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Resuscitation Ultrasound

This is the full version of ALS-conformed "Resuscitation Ultrasound" methods / protocols for practitioners. Almost all have been suggested within the ERC resuscitation guidelines of 2015 or later with POCUS in ERC 2021. Our clips should put a new complexion on those exam styles. The collection can be downloaded and may support your teaching activity. ... can be shared, kept, as you like...;-))

This is the full version of ALS-conformed "Resuscitation Ultrasound" methods / protocols for practitioners. Almost all have been suggested within the ERC resuscitation guidelines of 2015 or later with POCUS in ERC 2021.

Our clips should put a new complexion on those exam styles. The collection can be downloaded and may support your teaching activity. ... can be shared, kept, as you like...;-))

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ALS-conformed<br />

<strong>Resuscitation</strong><br />

<strong>Ultrasound</strong><br />

A concept with images and video clips of exam styles<br />

by<br />

Raoul Breitkreutz, MD (Frankfurt a.M. / Bad Rappenau)<br />

Domagoj Damjanovic, MD (Freiburg i. Brsg.)<br />

Tobias C. Schröder, MD (Frankfurt a.M.)<br />

Markus Geuting, MD (Bad Rappenau)<br />

A free online publication of the<br />

The Scientific Network SonoABCD with SonoSchool<br />

and SonoABCD Publishing Company<br />

D-64405 Fischbachtal, Germany<br />

ISBN - 978-3-96228-078-9<br />

Available at yumpu.com/en/SonoABCD


ABCD


Sonoscopy of trachea in emergencies<br />

Tracheal and Esophageal tube placement<br />

- Simple pattern recognition -<br />

Normal: Single (airway) tract<br />

Double (airway) tract sign*<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

No ventilation required.<br />

Observe: both lateral regions of airway tract<br />

*Zechner P, Breitkreutz R <strong>Resuscitation</strong> 2011<br />

Chou et al. <strong>Resuscitation</strong> 2011


Airway <strong>Ultrasound</strong> Exam<br />

Main Questions<br />

In emergency always use post-intubation check of trachea only.<br />

Edited by Raoul Breitkreutz (2020)<br />

#Q1. Esophageal misplacement? Yes or No?<br />

Only if ruled out - goto 2.<br />

#Q2. Main stem intubation? Yes or No?<br />

If ruled in - slightly withdraw and re-check.<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Available at www.yumpu.com/en/SonoABCD


Distinct clinical emergency scenarios define<br />

two widely different tracheal ultrasound exam methods<br />

Exam style #1: Post-intubation check<br />

(e.g. CPR at point-of-care or on arrival at shock room)<br />

- immediate, urgent action -<br />

Edited by Raoul Breitkreutz (2020)<br />

On-off evaluation<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Team H.K. Stanis, M.D., M. Negele, Bad Rappenau, Germany (2019)<br />

Airway <strong>Ultrasound</strong> Exam<br />

#Q1 - Esophageal misplacement? Yes or No?<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Edited by Raoul Breitkreutz (2020)<br />

In emergency always use post-intubation check of trachea only.


Team H.K. Stanis, M.D., M. Negele, Bad Rappenau, Germany (2019)<br />

Airway <strong>Ultrasound</strong> Exam<br />

#Q1 - Esophageal misplacement? Yes or No?<br />

Finding 1a: No, normal!<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

No ventilation required.<br />

Edited by Raoul Breitkreutz (2020)


Sonoscopy of trachea post-intubation<br />

Check tracheal tube placement<br />

Exam style #1 - Simple pattern recognition<br />

Edited by Raoul Breitkreutz (2020)<br />

Single (airway) tract<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Observe: both lateral regions of airway tract<br />

No ventilation required.


Team H.K. Stanis, M.D., M. Negele, Bad Rappenau, Germany (2019)<br />

Airway <strong>Ultrasound</strong> Exam<br />

#Q1 - Esophageal misplacement? Yes or No?<br />

Finding 1b: Yes! Immediate correction!<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

No ventilation required.<br />

Edited by Raoul Breitkreutz (2020)


Sonoscopy of trachea post-intubation<br />

Tracheal and Esophageal tube placement<br />

Exam style #1 - Simple pattern recognition<br />

Normal: Single (airway) tract<br />

Double (airway) tract sign*<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

No ventilation required.<br />

Observe: both lateral regions of airway tract<br />

*Zechner P, Breitkreutz R <strong>Resuscitation</strong> 2011<br />

Chou et al. <strong>Resuscitation</strong> 2011


Distinct clinical emergency scenarios define<br />

two widely different tracheal ultrasound exam methods<br />

Exam style #2: Visualization<br />

during entire intubation process<br />

(e.g. RSI, teaching) - planned action -<br />

Continuous evaluation<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Distinct clinical emergency scenarios define<br />

two widely different tracheal ultrasound exam methods<br />

Exam style #2: Visualization<br />

during entire intubation process<br />

(e.g. RSI, teaching) - planned action -<br />

Continuous evaluation<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Edited by Raoul Breitkreutz (2020)<br />

Nota bene:<br />

1st trial —> esophagus.<br />

Upon instruction of clinician supervisor,<br />

observing by sonography,<br />

—> uninterrupted 2nd trial.<br />

With support of M. Nickel, MD and M. Geuting, MD, Bad Rappenau


Sonoscopy of trachea during intubation<br />

Tracheal and Esophageal tube placement<br />

Exam style #2 - Simple pattern recognition<br />

Normal: Single (airway) tract<br />

- unspectacular observation -<br />

Double (airway) tract sign*<br />

prominent monitoring observation<br />

(2 attempts and withdrawals)<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

No ventilation required.<br />

Observe: both lateral regions of airway tract<br />

*Zechner P, Breitkreutz R <strong>Resuscitation</strong> 2011<br />

Chou et al. <strong>Resuscitation</strong> 2011


Comparison of<br />

Clinician sonographer<br />

Probe movement <br />

at frontal neck<br />

Supervision<br />

Immediate correction?<br />

Action of sonographer?<br />

Exam styles<br />

#1 #2<br />

post-intubation<br />

active,<br />

exploration of region<br />

yes, onto and away<br />

dynamic<br />

no add role <br />

or not necessary<br />

no,<br />

check only<br />

during entire<br />

intubation process<br />

passive<br />

no, still /static <br />

waiting for action<br />

active option for role,<br />

e.g. in teaching<br />

yes,<br />

option to correction <br />

while indwelling ETT<br />

Image as is can change markedly<br />

Time (secs)


Team K. Stanis, M.D., M. Negele, Bad Rappenau, Germany (2019)<br />

Airway <strong>Ultrasound</strong> Exam<br />

#Q2 - Main stem intubation?<br />

Extension of trachea check (exam style 1) and addition of the evaluation of lung motion<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

In emergency, after tracheal check, start lung sliding evaluation<br />

at left hemithorax. In this scenario, there was no emergency.<br />

Edited by Raoul Breitkreutz (2020)


Team K. Stanis, M.D., M. Negele, Bad Rappenau, Germany (2019)<br />

Airway <strong>Ultrasound</strong> Exam<br />

#Q2 - Main stem intubation?<br />

Finding 2a: No, normal!<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Edited by Raoul Breitkreutz (2020)<br />

In emergency, after tracheal check, start lung sliding evaluation at left hemithorax.


Sonoscopy of lung post-intubation<br />

Check for lung pulse / lung sliding<br />

Simple pattern recognition<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Observe:<br />

Lung Sliding. No full ventilation cycle required.


Sonoscopy of lung post-intubation<br />

Check for lung pulse / lung sliding<br />

Simple pattern recognition<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Observe: Lung Sliding. No full ventilation cycle required.


Team Markus Geuting, M.D., M. Negele, Bad Rappenau, Germany (2019)<br />

Airway <strong>Ultrasound</strong> Exam<br />

#Q2 - Main stem intubation?<br />

Exam style #1<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Edited by Raoul Breitkreutz (2020)<br />

In emergency, after tracheal check, start lung sliding evaluation at left hemithorax.


Team Markus Geuting, M.D., M. Negele, Bad Rappenau, Germany (2019)<br />

Airway <strong>Ultrasound</strong> Exam<br />

#Q2 - Main stem intubation?<br />

Finding 2b: Yes, correction required!<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Edited by Raoul Breitkreutz (2020)<br />

In emergency, after tracheal check, start lung sliding evaluation at left hemithorax.


Team Markus Geuting, M.D., M. Negele, Bad Rappenau, Germany (2019)<br />

Sonoscopy of lung post-intubation<br />

Check for lung pulse / lung sliding<br />

Simple pattern recognition<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Observe: Lung pulse.<br />

Action: SlIghtly withdraw tube and re-check. No full ventilation cycle required.<br />

Edited by Raoul Breitkreutz (2020)


Team Markus Geuting, M.D., M. Negele, Bad Rappenau, Germany (2019)<br />

Sonoscopy of lung post-intubation<br />

Check for lung pulse / lung sliding<br />

Simple pattern recognition<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Observe: Lung pulse or lung sliding.<br />

Action: Slightly withdraw tube and re-check. No full ventilation cycle required.<br />

Edited by Raoul Breitkreutz (2020)


Airway <strong>Ultrasound</strong> Exam<br />

Limitations of the check for main stem intubation<br />

Interprete sonographic signs per hemithorax<br />

In presence of (known or unknown) pneumothorax<br />

Trachea ultrasound is applicable to check for normal or esophageal intubation. <br />

Lung ultrasound: Mainstem intubation cannot be diagnosed. The air in the pleural<br />

space, resulting in sonographic signs of pneumothorax (no lung sliding, no lung<br />

pulse, no B-lines) overlay signs of one-sided intubation. Pneumothorax still could<br />

be ruled in.<br />

Edited by Raoul Breitkreutz (2020)<br />

In presence of (known or unknown) cardiac standstill<br />

Trachea ultrasound is applicable to check for normal or esophageal intubation. <br />

Lung ultrasound: A firm statement regarding mainstem intubation is not possible<br />

for the finding will be similar to sonographic findings as in pneumothorax (such as<br />

no lung sliding and no lung pulse). Pneumothorax still could be ruled out (if lung<br />

sliding or B-lines are present).<br />

In presence of both pneumothorax and cardiac standstill<br />

Trachea ultrasound is applicable to check for normal or esophageal intubation. <br />

Lung ultrasound: Neither mainstem intubation nor pneumothorax can be firmly<br />

diagnosed.<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Airway <strong>Ultrasound</strong> Exam<br />

Finding 3: no lung sliding, no lung pulse<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Consider pneumothorax, but only when heart beats!


Sonoscopy of lung post-intubation<br />

Check for lung pulse / lung sliding<br />

Simple pattern recognition<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Observe: Lung movements during ventilation.<br />

Think: If none, consider pneumothorax, but only if cardiac motion has been confirmed.<br />

Action: Decide side, consider or perform immediate needle puncture.


Additional information<br />

Esophageal misplacement?<br />

Comparing methods<br />

<strong>Ultrasound</strong> and Capnometry<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

3 2<br />

Use B-Mode<br />

Regarding the question <br />

of esophageal misplacement, in <br />

post-intubation check of trachea, <br />

ultrasound is faster and<br />

does not require ventilation trials.<br />

Capnometry is slower and <br />

insecure for this purpose<br />

because of slow drop, requirement of ventilation trials and not providing zero line results<br />

Zechner PM, Breitkreutz R<br />

<strong>Resuscitation</strong> (2011)


Additional information<br />

Airway <strong>Ultrasound</strong> Exam<br />

Main questions<br />

Edited by Raoul Breitkreutz (2020)<br />

#Q1. Esophageal<br />

misplacement? Yes or No?<br />

Esophageal misplacement?<br />

Re-Check after re-intubation<br />

Immediate action?<br />

Yes<br />

No, if<br />

normal<br />

Expected frequency<br />

ruling in<br />

ruling out<br />

#Q2. Main stem<br />

Main stem intubation?<br />

intubation? Yes or No?<br />

Re-Check after withdrawal<br />

Yes<br />

No, if<br />

normal<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Available at yumpu.com/en/SonoABCD


Additional information<br />

Airway <strong>Ultrasound</strong> Exam 1,2<br />

Method<br />

Edited by Raoul Breitkreutz (2020)<br />

Method: Sonoscopy<br />

Sonoscopy is the art of stethoscope-like use<br />

of ultrasound.<br />

Regarding Airway and Lung <strong>Ultrasound</strong> as part<br />

of „<strong>Resuscitation</strong> <strong>Ultrasound</strong>“ in the clinical<br />

context of Peri-<strong>Resuscitation</strong>: Check for trachea<br />

post-intubation, and, in case of tracheal<br />

placement, for lung sliding and -pulse.<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Additional information<br />

Types of airway ultrasound exams within a defined clinical context<br />

Types of airway ultrasound exams<br />

within a defined clinical context<br />

Action / ultrasound<br />

exam type<br />

Aim, emphasis on<br />

Approx. time for<br />

exam (seconds)<br />

Time pressure?<br />

/ remark<br />

Pre-check, e.g. for<br />

prep of dLT, difficult<br />

laryngoscopy,<br />

identify cricoid<br />

membrane<br />

planned evaluation<br />

of upper airway<br />

related<br />

sonoanatomy<br />

> 60<br />

no time pressure<br />

applicable, because of<br />

measurements<br />

Trachea exam only<br />

after any emergency<br />

intubation, double<br />

tract or single tract<br />

before ventilation<br />

< 10, when<br />

evaluating postintubation<br />

only<br />

yes, integration into a<br />

(fast driving) process,<br />

similar to one by one item<br />

in a RSI<br />

Airway <strong>Ultrasound</strong><br />

Exam<br />

Airway <strong>Ultrasound</strong> as<br />

part of <strong>Resuscitation</strong><br />

<strong>Ultrasound</strong><br />

routine check for<br />

trachea plus lung<br />

sliding or lung pulse<br />

or diaphragm or<br />

parts of it<br />

check of treatable<br />

conditions<br />

< 120 no, variety of indications*<br />

A;


Airway <strong>Ultrasound</strong> Exam 1,2<br />

References<br />

Slovis TL, Poland RL. Radiology. 1986; 160:262–3.<br />

Endotracheal tubes in neonates: (Its) sonographic positioning.<br />

Raphael DT, Conard FU. <strong>Ultrasound</strong> confirmation of endotracheal tube placement.<br />

J Clin <strong>Ultrasound</strong>. 1987; 15:459–62.<br />

Ma G et al. J Emerg Med 1999 (SAEM meeting Abstract 515), Acad Emerg Med. 1999; 6:515. full paper<br />

published in 2007 (Trachea, while and post-intubation, principle, cadavers)<br />

Drescher MJ et al.. Acad Emerg Med 2000;7:722–5.<br />

(First detailed description of sonograms in esophageal intubation, while and post-intubation, principle,<br />

cadavers)<br />

Weaver B et al. Acad Emerg Med. 2006;13(3):239-44 <br />

(Lung sliding to confirm trachea placement, post-intubation, principle, cadavers)<br />

Ma G et al. J Emerg Med 2007;32:405 (Trachea, while and post-intubation, principle, cadavers)<br />

Werner SL et al. Ann Em Med 2007;49:75–80 (Trachea, while intubation, principle)<br />

Chou HC et al <strong>Resuscitation</strong> 2011;82:1279–84 (Trachea, while intubation, double tract sign)<br />

1Zechner P, Breitkreutz R <strong>Resuscitation</strong> 82 (2011) 1259–61 (First description of the <br />

„Airway ultrasound protocol“, combining ALS-conformed trachea and lung evaluation) <br />

2Breitkreutz R et al. <strong>Resuscitation</strong> 83 (2012) 273–274 (add of Lung sliding, Lung pulse)<br />

Edited by Raoul Breitkreutz (2020)<br />

Adi O et al. Crit <strong>Ultrasound</strong> J 2013; 5:7 (Trachea, Post-intubation)<br />

Abbasi et al. Eur J Emerg Med 2015;22(1):10–6 (Trachea, Post-intubation)<br />

Soar J et al. <strong>Resuscitation</strong> 95 (2015) 100-142 (ERC guideline 2015)<br />

Chou EH et al. / <strong>Resuscitation</strong> 90 (2015) 97–103 (Metaanalysis)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Additional exam styles<br />

Sonoscopy of lung post-intervention<br />

Ruling out pneumothorax<br />

Simple pattern recognition<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Edited by Raoul Breitkreutz (2020)<br />

Observe: Lung movements during ventilation.<br />

Think: If lung sliding or lung pulse are present, you can rule out pneumothorax.<br />

Action: Perform planned repeated exam two-staged in clinical time course.


Additional exam styles<br />

Sonoscopy of lung: Screening for pleural effusion<br />

Simple pattern recognition<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Observe: Lung sliding, diaphragm<br />

Think: separation of diaphragm and lung?<br />

Action: evaluate clinical symptoms for puncture decision and if urgent


Additional exam styles<br />

Sonoscopy tests of double lumen intubation<br />

Simple pattern recognition<br />

Edited by Raoul Breitkreutz (2020)<br />

by Tobias C. Schröder, Frankfurt a.M.<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Observe: Lung movements during ventilation.<br />

Think: Lung sliding or lung pulse if not clamped or clamped.<br />

Action: Visualisation, clamping, visualisation and conclusion


Additional exam styles<br />

Sonoscopy test of congestion - B-lines<br />

Simple pattern recognition<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Observe: B-lines, multiple B-lines, effusion.<br />

Think: multiple B-lines? bilateral? white lung?<br />

Action: reporting, oxygen, induction of therapy


Review article<br />

nt, especially in its specificity value. Different settings, operperience,<br />

Ultrasonography and timing of the for ultrasound confirmation can cause of a endotracheal small but was tube used placement:<br />

in ten studies. 9,11,12,14–20 The sensitivity and spe<br />

mon ultrasound technique to detect esophageal intubatio<br />

nificant A influence on the diagnostic accuracy. Ultrasonogran<br />

be a useful tool for confirmation of tracheal intubation. real-time sonographic imaging during intubation has higher<br />

are both high in cadaveric models, ORs, and EDs. In ge<br />

systematic review and meta-analysis <br />

er, Eric the use H. Chou of ultrasonography a,1 , Eitan Dickmanor a , any Po-Yang method Tsouas b , Mark the sole Tessarotivity a , Yang-Ming for detection Tsai c , of esophageal Additional intubation information<br />

than post-intu<br />

Matthew Huei-Ming Ma d , Chien-Chang Lee c,d,∗ , John Marshall a<br />

a Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA<br />

b College of Medicine, National Yang-Ming University, Taipei, Taiwan<br />

c Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Douliou, Taiwan<br />

d Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan<br />

<strong>Resuscitation</strong> 90 (2015) 97–103<br />

a r t i c l e i n f o<br />

Article history:<br />

Received 19 November 2014<br />

Received in revised form 11 February 2015<br />

Accepted 12 February 2015<br />

Keywords:<br />

Intubation<br />

Airway management<br />

Ultrasonography<br />

<strong>Resuscitation</strong><br />

Meta-analysis<br />

Critical care<br />

a b s t r a c t<br />

Objective: This study aimed to undertake a systematic review and meta-analysis to summarize evidence<br />

on the diagnostic value of ultrasonography for the assessment of endotracheal tube placement in adult<br />

patients.<br />

Methods: The major databases, PubMed, EMBASE, and the Cochrane Library, were searched for studies<br />

published from inception to June 2014. We selected studies that used ultrasonography to confirm endotracheal<br />

tube placement. The search was limited to human studies, and had no publication date or country<br />

restrictions. Exclusion criteria included case reports, comments, reviews, guidelines and animal studies.<br />

Two reviewers extracted and verified the data independently. We summarized test performance characteristics<br />

with the use of forest plots, hierarchical summary receiver operating characteristic (HSROC)<br />

curves, and bivariate random effect models. Meta-regression analysis was performed to explore the<br />

source of heterogeneity. The methodological quality of individual studies was evaluated using the Quality<br />

Assessment of Diagnostic Accuracy Studies (QUADAS) tool.<br />

Results: A total of 12 eligible studies involving adult patients and cadaveric models were identified<br />

from 1488 references. For detection of esophageal intubation, the pooled sensitivity was 0.93 (95%CI:<br />

0.86–0.96) and the specificity was 0.97 (95%CI: 0.95–0.98). The area under the summary ROC curve was<br />

0.97 (95%CI: 0.95–0.98). The positive and negative likelihood ratios were 26.98 (95%CI: 19.32–37.66) and<br />

0.08 (95%CI: 0.04–0.15), respectively.<br />

Conclusions: Current evidence supports that ultrasonography has high diagnostic value for identifying<br />

esophageal intubation. With optimal sensitivity and specificity, ultrasonography can be a valuable adjunct<br />

in this aspect of airway assessment, especially in situations where capnography may be unreliable.<br />

© 2015 Elsevier Ireland Ltd. All rights reserved.<br />

1. Introduction<br />

Tracheal intubation serves as definite airway control when<br />

resuscitating critically ill patients. Confirmation of proper tube<br />

placement should be completed in all patients at the time of initial<br />

intubation. Unrecognized misplacement of the endotracheal tube<br />

may lead to avoidable morbidity including neurological damage,<br />

and death, with a reported incidence of 6–16%. 1,2 Thus, immediate<br />

post-intubation airway assessment is an essential clinical skill<br />

for every physician in emergency medicine (EM), anesthesia and<br />

critical care medicine. There are multiple options for confirming<br />

tracheal intubation and all methods have unique limitations. 3–5<br />

According to the 2010 American Heart Association (AHA) guideline,


Breitkreutz R et al. (2012)<br />

Additional<br />

information<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Sonoscopy of lung post-intubation<br />

Check for lung pulse / lung sliding<br />

Additional information<br />

Consider obtaining findings. Don´t try diagnoses.<br />

Edited by Raoul Breitkreutz (2020)<br />

Decide C-AB or A-B-C or else upon clinical context.<br />

Don´t get distracted by insecure interpretation of a finding.<br />

Team leaders should decide CPR process independently.<br />

B-Mode provides overview and is fast. Avoid M-Mode for lung<br />

evaluation in emergencies because of lesser overview and time consuming<br />

interaction with the ultrasound machine.<br />

Consider this method as secondary option whenever available. With<br />

ultrasound or capnometry you cannot intubate. However, with<br />

bronchoscopy you could.<br />

Train tracheal quick check, lung sliding or pulse and subcostal<br />

window. On yourself or in any health environment. These are very simple<br />

exams<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


ABCD


30% VF only<br />

>60% PEA / asystole


The problem is….<br />

High-quality CPR!<br />

Identify treatable<br />

conditions!<br />

How to integrate ALS-conformed ultrasound in (existing) interruptions?


The solution is<br />

1) With training<br />

ALS-conformed ultrasound is feasible.<br />

2) It has a potential to identify<br />

- tamponade<br />

- acute right heart pressure overload<br />

- hypovolemia.<br />

3) Minimize interruptions!


2015


2015


2015<br />

„Consider“ ≙ VAS 5!


2016<br />

1. Cardiac activity on ultrasound was most<br />

associated with survival following cardiac<br />

arrest.<br />

2. <strong>Ultrasound</strong> during cardiac arrest identifies<br />

interventions outside of the standard ACLS<br />

algorithm.


2018


Is <strong>Resuscitation</strong> <strong>Ultrasound</strong> = „Emergency TTE“?<br />

Main emphasis on<br />

Findings<br />

Probe positions<br />

Further regions<br />

Method of evaluation<br />

<strong>Resuscitation</strong> <strong>Ultrasound</strong><br />

resume chest compressions, driving force is<br />

ALS, identify treatable conditions, image at<br />

a glimpse only<br />

Pathologies (3) and „kinetic activity“<br />

2: cardiac, cava (sweep in subcostal area)<br />

A: airway - trachea only, post-intubation for<br />

observing single or double tract<br />

B: lung (sliding, pulse) main stem intubat.<br />

Screening, „Scanning“, simple gross<br />

pathologies, binary answer<br />

Emergency TTE<br />

function, acquisition of<br />

various views<br />

Pathologies (>10) and<br />

functional analysis<br />

5+: parasternal LAX,<br />

SAX, apical, subcostal,<br />

IVC LAX…<br />

-<br />

Diagnostic accuracy,<br />

quantitative information<br />

Duration 400 PoCUS<br />

longer time spans<br />

full specialized TTE<br />

training<br />

Concept with<br />

DEGUM / ÖGUM / SGUM


Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


low-cost, available at<br />

www.SonoABCD-Verlag.org


Sweep subcostal-LAX - IVC


During CPR<br />

subcostal window<br />

Edited by Raoul Breitkreutz (2020)<br />

Raoul Breitkreutz, Scientific Network Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


During CPR: EMD<br />

subcostal window<br />

interruption<br />

pause of chest compressions<br />

evaluation<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


asystole, after<br />

cessation no flow<br />

subcostal window<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


True - EMD<br />

parasternal, LAX<br />

Courtesy of H. Steiger, Darmstadt<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Pseudo - EMD<br />

parasternal, LAX<br />

Courtesy of H. Steiger, Darmstadt<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Tamponade<br />

subcostal window<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Tamponade<br />

subcostal window<br />

parasternal, SAX<br />

same patient<br />

by Tobias C. Schröder, Frankfurt a.M.<br />

Field examples, pocket-sized devices<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Signs of acute right heart pressure overload<br />

subcostal 4-chamber view<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Signs of acute right heart<br />

pressure overload<br />

parasternal window, SAX<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


two patients<br />

Field examples, pocket-sized devices<br />

by Tobias C. Schröder, Frankfurt a.M.<br />

Signs of acute right heart<br />

pressure overload<br />

parasternal window, SAX<br />

immediately after ROSC<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Signs of hypovolemia<br />

IVC, SAX, transhepatic view<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Field example, pocket-sized device<br />

after ROSC<br />

by Tobias C. Schröder, Frankfurt a.M.<br />

Signs of congestion<br />

IVC, SAX, transhepatic view<br />

Edited by Raoul Breitkreutz (2020)


IVC , eye-balling, B-Mode<br />

Edited by Raoul Breitkreutz (2020)<br />

„eye-balling“ evaluation<br />

✓1. diameter (end-expiratory) < 1,5 cm?<br />

✓2. pulsation visible?<br />

ev. 3. respiratory variability? 0-50%<br />

- (in CPR no sniff test to assess “collapsibility”)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


IVC, B-Mode, LAX, “eye-balling”<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


VCI, LAX - Pitfall false Diameter (fD)!<br />

- n o horizontal diameter<br />

- vertical diameter: median or not?<br />

Edited by Raoul Breitkreutz (2020)<br />

fD<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

after Scheiermann P et al. Ultraschall in der A&I, Kapitel 7.2., DÄV (2007)


(very) low EF - eyeballing<br />

sweep of IVC and<br />

subcostal 4-chamber view<br />

1st exam after ROSC<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Therapy: Puncture/Aspiration, Lysis, Volume, Catecholamines<br />

ER / ICU / shockroom - system has to be prepared - What about yours?<br />

Decide!<br />

If diagnostics - prepare also for therapy!<br />

Edited by Raoul Breitkreutz (2020)<br />

http://leitlinien.dgk.org/<br />

e.g.. 1:10<br />

(100 µg/ml)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Immediate<br />

(specialist / cardiologist was informed but immediate action was required)<br />

Emergency: First aspiration / withdrawal of fluid to unload pressure!<br />

Edited by Raoul Breitkreutz (2020)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.


Urgent<br />

(specialist / cardiologist was informed but not available)<br />

Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Edited by Raoul Breitkreutz (2020)


Scientific Network SonoABCD<br />

The fine art of Sonoscopy.<br />

Emergencies: main goal if tamponade<br />

unload pressure = puncture + aspiration/withdrawal<br />

Catheter insertion takes time. Can be done later!<br />

puncture / withdrawal<br />

Edited by Raoul Breitkreutz (2020)<br />

no primary catheter insertion


ALS-conformed<br />

<strong>Resuscitation</strong><br />

<strong>Ultrasound</strong><br />

A concept with images and video clips of exam styles<br />

by<br />

Raoul Breitkreutz, MD (Frankfurt a.M. / Bad Rappenau)<br />

Domagoj Damjanovic, MD (Freiburg i. Brsg.)<br />

Tobias C. Schröder, MD (Frankfurt a.M.)<br />

Markus Geuting, MD (Bad Rappenau)<br />

A free online publication of the<br />

The Scientific Network SonoABCD with SonoSchool<br />

and SonoABCD Publishing Company<br />

D-64405 Fischbachtal, Germany<br />

ISBN - 978-3-96228-078-9<br />

Available at yumpu.com/en/SonoABCD


Acknowledgement<br />

This work is dedicated to WINFOCUS, a non-profit organization.<br />

Ideas are results of mutual scientific exchange with world leading experts<br />

in the field of focused ultrasound now more known as „point-of-care ultrasound“.<br />

We gathered at several annual congresses and consensus conferences<br />

and listened and learned and talked with empathy and enthusiasm.<br />

WINFOCUS´ vision is to spread the ideas<br />

of the new methods of sonoscopy to the one world.

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