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The arrested patient

Adapted from Lichtenstein's SESAME protocol

(with permission)

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Summary

1 (Ongoing resus) Clinical assessment: formulate the question

2 Rapid arrest screen

3 Form a working diagnosis

4 Continue resuscitation

5 Re-scan / monitor progress / further investigations

1. Formulate the question

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1. Formulate the question

a. Why is the patient arrested: is there a reversible cause?

b. Have I successfully intubated? (If ETCO2 not recording)

Is there a reversible cause?

Tension PTX

Tamponade

Toxins

Thrombosis (MI)

Thromboembolism (PE)

Hypovolaemia

Hypothermia

Hypoglycaemia

Hyperkalaemia

Hydrogen (acidosis)

Is there a reversible cause?

Tension PTX

Tamponade

Toxins

Thrombosis (MI)

Thromboembolism (PE)

Hypovolaemia

Hypothermia

Hypoglycaemia

Hyperkalaemia

Hydrogen (acidosis)

Successful intubation?

Bilateral pleural sliding = both lungs ventilated

Unilateral sliding = 1 lung ventilation / PTX

No sliding = maybe the ETT is in the oesophagus / NB bilateral PTX?

2. The arrest screen

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Curved probe, abdominal preset

Sagittal axis

Just like FAST!

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A 3-step scan

1. Single view heart

2. Anterior lung fields (1 point each side)

2. At your discretion:• IVC (hypovolaemia)• Abdo (eg AAA / free fluid in trauma)• Or finish scanning

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Don’t get in the way of CPR

You need to scan during the pulse check

You have ten seconds!

CPR

Pulse check & scan lungs

CPR

Pulse check & scan heart

CPR

Pulse check & consider options

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The arrest scan

Step 1

Single view of heart

What am I looking for?

Is there a heartbeat?

Pericardial effusion?

RV > LV?

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Step 1: single view heart

• Using the curved probe, subcostal view is easiest• Probe transverse, marker to patient's right• ID heart (probe angled cephalad)• Options if you can't obtain an adequate view:

• Try different window (apical, parasternal)• Try different probe (phased array)• Get help

Subcostal scan heart

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1

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Big RV

squashing LVIt's a PE

Caveats:• Is it chronic? Thickened RV wall

• Is it dilated? Intra arrest

Action: consider thrombolysisIf in doubt, consider 3-point DVT scan

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2

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Pericardial fluid

It’s a tamponade

Caveat: it might be an incidental finding

What if you’re wrong?

What have you got to lose?

Action: pericardiocentesis

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3

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Active heart, small LV = PEA

Pseudo-EMDHypovolaemia

Action: replace volumeFind & treat cause = go to step 3

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4

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Cardiac standstill

Exclude other reversible causes (Hs, Ts)

Action: cease CPR

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Inadequate view

Options:Try another window

Try cardiac probeGet help

Step 1: single view heart

Big RV

Squashing LV

Pericardial fluid

Cardiac standstill

Inadequate

view

Small volume heart beating

?

Step 1: single view heart

Big RV

Pericardial fluid

Cardiac standstill

Inadequate

view

Pseudo-EMD

PE

Consider

thrombo-lysis

Tamponade

Drainage

Hypovolaemia

IV fluid

Proceed to step 3

R.I.P.

Exclude other reversible

causes

Cease CPR

Keep looking

Get help

Step 1: single view heart

Pseudo-EMD

Hypovolaemia

IV fluid

Proceed to step 2

Step 2

Anterior chest

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Step 2: anterior chest

• Probe sagittal, midclavicular line• Just 1 spot on each side• Ideally the most elevated portion of chest

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TOP TIP: you don’t need to be exact

• If tension PTX, it will fill the hemithorax• You’ll see it anywhere on the anterior chest

Step 2 findings

Neither lung is sliding?

One lung is not sliding?

Both lungs sliding

Step 2 findings

Neither lung is sliding?

One lung is not sliding?

Both lungs ventilating

PTX or1 lung ventilation

Not ventilating!(NB bilateral PTX?)

No PTXLungs are ventilating

Step 2 findings

Neither lung is sliding?

One lung is not sliding?

Both lungs ventilating

PTX or1 lung ventilation

Not ventilating! No PTX

Check the airway Check the ETTIs there a lung Point (PTO)?

Go to step 3

Recall: the lung point

At the edge of a PTX, you can sometimes see normal lung moving

US image: 1 side of image doesn't slide with breathing (= the PTX); the other side shows sliding (= the lung)

This spot is the lung point & is 100% specific to PTX

What if there's no lung point?

Maybe 1 lung ventilation

Maybe a massive PTX (entire lung

collapsed)

What if there's no lung point?

Maybe 1 lung ventilation

Maybe a massive PTX (entire lung

collapsed)

Be a doctor

Go back to clinical picture & urgently drain the PTX or pull back the ETT

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Step 3

Hypovolaemia

What’s the cause?

At your discretion:• Review clinical picture

• Scan the IVC ( confirm hypovolaemia)• Scan the abdomen (eg AAA / free fluid in

trauma)

Recap: the arrest screen

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A 3-step scan

• 1. Anterior lung fields• 2. Single view heart• 3. At your discretion:

• IVC (hypovolaemia)• Abdo (eg AAA / free fluid in trauma)• Or finish scanning

Step 1: single view heart

Big RV

Pericardial fluid

Cardiac standstill

Inadequate

view

Pseudo-EMD

PE

Consider

thrombo-lysis

Tamponade

Drainage

Hypovolaemia

IV fluid

Proceed to step 3

R.I.P.

Cease CPR Keep looking

Get help

Step 2: anterior lungs

Neither lung is sliding?

One lung is not sliding?

Both lungs ventilating

PTX or1 lung ventilation

Not ventilating! No PTX

Check the airway Check the ETTIs there a lung Point (PTO)?

Go to step 2

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Step 3 if hypovolaemia

At your discretion:• Review clinical picture

• Scan the IVC (confirm hypovolaemia)• Scan the abdomen (eg AAA / free fluid in

trauma)

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Watch the video again

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Further tests?

when resuscitation phase completed

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Arrest screen: summary

1 Don’t get in the way of CPR

2 Ten seconds for each step

3 Make a working diagnosis

4 Re-scan / monitor progress / further investigations