Objective Our primary objective was to determine if there was a difference in success of cardiac visualization by focused transthoracic echocardiography (TTE) location (subxiphoid, parasternal, or apical) during chest compression interruptions among cardiac arrest patients. Secondarily, we sought to determine whether there were differences in chest compression interruption times with the focused TTE locations. Methods We conducted a retrospective cohort study of video-recorded, adult, cardiac arrest resuscitations in a quaternary care Emergency Department from 11/2018 to 11/2023. Focused TTE was successful if 1) cardiac visualization was seen on video review, or 2) cardiac visualization was discussed in the recording. A chi-squared test was used to assess differences in success and ANOVA was used to assess differences in interruption times based on TTE locations. Repeated measures multivariable regression models were constructed to control for clinically relevant variables for the primary and secondary objectives. Results 136 patients and 365 focused TTE attempts were included in the study (241 subxiphoid, 101 parasternal, and 23 apical). There was no difference in the success rate: subxiphoid 83.4%, parasternal 88.1%, and apical 95.7% (p = 0.190) or in multivariable regression analysis (p = 0.189). There was no difference in the mean chest compression interruption time for each site: subxiphoid 15 sec. (IQR 12–23 sec.), parasternal 17 sec. (IQR 11–22 sec.), and apical 19 sec. (IQR 15–25 sec., p = 0.446) or in multivariable logistic regression analysis (p = 0.803). Sonographers with ≥ 50 quality assured focused TTEs had higher success than those without (94.4% vs. 75.1%; p < 0.001). Conclusions In cardiac arrest, the parasternal and apical TTE locations had similar success of cardiac visualization and similar compression interruption times to the more commonly used subxiphoid location.

Introduction: Currently, no consensus exists regarding the ideal location for obtaining a transthoracic echocardiography (TTE) image during cardiopulmonary resuscitation (CPR). Of the three common locations, sub-xiphoid (SX), parasternal (PS) and apical (AP), the SX is most frequently used in cardiac arrest (CA) to avoid interfering with CPR. The recent adoption of mechanical chest compression devices may have led to increased use of alternate locations. We aim to assess the association between successful TTE image acquisition and the locations, also to compare the duration of CPR interruptions at each location. Hypothesis: We hypothesized that PS location will have a higher success rate compared to SX, but not a longer CPR interruption time. Methods: This is a retrospective study of all video-recorded non-traumatic, CA patients ≥18 years old in a quaternary care Emergency Department (ED) from 08/07/2019 to 05/18/2022 where an intra-arrest TTE was performed. Video recordings of cardiac arrest patients were reviewed by 2 physicians with years of experience and a well-established process. Successful image acquisition was defined as 1) visualization of the heart on the ultrasound machine or 2) clinicians verbalizing visualization in the video recording. Chi-square and Kruskal-Wallis tests were performed to compare the success rates and duration of CPR interruptions based on TTE locations. Our health system’s Institutional Review Board approved the conduct of this study. Results: A total of 59 patients yielded a combined 154 video recorded TTE attempts 90 (58.4%) SX, 56 (36.4%) PS, and 8 (5.2%) AP. Median age was 81 years, 50.8% female, 81.4% non-shockable initial rhythm, and 89.8% were receiving mechanical CPR. Because there were only 8 AP attempts, PS and SX were the only locations analyzed. PS was successful in 89.3% (68 of 90) compared to 75.6% (50 of 56) for the SX (p=0.04). The median duration of interruptions for PS was 17.5 seconds (IQR: 12.0, 22.0) compared to 15 seconds (IQR: 11.0, 24.0) for SX (p=0.5). Conclusion: During CPR, PS location for TTE image acquisition is associated with higher success when compared to SX. However, the median CPR interruption times are not significantly different.

We present a case of a 12-year-old female with a history of congenital solitary kidney presenting to an academic pediatric emergency department (ED) in acute abdominal pain. Using ultrasound as the initial diagnostic modality, the patient was found to have Herlyn-Werner-Wunderlich syndrome (HWWS), an abnormal development of the Müllerian system during embryogenesis resulting in obstructed hemivagina with resulting hematometrocolpos. The patient presented with undifferentiated abdominopelvic pain, and in the course of the ED workup was diagnosed with a disorder infrequently encountered by emergency physicians. We present a case of markedly abnormal point-of-care ultrasound findings prompting additional studies, ultimately leading to a diagnosis of HWWS during the initial ED visit.