{"id":926,"date":"2017-10-08T23:57:36","date_gmt":"2017-10-08T23:57:36","guid":{"rendered":"http:\/\/emultrasound.sdsc.edu\/?p=926"},"modified":"2020-07-22T00:05:49","modified_gmt":"2020-07-22T00:05:49","slug":"variability-in-cardiac-standstill","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/10\/08\/variability-in-cardiac-standstill\/","title":{"rendered":"Variability in Interpretation of Cardiac Standstill Among Physician Sonographers"},"content":{"rendered":"<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-text-obj\">\n<h2 style=\"text-align: center;\">Background<\/h2>\n<p style=\"text-align: center;\">The use of point-of-care echocardiography to inform termination or continuation of cardiopulmonary resuscitative efforts remains controversial [1,2]. Current understanding of its utility in prognostication is limited by varying definitions of cardiac activity. Definitions of cardiac standstill range from absence of \u201corganized contractile activity (nonfibrillating) with a decrease in chamber size\u201d to absence of \u201cany visible movement of the myocardium, excluding movement of blood within the cardiac chambers or isolated valve movement\u201d to absence of \u201cany detected atrial, valvular, or ventricular motion within the heart\u201d [3-5]. Without a consistent definition of cardiac standstill, it is difficult to interpret studies reporting conflicting resuscitation outcomes in cardiac arrest.<\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/28870394\" target=\"_blank\" rel=\"noopener noreferrer\">Variability in Interpretation of Cardiac Standstill Among Physician Sonographers<\/a><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-accordion-obj motopress-accordion motopress-accordion-dark\" data-atts=\"{&quot;active&quot;:&quot;false&quot;,&quot;collapsible&quot;:true,&quot;header&quot;:&quot;&gt; div &gt; h3&quot;,&quot;heightStyle&quot;:&quot;content&quot;}\">\n<div class=\"motopress-accordion-item\"><h3>Clinical Question<\/h3><div>\n<p style=\"text-align: center;\">What is the interrater reliability among providers in classification of cardiac standstill in point-of-care echocardiography?<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Methods &amp; Study Design <\/h3><div>\n<ul>\n<li><\/li>\n<li><strong>Design<\/strong>\n<ul>\n<li>Cross-sectional convenience sample survey<\/li>\n<\/ul>\n<\/li>\n<li><strong>Population<\/strong>\n<ul>\n<li>Eligible: Residents, fellows, and faculty practicing in emergency medicine, critical care, or cardiology in attendance at one of six weekly emergency medicine (EM) conferences held at the following locations:\n<ul>\n<li>Icahn School of Medicine at Mount Sinai<\/li>\n<li>Beth Israel Medical Center<\/li>\n<li>St. Luke\u2019s-Roosevelt Hospital<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li><strong>Exclusion criteria<\/strong>\n<ul>\n<li>Providers who had previously participated at a prior conference<\/li>\n<\/ul>\n<\/li>\n<li><strong>Intervention<\/strong>\n<ul>\n<li>Participants were presented with the following clinical scenario: \u201c55-year-old man in cardiac arrest who remains pulseless after 20 minutes of CPR\u201d<\/li>\n<li>Participants were shown 15 clips (6 seconds each, looped for 20 seconds total) presenting a variety of sonographic features<\/li>\n<li>Asked to identify presence or absence of cardiac activity<\/li>\n<li>Responses transmitted via remote polling devices<\/li>\n<li>No definition of cardiac activity was provided<\/li>\n<\/ul>\n<\/li>\n<li><strong>Outcomes<\/strong>\n<ul>\n<li>Primary: interrater reliability in interpreting cardiac standstill (Krippendorff\u2019s alpha coefficient)<\/li>\n<li>Secondary: subgroup analyses by specialty, training level, and self-described point of care (POC)\u00a0ultrasound experience<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Results<\/h3><div>\n<ul>\n<li>\n<ul>\n<li>127 participants (majority EM residents with basic ultrasound skills)<\/li>\n<li>Overall <strong>moderate agreement<\/strong> with respect to identifying cardiac standstill (alpha 0.47)<\/li>\n<li><strong>Clips with stronger agreement<\/strong>:\n<ul>\n<li>No myocardial contraction<\/li>\n<li>Myocardial contraction<\/li>\n<li>Strong myocardial contraction<\/li>\n<\/ul>\n<\/li>\n<li><strong>Clips with poorer agreement<\/strong>:\n<ul>\n<li>Valve flutter<\/li>\n<li>Mechanical ventilation<\/li>\n<li>Weak myocardial contraction<\/li>\n<\/ul>\n<\/li>\n<li><strong>Moderate agreement<\/strong> across all training levels and self-reported ultrasonographic skill levels<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Strengths &amp; Limitations<\/h3><div>\n<ul>\n<li><strong>Strengths<\/strong>\n<ul>\n<li>All participants saw the same clips<\/li>\n<li>Response time limited (similar to clinical practice)<\/li>\n<\/ul>\n<\/li>\n<li><strong>Limitations<\/strong>\n<ul>\n<li>Bias: recruitment from academic conferences<\/li>\n<li>Majority with no or basic self-reported ultrasonographic skill level<\/li>\n<li>Reported discussion among participants throughout survey<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Author's Conclusions <\/h3><div>\n<p style=\"text-align: center;\">\u201cOur results support the possibility that previous studies have been subject to variability in the interpretation of cardiac standstill.\u201d<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Our Conclusions<\/h3><div>\n<p style=\"text-align: center;\">We agree with the authors\u2019 conclusions that there appears to be substantial variability in the interpretation of cardiac standstill. This study highlights a weakness in the current literature examining the utility of POC\u00a0echocardiography used during resuscitation futility assessment. While this study does not provide data on clinical outcomes of standstill misclassification, it identifies a potential weakness in the available research. It is difficult to interpret studies reporting outcomes after standstill (such as meaningful survival) when the predictor is not consistently identified.<\/p>\n<p style=\"text-align: center;\">As a follow-up study, it would perhaps be interesting to see how the interrater reliability changes when participants are provided with a clear definition of cardiac standstill. Does the variability persist even with a uniform definition? If this improves interrater reliability it would provide additional support for the need for a consensus\u00a0definition across future studies.<\/p>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-prvt-449-595bfa801309a mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-text-obj\">\n<h2 style=\"text-align: center;\">The Bottom Line<\/h2>\n<h3 style=\"text-align: center;\">There is significant\u00a0variability in classification of cardiac standstill among providers. A uniform definition of standstill may reduce this variability and aid in the interpretation of studies reporting conflicting outcomes after cardiac arrest.<\/h3>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-accordion-obj motopress-accordion motopress-accordion-dark\" data-atts=\"{&quot;active&quot;:&quot;false&quot;,&quot;collapsible&quot;:true,&quot;header&quot;:&quot;&gt; div &gt; h3&quot;,&quot;heightStyle&quot;:&quot;content&quot;}\">\n<div class=\"motopress-accordion-item\"><h3>Authors<\/h3><div>\n<p>This post was written by Carly Dougher, MS4 at UCSD. It was reviewed by Michael Macias, MD, Ultrasound Fellow at UCSD.<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>References <\/h3><div>\n<ol>\n<li>\n<ol>\n<li>Blyth, L., Atkinson, P., Gadd, K. &amp; Lang, E. Bedside Focused Echocardiography as Predictor of Survival in Cardiac Arrest Patients: A Systematic Review: Echocardiography in Cardiac Arrest. Acad. Emerg. Med. 19, 1119\u20131126 (2012).<\/li>\n<li>Cohn, B. Does the Absence of Cardiac Activity on Ultrasonography Predict Failed Resuscitation in Cardiac Arrest? Ann. Emerg. Med. 62, 180\u2013181 (2013).<\/li>\n<li>Schuster, K. M. et al. Pulseless Electrical Activity, Focused Abdominal Sonography for Trauma, and Cardiac Contractile Activity as Predictors of Survival After Trauma: J. Trauma Inj. Infect. Crit. Care 67, 1154\u20131157 (2009).<\/li>\n<li>Gaspari, R. et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation 109, 33\u201339 (2016).<\/li>\n<li>Kim, H. B., Suh, J. Y., Choi, J. H. &amp; Cho, Y. S. Can serial focussed echocardiographic evaluation in life support (FEEL) predict resuscitation outcome or termination of resuscitation (TOR)? A pilot study. Resuscitation 101, 21\u201326 (2016).<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"Background The use of point-of-care echocardiography to inform termination or continuation of cardiopulmonary resuscitative efforts remains controversial [1,2]. Current understanding of its utility in prognostication is limited by varying definitions of cardiac activity. Definitions of cardiac standstill range from absence of \u201corganized contractile activity (nonfibrillating) with a decrease in chamber size\u201d to absence of \u201cany &hellip; <p class=\"link-more\"><a href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/10\/08\/variability-in-cardiac-standstill\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> \"Variability in Interpretation of Cardiac Standstill Among Physician Sonographers\"<\/span><\/a><\/p>","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[5],"tags":[9,31,7],"class_list":["post-926","post","type-post","status-publish","format-standard","hentry","category-journal-club","tag-cardiac-arrest","tag-cardiac-standstill","tag-echocardiography"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Variability in Interpretation of Cardiac Standstill Among Physician Sonographers - UCSD Ultrasound<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/10\/08\/variability-in-cardiac-standstill\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Variability in Interpretation of Cardiac Standstill Among Physician Sonographers - UCSD Ultrasound\" \/>\n<meta property=\"og:description\" content=\"Background The use of point-of-care echocardiography to inform termination or continuation of cardiopulmonary resuscitative efforts remains controversial [1,2]. Current understanding of its utility in prognostication is limited by varying definitions of cardiac activity. 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