(Pre-hospital) Echocardiography

for CPR in Cardiac Arrest States

The ALS-conformed FEEL exam
Focused Echo Evaluation in Life Support
E. Mueller, H. Steiger, K. Rimbach, R. Breitkreutz
1

www.notfallsono.de

FEEL
Focussed Echocardiographic Evaluation in Life support
Edgar Mller1; Holger Steiger1,2, Klaus Rimbach1, Raoul Breitkreutz3

Inst.Notfallmedizin@klinikum-darmstadt.de

Disclosures: none
1

Darmstadt Hospital, Dept. of Emergency Medical Aid, Darmstadt, Germany

Heart Center, Dept. of Cardiology, Bad Nauheim, Germany
3 University Hospital, Johann Wolfgang Goethe, Frankfurt am Main, Germany
2 Kerckhoff

E. Mller, MEMC V

2009

ILCOR-Guidelines (2000):
consider correctable causes
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Hypoxia
Hypovolemia
4 Hs

Hyperkalemia/metabolic
Hypothermia

4 Ts

Tension pneumothorax
Tamponade (cardiac)
Toxins
Thrombosis
E. Mller, MEMC V

2009

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ERC-Guidelines 2005

During CPR..
..correct reversible
causes

E. Mller, MEMC V

2009

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Our Senses

Look.. ?

Look.. ?

Listen. ?

Listen. ?

Feel. ?

FEEL. !

. FEEL Focussed Echocardiographic Evaluation in Life

support
E. Mller, MEMC V

2009

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Emergency Ultrasound.

extension of the palpating

hand and a visual stethoscope
during the physical
examination
ACEP Policy Statement (2001) on
Emergency ultrasound guidelines

E. Mller, MEMC V

2009

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Aims
To introduce the concept of
ALS-based echocardiography
in pre-hospital cardiac arrest
To give background information

E. Mller, MEMC V

2009

Main theses
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Diagnostic gaps in cardiac arrests:

Echocardiography is a powerful tool
ALS-conformed Echocardiography is
possible
Basic Educational Training is mandatory
(suggested reading)

Breitkreutz, R et al: Crit Care Med (2007), 35, 5 (Suppl.) 150-161

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FEEL and ALS

ACLS

FEEL
Ultrasound

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Some
Other
Concerns
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A small feasibility study

2
3
1
E. Mller, MEMC V

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ALS-conformed echocardiography

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How to assess the heart during CPR?

liver
right ventr.
cavum
septum
left ventr.
cavum

Breitkreutz et al. CCM (2007), 35, 5 (Suppl.) 150-161

E. Mller, MEMC V

2009

FEEL and ALS

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(FEEL)

When to apply

FEEL

FEEL- UK
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Influence of FEEL
on no-flow intervals
(ACLS 2005)
Ohne
W/O
FEEL
FEEL

Basisversorgung
BLS
ALS

W Mit
FEEL
FEEL

150

300

450

600

Time (seconds),
no-flow
intervals:
Zeit (Sekunden)
NFI in schwarz,
CPR-Intervalle
in weiblack

750

900

bars

Ilper et al. 2008, unpublished results

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2009

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Crit Care Med (2007), 35, 5 (Suppl.) 150-161

E. Mller, MEMC V

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CPR and Preparation of

FEEL
1.
2.
3.
4.
5.

CPR - 5 cycles (minimum)

Switch on machine
Inform team of intention to perform FEEL
Position: sonographer & probe with gel
Instructions about countdown

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CPR  FEEL  CPR

countdown
6. Countdown 10 secs to pulse check
7. I will commence scan + please perform pulse check
8 + 9. Countdown further 10 secs and resume CPR

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2009

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CPR

(Ensure compressions recommenced)

10. Communicate findings

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19

Breitkreutz et al. CCM (2007)

E. Mller, MEMC V

2009

ALS-conformed algorithm FEEL

Focused Echocardiographic Evaluation in Life Support

www.notfallsono.de

FEEL

Breitkreutz et al. CCM (2007), 35, 5 (Suppl.) 150-161

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2009

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E. Mller, MEMC V

2009

ALS-conformed algorithm FEEL

a prospective trial

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228
228 patients
patients included
included into
into
the
the protocol
protocol
98
98
CPR
CPR
Clinical
Clinical diagnoses
diagnoses
ECG,
ECG, RR,
RR, SpO
SpO22

complete
complete exam
exam

FEEL <10 sec.

39/51
39/51
Pseudo-PEA
Pseudo-PEA

51/98
51/98
susp
susp.. PEA
PEA
12/51
12/51
true-PEA
true-PEA

E. Mller, MEMC V

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Quality of echocardiograms
subcostal

parasternal

apical

80
numbers of studies

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90
70
60
50
40
30
20
10
0
total

good

medium

poor

no view
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changes in %

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FEEL-supported changes in therapy

100
90
80
70
60
50
40
30
20
10
0

(85)
therapy on the
scene

(17)
choice of
hospital

(15)
feedback
dispatcher

(9)
no effect

E. Mller, MEMC V

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PEA: reversible conditions and survival

true PEA

Pseudo - PEA

25

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cases

survival

20

l
a
t
i
p
s
o
h
o
%
t
6
l
5
a
n
iv
v
o
i
r
Su miss
ad

15

10

0
PEA

red. LVF

LE

PE

Hypovol.

others

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e
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PEA or Pseudo-PEA ?
E. Mller, MEMC V

2009

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Emergency echocardiography in PEA or near

PEA states can detect pericardial effusions with
correctable etiologies versus true PEA with
ventricular standstill.
Tayal V. Resuscitation (2003)

Patients

presenting with cardiac standstill on

bedside echocardiogram do not survive to leave
the ED, regardless of their electrical rhythms.
Blaivas M and Fox Acad Em Med (2001)

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better have a direct view

E. Mller, MEMC V

2009

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Summary
There are diagnostic gaps in
peri-resuscitation care
and cardiac arrest states
Utilizing an algorithm-based ALScompliant echocardiographic
procedure such as FEEL can help
to close these gaps.

E. Mller, MEMC V

2009

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Resuscitation. 2008, 76(1):146-8

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2009

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Case: 14-year-old girl

. suffering from PEA

. owing to cardiac tamponade
4 weeks after closure of a VSD
Deterioration during transfer to
hospital
The doctor.
. never performed cardiocentesis
.. 8-hour-course in FEEL
. performed FEEL
. drained a collection of fluid
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2009

On admission
ph 6.66

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Temp. 33C --

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Without FEEL this girl would have died

E. Mller, MEMC V

2009