[
Ultrasound Corner
]
An Elderly Woman That Presents With Absent Vital Signs Robert T. Arntfield, MD, FCCP; Scott J. Millington, MD; and Edwin Wu, MD
CHEST 2014; 146(5):e156-e159
An elderly woman with a past medical history of hypertension, obesity, hypothyroidism, dyslipidemia, and atrial fibrillation presented to the ED via ambulance with cardiac arrest of unknown etiology. Further history from her family was nonspecific; the patient had experienced generalized malaise, diarrhea, and poor oral intake for several days. Her medications included furosemide, spironolactone, levothyroxine, warfarin, and simvastatin, although this information was unavailable initially. Upon arrival, a pulseless electrical activity (PEA) rhythm was diagnosed, and the patient was endotracheally intubated while CPR and advanced cardiac life support (ACLS) protocols were initiated. Following one round of CPR and resuscitative medications, the patient remained in PEA; thus, a point-of-care echocardiogram from the subcostal window was attempted. An indeterminate subcostal four-chamber view of the heart was shown during CPR. No meaningful information could be obtained about cardiac anatomy or reversible causes of cardiac arrest (Video 1). In this case, point-of-care transesophageal echocardiography (TEE) was performed to avoid CPR interruptions while capitalizing on the information that echocardiography can provide. The TEE probe was inserted without difficulty to reveal the following midesophageal fourchamber view (Video 2). Manuscript received March 11, 2014; revision accepted May 30, 2014. AFFILIATIONS: From the Division of Critical Care (Drs Arntfield and Wu), Western University, London; and Division of Critical Care (Dr Millington), University of Ottawa, Ottawa, ON, Canada. CORRESPONDENCE TO: Robert T. Arntfield, MD, FCCP, Western University, Division of Critical Care, 800 Commissioners Rd E, Room D2-521A, London, ON, N6A5W9, Canada; e-mail: robert.arntfield@ gmail.com © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-3029
e156 Ultrasound Corner
In this midesophageal four-chamber view of the heart, all cardiac chambers were visualized in addition to the pericardium. The heart (particularly the right ventricle) was being displaced by chest compressions during CPR. With a persistent bradycardic PEA rhythm, CPR was continued along with appropriate ACLS medications. Transcutaneous pacing was attempted but failed due to body habitus, thus, a transvenous pacemaker was indicated. Central venous cannulation requiring a linear array transducer was used to image the patient’s neck (Video 3). The carotid artery was seen deep to the internal jugular vein (IJ), with movement related to chest compressions. Given the high risk of arterial cannulation, confirmation of guidewire placement was essential (Video 4). With respect to cannulation of the IJ, catheter placement proceeded, as the unique “J” of the guidewire can be seen traversing the superior vena cava in to the right atrium as seen from the midesophageal bicaval view (Fig 1). Once central access was established with a 6F introducer, a 5F balloon-directed transvenous pacemaker was inserted. Positioning of the pacemaker using flow-directed guidance was impossible due to the lack of
Figure 1 – J wire in bicaval view.
[
146#5 CHEST NOVEMBER 2014
]
adequate cardiac output, requiring direct visualization using TEE (Videos 5-7: ultrasound images during pacer insertion).
What causes of cardiac arrest can be excluded based on the images demonstrating return of circulation?
journal.publications.chestnet.org
e157
Answer: Pulmonary embolism, pericardial tamponade, acute coronary syndrome Discussion The pacemaker is in good position near the apex of the right ventricle. The paced rhythm shows a paradoxical septal motion (“bounce”) that can be appreciated during systole with the septum contracting slightly later than the rest of the left ventricle (LV). Additionally, the absence of pericardial fluid and absence of a D-shaped LV (suggestive of right-sided pressure overload, as may be seen in pulmonary embolism) can be appreciated. Furthermore, the quality of the LV contraction and absence of significant wall motion abnormalities rule out an acute coronary syndrome. The time from initial cardiac arrest until successful pacemaker capture was approximately 45 min. Once capture was achieved, good BP was confirmed and, remarkably, the patient demonstrated purposeful movements and required sedation. The ultimate etiology of cardiac arrest was determined to be hyperkalemia. A serum potassium level of 6.8 mM was discovered in her blood work, the result of which was returned after return of paced circulation. The hyperkalemia was caused by acute kidney injury from diarrheal illness in the context of spironolactone use. After correction of potassium level, she was no longer pacemaker dependent and was discharged home with full neurologic and functional recovery 6 days later.
provides real-time feedback on return of circulation and quality of CPR6 and, as shown in this case, may also help guide procedures. TEE may be safely used by intensivists with approximately 30 full studies required to attain proficiency for critical care and hemodynamic applications.6 In this case of cardiac arrest of unclear etiology, the patient required immediate echocardiography to exclude a reversible cause, but the transthoracic examination was inconclusive due to ongoing CPR (Video 1). Without interrupting CPR, a TEE probe was inserted to reveal a midesophageal four-chamber view (Video 2) that demonstrated no evidence of pericardial effusion or signs of cor pulmonale, suggestive of pulmonary embolism. Due to the need for central venous access, ultrasound guidance was easily used to guide the procedure (Video 3) showing a high-risk relationship between the IJ and carotid artery. The risk of dilating the carotid was minimized by using the TEE to confirm venous guidewire location (Fig 1, Video 4). Transvenous pacemaker insertion was assisted by TEE visualization and was extremely valuable in the context of difficult electrical capture (Videos 5-7). For TEE in cardiac arrest, providers’ assessment of compression quality is guided largely by feedback regarding fatigue states from the individual performing compressions. Placement of a TEE probe may provide real-time visualization of chest compression quality through changes in chamber size and Doppler can be used to quantitatively analyze the output across the aortic valve.7
This case illustrates several challenges faced by clinicians during the resuscitation of a patient in cardiac arrest, particularly those with PEA. ACLS algorithms advocate for continued resuscitation while concomitantly considering and treating potentially reversible causes of the arrest.1 Transthoracic echocardiography (TTE) is a powerful tool in addressing reversible causes in arrest with pertinent findings identified in as many as 40% of patients.2 Furthermore, when complete cardiac standstill is seen during an arrest it is associated with uniformly poor clinical outcome,3-5 adding an important prognostic role for this tool.
TEE performed in intraoperative cardiac arrests during noncardiac surgeries has demonstrated the ability to identify an underlying etiology in eight of 10 cases, with subsequent direction to definitive management.8 In a study of in-hospital and out-of-hospital cardiac arrest, use of TEE intraarrest was found to have a sensitivity of 93%, specificity of 50% and a positive predictive value of 87% in identifying myocardial infarction, pulmonary embolus, aortic dissection, cardiac tamponade, and papillary muscle rupture as causes of the arrest.9
Realizing the potential of TTE in cardiac arrest typically requires interruption of CPR to permit image acquisition. This case demonstrates a technique to eliminate this compromise through the use of TEE. Providing very high-quality images, the probe may be left in situ throughout resuscitation, acting as an advanced diagnostic tool and continuous monitor. TEE
Though TEE is commonly seen as a tool to answer advanced clinical questions such as aortic dissection or endocarditis, basic questions such as the presence or absence of cardiac contractility during a pulse check may be answered easily and rapidly using TEE. Basic critical care echocardiography calls for competence in assessing a variety of clinical syndromes, including
e158 Ultrasound Corner
[
146#5 CHEST NOVEMBER 2014
]
circulatory arrest, with no distinction between TEE or TTE for this purpose.10
Reverberations
2.
1. TEE provides real-time anatomic monitoring during cardiac arrest, relieving tension over the importance of continuous CPR and the value of transthoracic echocardiographic information that typically requires interruptions to permit image generation.
4.
2. TEE during cardiopulmonary resuscitation is very effective at diagnosing potentially occult yet reversible etiologies of cardiac arrest.
5.
3.
3. Point-of-care TEE can help guide invasive procedures, especially in emergency scenarios.
6.
Acknowledgments
7.
Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
8.
Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
9.
Additional information: To analyze this case with the videos, see the online version of this article.
References 1. Sayre MR, Koster RW, Botha M, et al; Adult Basic Life Support Chapter Collaborators. Part 5: adult basic life support: 2010
journal.publications.chestnet.org
10.
international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2010;122(16)(suppl 2): S298-S324. Tayal VS, Kline JA. Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states. Resuscitation. 2003;59(3):315-318. Salen P, Melniker L, Chooljian C, et al. Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Am J Emerg Med. 2005;23(4): 459-462. Salen P, O’Connor R , Sierzenski P, et al. Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes? Acad Emerg Med. 2001;8(6): 610-615. Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med. 2001;8(6):616-621. Charron C, Prat G, Caille V, et al. Validation of a skills assessment scoring system for transesophageal echocardiographic monitoring of hemodynamics. Intensive Care Med. 2007;33(10):1712-1718. Pell AC, Guly UM, Sutherland GR, Steedman DJ, Bloomfield P, Robertson C. Mechanism of closed chest cardiopulmonary resuscitation investigated by transoesophageal echocardiography. J Accid Emerg Med. 1994;11(3):139-143. Lin T, Chen Y, Lu C, Wang M. Use of transesophageal echocardiography during cardiac arrest in patients undergoing elective non-cardiac surgery. Br J Anaesth. 2006;96(2):167-170. van der Wouw PA, Koster RW, Delemarre BJ, de Vos R, LampeSchoenmaeckers AJ, Lie KI. Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation. J Am Coll Cardiol. 1997;30(3):780-783. Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;135(4):1050-1060.
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Ultrasound Corner
]
An Elderly Woman That Presents With Absent Vital Signs Robert T. Arntfield, MD, FCCP; Scott J. Millington, MD; and Edwin Wu, MD
CHEST 2014; 146(5):e156-e159
An elderly woman with a past medical history of hypertension, obesity, hypothyroidism, dyslipidemia, and atrial fibrillation presented to the ED via ambulance with cardiac arrest of unknown etiology. Further history from her family was nonspecific; the patient had experienced generalized malaise, diarrhea, and poor oral intake for several days. Her medications included furosemide, spironolactone, levothyroxine, warfarin, and simvastatin, although this information was unavailable initially. Upon arrival, a pulseless electrical activity (PEA) rhythm was diagnosed, and the patient was endotracheally intubated while CPR and advanced cardiac life support (ACLS) protocols were initiated. Following one round of CPR and resuscitative medications, the patient remained in PEA; thus, a point-of-care echocardiogram from the subcostal window was attempted. An indeterminate subcostal four-chamber view of the heart was shown during CPR. No meaningful information could be obtained about cardiac anatomy or reversible causes of cardiac arrest (Video 1). In this case, point-of-care transesophageal echocardiography (TEE) was performed to avoid CPR interruptions while capitalizing on the information that echocardiography can provide. The TEE probe was inserted without difficulty to reveal the following midesophageal fourchamber view (Video 2). Manuscript received March 11, 2014; revision accepted May 30, 2014. AFFILIATIONS: From the Division of Critical Care (Drs Arntfield and Wu), Western University, London; and Division of Critical Care (Dr Millington), University of Ottawa, Ottawa, ON, Canada. CORRESPONDENCE TO: Robert T. Arntfield, MD, FCCP, Western University, Division of Critical Care, 800 Commissioners Rd E, Room D2-521A, London, ON, N6A5W9, Canada; e-mail: robert.arntfield@ gmail.com © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-3029
e156 Ultrasound Corner
In this midesophageal four-chamber view of the heart, all cardiac chambers were visualized in addition to the pericardium. The heart (particularly the right ventricle) was being displaced by chest compressions during CPR. With a persistent bradycardic PEA rhythm, CPR was continued along with appropriate ACLS medications. Transcutaneous pacing was attempted but failed due to body habitus, thus, a transvenous pacemaker was indicated. Central venous cannulation requiring a linear array transducer was used to image the patient’s neck (Video 3). The carotid artery was seen deep to the internal jugular vein (IJ), with movement related to chest compressions. Given the high risk of arterial cannulation, confirmation of guidewire placement was essential (Video 4). With respect to cannulation of the IJ, catheter placement proceeded, as the unique “J” of the guidewire can be seen traversing the superior vena cava in to the right atrium as seen from the midesophageal bicaval view (Fig 1). Once central access was established with a 6F introducer, a 5F balloon-directed transvenous pacemaker was inserted. Positioning of the pacemaker using flow-directed guidance was impossible due to the lack of
Figure 1 – J wire in bicaval view.
[
146#5 CHEST NOVEMBER 2014
]
adequate cardiac output, requiring direct visualization using TEE (Videos 5-7: ultrasound images during pacer insertion).
What causes of cardiac arrest can be excluded based on the images demonstrating return of circulation?
journal.publications.chestnet.org
e157
Answer: Pulmonary embolism, pericardial tamponade, acute coronary syndrome Discussion The pacemaker is in good position near the apex of the right ventricle. The paced rhythm shows a paradoxical septal motion (“bounce”) that can be appreciated during systole with the septum contracting slightly later than the rest of the left ventricle (LV). Additionally, the absence of pericardial fluid and absence of a D-shaped LV (suggestive of right-sided pressure overload, as may be seen in pulmonary embolism) can be appreciated. Furthermore, the quality of the LV contraction and absence of significant wall motion abnormalities rule out an acute coronary syndrome. The time from initial cardiac arrest until successful pacemaker capture was approximately 45 min. Once capture was achieved, good BP was confirmed and, remarkably, the patient demonstrated purposeful movements and required sedation. The ultimate etiology of cardiac arrest was determined to be hyperkalemia. A serum potassium level of 6.8 mM was discovered in her blood work, the result of which was returned after return of paced circulation. The hyperkalemia was caused by acute kidney injury from diarrheal illness in the context of spironolactone use. After correction of potassium level, she was no longer pacemaker dependent and was discharged home with full neurologic and functional recovery 6 days later.
provides real-time feedback on return of circulation and quality of CPR6 and, as shown in this case, may also help guide procedures. TEE may be safely used by intensivists with approximately 30 full studies required to attain proficiency for critical care and hemodynamic applications.6 In this case of cardiac arrest of unclear etiology, the patient required immediate echocardiography to exclude a reversible cause, but the transthoracic examination was inconclusive due to ongoing CPR (Video 1). Without interrupting CPR, a TEE probe was inserted to reveal a midesophageal four-chamber view (Video 2) that demonstrated no evidence of pericardial effusion or signs of cor pulmonale, suggestive of pulmonary embolism. Due to the need for central venous access, ultrasound guidance was easily used to guide the procedure (Video 3) showing a high-risk relationship between the IJ and carotid artery. The risk of dilating the carotid was minimized by using the TEE to confirm venous guidewire location (Fig 1, Video 4). Transvenous pacemaker insertion was assisted by TEE visualization and was extremely valuable in the context of difficult electrical capture (Videos 5-7). For TEE in cardiac arrest, providers’ assessment of compression quality is guided largely by feedback regarding fatigue states from the individual performing compressions. Placement of a TEE probe may provide real-time visualization of chest compression quality through changes in chamber size and Doppler can be used to quantitatively analyze the output across the aortic valve.7
This case illustrates several challenges faced by clinicians during the resuscitation of a patient in cardiac arrest, particularly those with PEA. ACLS algorithms advocate for continued resuscitation while concomitantly considering and treating potentially reversible causes of the arrest.1 Transthoracic echocardiography (TTE) is a powerful tool in addressing reversible causes in arrest with pertinent findings identified in as many as 40% of patients.2 Furthermore, when complete cardiac standstill is seen during an arrest it is associated with uniformly poor clinical outcome,3-5 adding an important prognostic role for this tool.
TEE performed in intraoperative cardiac arrests during noncardiac surgeries has demonstrated the ability to identify an underlying etiology in eight of 10 cases, with subsequent direction to definitive management.8 In a study of in-hospital and out-of-hospital cardiac arrest, use of TEE intraarrest was found to have a sensitivity of 93%, specificity of 50% and a positive predictive value of 87% in identifying myocardial infarction, pulmonary embolus, aortic dissection, cardiac tamponade, and papillary muscle rupture as causes of the arrest.9
Realizing the potential of TTE in cardiac arrest typically requires interruption of CPR to permit image acquisition. This case demonstrates a technique to eliminate this compromise through the use of TEE. Providing very high-quality images, the probe may be left in situ throughout resuscitation, acting as an advanced diagnostic tool and continuous monitor. TEE
Though TEE is commonly seen as a tool to answer advanced clinical questions such as aortic dissection or endocarditis, basic questions such as the presence or absence of cardiac contractility during a pulse check may be answered easily and rapidly using TEE. Basic critical care echocardiography calls for competence in assessing a variety of clinical syndromes, including
e158 Ultrasound Corner
[
146#5 CHEST NOVEMBER 2014
]
circulatory arrest, with no distinction between TEE or TTE for this purpose.10
Reverberations
2.
1. TEE provides real-time anatomic monitoring during cardiac arrest, relieving tension over the importance of continuous CPR and the value of transthoracic echocardiographic information that typically requires interruptions to permit image generation.
4.
2. TEE during cardiopulmonary resuscitation is very effective at diagnosing potentially occult yet reversible etiologies of cardiac arrest.
5.
3.
3. Point-of-care TEE can help guide invasive procedures, especially in emergency scenarios.
6.
Acknowledgments
7.
Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
8.
Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
9.
Additional information: To analyze this case with the videos, see the online version of this article.
References 1. Sayre MR, Koster RW, Botha M, et al; Adult Basic Life Support Chapter Collaborators. Part 5: adult basic life support: 2010
journal.publications.chestnet.org
10.
international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2010;122(16)(suppl 2): S298-S324. Tayal VS, Kline JA. Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states. Resuscitation. 2003;59(3):315-318. Salen P, Melniker L, Chooljian C, et al. Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Am J Emerg Med. 2005;23(4): 459-462. Salen P, O’Connor R , Sierzenski P, et al. Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes? Acad Emerg Med. 2001;8(6): 610-615. Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med. 2001;8(6):616-621. Charron C, Prat G, Caille V, et al. Validation of a skills assessment scoring system for transesophageal echocardiographic monitoring of hemodynamics. Intensive Care Med. 2007;33(10):1712-1718. Pell AC, Guly UM, Sutherland GR, Steedman DJ, Bloomfield P, Robertson C. Mechanism of closed chest cardiopulmonary resuscitation investigated by transoesophageal echocardiography. J Accid Emerg Med. 1994;11(3):139-143. Lin T, Chen Y, Lu C, Wang M. Use of transesophageal echocardiography during cardiac arrest in patients undergoing elective non-cardiac surgery. Br J Anaesth. 2006;96(2):167-170. van der Wouw PA, Koster RW, Delemarre BJ, de Vos R, LampeSchoenmaeckers AJ, Lie KI. Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation. J Am Coll Cardiol. 1997;30(3):780-783. Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;135(4):1050-1060.
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