Written by Jonathan Brewer
Spoon Feed
Point-of-care ultrasound (POCUS) is a powerful adjunct during cardiac arrest that can identify reversible causes, improve pulse checks, optimize chest compressions, and aid prognostication—as long as it does not interrupt high-quality CPR. When utilized correctly, POCUS may meaningfully guide resuscitation without prolonging pauses.
Get ready: POCUS has purpose
This narrative review summarizes the latest contemporary evidence on POCUS in cardiac arrest. Cardiac applications include identifying pericardial effusion/tamponade, right ventricular dilation (though this can be nonspecific for PE in arrest), occult ventricular fibrillation (VF not seen on ECG), and the presence or absence of cardiac activity. Occult VF occurs in ~3–5% of arrests and has similar outcomes to ECG-detected VF: i.e. suggesting missed defibrillation opportunities if ultrasound is not used. We also know that cardiac activity discovered with POCUS during PEA/asystole is associated with higher rates of ROSC, though it should not be used in isolation to terminate resuscitation.
Non-cardiac applications include confirming endotracheal tube placement (highly accurate even during compressions), detecting pneumothorax, and assessing for the etiology of the arrest (i.e. abdominal free fluid). POCUS also outperforms manual palpation for pulse checks; femoral/carotid Doppler is faster and more accurate, and a peak systolic velocity ≥20 cm/s correlates with SBP ≥60 mmHg.
However, a key concern is the delay in compressions. Studies show POCUS can prolong pauses, which is why protocols such as the Cardiac Arrest Sonographic Assessment (CASA) exam exist. Best practices include pre-positioning the probe, recording clips during ≤ 5–10 second pauses, then analyzing after compressions resume, and assigning the most experienced sonographer. Resuscitative transesophageal echocardiography (TEE) also offers advantages by allowing continuous imaging during compressions to guide hand position along with identifying reversible causes.
How does this change my practice?
As more evidence emerges demonstrating the benefit of POCUS in cardiac arrest, I will continue to encourage use of POCUS selectively and intentionally during rhythm checks. However, while we should be utilizing POCUS during cardiac arrest, we must ensure that we are not delaying compressions as well. I also expect more and more centers to adopt resuscitative TEE in the upcoming years and look forward to the widespread implementation of this practice for our patients.
Source
Emergency medicine updates: Point-of-care ultrasound in cardiac arrest. Am J Emerg Med. 2026 Jan;99:176-187. doi: 10.1016/j.ajem.2025.09.021. Epub 2025 Sep 15. PMID: 41045789.
