Here's a video I made breaking down this Cardiac Arrest Echo that was recorded during CPR #FOAMed

Repost to save a life

If you take care of Cardiac Arrest patients, don't miss this one!

Fascinating video about enhancing CPR and Diagnosis during cardiac arrest. Here's the transcript: Alright, so this is a case of cardiac arrest and what follows is a series of cardiac echo clips that were recorded throughout the resuscitation. And what you'll see is that there are several advantages to echo in cardiac arrest, specifically to transesophageal echo or TEE, which is what you're seeing here. I'm going to press play and this was the first shot that was recorded in this case as the paramedics rolled through the doors. This was a pre-hospital cardiac arrest. And as you can see, there is CPR in progress. Chest compressions are ongoing here. And this is one of the main advantages of TEE is you don't have to compete with the hands of the chest compressor or the mechanical CPR device. You don't have to wait for a pulse check or a rhythm check. You just slide the probe into the esophagus and the probe is right behind the left atrium, which you see here, and you have a continuous view of what is going on with the heart the entire time. This view is known as a mid esophageal five chamber view. So this is the left side of the heart here and this is the right side of the heart. And look what we see in the right atrium and the right ventricle here. There are numerous of these echogenic rounded material just swirling around here in this clinical scenario. This is absolutely diagnostic for massive PE. Instantly you have a diagnosis and you know why this man collapsed to the ground in cardiac arrest. And these are known as clots in transit. So essentially they are emboli that have traveled from a DVT somewhere in the body, usually the lower extremities, and they are threatening to become further PEs. But this patient has already coded. So you know that there is already a massive clot burden in the pulmonary arteries. This should give you the impetus to push IV thrombolytics. In this case, this patient got 50 milligrams of IV tenecteplase or T and K. Alright now I am going to go to another clip here. This is very interesting. I am going to push play. Look at the mitral valve here. You see how it is quivering and it is actually causing some tumultuous blood flow around the valve. This is a classic appearance of fine V-fib or ventricular fibrillation on echo. And what happens on the monitor is it almost looks like a systole. But if you look closely, it is a very very fine V-fib. This, when you see this, you know it is fine V-fib and this is obviously a shockable rhythm. Now here is another clip. This is the next clip. You see the V-fib, the shock and then boom right back on the chest. And when you are approaching, when you are coming on to these rhythm checks, you should always have the defibrillator already pre-charged so that when you identify a shockable rhythm, you can shock right away. Alright now let us go to another clip. I am going to press play here. This is known as a mid-esophageal long axis. This is analogous to the parasternal long axis view on trans thoracic echo. I want you to keep a close eye on this area here. This is where the aortic valve is. This is the aortic outflow tract. And while you can see that the compressions are doing pretty good at compressing the left ventricle here, they are obstructing the aortic outflow. And if TEE ever proves to improve survival and outcomes in cardiac arrest, I think this is going to be one of the major reasons why. What you do in this case is reposition the hands, go more inferior and more apically, which was done here. And now look, the compressions are still compressing the left ventricle, but now we are not obstructing the aortic outflow tract. It is remaining, the aortic valve is remaining open during compressions, which means more forward flow, which is exactly what you want. And that translates into improved circulation and more efficient and effective CPR. Notice too that the bubbles from the previous clip are gone completely. Let us go back to that just to show you. These bubbles are actually created by the outflow tract obstruction and the result of turbulent flow. The other thing that you will see clinically every single time you do this is you will see a spike in the end tidal CO2, which is exactly what you want. And this whole concept is so interesting and kind of crazy because everybody's heart sits differently in their body. And without TEE, you could be doing perfect, perfect chest compressions with perfect form. And you would never know that you are obstructing the outflow tract. All right, now one more clip here to show you. The patient here was an asystole. This is known as this echogenic appearance of the blood. This is known as smoke. And this is from stasis. This patient at this time was an asystole. And this is actually cardiac standstill. This is a pitfall. Do not confuse this with cardiac activity. What you are seeing here, this movement right there, and there, that's from ventilations. So don't make that mistake. Now you're not going to be able to save every single patient. You're just not going to be able to do it. But what you can do is keep learning and keep growing and learn from every single patient so that you can be better for the next patient. And pay attention to these fine details. Because in the right patient, it will make all the difference in the world.

Catching clot in transit, amazing! Thanks for sharing Dr Sam 🙌🏼

Air bubbles? Do the bubbles dissipate, or could they get into the coronary arteries? or other critical microvascular areas? I guess it's the wrong valve, but can chest compression cause pulmonary air embolism (emboli)?

Good question. These are just microbubbles, so way too tiny to actually cause any damage.

Been a while since I've been a floor nurse. Is TEE a new standard during a code or is it up and coming?

Hi Chloe, good question. TEE in arrest has really taken off over the last several years here, but I would say at this stage the overwhelming majority of providers do not have access to it and not using it. So therefore it’s still as you say in the “up-and-coming” phase!

Doc, plz also migrate to Bluesky. Reposted

Silly question alert! How does one do an echo "during"CPR? Toe or Trans thoracic?

TTE: subcostal or apical view during CPR, can do parasternals (or any) at rhythm check TEE: probe in the esophagus so great continuous view through the resus