Where's the balancing point in this when we consider the narrow complex patient that is PEA but most likely to be pseudo-PEA? If the patient does have a reversible cause, then US is going to be the best way to find it. CPR will temporize but won't fix PTX, pericardial effusion, PE or internal hemorrhage.
I think an initial evaluation for reversible causes is essential, but after that initial evaluation I am unsure of the value of continued subcostal ultrasound, with possible exception of assessment for barotrauma.
My immediate thought upon listening was that the carotid is where we manually check a pulse, but it is also the most available place to check a pulse with ultrasound. The exception of course being C-collared patients, which could be removed. After a (very) brief search there are several studies looking at the feasibility of this technique. Would love to hear any comments from others about this.
I like to use the brachial with the arm abducted 90 degrees. It helps get me and the machine away from the patient and helps prevent overcrowding at the bedside where a lot is happening. Still easy enough to rapidly acquire the needed view. Usually Ill be watching before the end of a CPR cycle, can usually detect presence/absence of pulsatile flow in 2-3 seconds. I have no data to back this technique up but it seems to work so far and shorten pulse checks, no more "I think I feel one but cant tell"
I wonder if this is an indication for double sequential sonography? Part of the delay is in image aquisition. If there were enough resources, nothing stopping you using two machines and two operators getting looking for cardiac views at the same time ( e.g. PLAX and Subxiphi etc. ) I think it is important to emphasise that sonography in cardiac arrest is not just about pulse check, so the comparison is not really valid.
I understand its not just about the pulse check, but in that sense it can be a helpful adjunct. As they mentioned, we're not always very good at manual palpation. The two questions are 1. After the first cardiac ultrasound rules out the usual reversible causes, what are the chances of finding a reversible cause on subsequent cardiac ultrasounds? 2. Can you reliably bring the average number of 21 seconds per pulse check into an acceptable range while still getting good views. Two sonographers may mean that one captures a better view faster but the physical logistics of that seem impractical in a code situation.
A question about Pseudo PEA: As mentioned in November 2017 episode. Ultrasound in Cardiac arrest delays chest compressions. However, there is also some evidence that some cardiac movement has some predictive value for ROSC. The question is: when do we call a code if the patient has no pulse, but some cardiac activity on POCUS? It seems you can end up running a code for a long time if you wait until cardiac standstill on US. When do we stop? Should we just only put the US on to look for reversible causes and then stop?
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James H. - November 7, 2017 11:55 AM
Where's the balancing point in this when we consider the narrow complex patient that is PEA but most likely to be pseudo-PEA? If the patient does have a reversible cause, then US is going to be the best way to find it. CPR will temporize but won't fix PTX, pericardial effusion, PE or internal hemorrhage.
Brandon W. - November 14, 2017 8:55 AM
I think an initial evaluation for reversible causes is essential, but after that initial evaluation I am unsure of the value of continued subcostal ultrasound, with possible exception of assessment for barotrauma.
My immediate thought upon listening was that the carotid is where we manually check a pulse, but it is also the most available place to check a pulse with ultrasound. The exception of course being C-collared patients, which could be removed. After a (very) brief search there are several studies looking at the feasibility of this technique. Would love to hear any comments from others about this.
Jon P. - November 25, 2017 2:41 PM
I like to use the brachial with the arm abducted 90 degrees. It helps get me and the machine away from the patient and helps prevent overcrowding at the bedside where a lot is happening. Still easy enough to rapidly acquire the needed view. Usually Ill be watching before the end of a CPR cycle, can usually detect presence/absence of pulsatile flow in 2-3 seconds. I have no data to back this technique up but it seems to work so far and shorten pulse checks, no more "I think I feel one but cant tell"
Owen D. - November 27, 2017 2:30 PM
I wonder if this is an indication for double sequential sonography? Part of the delay is in image aquisition. If there were enough resources, nothing stopping you using two machines and two operators getting looking for cardiac views at the same time ( e.g. PLAX and Subxiphi etc. )
I think it is important to emphasise that sonography in cardiac arrest is not just about pulse check, so the comparison is not really valid.
Jon P. - November 28, 2017 8:24 AM
I understand its not just about the pulse check, but in that sense it can be a helpful adjunct. As they mentioned, we're not always very good at manual palpation. The two questions are 1. After the first cardiac ultrasound rules out the usual reversible causes, what are the chances of finding a reversible cause on subsequent cardiac ultrasounds? 2. Can you reliably bring the average number of 21 seconds per pulse check into an acceptable range while still getting good views. Two sonographers may mean that one captures a better view faster but the physical logistics of that seem impractical in a code situation.
Robb R. - October 17, 2018 2:08 AM
A question about Pseudo PEA: As mentioned in November 2017 episode. Ultrasound in Cardiac arrest delays chest compressions. However, there is also some evidence that some cardiac movement has some predictive value for ROSC. The question is: when do we call a code if the patient has no pulse, but some cardiac activity on POCUS? It seems you can end up running a code for a long time if you wait until cardiac standstill on US. When do we stop? Should we just only put the US on to look for reversible causes and then stop?