Eric J Adkins1, David P Bahner2 1 Department of Emergency Medicine; Department of Internal Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA 2 Department of Emergency Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
Ultrasound use in cardiac arrest (CA) has been associated with poor outcome when cardiac activity is unable to be visualized.  The focused echocardiographic evaluation in life support (FEEL) protocol evolved as a systematic approach to using focused echo in CA.  Use in the United States is sporadic and relies on having trained personnel in the use of ultrasound available at the site of the CA. Ultrasound is not yet a standard part of advanced cardiac life support (ACLS). This case illustrates; how use of point-of-care (POC) ultrasound can be utilized for decision making in the CA patient.
A 55-year-old male was admitted for abdominal pain, nausea, vomiting, and weight loss. CT scan of the abdomen revealed a cirrhotic liver with mass and intravascular thrombus. Liver biopsy confirmed hepatocellular carcinoma. Post procedure the patient became anemic and received blood products following the biopsy. The abdominal exam remained soft and non-tender. On hospital day (HD) #6 the patient developed altered mental status requiring intubation.
A multidisciplinary team led by emergency physicians that conducts weekly intensive care unit (ICU) ultrasound rounds arrived in the medical ICU (MICU). The patient was suggested for the educational ultrasound rounds. While preparing the ultrasound machine, the patient became hypotensive. A focused cardiac echo was done showing a severely hypokinetic heart without pericardial effusion. The ratio of the right and left ventricles were normal. The arterial waveform showed narrowed pulse pressure. Within seconds, the patient had a pulseless electrical activity (PEA) CA. ACLS was initiated. During the pulse check, cardiac activity was assessed as described in the FEEL protocol  [Video 1]. The echo showed cardiac activity with severe hypokinesis [Video 2]. During cardiopulmonary resuscitation (CPR), a focused assessment with sonography in trauma (FAST) scan demonstrated free fluid within Morrison's pouch. Return of spontaneous circulation (ROSC) occurred after intravenous (IV) epinephrine and aggressive volume resuscitation. The cause of the pulseless electrical activity (PEA) arrest was felt to be hypovolemia and anemia. The heart was reexamined and showed improved contractility with a relatively hypokinetic state [Video 3]. Surgery was consulted and exploratory laparotomy was performed. Large amounts of blood and blood clots were removed and the liver was packed at the biopsy site.
This case highlights the benefits of POC ultrasound in the ICU setting. Initial images obtained at the onset of this patient's instability led to the early recognition and mobilization of the CA response teams. The use of ultrasound in CA can provide information to help guide resuscitation and identify reversible causes.  The FEEL protocol demonstrated the feasibility of applying ultrasound during CPR. Physicians were able to detect reversible conditions as causes of PEA (hypovolemia, tamponade, etc.) and alter the management of the arresting patient.  In our patient, the ultrasound provided value during CPR by demonstrating hypokinetic cardiac activity, excluded pericardial tamponade, and showed free fluid in the abdomen associated with the hemorrhagic shock.
The use of ultrasound during CA is feasible by nonexpert sonographers.  Image acquisition during the pulse check should not exceed the 10-s allotment in a pulseless patient to avoid interference with CPR. Real time scanning during CPR can occur as well. Imaging during CPR is best performed using the subcostal window to prevent any obstruction of the provider giving chest compressions. 
Our case shows how real-time POC ultrasound technology in critically ill patients can assist in recognition of reversible causes of CA. Identifying ways to increase use of ultrasound during CA may result in improved outcomes for critically ill patients.
Breitkreutz R, Price S, Steiger HV, Seeger FH, Ilper H, Ackermann H, et al. Emergency Ultrasound Working Group of the Johann Wolfgang Goethe-University Hospital, Frankfurt am Main. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: A prospective trial. Resuscitation 2010;81:1527-33.