Text Genevieve Carbonatto
The management of cardiac arrest has been intensively studied over the past 20 year and other than early and good quality CPR and early defibrillation in VF, very little has shown to improve the prognosis in cardiac arrest.
The last 20 years has shown that high dose adrenaline, vasopressin, supplementary oxygen, treatment of VT with amiodarone and lignocaine are not effective. Adrenaline has been shown to be successful in getting return of spontaneous circulation but makes little difference to neurological outcomes at 28 days. We now have ECMO which has shown promising results if started within 40 minutes of cardiac arrest. Technology affordable to the few and fortunate.
At the moment the decision tree in the treatment of cardiac arrest depends on 2 pathways. One for patients in PEA or asystole, the other for patients with VF. What if we further categorised those patients to better manage them early?
Focused echocardiography was proposed to be part of the diagnostic and management pathway in cardiac arrest in 2010. It was proposed that this should be done during the 2min rhythm check. This was introduced to enable the diagnosis of potentially reversible causes of cardiac arrest (hypovolaemia, pericardial effusion, pulmonary embolism) and to help support the cessation of cardiac arrest in patients with no cardiac activity .
3 reservations regarding the use of echocardiography in this situation have been expressed.
1. it has been found to delay chest compressions
2. there is not a clear protocol for it’s inclusion in the management of cardiac arrest
3. there are concerns regarding safety of the sonographer during the delivery of the shock
Thomas Finn et al have proposed a safe and timely protocol incorporating focused echocardiography into the rhythm check during cardiopulmonary resuscitation which addresses these problems. Finn et al have proposed that:
- Simultaneous team leading and focused echocardiography should not occur, as this has been associated with prolonged interruptions to chest compressions
- Echocardiography should be performed by physicians with at least a basic accreditation in echocardiography, as this likely minimises interruptions to chest compressions
- Echocardiography should be performed as part of a standardised drill like protocol, as this is likely to minimise interruptions to chest compressions.
- The ultrasound machine is prepared and the views are optimised prior to the rhythm check
- The machine is set so that there are 10 seconds of prospective loops
- The details of the patient are entered in the machine
- The appropriate probe is chosen using the cardiac preset
- The machine is placed so as not to obstruct chest compressions or the view of the monitor
- The view is optimised (window, depth, gain…) while chest compressions are taking place
- The images are reviewed and interpreted during compressions
- While the subcostal view is usually most practical, the echosonographer can choose whichever view gives the best information
- Echo is performed while chest compressions are interrupted for the the rhythm check using the COACHRED drill (below)
- The images are reviewed and interpreted once chest compressions have recommenced
The COACHRED protocol. This specifically guides actions during the rhythm check only, and is intended to be used in conjunction with standard advanced life support algorithms.
Suggested team and equipment placement. The echosonographer positions themselves and their machine so as to avoid obstructing access to the chest for compressions
or obstructing the team leader’s view of the monitor. Team members and equipment are indicated as follows: A, airway support provider; C, compressions provider; D, defibrillator
operator; E, echosonographer; TL, teamleader; 1, ultrasoundmachine; 2, defibrillator.
Video simulation of the COACHED protocol can be seen below for both shockable and non shockable rhythm can be seen below.
What next?
We need a multicenter study to evaluate COACHED in the clinical setting as this may be the answer to incorporating good, high quality CPR with diagnostic accuracy and tailored management
Dear Genevieve
Thanks for recognising this article and glad that you agree with our idea, in safe and sleek incorporation of ultrasound in cardiac arrest. As I said, it is just an idea/concept that we (ultrasound fanatics at SAN ED) proposed in that article after we dug deep to find all possible issues and current pieces of evidence available. On our search, we found a few widespread consensus and surprising neglects.
There is a general acceptance that ultrasound is helpful in cardiac arrest, for identifying reversible causes, guide procedures and somewhat in prognostication. But internationally, the recommendation by various resuscitation councils to use ultrasound in cardiac arrest is weak, for apparent reasons, lack of evidence and fear of compromising effective CPR.
Recent articles from the USA, about prolonged compression pause, due to ultrasound usage during rhythm check, triggered us to do something about this. The surprising thing came about during this search was, there is no uniform or widely accepted “drill-like” protocol or cognitive aid in performing rhythm check (with or without using ultrasound), even within Australia. At NSW we are using COACHED for rhythm check, but it’s unheard of at other states, and interestingly, most places (including the centres from the USA, reporting prolonged chest compression pauses) have no protocol or cognitive aid. We strongly believe that ultrasound is a vital part in resuscitation (I can’t wait for the day I could use TOE in cardiac arrest!!) and a simple but effective aid like COACHRED is one step forward n the right direction.
The echosonographer in COACHRED, shouldn’t have to be a physician/ doctor, who is accredited to perform ECHO or BELS.
– A trained “emergency care provider”, a nurse or any technician can acquire images if they are “trained” to do so: Pick up the probe, select the correct preset (COACHRED), place at subcostal space and acquire a video clip. “Training” to do the above is necessary but not necessarily to the extent of CCPU/ accreditation.
– Echosonographer is not expected to interpret the images. The team leader can do it based on captured images once chest compressions recommenced.
– If it’s a non-doctor performing the ultrasound, they will be focused only on acquiring the image and not interpreting it, as they don’t know how to interpret it. This could potentially be a beneficial move as they won’t waste time interpreting it.
– this will be of great advantage in human resource-poor conditions (night shifts and at departments with one doctor on floor, who should take the team leader role).
We are currently doing research at SAN on nurses performing COACHRED and will let you all know how that went!.
In our paper, we just proposed a cognitive aid, COACHRED. As you suggested, we need a larger multicenter trial on this to assess its real-time feasibility. I’m in the process of drafting a protocol for this, hoping to expect support from all like-minded ultrasound enthusiasts to trial this out. Will get back on this soon!
cheers
Vijay
Dr Vijay Manivel FACEM DDU
Hi Vijay
Interested to hear about your protocoling COACHRED and further research on outcomes. I’m interested to hear in particular about the impact on team dynamics in resus and physician satisfaction regarding their cardiac arrest workup. I’m enthused to try this out at our ED.
I think COACHRED is a really neat way of incorporating the whole resus team into POCUS use in cardiac arrest. I see it as a very simple and feasible method and an excellent shared mental model for all involved. Also very sim-mable! Thank you to you and your team, Vijay. I’m impressed with it and have spoken about this now in 2 Victorian hospital EDs. I’m hoping to make it into an in-situ simulation in the not so distant future.
Thought provoking