Ep 170 Cardiac Arrest – PoCUS Integration, Communication Strategies, E-CPR, Calling the Code

In part 1 of our 2 part series on cardiac arrest with Sara Gray, Bourke Tillman, Scott Weingart and Rob Simard we delved into the core components of cardiac arrest care: chest compressions, defibrillation, medications and airway. In this part 2 we discuss some of the finer art of cardiac arrest care and answer questions such as: how should we best communicate to EMS, the ED team and the family of the patient to keep the team focused, garner the most important info and keep the flow of the code going? How should we integrate PoCUS into cardiac arrest care so we do not interrupt the core components, yet we gain valuable data? What are the indications for consideration of ECPR/ECMO in cardiac arrest? What factors need to be taken into consideration to decide on when to terminate resuscitation of the cardiac arrest patient - when to call the code? and many more...

Podcast production, sound design & editing by Anton Helman

Written Summary and blog post by Saswata Deb, edited by Anton Helman June, 2022

Cite this podcast as: Helman, A. Episode 170 Cardiac Arrest - PoCUS Integration, Communication Strategies, E-CPR, Calling the Code. Emergency Medicine Cases. June, 2022. https://emergencymedicinecases.com/cardiac-arrest-pocus-integration-communication-strategies-e-cpr. Accessed [date]

Intergration of PoCUS into cardiac arrest resuscitation

PoCUS pulse checks

Pulse checks are only needed if an organized rhythm is seen on the monitor.

Manual pulse checks have been shown to be insensitive, not specific and have poor inter-rater reliability. One study showed that rescuer pulse palpation was only 78% accurate. Even if a pulse is felt, this does not guarantee adequate perfusion to vital organs.

Have a dedicated experienced provider look on PoCUS for a carotid pulse during chest compressions so that as soon as a pause in chest compressions to assess for cardiac rhythm occurs at the end of 2 minutes of compressions, the pulse can be rapidly assessed along with the cardiac rhythm in less than 5 seconds (as opposed to less than 10 seconds as recommended in the guidelines).

Several observational studies have shown that use of PoCUS during cardiac arrest prolongs pauses in chest compressions, however a recent study showed that with minimal training PoCUS pulse checks were more accurate than manual pulse checks and completed accurately within 5 seconds.

The REASON Trial was a multicenter prospective observational study of 793 patients with out-of-hospital cardiac arrest comparing arrests run with PoCUS performed at the beginning and end of the arrest and without. While survival to hospital admission and hospital discharged looked promising for the PoCUS group, it is unclear whether PoCUS improved neurologically intact long term survival.

Update 2022: A prospective study found that pulse checks using carotid artery compression with an ultrasound probe was faster compared to manual palpation (1.62 seconds vs 3.5 seconds respectively), and the time to determine ROSC was significantly shortened to 0.44 times the manual palpation time (P<0.001). Abstract

How to prevent long pauses in chest compressions using POCUS

* Generate the image during chest compressions

* Team member counts down from 10 before pause in chest compressions while PoCUS team member prepares to interpret and record image

* Record a video for 4-5 seconds during the chest compression...