We hope the integration of a simplified, step-wise exam into the resuscitation of the OHCA patient will limit prolonged CPR pauses while allowing POCUS to improve diagnostic accuracy.
Keys to Shorter CPR Pauses
- Place ultrasound probe on chest and find view before stopping CPR.
- Have separate providers perform POCUS and run code.
- Ask a registered nurse to count down from 10 out loud during the POCUS.
FAQ
Why should I use a protocol?
Many ED providers’ CPR pauses are too long. Our CPR pauses last on average 19 seconds with POCUS and 14 seconds without it. Using an ultrasound protocol focuses the provider on the most pertinent clinical questions on which we can intervene.
Why is the protocol in this order?
According to prior studies, tamponade is the most frequent cause of PEA that can be identified with ultrasound, and it accounts for 4 to 15 percent of PEA cardiac arrests. PE is the next most likely cause of PEA found on POCUS and is found in 4 to 7.6 percent of patients.
What if I can look at right heart strain and tamponade in the same CPR pause?
Nice job! That means that you are an advanced POCUS practitioner. This protocol is designed for entry level POCUS users, but be careful that your CPR pauses are not actually over 10 seconds long.
Why is pneumothorax/FAST on the side?
We believe that pneumothorax and FAST scans can be performed during CPR. If you are unsure, then check during a <10 second CPR pause.
I know how to improve this protocol. Who should I email?
References
- Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult advanced cardiovascular life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S444-464.
- Clattenburg EJ, Wroe P, Brown S, et al. Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: a prospective cohort study. Resuscitation. 2018;122:65-
- Huis In ‘t Veld MA, Allison MG, Bostick DS, et al. Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions. Resuscitation. 2017;119:95-98.
- Gardner KF, Clattenburg EJ, Wroe P, et al. The Cardiac Arrest Sonographic Assessment (CASA) exam – a standardized approach to the use of ultrasound in PEA [published online ahead of print Aug. 26, 2017]. Am J Emerg Med.
- Gaspari R, Weekes A, Adhikari S, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016;109:33-39.
- Tayal VS, Kline JA. Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states. Resuscitation. 2003;59(3):315-318.
- Chardoli M, Heidari F, Rabiee H, et al. Echocardiography integrated ACLS protocol versus conventional cardiopulmonary resuscitation in patients with pulseless electrical activity cardiac arrest. Chin J Traumatol. 2012;15(5):284-287.
- Hayhurst C, Lebus C, Atkinson PR, et al. An evaluation of echo in life support (ELS): is it feasible? What does it add? Emerg Med J. 2011;28(2):119-121.
- Zengin S, Yavuz E, Al B, et al. Benefits of cardiac sonography performed by a non-expert sonographer in patients with non-traumatic cardiopulmonary arrest. Resuscitation. 2016;102:105-109.
- Breitkreutz R, Price S, Steiger HV, et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation. 2010;81(11):1527-1533.
- Beun L, Yersin B, Osterwalder J, et al. Pulseless electrical activity cardiac arrest: time to amend the mnemonic “4H&4T”? Swiss Med Wkly. 2015;145:w14178.
- Kürkciyan I, Meron G, Sterz F, et al. Pulmonary embolism as a cause of cardiac arrest: presentation and outcome. Arch Intern Med. 2000;160(10):1529-1535.
- Comess KA, DeRook FA, Russell ML, et al. The incidence of pulmonary embolism in unexplained sudden cardiac arrest with pulseless electrical activity. Am J Med. 2000;109(5):351-356.
- Jaff MR, McMurtry MS, Archer SL, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123(16):1788-1830.
- Hu K, Gupta N, Teran F, et al. Variability in interpretation of cardiac standstill among physician sonographers. Ann Emerg Med. 2018;71(2):193-198.
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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