L ECOGRAFIA CLINICA INTEGRATA NELL ARRESTO CARDIACO

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1 ECOGRAFIA CLINICA IN EMERGENZA URGENZA APPROCCIO BASE Università Cattolica del Sacro Cuore Facolta di Medicina e Chirurgia ROMA MASTER EMERGENZE PEDIATRICHE UNIVERSITA LA SAPIENZA di ROMA Roma, 20 Aprile 2012 Scuola di Ecografia Clinica in Urgenza, D.E.A. U.C.S.C - ROMA L ECOGRAFIA CLINICA INTEGRATA NELL ARRESTO CARDIACO Americo Testa americotesta@gmail.com Scuola S.I.M.E.U. di Ecografia Clinica in Emergenza-Urgenza Dipartimento di Emergenza ed Accettazione POLICLINICO UNIVERSITARIO A. GEMELLI L.go A. Gemelli, 8 ROMA Scuola Specialistica S.I.U.M.B. di Ecografia in Emergenza-Urgenza

2 ARRESTO CARDIACO Il giorno dopo, 1894/95. Olio su tela, Oslo. Edvard Munch

3 ALGORITMO ALS PER ARRESTO CARDIACO Non riponde? Apri le vie aeree Cerca segni di vita RCP 30:2 Fino al collegamento del monitor/defibrillatore Valuta il ritmo Defibrillabile (FV/TV senza polso) Non defibrillabile (PEA/Asistolia) 1 Shock J bifasico o 360 monofasico Ricomincia RCP 30:2 per 2 min Ricomincia RCP 30:2 per 2 min Considera cause reversibili: 4I e 4T Ecografia nelle pause

4 L ECOGRAFIA NELL ARRESTO CARDIACO ERC (ALS) / AHA guidelines (ACLS) recommend: 1. Minimal interruption of CPR to reduce the no-flow intervals 2. Identification and Treatment of reversible causes Nolan JP et al. Resuscitation 67: S39-S86, 2005 Hazinski MF et al. Circulation 112: , 2005 Christenson J et al. Circulation 120: , 2009 J.P. Nolan et al. Resuscitation 81: , 2010

5 L ECOGRAFIA NELL ARRESTO CARDIACO 1. Minimal interruption of CPR to reduce the no-flow intervals La Emergency US non ostacola la RCP 2. Identification and Treatment of reversible causes La Emergency US identifica le cause reversibili di ACC e guida il trattamento Breitkreutz R et al. Crit Care Med 35:S , 2007 Hayhurst C et al. Emerg Med J 28: , 2011

6 L ECOGRAFIA NELL ARRESTO CARDIACO Quali cause reversibili sono indagabili con US? 4 I Ipovolemia Ipotermia Ipossia Ipo- iperpotassiemia 4T Tamponamento cardiaco PneumoTorace iperteso Tromboembolia polmonare / coronarica Tossici Hughes S and McQuillan PJ. Resuscitation 37: 51, 1998 Hernandez C et al.. Resuscitation 76: , 2008

7 Use of ultrasound imaging during advanced life support ultrasound may be of use in assisting with diagnosis and treatment of potentially reversible causes of cardiac arrest. pp

8 Use of US to detect and treat reversible causes during CPR Sir, We agree with Dr. Sloth and colleagues that ultrasound (including cardiac echocardiography) can have a useful role for identifying and treating reversible causes of cardiac arrest. The use of ultrasound is already recommended in the current guidelines to help treatment of cardiac arrest in certain special circumstances. Soar J, Nolan JP (Letter). Resuscitation doi: /j.resuscitation Echocardiography during CPR: more studies needed Echocardiography during ALS is a promising advance in resuscitation care. However, further studies are needed to help clarify the true value and praticality of ecochardiography in cardiac arrest patients. Its use during CPR appears to be useful in expert hands. Rani Robson (Editorial). Resuscitation 81: , 2010.

9 L ECOGRAFIA NELL ARRESTO CARDIACO Cardiac contractile activity visualized on bedside US may be used as prognostic factor in cardiac arrest Immediate subxiphoid or parasternal cardiac ultrasound examination by EP plus brief repeat US examination during the CPR when pulses were checked. 169 out-of-hospital pts with cardiac arrest: 65/169 had asystole, 38/169 had PEA and 66/169 had VF. 136/169 without wall motion on US: no survived 33/169 with wall motion on US: 20/33 survived. Cardiac standstill on US resulted in a positive predictive value of 100% for death in the ED, with a negative predictive value of 58%. It may be an additional marker for cessation of resuscitative efforts. Blaivas M., Fox JC. Academic Emergency Medicine 8: , 2001 Salen P et al. Acad Emerg Med 8: , 2001 Tayal VS, Kline JA. Resuscitation 59: , 2003

10 L ECOGRAFIA NELL ARRESTO CARDIACO Cardiac contractile activity visualized on bedside US may be used as prognostic factor in cardiac arrest after trauma The pericardial view of the FAST can differentiate between patients with and without organized cardiac activity and may assist in the decision to terminate ongoing resuscitation. 28 pts presenting to a trauma center who had PEA: 12/28 patients had contractile cardiac activity on US; 3/12 survived, with tension pneumothorax, tension hemothorax, and hypovolemia. Bedside US may identify those patients with potential for survival. Schuster KM et al.. J Trauma 67: , 2009

11 L ECOGRAFIA NELL ARRESTO CARDIACO It may not be an additional marker for cessation of resuscitative efforts. Initial lack of cardiac motion in 18/20 patients: it returned in 4/18, of whom 2 survived. Lack of cardiac motion on single10 sec evaluation alone is not a reliable indication to stop CRP (NPV of 97% for predicting ROSC). On the other hand, vigorous cardiac motion is a powerful reason to continue CRP (PPV of 55% for predicting ROSC). ECoCG verification of a pseudo-pea state enabled additional treatment and cessation of chest compressions. It is associated to high rate of ROSC (15/16 = 94%). Varriale P and Maldonado JM. Crit Care Med 25: , 1997 Hayhurst C et al. Emerg Med J 28: , 2011 Prosen G et al. J Intern Med Res 38: , 2010 Breitkreutz R et al. Resuscitation 81: , 2010

12 L ECOGRAFIA NELL ARRESTO CARDIACO Many of the conditions underlying PEA are associated with specific cardiac US findings ECHOCARDOGRAPHIC observation in conjunction with conventional CPR in 20 in-hospital patients. PORTABLE echocardiographic system and alerted CARDIOLOGY team skilled in this technique. ECHOCARDOGRAPHIC examination feasible during CPR and may depict the cause of cardiac arrest: PULMONARY EMBOLISM, CARDIAC TAMPONADE and HYPOVOLEMIA. Varriale P and Maldonado JM. Crit Care Med 25: , 1997

13 L ECOGRAFIA NELL ARRESTO CARDIACO ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND DURING CARDIAC ARREST Focused Assessed Transthoracic Echocardiography Jensen MB et al. Eur J Anaesthesiol 21: , 2004

14 L ECOGRAFIA NELL ARRESTO CARDIACO ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND DURING CARDIAC ARREST Focused Assessed Transthoracic Echocardiography Focused cardiac ultrasound (3 standard views) in cardiac arrest performed by non cardiologist Jensen MB et al. Eur J Anaesthesiol 21: , 2004 Rapid cardiac ultrasound (subcostal view) of inpatients suffering PEA arrest performed by nonexpert sonographers Niendorff DF et al. Resuscitation 67:81-87, 2005

15 Nonexpert sonographers Effectiveness of a standardised one-day training course designed to be the first step to deliver ALS-compliant Ecochardiography skills. All 41 students obtained a subcostal view of diagnostic quality, with acquisition in less than 10 sec during rhythm checks in 86% of cases. Price S et al. Resuscitation 81: , 2010.

16 L ECOGRAFIA NELL ARRESTO CARDIACO Focused ALGORITHMIC APPROACH FOR THE USE OF Assessment with Sonography for Trauma, ULTRASOUND DURING CARDIAC ARREST Cardiac arrest / failure, Respiratory arrest / failure, Acute abdomen and Shock and Hypotension Cibinel GA. Ecografia Clinica in Emergenza-Urgenza. C.G. Edizioni Medico Scientifiche, 2005

17 L ECOGRAFIA NELL ARRESTO CARDIACO FAST-CRASH IMPATTO DIAGNOSTICO E TERAPEUTICO 30 pazienti: 14 in ACC e 16 in Periarresto FATTIBILITA : 100% dei casi senza interferenza con manovre rianimatorie. IMPATTO DIAGNOSTICO: nel 63% dei casi diagnosi grazie ad ecografia tra cui 7 EP, 1 Tamponamento, 2 IMA, 3 Ipovolemia, 1 PNX etc. IMPATTO TERAPEUTICO: 43% dei casi terapia grazie ad ecografia tra cui 6 trombolisi, 1 pericardiocentesi, 2 fluidi, 1 drenaggo toracico, 2 sospensioni massaggio etc. + 30% manovre interventistiche ecoguidate. Cibinel GA et al. VI Congresso Nazionale SIMEU, Nov. 2008, Atti p.141

18 L ECOGRAFIA NELL ARRESTO CARDIACO ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND DURING CARDIAC ARREST Focused Echocardiographic Evaluation in Resuscitation management Breitkreutz R et al. Crit Care Med 35:S , 2007

19 L ECOGRAFIA NELL ARRESTO CARDIACO ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND DURING CARDIAC ARREST Focused Echocardiographic Evaluation in Life support Breitkreutz R et al. Resuscitation 81: , 2010

20 Focused Echocardiographic Evaluation in Resuscitation management L ECOGRAFIA NELL ARRESTO CARDIACO FEER Protocol DIAGNOSTIC AND THERAPEUTIC IMPACT Patients: 77 out-of-hospital CPR cases, 30 with suspected PEA. Methods: developed an algorythm to obtain an EcoCG within 5 sec pause of CPR with Subcostal long axis 4chamber view, alternatively with Parasternal short and/or long axis or Apical 4 chamber view Results: Accuracy: 19/30 cases: pseudo-pea. Detected cardiac wall movement (3 pericardial tamponade, 14 poor ventricolar function, 2 hypovolemia): 13/19 survived. 11/30 cases: true PEA, with true cardiac standstill: all died. Therapy: FEER based changes in 24/30 cases. Breitkreutz R et al. Crit Care Med 35:S , 2007

21 Focused Echocardiographic Evaluation in Life support L ECOGRAFIA NELL ARRESTO CARDIACO FEEL Protocol DIAGNOSTIC AND THERAPEUTIC IMPACT Patients: prospective observational study in a pre-hospital emergency setting. Results: 88/230 patients had a suspected PEA or asystole. Feasibility: images of diagnostic quality were obtained in 96%. Incidence of potentially treatable conditions: 51/88 PEA, 13/51 without wall motion (1 survived) e 38/51 with wall motion (21 survived); 37/88 asystole, 24/37 without wall motion (4 survived) e 13/37 with wall motion (9 survived); Conclusion: Application of FEEL in pre-hospital care is feasible, and alters diagnosis and management in a significant number (78%) of patients. Breitkreutz R et al. Resuscitation 81: , 2010

22 L ECOGRAFIA NELL ARRESTO CARDIACO ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND DURING CARDIAC ARREST Cardiac Arrest Ultra Sound Examen Hernandez C et al.. Resuscitation 76(2): , 2008

23 Cardiac Arrest Ultra Sound Examen L ECOGRAFIA NELL ARRESTO CARDIACO CAUSE Protocol DIAGNOSTIC AND THERAPEUTIC IMPACT It reasserts the use of THORACIC other than classic CARDIAC scans to look for the most common and easily reversible underlying causes, including TENSION PNEUMOTHORAX. Conclude that the C.A.U.S.E. protocol reduces the time required to determine the etiology of a cardiac arrest and the time between arrest and the time therapy Hernandez C et al.. Resuscitation 76(2): , 2008

24 L ECOGRAFIA NELL ARRESTO CARDIACO ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND DURING CARDIAC ARREST Echo in Life Support Hayhurst C et al. Emerg Med J 28: , 2011

25 Echo in Life Support L ECOGRAFIA NELL ARRESTO CARDIACO ELS Is it feasible? What does it add? Patients: ELS was performed on 50 patients during CA with subxiphoid, parasternal, apical or combined view: 7 traumatic e 43 non-traumatic Results: 43/50 patients had a suspected PEA or asystole. Feasibility: adequate views obtained in 97%, within the 10 sec rhythm check in 90%. Incidence of potentially treatable conditions: 20/50 (40%) with wall motion (1 survived) e 38/51 with wall motion (21 survived); 3/50 (6%) with pericardial effusion; Management: 7/50 (14%) treated as result of ELS (thrombolysis, insert of chest drain and pericardiocentesis). Hayhurst C et al. Emerg Med J 28: , 2011

26 L ECOGRAFIA NELL ARRESTO CARDIACO ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND DURING CARDIAC ARREST Pulmonary Epigastric Abdominal Testa A et al. Eur Rev Med Pharmacol Sci 14:77-88, 2010

27 ARRESTO CARDIACO: PEA protocol Approccio con 3 sequenze di scansioni mirate ( focused o goal-directed ) su Cuore, Polmoni, Addome e Arti Abdominal and other scans (Aorta, bowel occlusion, abdominal effusion, DVT) Pulmonary scans (Pneumothorax, pleural effusion, wet or dry lung) Epigastric and other scans (Tamponade, IVC, heart sides and motion) Testa A et al. Eur Rev Med Pharmacol Sci 14:77-88, 2010

28 SCANSIONI FONDAMENTALI Il cuore è come LA SCATOLA NERA di un aereo : Meglio non aspettare ad aprirla per vedere cosa non ha funzionato!!! Epigastric and other scans (Tamponade, IVC, heart sides and motion) Hayhurst C et al. Emerg Med J 28: , 2011

29 J Am Soc Echocardiogr 2010;23: Goals of the focused cardiac US: 1. PEA vs pseudopea; 2. the assessment for pericardial effusion; 3. the RV enlargement/dysfunction; 4. global cardiac LV systolic function; 5. patient volume status.

30 SCANSIONI FONDAMENTALI Epigastric and other scans (Tamponade, IVC, heart sides and motion) 1. Cuore fermo (PEA)

31 SCANSIONI FONDAMENTALI Epigastric and other scans (Tamponade, IVC, heart sides and motion) 4. Tamponamento cardiaco

32 SCANSIONI FONDAMENTALI Epigastric and other scans (Tamponade, IVC, heart sides and motion) 5. Embolia polmonare

33 SCANSIONI FONDAMENTALI Epigastric and other scans (Tamponade, IVC, heart sides and motion) 2. Cuore ipocinetico

34 SCANSIONI FONDAMENTALI Epigastric and other scans (Tamponade, IVC, heart sides and motion) 3. Cuore piccolo ipercinetico

35 SCANSIONI FONDAMENTALI Epigastric and other scans (Tamponade, IVC, heart sides and motion) Riempimento VCI

36 SCANSIONI COMPLEMENTARI Pulmonary scans (Pneumothorax, pleural effusion, wet or dry lung) Sì Gliding = Normale NO Gliding = PNX

37 SCANSIONI COMPLEMENTARI Pulmonary scans (Pneumothorax, pleural effusion, wet or dry lung) Tendina Normale Versamento

38 SCANSIONI COMPLEMENTARI Pulmonary scans (Pneumothorax, pleural effusion, wet or dry lung) Normale Wet lung

39 SCANSIONI SUPPLEMENTARI Abdominal and other scans (Aorta, bowel occlusion, abdominal effusion, DVT) CUS Comprimibile= Normale CUS NON Comprimibile=TVP

40 P Not running E Ectasic IVC A TRUE PEA STOP CPR?

41 Wet lung P Small effusion Not running Hypokinetic E Ectasic IVC Ectasic IVC Smal effusion A TRUE PEA STOP CPR? MYOC. INSUFFIC. THROMBO- LISIS / PTCA

42 Wet lung Normal lung P Not running Small effusion Hypokinetic Normal pleura Empty hyperkinetic E Ectasic IVC Ectasic IVC Small effusion Flat IVC Occlusion A TRUE PEA STOP CPR? MYOC. INSUFFIC. THROMBO- LISIS / PTCA HYPOVOLEMIA VOLUME REPLACEMENT

43 Wet lung Normal lung Normal lung P Small effusion Normal pleura Normal pleura Not running Hypokinetic Empty hyperkinetic Effusion E Ectasic IVC Ectasic IVC Flat IVC Ectasic IVC Smal effusion Occlusion TAA A TRUE PEA MYOC. INSUFFIC. HYPOVOLEMIA TAMPONADE STOP CPR? THROMBO- LISIS / PTCA VOLUME REPLACEMENT PERICARDIO- CENTESIS

44 Wet lung Normal lung Normal lung Normal lung P Small effusion Normal pleura Normal pleura Normal pleura Not running Hypokinetic Empty hyperkinetic Effusion Large RV E Ectasic IVC Ectasic IVC Flat IVC Ectasic IVC Ectasic IVC Smal effusion Occlusion TAA DVT A TRUE PEA MYOC. INSUFFIC. HYPOVOLEMIA TAMPONADE PULM. EMBOL. STOP CPR? THROMBO- LISIS / PTCA VOLUME REPLACEMENT PERICARDIO- CENTESIS THROMBO- LYSIS

45 Wet lung Normal lung Normal lung Normal lung No gliding P Small effusion Normal pleura Normal pleura Normal pleura Normal pleura Not running Hypokinetic Empty hyperkinetic Effusion Large RV Normal E Ectasic IVC Ectasic IVC Flat IVC Ectasic IVC Ectasic IVC Ectasic IVC Smal effusion Occlusion TAA DVT Normal abdomen A TRUE PEA MYOC. INSUFFIC. HYPOVOLEMIA TAMPONADE PULM. EMBOL. PNEUMOTHORAX STOP CPR? THROMBO- LISIS / PTCA VOLUME REPLACEMENT PERICARDIO- CENTESIS THROMBO- LYSIS THORACIC DRAINAGE

46 The Emergency US integrata nella gestione ABCDE del paziente critico (periarresto, arresto, post-rosc): la FAST-ABCDE A=Airway B=Breath C=Circulation D=Disability E=Exposure Assistenza alla tracheostomia. Controllo malposizione tubo oro-tracheale. Ricerca di PNX iperteso. Assistenza a decompressione con ago / drenaggio PNX. Ricerca di emotorace, emopericardio ed emoperitoneo. Assistenza a toracentesi / pericardiocentesi. Assistenza ad accesso venoso periferico o centrale. Performance cardiaca e riempimento VCI. Pressione endocranica da nervo ottico. Fratture sternali, costali. Contusioni. PNX minimo. Ricerca di lesioni parenchimali organi addominali. Lesioni tessuti molli superficiali. Blocco anestetico loco-regionale. Neri L, Storti E, Lichtenstein D. Crit Care Med, 35: S290-S304, 2007.

47 L ECOGRAFIA CLINICA IN EMERGENZA - URGENZA -NB: L esame ecografico in urgenza è uno strumento diagnostico accessorio mirato al quesito clinico, pertanto con valore limitato, e non sostituisce l esame ecografico in elezione. -Dr. Mario Rossi 1234 Referto -Ecografia eseguita in urgenza, mirata alla valutazione clinica integrata in paziente in arresto cardiaco: -Esame tecnicamente adeguato. -Esito: -Attività cardiaca rilevata. Non versamento pericardico tamponante. Sezioni destre non prevalenti, cinesi conservata. VS con funzione contrattile non compromessa. Camere normo-dilatate. non ectasica e responsiva a dinamica respiratoria. VCI Non segni di PNX. Non versamento pleurico. Non segni di s. interstiziale bilateralmente. Non ectasia aorta toracica/addominale. Non versamento endoperitoneale o segni di occlusione/perforazione. Non segni di trombosi venosa a carico degli assi venosi profondi. -Commenti e rilievi collaterali: nessuno. Testa A. Manuale di Ecografia Clinica in Urgenza. Verduci Editore, Roma, 2008

48 ERC chain of survival Aggiunta degli US nel 3 anello Cibinel GA. Corso Eco-ALS, SIMEU. Pinerolo (To), 2007.

49 ERC chain of survival Aggiunta di un 5 anello con US Sloth E et al. Resuscitation 74(1):

50 Among the BLIND, the ONE-EYED man is KING (Erasmo da Rotterdam) Perché restare ciechi

51 quando si può lavorare protetti?

52 BUON LAVORO Vi ringrazio per l attenzione.