Do combined ultrasound and electrocardiogram-rhythm findings predict survival in emergency department cardiac arrest patients? The Second Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED2) study

Abstract

ObjectivesPoint-of-care ultrasound (POCUS) is used increasingly during resuscitation. The aim of this study was to assess whether combining POCUS and electrocardiogram (ECG) rhythm findings better predicts outcomes during cardiopulmonary resuscitation in the emergency department (ED).MethodsWe completed a health records review on ED cardiac arrest patients who underwent POCUS. Primary outcome measurements included return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge.ResultsPOCUS was performed on 180 patients; 45 patients (25.0%; 19.2%–31.8%) demonstrated cardiac activity on initial ECG, and 21 (11.7%; 7.7%–17.2%) had cardiac activity on initial POCUS; 47 patients (26.1%; 20.2%–33.0%) achieved ROSC, 18 (10.0%; 6.3%–15.3%) survived to admission, and 3 (1.7%; 0.3%–5.0%) survived to hospital discharge. As a predictor of failure to achieve ROSC, ECG had a sensitivity of 82.7% (95% CI 75.2%–88.7%) and a specificity of 46.8% (32.1%–61.9%). Overall, POCUS had a higher sensitivity of 96.2% (91.4%–98.8%) but a similar specificity of 34.0% (20.9%–49.3%). In patients with ECG-asystole, POCUS had a sensitivity of 98.18% (93.59%–99.78%) and a specificity of 16.00% (4.54%–36.08%). In patients with pulseless electrical activity, POCUS had a sensitivity of 86.96% (66.41%–97.22%) and a specificity of 54.55% (32.21%–75.61%). Similar patterns were seen for survival to admission and discharge. Only 0.8% (0.0–4.7%) of patients with ECG-asystole and standstill on POCUS survived to hospital discharge.ConclusionThe absence of cardiac activity on POCUS, or on both ECG and POCUS together, better predicts negative outcomes in cardiac arrest than ECG alone. No test reliably predicted survival.

Diagnostic performance of point-of-use ultrasound of resuscitation outcomes: A systematic review and meta-analysis of 3265 patients

“…The publication dates of these studies ranged from 2001 to 2019. Six studies were conducted in the United States [ 25 , 30 , 37 – 40 ], 3 in Turkey [ 27 , 36 , 41 ], 2 in Canada [ 22 , 24 ], and 1 in each of the following countries: Austria [ 23 ], Germany [ 26 ], Iran [ 28 ], Singapore [ 29 ], Brazil [ 31 ], United Kingdom [ 33 ], Republic of Korea [ 34 ], and Taiwan [ 35 ]. One study was also conducted as a multi-country trial.…”

Point-of-care ultrasound in cardiorespiratory arrest (POCUS-CA): narrative review article

“…The cardiac activity present in the POCUS-CA is a finding of prognostic importance for ROSC and survival, as evidenced in multiple studies [23,24,[64][65][66][67][68][69][70][71][72][73][74][75][76].…”

“…Ultrasound performed during cardiopulmonary resuscitation in intensive care unit (ICU) patients can be performed without interfering with care protocols and can contribute to the differential diagnosis of arrest and the identification of a subgroup of patients with a better prognosis [ 22 ]. Although the ROSC and the overall survival rate are low when the cardiac contraction was not observed there is no conclusive evidence to define a standard criterion for decision-making about not starting or stopping resuscitation efforts; since there are still a low number of patients who can come out of the arrest; especially those with witnessed arrest, early CPR, short downtime, or a potentially reversible cause [ 23 , 24 ].…”

Diagnostic Modalities in Critical Care: Point-of-Care Approach

“…In cardiac arrest, POCUS can be immeasurably helpful in ruling out reversible causes, such as cardiac tamponade, tension pneumothorax or pulmonary embolism, leading to adapted and immediate therapy [ 21 ]. Moreover, POCUS is used in the prognosis of cardiac arrest, as the absence of organized contractions of the heart muscle after three circles of advanced life support suggests a negligible likelihood of the return of spontaneous circulation [ 162 , 163 , 164 , 165 ]. This can further help in decision-making of other invasive measurements like initiation of extracorporeal membrane oxygenation.…”