Point-of-Care Cardiac Ultrasound during Pediatric Cardiac Arrest (PLS #814): Scoping Review

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This Review is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final Review will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None applicable

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: None applicable

Task Force Scoping Review Citation

Atkins DL, VandeVoorde P, Maconochie I, Aicken R, Bingham R, Couto TB, de Caen A, Guerguerian AM, Nadkarni V, Ng KC, Nuthall G, Ong G, Reis A , Schexynader S, Tijssen J , Scholefield B, Scholefield B on behalf of the International Liaison Committee on Resuscitation Paediatric Life Support Task Force. Point-of-Care Ultrasound during pediatric cardiac arrest. Pediatric Life Support Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation, and Teams Task Force, 2020 January 03. Available from: http://ilcor.org

Methodological Preamble

The continuous evidence evaluation process started with a scoping review of Point-of-care cardiac ultrasound during cardiac arrest conducted by the ILCOR PLS Task Force Scoping Review team. Evidence for pediatric literature was sought and considered by Pediatric Task Force.

Scoping Review

Not published at this stage.

PICOST

Population: Infants & Children in any setting (in-hospital or out-of-hospital) with cardiac arrest

Intervention Point-of-care ultrasound (echocardiography) during cardiac arrest: the presence of variables -images, cut-off values or trends- during CPR (intra-arrest) that can provide physiologic feedback to guide resuscitation efforts.

Comparators: the absence of such factors -images, cut-off values or trends

Outcomes: Any clinical outcome.

Study Designs:

Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies). If it is anticipated that there will be insufficient studies from which to draw a conclusion, case series may be included in the initial search. The minimum number of cases for a case series to be included will be 3. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded.

Timeframe: All literature from 2010 and all languages are included, as long as there is an English abstract.

Search Strategies

Pub Med

(((((((((((((((((((Cardiopulmonary resuscitation) AND Point-of-care systems)) OR ((cardiopulmonary resuscitation) AND echocardiography, transesophageal)) OR ((cardiopulmonary resuscitation) AND echocardiography, transthoracic)) OR ((cardiopulmonary resuscitation/methods*) AND Echocardiography)) OR heart arrest/diagnostic imaging*) OR ((out-of-hospital cardiac arrest/diagnostic imaging) AND echocardiography))) OR ((Cardiopulmonary resuscitation) AND Point-of-care systems)) OR ((cardiopulmonary resuscitation) AND echocardiography, transesophageal)) OR ((cardiopulmonary resuscitation) AND echocardiography,transthoracic)) OR ((cardiopulmonary resuscitation/methods*) AND Echocardiography)) OR heart arrest/diagnostic imaging*) OR ((out-of-hospital cardiac arrest/diagnostic imaging) AND echocardiography)) OR (in-hospital cardiac arrest/diagnostic imaging AND echocardiography)) AND Humans[Mesh])) OR ((in-hospital cardiac arrest) AND echocardiography AND Humans[Mesh])) OR ((in hospital cardiac arrest) AND point-of-care systems AND Humans[Mesh]) Filters: Humans

Searched Aug 14 2019 2265 articles, 2 selected

Searched Dec 6 2019 No new articles

EMBASE

Resuscitation AND transthoracic echocardiography AND diagnostic imaging

References 69

No new references

Cochrane

(Cardiopulmonary arrest AND echocardiography) OR (heart arrest AND echocardiography) or heart arrest AND diagnostic imaging or cardiopulmonary resuscitation AND point0of-care systems)

No new references

Inclusion and Exclusion criteria

Inclusion criteria:

Studies that address the population and intervention described above are eligible for inclusion.

Use of Echocardiography during pediatric cardiac arrest

Age < 18 years

Exclusion criteria:

1. Newborn at Delivery

2. Pre-arrest ‘case’ features, not influenced by ALS: time of day, location, bystander CPR, gasping, age, etiology, initial rhythm, unwitnessed…

3. The ALS interventions themselves, performed to influence the parameters mentioned e.g. ventilation strategies, fluids, firm surface, medications given, eCPR, length and Quality of CPR….

4. Post-ROSC parameters such as lactate clearance, post-arrest rhythm, hypotension nor any actions to provide neuroprotective care post-ROSC.

5. Adults/animals, simulation and mannikin studies.

6. Ultrasound of other part of the body including abdomen or vascular anatomy

7. Unpublished studies (e.g., conference abstracts, trial protocols).

Data Tables

Table 1 Pediatric studies Echocardiography during cardiopulmonary resuscitation

Author,

year

Design, Country

Population

Intervention/Comparator

Main findings

Notes

Steffen, 2017 {Steffen 2017 58}

Retrospective

Case series,

n=3 patients IHCA Single center, urban hospital

Subcostal 4-chamber images obtained to assess for reversible causes of cardiac arrest, images acquired by intensive care physician.

Cardiac standstill noted in all 3 patients, all with ECPR. Cardiac contractility regained on ECMO

1 patient successfully decannulated, suffered 2nd arrest 3 months later and died. ECMO withdrawn from other two secondary to hypoxic brain injury and complications of ECMO

Morgan, 2018 {Morgan, 2018 3229

Retrospective case series USA

n=5 patients IHCA, Single center, large children’s hospital

Age15-17 years

Bedside echocardiography during CPR in patients at high risk for pulmonary embolism

RV dilatation and systolic dysfunction, all associated with low ETCO2. Embolus not directly seen on echocardiographic images

No description of location of images, all patients at high risk for PE, all received thrombolysis, 4 patients survived, 3 with no neurologic injury

Task Force Insights

1. Why this topic was reviewed.

This topic was reviewed because it had not been reviewed by ILCOR since 2010 and there has been a marked increase in use of the technology since that time.

The current treatment recommendation:

There is insufficient evidence to recommend for or against the routine use of echocardiography during pediatric cardiac arrest. Echocardiography may be considered to identify potentially treatable causes of an arrest when appropriately skilled personnel are available, but the benefits must be carefully weighed against the known deleterious consequences of interrupting chest compressions

  1. Narrative summary of evidence identified

Only two pediatric studies were identified. The first pediatric study, where pulmonary emboli were diagnosed, subcostal 4-chamber images were obtained by intensive care physicians to assess for reversible causes of cardiac arrest, all patients were treated with thrombolysis and 80% survived to hospital discharge. {Morgan2018 e229} These patients were known to be a high risk for PE and 2/5 were known to have had pulmonary emboli prior to or during the arrest.

The other study was a published report of complete standstill, where bedside echocardiography was performed during CPR in patients at high risk for pulmonary embolism. RV dilatation and systolic dysfunction were associated with low ETCO2. Emboli were not directly seen on echocardiographic images. The study recognised that with the addition of ECMO, standstill during the resuscitation may not indicate complete lack of resuscitation success. {Steffen 2017 58}.

  1. Narrative Reporting of the task force discussions

The use of bedside, focused echocardiography during cardiac arrest is growing in the adult and pediatric population. The technique has been recommended by several international groups{Atkinson 2017 459} and guidelines have been published.{Levitov 2016 1206} Additionally, the American Academy of Pediatrics has also published guidelines for point-of-care ultrasonography by pediatric emergency physicians.{Marin 2015 472} Thus, use of the imaging technique is frequently used despite a lack of good evidence in the pediatric cardiac arrest population. The task force recognizes three questions that pertain to the use of point-of-care ultrasound during pediatric cardiac arrest:

1. Can diagnostic level images be reliably obtained by non-cardiology sonographers

2. Can reversible causes of cardiac arrest (i.e., pulmonary embolus, cardiac tamponade) be diagnosed with high sensitivity and specificity.

3. Can the procedure be used to predict outcome?

Multiple studies demonstrate that both in-hospital and pre-hospital providers can adequately and quickly obtain images from which clinical decisions can be made, although there is concern about delay or longer pauses in chest compressions which will have deleterious effects on outcomes.{Fitzgibbon 2019 297; Hu 2018 193; Chin 2013 142} Pauses in CPR increased from a median of 11 seconds to a median 17 seconds when echocardiography was used. However, implementation of a protocol shortened these pauses.{Clattenburg 2018 69; Clattenburg 2018 122} There is also inconsistency in the interpretation of cardiac activity.{Hu 2018 193} Definitions have included synchronous change in chamber diameter, any wall motion, valve motion or twitching. In children, acquisition of images may be more difficult related to smaller chest sizes, especially when defibrillator pads are attached. There may be insufficient space to place the transducer without pauses in chest compressions which could be prolonged. The presence of abnormal cardiac anatomy with baseline abnormalities in ventricular size or presence may compound difficulties in interpretation. Longjohn et al, in a study of POC echocardiography by pediatric emergency physicians in acutely ill children specifically excluded patients with single ventricle anatomy because of the complexity of interpreting the images as well as altered IVC physiology.{Longjohn 2011 693}

Detection of reversible causes of cardiac arrest has potential to dramatically improve outcomes. The guidelines have long recognized the need to search for a reversible cause and the 4 H’s and 4 T’s are a common part of most algorithms. Empiric tests, potentially time-consuming, are not as necessary if a reversible diagnosis can be made directly at the onset of the resuscitation. Diagnosis of pulmonary emboli and cardiac tamponade are well documented in the adult literature. {Long 2018 488; Miesemer 2017 40} In the one pediatric study where pulmonary emboli were diagnosed, all patients were treated with thrombolysis and 80% survived to hospital discharge. {Morgan2018 e229} These patients were known to be a high risk for PE and 2/5 were known to have had pulmonary emboli prior to or during the arrest. Diagnosis of pulmonary emboli is presumed when the RV is dilated with poor function. This may be a baseline finding in children with congenital heart disease making the diagnosis of a PE more problematic in children. Diagnosis of a pericardial effusion with tamponade is made by a large echo-free space completely surrounding the ventricles.

Several large adult studies have reported mortality of 94-100%, in patients with out-of-hospital cardiac arrest who demonstrated cardiac standstill {Salen 2005 459; Salen 2001 610; Breitkreutz 2010 1527} The use of echocardiography to assess prognosis and especially futility is perhaps a more difficult problem in pediatrics since differences in physiology and etiology affect outcomes. The one published report of complete standstill demonstrated that with the addition of ECMO, standstill during the resuscitation may not indicate complete lack of resuscitation success. {Steffen 2017 58}

There is significant cost associated with purchase of equipment and training of users. This may limit its use, especially in limited resource settings.

Although the Task Force recognizes that this technology is undergoing great acceptance with the pediatric critical care, emergency and resuscitation communities and has great potential within the pediatric population, the Task Force urges caution is extrapolating directly from the adult studies. There are significant differences in etiology, anatomy, and technical issues which may impact the usefulness and accuracy of echocardiography during cardiac resuscitation.

Echocardiography may be able to identify potentially treatable causes of an arrest when appropriately skilled personnel are available, but the benefits must be carefully weighed against the known deleterious consequences of interrupting chest compressions. Additionally, there is inadequate data in the pediatric literature about intra-arrest prognostic value and the Task Force urges great caution until more literature is available.

This scoping review has not identified sufficient new evidence to prompt new systematic reviews or reconsideration of current resuscitation guidelines/treatment recommendations,

Knowledge Gaps

There were no prospective or controlled trials of cardiac ultrasound during pediatric cardiac arrest. Surrogate and short-term outcomes such as ability to make or confirm a reversible diagnosis and documentation of cardiac standstill were the only outcomes studied.

References

References listed alphabetically by first author last name in this citation format (Circulation)

Atkinson P, Bowra J, Milne J, Lewis D, Lambert M, Jarman B, Noble VE, Lamprecht H, Harris T and Connolly J. International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest. Cjem. 2017;19:459-470.

Breitkreutz R, Price S, Steiger HV, Seeger FH, Ilper H, Ackermann H, Rudolph M, Uddin S, Weigand MA, Muller E and Walcher F. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation. 2010;81:1527-33.

Chin EJ, Chan CH, Mortazavi R, Anderson CL, Kahn CA, Summers S and Fox JC. A pilot study examining the viability of a Prehospital Assessment with UltraSound for Emergencies (PAUSE) protocol. J Emerg Med. 2013;44:142-9.

Clattenburg EJ, Wroe PC, Gardner K, Schultz C, Gelber J, Singh A and Nagdev A. Implementation of the Cardiac Arrest Sonographic Assessment (CASA) protocol for patients with cardiac arrest is associated with shorter CPR pulse checks. Resuscitation. 2018;131:69-73.

Clattenburg EJ, Wroe P, Brown S, Gardner K, Losonczy L, Singh A and Nagdev A. Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: A prospective cohort study. Resuscitation. 2018;122:65-68.

Fitzgibbon JB, Lovallo E, Escajeda J, Radomski MA and Martin-Gill C. Feasibility of Out-of-Hospital Cardiac Arrest Ultrasound by EMS Physicians. Prehosp Emerg Care. 2019;23:297-303.

Hu K, Gupta N, Teran F, Saul T, Nelson BP and Andrus P. Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med. 2018;71:193-198.

Levitov A, Frankel HL, Blaivas M, Kirkpatrick AW, Su E, Evans D, Summerfield DT, Slonim A, Breitkreutz R, Price S, McLaughlin M, Marik PE and Elbarbary M. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part II: Cardiac Ultrasonography. Crit Care Med. 2016;44:1206-27

Long B, Alerhand S, Maliel K and Koyfman A. Echocardiography in cardiac arrest: An emergency medicine review. Am J Emerg Med. 2018;36:488-493

Longjohn M, Wan J, Joshi V and Pershad J. Point-of-care echocardiography by pediatric emergency physicians. Pediatr Emerg Care. 2011;27:693-6

Marin JR and Lewiss RE. Point-of-care ultrasonography by pediatric emergency physicians. Policy statement. Ann Emerg Med. 2015;65:472-8.

.Miesemer B. Using Ultrasound for Cardiac Arrest POCUS can improve detection and treatment of underlying pathologies. EMS World. 2017;46:40-42

Morgan RW, Stinson HR, Wolfe H, Lindell RB, Topjian AA, Nadkarni VM, Sutton RM, Berg RA and Kilbaugh TJ. Pediatric In-Hospital Cardiac Arrest Secondary to Acute Pulmonary Embolism. Crit Care Med. 2018;46:e229-e234

Salen P, O'Connor R, Sierzenski P, Passarello B, Pancu D, Melanson S, Arcona S, Reed J and Heller M. Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes? Acad Emerg Med. 2001;8:610-5.

Salen P, Melniker L, Chooljian C, Rose JS, Alteveer J, Reed J and Heller M. Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Am J Emerg Med. 2005;23:459-62

Steffen K, Thompson WR, Pustavoitau A and Su E. Return of Viable Cardiac Function After Sonographic Cardiac Standstill in Pediatric Cardiac Arrest. Pediatr Emerg Care. 2017;33:58-59


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