When Ultrasound Is Not Your Friend

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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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Patrick B. -

POCUS is not getting much love on this chapter, and while the discussion provided makes sense, I don't think POCUS got a fair shake. Particularly since there was a 4x increase in survival with pocus for asystole & PEA patients here:

https://www.sciencedirect.com/science/article/pii/S0300957216304786

Cheers. Great episode, point taken on minimizing hands off time.

Dharmesh S. -

At our shop we use mechanical CPR (LUCAS). During ongoing chest compressions, the POC US person tries to find a cardiac window around the LUCAS suction cup on the chest. Usually some variant of parasternal long view is possible scanning just above the suction cup. The cardiac views during chest compressions are usually indeterminate to assess for motion, but enough to rule out pericardial tamponade. At pulse check, we take a 4 sec clip while another person is palpating the femoral artery. Loud countdown of 10 to 1 is spoken out, and at 0 LUCAS restarts if there is no pulse.

We believe we are doing a better job than without POCUS in PEA arrests:
- usually the POCUS person shouts out "no pump" within 5 sec if no cardiac movement - so our duration of pulse check is actually lesser than without POCUS.
- we have had patients in whom we discovered hugely dilated right ventricle and survived due to thrombolytic given during CPR
- we also have had unexpected cardiac tamponade patients who survived due to POCUS allowing timely diagnosis and decompression

I think Reed's points may apply when manual as opposed to mechanical CPR is being performed.
However I think his views are too extreme, and it is simply not possible to assess for reversible causes of PEA arrest without ultrasound (and blood gas). Even with manual CPR, every PEA patient should get at least 1 assessment with POCUS, since the best quality of chest compressions will not result in relief of cardiac tamponade or lysis of a massive pulmonary embolus.

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