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Ultrasound Corner |

“Code Blue” in a 66-Year-Old Man in the Cardiology Department FREE TO VIEW

Kim M. Phan, DO; Pamela V. Lam, DO; Bruce J. Kimura, MD
Author and Funding Information

Departments of Cardiology and Graduate Medical Education, Scripps Mercy Hospital, San Diego, CA

CORRESPONDENCE TO: Bruce J. Kimura, MD, Medical Director, Cardiovascular Ultrasound Lab, Scripps Mercy Hospital, 4077 Fifth Ave, San Diego, CA, 92103


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(2):e37-e40. doi:10.1016/j.chest.2016.02.689
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Published online

A 66-year-old man was undergoing transesophageal echocardiography in preparation for valve surgery for aortic stenosis when he experienced respiratory arrest during the procedure. The transesophageal echocardiography probe was withdrawn, and his ventilation was assisted using a bag-valve mask. The patient then experienced significant bradycardia with hypotension and a code blue was activated within the hospital. On arrival, the code team noted an agonal rhythm on telemetry. Blood pressure and oxygen saturation readings were unable to be obtained. A pocket-sized ultrasonographic device (Vscan, GE Healthcare) carried by a cardiologist responding to the code recorded subcostal views intermittently throughout the resuscitation (Video 1).

Question: What can one infer from these images during a code?

Answer: The appearance of the blood pool during cardiopulmonary resuscitation (CPR) included (1) echogenic smoke, a sign of blood stasis, (2) a subsequent clear cavity, a sign of effective chest compressions, and (3) right ventricular “bubbles,” a marker of successful IV drug delivery.

During the initial assessment of the pulse, the subcostal four-chamber view in Video 1 demonstrated the presence of an echogenic blood pool, or dense “smoke,” filling all cardiac chambers prior to the initiation of chest compressions (Fig 1A). Two minutes after initiation of CPR during the first pulse check, clearance of the echogenic blood pool was noted on ultrasonography and asystole was the rhythm (Fig 1B). At the second pulse check, bubbles were seen in the right side of the heart during slow pulseless electrical activity (Fig 1C). The patient had return of spontaneous circulation (ROSC) after 8 min of the advanced cardiac life support (ACLS) protocol, having received a total of 3 mg of epinephrine and 1 mg of atropine. With ROSC, bubbles were seen circulating in the right side of the heart, the inferior vena cava (IVC), and the hepatic veins (Fig 1D) on ultrasonography. The patient was intubated and transferred to the ICU for continued supportive care. Despite a trial of induced hypothermia, the patient had no meaningful neurologic recovery and died 5 days later.

Figure Jump LinkFigure 1 A, “Smoke”-filled cardiac chambers prior to CPR. B, Images during first pulse check after 2 min of chest compressions show clearance of smoke. C, Images during second pulse check demonstrate “bubbles” in the right heart. D, Bubbles seen in inferior vena cava and hepatic veins.Grahic Jump Location

CPR was first developed in 1960, at which time the American Heart Association started a program to train physicians in closed-chest cardiac resuscitation., Today, it is recommended that every health-care provider be certified in basic cardiac life support or ACLS and that every patient consider its use in an advanced directive. Cardiac arrests are not uncommon, with an estimated 359,400 events occurring outside the hospital and 209,900 occurring in the hospital each year.,, Bedside ultrasonography has been used increasingly in emergency and critical care medicine as a rapid diagnostic technique, and can now be performed using pocket-sized devices. However, once a patient has deteriorated into cardiac arrest, no formal guidelines exist for the incorporation of bedside ultrasonographic techniques into ACLS protocols. During a code, multiple considerations such as cardiac standstill, intervening hypoxemia, metabolic acidosis, and central blood shifting, as well as resuscitative efforts, including chest compressions, positive pressure ventilation, and administered epinephrine, may confound the accuracy of a causal diagnosis. Furthermore, because of the extreme urgency and space limitations imposed by a code situation, the practical use of bedside ultrasonography may be to rapidly provide intermittent information to assess the resuscitation process itself (Video 2, Discussion video).

We found that the cardiac transducer from a subcostal site places the physician in an optimal position to assess the code and allows for imaging during CPR and at pulse checks. The subcostal four-chamber view provides pertinent information both initially and during the resuscitation, such as the presence of cardiac contraction, pericardial fluid, isolated right-sided heart enlargement, and abnormal IVC size. During asystole, right-sided heart and IVC dilatation may represent the combined effects of central shifting of blood without cardiac contraction to unload venous return. Perhaps more importantly, as in the case presented, bedside ultrasonography on arrival allows the first responder to immediately recognize the presence of blood stasis or smoke and later assess the efficacy of chest compressions to clear the blood stasis. The hyperechoic static cardiac blood pool with darker myocardial walls can create a misleading appearance of a noncardiac structure and must be recognized so as not to delay chest compressions. In animal models of cardiac arrest, blood pool echogenicity was seen to increase in acoustic intensity during the progression to asystole. Homogeneous echogenicity was seen to initially appear in the right ventricle and was found to disappear with external cardiac massage in a canine model. The presence of an echogenic blood pool may be due to RBC microaggregates,, and has been associated with adverse outcomes. In a study using transesophageal echocardiography during resuscitation, smoke was observed in patients with mechanical asystole 20 to 30 min after initiation of CPR; all these patients had failed outcomes. Perhaps because of impaired passage through the cerebral microcirculation, the presence of smoke may be a predictor for poor neurologic outcome regardless of its clearing by chest compressions or the return of spontaneous circulation as suggested by the case presented. Given the potential for ultrasonographic device connectivity in the future, transmitted images from first responders at the scene could contain valuable prognostic information, including smoke, from one simple initial view.

Within 4 min of the resuscitation, echogenic “bubbles” were noted in the right side of the heart and were later noted in the IVC and hepatic veins. These bubble findings were temporally coincident with the incidental injection of trivial amounts of air associated with drug injection during resuscitation. Importantly, the presence of bubbles suggests patency of the IV access and documents drug delivery to the heart. However, the presence of bubbles in the IVC could represent reflux into the abdominal venous system during chest compressions, resulting in only partial dosing efficacy. Mitigating this reflux by raising intraabdominal pressure could be beneficial and may be an alternative explanation to the enhanced ROSC rate reported with interposed abdominal compression techniques. Despite extensive literature review, there have been no reports of the utility or prognosis of the finding of bubbles appearing in the heart, IVC, or hepatic veins on ultrasonographic imaging during resuscitation. Future studies are needed to clarify the frequency, timing, and distribution of these bubbles during ACLS, as this finding could be used in assessing IV drug delivery.

We present novel ultrasonographic findings obtained by a pocket-sized device that could potentially assist any resuscitation regardless of initial cause by providing initial prognostication, allowing monitoring of the efficacy of chest compressions, and confirming the delivery of IV therapies. During CPR for a nontraumatic code, there may be potential for additional ultrasonographic views and transducers to monitor the thorax for symmetrical lung aeration and assist in central line placement while monitoring venous and arterial flow patterns during compressions. Future studies are needed to address the value of incorporating portable ultrasonographic techniques into ACLS to assess fundamental goals common to all resuscitative efforts.

  • 1.

    The presence of echogenic blood pool or smoke is a poor prognostic sign and has been associated with adverse outcomes. This phenomenon may represent prolonged stasis resulting in poor neurologic recovery. The clearing of smoke likely demonstrates the efficacy of chest compressions.

  • 2.

    Echogenic bubbles in the right side of the heart could be most easily attributed to the multiple IV injections given during a code situation and confirms patency of the IV accessand successful drug delivery to the heart.

  • 3.

    Subcostal four-chamber view provides clinical information during an arrest and places the physician in an optimal, central position to assess a code situation using ultrasonography.

  • 4.

    A battery-operated, pocket-sized ultrasonographic device with a rapid boot time is an ideal instrument to assist resuscitative efforts.

  • 5.

    Well-designed outcome studies using ROSC, neurologic recovery, and mortality as end points will be necessary to understand the benefits of ultrasonographic data acquired during resuscitation.

Financial/nonfinancial disclosures: None declared.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

American Heart Association. History of CPR, 2015. American Heart Association website.http://cpr.heart.org/AHAECC/CPRAndECC/AboutCPRFirstAid/HistoryofCPR/UCM_475751_History-of-CPR.jsp. Accessed November 22, 2015.
 
Kouwenhoven W. .Jude J. .Knickerbocker G. . Closed-chest cardiac massage. JAMA. 1960;173:1064-1067 [PubMed]journal. [CrossRef] [PubMed]
 
Chugh S.S. .Jui J. .Gunson K. .et al Current burden of sudden cardiac death: multiple source surveillance versus retrospective death certificate-based review in a large U.S. community. J Am Coll Cardiol. 2004;44:1268-1275 [PubMed]journal. [CrossRef] [PubMed]
 
Merchant R.M. .Yang L. .Becker L.B. . American Heart Association Get With The Guidelines-Resuscitation Investigatorset al Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39:2401-2406 [PubMed]journal. [CrossRef] [PubMed]
 
Go A.S. .Mozaffarian D. .Roger V.L. . American Heart Association Statistics Committee and Stroke Statistics Subcommitteeet al Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2013;127:e6-e245 [PubMed]journal. [CrossRef] [PubMed]
 
van der Wouw P.A. .Koster R.W. .Delemarre B.J. .Rien de Vos A.J. .Lie K.I. . Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary arrest. JACC. 1997;30:780-783 [PubMed]journal. [CrossRef] [PubMed]
 
Oren-Grinberg A. .Talmor D. .Brown S.M. . Concise definitive review: focused critical care echocardiography in the ICU. Crit Care Med. 2013;41:2618-2626 [PubMed]journal. [CrossRef] [PubMed]
 
Wang F.S. .Lien W.P. .Fong T.E. . Terminal echocardiographic findings during death process in man and dogs. J Formosan Med Assoc. 1991;90:31-62 [PubMed]journal. [PubMed]
 
Machi J. .Sigel B. .Beitler J.C. .Coelho J.C.U. .Justin J.R. . Relation of in vivo blood flow to ultrasound echogenicity. J Clin Ultrasound. 1983;11:3-10 [PubMed]journal. [CrossRef] [PubMed]
 
Reeder G.S. .Charlesworth J.E. .Moore S.B. . Cause of spontaneous echocardiographic contrast as assessed by scanning electron microscopy. J Am Soc Echoardiogr. 1994;7:169-173 [PubMed]journal. [CrossRef]
 
Merino A. .Hauptman P. .Badimon L. .et al Echocardiographic “smoke” is produced by an interaction of erythrocytes and plasma proteins modulated by shear forces. J Am Coll Cardiol. 1992;20:1661-1668 [PubMed]journal. [CrossRef] [PubMed]
 
Varriale P. .Maldonado J.M. . Echocardiographic observations during inhospital cardiopulmonary resuscitation. Crit Care Med. 1997;25:1717-1720 [PubMed]journal. [CrossRef] [PubMed]
 
Babbs C.F. . The case for interposed abdominal compression CPR in hospital settings. Analg Resusc: Curr Res. 2014;3:1-6 [PubMed]journal
 

Figures

Figure Jump LinkFigure 1 A, “Smoke”-filled cardiac chambers prior to CPR. B, Images during first pulse check after 2 min of chest compressions show clearance of smoke. C, Images during second pulse check demonstrate “bubbles” in the right heart. D, Bubbles seen in inferior vena cava and hepatic veins.Grahic Jump Location

Tables

References

American Heart Association. History of CPR, 2015. American Heart Association website.http://cpr.heart.org/AHAECC/CPRAndECC/AboutCPRFirstAid/HistoryofCPR/UCM_475751_History-of-CPR.jsp. Accessed November 22, 2015.
 
Kouwenhoven W. .Jude J. .Knickerbocker G. . Closed-chest cardiac massage. JAMA. 1960;173:1064-1067 [PubMed]journal. [CrossRef] [PubMed]
 
Chugh S.S. .Jui J. .Gunson K. .et al Current burden of sudden cardiac death: multiple source surveillance versus retrospective death certificate-based review in a large U.S. community. J Am Coll Cardiol. 2004;44:1268-1275 [PubMed]journal. [CrossRef] [PubMed]
 
Merchant R.M. .Yang L. .Becker L.B. . American Heart Association Get With The Guidelines-Resuscitation Investigatorset al Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39:2401-2406 [PubMed]journal. [CrossRef] [PubMed]
 
Go A.S. .Mozaffarian D. .Roger V.L. . American Heart Association Statistics Committee and Stroke Statistics Subcommitteeet al Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2013;127:e6-e245 [PubMed]journal. [CrossRef] [PubMed]
 
van der Wouw P.A. .Koster R.W. .Delemarre B.J. .Rien de Vos A.J. .Lie K.I. . Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary arrest. JACC. 1997;30:780-783 [PubMed]journal. [CrossRef] [PubMed]
 
Oren-Grinberg A. .Talmor D. .Brown S.M. . Concise definitive review: focused critical care echocardiography in the ICU. Crit Care Med. 2013;41:2618-2626 [PubMed]journal. [CrossRef] [PubMed]
 
Wang F.S. .Lien W.P. .Fong T.E. . Terminal echocardiographic findings during death process in man and dogs. J Formosan Med Assoc. 1991;90:31-62 [PubMed]journal. [PubMed]
 
Machi J. .Sigel B. .Beitler J.C. .Coelho J.C.U. .Justin J.R. . Relation of in vivo blood flow to ultrasound echogenicity. J Clin Ultrasound. 1983;11:3-10 [PubMed]journal. [CrossRef] [PubMed]
 
Reeder G.S. .Charlesworth J.E. .Moore S.B. . Cause of spontaneous echocardiographic contrast as assessed by scanning electron microscopy. J Am Soc Echoardiogr. 1994;7:169-173 [PubMed]journal. [CrossRef]
 
Merino A. .Hauptman P. .Badimon L. .et al Echocardiographic “smoke” is produced by an interaction of erythrocytes and plasma proteins modulated by shear forces. J Am Coll Cardiol. 1992;20:1661-1668 [PubMed]journal. [CrossRef] [PubMed]
 
Varriale P. .Maldonado J.M. . Echocardiographic observations during inhospital cardiopulmonary resuscitation. Crit Care Med. 1997;25:1717-1720 [PubMed]journal. [CrossRef] [PubMed]
 
Babbs C.F. . The case for interposed abdominal compression CPR in hospital settings. Analg Resusc: Curr Res. 2014;3:1-6 [PubMed]journal
 
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