Clinical paperFocused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: A prospective trial☆,☆☆
Introduction
Pulselessness or severe shock of unknown origin is generally initially managed according to Basic and Advanced Life Support guidelines.1, 2, 3 Emergency echocardiography has been proposed as a basic diagnostic tool for the haemodynamically unstable critically ill patient, for acute severe dyspnoea, and during cardio-pulmonary resuscitation.4, 5, 6, 7, 8 Further, early echocardiography is now recommended in guidelines relating to the diagnosis of suspected pulmonary embolism or pericardial effusion.9, 10 Focused echocardiographic evaluation in life support (FEEL) has been developed to be used by cardiologists and non-cardiologists alike, as an adjunct to resuscitation in an ALS-compliant manner.11, 12, 13 The aim is to use FEEL to diagnose/exclude some of the potentially treatable causes of cardiac arrest, including tamponade, massive pulmonary embolism, severe ventricular dysfunction, and hypovolaemia as well as fine ventricular fibrillation missed by surface ECGs thereby optimizing peri-resuscitation care. Hence the use of FEEL is to improve resuscitative efforts but not to terminate resuscitation. The purpose of this study was to evaluate the feasibility of FEEL in pre-hospital resuscitation, the incidence of potentially treatable conditions detected, and the influence on patient management.
Section snippets
Study design
Ethical approval was obtained from the Institutional Ethics Committee for Human Studies, University Hospital, Frankfurt am Main, Germany. A prospective observational study with data acquisition controlled using STARD criteria for diagnostic trials and abbreviated Utstein-style data sets was performed.14, 15
Study setting
Patients were enrolled between August 2002 and December 2007. Four emergency medical systems (EMS) were involved: Frankfurt (urban), Darmstadt (urban and rural) and Raststatt (suburban). The
Results
A total of 230 patients (male 141, female 84; age: 65 ± 19 years) were enrolled in the study (Fig. 1). CPR was required in 100 patients and performed according to the ALS guidelines. Peri-resuscitation echocardiography was performed in all of these cases according to the FEEL protocol. Echocardiography was used in an additional 104 cases where the patient was judged to be in a peri-resuscitation state (but not currently requiring CPR). In 26 cases ultrasound was used additionally for abdominal or
Discussion
The concept of ALS-compliant echocardiography using the FEEL algorithm is gaining acceptance.11, 12, 13, 36 This study demonstrates that FEEL can be performed in the pre-hospital setting, resulting in the diagnosis of a significant number of potentially treatable underlying conditions and subsequent alteration in patient management.
The use of echocardiography or ultrasound by novice practitioners has been shown to be feasible in the emergency setting, with success in obtaining images and
Conclusion
Out-of hospital echocardiography using FEEL is feasible, and can be performed by EPs. The findings of this study call into question some of the peri-arrest diagnoses that are made, and demonstrate that echocardiography can be used in the pre-hospital setting to diagnose many of the potentially reversible causes of cardiac arrest, not identifiable by any other means, thereby changing patient management. The potential to improve patient outcome, and the implications upon fine-tuning the
Conflict of interest
There are no conflicts of interest to declare.
Author contributions
RB, FHS, FW designed the study. HVS, FS reviewed results for the study protocol. EM, FHS and FW performed data collection. RB, HS, HI, HA, EM, FW analysed the data. RB, MAW, SU and SP prepared and revised the manuscript. RB, HVS, EM and FW take responsibility of the results and the paper as a whole.
Acknowledgements
We are obliged to the participating EP and patients, the Frankfurt Fire Department (Prof. R. Ries) and chief of pre-hospital EMS of the city of Frankfurt am Main (Prof. Leo Latasch). Following colleagues were generously participating in data acquisition or advised in planning or execution of the study: U. Hannemann, M. Goebel, S. Kortüm, D. Oberndörfer, Th. Weber, K. Rimbach, C. Byhahn, S. Fichtlscherer. We thank I. Marzi, B. Zwißler and P. Kessler for continuous support.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.07.013.
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The study was presented in part during the 9th Congress of the European Resuscitation Council in Budapest/Hungary, 8th September 2004.