Point-of-care ultrasound (POCUS) is a powerful diagnostic tool in the emergency department. To identify reversible causes of pulseless electrical activity (PEA), emergency physicians have started integrating POCUS into the evaluation of patients in cardiac arrest, leading to its current recommendation from the American Heart Association (AHA).1
However, two recent studies have demonstrated that ED POCUS use in the resuscitation of out-of-hospital cardiac arrests (OHCAs) may prolong CPR pauses, which has been shown to negatively impact survival.2,3 In our experience, even experienced ED sonographers can have difficulty simultaneously obtaining adequate echocardiographic views and interpreting their images in the 10-second CPR pause interval, leading to unintended prolonged CPR pauses.
Protocol = Solution
A potential solution for minimizing CPR interruptions may be to protocolize POCUS integration in the resuscitation of the OHCA patient. Prior protocols have been suggested, but they are too complex and can reduce the possibility of clinical implementation. A simplified protocol most ED sonographers can easily perform may reduce the cognitive load of running a complex resuscitation, facilitate detection of reversible causes of OHCA, and prevent prolonged CPR pauses.
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2 Responses to “Introducing the CASA Exam: A New Protocol to Guide Point-Of-Care Ultrasound in Cardiac Arrest”
May 6, 2018
Chris WiesnerRespectfully, no way that “pericardial effusion causing cardiac tamponade is…the cause of cardiac arrest in 4 to 15 percent of patients”.
The high-end 15% figure appears to come from reference #6, an 2003 observational study of 20 cardiac arrest patients at a single hospital over an 18 month period. Perhaps not what you should hang your hat on statistically.
Also, while certainly the article is focused on patients in PEA, you should be careful about making that clear when quoting statistics — the sentence about the rate of tamponade-induced cardiac arrest does not indicate you are limiting yourself to patients in PEA, although the underlying study is so limited.
I ultrasound every cardiac arrest I see. Even in patients with PEA, my clinical experience is that nowhere near 15% of them have tamponade or even an effusion.
May 13, 2018
arun nagdevCompletely agree with your comment. The rates are much lower than the 15%, but this is really all we have in the way of literature. In our just published 2018 Resuscitation paper “Clattenburg, et al.”, we did not have those numbers as well for pericardial effusions.
The goal of the CASA protocol is to allow the clinician to simplify the ultrasound aspect when running an OHCA, and ensure high quality CPR. By making the clinician look quickly for the presence or absence of a pericardial effusion, it allows him/her to move to other items that are on the differential.
Thanks for your great comment.
Arun