The Feasibility of Using Point-of-care Ultrasound (POCUS) for Cardiac Arrest in the Pediatric Emergency Department: Rapid Apical Contractility Evaluation (RACE)

Background: Cardiac arrest is an infrequent but high-stakes scenario in pediatrics. PALS and AHA guidelines emphasize minimal interruption of CPR during resuscitation. Manual pulse checks are unreliable and interrupt chest compressions. Point-of-care ultrasound (POCUS) may be used as an adjunct to, or in place of, pulse checks to visualize cardiac contractility and central artery pulsatility. Specifically, the apical four-chamber (A4) and subxiphoid (SX) windows may be used in patients undergoing active chest compressions, and in cases where defibrillator pads preclude parasternal views. To our knowledge, there are no prior studies that describe the feasibility of POCUS pulse checks in pediatric patients.

We hypothesize that PEM physicians, PEM fellows, and EM residents in the Pediatric Emergency Department (PED) are able to obtain interpretable POCUS clips in children from the A4 and SX positions within 10 seconds.

Methods: This is a prospective study of a convenience sample PEM attendings, PEM fellows, and EM residents in an urban academic hospital. Patients receiving an ultrasound are stable patients 12 years old or younger who provide verbal consent and assent as applicable. Sonologists are asked to obtain and acquire an A4, SX, and femoral view, in that order. A timer is set for 10 seconds, after which the sonologist removed the probe. Primary outcome is whether their A4 and SX scans are interpretable for contractility, and if their femoral artery scan was interpretable for the presence of a pulse. A POCUS expert reviews scans to confirm interpretability.

Results: A total of 8 sonologists performed 17 scans on 7 different patients. Patient age range was 2 months to 11 years, and weight range was 7.9 to 46.5 kilograms. Of sonologists, 3 were PEM attendings, 3 PEM fellows, and 2 EM residents. A view that was interpretable for contractility was obtained on the first attempt in 88% (15/17) of A4 and SX scans. A femoral view that was interpretable for pulsatility was obtained on the first attempt in 88% (15/17) of scans.

Expert review was concordant with sonologist interpretation in all cardiac scans. In one of 17 femoral scans, sonologist did not visualize arterial pulsations but POCUS expert did.

Conclusion: Physicians who routinely perform POCUS in an academic PED can frequently obtain interpretable A4 and SX cardiac views and femoral artery views in children within 10 seconds. POCUS has the potential to replace manual pulse and rhythm checks in pediatric resuscitations without delay in chest compressions. This is an ongoing study and more data will be available at the time of presentation. Future studies are necessary to evaluate the effects of POCUS pulse checks in pediatric resuscitations.