ECHO IN CARDIAC ARREST

Both ILCOR and AHA no longer recommend echo in cardiac arrest because it tends to interrupt CPR. They suggest using it as an adjunct tool if there is a skilled operator who can diagnose pathology without interrupting CPR (1). Further the sensitivity of diagnosing PE, tamponade and RWMA during an arrest with echo is low (2). Similarly, the 2015 review of the ANZCOR guidelines recommend against the routine use of echo in cardiac arrest (3).

I find, it is rare to make a meaningful difference with echo during an arrest. You are more likely to get in the way. It is more helpful post ROSC.

If you are going to have a look with echo during CPR, the main things to consider are:

1. Be mindful of the use of US gel (slippery for the cardiac compressions)

2. Do no interfere with CPR

3. Do not also try to run the resus (all your brain power should be used for echo diagnosis of the cause of arrest).

HOW TO PERFORM BEDSIDE ECHO IN A CARDIAC ARREST

The best sonographer available should perform the echo.

With conventional CPR, the subxyphoid view is optimal. With an external compresison device, the PLAx is usually accessible.

Set you machine to save 10 second prospective clips. During CPR try get on axis images and save clips as you go. During the pulse checks get as many on axis images in as many planes as possible. DO NOT try to make a diagnosis during the pulse check. In the hands off/ echo off time, review the clips you have saved and communicate your findings to the team leader.

If unsure about the diagnosis, look for corroborating evidence with other forms of US or other cardiac views.

The aim of echo in cardiac arrest is to look for 1. cardiac contractility, 2. reversible causes

REVERSIBLE CAUSES

Always keep the 4Hs and 4Ts in mind. Echo is probably best for the Ts.

Ts seen on echo

1. Thrombus: dilated RV 1:1 with LV

2. Toxins: LV may be dilated

3. Tamponade: pericardial effusion

4. Tension pneumothorax: absent pleural sliding

CARDIAC ACTIVITY

Echo is able to easily differentiate true PEA (no cardiac activity on echo) from pseudo PEA (pulseless electrical activity with coordinated contractions). Patients with pseudoPEA have been shown to have higher levels of ROSC and survival post arrest (6). Be careful with you assessment, sometimes fluids and other intravenous therapies can cause fluttering of valves which may look like cardiac activity,

Blaivas et al (7) showed that there was 0% chance of survival for patients with true PEA. However, since then Gaspari et al (8) has shown that ROSC is still possible in true PEA. Thus the current AHA guidelines' recommendation is not to rely solely on echo for the termination of resuscitation (9).

PLAx: Pseudo-PEA: coordinated contraction of the IV septum and inferiolateral LV wall

PLAx: True PEA: note the valves move due to the passage of IV fluids but there is nor myocardial contraction

Subxyphoid: true PEA

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POCUS MODULES

REFERENCES

1. Olasveengen TM, de Caen AR, Mancini ME, et al. ILCOR Collaborators. 2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary. Resuscitation. 2017 Dec;121:201-214.

2. https://costr.ilcor.org/document/diagnostic-test-accuracy-of-point-of-care-ultrasound-during-cardiopulmonary-resuscitation-to-indicate-the-etiology-of-cardiac-arrest.

Accessed July 7 2026

3. ANZCOR cardiac arrest Guideline 11.6 – Equipment and Techniques in Adult Advanced Life Support. https://www.anzcor.org/home/adult-advanced-life-support/guideline-11-6-equipment-and-techniques-in-adult-advanced life support#Ultrasound+during+cardiac+arrest

Accessed July 7 2026.

5. Tsou PY, Kurbedin J, Chen YS, Chou EH, Lee MG, Lee MC, Ma MH, Chen SC, Lee CC. Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Resuscitation. 2017 May;114:92-99. doi: 10.1016/j.resuscitation.2017.02.021. Epub 2017 Mar 2. PMID: 28263791.

6. Blyth L, Atkinson P, Gadd K, Lang E. Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review. Acad Emerg Med. 2012 Oct;19(10):1119-26. doi: 10.1111/j.1553-2712.2012.01456.x. Epub 2012 Oct 5. Erratum in: Acad Emerg Med. 2015 Jul;22(7):892. PMID: 23039118.

7. Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med. 2001 Jun;8(6):616-21. doi: 10.1111/j.1553-2712.2001.tb00174.x. PMID: 11388936.

8. Gaspari R, Weekes A, Adhikari S, et al Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016 Dec;109:33-39. doi: 10.1016/j.resuscitation.2016.09.018. Epub 2016 Sep 28. PMID: 27693280.

9. Soar J, Berg KM, Andersen LW, et al Adult Advanced Life Support Collaborators. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2020 Nov;156:A80-A119. doi: 10.1016/j.resuscitation.2020.09.012. Epub 2020 Oct 21. PMID: 33099419; PMCID: PMC7576326.