l’ecografia clinica integrata nell’arresto … · l’ecografia clinica integrata...

Americo Testa [email protected]

Università Cattolica del Sacro Cuore

Facolta’ di Medicina e Chirurgia

ROMA

Scuola di Ecografia Clinica

in Urgenza, D.E.A.

U.C.S.C - ROMA

Dipartimento di Emergenza ed Accettazione POLICLINICO UNIVERSITARIO “A. GEMELLI “

L.go A. Gemelli, 8 – ROMA www.ecourgenza.com

Scuola S.I.M.E.U.

di Ecografia Clinica in

Emergenza-Urgenza

Scuola Specialistica

S.I.U.M.B.

di Ecografia in

Emergenza-Urgenza

ECOGRAFIA CLINICA IN EMERGENZA – URGENZA

APPROCCIO BASE

MASTER EMERGENZE PEDIATRICHE UNIVERSITA’ “LA SAPIENZA” di ROMA

Roma, 20 Aprile 2012

L’ECOGRAFIA CLINICA INTEGRATA

NELL’ARRESTO CARDIACO

ARRESTO CARDIACO

“Il giorno dopo”, 1894/95. Olio su tela, Oslo. Edvard Munch

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 150-200 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

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: 206-211, 2005

Christenson J et al. Circulation 120:1241-1247, 2009

J.P. Nolan et al. Resuscitation 81:1219–1276, 2010

2005-2010 ERC (ALS) / AHA guidelines (ACLS)

recommend:

L’ECOGRAFIA NELL’ARRESTO CARDIACO

La “Emergency US” non ostacola la RCP

Breitkreutz R et al. Crit Care Med 35:S150-161, 2007

Hayhurst C et al. Emerg Med J 28:119.121, 2011

1. “Minimal interruption of CPR to reduce the no-flow intervals”


2. “Identification and Treatment of reversible causes”

La “Emergency US” identifica le cause

reversibili di ACC e guida il trattamento

4 I Ipovolemia

Ipotermia

Ipossia

Ipo- iperpotassiemia

4T Tamponamento cardiaco

PneumoTorace iperteso

Tromboembolia polmonare / coronarica

Tossici

Quali cause reversibili sono indagabili con US?

Hughes S and McQuillan PJ. Resuscitation 37: 51, 1998

Hernandez C et al.. Resuscitation 76:198-206, 2008


“…ultrasound may be of use in assisting with diagnosis

and treatment of potentially reversible causes of cardiac

arrest.”

pp. 1234-1235

“ Use of ultrasound imaging during advanced life support”

Rani Robson (Editorial). Resuscitation 81:1453-1454, 2010.

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: 10.1016/j.resuscitation.2007.03.005

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.

Blaivas M., Fox JC. Academic Emergency Medicine 8:616–621, 2001


“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.

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.

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.

Salen P et al. Acad Emerg Med 8:610-615, 2001

Tayal VS, Kline JA. Resuscitation 59:315-318, 2003

Schuster KM et al.. J Trauma 67:1154-1157, 2009


“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.

Bedside US may identify those patients with potential for survival.

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.

Varriale P and Maldonado JM. Crit Care Med 25:1717-1720, 1997


Prosen G et al. J Intern Med Res 38:1458-1467, 2010

Breitkreutz R et al. Resuscitation 81:1527-1533, 2010


“It may not be an additional marker for cessation of resuscitative efforts.

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%).

Initial lack of cardiac motion in 18/20 patients: it returned in 4/18, of

whom 2 survived.

ECHOCARDOGRAPHIC observation in conjunction with

conventional CPR in 20 in-hospital patients.

Varriale P and Maldonado JM. Crit Care Med 25:1717-1720, 1997


“Many of the conditions underlying PEA are associated with specific cardiac US findings”

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.

Focused

Assessed

Transthoracic

Echocardiography

Jensen MB et al. Eur J Anaesthesiol 21:700-707, 2004

ALGORITHMIC APPROACH FOR THE USE OF ULTRASOUND

DURING CARDIAC ARREST


Niendorff DF et al. Resuscitation 67:81-87, 2005



“Rapid cardiac ultrasound (subcostal view) of

inpatients suffering PEA arrest performed by

nonexpert sonographers”

“Focused cardiac ultrasound (3 standard views) in

cardiac arrest performed by non cardiologist”

Jensen MB et al. Eur J Anaesthesiol 21:700-707, 2004


Focused

Assessed

Transthoracic

Echocardiography

Price S et al. Resuscitation 81:1534-1539, 2010.

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.

“Nonexpert sonographers”

Focused

Assessment with

Sonography for

Trauma,

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

ALGORITHMIC APPROACH FOR THE USE OF

ULTRASOUND DURING CARDIAC ARREST


FAST-CRASH

IMPATTO DIAGNOSTICO E TERAPEUTICO

Cibinel GA et al. VI Congresso Nazionale SIMEU, 12- 16 Nov. 2008, Atti p.141

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 eco-guidate.


Focused

Echocardiographic

Evaluation in

Resuscitation management







Focused

Echocardiographic

Evaluation in

Life support



Focused

Echocardiographic

Evaluation in

Resuscitation management


Patients: 77 out-of-hospital CPR cases, 30 with suspected PEA.

FEER Protocol

DIAGNOSTIC AND THERAPEUTIC IMPACT

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.


Focused

Echocardiographic

Evaluation in

Life support

Conclusion: Application of FEEL in pre-hospital care is feasible, and alters diagnosis and management in a significant number (78%) of patients.

FEEL Protocol


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);


Patients: prospective observational study in a pre-hospital emergency setting.


Cardiac

Arrest

Ultra

Sound

Examen

Hernandez C et al.. Resuscitation 76(2):198-206, 2008




Cardiac

Arrest

Ultra

Sound

Examen

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


CAUSE Protocol


Hernandez C et al.. Resuscitation 76(2):198-206, 2008

Echo in

Life

Support






ELS

Is it feasible? What does it add?

Echo in

Life

Support


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).

Pulmonary

Epigastric

Abdominal




Testa A et al. Eur Rev Med Pharmacol Sci 14:77-88, 2010

Approccio con 3 sequenze di scansioni mirate (“focused o goal-directed”)

su Cuore, Polmoni, Addome e Arti

ARRESTO CARDIACO: “PEA protocol”

Pulmonary

scans (Pneumothorax, pleural

effusion, wet or dry lung)

Epigastric

and other scans (Tamponade, IVC,

heart sides and motion)

Abdominal

and other scans (Aorta, bowel occlusion,

abdominal effusion, DVT)

Testa A et al. Eur Rev Med Pharmacol Sci 14:77-88, 2010

Epigastric



SCANSIONI FONDAMENTALI “Il cuore è come LA SCATOLA NERA di un aereo”:

Meglio non aspettare ad aprirla per vedere cosa

non ha funzionato!!!


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.

J Am Soc Echocardiogr 2010;23:1225-30.

Epigastric



SCANSIONI

FONDAMENTALI

1. Cuore fermo

(PEA)

Epigastric



SCANSIONI

FONDAMENTALI

4. Tamponamento cardiaco

Epigastric



SCANSIONI

FONDAMENTALI

5. Embolia polmonare

Epigastric



SCANSIONI

FONDAMENTALI

2. Cuore ipocinetico

Epigastric



SCANSIONI

FONDAMENTALI

3. Cuore piccolo ipercinetico

Epigastric



SCANSIONI

FONDAMENTALI

Riempimento VCI

Sì Gliding = Normale

Pulmonary



NO Gliding = PNX

SCANSIONI

COMPLEMENTARI

Tendina Normale

Pulmonary



Versamento

SCANSIONI

COMPLEMENTARI

Normale Wet lung

Pulmonary



SCANSIONI

COMPLEMENTARI

SCANSIONI

SUPPLEMENTARI

Comprimibile= Normale NON Comprimibile=TVP

Abdominal

and other scans (Aorta, bowel occlusion,

abdominal effusion, DVT)

CUS CUS

STOP

CPR ?

Not running

Ectasic IVC

P

E

A TRUE PEA

STOP

CPR ?

Not running

Ectasic IVC

Wet lung

Hypokinetic

Ectasic IVC

THROMBO-

LISIS / PTCA

P

E

A MYOC. INSUFFIC.

Small effusion

Smal effusion

TRUE PEA

STOP

CPR ?

Not running

Ectasic IVC

Wet lung

Hypokinetic

Ectasic IVC Flat IVC

Normal lung

THROMBO-

LISIS / PTCA

HYPOVOLEMIA

P

E

A

Empty hyperkinetic

VOLUME

REPLACEMENT

MYOC. INSUFFIC.

Small effusion

Occlusion

Small effusion

Normal pleura

TRUE PEA

STOP

CPR ?

Not running

Ectasic IVC

Wet lung

Hypokinetic

Ectasic IVC

Normal lung Normal lung

Ectasic IVC

THROMBO-

LISIS / PTCA

HYPOVOLEMIA TAMPONADE

P

E

A

Effusion

PERICARDIO-

CENTESIS

VOLUME

REPLACEMENT

MYOC. INSUFFIC.

Small effusion

Occlusion TAA

Smal effusion

Normal pleura Normal pleura

TRUE PEA

Empty hyperkinetic

Flat IVC

STOP

CPR ?

Not running

Ectasic IVC

Wet lung

Hypokinetic

Ectasic IVC


Ectasic IVC Ectasic IVC

Large RV

Normal lung

THROMBO-

LISIS / PTCA


P

E

A

Effusion

PULM. EMBOL.

THROMBO-

LYSIS PERICARDIO-

CENTESIS

VOLUME

REPLACEMENT

MYOC. INSUFFIC.

Small effusion

Occlusion TAA DVT

Smal effusion

Normal pleura Normal pleura Normal pleura

TRUE PEA

Empty hyperkinetic

Flat IVC

STOP

CPR ?

Not running

Ectasic IVC

Wet lung

Hypokinetic

Ectasic IVC


Ectasic IVC Ectasic IVC

Large RV

Normal lung No gliding

Normal

Ectasic IVC

THROMBO-

LISIS / PTCA


THORACIC

DRAINAGE

PNEUMOTHORAX

P

E

A

Effusion

PULM. EMBOL.

THROMBO-

LYSIS PERICARDIO-

CENTESIS

VOLUME

REPLACEMENT

MYOC. INSUFFIC.

Small effusion Normal pleura

Occlusion TAA DVT Normal abdomen

Smal effusion

Normal pleura Normal pleura Normal pleura

TRUE PEA

Empty hyperkinetic

Flat IVC

The “Emergency US” integrata nella gestione ABCDE del paziente

critico (periarresto, arresto, post-ROSC): la FAST-ABCDE

A=Airway Assistenza alla tracheostomia.

Controllo malposizione tubo oro-tracheale.

B=Breath Ricerca di PNX iperteso.

Assistenza a decompressione con ago / drenaggio PNX.

C=Circulation Ricerca di emotorace, emopericardio ed emoperitoneo.

Assistenza a toracentesi / pericardiocentesi.

Assistenza ad accesso venoso periferico o centrale.

Performance cardiaca e riempimento VCI.

D=Disability Pressione endocranica da nervo ottico.

E=Exposure 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.

-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

L’ECOGRAFIA CLINICA IN EMERGENZA - URGENZA

Testa A. Manuale di Ecografia Clinica in Urgenza. Verduci Editore, Roma, 2008

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.

Cibinel GA. Corso Eco-ALS, SIMEU. Pinerolo (To), 2007.

“ERC chain of survival”…

Aggiunta degli US nel 3° anello

Sloth E et al. Resuscitation 74(1):198-199.2007

“ERC chain of survival”…

Aggiunta di un 5° anello con US

Perché restare ciechi…

“Among the BLIND, the ONE-EYED man is KING” (Erasmo da Rotterdam)

… quando si può lavorare protetti?

Vi ringrazio per l’attenzione.

BUON LAVORO

l’ecografia clinica integrata nell’arresto … · l’ecografia clinica integrata...

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