Resuscitation 87 (2015) e13–e14
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Ultrasound guided chest compressions during cardiopulmonary resuscitation Sir, Is point of care critical ultrasound (CCUS) during cardiopulmonary resuscitation a hazard or an opportunity? CCUS gives an important advantage for the management of cardiac arrests, as shown by many papers published in the last decade.1–3 The majority of studies evaluated the possibility to improve the success of resuscitation through the identification of reversible causes of cardiac arrest. The FEER study suggested to evaluate the heart after at least 2 cycles of CPR during rhythm check and for no more than 10 s.2 RUSH protocol extended the indication of CCUS during CPR to other organs and districts: abdominal aorta, inferior vena cava, lungs, venous of the legs.3 Our challenge is to do something more: to evaluate efficacy of heart compressions with ultrasound while cardiopulmonary resuscitation is ongoing. In 2010 guidelines of American Heart Association (AHA) on cardiopulmonary resuscitation a simplified technique for chest compressions was recommended: . . .“for adults receiving chest compressions, it is reasonable for rescuers to place their hands on the lower half of the sternum. It is reasonable to teach this location in a simplified way, such as, ‘place the heel of your hand in the center of the chest with the other hand on top’.”4 But is a standard position effective in all subjects? In one study the efficacy of heart compressions was evaluated using transesophageal echocardiography. The narrowing of the
base of left ventricle and of the aorta root was sometime observed using a position identified by standard anatomical landmarks.5 Since chest compressions are the most important therapy during CPR, the aim of our analysis was to evaluate the possibility to check the efficacy of heart compressions using ultrasound and to guide changes of hands position in order to improve heart contractility. We collected 6 cases of non-traumatic cardiac arrests. Ultrasound was performed after at least 2 complete CPR cycles in agreement with FEER protocol. A subcostal or apical view was chosen according with the quality of images using either a convex or a sector probe. In 3 out of 6 cases chest compressions were not satisfactory and changes of hands positions guided by ultrasound improved the quality of CPR (Fig. 1). In the other 3 cases the compression of left ventricle was good and changes of hands positions were not suggested. Another important finding was the possibility to evaluate the heart without stopping CPR, obtaining important clinical information. For example looking at the Fig. 1 we can easily appreciate the absence of right ventricle overload, cardiac tamponade, left ventricle dilatation or hypertrophy. Our preliminary observations indicate that changes of hands position guided by CCUS could improve the quality of chest compressions and important clinical information could be obtained without stopping CPR. We are certainly aware that our analysis does not permit to estimate if changes of hands position could affect the outcome of CPR, but we think this is a new and interesting field of application of CCUS that deserves attention and consideration in the future.
Fig. 1. A static representation of effective heart compressions during CPR: heart decompression (A) and compression (B). An estimation of ejection fraction (arrow) is reported in the figure (EF 65%). Important information on heart chambers, left ventricular wall and pericardium are available without stopping CPR. http://dx.doi.org/10.1016/j.resuscitation.2014.12.001 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
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Letter to the Editor / Resuscitation 87 (2015) e13–e14
Conflict of interest statement Dr. Mirko Zanatta and Dr. Piero Benato have nothing to disclose. Dr. Vito Cianci reports personal fees from Winfocus, outside the submitted work. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at http://dx.doi.org/10.1016/j.resuscitation. 2014.12.001. References 1. Hernandez C, Shuler K, Hannan H, Likourezos A, Marshall J. C.A.U.S.E.: cardiac arrest ultra-sound exam–a better approach to managing patients in primary nonarrhythmogenic cardiac arrest. Resuscitation 2008;76:198–206. 2. Breitkreutz R, Walcher F, Seeger FH. Focused echicardiographic evaluation in resuscitation management: concept of an advances life supporto-comformed algorithm. Crit Care Med 2007;35:S150–61.
3. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically III. Emerg Med Clin North Am 2010;28:29–56. 4. Sayre MR, Koster RW, Botha M, et al. Part 5: adult basic life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010;122:S298–324. 5. Hwang O, Zhao PG, Choi HJ, et al. Compression of the left ventricular outflow tract during cardiopulmonary resuscitation sung. Acad Emerg Med 2009;16:928–33.
Mirko Zanatta ∗ Piero Benato Vito Cianci Emergency Department of Arzignano Hospital, ULSS5 Ovest Vicentino, Via Parco 1, 36071 Arzignano, Vicenza, Italy ∗ Corresponding author. E-mail address: [email protected] (M. Zanatta)
1 December 2014
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Ultrasound guided chest compressions during cardiopulmonary resuscitation Sir, Is point of care critical ultrasound (CCUS) during cardiopulmonary resuscitation a hazard or an opportunity? CCUS gives an important advantage for the management of cardiac arrests, as shown by many papers published in the last decade.1–3 The majority of studies evaluated the possibility to improve the success of resuscitation through the identification of reversible causes of cardiac arrest. The FEER study suggested to evaluate the heart after at least 2 cycles of CPR during rhythm check and for no more than 10 s.2 RUSH protocol extended the indication of CCUS during CPR to other organs and districts: abdominal aorta, inferior vena cava, lungs, venous of the legs.3 Our challenge is to do something more: to evaluate efficacy of heart compressions with ultrasound while cardiopulmonary resuscitation is ongoing. In 2010 guidelines of American Heart Association (AHA) on cardiopulmonary resuscitation a simplified technique for chest compressions was recommended: . . .“for adults receiving chest compressions, it is reasonable for rescuers to place their hands on the lower half of the sternum. It is reasonable to teach this location in a simplified way, such as, ‘place the heel of your hand in the center of the chest with the other hand on top’.”4 But is a standard position effective in all subjects? In one study the efficacy of heart compressions was evaluated using transesophageal echocardiography. The narrowing of the
base of left ventricle and of the aorta root was sometime observed using a position identified by standard anatomical landmarks.5 Since chest compressions are the most important therapy during CPR, the aim of our analysis was to evaluate the possibility to check the efficacy of heart compressions using ultrasound and to guide changes of hands position in order to improve heart contractility. We collected 6 cases of non-traumatic cardiac arrests. Ultrasound was performed after at least 2 complete CPR cycles in agreement with FEER protocol. A subcostal or apical view was chosen according with the quality of images using either a convex or a sector probe. In 3 out of 6 cases chest compressions were not satisfactory and changes of hands positions guided by ultrasound improved the quality of CPR (Fig. 1). In the other 3 cases the compression of left ventricle was good and changes of hands positions were not suggested. Another important finding was the possibility to evaluate the heart without stopping CPR, obtaining important clinical information. For example looking at the Fig. 1 we can easily appreciate the absence of right ventricle overload, cardiac tamponade, left ventricle dilatation or hypertrophy. Our preliminary observations indicate that changes of hands position guided by CCUS could improve the quality of chest compressions and important clinical information could be obtained without stopping CPR. We are certainly aware that our analysis does not permit to estimate if changes of hands position could affect the outcome of CPR, but we think this is a new and interesting field of application of CCUS that deserves attention and consideration in the future.
Fig. 1. A static representation of effective heart compressions during CPR: heart decompression (A) and compression (B). An estimation of ejection fraction (arrow) is reported in the figure (EF 65%). Important information on heart chambers, left ventricular wall and pericardium are available without stopping CPR. http://dx.doi.org/10.1016/j.resuscitation.2014.12.001 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
e14
Letter to the Editor / Resuscitation 87 (2015) e13–e14
Conflict of interest statement Dr. Mirko Zanatta and Dr. Piero Benato have nothing to disclose. Dr. Vito Cianci reports personal fees from Winfocus, outside the submitted work. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at http://dx.doi.org/10.1016/j.resuscitation. 2014.12.001. References 1. Hernandez C, Shuler K, Hannan H, Likourezos A, Marshall J. C.A.U.S.E.: cardiac arrest ultra-sound exam–a better approach to managing patients in primary nonarrhythmogenic cardiac arrest. Resuscitation 2008;76:198–206. 2. Breitkreutz R, Walcher F, Seeger FH. Focused echicardiographic evaluation in resuscitation management: concept of an advances life supporto-comformed algorithm. Crit Care Med 2007;35:S150–61.
3. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically III. Emerg Med Clin North Am 2010;28:29–56. 4. Sayre MR, Koster RW, Botha M, et al. Part 5: adult basic life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010;122:S298–324. 5. Hwang O, Zhao PG, Choi HJ, et al. Compression of the left ventricular outflow tract during cardiopulmonary resuscitation sung. Acad Emerg Med 2009;16:928–33.
Mirko Zanatta ∗ Piero Benato Vito Cianci Emergency Department of Arzignano Hospital, ULSS5 Ovest Vicentino, Via Parco 1, 36071 Arzignano, Vicenza, Italy ∗ Corresponding author. E-mail address: [email protected] (M. Zanatta)
1 December 2014
