Peri-resuscitation echocardiography: Training the novice practitioner

Aims

Echocardiography performed in an ALS-compliant manner provides a tool whereby some of the potentially reversible causes of cardiac arrest can be diagnosed in real time by minimally trained practitioners. One of the major concerns this raises is how to deliver effective training to the required standard. The objective of this study was to determine the effectiveness of number of different educational methods used teach echocardiography to novices. This involved assessment of cognitive, psychomotor skills and affective aspects in five key areas.

Methods

The study population was a convenience sample from participants attending standardised structured one-day training courses in peri-resuscitation echocardiography (n = 204). Subjects were assessed for five learning outcomes including knowledge and image interpretation, practical performance of echocardiography including time taken to obtain a diagnostic view, integration into the ALS algorithm and overall compliance with established resuscitation guidelines.

Results

There was a significant improvement in knowledge and interpretation of echocardiographic images before and after completion of the one-day course (pre 62%, post 78%, p < 0.01). Skills acquisition resulted in 100% of participants being able to obtain a subcostal view of diagnostic quality by the end of the course, and 86% with a mean time to acquisition of <10 s. On completion of the training programme, incorporation of echocardiography into current resuscitation practice did not compromise ALS-compliance.

Conclusion

Novice echocardiographers can obtain knowledge and skills relevant to ALS-compliant peri-resuscitation echocardiography using a range of educational techniques. In addition to the standard one-day training courses available, continued mentored practice and didactic adherence to ALS algorithms is required.     

Integrating lung ultrasound in the hemodynamic evaluation of acute circulatory failure (the fluid administration limited by lung sonography protocol)

In circulatory failure, fluid administration limited by lung sonography protocol uses lung ultrasound artifacts and makes sequential diagnosis of obstructive, cardiogenic, hypovolemic, and septic shock. Lung ultrasound is used along with simple cardiac and vena cava analysis. Whenever echocardiography cannot be performed, fluid administration limited by lung sonography protocol is favored because of its simplicity and could prove contributive. It is based on the presence (B profile) or the absence (A profile) of interstitial pulmonary edema. However, the latter does not represent actual alveolar edema, and transthoracic echocardiography is still used by intensivists as a pivotal hemodynamic measure. Tissue Doppler imaging facilitates the estimation of left ventricular filling pressures, whereas assessing right ventricular function is of prognostic value in states of shock due to massive pulmonary embolism and acute respiratory distress syndrome. In mechanically ventilated patients, poor acoustic windows are evident and performing transesophageal echocardiography may be necessary. Whenever noninvasive hemodynamic measures are inconclusive, in a deteriorating patient, a pulmonary artery catheter may be placed. Ultrasound is not a therapy but a guide for treatment, and physicians should aim to treat underlying pathologies. Despite its limitations, general chest ultrasound (lung and cardiac ultrasound) is a powerful diagnostic and monitoring tool reflecting an era of genuine “visual” medicine.     

Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: A prospective trial

Purpose of the study

Focused ultrasound is increasingly used in the emergency setting, with an ALS-compliant focused echocardiography algorithm proposed as an adjunct in peri-resuscitation care (FEEL). The purpose of this study was to evaluate the feasibility of FEEL in pre-hospital resuscitation, the incidence of potentially treatable conditions detected, and the influence on patient management.

Patients, materials and methods

A prospective observational study in a pre-hospital emergency setting in patients actively undergoing cardio-pulmonary resuscitation or in a shock state. The FEEL protocol was applied by trained emergency doctors, following which a standardised report sheet was completed, including echo findings and any echo-directed change in management. These reports were then analysed independently.

Results

A total of 230 patients were included, with 204 undergoing a FEEL examination during ongoing cardiac arrest (100) and in a shock state (104). Images of diagnostic quality were obtained in 96%. In 35% of those with an ECG diagnosis of asystole, and 58% of those with PEA, coordinated cardiac motion was detected, and associated with increased survival. Echocardiographic findings altered management in 78% of cases.

Conclusions

Application of ALS-compliant echocardiography in pre-hospital care is feasible, and alters diagnosis and management in a significant number of patients. Further research into its effect on patient outcomes is warranted.