[iii]) during cardiac arrest.  However, AHA has added ultrasound as an additional method for confirmation of endotracheal tube placement, with the caveat that ultrasound should never interfere with the continuous conduction of high-quality CPR.


 

How to confirm ETT with PoCUS:

Video by Haney Mallemat

 

Video by Joseph Minardi


 

Abridged Instructions from ACEP Tips and Tricks [iv]

  • Place the high frequency linear probe transversely just above the sternal notch (Image A); note normal airway anatomy (Image B), prior to ETT placement (if time permits)
Image A

Image A

From: Joseph Minardi’s Video [see above]

 

Image B

Image B

From: Halley Mallemat’s video [see above]

 

Trachea: Hyperechoic, curvilinear with comet-tail artifact

Esophagus: more distal, oval with heyperchoic wall and hypoechoic center


 

  • PoCUS ETT confirmation can be done in real time, as ETT is placed, or done post placement. Successful ETT: there will be a slight increase in artifact/shadowing in trachea region only, known as the “Bullet Sign” (Image C) [v].  The operator should see reverberations in the trachea’s anterior lumen.  To further confirm can slightly shake the ETT, this should only show trachea movement.
Image C

Image C

From: Mark Favot [v]


 

 

  • Esophageal Intubation: will cause a second ‘trachea’ appear (Image D and E), referred to as the “double tract sign”
Untitled4

Image D

From: Halley Mallemat’s video [see above]

Image E

Image E

From ACEP Tips and Tricks [iv]


 

  • Pitfalls: the esophagus may be located directly posterior to the trachea, therefore esophageal intubation may be missed if inadequate depth is used.
  • Additionally, observing bilateral lung sliding while bagging a paralyzed patient also suggest ETT confirmation.

References

[i] Web-based Integrated 2010 & 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; Part 7: Adult Advanced Cardiovascular Life Support.  (Nov. 25, 2015) https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-7-adult-advanced-cardiovascular-life-support/

[ii] Sun, Jen-Tang, Sim, Shyh-Shyong, et al. “Ultrasonography for proper endotracheal tube placement confirmation in out-of-hospital cardiac arrest patients: two-center experience.”  Critical Ultrasound Journal 6 (2014): A29 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4101346/

[iii] Hayden, SR., and Sciammerella, J., et al. “Colorimetric end-tidal CO2 detector for verification of endotracheal tube placement in out-of-hospital cardiac arrest.” Acad Emerg Med 6 (1995): 499-502 http://www.ncbi.nlm.nih.gov/pubmed/7497049

[iv] Chao, Alice and Ghrahbaghaian, Laleh. “Tips and Tricks: Airway Ultrasound.” American College of Emergency Physicians Emergency Ultrasound Section Newsletter (June, 2015). http://www.acep.org/Content.aspx?ID=102309

[v] Favot, Mark. “Ultrasound for Verification of Endotracheal Intubation.” FOAM EM (March, 2015). http://www.foamem.com/2015/03/02/ultrasound-for-verification-of-endotracheal-tube-location/

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Emergency Department ECMO and Echo – better together?

Click here for publication

As highlighted by Chou et al[1] it is becoming more evident that extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR) is feasible and compares well against conventional CPR. As technologies such as ECMO[2] and echocardiography (Echo),[3] previously limited to intensive care units and cardiology suites, become increasingly available in the Emergency Department (ED), it is important that we fully utilize the information and support they can provide to carefully select cardiac arrest patients for advanced ED resuscitation.

The percentage of patients who leave hospital alive following CPR varies from 0% to 20% and has not significantly improved in the last 30 years.[4] The recently published CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion), a single center, prospective, observational study from Australia, assessed the CHEER protocol, developed for selected patients with refractory in-hospital and out-of-hospital cardiac arrest.[5] The protocol involved mechanical CPR, induction of intra-arrest therapeutic hypothermia, early commencement of veno-arterial ECMO, and early coronary angiography for patients with suspected coronary artery occlusion. ECMO was established in 24 (92%) of 26 eligible patients, with a median time from collapse until initiation of ECMO of 56 min. Return of spontaneous circulation was achieved in 25 (96%) patients. Survival to hospital discharge with full neurological recovery occurred in 14/26 (54%) patients. Another study from the United States recently reported similar survival rates; 13 of 24 (54%) patients survived to hospital discharge with an ECMO based CPR protocol. Seven of these patients were discharged without any neurological deficit.[6] While these early results show promise for this form of advanced ED resuscitation, caution is required before rolling out this technology for all cardiac arrest patients.

Can our health care systems afford the increased requirement of intensive care bed-hours that such a policy would lead to? Can we select which patients are most likely to benefit from ED-ECMO?

A meta-analysis of predictors of survival from out-of-hospital cardiac arrest in 2010 found that survival to hospital discharge was more likely among those witnessed by a bystander or emergency medical services (EMS), those who received bystander CPR, were found in a shockable rhythm (VF/VT), or achieved return of spontaneous circulation (ROSC).[4] A further meta-analysis in 2012 looked at the of detection of cardiac activity on echo to predict survival during cardiac arrest. Pooled data showed that as a predictor of ROSC during cardiac arrest, echo had a pooled sensitivity of 91.6%, and specificity was 80.0%;[7] promising, but not independently predictive of survival.

Protocols including ED-ECMO are feasible and may be associated with a relatively high survival rate. The introduction of such protocols to emergency medicine should be encouraged, but must involve careful patient selection, optimizing survival benefit. This may involve bedside echo in the ED, as well as other demographic and clinically derived predictors of survival.

Paul R AtkinsonProfessor in Emergency Medicine

1. Chou T.-H. An observational study of extracorporeal CPR for in- hospital cardiac arrest secondary to myocardial infarction. Emerg Med J 2014;31: 441-7.

2. Shinar Z, Bellezzo J, Paradis N, et al. Emergency department initiation of cardiopulmonary bypass: a case report and review of the literature. J Emerg Med. 2012;43(1):83-6.

3. Hayhurst C, Lebus C, Atkinson PR, et al. An evaluation of echo in life support (ELS): is it feasible? What does it add? Emerg Med J. 2011 Feb;28(2):119-21.

4. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation 2014. DOI: http://dx.doi.org/10.1016/j.resuscitation.2014.09.010.

5. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta- analysis. ?Circ Cardiovasc Qual Outcomes 2010;3:63-81.

6. Peigh G, Pitcher H, Cavarocchi N, Hirose H. Saving Life And Brain With Extracorporeal Cardiopulmonary Resuscitation (E-Cpr) Chest. 2014;146(4_MeetingAbstracts):722A. doi:10.1378/chest.1990723.

7. Blyth L, Atkinson P, Gadd K, Lang E. Bedside Focused Echocardiography as Predictor of Survival in Cardiac Arrest Patients: A Systematic Review. Acad Emerg Med 2012;19: 1119-1126.

Conflict of Interest:

None declared

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Medical Student Clinical Pearl – Wooden Splinter detected by PoCUS

Approach to wooden foreign bodies in the hand using Point of Care Ultrasound.

Jefferson Hayre, Med II

Dalhousie Medicine New Brunswick

 

Detection and removal of a wooden foreign body is often a challenge and time consuming procedure. Failure to detect and remove, and subsequent retention in the soft tissue leads to increased morbidity through infection, pain, multiple clinical visits, and surgery.

 

Wood is radiolucent and therefore generally goes undetected in plain radiography. One study showed that only 15% of wooden foreign bodies were visible on plain radiography compared to metal (100%) and glass (96%).

 

Some studies of ultrasound has shown sensitivies of >89% and specificities of >93% in detection of wooden foreign bodies in soft tissue.

 

We were able to use ultrasound to detect a wooden foreign body (figure 1), as wells as it’s size (figure 2) and orientation. On ultrasound wooden foreign bodies appear as a hyperechoic foci with acoustical shadowing and a hypoechoic halo, usually only seen after 24 hours due to the inflammatory response.

fb2

 

Figure 1 – Wooden foreign body in the hand. Note the hyperechoic line and the acoustic shadow below.

 

fb1

 

Figure 2 – Measurement of a wooden foreign body in the hand. Using the measuring tools on the ultrasound machine we successfully measured the wooden foreign body to be 85mm.

 

In addition to removal of the foreign body, the patient’s tetanus immunization status must be reviewed. Immunization should be delivered to those patients who need it.

 

The wound should be cleaned with an iodophor or other antiseptic solution, and any jagged edges of the wound should be trimmed.

 

There is currently no solid evidence on the efficacy of prophylactic antibiotics in puncture wounds.

 

Further Reading on PoCUS for FB – Here

 

References:

Anderson MA, Newmeyer WL 3rd, Kilgore ES Jr. Diagnosis and treatment of retained foreign bodies in the hand. Am J Surg. 1982 Jul;144(1):63-7.

Baddour LM. Overview of puncture wounds. In: UpToDate, Sexton DJ (Ed), UpToDate, Waltham, MA. (Accessed on May 1, 2015.)

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Congratulations to all involved from SJRHEM in the REASON Study – Top Research Award – Dalhousie DEM Research Day

The results from the Real-time Assessment and Evaluation with Sonography – Outcomes Network (REASON) were presented by Dr Paul Atkinson at the Dalhousie Department of Emergency Medicine Research Day. The presentation won the Dalhousie DEM Top Research Award!  Congratulations to all those at SJRHEM involved in helping to collect the data for this prize-winning study!

This study will be presented as a plenary at CAEP 2015 by Dr Paul Atkinson, where it has already been judged 2nd place overall CAEP 2015 research abstract.

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Ultrasound in Sports Medicine

Are you interested in Sports Medicine? The you had better be interested in Point of Care Ultrasound (PoCUS)! Emergency Physicians have been using PoCUS for musculoskeletal (MSK) applications (foreign bodies, fractures, muscle injuries, joint effusions, nerve blocks, etc) for many years. Sport Physicians are even more enthusiastic about the  potential for MSK PoCUS.

See this blog from the Clinical Journal of Sports Medicine

Here is the AMSSM Sports Med. Ultrasound Fellowship Curriculum

Also if you are interested in MSK PocUS – Join us at the Fall ECCU Festival in September.

Anterior thigh – Quadraceps injury

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