Using Ultrasound in the Decision to Terminate Cardiac Resuscitation Byron Czerniski, MS4 SKMC of Thomas Jefferson University

Summary Overview of the decision to Terminate Resuscitation efforts Importance of clear termination guidelines How Ultrasound can be used to decide to terminate resuscitation. How accurate is ultrasound in deciding when to terminate efforts? Journal Review: “Outcome in Cardiac Arrest Patients Found to Have Cardiac Standstill on the Bedside Emergency Department Echocardiogram.” Academic Emergency Medicine (June 2001).

Current Guidelines Unclear Physicians’ determination of Futility complicated by clinical features: -Comorbid disease, time to CPR/defibrillation, baseline status, etiology of arrest, etc. Prehospital BLS rule Cardiac Standstill on Bedside Echo End-Tidal CO2 <10-15. Stop after 20 min of Asystole Continue as long as there is VF

Importance of Clear Guidelines 300,000 Outside Hospital Cardiac Arrests in United States with 9.6% survival rate. Cost: Mollberg et al. found 294 traumatic arrest patients met criteria for EMS TOR $3,852,446.65. 0.3% survived but had GCS of 6. Pressure on ED Physicians: Goto et al. found 92% of physicians stated fear of litigation as the reason for continued efforts. Bias: Kang et al. found ED physicians terminated resuscitation earlier for women and older patients independently of currently recognized poor prognostic factors.

Bedside Ultrasound for determining TOR Use curvilinear or phase array probe. Subxiphoid view is common. Standstill is no myocardial contraction. Valves may still move due to fluid movement in the vasculature. Standstill can be documented as a video clip or in M mode. Cardiac Standstill Can differentiate fine Vfib vs. Asystole Pericardial effusion.

MICHAEL BLAIVAS, MD, JOHN CHRISTIAN FOX, MD How accurate is bedside US for determining Mortality in Outside hospital Cardiac Arrest? Journal Article: Outcome in Cardiac Arrest Patients Found to Have Cardiac Standstill on the Bedside Emergency Department Echocardiogram MICHAEL BLAIVAS, MD, JOHN CHRISTIAN FOX, MD

Goals of the Study To determine if bedside ultrasound in the ED can accurately predict mortality in outside hospital cardiac arrest patients. Hypothesis: Patients with Cardiac Standstill on TTE have zero chance of survival.

Study Design Prospective Observational Study of patients brought to the ED in CPR Convenience sample when a study physician was available. High Acuity Urban Community Hospital from 1999 to 2000

Methods 173 patients over 18 years old receiving CPR. 4 excluded = 169 subjects 2.5 MHz curvilinear or phase array probe used. TTE was Subxiphoid. Parasternal when not well visualized. 30% by Attendings 40% by Residents under supervision from Attendings 30% by Residents unsupervised. Asystole defined as no myocardial contractions during the 5-10 second carotid or femoral pulse check. For patients declared dead, another 20 second TTE was performed to confirm.

Results -100% of patients with Cardiac standstill on US died -PPV 100% Asystole and Standstill PEA and Standstill PEA and Contractions VF and Standstill VF and Contractions Survived 12 8 Died 65 20 6 51 7 -100% of patients with Cardiac standstill on US died -PPV 100% -NPV 58% -Positive likelihood ratio of infinity -Negative likelihood ratio of 0.17

Limitations Sample size Lack of blinding Lack of randomization Accuracy of information provided about patient could not be verified. Physicians had varying levels of ultrasound experience (though all scans were reviewed by committee). TTE may have interfered with resuscitation. Patients were only selected when physician was available, may have compromised randomization. Future studies needed with multiple centers, heterogenous patient populations, and physicians with all levels of ultrasound experience.

Conclusions Ultrasound showed a 100% PPV for death when standstill was present. Standstill may represent the exhaustion of myocardial reserve and are therefore unable to be resuscitated. Ultrasound may be particularly helpful in cases of PEA and VF. Consider halting resuscitation when standstill is seen on US.

References Blaivas, M. and Fox, J. “Outcome in Cardiac Arrest Patients Found to Have Cardiac Standstill on the Bedside Emergency Department Echocardiogram.” Academic Emergency Medicine. 2001; 8:6 616-621. Goto, Y., Maeda, T., and Goto, Y. “Termination-of-resuscitation rule for emergency department physicians treating out-of-hospital cardiac arrest patients: an observational cohort study.” Critical Care. 2013; 17(5): R235. Kang, M., Kim, J., and Kim, K. “Resuscitation duration inequality by patient characteristics in emergency department out-of-hospital cardiac arrest: an observational study.” Clinical Experimental Emergency Medicine. 2014 Dec31;(2):87-93. Mollberg, N., Wise, S., Berman, K., Chowdhry, S., Holevar, M., Sullivan, R., and Vafa, A. The Consequences of Noncompliance with Guidelines for Withholding or Terminating Resuscitation in Traumatic Cardiac Arrest Patients.” Journal of Trauma. 2001 Oct;71(4):997-1002.