Post on 30-May-2020
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WINFOCUS BASIC ECHO (WBE)!
FOCUSED ECHOCARDIOGRAPHY
DURING ACLS
S. PATRICK BENDER MD
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Outline
• Rationale for the use of echocardiography during ACLS
• Algorithm
• Implementation
• Interpretation
• Questions and Cases
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Rationale
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Rationale
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Rationale
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Rationale
Causes of “Pseudo-PEA”
Pericardial Effusion with Tamponade
Hypovolemia
Pulmonary Embolism
Severe Ventricular Dysfunction
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Rationale
“True-PEA” “Pseudo-PEA”
Severe Ventricular Dysfunction
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Rationale
“True-PEA” “Pseudo-PEA”
Severe Ventricular Dysfunction
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Rationale
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Rationale
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Rationale
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Rationale
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Rationale
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Rationale
• Cardiac Activity Strongly Associated With Return of Spontaneous Circulation
• 8/11 Patients With Cardiac Activity Had ROSC
• 0/23 Patients Without Cardiac Activity Had ROSC
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Rationale
• Cardiac Activity Strongly Associated With Return of Spontaneous Circulation
• 8/11 Patients With Cardiac Activity Had ROSC
• 0/23 Patients Without Cardiac Activity Had ROSC
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Rationale
• Cardiac Activity Strongly Associated With Return of Spontaneous Circulation
• 8/11 Patients With Cardiac Activity Had ROSC
• 0/23 Patients Without Cardiac Activity Had ROSC
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Algorithm
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Algorithm
When to apply
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Algorithm
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Algorithm
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Algorithm
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Algorithm
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Algorithm
Echocardiography Performed in Parallel With Pulse Checks -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐
Less Than 10 seconds of Compression Interrup?on
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Implementation
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ImplementationPreparation
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Implementation
• Perform High Quality Compressions - At Least 5 cycles
Preparation
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Implementation
• Perform High Quality Compressions - At Least 5 cycles
• Announce “We are going to do an echocardiogram during next pulse check.”
Preparation
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Implementation
• Perform High Quality Compressions - At Least 5 cycles
• Announce “We are going to do an echocardiogram during next pulse check.”
• Prepare Probe
Preparation
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Implementation
• Perform High Quality Compressions - At Least 5 cycles
• Announce “We are going to do an echocardiogram during next pulse check.”
• Prepare Probe
• Prepare Patient by Removing Any Barriers to Image Acquisition
Preparation
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ImplementationExecution
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ImplementationExecution
• Place Probe on Patient
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ImplementationExecution
• Place Probe on Patient
• Announce a Pulse Check and Echo Exam Will be Done in 10 Seconds
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ImplementationExecution
• Place Probe on Patient
• Announce a Pulse Check and Echo Exam Will be Done in 10 Seconds
• Countdown 10 Seconds
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ImplementationExecution
• Place Probe on Patient
• Announce a Pulse Check and Echo Exam Will be Done in 10 Seconds
• Countdown 10 Seconds
• Perform and Record Echo While Code Leader Counts Down to Resume Compressions
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ImplementationResumption of Compressions
and Echo Interpretation
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ImplementationResumption of Compressions
and Echo Interpretation
• Resumption of Compressions
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ImplementationResumption of Compressions
and Echo Interpretation
• Resumption of Compressions
• Interpretation of Images During Continuation of ACLS
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Implementation
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Implementation
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Implementation
• Immediately Resume Compressions
• Attempt Again, Possibly in Different Echocardiographic Window
Difficult Image Acquisition
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ImplementationDifficult Image Acquisition
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ImplementationDifficult Image Acquisition
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InterpretationTrue-PEA
Absence of Cardiac Activity
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InterpretationTrue-PEA
Absence of Cardiac Activity
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Interpretation
Pericardial Tamponade
RV CollapseEffusion
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Interpretation
Pericardial Tamponade
RV CollapseEffusion
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InterpretationPulmonary Embolism
Hypokinetic and Dilated RV
Underfilled LV
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InterpretationPulmonary Embolism
Hypokinetic and Dilated RV
Underfilled LV
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Interpretation
Hypovolemic RV
Hypovolemic LV
Hypovolemia
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Interpretation
Hypovolemic RV
Hypovolemic LV
Hypovolemia
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Interpretation
Severely Hypokinetic LV
Severe Ventricular Dysfunction
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Interpretation
Severely Hypokinetic LV
Severe Ventricular Dysfunction
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Summary
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Summary
• Focused Echo During ACLS Can Be Both Diagnostic and Prognostic
• Differentiating “True-PEA From “Pseudo-PEA” Can Guide Treatment
• Focused Echo Is Easily Integrated Into ACLS
• REMEMBER TO MINIMIZE INTERRUPTIONS IN CHEST COMPRESSIONS!
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Summary
• Focused Echo During ACLS Can Be Both Diagnostic and Prognostic
• Differentiating “True-PEA From “Pseudo-PEA” Can Guide Treatment
• Focused Echo Is Easily Integrated Into ACLS
• REMEMBER TO MINIMIZE INTERRUPTIONS IN CHEST COMPRESSIONS!
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
Summary
• Focused Echo During ACLS Can Be Both Diagnostic and Prognostic
• Differentiating “True-PEA From “Pseudo-PEA” Can Guide Treatment
• Focused Echo Is Easily Integrated Into ACLS
• REMEMBER TO MINIMIZE INTERRUPTIONS IN CHEST COMPRESSIONS!
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
Summary
• Focused Echo During ACLS Can Be Both Diagnostic and Prognostic
• Differentiating “True-PEA From “Pseudo-PEA” Can Guide Treatment
• Focused Echo Is Easily Integrated Into ACLS
• REMEMBER TO MINIMIZE INTERRUPTIONS IN CHEST COMPRESSIONS!
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Cases/QuestionsDuring a PEA Arrest, the below image is obtained. The patient remains pulseless.
1.
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Cases/QuestionsDuring a PEA Arrest, the below image is obtained. The patient remains pulseless.
1.
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Cases/Questions
What is the appropriate next step?
A. Attempt Parasternal View
B. Immediately Resume Compressions
C. Bolus Normal Saline
D. Administer Thrombolytics
1.
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Cases/Questions
What is the appropriate next step?
A. Attempt Parasternal View
B. Immediately Resume Compressions
C. Bolus Normal Saline
D. Administer Thrombolytics
1.
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Cases/Questions!
B. Immediately Resume Compressions
Poor Image Quality
1.
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Cases/Questions!
B. Immediately Resume Compressions
Poor Image Quality
1.
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Cases/Questions2.
A patient is admitted to the Emergency Department in PEA Arrest. The below image is obtained.
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Cases/Questions2.
A patient is admitted to the Emergency Department in PEA Arrest. The below image is obtained.
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Cases/Questions
What is the most likely cause of the arrest?
A. Pulmonary Embolism
B. Pericardial Tamponade
C. Severe Hypovolemia
D. Myocardial Infarction
2.
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Cases/Questions
What is the most likely cause of the arrest?
A. Pulmonary Embolism
B. Pericardial Tamponade
C. Severe Hypovolemia
D. Myocardial Infarction
2.
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Cases/Questions
Severely Hypokinetic
LV
2.
D. Myocardial Infarction
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Cases/Questions
Severely Hypokinetic
LV
2.
D. Myocardial Infarction
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Cases/Questions
During a Cardiac Arrest, what is the maximum amount of time that cardiac compressions should be interrupted to allow for pulse check and focused echocardiography? !
A. 10 seconds
B. 15 seconds
C. 20 seconds
D. 30 seconds
3.
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Cases/Questions!
A. 10 seconds
3.
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