Name: ultrasonographic assessment during cardiopulmonary resuscitation
Uploaded: 2020-10-24T15:00:00
Description: Watch this Scientific Journal Video about Ultrasonographic Assessment During Cardiopulmonary Resuscitation at JoVE.com

This study was supported in part by the grants from the Ministry of Science and Technology, Taiwan (MOST 103-2511-S-002-007). The authors would like to thank Dr. Chih-Hsien Wu and Mr. Jen-Chih Sung for helping the preparation of the photographs and film.

This procedure was approved by the Institutional Review Board of the National Taiwan University Hospital and registered at ClinicalTrials.gov (NCT02952768).
1. Instrumentation
<ol>
	<li>Use a US machine equipped with a curvilinear 2&#8211;5 MHz probe. A portable US is more suitable for CPR.</li>
</ol>
2. Personnel and their roles in the resuscitation team
<ol>
	<li>Ideally, a resuscitation team should be comprised of six members: 1) a leader; 2) a member for airway ...

<ol>
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US is a noninvasive, real-time, and readily available imaging modality in emergency and critical care settings. Application of US during CPR plays an important role in diagnosis, guidance of therapeutic intervention, or monitoring15. While many US protocols have been introduced for use with CPR, the US-CAB protocol complies with the sequence of advanced life support (ALS). It integrates important US techniques to detect possibly reversible causes of any issues, and to evaluate the C-A-B status dur...

Effective cardiopulmonary resuscitation (CPR) for cardiac arrest is key to successful revival of a patient. Circulation (C), airway (A), and breathing (B) are the three crucial components in either basic (BLS) or advanced life support (ALS). The evaluation of the C-A-B status during CPR basically relies on pulse checks, auscultation, and capnography1. In true clinical conditions, however, CPR is often complex and chaotic, and these methods may have limitations2,3. For example, the accuracy of pulse checks is often suboptimal even when performed by healthcare providers4. More than half of one lung intubations might be misdirected if guided by auscultation alone5. Even wave capnography can be affected by factors such as low cardiac output, low pulmonary flow, and use of epinephrine during CPR2. Therefore, more effective, accurate evaluation of the C-A-B status is mandatory.
When trying to search for the etiology of cardiac arrest or any potentially reversible factors during CPR, medical history and physical examination are often insufficient. The detection of reversible causes, such as the 5Hs (i.e., hypoxia, hypovolemia, hyperkalemia/hypokalemia, acidosis, and hypothermia) and the 5Ts (i.e., cardiac tamponade, tension pneumothorax, pulmonary thromboembolism, coronary thrombosis, and toxins or tablets), often requires advanced examinations.
Ultrasound (US) is a useful imaging modality in emergency and critical care settings. The European Resuscitation Council (ERC) Guidelines suggest that US can be an integral part of resuscitation6. US can readily identify critical but potentially reversible factors that negatively affect CPR, such as cardiac tamponade, pulmonary thromboembolism, and hypovolemia7,8,9. US also helps rule out pneumothorax and acute coronary syndrome. Moreover, US confers prognostic implications even when CPR is being performed. The presence of sonographic cardiac activity during CPR has been reported to confer higher chances of ROSC, survival, and hospital discharge10,11. In addition to sonographic evaluation of the heart and circulation status, tracheal US is employed for confirmation of proper endotracheal intubation12, while lung US is applied to confirm proper bilateral pulmonary ventilation13.
While high-quality CPR with minimal interruptions to the compressions is the most important factor for resuscitation, it is important to understand how to seamlessly integrate US into the process of resuscitation without interfering with CPR. We therefore developed a novel, ALS-compliant US-CAB protocol for use during CPR14. This paper presents a detailed description of the settings, personnel, and instruments necessary for better integration of the US protocol into the regular CPR process that first-line physicians can easily incorporate and implement into their practice.

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			<td class="xl65" height="21" style="height:15.75pt;width:162pt" width="216">Ultrasound</td>
			<td class="xl65" style="width:140pt" width="186">Cannon, Japan</td>
			<td class="xl65" style="width:89pt" width="119">SSA-550A</td>
			<td class="xl66" style="width:125pt" width="167">nil</td>
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ultrasonographic assessment during cardiopulmonary resuscitation

The US-CAB (Ultrasound, Circulation/Airway/Breathing) protocol integrates several sonographic techniques into a structured assessment of the circulation, airway, and breathing status of a patient during cardiopulmonary resuscitation (CPR) in an advanced life support-compliant manner. US-C provides a subxiphoid view of the heart, to look for potentially reversible causes of disease, such as pericardial effusion, pulmonary embolism, hypovolemia, and acute coronary thrombosis. Sonographic cardiac activity during CPR not only helps differentiate pseudo-pulseless electrical activity (PEA) from true PEA but also represents a higher chance of the return of spontaneous circulation (ROSC) and survival. Evaluation of the inferior vena cava (IVC) shows the fluid status of the patient and indicates the best methods to use for fluid resuscitation. If aortic dissection is suspected, a subxiphoid view of the aorta is suggested for identifying an intimal flap. Once intubation is done, tracheal ultrasound (US-A) at the suprasternal notch helps differentiate endotracheal intubation (one air-mucosal interface with one comet-tail) from esophageal intubation (double tract sign). Immediately following US-A, bilateral lung US (US-B) should be done to confirm proper bilateral ventilation using the lung sliding sign. In addition, US-C can be serially followed to see the dynamic changes in the cardiac chambers and IVC, or any cardiac contraction suggestive of ROSC. US-B can also detect coexisting lung or pleural pathologies without interfering with the performance of CPR. The main concern when implementing this method is maintaining high-quality CPR without delays in chest compressions when performing US-CAB. Rigorous training and continued practice are key to minimize any interruptions during resuscitation.

US-C with subxiphoid evaluation of the heart displays a cardiac four-chamber view as shown in Figure 3A. At this point, detection of any of the three typical patterns suggestive of specific etiologies or reversible factors is possible.
Identify the presence and characters of pericardial effusion: If pericardial effusion is present, notice if the right heart chambers (i.e., the right atrium or even the right ventricle) are compressed. If compression of the right at...

Watch this Scientific Journal Video about Ultrasonographic Assessment During Cardiopulmonary Resuscitation at JoVE.com

Ultrasonographic Assessment During Cardiopulmonary Resuscitation

Here, we present a US-CAB (Ultrasound, Circulation/Airway/Breathing) protocol for use during cardiopulmonary resuscitation (CPR). US-C evaluates the subxiphoid view of the heart and inferior vena cava. After intubation, tracheal US (US-A) and lung US (US-B) help confirm endotracheal intubation and proper ventilation.

The US-CAB (Ultrasound, Circulation/Airway/Breathing) protocol integrates several sonographic techniques into a structured assessment of the circulation, ...

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