- Introduction8:57Cardiology Corner - Computers Suck at EKG14:37Paper Chase 1 - The Loop Technique6:29When Ultrasound Is Not Your FriendFree Chapter11:56Paper Chase 2 - NG Tube Decompression for SBO4:40Trauma Surgeons Gone Wild - Wide Mediastinum - Part 1 - Penetrating Trauma24:17EMS Loyalty Program11:37Event Medicine17:40Trauma Surgeons Gone Wild - Wide Mediastinum Part 2 - Blunt Trauma10:20Paper Chase 3 - Risk Factors in Pediatric Emergency Department Procedural Sedation6:04Rhabdomyolysis - Part 123:13Rhabdomyolysis - Part 211:11Knee Dislocation3:58Mass Sociogenic Illness8:23Perforated Eardrum10:36Paper Chase 4 - Adding Diazepam in Acute Low Back Pain4:13NEXUS Chest CT Rule8:46EMS Handoffs Part Deux14:11Pediatric UTI17:32Annals of Emergency Medicine - Intoxicated Patients10:19Bleeding Circumcision7:46Paper Chase 5 - Point of Care Ultrasound for Acute Appendicitis4:18Surfers Myelopathy16:15Mailbag and Summary22:52EM:RAP 2018 March Canadian Edition23:47EMRAP 2018 March Spanish Edition1h, 28mEM:RAP 2018 March German Edition1h, 35mEM:RAP 2018 March Aussie Edition25:49
When Ultrasound Is Not Your Friend
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Nurses Edition Commentary
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When Ultrasound is Not Your Friend
Rob Orman MD and Bill Reed MD
Take Home Points
- The four components of high performance CPR are rate (100-120), depth (2-2.5 inches), full recoil and minimized pauses.
- Ultrasound can be used on the femoral artery to evaluate CPR.
- In our November 2017 episode, we had a conversation about ultrasound in cardiac arrest.
- Huis, In’t Veld, MA et al. Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions. 2017 Oct;119:95-98.PMID: 28754527
- The take-home point was doing ultrasound prolongs pauses in CPR. The duration of pause was 21 seconds with ultrasound compared to 13 seconds without ultrasound. You need to be cognizant of the ultrasound and how long you are pausing during CPR.
- Reed felt the segment missed the point. This is the first study that shows you shouldn’t have the ultrasound anywhere near a cardiac arrest patient. There may be a small segment of the population where there is benefit. Reed believes the device causes harm.
- This study didn’t demonstrate harm but found pauses associated with use. However, there are other studies that show pauses increase mortality.
- How long does it take to regain perfusion after a pause? The pressure drops back to zero within about 3 seconds. It is not 1 to 1 to get back to where you were. Essentially you have lost about 21 seconds for that 3 second pause. It takes roughly 16 seconds or 30 compressions to get back to where you left off. That is a huge deficit. If you extend that pause up to 21 seconds, it has a negative impact on survivability. We need to do this right.
- The four components of high performance CPR are rate (100-120), depth (2-2.5 inches), full recoil and minimized pauses. That is all you have to do. Precharge your defibrillator 10 seconds before your pause. See what you have. No ultrasound, airway or IV. Intraosseous is faster if available.
- When should ultrasound be used in all-cause cardiac arrest? Reed likes to put it on the femoral artery. He can watch compressions. He can evaluate how the compressor is doing and adjust the quality. He can correlate it with end-tidal CO2. You can watch to see how fast it stops when the compressor comes off the chest.
- Does the subxiphoid view help you in asystole? It may help if there is a return to an organized rhythm. What is the heart doing?
- Count down 10 seconds. If you hit 5 seconds, your CPR fraction will be above 95% which is phenomenal. Our goal is 80%. The AHA says 60% but it is unclear how they arrived at that number. It is easy to do, but you need to cognizant of time.
- You shouldn’t be relying on ultrasound with every pulse check. Keep your hands on the chest. If you bump your CPR fraction by 10%, survivability increases (at least for ventricular fibrillation).
- Think about if ultrasound is going to change your management. Do you really need it?