How should point‑of‑care ultrasound be utilized during cardiac arrest without delaying chest compressions?

Point-of-Care Ultrasound in Cardiac Arrest

POCUS should NOT be routinely used during cardiac arrest, but if performed by experienced personnel, it must be obtained during the standard pulse check window (<10 seconds) without interrupting chest compressions, and should only be considered when there is specific clinical suspicion for a reversible cause. 1

Primary Recommendation

The 2025 AHA Guidelines explicitly state that minimizing interruptions in CPR is the absolute priority, as POCUS has been consistently associated with longer compression pauses, longer resuscitation duration, and higher intervention rates—yet no improvement in mortality or neurological outcomes 1. Multiple systematic reviews and meta-analyses confirm POCUS does not improve survival during cardiac arrest 1.

When POCUS May Be Considered

POCUS can be used as an additional diagnostic tool only when:

• Experienced operator is immediately available
• Strong clinical suspicion exists for specific reversible causes:
  • Cardiac tamponade
  • Massive pulmonary embolism
  • Tension pneumothorax
  • Severe hypovolemia
  • Aortic dissection
• Can be performed during pulse checks without extending pauses beyond 10 seconds
• Does not delay defibrillation or other critical interventions 1, 2

Critical Implementation Strategy

Timing Protocol

• Integrate into pulse check rhythm: Obtain images ONLY during the standard 10-second pulse check that occurs every 2 minutes 1
• Never pause compressions specifically for ultrasound imaging
• Carotid views are superior: Recent evidence shows carotid POCUS achieves adequate views more quickly (83% vs 63%) with shorter pauses than subxiphoid approaches 3

Structured Approach

Use standardized protocols (CASA - Cardiac Arrest Sonographic Assessment) to maximize efficiency:

• Subxiphoid view: Best for pericardial effusion/tamponade
• Parasternal long axis: Cardiac activity, wall motion
• Apical 4-chamber: Right heart strain (PE), global function
• Limit to single best view per pulse check 4, 5

Evidence Quality and Limitations

The 2022 International Consensus and 2025 AHA Guidelines both rate evidence as very low certainty due to 2, 1:

• High risk of bias across all studies
• Inconsistent definitions of sonographic findings
• Verification bias in nearly all studies
• Extreme clinical heterogeneity
• No standardized protocols for image acquisition

Critical caveat: The diagnostic accuracy data is severely limited—only one study provided sensitivity/specificity calculations, showing variable performance even for "classic" findings like tamponade 2.

Harm Profile

POCUS during cardiac arrest carries documented risks 1:

• Prolonged compression pauses: Prospective data shows significant association with extended CPR interruptions 1
• Misinterpretation risk: Wall motion abnormalities during CPR may reflect low-flow state rather than acute MI; findings lack specificity during arrest 2
• False reassurance: May lead to inappropriate interventions or delayed recognition of true cause
• Resource diversion: Takes skilled personnel away from high-quality CPR delivery

Alternative: Transesophageal Echocardiography

TEE can provide high-quality imaging without interrupting chest compressions, but remains a knowledge gap requiring further research 1. Consider in specialized centers with immediate availability and expertise.

What NOT to Do

Do not use POCUS as the sole criterion for termination of resuscitation 1, 4. Absence of cardiac motion on ultrasound, even when combined with other modalities, has insufficient evidence to guide termination decisions—only small observational studies with significant limitations exist 1.

Bottom Line Algorithm

1. High-quality CPR is non-negotiable—never compromise compressions for imaging
2. If experienced operator present + specific clinical suspicion → obtain single focused view during 10-second pulse check
3. If reversible cause identified → treat immediately (pericardiocentesis, thrombolysis, needle decompression)
4. If no clear finding or operator inexperienced → do not use POCUS; focus on standard ACLS
5. Monitor with ETCO2 instead: More reliable for predicting ROSC (values >10-20 mmHg associated with better outcomes) without interrupting compressions 1

The 2025 guidelines represent a clear shift toward restrictive use of POCUS during cardiac arrest, emphasizing that uninterrupted chest compressions remain the cornerstone of survival 1.