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REVIEW

Global Ultrasound Check for the Critically lll

(GUCCI)—a new systematized protocol unifying
point-of-care ultrasound in critically ill patients
based on clinical presentation
This article was published in the following Dove Press journal:
Open Access Emergency Medicine

João Tavares 1 Abstract: Ultrasound technology is an essential tool in the management of critically ill
Rita Ivo 2 patients. Point-of-care ultrasonography (POCUS) enables data collection from different
Filipe Gonzalez 3 anatomic areas to achieve the most probable diagnosis and administer the right therapy at
Tomás Lamas 4 the right time. Despite the increasing utilization of POCUS, there is still a lack of standards
João João Mendes 4 to establish how to use different bedside ultrasound protocols, and it is imperative to develop
a unifying protocol. Thus, the aim of this paper is to establish a new systematized approach
1
Internal Medicine Department, Hospital
that can be adopted by all physicians to implement POCUS for critically ill patient manage-
da Luz, Lisbon, Portugal; 2Internal
Medicine Department, Hospital Egas ment. To achieve this, we propose a new systematized approach—Global Ultrasound Check
Moniz, Lisbon, Portugal; 3Intensive Care for the Critically Ill (GUCCI)—that integrates multiple protocols. This protocol is organized
Unit, Hospital Garcia de Orta, Almada,
Portugal; 4Intensive Care Unit, Hospital
based on three syndromes (acute respiratory failure, shock, and cardiac arrest) and includes
CUF Infante Santo, Lisbon, Portugal ultrasound-guided procedures.
Keywords: ultrasonography, interventional ultrasonography, respiratory failure, shock,
cardiac arrest, echocardiography, intensive care

Introduction
Point-of-care ultrasound (POCUS) is a technique that employs ultrasound imaging
to answer objective clinical questions. Clinicians perform POCUS as an extension
of the physical examination in a problem-oriented approach. In critical care,
POCUS should be objective, quick, and repeated as often as necessary to monitor
the rapid evolution of the patient’s critical condition.1
While using POCUS, one has to keep in mind the sensitivity, specificity, and
pretest and posttest condition probability to wisely guide diagnosis and treatment. It
should be noted that clinical evaluation is necessary to define the pretest probability
of the condition, whereas the specific sensitivity and specificity of a given ultra-
sound finding will help determine the posttest probability of a given condition.2 For
example, the presence of B-lines has been reported to have 94% sensitivity and
92% specificity with respect to the diagnosis of cardiogenic pulmonary edema.3 If
B-lines are used as a screening method in a healthy 30-year-old man (1% pretest
Correspondence: João Tavares probability for heart failure), the posttest probability will just be 10%. However, if
Internal Medicine Department, Hospital
da Luz, Avenida Lusíada, 100, Lisbon it is used as a screening method in patients with acute dyspnea in the emergency
1500-650, Portugal department (pretest probability of around 43%), the posttest probability will
Tel +35 192 616 6190
Email joao.ttavares@hospitaldaluz.pt be 90%.4

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Since 2001, several protocols have been published to chest wall and aerated lung. The reverberation of ultra-
standardize the specific use of POCUS to examine criti- sound waves between the pleura and the probe produces
cally ill patients (Table 1). For the purpose of integrating horizontal artifact lines that are equidistant from each
POCUS protocols, we propose a new systematized other; they are referred to as A-lines.30 Respiratory move-
approach—Global Ultrasound Check for the Critically Ill ments cause the lung to expand and contract, generating
(GUCCI). This is organized based on three syndromes the lung sliding sign30 that represents the sliding of the
(acute respiratory failure, shock, and cardiac arrest) and visceral pleura against the parietal pleura. This sign, which
includes ultrasound-guided procedures. is dynamic on B-mode, can be recorded as a static sign on
M-mode, generating the characteristic seashore sign30
Acute respiratory failure (Figure 3B) (the pleural surface is the boundary between
Acute respiratory failure represents loss of the ability of a wave-like pattern, representing the motionless chest
the respiratory system to ventilate adequately or to provide wall, and a sandy beach-like pattern, representing the air-
adequate oxygen delivery to meet metabolic demands. The filled lung). The pattern of the predominant A-lines along
diagnosis of acute respiratory failure is based on clinical with lung sliding represents the normal lung pattern—A-
data and blood gas analysis, but POCUS can be extremely profile.30
useful in terms of differential diagnosis.11 The absence of the lung sliding sign, which generates
Studies have shown that, in these patients, lung ultra- the characteristic barcode sign30 on M-mode (the normal
sound has high diagnostic accuracy in identifying pneu- sandy beach-like pattern below the pleural line is replaced
mothorax, consolidation/atelectasis, interstitial syndromes by horizontal lines), signifies no lung movement (Figure 4).
(eg, pulmonary edema of cardiogenic or noncardiogenic Two conditions, lung atelectasis and pneumothorax, may
origin), pleural effusion, and pneumonia.25–27 As a result, generate these findings, which can be differentiated by two
lung ultrasound is likely to have a significant impact on specific signs. The presence of a lung pulse (heart activity
clinical decision-making and therapeutic management of perception at the pleural line) aids in identifying lung
these patients.28 atelectasis, whereas the presence of a lung point (alternating
GUCCI proposes a two-step approach using a quick seashore sign, indicating lung sliding, and barcode sign,
algorithm to integrate lung ultrasound with complementary indicating absent lung sliding in the same intercostal
cardiac and vascular ultrasound in a stepwise approach to space) aids in identifying pneumothorax.30
exclude the most severe diagnoses and those with possible Pleural effusion is characterized by the presence of
immediate intervention (Figure 1). an anechoic space between the visceral and parietal
With respect to lung ultrasound, different probes such as pleura. However, quantifying the volume of pleural
low-frequency probes (3.5–5 MHz) to examine deeper struc- effusion still remains a challenge although there are
tures (eg, heart, pleural effusion) and high-frequency probes multiple methods to do so.31 We generally estimate
(>5 MHz) to examine superficial structures (eg, pleural slid- its volume (in milliliters) in the supine patient with
ing) can be used.11 However, an organized approach with the probe positioned transversally in the posterior axil-
multiple points of examination is recommended.29 Initially, lary line at the pulmonary base. Following this, we
with the patient in a dorsal decubitus position, the chest is measure the maximum distance (in millimeters)
scanned bilaterally in four different areas, which are defined between the lung and the thoracic wall and multiply
by the anterior axillary line and fifth intercostal space line it by twenty.32 Pleural effusions can exhibit one of the
(Figure 2). The diaphragm should be carefully identified. In following sonographic patterns:33 1) anechoic, which is
some cases, to allow better pleural effusion and consolidation typical of transudates; 2) complex nonseptated (echo-
pattern recognition, the patient is placed in the lateral decu- genic material strewn in a nonhomogeneous pattern
bitus position. without septations), which is typical of exudates; 3)
With the probe placed between two rib spaces in the complex septated (evidence of strands or septae in a
craniocaudal direction, the typical lung pattern (Figure 3A) lattice-like pattern), which is typical of various types of
consists of two echogenic interfaces: the acoustic shadows exudates; and 4) homogeneously echogenic (echogenic
(produced by the two adjacent ribs), and a hyperechoic material strewn homogeneously), which is typical of
horizontal line (produced by the visceral and parietal hemorrhagic effusion and empyema. In the presence
pleural surfaces) that represents the interface between the of moderate to large pleural effusions, the adjacent

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Table 1 Chronology of point-of-care ultrasound protocols

UH- TRI- Jones BLE- FAT- FE- BL- CA- BE- EC- AC- RU- RU- FE- El- EG- FR- FA- PO- CO- SH- GU-
P5 NIT- et al7 EP8 E9 ER- UE- US- AT- HO- ES5 SH SH- EL17 mer LS19 EE20 LL- CU- RE2- oC CCI
10 11 13 14 16 3 24
Y6 (UH- E12 (HI- and S21 S22

Open Access Emergency Medicine 2019:11

P+) MA- No-
P)15 ble
18

2001 2002 2004 2004 200- 20- 200- 200- 20- 200- 200- 200- 20- 201- 201- 201- 201- 201- 201- 201- 201- 2019
4 07 8 8 08 9 9 9 10 0 0 1 1 2 2 4 6

Cardiac X X X X X X X X X X X X X X X X X X X X
IVC X X X X X X X X X X
Lungs X X X X X X X X X X
(pneumothorax)
Lungs X X X
(effusion)
Lungs X X X X
(edema)
Lungs X
(other)
FAST X X X X X X X X X X X
Aorta X X X X X X X X X
DVT X X X X
Ultrasound- X
guided
procedures

Abbreviations: DVT, deep vein thrombosis; FAST, focused assessment with sonography for trauma; GUCCI, Global Ultrasound Check for the Critically Ill; IVC, inferior vena cava.

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Lung point Pneumothorax

Clinical Ø lung sliding
evaluation barcode sign
Lung pulse Active atelectasis

Pleural effusion
Lung ultrasound Anechoic area
sinusoid sign

Passive atelectasis

Tissue-like pattern Shred sign

dynamic air bronchogram Pneumonia

Focal or multifocal
B-profile heterogeneous
Cardiac ultrasound
(alveolar-interstitial)
Cardiogenic pulmonary
edema
Homogeneous Cardiac
bilateral dysfunction
ARDS
Vascular ultrasound

Pulmonary
thromboembolism
Signs of venous
thrombosis
A-profile
Asthma

Figure 1 Acute respiratory failure algorithm. ARDS: Acute Respiratory Distress Syndrome.

lung may become atelectatic and appear as a tissue-like space.11 A focal or multifocal heterogeneous B-profile is
pattern flapping in the pleural effusion (flapping lung suggestive (but not diagnostic) of pneumonia,35 whereas a
sign). Clinically, if the pleural effusion is identified as homogeneous bilateral B-profile is suggestive of diffuse
the cause (or a major contributor) of acute respiratory pulmonary edema35 of cardiogenic (acute cardiogenic pul-
failure, ultrasound-guided therapeutic thoracentesis or monary edema) or noncardiogenic etiology (acute respiratory
chest drain insertion should be considered. distress syndrome), which can be distinguished both clini-
In the presence or absence of pleural effusion, the cally and by evaluating the cardiac function (see “Shock”).
tissue-like pattern may be associated with either pneumo- Isolated B-lines (<3 per intercostal space) or B-lines that are
nia (Figure 5) or atelectasis.30 If the presence of a dynamic confined to the last intercostal space above the diaphragm
air bronchogram (punctiform or linear hyperechoic arti- can be observed in healthy subjects and are of little clinical
facts within the tissue-like pattern with centrifugal inspira- significance.30
tory movement >1 mm) is detected, this indicates patent If respiratory failure is detected along with a normal A-
bronchi. Furthermore, the presence of a dynamic air profile, then two conditions must be considered: obstruc-
bronchogram has a high positive predictive value with tive pulmonary disease (asthma or chronic obstructive
respect to diagnosing pneumonia,34 which is further aug- pulmonary disease) and pulmonary thromboembolism.11
mented by the presence of a shred sign29 (subpleural Although clinical evaluation will differentiate them in
hypoechoic area with ragged margins). most cases, searching for deep venous thrombosis with
The alveolar-interstitial syndrome35 includes several het- two-point compression ultrasound36 will help to corrobo-
erogeneous conditions and is characterized by a B-profile rate pulmonary thromboembolism (Figure 7). To achieve
(Figure 6). In contrast to the normal (A-profile) pattern, the this, a linear high-frequency probe is placed axially in two
B-profile is present when three or more B-lines30 (hypere- points (common femoral and popliteal vessels), and the
choic comet-tail-like artifacts perpendicular to the pleural vein is compressed. If a thrombus is visualized or a vein is
line that erase A-lines) are identified at the same intercostal not compressible, then deep vein thrombosis is likely.

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fluid and the clinical presentation should be used to select

the drain (eg, thoracentesis catheters for anechoic pleural
effusions, large-bore chest tubes for the homogeneously
echogenic suspect of hemothorax or empyema). To guide
needle/trocar insertion and confirm the pleural space needle
tip position, an in-plane technique can be used. Following
this, the classic thoracentesis or chest drain insertion
technique37 is used. However, one major pitfall is the con-
fusion regarding distinguishing ascitic and pleural fluid;
thus, it is mandatory to identify the diaphragm and liver
on the right side and the spleen on the left side.

Shock
Shock refers to the failure of the cardiocirculatory system
to provide adequate oxygen to meet metabolic demands,
which are clinically manifested by tissue hypoperfusion.38
Classically, shock can be classified into four broad etiolo-
gical categories, which have been listed as follows: hypo-
volemic, cardiogenic, obstructive, and distributive. Even
though this classification provides a useful way of deter-
mining the main underlying mechanism of shock, it is
somewhat of an oversimplification. Moreover, it should
be noted that multiple mechanisms may coexist, as is
often the case in sepsis. Although the type and etiology
Figure 2 Systematic approach for lung ultrasound probe placement locations.
Abbreviations: AS, anterior-superior area; LS, lateral-superior area; AI, anterior- of shock may be apparent from the medical history, phy-
inferior area; LI, lateral-inferior area; 5ºIS, fifth intercostal space; MAL, midaxillary line.
sical examination, or clinical investigations, the diagnosis
can be refined by conducting a POCUS evaluation.
Irrespective of whether the cause of shock is unknown
or has been suspected/established, ultrasound may prove
very useful in its diagnosis and management, and in mon-
itoring ongoing treatments and clinical progression. It is
recommended as a first-choice examination in consensus
guidelines,39 as no other bedside tool possesses similar
diagnostic capability.
GUCCI proposes a stepwise holistic approach for diag-
nosing shock, integrating cardiac, lung, vascular, and
abdominal ultrasound, and guiding directed immediate
therapeutic management (Figure 8).
Figure 3 Ultrasound images of normal lung pattern (A-profile): A) B-mode and B) For cardiac ultrasound, low-frequency sectorial probes
M-mode (seashore sign).
(3.5–5 MHz) are used, and an organized approach is
recommended (Figure 9). Ideally, the heart is scanned in
Therapeutic thoracentesis and chest the left lateral decubitus position, but more frequently in
drain insertion the dorsal decubitus position, and three different views
With the patient in a semi-recumbent position, a low-fre- (parasternal long axis, apical four-chamber, and subxi-
quency (3.5–5 MHz) probe is used to visualize the pleural phoid window) are obtained. This approach permits the
fluid distribution and select the best access site (the point at evaluation of the crucial elements of the cardiac ultrasound
which the maximum width of the pleural effusion is examination (chamber size and shape, left ventricular sys-
detected). Qualitative information about the nature of the tolic function, inferior vena cava (IVC) size, and

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superior area) can be conducted to confirm diagnosis (see

“Acute respiratory failure”) while waiting for the drainage
material.
If cardiac tamponade is clinically suspected, a cardiac
ultrasound demonstrating pericardial effusion and collapse
of the right heart chambers along with dilated IVC can be
conducted to confirm the diagnosis.40 The pericardial effu-
sion appears as an anechoic image surrounding the heart
(there may be echogenicity within the pericardial sac if the
effusion is exudative or hemorrhagic), best seen in the
parasternal long axis and subxiphoid views (Figure 10).
In the parasternal long axis, pericardial effusion can be
differentiated from pleural effusion, as pericardial effusion
is located anterior to the descending aorta. The effusion
can be quantified according to its maximum thickness,
which is measured during diastole: small, <1 cm not
circumferential; moderate, <1 cm circumferential around
the heart; large, 1–2 cm circumferential; and very large, >2
cm. It should be noted that recognizing the features of the
cardiac tamponade ultrasound is extremely important. The
observable features have been listed as follows: right atria
collapse (right atria inversion during ventricular end-dia-
stole), right ventricular diastolic collapse (absence of right
Figure 4 Ultrasound image of abnormal lung presentation with the absence of lung
sliding (M-mode): barcode sign. ventricular free wall expansion during early diastole), and
dilated IVC. After the diagnosis of cardiac tamponade is
established, ultrasound-guided pericardiocentesis should
be considered as the standard of care.
Massive pulmonary thromboembolism should be sus-
pected in the adequate clinical context if right heart chamber
dilatation (right/left ventricular ratio >0.6 in the apical four-
chamber view (Figure 11)) is detected. Rarely, an intracar-
diac free-flowing echogenic thrombus or, more frequently, a
deep venous thrombosis can be seen with two-point com-
pression ultrasound (see “Acute respiratory failure”).40
Cardiogenic shock is most commonly caused due to left
ventricular systolic dysfunction (as evaluated by ejection
fraction) in the presence of elevated filling pressure, which
results in hydrostatic pulmonary edema (as evaluated by
Figure 5 Tissue-like pattern characteristic of pneumonia.
diffuse B-lines (see “Acute respiratory failure”)). Visually,
collapsibility and pericardial effusion) and other gross left ventricular ejection fraction estimation (“eyeball”) is a
morphological abnormalities (eg, mass in the heart feasible and accurate method to evaluate left ventricular
chambers).40–42 Subsequent evaluation depends on the systolic function and is well correlated with other quantita-
type of shock, combining clinical evaluation and cardiac tive methods43 (eg, Simpson biplane ejection fraction). The
ultrasound as follows. normal left ventricular ejection fraction is usually >55%;
If a tension pneumothorax is suspected either clinically however, when it is <30%, this indicates severe left ventri-
or through cardiac ultrasound (mediastinal shift associated cular systolic dysfunction.44 With focused training on eyeball
with pressure overload and/or dilated IVC in the right heart cardiac function evaluation, even nonexperienced physicians
chambers), a lung ultrasound (limited to the anterior– can achieve good agreement with cardiologists.45

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Pericardiocentesis
With the patient in the dorsal decubitus position, a low-
frequency cardiac probe (3.5–5 MHz) is used to visualize
the distribution of the pericardial fluid and select the best
approach (apical, parasternal, or subxiphoid). An in-plane
technique is used to guide needle insertion, whereas the tip
position of the pericardial space needle is confirmed
through a saline bubble injection. Following this, a classic
Seldinger technique is used to insert the pericardial
catheter.49

Shock treatment
Figure 6 B-profile with more than three B-lines in the same intercostal space.
The first step in the shock treatment algorithm includes
treating shock-reversible etiologies by following the shock
diagnosis protocol (eg, thoracic drainage in tension pneu-
mothorax, pericardiocentesis in cardiac tamponade, fibri-
nolysis in massive pulmonary thromboembolism).
The second step includes assessing preload and fluid
responsiveness using IVC dynamics (Figure 14). The eva-
luation of the IVC can begin at the subcostal classical
view, moving slightly off the midline to the right of the
abdominal aorta on the transverse view.40 The IVC size
should be measured in the longitudinal view—2 cm caudal
to the point where the IVC joins the right atrium. In
patients with spontaneous breathing effort, due to a change
in intrathoracic pressure, the IVC collapses on inspiration
Figure 7 Two-point compression ultrasound for the diagnosis of deep venous and distends on expiration, whereas the reverse occurs in
thrombosis: (A) Left femoral vein-non-compressible thrombus; (B) Normal, com-
pressible popliteal vein. patients on mechanical ventilation. A totally collapsed
IVC implies low preload and fluid responsiveness; on the
In patients who experience hypovolemic shock, the left other hand, a plethoric IVC (dilated with no collapse)
ventricle becomes small (the lumen may even become obliter- implies high preload and no fluid responsiveness. For
ated with “kissing” ventricular46 walls), and the IVC collapses patients with IVC dynamics that stand between these
(Figure 12). In this setting, it is mandatory to conduct an opposite scenarios, the collapsibility index should be
abdominal ultrasound to check for hemorrhage, aortic aneur- used [(maximum IVC diameter—minimum IVC dia-
ysm rupture, or other organ lesions. A global abdominal ultra- meter)/maximum IVC diameter] if spontaneously breath-
sound, employing the three focused assessment with ing, and the distensibility index should be used
sonography for trauma views (right flank, left flank, and pel- [(maximum IVC diameter—minimum IVC diameter)/
vis), should be performed when no obvious sources of bleeding minimum IVC diameter] if mechanically ventilated. A
can be identified in the context of hypovolemic shock40 to collapsibility index50 superior to 0.40 or a distensibility
allow the detection of other arterial catastrophes (eg, rupture index51 superior to 0.18 translates into potential fluid
of splenic artery aneurysm47). The proximal section of the responsiveness. The endpoint of fluid administration
abdominal aorta lies along the mid-line of the abdomen on entails the appearance of anterior B-lines, indicating iatro-
the left side of the IVC and should be screened to detect aortic genic interstitial edema (which is often clinically silent but
aneurysm (aortic diameter >3 cm) (Figure 13) which, in the precedes alveolar edema and worsens respiratory failure).
adequate clinical context, makes aneurysmal rupture Thus, striking a balance between fluid responsiveness and
probable.48 interstitial edema is key to administering adequate fluids.52

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Lung ultrasound
Clinical
evaluation
Hypertensive
pneumothorax
Cardiac ultrasound Ø lung sliding
barcode sign

Obstructive shock
Vascular ultrasound
RV:LV ratio >1:1
IVS paradoxical movement
Pulmonary
thromboembolism

Signs of venous
thrombosis

Cardiac
tamponade
Pericardial effusion
RA/RV collapse Cardiac ultrasound

Cardiogenic shock
Left ventricular dysfunction ≥3 B-lines
± segmental changes per intercostal space
mechanical causes
Abdominal ultrasound

Hypovolemic shock

Hyperkinectic heart
collapsed inferior vena cava Evaluation of
fluid challenge response hemorrhagic focus
Distributive shock

Figure 8 Shock algorithm.

Abbreviations: RV, right ventricle; LV, left ventricle; IVS, interventricular septum.

The third and final step includes evaluating the left ven-
tricular systolic function (see “Shock”). In patients with high
preload, fluid responsiveness, or fluid responsiveness with
interstitial edema, a depressed left ventricular systolic function
signifies that inotropic drug support should be considered. On
the other hand, in the case of normal systolic left ventricle
function (or hyperdynamic heart), vasopressors should be
considered. The treatment protocol should be repeated after
each intervention or if clinical changes are noted.

Cardiopulmonary resuscitation
Patients in cardiac arrest must be treated through algo-
rithm-based management, such as basic life support and
advanced life support. However, the resuscitation guide-
lines of the American Heart Association, the European
Resuscitation Council, and the International Liaison
Figure 9 Systematic approach for cardiac ultrasound placement locations.
Abbreviations: PLAX, parasternal long axis; A4C, apical four-chamber; SX, subxiphoid;
Committee on Resuscitation21,53 recommend identifying
RV, right ventricle; LV, left ventricle; LA, left atrium; RA, right atrium; L, liver; Ao, aortic valve. and treating the correctable causes of cardiac arrest.

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pulmonary embolism, severe ventricular dysfunction, and

hypovolemia. Moreover, it can help distinguish “pseudo-pul-
seless electric activity” (PEA) (coordinated electrical activity
with no palpable pulse, but with coordinated cardiac activity)
from “true-PEA” (coordinated electrical activity with no palp-
able pulse or detectable cardiac motion). Breitkreutz et al17
demonstrated that 35% of patients with an electrocardio-
graphic diagnosis of asystole experienced ongoing coordinated
cardiac motion. This was associated with a better prognosis
with 55% surviving to hospital admission, in contrast to “true-
PEA”, which conferred a poor prognosis with only 8% surviv-
ing to hospital admission. This survival benefit further
improved when a potentially treatable cause was detected
Figure 10 Pericardial effusion with tamponade. through echocardiography.54,55 Namely, 59% were detected
with reduced left ventricular function, whereas 8% had a
dilated right ventricle and 4% were hypovolemic.
Furthermore, patient management was directly altered as a
result of echocardiographic findings in 51% of cases.
GUCCI proposes a stepwise holistic approach for car-
diopulmonary resuscitation and integrating cardiac, lung,
vascular, and abdominal ultrasound (Figure 15). A member
of the ultrasound check should be a part of the cardiopul-
monary resuscitation team and, to obtain the best echocar-
diographic view, must be positioned on the right side caudal
to the compressor member (Figure 16). GUCCI proposes a
three-step approach using an ultrasound cardiac low-fre-
quency (3.5–5 MHz) probe in a subcostal view in nonshock-
able rhythms (and selected cases of shockable rhythms),
Figure 11 Massive pulmonary thromboembolism. which are eventually complemented by thoracic, abdom-
inal, and vascular ultrasound. A unique probe type and a
single window are used to minimize the time spent acquir-
ing the appropriate cardiac window (maximum 10-s inter-
val). It should be noted that previous studies have shown
that it is possible to acquire echocardiographic images dur-
ing a cardiac arrest on a timely basis.10
The first step includes seeking one out of four patterns
(subcostal window during pulse check)—myopathic pat-
tern, pericardial effusion, right heart chamber dilatation, or
hyperdynamic heart—and acting quickly accordingly. The
myopathic pattern includes ineffective myocardial contrac-
tion (intrinsic movement of the myocardium coordinated
with cardiac valve movement), disorganized myocardial
contraction (which implies probable ventricular fibrilla-
Figure 12 "Kissing" ventricular walls in hypovolemic shock. tion), and standstill. In the case of ineffective myocardial
contraction, adrenaline should be withheld and mechanical
POCUS included in the advanced life support algorithm7,53 support (eg, veno-arterial extracorporeal membrane oxy-
can help to diagnose/exclude some of the potentially treatable genation) considered,56 whereas in the case of disorga-
causes of cardiac arrest, such as cardiac tamponade, massive nized myocardial contraction, delivery of a shock should

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arrest indicates tamponade until proven otherwise, and for

which immediate pericardiocentesis should be performed.
Pericardial effusion size can be misleading, as severity
depends on the rate of pericardial fluid accumulation.
Furthermore, dilatation of right heart chambers during
cardiac arrest can be difficult to define according to the
usual guidelines (right/left ventricular ratio >0.6).
Generally, when the right ventricle is bigger than the left
ventricle, there is a likelihood of a massive pulmonary
embolism or hypertensive pneumothorax. A hyperdynamic
heart is characterized by a small hyperkinetic left ventricle
and an obliterated cavity in some cases—“kissing ventri-
Figure 13 Aortic aneurysm using FAST views. cle” sign—associated with a collapsed IVC, which
prompts rapid fluid therapy.
be considered (after optimization of myocardial perfu- The second step includes conducting a noncardiac ultra-
sion). Standstill refers to a situation where a patient is in sound evaluation to complement the pattern found in the
“true-PEA”/asystole and, besides a bad prognosis, the first step. This can be accomplished during chest compres-
cardiac arrest etiology is inconclusive. Thus, in such sions to avoid further delay in the diagnosis. In the case of
cases, one must think about other nonmechanical reversi- right heart dilatation, hypertensive pneumothorax must be
ble causes (eg, metabolic, hypoxia, and hypothermia). excluded with lung ultrasound (see “Acute respiratory fail-
Pericardial effusion refers to a situation where a cardiac ure” and “Shock”). To establish the absence of lung sliding,

Hypertensive pneumothorax
Cardiac tamponade
Pulmonary thromboembolism
Morphological evaluation Others

Inferior vena cava dynamics Specific therapy

Collapsed Invasive mechanical ventilation* Spontaneous breathing Plethoric

(>20 mm with no collapse)

Distensibility index ≥18% ? Collapsibility index ≥42% ?

(maximum diameter–minimum diameter)/minimum diameter (maximum diameter–minimum diameter)/maximum diameter

Yes No
Low preload Normal/high preload
fluid responsive nonfluid responsive

Left ventricular
function assessmrnt
Consider
volume lung ultrasound

STOP variable Compromised Normal

– Extravascular lung water
≥3 B-lines per intercostal space Consider Consider
(four-quadrant evaluation) inotropes vasopressors

Figure 14 Shock treatment algorithm. *Tidal volume 8-10 mL/Kg, volume-controlled ventilation, positive end-expiratory pressure (PEEP) 4-6 cm H2O and plateau pressure <30 cm H2O.

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Ventricular
fibrillation Cardiac arrest
Ventricular
tachycardia
assistolia
PEA
(pseudo-PEA)

Cardiac ultrasound
Ineffective myocardial contration
≠TOR

Stand still
Assessment in the subcostal window during pulse check (<10 s)

VF ?
Disorganized myocardial contraction
Cardiac tamponade
(probable)
Lung ultrasound
drainage
Hypertensive
pericardial effusion pneumothorax
(probable)
Ø lung sliding
barcode sign
drainage
Vascular ultrasound

Pulmonary
thromboembolism
Pressure overload of (probable)
right chambers Signs of venous
thrombosis
thrombolysis EtCO2>20mmHg DBP>25mmHg
Abdominal ultrasound

Hypovolaemia
(probable)
hyperdynamic heart
Evaluation of
hemorrhagic focus fluids
during chest compressions

Figure 15 Cardiopulmonaryresuscitation diagnosis algorithm.

Abbreviations: PEA, pulseless electrical activity; TOR, termination of resuscitation; VF, ventricular fibrillation; EtCO2, end-tidal CO2; DBP, diastolic blood pressure.

Airway
In the case of a hyperdynamic heart, a hemorrhagic focus
should be sought (see “Shock”).
The third step embodies three main goals, which have
been listed as follows: confirm the previous findings,
Chest conduct reevaluation after therapy (eg, thrombolysis,
compressions
fluids), and determine prognosis (eg, persistent standstill
after recovery of spontaneous circulations seems very
unlikely after 10 min).57
Ultrasound Venous
access
Conclusions
We propose a new systematized protocol—GUCCI
Team (Global Ultrasound Check for the Critically Ill)—that
leader
integrates all POCUS protocols in critical care. It is
organized according to three syndromes—acute respira-
Figure 16 Ultrasound check member position in CPR team. tory failure, shock, and cardiac arrest—and includes
ultrasound-guided procedures. The GUCCI strategy
ventilation is mandatory. The absence of pneumothorax will help intensivists and naive ultrasound doctors to
signs with right heart dilatation increases the possibility of adopt a global approach without a dead-end protocol.
massive pulmonary embolism. Further echocardiography The primary aim of GUCCI is to provide the right
and vascular ultrasound can reveal an intracavitary throm- therapy at the right moment to prevent missed emer-
bus or deep vein thrombosis to corroborate the diagnosis.40 gent diagnosis.

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Tavares et al Dovepress

Abbreviation list 14. Boyd JH, Walley KR. The role of echocardiography in hemodynamic
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