Background Information: The successful placement of an endotracheal tube (ETT) is a necessary skill all emergency physicians must possess. Performing life-saving interventions are understandably stressful as their failure can lead to morbid consequences and expedited patient death.1,2 The intensive training of emergency physicians, the availability of multiple alternative airway adjuncts and the use of rapid-sequence intubation has helped reduce the intubation complication rate among trauma and medical patients.3-5 Confirmatory methods to ensure the placement of the endotracheal tube are ever changing with no single method being infallible.6. Physical exam findings such as auscultation of the chest and epigastrium, visualization of thoracic movement and fogging of the ETT are not sufficiently reliable to confirm placement.7,8 The use of end-tidal CO2 detection has been shown to have a cumulative false-positive and false-negative failure rate of 10% in accurately confirming the ETT’s location according to the authors of this paper (The paper referenced is a bit dated).6 Furthermore, the usage of these devices may contribute to the complications as they frequently require up to 5 ventilations to obtain an accurate reading.9-11 This puts the patient at risk for aspiration especially if the tube is in the esophagus. No.12 Despite a post-intubation CXR taking time, exposing the patient to more radiation and adding to the cost of treatment, it still continues to remain the standard of care.12-14 The authors of this study wished to better understand the test characteristics of utilizing ultrasound to confirm ETT placement. They conducted a systematic review and meta-analysis to quantify the accuracy of this ETT confirmatory method....Read More
As we have discussed in previous posts, the care of patients with cardiac arrest is a key skill for Emergency Providers. ACLS provides a foundation for care but is rife with shortcomings including, but not limited to, reliance on outdated data and inability to adapt in the face of improved understanding of cardiac arrest pathophysiology. The incorporation of technological advances and skills is another massive limitation of ACLS. One of these technologies is point of care ultrasound (POCUS).
Over the last two decades, POCUS has become a integral part of Emergency Medicine training and practice. POCUS allows for rapid, bedside diagnosis of a number of conditions including cholecystitis, urinary retention and ectopic pregnancy. Additionally, it is becoming a greater component in the management of the critical patient where it can be used to assess cardiac contractility, wall motion abnormalities, intraperitoneal free fluid and more. Application of POCUS in all patients with cardiac arrest is simply the next step. This diagnostic modality is not highlighted in the current iteration of ACLS but is a practice changer. The bottom line is that application of POCUS in cardiac arrest allows the emergency provider to guide resuscitation with a direct look into the body - we are no longer blind.
For this post, I want to discuss two ways that we can use ultrasound in cardiac arrest patients, specifically in pulseless electrical activity (PEA), in the Emergency Department: