Ventricular fibrillation on POCUS during CPR

Case contributed by MD Guilherme Resener

Presentation

Recent history of percutaneous coronary intervention. Patient had a seizure in a public place. Cardiac arrest was recognized and basic life support was initiated. Patient had received two shocks by automated external defibrillator and there were alternating cycles of pulseless electrical activity, ventricular fibrillation and temporary return of spontaneous circulation. Then, an ambulance helicopter crew arrived. A mechanical chest compressor was installed. The patient was intubated and point-of-care ultrasound was performed. Advanced cardiac life support was then initiated. The video in this case was obtained during one of the pulse checking, with the probe placed in the parasternal position.

Patient Data

Age: 65 years
Gender: Male

Point-of-care ultrasound (POCUS) during resuscitation. During pulse check, patient had return of spontaneous circulation, but during ultrasound examination, cardiac rhythm was converted to ventricular fibrillation.

In the beginning of the clip, on parasternal short axis view, contraction of the left ventricle is seen. The probe orientation is then switched to parasternal long axis view (at 0:10). During this evaluation, the left ventricle stopped contracting and "flickered", demonstrating ventricular fibrillation. The ultrasound examination was interrupted and shock was administered, followed by continuation of cardiopulmonary resuscitation.

Case Discussion

Point-of-care ultrasound (POCUS) is a very useful tool during cardiac arrest. It can be used to identify various possible causes, such as pulmonary embolism, pneumothorax and cardiac tamponade.

More recently POCUS has gained traction in evaluating the adequacy of chest compressions, seeing in real time the compression of the left ventricle. It has also been in the spotlight with discussion of "pseudo-PEA" (pseudo pulseless electrical activity) or PREM (pulseless rhythm with echocardiographic motion), and how to manage these patients.

POCUS also helps to differentiate asystole from fine ventricular fibrillation. The electrical activity may be too low for the monitor to perceive, but the "flickering" of the ventricle may be seen on ultrasound.

In this case, cardiac motion was seen and while other parameters were being evaluated, the patient developed ventricular fibrillation and immediate defibrillation was provided.

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