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POCUS in ACLS Algorithm

Multiple protocols have been designed with the intent of integrating POCUS into advanced cardiac life support (ACLS safely). However there is no single best approach is widely accepted as best practice. What is clear though is that time is of the essence in arrest cases and a clinician should avoid exceeding the 10 second pauses between chest compressions. POCUS should not be used for prognostication purposes. As of now it is acceptable to continue resuscitation efforts that end up proving futile than to erroneously terminate resuscitation in a patient who would have otherwise survived. 

The following is a concerted attempt at facilitating your differential while following best practices.  To learn more about the theory behind the use of POCUS click here. Before you start make sure you have followed best practices here.  To proceed click start. In order to review what TEE probe is compatible with your US machine click What TEE probe to use.

Best Practices for the use of POCUS in ACLS

  1. POCUS should only be used during rhythm check and should not interfere with CPR efforts

  2. Prepare the curvilinear or the phased array probe so that image acquisition lasts 10 seconds. When you click the 'aquire' button, it usually records only 3 seconds of your scan and may not be time enough for you to record. 

  3. Appoint a 'Time Keeper' so that POCUS lasts less than 10 seconds.

  4. On pulse check ONLY acquire. Interpret images when chest compressions have resumed.

  5. During the time of chest compressions, the sonographer can look at extra cardiac images such as Lung/Abdomen/ Vascular.

  6. Communicate results with the rest of the team. 

  7. You should continue to obtain more scans once you have returns of spontaneous circulation to verify your impression or to change management.

Best Practices
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Scanning Regions

Colors indicate timing of scan:

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Blue: During Chest Compressions

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Red: During Pulse Check

Scan Regions

PEA vs Shockable rythms

True vs Pseudo PEA

Differentiate between True PEA vs Pseudo PEA. Are you seeing any of the following images?

Asystole| PEA

VT|VF or SVT

VT|VF or SVT

PEA 

Your are seeing a True PEA an thus need to continue to look for a reversible  cause:

Ultrasound will not be able to help you with the following differential diagnosis and you should tackle them as you proceed with this algorithm:

1.  Hydrogen ion. Acidosis.
2. Hypothermia.
3. Hypoglycemia.
4. Hypokalemia/ Hyperkalemia.
5. Toxins.



 

True PEA

Shockable rythms

Based on the images displayed the differential diagnosis:

1. If you see a wide complex QRS, this is VT or VF. In which case defribillation is warranted.





2. If you observe a narrow complex QRS this is SVT. In which case synchronized cardioversion is warranted.




 

SVT-shock-advised.jpg
ventricular-fibrillation-rhythm-strip-VF-shock-advised.jpg
Pseudo PEA

Hypoxemia

Address hypoxemia by either Mask Ventilation, placing an Laryngeal Mask Airway and performing intubation as recommended by the ACLS guidelines. Ultrasound at this point may help you understand the cause of hypoxemia if the cardiac arrest was secondary. Look at both the lung and the gastric antrum. Pneumothorax determination next:

Hypoxemia

Consolidation

Pulm Edema

Pleural Effusion

Click here for lung exam.

Gastric Ultrasound:

 

Grade 2 Antrum

Full Stomach

Full Stomach

Click here for gastric exam evaluation

Hypovolemia

Presence of normal filled ventricles and a collapsed inferior vena cava is suggestive of hypovolemia. You may not see a collapsed ventricles. Should any of the following images are seen, consider acute blood loss anemia and FAST exam. 

Hypovolemia

Heart, Lung and Abdomen POCUS can assist you in evaluating for signs of hypovolemia:

 

Hyperdynamic LV

Collapsed IVC

Positive FAST exam

Pleural effusion

Click on link: Fluid responsiveness algorithm and  FAST exam for more information

If these were not seen then:

Cardiac Tamponade

Rule out cardiac tamponade by NOT seeing pericardial fluid. 

ACLS Tamponade

Cardiac Tamponde

Cardiac Tamponde

For more information on how to evaluate tamponade click the link: pericardial effusion 

If these were not seen then:

Tension Pneumothorax

Click here to take you to the pneumothorax algorithm:

ACLS pneumth

Thrombosis, Coronary

Visualizing severe left or right ventricular hypokinesis raises the concern for coronary thrombosis on the differential. 

Possible LV MI

Possible RV MI

For more information click on this text.

If these were not seen then:

ACLS ACS

Thrombosis, Pulmonary

You can rule it in with the following images but there is no finding that can rule it out. LH for likelihood.

ACLS PE

High LH PE

High LH PE

High LH PE

High LH PE

For more information click on the links:

References

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1. Jonathan A. Paul, Oliver P. F. Panzer; Point-of-care Ultrasound in Cardiac Arrest. Anesthesiology 2021; 135:508–519 doi: https://doi.org/10.1097/ALN.0000000000003811

2. Merchant R and all. Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation. 2020;142:S337–S357.  https://doi.org/10.1161/CIR.0000000000000918

3. Berg KM and all. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142:S92–S139. https://doi.org/10.1161/CIR.0000000000000893

4. Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, Porter TR, Spencer KT, Tayal VS, Wei K: Focused cardiac ultrasound in the emergent setting: A consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010; 23:1225–30

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