Monday, November 5, 2012

Sometimes, the Dead (by Ultrasound) Rise

This article received a little bit of dissemination, with the assertion that some apparently futile resuscitations may yet be salvaged despite the lack of cardiac activity on ultrasound.

But, this article doesn't necessarily tell the entire story.  It's a systematic review of several small, poor-quality cardiac arrest cohorts for whom bedside cardiac ultrasonography was performed.  In aggregate, there were 378 patients with no cardiac activity visualized during resuscitation – and 9 went on to have return of spontaneous circulation.  They calculate this out as an LR of 0.18 for ROSC after finding no cardiac activity.

The problem is, this is the only information we have regarding the context of the ultrasound findings or the performance characteristics of the ultrasonographers at work.  The authors also appropriately note that ROSC is not necessarily the ultimate patient-oriented outcome of interest – since we know that most ROSC after cardiac arrest admitted to the hospital still goes on to have a dismal outcome.  

I'm not entirely sure what my takeaway should be from this study, and it's not going to significantly modify my practice.  In the appropriate clinical context, a lack of cardiac activity will still lead me to cease resuscitative efforts.  It would be extraordinarily helpful to have a larger body of data specifically regarding the patient characteristics of those who did have ROSC despite lack of cardiac activity, to see if there is a usable pattern to this small population of exceptions.

"Bedside Focused Echocardiography as Predictor of Survival in Cardiac Arrest Patients: A Systematic Review"

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