SonoOpinion: Does absence of cardiac activity predict resuscitation failure? #FOAMed

In a post in Annals of Emergency Medicine, Dr. Brian Cohn from Washington School of Medicine gave his opinion and reviewed a few articles on cardiac activity and its relation to return of spontaneous circulation.

Does the Absence of Cardiac Activity on Ultrasonography Predict Failed Resuscitation in Cardiac Arrest?

Take-Home Message:

The absence of cardiac activity on ultrasonography does not universally lead to failure of resuscitation in cardiac arrest.

So, it doesnt surprise me, but I would ask this question though: How many with no cardiac activity on bedside ultrasound (no wall motion and no valvular activity) have survived to hospital discharge?  none. I have posted on this before, so you know my opinion already, which is: continue for organ donation purposes, otherwise no resources are needed to be used due to no survival potential. I know, it’s tough to think (and do) that.

Methods

Data Sources

MEDLINE, EMBASE, CINAHL, and the Cochrane Library were searched on February 23, 2011, and again on January 29, 2012. The references of relevant articles were searched for any additional studies. Expert contact, a screening of gray literature, and a review of conference proceedings were also conducted.

Study Selection

Studies in which a clinician performed bedside transthoracic cardiac ultrasonography in adult patients receiving cardiopulmonary resuscitation, and in which the outcome was reported, were selected for further review. Two reviewers assessed the selected articles for inclusion, with disagreement settled by consensus.

Data Extraction and Synthesis

Studies were critically appraised with 8 of the original 14 criteria of the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS)1 that were believed to be relevant to the selected studies.

Results

Of 2,539 articles screened, 12 were selected for full review. Four of these did not meet inclusion criteria. The 8 articles in the final analysis included 568 patients, of whom 378 had no cardiac activity present on ultrasonography. The random-effects pooled results for sensitivity and specificity of bedside cardiac ultrasonography as a predictor of return of spontaneous circulation were 92% (95% confidence interval [CI] 85% to 96%) and 80% (95% CI 76% to 84%), respectively. The positive likelihood ratio was 4.3 (95% CI 2.6 to 6.9) and the negative likelihood ratio was 0.2 (95% CI 0.1 to 0.3). Of 378 patients without cardiac activity present, 9 (2.4%; 95% CI 1.3% to 4.5%) achieved return of spontaneous circulation (ROSC) (Table).

Pooled outcomes from the 8 included trials.

	ROSC	No ROSC
Cardiac activity observed on ultrasonography	98	92
No cardiac activity observed on ultrasonography	9	369

Commentary

Given the low likelihood of survival in cardiac arrest patients presenting to the emergency department without a pulse, as low as 0.9% in one large database,2 efforts have been made to identify predictors of futility in ongoing resuscitation, including cardiac standstill on ultrasonography. In one survey of graduates from the LA County/USC Medical Center residency program, 68% reported using ultrasonography during cardiac arrest, and 91% of these reported using the results in deciding when to terminate resuscitation efforts.3

This systematic review yielded a survival to admission rate of 2.4% in patients with cardiac standstill. Although these results seem to indicate that resuscitation in such patients is not futile, longer-term outcomes should be considered. In previous resuscitation research, survival to hospital admission has proven to be a poor surrogate for survival to hospital discharge or neurologic outcomes.4 The Research Working Group of the American Heart Association Emergency Cardiovascular Care Committee has recommended evaluating survival at 90 days coupled with neurologic assessment by modified Rankin Scale or Cerebral Performance Categories score.5 The current evidence does not support using ultrasonography alone to predict outcomes in cardiac arrest patients.

References

1. Whiting PF , Weswood ME , Rutjes AW , et al.  Evaluation of QUADAS, a tool for the quality assessment of diagnostic accuracy studies . BMC Med Res Methodol . 2006;6:e9
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1. McNally B , Robb R , Mehta M , et al. Centers for Disease Control and Prevention   Out-of-hospital cardiac arrest surveillance—Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005-December 31, 2010 . MMWR Surveill Summ . 2011;60:1–19
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1. Shoenberger JM , Massopust K , Henderson SO . The use of bedside ultrasound in cardiac arrest . Cal J Emerg Med . 2007;8:47–50
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1. Gueugniaud PY , Mols P , Goldstein P , et al.  A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital (European Epinephrine Study Group) . N Engl J Med . 1998;339:1595–1601
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   • MEDLINE
   • CrossRef

1. Becker LB , Aufderheide TP , Geocadin RG , et al. American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation   Primary outcomes for resuscitation science studies: a consensus statement from the American Heart Association . Circulation . 2011;124:2158–2177
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   • CrossRef

SonoStudy: Survival potential – US evaluating cardiac motion during traumatic cardiac arrest… AND an assessment of the literature

An interesting study in the July issue of the Journal of Trauma and Acute Care Surgery (see full article here) discussing the utility of bedside ultrasound during traumatic cardiac arrest. For anyone who works at a trauma center, or who just so happens to receive a patient dropped off by a friend on the driveway of the ED (we have all had that happen), or who received a patient by ambulance who is in cardiac arrest at a non-trauma center to soon find evidence of trauma upon exposure of the patient….. this study is quite relevant when it comes to survival potential and how bedside ultrasound may help. What they say….

Pre-hospital (paramedic) US: Re-appreciating the Golden Hour…

HAPPY EMS WEEK!!!! We so appreciate all that you do! Along those lines…… and along with many others all over the world in years past, at Stanford there has been a 2-part study being done supervised by Drs. Sarah Williams and Jessica Pierog (PEEPS study) and at UCI supervised by Dr. Chris Fox and others (PAUSE protocol) on the prehospital use/acquisition/ interpretation of emergencies visible by bedside US.  It is evident (an understatement, actually) that US needs to go into our ambulances.