Skip to main content

Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest

Journal Club

Methodology Score: 3/5
Usefulness Score: 3.5/5

Gaspari R, et al.
Resuscitation. 2016 Sep 28;109:33-39.

Abstract Link

This prospective, per-protocol observational study is now the largest study on the point of care ultrasound in cardiac arrest (specifically PEA/asystole). It demonstrates that the presence of cardiac activity is the variable most associated with survival in cardiac arrest (more than bystander CPR, for example), with an OR of 3.6 for survival to admission, and 5.7 for survival to discharge. Ultrasound may also allow one to diagnose tamponade or right heart strain (due to massive PE) as potential causes of an arrest. Hence, it should likely be included as a part of any PEA/asystole resuscitation algorithm.

However, it should be noted that the strength of this study is limited by the potential selection bias that occurred with convenience sample enrolment, as well as the performance bias that resulted from it being unblinded (allowing clinicians to alter their care based on the ultrasound, and thus potentially affect outcomes). As well, it should be noted that the lack of cardiac activity cannot predict futility with absolute certainty, as 3 of the patients without cardiac activity (0.6%) still survived to discharge. Rather than acting as a hard decision point, the lack of cardiac activity (or presence) should be intergrated into the total clinical picture, albeit as likely the strongest prognostic factor.
By: Dr. Francis Bakewell

Epi lesson

Performance Bias
Performance bias in this study refers to potential systematic differences in the care provided between groups other than the interventions of interest (point-of-care ultrasound). After enrolment, blinding (or masking) of physicians to the ultrasound results (specifically with regards to cardiac activity) might have reduced any bias introduced by the vigour of resuscitation which in itself affects outcomes. Hence, effective blinding would have ensured that the groups (with and without cardiac activity) received similar amount of attention and treatment.
By: Dr. Venkatesh Thiruganasambandamoorthy


Popular posts from this blog

Tips for Success in your Emergency Medicine Rotation

Our wonderful medical students are preparing to start their first clinical rotations. With this in mind here are some of the top tips for success in your EM rotation
1)Be On Time – show up to your shifts on time, better yet 5 minutes early.That first impression is immensely important.
2)Introduce yourself to the team - “Hi my name is John Doe, I am the medical student on shift today” introduce yourself to the attending, residents, nurses, etc.You will be called on a lot more to help when there is something interesting going on if they know your name.
3)Be goal-oriented – have a goal for each shift, whether it’s a procedure or a type of presentation to see.
4)Don’t just stand there, do something – whenever there is a trauma or code, come to the bedside.Get gowned up for traumas and pay attention.Help with things that are within your scope of practice: chest compressions, moving patient, cardioversion
5)Don’t just stand there, do nothing – there are times in medicine when the best thing to d…

2014 Canadian Guidelines for AF Management: Part 1: Introduction and CCS “CHADS-65” Algorithm

by Ian Stiell MD @EMO_Daddy

In this and subsequent postings we will discuss the latest recommendations for ED management of atrial fibrillation (AF) as presented in the newly published 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. The Guidelines PDF can be downloaded from the CCS website at 2014 Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation
The 2014 Focused Update uses the GRADE system of evidence evaluation as was the case in the comprehensive 2010 AF Guidelines and the 2012 Update. The CCS AF Guidelines Panel is comprised of Canadian cardiologists plus physicians from internal medicine, family medicine, neurology, and emergency medicine. This 2014 Update provides evidence review and recommendations for 8 aspects of AF care, including ED Management (written by myself and Dr. Laurent Macle of the Montreal Heart Institute). The 2014 Update focuses on advances in oral anticoagulant (O…

You CAN reverse that! Reversal of NOAC's and more..

We have seen a large surge of the utilization of New Oral Anticoagulants (NOAC's) in the past few years, as such, it has been a novel challenge when these patients present to the Emergency Department (ED) with life threatening bleeding. Dr. Michael Ho looks to discuss treatment options, and future options in these patients. 
NOACs vs WarfarinDabigatran, Rivaroxaban and Apixaban have seen a dramatic increase in use since their approval in Canada. Dabigatran is a direct thrombin (Factor II) inhibitor, while the latter two are direct Xa inhibitors. These drugs are collectively referred to as novel oral anticoagulants (NOACs). They have also been called direct, or target-specific oral anticoagulants (DOACs or TSOACs) [1]. 
The NOACs have many practical advantages over warfarin: Rapid onset of actionShorter half-lifeLess food and drug interferencePredictable pharmacokineticsEase of use and no requirement for monitoringThe downsides to NOACs are the higher cost to the patient, the inabilit…