Ultrasound in intraoperative cardiac arrest: usefulness, limits and teamwork
Imaging can provide information. Its value depends on the clinical question, who obtains it, and how it is integrated into resuscitation. This reading connects our scientific publication with the guidelines and with a central question: what can we conclude, and what remains uncertain?
An image does not replace resuscitation or decide on its own.Impacto de la ecocardiografía en la práctica anestésica
Molina-Méndez, Francisco Javier; Lespron-Robles, Ma del Carmen; Angulo-Lara, Oscar Mauricio; Herrera-Elizalde, Rafael. Rev Mex Anest. 2019;42(Supl. 1):S16–S22.
Information for decision-making does not equate to demonstrated benefit in outcomes. Molina-Méndez, Lespron-Robles, Angulo-Lara, and Herrera-Elizalde review the role of echocardiography in anesthesiology. The article recognizes the usefulness of perioperative information, the need for competence, and the limited evidence available then regarding postoperative outcomes. It is not a POCUS trial during CPR and its historical indications should not be automatically transferred to current practice.
Consult the original article ↗First, specify which ultrasound we are talking about
POCUS is ultrasound performed at the point of care to answer specific clinical questions. Focused echocardiography is its cardiac application; it is not equivalent to a complete echocardiographic study. Transthoracic (TTE) and transesophageal (TEE) approaches have different access routes, requirements, and limitations. Also, the assessment of hypotension with circulation present, the exploration during cardiac arrest, and the evaluation after return of spontaneous circulation (ROSC) are not interchangeable.
Three questions to understand the role of ultrasound
What are we looking for?
A specific clinical question, linked to the context and a possible reversible cause.
What do we observe?
A finding described with its quality, timing, and limitations.
What can we conclude?
An interpretation contrasted with the rest of the clinical information.
Editorial questions to organize the reading. They do not constitute a diagnostic protocol nor a validated decision rule.
Selective use, without making it a mandatory routine
ILCOR 2025 suggests not routinely using POCUS during CPR to diagnose reversible causes: the recommendation is weak and the certainty of evidence very low. Possible selective use requires a specific clinical suspicion, competent personnel, and that it does not interfere with CPR. The availability of an ultrasound device does not make its use mandatory. [2]
Movement is not synonymous with circulation
Seeing cardiac activity alone does not confirm ROSC. Visible movement must be correlated with rhythm, clinical assessment, and available monitoring. It does not by itself authorize stopping compressions.
See source [3] ↓One chamber does not reveal the whole cause
Isolated right ventricular dilation does not diagnose pulmonary embolism during cardiac arrest. A finding must be interpreted together with the clinical suspicion and other evidence. We avoid formulas that turn a single image into a therapeutic indication.
See source [3] ↓Without an interpretable window, the question remains open
A non-interpretable acquisition does not equate to absence of pathology. In this synthesis, we propose explicitly communicating uncertainty instead of turning an insufficient image into a negative result.
An image alone does not determine when to stop CPR
The absence of movement should not be the sole reason to terminate CPR. Ultrasound assessment of contractility alone does not constitute a sufficient criterion. Decisions require integrating the context and the full clinical information.
See source [3] ↓Before turning on the ultrasound, organize the team.
Image acquisition must not add or prolong interruptions of compressions. Advanced life support guidelines reserve intra-arrest POCUS for trained operators. Team attention cannot rely exclusively on the screen. Our editorial proposal is to agree on the question, operator responsibility, and how to communicate the finding and its uncertainty. The CPR Coach can help monitor CPR quality within locally agreed functions; it does not replace the operator or the leader. [3]
The concrete integration of these roles is a proposed REASEL organization model. It is not presented as a validated intervention that, by itself, increases survival.
TEE in the operating room: a conditional possibility
It is not a universal indication nor a risk-free alternative. The 2023 ESAIC/ESTES perioperative consensus suggests considering TEE during peri-procedural cardiac arrest if there is experience, equipment, and patient conditions that allow it. The recommendation is weak, with low-quality evidence (2C). This possibility does not eliminate the need to assess contraindications, specific competence, and coordination. Obtaining additional information alone does not demonstrate better survival. [4]
What EXECT-CPR offers — and what it does not
Did not demonstrate a statistically significant difference in the primary outcome. At a center in Taiwan, 132 adults arriving at the emergency department with ongoing CPR for nontraumatic out-of-hospital cardiac arrest were randomized. The TEE-guided strategy adjusted the compression site. Sustained ROSC lasting at least 20 minutes occurred in 29/66 patients versus 26/66 with conventional CPR: adjusted OR 1.21; 95% CI: 0.64–2.29. According to the authors, the trial had insufficient statistical power. A neutral result does not demonstrate equivalence or establish benefit. The study population did not consist of patients with intraoperative cardiac arrest. [5]
This reading relies on the indexed original abstract. We do not attribute results to supplements or full-text analyses we have not verified.
Our Substacks: deepen with critical reading
They complement the scientific article and the guidelines. They are educational and editorial developments; their organizational proposals do not become validated recommendations simply by appearing in this library.
Before turning on the ultrasound device, organize the resuscitation
The tool requires a prepared team. A reflection on organization, evidence interpretation, and the risk of attributing to the ultrasound device results that depend on multiple factors.
Read on Substack ↗POCUS during CPR: looking better without stopping resuscitation
What is observed has a moment and a context. Distinguishes visible activity, circulation, and uncertainty. Invites to avoid decisions based on a single image or an observation outside its clinical trajectory.
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Connect with the REASEL clinical library
Scientific sources: what supports each one
- Impacto de la ecocardiografía en la práctica anestésica ↗
Own narrative review, 2019;42(Supl. 1):S16–S22. Full seven-page text cross-checked in our library and bibliographic data corroborated in Medigraphic. Perioperative context; does not demonstrate efficacy of POCUS during CPR.
- 2025 ILCOR Consensus on Science With Treatment Recommendations — Adult Advanced Life Support ↗
ILCOR, science consensus and treatment recommendations, advanced life support, 2025. Supports the distinction between routine and selective use; diagnostic evidence of very low certainty.
- Resuscitation Council UK 2025 — Adult advanced life support ↗
RCUK adult advanced life support guideline, 2025, based on ERC. Supports operator competence, protecting compressions from interruptions, and the limits of interpreting isolated right ventricular dilation or contractility.
- Cardiac arrest in the perioperative period — ESAIC/ESTES consensus guideline (2023) ↗
ESAIC/ESTES Consensus, 2023. Conditional perioperative recommendation for TEE; does not establish a general obligation to use it.
- Transesophageal Echocardiography During CPR in Patients With Out-of-Hospital Cardiac Arrest: The EXECT-CPR Randomized Clinical Trial (2026) ↗
Chu et al. EXECT-CPR, JAMA Internal Medicine, 2026;186(5):557–566. Original abstract: trial in adults with out-of-hospital cardiac arrest, with limitations in statistical power and extrapolation.