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Abstract

Echocardiography is being increasingly deployed as a diagnostic and monitoring tool in the critically ill. This rise in popularity has led to its recommendation as a core competence in intensive care, with several training routes available. In the peri-arrest and cardiac arrest population, point of care focused echocardiography has the potential to transform patient care and improve outcomes. Be it via diagnosis of shock aetiology and reversibility or assessing response to treatment and prognostication. This narrative review discusses current and future applications of echocardiography in this patient group and provides a structure with which one can approach such patients.

Keywords

Echocardiography focused echocardiography critical care intensive care anaesthesia

Introduction

In 1953, Elger and Hellmuth recorded the first ultrasound images of a moving heart. In the near 70 years since, echocardiography has come a long way, and is now the most rapidly growing image modality.¹

Focused scanning, echocardiography training and the use of portable machines have become common features on critical care units worldwide as we start to realise its full potential.²

When used correctly, the ability to incorporate echocardiographic findings into the management of critically ill patients can prove invaluable. Be it in differentiation of shock aetiologies, or contributing to management and prognostication in cardiac arrest.³

Whilst intensivists acknowledged the positive impacts of bedside focused echocardiography in critical care,^4,5 we must also remain cognisant of its limitations.⁵

In this review we will cover the basic principles of focused echocardiography, its potential as a diagnostic tool, and provide a structured approach to peri-arrest and cardiac arrest scenarios.

The evolution of critical care echocardiography

Over the past decade, the use of critical care echocardiography has seen a sharp rise in popularity, with its use in critically ill patients widely discussed.⁶

Focused transthoracic echocardiography (FTTE) is the most common modality used by intensivists and has been recommended as a core competence in intensive care medicine.

In the United Kingdom, there are several available training pathways for FTTE in the critically ill:

Focused ultrasound in intensive care (FUSIC; formerly ‘focused intensive care echocardiography’);⁷

Focused echocardiographic evaluation in life support (FEEL);⁸

British Society of Echocardiography (BSE) Level 1 accreditation.⁹

Such focused echocardiographic curricula are largely based on inferences made from four standard cardiac views (Table 1).

Table 1.

A description of the four main cardiac views used in basic focused echocardiography.

Cardiac window	Location of view	Example
Para-sternal long axis (PLAX)	Commonly, 4th–5th intercostal space, with the probe at an oblique angle pointing towards the patient's right shoulder
Para-sternal short axis (PSAX)	Rotate the probe approximately 90° clockwise from the PLAX position
Apical four chamber (A4C)	Found at the apex, with the probe marker pointed to the left flank
Sub-costal (SC)	Probe in the subxyphoid region, pointing cranially and tilted tail down, with probe marker to the left flank

LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle.

These are often combined with imaging of the inferior vena cava (IVC) and lung bases. FTTE limits itself to identifying a short list of significant abnormalities. These include basic assessment of left ventricular (LV) and right ventricular (RV) function; the presence of pericardial and pleural effusions, and a brief inference of fluid status.¹⁰

If the skill set is available, more advanced critical care echocardiography (ACCE) may be used to comment on valve pathology, cardiac output and changes in cardiac function following intervention(s). These ACCE techniques require expert training beyond that of FTTE. The main UK accreditation in ACCE is through a collaboration between the Intensive Care Society and the BSE.¹¹ An alternative accreditation is offered through the European Society of Intensive Care Medicine (ESICM).¹²

Focused transoesophageal echocardiography (FTOE) can also be performed in the critically unwell, albeit less commonly. Its use is mainly limited to cardiothoracic anaesthesia and cardiothoracic intensive care, partly due to equipment availability, and partly due to expertise.¹³ Nonetheless, FTOE is gaining increasing traction with a number of available training programmes^14,15 and an incoming FUSIC module, with advanced training offered through the European Society of Cardiology (ESC), BSE and ESICM.¹²

Echocardiography in the peri-arrest patient

FTTE has an important role to play in the peri-arrest patient. When combined with the physical examination it can aid in diagnosis, fluid status assessment and quantifying response to intervention.¹⁶

In this section we will discuss the main echocardiographic findings in peri-arrest patients and provide an algorithm with which to approach such scenarios.

Cardiac tamponade

Tamponade occurs when either fluid or thrombus accumulates in the pericardial space, leading to pericardial pressures exceeding that of the ventricles (typically the RV before the LV). The resultant impaired ventricular filling and cardiac output lead to haemodynamic compromise and potentially cardiac arrest.¹⁷ Echocardiographic signs of cardiac tamponade are numerous and reflect these pericardial pressure affects.

The presence of pericardial fluid or thrombus should first be confirmed in all available windows, allowing assessment of size and volume. Pericardial fluid typically appearing as a black anechoic strip, and a thrombus as a hyperechoic structure, within the pericardial space (see Figure 1).¹⁷

Figure 1.

Echocardiographic views of a pericardial effusion (i) A4C view of a pericardial effusion with RA collapse, (ii) PSAX view of a pericardial effusion, (iii) SC view of a pericardial effusion and thrombus (courtesy of thepocusatlas.com). PF: pericardial fluid; T: thrombus.

The rate of fluid accumulation is more significant than its size. Chronic effusions may present with volumes >1.5 l with nil haemodynamic effect, whilst acute effusions of 100 ml may result in cardiac arrest.¹⁸

When assessing the pressure effects of an effusion, all four chambers should be visualised. Due to the low pressures the right atrium (RA) is usually the first chamber affected, with collapse in diastole seen. Duration of RA collapse has been associated with the presence of tamponade, with a collapse for >1/3 of the cardiac cycle quoted as being 100% sensitive and specific.¹⁹

As pressure increases, the effusion may progress to collapse the RV, initially in early diastole, and progressing over a larger proportion of the cardiac cycle as severity increases.²⁰

Other ACCE echocardiographic parameters that can aid in the diagnosis of tamponade include:

Increased variation in ventricular diastolic size with the respiratory cycle.

The presence of a distended IVC with reduced respiratory variation.

Variation of ventricular inflow patterns during respiration.²⁰

It is important to emphasise that cardiac tamponade remains a clinical diagnosis. Whilst echocardiography may aid diagnosis, the echocardiographic signs of tamponade can appear in haemodynamically stable patients.

Hypovolaemic shock and fluid responsiveness

The use of echocardiography in the assessment of hypovolaemic shock is a controversial subject. Whilst it can certainly add to the clinical examination, findings must be taken in clinical context, as recent data have shown a poor correlation between some echocardiographic parameters and absolute volume status.²¹

In echocardiography the terms ‘fluid responder’ or ‘fluid tolerant’ are increasingly preferred over absolute statements of volume status. A ‘fluid responder’ is a patient in whom cardiac output increases following a bolus of fluid.²² A ‘fluid tolerant’ patient is one in whom fluid can be administered without causing fluid overload.²³

Ventricular size

A basic assessment of ventricular size provides a simple guide to fluid status. This is commonly done via the para-sternal long axis (PLAX) and para-sternal short axis (PSAX) views, with measurements in end diastole and systole.

Those with small ventricles, or ‘kissing’ papillary muscles (i.e. approximation of papillary muscles during systole), may be considered fluid-responders, and those with dilated ventricles and a bowing septum, to be non-responders. While there may be some correlation in the extremes, there is a large grey area that requires cautious interpretation.²⁴

Inferior vena cava

A popular and controversial TTE parameter for fluid status is the diameter and respiratory variation of the IVC.

The IVC is usually imaged longitudinally, approximately 1–2 cm before the right atrial (RA) junction, with measurements used as a surrogate for right atrial pressure.

The acquisition of accurate IVC views and measurements is crucial. The presence of RV failure, pericardial effusions or raised intraabdominal pressures will also reduce its reliability.²⁵

For dynamic measurements, 2D or M Mode measurements of the IVC are performed at peak inspiration and end expiration; the change in diameter in inspiration and expiration is then calculated. Traditionally, an IVC diameter of <2 cm with respiratory variation of >50% suggests fluid responsiveness, whilst a diameter of >2 cm with respiratory variation of <50% suggests non-responsiveness or fluid intolerance.

In mechanically ventilated patients, the use of the distensibility index of the IVC (diIVC) has a 90% specificity and sensitivity for fluid responsiveness, when a cut off value of ≥18% is used.²⁶

When used in spontaneously ventilated patients, a diIVC value of >40% is associated with increased probability of fluid responsiveness, but it is not effective in identifying non-responders.²⁷

Of note, recent evidence has significantly challenged the role of both static and dynamic IVC parameters in estimating volume status.²⁸

The superior vena cava (SVC) can be used in a similar fashion and is most easily visualised with transoesophageal echocardiography (TOE). With evidence demonstrating a 90% sensitivity and 100% sensitivity for fluid responsiveness in the presence of an SVC diIVC of >36%.^24,29

Estimates of stroke volume and stroke volume variation

Measurement of volume responsiveness involves assessing for an increase in stroke volume. It thus follows that echocardiographic estimation of stroke volume before and after a fluid bolus would provide a valuable insight into fluid status. Stroke volume estimation requires ACCE techniques, including:

Use of 2D parameters (measuring changes in end diastolic and end systolic diameters or areas) – this is limited by the quality of views in the critically ill patient.

Use of 3D echocardiography – limited by the quality of views, and requiring specialist equipment and training.

Using Doppler parameters – in particular calculation of velocity–time interval (VTI).

The latter allows for a highly accurate estimation of SV and may be used as a surrogate measurement. With respiratory VTI variation of >18%, or maximum velocity variation of >12% suggestive of fluid responsiveness.³⁰ Precise measurements require training beyond FTTE and a detailed description of this is beyond the scope of this article.

The use of miniature TOE probes to provide constant haemodynamic monitoring has also been suggested as a useful adjunct when assessing shocked patients.³¹

Pulmonary embolism

The use of echocardiography in suspected massive pulmonary embolism (PE) is recommended by the British Thoracic Society.³² However, with a negative predictive value of 40–50% in PE, it should not be used as a ‘rule out’ investigation.³³ Echocardiographic signs in massive PE result from increased resistance to RV outflow, and thus raised RV pressures. Given this, one must consider the list of other pathologies (e.g. pulmonary hypertension) that may present with similar findings.³³

The 2019 ESC guidelines for management of suspected PE with haemodynamic compromise suggest TTE as the first-line investigation. The guidelines state that if signs of RV pressure overload are found and computed tomography pulmonary angiogram is not immediately available or feasible, then treatment of suspected PE is justified. In those with nil sign of RV dysfunction, PE is unlikely to be the cause of the instability.³³

The signs of PE that may be visible on TTE are shown in Table 2 and Figure 2.³³

Figure 2.

Echocardiographic signs of PE (i) PLAX view – dilated RV with septal bowing, (ii) PSAX view – dilated RV with septal bowing, (iii) apical five chamber view – McConnell's sign.

Table 2.

Echocardiographic signs of pulmonary embolism.

Echocardiographic sign	Comments
Enlarged RV – measure in PLAX/A4C	Seen in around 25% of PEs; multiple other causes
McConnell's sign (Akinetic free wall with hyperdynamic apex)^19,20	Poor sensitivity (20%, potentially high specificity (close to 100%)
Flattening of the interventricular septum	High sensitivity (81%, low specificity (41%)¹⁹
Distended non-collapsing IVC	Multiple caveats – see previous section
Direct clot visualisation in the RA, RV, or RVOT	Uncommonly seen
RV dysfunction (e.g. TAPSE < 16 mm)	Non-specific, may aid in prognostication, requires more training than FTTE²³
Systolic notching of the pulmonary artery ejection waveform⁵⁰	Requires more training than FTTE
60:60 sign (pulmonary acceleration time <60 ms, RVSP <60 mmHg)	Low sensitivity (25%), high specificity (>90%), requires more training than FTTE

A4C: apical four chamber; FTTE: focused transthoracic echocardiography; IVC: inferior vena cava; PEs: pulmonary embolisms; PLAX: para-sternal long axis; RA: right atrium; RV: right ventricle; RVOT: right ventricular outflow tract; RVSP: right ventricular systolic pressure; TAPSE: tricuspid annular plane systolic excursion.

Left ventricular failure

Cardiogenic shock contributes significantly to morbidity and mortality in critical care. The use of echocardiography can be invaluable in identifying ventricular failure as the cause of shock and assessing response to treatment.

The LV should be assessed using as many views as possible to increase accuracy, as the final assessment is highly dependent on experience and quality of views attained.⁵

The most commonly used method is visual estimation of ventricular function. The accuracy and precision of such estimates are dependent on the scanner's experience. In FTTE, a simple statement of ‘normal’ ‘impaired’ or ‘severely impaired’ is used. More advanced scanners may be able to provide visual estimates of ejection fraction.^2,5

Objective methods to assess cardiac function require full ACCE accreditation, and include:

Fractional shortening – change in LV diameter from end diastole to end systole, measured in the PLAX view, with a value of <15% deemed as severely impaired.

Fractional area change (FAC) – this is a measurement of the change in LV area from end diastole and end systole, providing a more global assessment of radial LV systolic function.

Biplane estimates of stroke volume – providing a 3D interpretation of SV, but limited by difficulty of cardiac windows in critical illness.

VTI estimates of stroke volume – as mentioned in the SV section.

Mitral annular plane systolic excursion – may be used alongside FAC as a measure of longitudinal function.⁵

Right ventricular failure

RV assessment can be profoundly challenging in the peri-arrest situation. FTTE focuses on simple visual assessments of size and function. The most commonly used objective measure of RV function is tricuspid annular plane systolic excursion (TAPSE). This is done via the use of M-mode over the tricuspid annulus from the apical view, with values of <16 mm being suggestive of reduced longitudinal function.³⁴ If TAPSE is not possible, the subcostal echocardiographic assessment of tricuspid annular kick (SEATAK) may be used.³⁵ ACCE techniques for RV assessment include tissue Doppler, measurements of RV size (>4.2 cm is considered dilated), FAC, and strain.³⁶

Alternative cardiac windows in unwell patients

Obtaining standard views can be challenging in the critically ill patient, be it due to patient factors or lack of bedside space. In such circumstances, alternative views should be sought.

The subcostal window often remains easily accessible and provides the opportunity for numerous alternative views:

Subcostal short axis mid papillary and aortic valve view – achieved with anti-clockwise rotation of the probe from the standard subcostal view (usually between 30° and 60°), with tilting to pan through the heart from the base to the apex.

The subcostal bicaval view – achieved with clockwise rotation of the probe from the SC IVC view until RA, IVC and SVC are visualised. This view is useful for cannulation during initiation of extracorporeal membrane oxygenation (ECMO) support and confirming position of the ECMO cannulae.

Subcostal aortic view – requires probe tilting from the IVC view, used in identification of aortic aneurysms and dissection.

The IVC and aortic ‘double barrelled’ view – a transhepatic view allowing simultaneous coronal visualisation of the IVC and abdominal aorta, particularly useful in confirming passage of guidewire in the IVC/aorta during insertion of ECMO cannula and intra-aortic balloon pumps.³⁷

If acquired TTE views remain inadequate then TOE, if feasible, should be considered.³⁸

Putting it all together

Attempts to combine multiple FTTE assessments to create a structured pathway have been made, one example being the ‘Echo-Guided Life Support’ algorithm.³⁹

It provides a logical structure to be used when approaching the peri-arrest patient, combining the techniques previously mentioned (see Figure 3).³⁹

Figure 3.

Echo-Guided Life Support algorithm – a proposed approach to the peri-arrest patient. Reproduced with the permission of Professor Jean-François Lanctôt.

Use of echocardiography in cardiac arrest

The use of echocardiography in cardiac arrest is becoming common practice, with the UK Resuscitation Council acknowledging its importance.⁴⁰ However, it is imperative that it does not interrupt compressions or other interventions within the Advance Life Support algorithm.

Approach to TTE in cardiac arrest

In the majority of arrest settings, the most easily accessible form of echocardiography is TTE with numerous algorithms proposed. Figure 4 is our adaptation of the FEEL protocol.⁸

Figure 4.

Suggested approach to the use of echocardiography in cardiac arrest, adapted from the FEEL protocol. Emphasis should be places on rapid and efficient scanning to ensure minimal interruption to compressions.

TOE technique in cardiac arrest

Whilst not routinely used, intra-arrest TOE is an application of growing interest.⁴¹ Apart from aiding in diagnoses, it allows for optimisation of CPR by providing a continuous view of the heart and the chambers compressed during cardiac massage. This allows for adjustment to ensure optimal hand placement and thus optimal stroke volume with each compression.⁴¹ With the rise of extracorporeal cardiopulmonary resuscitation, intra-arrest TOE (and TTE) has a place in assisting cannulation and initiating mechanical support.⁴²

Echocardiography for diagnosis in cardiac arrest

The pathologies amenable to diagnosis with echocardiography are similar to those discussed in the peri-arrest patient, with a few caveats to be acknowledged mentioned below.

Cardiac tamponade

Whilst the physiological signs of tamponade may not be appreciable in an arrest scenario, pericardial fluid can still be visualised. This should be combined with the clinical history and examination to ascertain its significance, with tamponade being the leading cause of pulseless electrical activity (PEA) associated arrest in young trauma patients.⁴³

Thus, a patient in cardiac arrest with a pericardial effusion warrants consideration of tamponade as the cause.

Pulmonary embolism

The diagnosis of PE in cardiac arrest is controversial. Whilst historically a dilated RV was felt to be akin to the diagnosis of PE, multiple studies have shown this not to be the case.^44,45

Animal studies have demonstrated the RV to be dilated in cardiac arrest of almost any aetiology.^44,45 Whilst the RV appears to be more dilated in the presence of a PE, this cannot be accurately relied upon in a resuscitation scenario.

Thus, it must be used in context of clinical history and examination, and not as a rule in investigation. Other forms of obstructive shock should be considered simultaneously – in particular tension pneumothorax.

Can echocardiography aid in prognostication?

A proposed use of echocardiography in cardiac arrest is in confirmation of the underlying rhythm and prognostication.⁴⁶ Studies have demonstrated that without the use of ultrasound, the diagnosis of PEA is incorrectly made in up to 75% of cases.³

The inaccuracy of PEA diagnosis without ultrasound is likely in part due to the unreliability of manual pulse palpation.³ Thus, the use of an ultrasound pulse in combination with FTTE appears to present a different cohort of ‘pseudo-PEA’ patients. In comparison to true PEA, this ‘pseudo-PEA’ population have a seven-fold increase in survival to admission (55% vs. 8%).^3,47

A similar pattern rings true in asystole, with the use of FTTE demonstrating 35% of these patients to have spontaneous cardiac movements. The presence of which doubled their survival to hospital (24% vs. 11%).³

Whilst not 100% specific for non-survivors, the absence of spontaneous cardiac activity is associated with significantly reduced survival (3.8% vs. 0.6%)⁴⁸ and reduced chance of return of spontaneous circulation (OR 12.4).⁴⁹

The International Liason Committee on Resuscitation (ILCOR) has made a weak recommendation against the use of ultrasound to prognosticate in cardiac arrest; however, this remains up for review.⁴⁹

What does the future hold?

FTTE is a core competency of training in a number of countries (including the USA, Spain and Australia) with the UK likely to follow suit. Ultraportable devices are increasingly available, with the potential to make ultrasound ubiquitous throughout medicine. Improvements in processing power and the addition of artificial intelligence will make FTTE easier, whilst also providing more advanced assessments to the toolbox of the ACCE practitioner.

Stethoscopes probably are not quite ready to be thrown to the side as mere ‘wheeze detectors’, but it is important we acknowledge that medical imaging has come a long way. To not embrace echocardiography is to ignore some of this progress.^5,13,16

Conclusion

As the use of critical care echocardiography continues to grow, it is imperative we ensure our training, clinical governance and guidelines keep up.

When approaching a peri-arrest patient, FTTE can provide invaluable insight. It may assist in differentiation of shock aetiology, guide management strategies and asses response following interventions. In the cardiac arrest scenario, it can aid diagnosis of reversible causes, confirmation of the underlying rhythm, and potentially contribute to prognostication.

Whilst appreciating the potential benefits of echo in critical illness, we must ensure we acknowledge its limitations and view it as another component of our examination, not a replacement. Handheld ultrasound probes may well become the stethoscope of the next generation, but with this power comes huge responsibility for trainers and users alike.

Supplemental Material

sj-pdf-1-inc-10.1177_1751143720936998 - Supplemental material for The use of critical care echocardiography in peri-arrest and cardiac arrest scenarios: Pros, cons and what the future holds

Supplemental material, sj-pdf-1-inc-10.1177_1751143720936998 for The use of critical care echocardiography in peri-arrest and cardiac arrest scenarios: Pros, cons and what the future holds by Luke Flower, Olusegun Olusanya and Pradeep R Madhivathanan in Journal of the Intensive Care Society

Footnotes

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: OO is an associate editor of the Journal of the Intensive Care Society, a member of the FUSIC committee, and has received honoraria from GE and Sonosite to teach ultrasound.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Luke Flower

References

Singh

Goyal

. The origin of echocardiography: a tribute to Inge Edler. Texas Hear Inst J 2007; 34: 431–438.

Zieleskiewicz L, Muller L, Lakhal K, et al. Point-of-care ultrasound in intensive care units: assessment of 1073 procedures in a multicentric, prospective, observational study. Intensive Care Med 2015; 41: 1638–1647. doi:10.1007/s00134-015-3952-5.

Breitkreutz

Price

Steiger

, et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation. 2010; 81: 1527–1533. doi:10.1016/j.resuscitation.2010.07.013.

Cecconi

De Backer

Antonelli

, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014; 40: 1795–1815. doi:10.1007/s00134-014-3525-z.

Orde

Slama

Hilton

, et al. Pearls and pitfalls in comprehensive critical care echocardiography. Crit Care 2017; 21: 279.

Yang

Royse

, et al. Survey of the training and use of echocardiography and lung ultrasound in Australasian intensive care units. Crit Care 2016; 20: 339.

Intensive Care Society. FUSIC Heart Accreditation, https://www.ics.ac.uk/ICS/ICS/FUSIC/FUSIC_Heart_Registration.aspx (2020, accessed 13 February 2020).

Council R (UK). FEEL – Focused Echocardiography in Emergency Life Support course, https://www.resus.org.uk/information-on-courses/focused-echocardiography-in-emergency-life-support/?assetdetc207366f-7f73-4e50-9d9f-d19f96b9a7f8=1359 (2020, accessed 13 February 2020).

British Society of Echocardiography. Level 1 accreditation, https://www.bsecho.org/Public/Accreditation/Personal-accreditation/Level-1/Public/Accreditation/Accreditation-subpages/Personal-accreditation-subpages/Level-1-accreditation.aspx?hkey=6099b4b8-5cb9-4425-a201-1874aadcb73f (2020, accessed 13 February 2020).

10.

Via

Hussain

Wells

, et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014; 27: 683.e1-683.e33. doi:10.1016/j.echo.2014.05.001.

11.

British Society of Echocardiography. Critical care echocardiography accreditation, https://www.bsecho.org/Public/Accreditation/Accreditation-subpages/Personal-accreditation-subpages/Critical-care-echocardiography-accreditation.aspx (2020, accessed 13 February 2020).

12.

European Society of Intensive Care Medicine. EDEC – ESICM, https://www.esicm.org/education/edec-2/ (2020, accessed 13 February 2020).

13.

Nanjayya

Orde

Hilton

, et al. Levels of training in critical care echocardiography in adults. recommendations from the College of Intensive Care Medicine Ultrasound Special Interest Group. Australas J Ultrasound Med. 22: 73-79. doi:10.1002/ajum.12127.

14.

Dawkins Arce

Berrío-Valencia

. Rescue transesophageal echocardiography: approach and future. Colomb J Anesthesiol 2017; 45: 1–3.

15.

Project RT. RESUSCITATIVE TEE PROJECT, https://www.resuscitativetee.com/ (2018, accessed 22 February 2020).

16.

Price

Via

Sloth

, et al. Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS). Cardiovasc Ultrasound. 2008; 6: 49. Published 2008 Oct 6. doi:10.1186/1476-7120-6-49.

17.

Ceriani

Cogliati

. Update on bedside ultrasound diagnosis of pericardial effusion. Intern Emerg Med. 2016; 11: 477-480. doi:10.1007/s11739-015-1372-8.

18.

Imazio

Adler

. Management of pericardial effusion. Eur Heart J. 2013; 34: 1186-1197. doi:10.1093/eurheartj/ehs372.

19.

Gillam

Guyer

Gibson

, et al. Hydrodynamic compression of the right atrium: a new echocardiographic sign of cardiac tamponade. Circulation. 1983; 68: 294-301. doi:10.1161/01.cir.68.2.294.

20.

Pérez-Casares

Cesar

Brunet-Garcia

, et al. Echocardiographic evaluation of pericardial effusion and cardiac tamponade. Front Pediatr. 2017; 5: 79. Published 2017 Apr 24. doi:10.3389/fped.2017.00079.

21.

Yastrebov

Aneman

Slama

, et al. The stop-flow arm equilibrium pressure in preoperative patients: stressed volume and correlations with echocardiography. Acta Anaesthesiol Scand 2019; 63: 594–600.

22.

Monnet

Marik

Teboul

. Prediction of fluid responsiveness: an update. Ann Intensive Care. 2016; 6: 111. doi:10.1186/s13613-016-0216-7.

23.

Weingart S. EMCrit Wee – Advanced Ultrasound Assessment of Volume Status. In: EMCrit Blog, https://emcrit.org/emcrit/emcrit-wee-advanced-ultrasound-assessment-volume-status/ (2017, accessed 13 February 2020).

24.

McLean

. Echocardiography in shock management. Crit Care 2016; 20: 275.

25.

Via

Tavazzi

Price

. Ten situations where inferior vena cava ultrasound may fail to accurately predict fluid responsiveness: a physiologically based point of view. Intensive Care Med. 2016; 42: 1164-1167. doi:10.1007/s00134-016-4357-9.

26.

Barbier

Loubières

Schmit

, et al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med 2004; 30: 1740–1746.

27.

Muller

Bobbia

Toumi

, et al. Respiratory variations of inferior vena cava diameter to predict fluid responsiveness in spontaneously breathing patients with acute circulatory failure: need for a cautious use. Crit Care. 2012; 16: R188. Published 2012 Oct 8. doi:10.1186/cc11672.

28.

Millington

. Ultrasound assessment of the inferior vena cava for fluid responsiveness: easy, fun, but unlikely to be helpful. Can J Anesth. 2019; 66: 633-638. doi:10.1007/s12630-019-01357-0.

29.

Vieillard-Baron

Chergui

Rabiller

, et al. Superior vena caval collapsibility as a gauge of volume status in ventilated septic patients. Intensive Care Med. 2004; 30: 1734-1739. doi:10.1007/s00134-004-2361-y.

30.

Muller

Toumi

Bousquet

, et al. An increase in aortic blood flow after an infusion of 100 ml colloid over 1 minute can predict fluid responsiveness: the mini-fluid challenge study. Anesthesiology. 2011; 115: 541-547. doi:10.1097/ALN.0b013e318229a500.

31.

Merz

Cioccari

Frey

, et al. Continual hemodynamic monitoring with a single-use transesophageal echocardiography probe in critically ill patients with shock: a randomized controlled clinical trial. Intensive Care Med 2019; 45: 1093–1102.

32.

Campbell

Fennerty

Miller

, et al. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax. 2003; 58: 470-483. doi:10.1136/thorax.58.6.470.

33.

Konstantinides

Meyer

Becattini

, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ECS). Eur Heart J 2019; 41: 543–603.

34.

Bleeker

Steendijk

Holman

, et al. Assessing right ventricular function: the role of echocardiography and complementary technologies. Heart. 2006; 92 Suppl 1(Suppl 1): i19-i26. doi:10.1136/hrt.2005.082503.

35.

Díaz-Gómez

Alvarez

Danaraj

, et al. A novel semiquantitative assessment of right ventricular systolic function with a modified subcostal echocardiographic view. Echocardiography 2017; 34: 44–52.

36.

Barthélémy

Roy

Javanainen

, et al. Comparison of echocardiographic indices of right ventricular systolic function and ejection fraction obtained with continuous thermodilution in critically ill patients. Crit Care. 2019; 23: 312. Published 2019 Sep 13. doi:10.1186/s13054-019-2582-7.

37.

Smith

Madhivathanan

. The “double-barrel view”: a useful point-of-care ultrasound (POCUS) view in extra-corporeal membrane oxygenation patients. Perfusion 2019; 34: 82–251.

38.

Colebourn

Barber

Salmon

, et al. The accuracy of diagnostic and haemodynamic data obtained by transthoracic echocardiography in critically ill adults: a systematic review. J Intensive Care Soc. 9: 128–134. https://doi.org/10.1177/175114370800900207.

39.

Lanctôt

Valois

Beaulieu

. EGLS: echo-guided life support. Crit Ultrasound J. 2011; 3: 123–129. https://doi.org/10.1007/s13089-011-0083-2.

40.

Parfitt

. Resuscitation guidelines. Lancet 2006; 367: 283–284.

41.

Lin

Chen

, et al. Use of transoesophageal echocardiography during cardiac arrest in patients undergoing elective non-cardiac surgery. Br J Anaesth. 2006; 96: 167-170. doi:10.1093/bja/aei303.

42.

Murphy DM and Bhagyalakshmi Nanjayya V. Ultrasound Guidance for Extra-corporeal Membrane Oxygenation General Guidelines, 2015.

43.

Zafiropoulos

Asrress

Redwood

, et al. Critical care echo rounds: echo in cardiac arrest. Echo Res Pract. 2014; 1: D15-D21. doi:10.1530/ERP-14-0052.

44.

Berg

Sorrell

Kern

, et al. Magnetic resonance imaging during untreated ventricular fibrillation reveals prompt right ventricular overdistention without left ventricular volume loss. Circulation. 2005; 111: 1136-1140. doi:10.1161/01.CIR.0000157147.26869.

45.

Aagaard

Caap

Hansson

, et al. Detection of pulmonary embolism during cardiac arrest-ultrasonographic findings should be interpreted with caution. Crit Care Med. 2017; 45: e695-e702. doi:10.1097/CCM.0000000000002334.

46.

Tsou

Kurbedin

Chen

, et al. Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: a systematic review and meta-analysis. Resuscitation. 2017; 114: 92-99. doi:10.1016/j.resuscitation.2017.02.021.

47.

Atkinson

Beckett

French

, et al. Does point-of-care ultrasound use impact resuscitation length, rates of intervention, and clinical outcomes during cardiac arrest? A study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators. Cureus. 2019; 11: e4456. Published 2019 Apr 13. doi:10.7759/cureus.4456.

48.

Gaspari

Weekes

Adhikari

, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016; 109: 33-39. doi:10.1016/j.resuscitation.2016.09.018.

49.

Kedan

Ciozda

Palatinus

, et al. Prognostic value of point-of-care ultrasound during cardiac arrest: a systematic review. Cardiovasc Ultrasound 2020; 18: 1.

50.

Afonso

Sood

Akintoye

, et al. A doppler echocardiographic pulmonary flow marker of massive or submassive acute pulmonary embolus. J Am Soc Echocardiogr. 2019; 32: 799-806. doi:10.1016/j.echo.2019.03.004.

Supplementary Material

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The use of critical care echocardiography in peri-arrest and cardiac arrest scenarios: Pros,cons and what the future holds

Abstract

Keywords

Introduction

The evolution of critical care echocardiography

Echocardiography in the peri-arrest patient

Cardiac tamponade

Hypovolaemic shock and fluid responsiveness

Ventricular size

Inferior vena cava

Estimates of stroke volume and stroke volume variation

Pulmonary embolism

Left ventricular failure

Right ventricular failure

Alternative cardiac windows in unwell patients

Putting it all together

Use of echocardiography in cardiac arrest

Approach to TTE in cardiac arrest

TOE technique in cardiac arrest

Echocardiography for diagnosis in cardiac arrest

Cardiac tamponade

Pulmonary embolism

Can echocardiography aid in prognostication?

What does the future hold?

Conclusion

Supplemental Material

sj-pdf-1-inc-10.1177_1751143720936998 - Supplemental material for The use of critical care echocardiography in peri-arrest and cardiac arrest scenarios: Pros, cons and what the future holds

Footnotes

Declaration of conflicting interests

Funding

ORCID iD

References

Supplementary Material