Echocardiographic observations during inhospital cardiopulmonary resuscitation

OBJECTIVE: To assess echocardiographic observations during in hospital cardiopulmonary resuscitation (CPR) and the utility of this information in the management of cardiac arrest. DESIGN: Echocardiographic system brought to the hospital site of cardiac arrest and applied to patients in conjunction with conventional CPR. SETTING: Large community-hospital with portable echocardiographic system and an alerted cardiology team skilled in this technique. MEASUREMENTS AND MAIN RESULTS: Mechanical asystole was initially observed in 18 (90%) of 20 cardiac arrest patients during CPR, including four patients with severe bradyarrhythmia as the arrest rhythm. The return of ventricular contractions in four of these 18 patients a short time after starting CPR prompted positive inotropic therapy. Ventricular wall motion was noted in two patients with severe bradyarrhythmia (pseudo-electromechanical dissociation) and the causes of cardiac arrest identified as massive pulmonary embolism and hypovolemia, respectively. A gel-like, coalescent echo contrast within the cardiac chambers was observed 20 to 30 mins after CPR in ten patients with unrelenting cardiac arrest and uniformly associated with an adverse outcome. Six patients survived resuscitation but only two patients survived to hospital discharge. CONCLUSIONS: An echocardiographic examination is feasible during CPR and may offer useful information in the management of the individual patients with cardiac arrest. It may depict the proximate cause of cardiac arrest, e.g., pulmonary embolism, cardiac tamponade, or hypovolemia, and signal the return of ventricular contractions in patients with initially absent mechanical activity. The appearance of intracardiac coalescent echo contrast in our patients with unrelenting cardiac arrest was associated with a failed outcome. The role of echocardiographic imaging in the setting of advanced cardiac life support requires further study.