Breitkreutz R, Walcher F, Ilper H Focused echocardiography in life support: the subcostal window: what the surgeon should know for critical care applications. Eur J Trauma Emerg Surg. 2009; 35:(4)

Cardiac Arrest Registry to Enhance Survival. 2017 Annual report. 2017. https// (accessed 35 May 2021)

Cardim N, Dalen H, Voigt JU The use of handheld ultrasound devices: a position statement of the European Association of Cardiovascular Imaging (2018 update). Eur Heart J Cardiovasc Imaging. 2019; 20:(3)245-252

Deakin CD, Koster RW. Chest compression pauses during defibrillation attempts. Curr Opin Crit Care. 2016; 22:(3)206-211

Gardner KF, Clattenburg EJ, Wroe P, Singh A, Mantuani D, Nagdev A. The Cardiac Arrest Sonographic Assessment (CASA) exam—a standardized approach to the use of ultrasound in PEA. Am J Emerg Med. 2018; 36:(4)729-731

Gaspari R, Weekes A, Adhikari S Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016; 109:33-39

Grundgeiger T, Scharf M, Grundgeiger J, Scheuchenpflug R. Manual distractions of ambulance drivers: light-and-siren vs non-light-and-siren travel. Proc Hum Factors Ergon Soc Annu Meet. 2014; 58:(1)1134-1138

Heegaard W, Hildebrandt D, Spear D, Chason K, Nelson B, Ho J. Prehospital ultrasound by paramedics: results of field trial. Acad Emerg Med. 2010; 17:(6)624-630

Cardiac arrest annual report 2017–2018.London: London Ambulance Service; 2018

Out-of-Hospital Cardiac Arrest Outcomes Project Team. Out-of-hospital cardiac arrest outcomes registry epidemiology report, 2018. English ambulance services. https// (accessed 13 May 2021)

Perkins GD, Jacobs IG, Nadkarni VM Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the utstein resuscitation registry templates for out-of-hospital cardiac arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Resuscitation. 2015; 96:328-340

Perkins GD, Ji C, Deakin CD, Quinn T A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med. 2018; 379:(8)711-721

Quinn T, Price S. Where do we go with PoCUS?. Resuscitation. 2017; 112:A1-A2

Reed MJ, Gibson L, Dewar A, Short S, Black P, Clegg GR. Introduction of paramedic led echo in life support into the pre-hospital environment: the PUCA study. Resuscitation. 2017; 112:65-69

Resuscitation Council UK. Adult advanced life support guidelines. 2021. https// (accessed 25 May 2021)

Reynolds JC, Issa MS, C Nicholson T Prognostication with point-of-care echocardiography during cardiac arrest: a systematic review. Resuscitation. 2020; 152:56-68

Rooney KP, Lahham S, Lahham S Pre-hospital assessment with ultrasound in emergencies: implementation in the field. World J Emerg Med. 2016; 7:(2)117-123

Echo in life support. 2018. https// (accessed 13 May 2021)

Tsou PY, Kurbedin J, Chen YS Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: a systematic review and meta-analysis. Resuscitation. 2017; 114:92-99

von Vopelius-Feldt J, Benger J. Critical care paramedics in England: a national survey of ambulance services. Eur J Emerg Med. 2014; 21:(4)301-304

Focused ultrasound in out-of-hospital cardiac arrest by advanced paramedics

02 June 2021
Volume 11 · Issue 2



This study describes and evaluates advanced paramedic practitioner (APP) use of focused cardiac ultrasound (FoCUS) in out-of-hospital cardiac arrest (OHCA), and relates ultrasound findings with decisions to terminate resuscitation. The authors report characteristics of patients who do/do not undergo a FoCUS examination by APPs, ultrasound probe positions used and whether FoCUS findings were associated with decisions to terminate resuscitation or to convey patients to an emergency department (ED) with ongoing resuscitation.


A retrospective, observational cohort study of all adult medical OHCA patients attended by APPs in Greater London during 2018 was carried out using data from EMS and APP databases.


Twenty-eight APPs attended 1444 OHCA patients in 2018, of whom 744 underwent FoCUS. The subcostal probe position was used most frequently (74%), followed by the parasternal long axis (19%), with significantly smaller use of the parasternal short axis and apical windows. Absence of spontaneous cardiac motion (SCM) was associated with resuscitation being terminated (333 out of 391; 85%) and the presence of SCM was associated with conveyance to the emergency department (213 out of 264 patients; 80%). All decisions to terminate resuscitation were within the APP scope of practice.


The authors believe this is the largest prehospital study involving FoCUS in OHCA. An association between FoCUS findings and decisions made to either convey patients to hospital or terminate resuscitation was found. The SC window was most used and ROLE decisions were deemed to be in accordance with local guidance and practice.

Some UK ambulance trusts have introduced an innovative paramedic role of critical care paramedic or advanced paramedic practitioner in critical care (APP). APPs are experienced paramedics who undergo additional training, including master's level education, which allows them to gain additional competencies in prehospital critical care (von Vopelius-Feldt and Benger, 2014). In the London Ambulance Service (LAS), APPs are targeted to the most seriously ill and injured patients, including those experiencing an out-of-hospital cardiac arrest (OHCA), with each APP attending on average 1.4 OHCAs per shift.

The primary focus of an APP is to ensure high standards in the delivery of resuscitation through on-scene leadership. APPs also provide enhanced decision making and clinical interventions above those practised by paramedics. All APPs in the LAS are equipped with handheld ultrasound devices (HUDs).

Guidelines from the Resuscitation Council UK (2021) recognise the role of FoCUS in identifying futile resuscitations if used by skilled operators. However, it emphasises that assessing spontaneous cardiac motion (SCM) of the heart should not be used as the sole indicator.

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