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Emergency ultrasound is suggested to be an important tool in minimal interruptions to reduce the no-flow intervals. However,
critical care medicine. Time-dependent scenarios occur during they also recommended identification and treatment of reversible
preresuscitation care, during cardiopulmonary resuscitation, and causes or complicating factors. Therefore, clinicians must be
in postresuscitation care. Suspected myocardial insufficiency due trained to use echocardiography within the brief interruptions of
to acute global, left, or right heart failure, pericardial tamponade, advanced life support, taking into account practical and theoret-
and hypovolemia should be identified. These diagnoses cannot be ical considerations. Focused echocardiographic evaluation in re-
made with standard physical examination or the electrocardio- suscitation management was evaluated by emergency physicians
gram. Furthermore, the differential diagnosis of pulseless electri- with respect to incorporation into the cardiopulmonary resusci-
cal activity is best elucidated with echocardiography. Therefore, tation process, performance, and physicians’ ability to recognize
we developed an algorithm of focused echocardiographic evalu- characteristic pathology. The aim of the focused echocardio-
ation in resuscitation management, a structured process of an graphic evaluation in resuscitation management examination is to
advanced life support– conformed transthoracic echocardiogra- improve the outcomes of cardiopulmonary resuscitation. (Crit
phy protocol to be applied to point-of-care diagnosis. The new Care Med 2007; 35[Suppl.]:S150–S161)
2005 American Heart Association/European Resuscitation Coun- KEY WORDS: emergency echocardiography; focused echocardio-
cil/International Liaison Committee on Resuscitation guidelines graphic evaluation in resuscitation; resuscitation; cardiopulmo-
recommended high-quality cardiopulmonary resuscitation with nary resuscitation; algorithm; critical care ultrasound
I n emergency and critical care support (ALS). Time is an essential com- after thoracic and cardiac surgery and in
medicine, the old and new Amer- ponent for successful cardiopulmonary nontrauma in-hospital emergencies (7, 8).
ican and European resuscitation resuscitation (CPR) (5). Any diagnostic Another important issue is the differential
guidelines of the American Heart procedures and interventions must yield diagnosis of pulseless electrical activity
Association, European Resuscitation quick results to identify the underlying (PEA), which essentially requires echocar-
Council, and the International Liaison cause. “Point-of-care focused ultrasound” diography to either rule in or rule out crit-
Committee on Resuscitation (1– 4) rec- or “goal-directed ultrasound” in the eval- ical findings (9–13). However, the new Eu-
ommended identifying and treating cor- uation of nontraumatic, symptomatic, ropean Resuscitation Council 2005
rectable causes of cardiopulmonary ar- undifferentiated hypotension in adult pa- guidelines recommend echocardiography
rest. Patients must be treated using tients results in a narrower differential in PEA or asystole after cardiotomy only,
algorithm-based management such as ba- diagnosis and a more accurate physician but they do not stipulate how it is to be
sic life support (BLS) and advanced life impression of final diagnosis (6). These performed (7). Furthermore, the new Amer-
authors have shown that, in emergency ican Heart Association/European Resuscita-
rooms, the immediate application of tion Council/International Liaison Commit-
sonography could result in improved pa- tee on Resuscitation 2005 resuscitation
From the Department of Anesthesiology, Intensive
Care, and Pain therapy (RB), the Department of Trauma tient outcome (6). Myocardial function guidelines set narrow time intervals for
Surgery (FW), and the Department of Cardiology (FHS), during CPR is still underdiagnosed and echocardiographic examination, due to po-
Hospital of the Johann-Wolfgang-Goethe University, remains a “black box” in most cases. Po- tential detrimental effects and the require-
Frankfurt am Main, Germany. tentially treatable causes of sudden car- ment of rebuilding coronary perfusion
The authors have not disclosed any potential con-
flicts of interest.
diac arrest, such as pericardial tampon- pressure (14). Pauses in chest compression
Presented, in part, at the First and Second World ade, cardiogenic shock, myocardial were recommended to be “brief interrup-
Congresses on Ultrasound in Emergency and Critical insufficiency (resulting from coronary or tions” for adult ALS (4, 7) and of a maxi-
Care Medicine, Milan, Italy, June 2005, and New York, pulmonary artery thrombosis), or hypo- mum of 10 secs for pediatric ALS (15) to
NY, June 2006 (http://www.winfocus.org).
For information regarding this article, E-mail:
volemia, should be detected or excluded reduce the duration of no-flow intervals
raoul.breitkreutz@gmail.com. as soon as possible, even on scene. (NFIs), thereby limiting potential transtho-
Copyright © 2007 by the Society of Critical Care Important treatable causes of asystole racic ultrasound examinations. Unfortu-
Medicine and Lippincott Williams & Wilkins are large, hemodynamically relevant peri- nately, there is a lack of recommendations
DOI: 10.1097/01.CCM.0000260626.23848.FC cardial effusions, which are regularly found regarding time frames of any interruptions,
Figure 1. Focused echocardiographic evaluation in resuscitation management (FEER) in emergency and critical care medicine. Algorithm with indications
and workflow (a); integration into advanced life support (ALS) (b); road map of repeated use of FEER during resuscitation stages (c). FEER has to be
completed within 5 secs during pauses of cardiopulmonary resuscitation (CPR). PEA, pulseless electrical activity; PM-ECG, pacemaker– electrocardiogram;
RV, right ventricle; LV, left ventricle; VF/pulseless VT, ventricular fibrillation/pulseless ventricular tachycardia; end-exp. CO2, end-expiration CO2; BLS,
basic life support; ED/ICU, emergency department/intensive care unit.
and no specific time intervals are given for algorithm (1–3, 15). Therefore, we devel- selves have to adapt to the patient’s su-
a maximum duration of rhythm analysis or oped a simple algorithm of focused echo- pine position. The probe should be loaded
other standard care interventions. cardiographic evaluation in resuscitation with transmission gel, be functionally
A major challenge is recognizing re- (FEER) to be performed in a time-sensitive tested, and be kept ready to start. These
turn of spontaneous circulation when no manner (21) (Fig. 1, Table 1). steps are important to minimize CPR in-
central pulse is palpable. New evidence is terruption time. The preparation phase
available that a “subclinical” return of Focused Echocardiographic ends with signaling the team to be ready
spontaneous circulation (mechanical car- Evaluation in Resuscitation: to perform an echocardiogram.
diac output) can be detected with the use Practical Considerations Obtaining an Echocardiogram Within
of an echocardiogram (9, 12). We know Approximately a 5-sec Pause of CPR. In
that even health professionals are inse- The FEER examination is a ten-step the second phase, one rescue team mem-
cure and take too long in detecting a procedure (Table 1). Its structure is de- ber should be selected to count down 10
carotid pulse or respiratory effort (16 – signed to be executed simultaneously secs and to palpate the carotid pulse si-
19). Standard measurements, including during CPR cycles to prevent any in- multaneously within the interruption.
peripheral oxygen saturation with pulse crease in the duration of the NFI and to Thereafter, the examiner should give a
curve or noninvasive blood pressure mea- reduce unwanted interruptions. It in- concise command, “Interrupt at the end
surement, are unreliable in severe hypo- cludes a practical approach that can be of this cycle for echocardiography,” to the
tension or shock, and it can take !10 separated into four distinct phases. The team. Parallel to the chest compressions,
secs to obtain such a critical result (2, practical approach of the FEER examina- the examiner should palpate the patient’s
15). In fact, such measures have not been tion follows in more detail. xiphoid and press the probe during the
studied as independent markers during Preparation Parallel to CPR. In the final chest compressions, about 2 cm,
CPR. Only limited evidence is available first phase, high-quality CPR should be slightly to the right side lower in the
on strategies using end-tidal CO2 mea- initiated (1–3, 15) by at least two rescuers subxiphoid region and in a flat angle (10
surement (20). according to the resuscitation guidelines. degrees) relative to the abdomen to ob-
Any CPR, regardless of the environ- The preparation of the FEER examination tain a glimpse of the ventricles. On dis-
ment, is a relatively chaotic situation, po- starts with informing the rescue team continuation of chest compression, the
tentially involving several health profes- that a qualified person, the emergency probe must be positioned and calibrated
sionals. Consequently, a structured process physician (EP) or intensivist (INT), is pre- as fast as possible to gain a complete
for a focused echocardiographic examina- paring to obtain an echocardiogram. four-chamber view from the subcostal
tion and for recognition of relevant pathol- Preparation includes removing clothes window. The ventricles, atria, and valves
ogy during resuscitation management is from the patient as needed, preparing the should be visualized in one view (12).
mandatory. This type of echocardiography ultrasound device and ultrasound gel, Ideally, a description of the real-time ob-
also has to conform to the universal ALS and most importantly, the EP/INT them- servation should be reported directly to
tricular ejection fraction by echocardiogra- the heart within a large effusion, the postcardiotomy syndrome. Further consid-
phy is closely correlated with formal “swinging heart.” Although this diagnosis erations include cases of penetrating injury
quantitative methods (26). To understand seems to be relatively simple (Fig. 5) and or acute severe or atypical chest pain and
graded ventricular function, one has to un- is only of interest in emergency medicine other nontraumatic medical situations
dertake structured training (37, 41, 43) when the effusion is huge, EP/INT should with respect to the practical consequences
with expert supervision. In addition, one be able to differentiate small or massive of an immediate pericardiocentesis (Table
should obtain video loops from numerous effusions and signs of functional rele- 3). However, differential diagnoses include
patients and discuss it with a coaching car- vance (Fig. 5d) and tamponade. They small effusions that can be physiologic (Fig.
diologist until discriminating normal, low- should train to confirm their findings in 5a). With the M-mode echocardiogram,
grade, or high-grade limited ventricular all approaches (subcostal, parasternal, only systolic separations are normally visi-
function (Fig. 1a). apical) and combine it within the context ble (Fig. 2). Thus, any diastolic separation
Pericardial Effusion and Tamponade. of the clinical findings. may be a pathologic finding. The pericar-
Two-dimensional echocardiographic The detection and evaluation of a peri- dial fat pad is mainly located adjacent to the
signs of tamponade in pericardial effusion cardial effusion must take into account the anterior wall or ventral to the right ventri-
contain right atrial or right ventricular clinical setting. One has to consider cle, and it can be misinterpreted as an ef-
diastolic collapse and noncollapsible infe- whether there is a history of pacemaker fusion (Figs. 2b and 5b) (44). In the pres-
rior vena cava and hepatic veins. More insertion or cardiac surgery, especially ence of a pleural effusion (Fig. 2d), the
impressive is the pendulum movement of those involving cardiotomy and cases of parasternal long axis allows distinction be-