Spotlight on Research
Thursday, April 2, 2015
Ultrasound in cardiac arrest: a feasibility studyOver the years there has been growing interest in the use of ultrasound as a diagnostic tool to enhance paramedic practice when managing patients with a variety of clinical presentations.This study aimed to evaluate whether paramedics can be educated to carry out focused echocardiography in life support (ELS) involving the use of ultrasound scanning to assess cardiac function, as well as recognise reversible causes of cardiac arrest.The study was undertaken in the Scottish Ambulance Service using paramedics from the Resuscitation Rapid Response Unit (3RU) who are regularly exposed to out-of-hospital cardiac arrest. Eleven of the 3RU staff attended a one-day training course focused on ELS.They were taught to acquire both parasternal and subxiphoid views, and to assess the images for presence of movement, quality of function, recognition of rhythm, presence of fluid (i.e. pericardial effusion), and size of the chambers of the heart.In total, nine paramedics participated in the data collection. Participants' knowledge was assessed through the use of pre- and post-course questionnaires to assess whether there was any difference in theoretical knowledge level (including interpretation) linked to participation in the educational intervention.Additionally, after completion of the course, each paramedic was assessed on their ELS performance on three healthy volunteers. Participants had to a) perform one subxiphoid and one parasternal scan—they were assessed on time taken and quality of image; b) perform both scans in a 10-second window simulating the rhythm checks during a cardiac arrest (only if they managed this was the quality of the image assessed). Image quality was evaluated using a five-point scale with 1 being poor quality, and 5 being high quality.Results demonstrated a significant improvement in knowledge from a mean pre-course score of 54% to a post-course score of 89% (p<0.001).During the moulages, in relation to practical skills, all nine participants managed to produce images from both parasternal and subxiphoid views on every attempt. For the parasternal view the mean time taken to acquire an image was 13.1 seconds and the mean image quality was 4.1. For the subxiphoid view, mean time was 13.2 seconds with a mean image quality of 3.8.During simulated resuscitation, in both views the success rate was 88% of images attained within the 10-second time frame, with a mean image quality of 3.8 in the subxiphoid view, and 4.0 in the parasternal view.Ten weeks after the course, four participants were re-assessed involving a repeat questionnaire and another practical assessment. Three participants acquired a subxiphoid image (mean quality 3) and one achieved a parasternal view (image quality 4). Theoretical knowledge was reduced (82%; p=0.13), and this was deemed as non-significant; however, it is not possible to draw any firm conclusions from such a small sub-group.The authors recognise that their study has limitations—for example, the small sample size and the use of a specific cohort of paramedics who are exposed to a high number of cardiac arrests (which prohibits generalisation of the results). Additionally, the participants were scanning healthy volunteers in a controlled environment, which does not accurately reflect the nature of the out-of-hospital environment.In conclusion, although this is a small-scale feasibility study, the results demonstrate that paramedics can be trained to perform ELS. However, before implementing this practice across all Trusts, there is a need for larger studies to be undertaken involving non-specialist paramedics to establish whether these findings can be repeated. In addition, the authors recommend that future research should focus on establishing whether ELS actually contributes in a meaningful way to paramedics' clinical decision-making about management of patients in cardiac arrest in the pre-hospital setting.
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