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Letter to the Editor: Resuscitative ultrasound – underappreciated need for the clarity in terminology

Published online by Cambridge University Press:  02 March 2020

Igor Barjaktarevic Open the ORCID record for Igor Barjaktarevic [Opens in a new window]  and
Oren Friedman
Igor Barjaktarevic*
Affiliation:
Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
Oren Friedman
Affiliation:
Division of Cardiothoracic surgery, Cedars Sinai Medical Center
*
Correspondence to: Dr. Igor Barjaktarevic, Division of Pulmonary and Critical Care, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, CHS Building, Los Angeles, CA, 90095; Email: ibarjaktarevic@mednet.ucla.edu

Abstract

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Keywords

POCUScardiac arrestresuscitationultrasound
Type
Letter
Information
Canadian Journal of Emergency Medicine , Volume 22 , Issue 3 , May 2020 , E2
Copyright
Copyright © Canadian Association of Emergency Physicians 2020

Dear Editor,

With pleasure, we read the manuscript of Dr. BecketReference Beckett, Atkinson and Fraser1 that reports SHoC-ED2 data analysis and suggests that absence of cardiac activity on point-of-care ultrasound (POCUS) better predicts negative outcomes in cardiac arrest (CA) than electrocardiogram (ECG) alone. Agreeing that this report solidifies the evidence for POCUS use in resuscitative medicine, we notice the need for additional clarification surrounding the terminology of resuscitative ultrasound.

The term, resuscitative ultrasound, has been used in published literature in reference to three different concepts: 1) POCUS in CAReference Beckett, Atkinson and Fraser1; 2) protocolized diagnostic POCUS in a hemodynamically unstable patientReference Perera, Mailhot, Riley and Mandavia2; and 3) POCUS in fluid resuscitation management in shock.Reference Lee, Kory and Arntfield3 International Federation for Emergency Medicine recognized this problem and offered a position statement on sonography in hypotension and cardiac arrest (SHoC) that divides resuscitative POCUS into protocolized SHoC-hypotension and SHoC-CA.Reference Atkinson, Bowra and Milne4 Although attempting to add clarity, by joining POCUS in CA together with the much larger field of POCUS in hemodynamically unstable patients, it actually limits the ability of resuscitative POCUS in CA to grow as a field in bedside ultrasonography.

Protocolized POCUS in hemodynamically unstable patients has been widely used, and mnemonics such as “RUSH” (rapid ultrasound in shock) help avoid unnecessary diagnostic procedures or interventions in early management. The interest for the use of POCUS in fluid resuscitation in shock grew, along with recognition of the detrimental effect of fluid over-resuscitation. Dynamic POCUS parameters offer guidance in fluid management and include cardiac output (CO) and left ventricular (LV) outflow tract Velocity Time Integral,Reference Bobbia, Muller and Claret5 corrected flow time variability, or inferior vena cava distensibility,Reference Lee, Kory and Arntfield3 allowing for more precise quantitative hemodynamic assessment and trending. In contrast, POCUS in cardiopulmonary arrest has been less systematically studied, although it has great potential as an additional comprehensive tool in advanced cardiovascular life support (ACLS). It can discriminate etiologies of the CA, identify reversible processes, aide with chest compressions, detect return of spontaneous circulation, and improve survival.

Appreciating the diversity and broad applicability of POCUS in hypotensive patients, we feel using the term “resuscitative ultrasound” as an umbrella term for all these concepts may not be appropriate. In its narrow sense, this term refers to the use of POCUS in CA, and we propose using the term primarily in reference to POCUS in CA that may offer clarity in terminology and allow this field to expand, as it deserves.

Competing interests

Dr. Barjaktarevic reports grants and personal fees from GE Healthcare, outside the submitted work.

References

REFERENCES

1.Beckett, N, Atkinson, P, Fraser, J, et al. Do combined ultrasound and electrocardiogram-rhythm findings predict survival in emergency department cardiac arrest patients? The Second Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED2) study. CJEM 2019;21(6):739–43.CrossRefGoogle ScholarPubMed
2.Perera, P, Mailhot, T, Riley, D, Mandavia, D.The RUSH exam: rapid Ultrasound in SHock in the evaluation of the critically lll [vii.]. Emerg Med Clin North Am 2010;28(1):29–56.CrossRefGoogle Scholar
3.Lee, CW, Kory, PD, Arntfield, RT.Development of a fluid resuscitation protocol using inferior vena cava and lung ultrasound. J Crit Care 2016;31(1):96–100.CrossRefGoogle ScholarPubMed
4.Atkinson, P, Bowra, J, Milne, J, et al. 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 - CORRIGENDUM. CJEM 2017;19(4):327.CrossRefGoogle ScholarPubMed
5.Bobbia, X, Muller, L, Claret, PG, et al. A new echocardiographic tool for cardiac output evaluation: an experimental study. Shock 2019;52(4):449–55.CrossRefGoogle Scholar