Text Genevieve Carbonatto
The management of cardiac arrest has been intensively studied over the past 20 year and other than early and good quality CPR and early defibrillation in VF, very little has shown to improve the prognosis in cardiac arrest.
The last 20 years has shown that high dose adrenaline, vasopressin, supplementary oxygen, treatment of VT with amiodarone and lignocaine are not effective. Adrenaline has been shown to be successful in getting return of spontaneous circulation but makes little difference to neurological outcomes at 28 days. We now have ECMO which has shown promising results if started within 40 minutes of cardiac arrest. Technology affordable to the few and fortunate.
At the moment the decision tree in the treatment of cardiac arrest depends on 2 pathways. One for patients in PEA or asystole, the other for patients with VF. What if we further categorised those patients to better manage them early?
Focused echocardiography was proposed to be part of the diagnostic and management pathway in cardiac arrest in 2010. It was proposed that this should be done during the 2min rhythm check. This was introduced to enable the diagnosis of potentially reversible causes of cardiac arrest (hypovolaemia, pericardial effusion, pulmonary embolism) and to help support the cessation of cardiac arrest in patients with no cardiac activity .
3 reservations regarding the use of echocardiography in this situation have been expressed.
1. it has been found to delay chest compressions
2. there is not a clear protocol for it’s inclusion in the management of cardiac arrest
3. there are concerns regarding safety of the sonographer during the delivery of the shock
Thomas Finn et al have proposed a safe and timely protocol incorporating focused echocardiography into the rhythm check during cardiopulmonary resuscitation which addresses these problems. Finn et al have proposed that:
- Simultaneous team leading and focused echocardiography should not occur, as this has been associated with prolonged interruptions to chest compressions
- Echocardiography should be performed by physicians with at least a basic accreditation in echocardiography, as this likely minimises interruptions to chest compressions
- Echocardiography should be performed as part of a standardised drill like protocol, as this is likely to minimise interruptions to chest compressions.
- The ultrasound machine is prepared and the views are optimised prior to the rhythm check
- The machine is set so that there are 10 seconds of prospective loops
- The details of the patient are entered in the machine
- The appropriate probe is chosen using the cardiac preset
- The machine is placed so as not to obstruct chest compressions or the view of the monitor
- The view is optimised (window, depth, gain…) while chest compressions are taking place
- The images are reviewed and interpreted during compressions
- While the subcostal view is usually most practical, the echosonographer can choose whichever view gives the best information
- Echo is performed while chest compressions are interrupted for the the rhythm check using the COACHRED drill (below)
- The images are reviewed and interpreted once chest compressions have recommenced
The COACHRED protocol. This specifically guides actions during the rhythm check only, and is intended to be used in conjunction with standard advanced life support algorithms.
Suggested team and equipment placement. The echosonographer positions themselves and their machine so as to avoid obstructing access to the chest for compressions
or obstructing the team leader’s view of the monitor. Team members and equipment are indicated as follows: A, airway support provider; C, compressions provider; D, defibrillator
operator; E, echosonographer; TL, teamleader; 1, ultrasoundmachine; 2, defibrillator.
Video simulation of the COACHED protocol can be seen below for both shockable and non shockable rhythm can be seen below.
We need a multicenter study to evaluate COACHED in the clinical setting as this may be the answer to incorporating good, high quality CPR with diagnostic accuracy and tailored management