FOCUSED ECHOCARDIOGRAPHY INEMERGENCY LIFE
SUPPORT(FEEL-UK)
This text has been reprinted from a 2010 article in ECHO;
issue 70
BACKGROUND
The two key components of successful resuscitation are high
quality CPR, and identification and treatment of any
underlyingreversible cause(s). Although ancillary devices are
routinely used by the resuscitation team (ECG, pulse oximetry,
capnography, NIBP/arterial line), and diagnostic tests performed
(ECG, CXR, ABGs) the routine use of echocardiography is not yet
widespread. This is despite persistent/worsening haemodynamic
instability being a Class I indication for its use.
The reasons for the apparent reluctance to incorporate focused
echocardiography into peri-resuscitation care are numerous. These
relate to lack of availability and portability of equipment, and
the fact that echocardiography has remained largely the province of
cardiologists and cardiac physiologists, who are not routinely part
of the cardiac arrest team. In recent years the development of
simpler, cheaper, more portable machines with rapid boot-up times
has led to the widespread use of ultrasound(US) in emergency &
critical care medicine. Indeed, most acute clinicians are now
familiar with the routine use of US for vascular access and pleural
imaging, and FAST scanning (focused US) is now considered a
standard part of Advanced Trauma Life Support (ATLS). These
developments have led to a demand for training in focused US and
echocardiography for the critically ill patient.
FEEL-UK
There is a growing body of evidence supporting the performance
of focused echocardiography by novice/minimally trained
practitioners in the context of significant haemodynamic
instability including cardiac arrest. Despite this, there has been
an apparent reluctance of the accrediting echocardiography bodies
to formally endorse this practice, primarily due to concerns
regarding standards of training and practice. FEEL UK is a
programme intended to train practitioners in the use of
transthoracic echocardiography (TTE) in a standardised manner
during the peri-resuscitation period. The course has been developed
using experience from various international courses of focused
echocardiography in the critically ill.
FEEL UK was piloted in the UK in 2009 with invited delegates
from all relevant specialities, the Royal Colleges and other
Societies involved in managing the critically ill, together
with the Resuscitation Council and the British Society of
Echocardiography (BSE). The FEEL-UK programme comprises a
didactic one-day course containing a 50:50 mixture of lectures and
small group (maximum 3 students) hands-on training sessions,
computer based teaching and simulated resuscitation scenarios.
FEEL-UK is run along the lines of the ALS/ATLS, being highly
standardised and regulated thus ensuring minimal standards are
achieved. The course objectives are outlined in Table 1. The
delegates are then required to continue their training locally by
performing focused studies on critically ill patients under the
supervision of a local mentor.
Table 1 The objectives of the one-day
training course in ALS-compliant peri-resuscitation
echocardiography, FEEL-UK. TTE; transthoracic echocardiography,
ALS; advanced life support
In mentoring trainees, several key differences exist when
compared with supervision and training for standard
echocardiography. First, focused peri-resuscitation
echocardiography does not require the practitioner to perform all
standard views, but simply obtain a view that may rule in/rule out
some of the important causes of cardiac arrest. Second,
potentially treatable findings in the peri-resuscitation period are
expected to be gross and easily recognisable by eyeballing an echo
study. Examples would include severe systolic left ventricular
dysfunction, profound hypovolaemia or massive pericardial
collection. Thus, there are no requirements for any
echocardiographic measurements or Doppler echocardiography. Third,
reporting comprises a simple binary diagnostic approach, applicable
in the context of cardiac arrest, and easily communicable to the
resuscitation team. For FEEL UK a tick-box report sheet is
available (Figure 1). In practice, each delegate is required
to identify a local mentor (BSE accredited TTE practitioner or
equivalent). This will generally be their local cardiologist,
cardiac physiologist or an appropriately qualified cardiology
registrar.
Figure 1 Standard reporting sheet
used for focused echocardiography studies provided for FEEL-UK.
DOB; date of birth, CPR; cardiopulmonary resuscitation, PLAX;
parasternal long axis, PSAX; parasternal short axis, ECG;
electrocardiogram, PEA; pulseless electrical activity, VF;
ventricular fibrillation, LV; left ventricle, RV; right
ventricle
Following the course, the student is required to
demonstrate competence to their local mentor in performance and
interpretation of focused echocardiography in critically ill
patients.
The main points relevant to the mentor are:
- The onus is on the student to identify, approach and liaise
withtheir mentor(s)
- The TTE examinations must be performed on supine Level III
(intensive care) patients in addition to during resuscitation
- 2D imaging only is required, and the report should
simplyreflect the questions relevant to the peri-resuscitation
scenario(see Figure 1, report sheet)
- The mentor need not be present for all scans, however the first
ten or so should be directly observed as this provides
anopportunity to ensure correct technique and feedback on image
optimisation
- Subsequently, trainees should perform, record and
reportsystematic scans, attempting to achieve all 4 views if
possible,and arrange to meet with their mentor at a mutually
convenient time to review the images and their interpretation
- An examination may be repeated on the same patient ondifferent
occasions if their condition has changed and a repeatecho would be
clinically appropriate. An example is after successful diagnosis
and drainage of a pericardial collection arepeat scan in the
presence of ongoing shock may demonstrate severe hypovolaemia or
underlying severe LVdysfunction.
- Each study takes only a few minutes. The aim is to perform
afocused echo scan, and not undertake a full
echocardiographicstudy
- Each student may have more than one mentor, as there will often
be more than one within an institution or (if the traineeis a
junior doctor) they move between institutions
- Completion of a minimum of 50 scans is required to obtain
FEEL-UK certification
The student will keep a logbook of scans performed and the
mentor should sign this once satisfied the student is performing
and interpreting a FEEL examination adequately. The student will
then send the front sheet back to their course director, who will
notify the BSE that the student has adequately completed the entire
programme. The BSE will then issue them with acertificate of
competency in peri-resuscitation focused echocardiography.
Re-certification requires evidence of ongoing practice and will be
performed at three yearly intervals using web-based assessment
tools.
Although increasing pressures on echocardiography departments
may make this additional demand seem prohibitive, in practice, the
amount of time required for supervision is minimal. There are ample
opportunities to fit training into current practice. For example,
the student may accompany their mentor for the performance of
urgent inpatient ward based echo studies. Where based on an ICU,
students should prepare the patient and machine in anticipation of
the arrival of their mentor and perform an initial focused scan
prior to (or after) the full study being undertaken by the
echocardiographer.
Further information, along with a brief guide for mentors is
obtainable via the FEEL-UK website: www.FEEL-UK.com
Conclusion
Focused echocardiography is increasingly widespread, and it
isessential that standards are clearly defined and maintained by
the appropriate bodies. The BSE has taken an important step in
recognising this, and its role in supporting the development of a
peri-resuscitation echocardiography certification for the UK is
fundamental. Continued support of this process from
echocardiography practitioners is equally central to its successful
implementation, ensuring that focused echocardiography is practised
to an adequate standard within existing clinical governance
frameworks.
Susanna Price, Royal Brompton Hospital,
FEEL-uk
Shahana Uddin, Barts and the London Hospital,
FEEL-uk