Accepted Manuscript

A comparison of carotid doppler ultrasonography and

capnography in evaluating the efficacy of cardiopulmonary
resuscitation: The first study

Gökhan Yilmaz, Mustafa Silcan, Süha Serin, Bahadır Çağlar,

Özkan Erarslan, İsmet Parlak

PII: S0735-6757(18)30022-6
DOI: https://doi.org/10.1016/j.ajem.2018.01.022
Reference: YAJEM 57230
To appear in:
Received date: 9 November 2017
Revised date: 3 January 2018
Accepted date: 5 January 2018

Please cite this article as: Gökhan Yilmaz, Mustafa Silcan, Süha Serin, Bahadır Çağlar,
Özkan Erarslan, İsmet Parlak , A comparison of carotid doppler ultrasonography and
capnography in evaluating the efficacy of cardiopulmonary resuscitation: The first study.
The address for the corresponding author was captured as affiliation for all authors. Please
check if appropriate. Yajem(2017), https://doi.org/10.1016/j.ajem.2018.01.022

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 ACCEPTED MANUSCRIPT

A comparison of carotid doppler ultrasonography and capnography in evaluating the

efficacy of cardiopulmonary resuscitation: The First Study

1 2 3 4
Gökhan Yilmaz, MD, Mustafa Silcan, MD, Süha Serin, MD, Bahadır Çağlar, MD, Özkan
2 5
Erarslan, MD , and İsmet Parlak, MD

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1 Specialist, Emergency Medicine Clinic, Ardahan City Hospital, Ardahan ,Turkey

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2 Trainee, Emergency Medicine Clinic, Bozyaka Training and Research Hospital, Izmir,
Turkey

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3 Specialist, Emergency Medicine Clinic ,Urla City Hospital, Urla/Izmir, Turkey

4 Specialist, Emergency Medicine Clinic, Elazig Training and Research Hospital, Elazig,
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Turkey

5 Associate Professor, Emergency Medicine Clinic, Bozyaka Training and Research Hospital,
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Izmir, Turkey

Corresponding Author:
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Gökhan YILMAZ, +905077866282, gokhanyilmaz36@yahoo.com.tr

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Alternate Corresponding Author:

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Bahadir Caglar, +905235215078, mail@bahadircaglar.com

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Abstract word count : 318

Main text word count :2246

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A COMPARISON OF CAROTID DOPPLER ULTRASONOGRAPHY AND

CAPNOGRAPHY IN EVALUATING THE EFFICACY OF CARDIOPULMONARY
RESUSCITATION; the First Study

ABSTRACT

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Introduction and Purpose: The end-tidal carbon dioxide (ETCO2) measurement is accepted
as the gold standard method for assessing cardiopulmonary resuscitation (CPR) efficacy. In
recent studies, the use of Carotid Doppler Ultrasonography has become widespread in

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showing CPR efficacy. In the present study, the carotid blood flow measurement was
compared with ETCO2 measurement and an evaluation was made of whether this method

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could be used as an alternative method to capnography in the assessment of CPR efficacy.

Material and Method: This study was conducted on patients who presented at the
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Emergency Department (ED) with non-traumatic arrest or began to suffer from arrest during
emergency service follow-up. The main carotid artery peak systolic velocity (PSV), end
diastolic velocity (EDV) and time-dependent mean flow velocity (MNV), and ETCO2 values
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were measured and recorded after the 100th chest pressure of the CPR cycle and the results
were statistically analyzed.

Results: The mean age of the patients was 54.5±12.3 years and 65.6% of the patients were
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male. The mean values of patients measured from the carotid artery during the CPR were PSV
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67.1±17.3, EDV 16.3±4.5, MNV 25.5±8.1 and ETCO2 22.2±8.1. A significant difference was
found between in-hospital and out-of-hospital arrests in terms of patient outcome (return of
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spontaneous circulation (ROSC) and death) (p<0.05). The mean ETCO2 values of those who
died were found to be lower than those of the ROSC group (p<0.05). Although there was a
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positive and low-level of correlation between the ETCO2 values and PSV values, and a
positive and very low-level of correlation between the EDV and MNV values of all patients,
these correlations were not statistically significant. (p>0.05)
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Conclusion: A low correlation was found between the PSV and ETCO2 values. With
effective CPR, the results close to carotid blood flow in normal healthy individuals were
obtained. However, the study showed that carotid blood flow measurement results during
CPR were not as valuable as ETCO2 in demonstrating CPR efficacy.

Key Words: cardiopulmonary resuscitation, end-tidal CO2. carotid doppler ultrasonography,

carotid blood flow
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INTRODUCTION

Advances in emergency medical science have increased the rate of reanimated patients
after cardiopulmonary resuscitation (CPR). Although different results have been obtained in
other studies conducted, the rate of discharge from hospital after CPR is between 1% and 16%
in general. Each year, 450,000 sudden cardiac deaths occur in the United States with an
average survival rate of less than 5% (1,2).

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End-tidal CO2 (ETCO2) monitoring has been used in modern anesthesiology and
reanimation units since the early 1980s and has been an important component of

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cardiopulmonary resuscitation and critical patient monitoring in emergency services in recent

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years. This method has been used to validate endotracheal intubation, to assess CPR efficacy
and as a sign of spontaneous circulation as defined in the guidelines (3).
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Existing cardiopulmonary resuscitation goals have focused primarily on the chest
compressions and ventilation from hemodynamically measured cardiopulmonary
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resuscitation. Hemodynamic information obtained from the measurement of blood flow of

large vessels using ultrasonography (USG) allows objective evaluation of the effectiveness of
chest compressions (4, 5). There have been studies on the feasibility of measuring carotid
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blood flow with Doppler USG in evaluating CPR efficacy (6). However, further studies are
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needed on this subject.

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The purpose of this study was to compare the carotid blood flow measurement with
the ETCO2 measurement in the evaluation of cardiopulmonary resuscitation efficacy and to
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evaluate the usability of this method as an alternative to capnography.

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MATERIALS AND METHOD

This prospective clinical trial was performed in a 6-month period in 2016 in the Health
Sciences University Izmir Bozyaka Training and Research Hospital Emergency Medicine
Clinic. Before beginning the study, approval was obtained from the Local Ethics Committee.

The study included 32 non-traumatic patients aged between 18 and 65 years

comprising those who presented with cardiopulmonary arrest to the emergency service and

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those who began to suffer from cardiopulmonary arrest during assessment in the emergency
service and underwent endotracheal intubation.

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Victims of trauma, patients aged <18 years or >65 years, pregnant women, patients
with carotid stenosis or plaque history (including carotid operation history), patients

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sustaining return of spontaneous circulation ROSC by CPR before the USG measurement,
patients who could not be measured within the first 5 cycles of the CPR, patients with
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gastrointestinal system (GIS) bleeding and hypovolemia such as advanced dehydration were
not included in the study.
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Cardiopulmonary resuscitation was performed for 2 minutes with a rate of 100-120

compressions per minute, as described in the American Heart Association (AHA) 2015 Guide
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to Advanced Cardiac Life Support. Patients in the first 5 cycles of CPR were included in the
study. The first 5 cycle measurements were considered to be more accurate because the
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ETCO2 value was thought to be affected by rib fractures and impaired thoracic expansion in
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later cycles of the CPR. The measurements were taken after the 100th chest press of the
relevant cycle and recorded when they reached the highest values in that cycle. The
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concurrent main carotid peak systolic velocity (PSV), end diastolic velocity (EDV) and time
dependent mean flow velocity (MNV) values and ETCO2 values during the CPR were
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recorded for these patients.

Measurement of carotid blood flow was performed by measuring the main PSV, EDV,
and MNV in a transverse or longitudinal position with a 10 MHz linear probe using Esaote
brand Mylab 30 gold model USG in the right main carotid tract, lateral to the trachea and
medial to the sternocleidomastoidium muscle. The study was carried out by emergency
physician with over 3 years of experience who had received advanced USG course training.

The ETCO2 values were measured by means of concurrent EMMA brand capnometer
and by the mainstream method and recorded on the data collection form.
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Statistical analysis was performed using the SPSS 15.0 program for Windows. The
descriptive criteria were presented as mean and percentage distribution. The conformity of the
data to normal distribution was assessed with the Kolmogorov-Smirnov test. The Student's t-
test was used to determine the mean differences between the groups in cases when the
parametric conditions were met, and the Mann Whitney U test was used when these
conditions were not met. Kruskal-Wallis analysis was applied for more than two groups, the
Pearson Chi-Square test was used to compare the differences between the percentages, and
the Fisher's Exact test was used when needed. Pearson Correlation Analysis was used to

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evaluate the correlations. A value of p <0.05 was accepted as statistically significant.

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RESULTS

The age, gender, comorbid diseases, cardiac rhythm at the time of admission, arrest
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patterns, carotid measurement values and ETCO2 values of the patients were documented.

Of the 32 patients included in the study, 11 were female and 21 were male. The mean
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age of the patients was 54.5±12.3 years. The most common comorbid diseases were diabetes
mellitus (DM) and hypertension (HT). The patients presented at ED most frequently with the
complaints of asystole (n=24, 75.0%), followed by pulseless electrical activity (n=6,18.8%)
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and ventricular fibrillation (VF) (n=2, 6.3%), respectively. Of the applications, 10 (31.2%)
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were from within the hospital and 22 (68.8%) were from outside the hospital. In arrest
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patients from outside the hospital, the mean duration of out-of-hospital arrest was 15.9±11.2
mins (median = 10). The values of the patients measured from the carotid during CPR were
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PSV 67.1±17.3, EDV 16.3±4.5, and MNV 25.5±8.1. The mean ETCO2 value of the patients
was 22.2±8.1. The general characteristics of the 32 patients included in the study are shown in
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(Table 1).

A statistically significant difference was determined between the in-hospital and out-
of-hospital arrests in terms of patient outcome (return of spontaneous circulation = ROSC or
Death) (p< 0.05) (Table 2).

No statistically significant correlation was determined when the mean values of PSV,
EDV, and MNV were compared in patients with the outcomes of ROSC and death (p > 0.05).
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The mean ETCO2 value of the death group (19.1±7.8) was determined to be significantly
lower than that of the ROSC group (26.3±6.5) (p< 0.05) (Table 3).

When the correlation between the ETCO2 values and the PSV, EDV, MNV values is
examined, there was a low and positive correlation between the ETCO2 values and the PSV
values, and a very low and positive correlation between the ETCO2 and the EDV and MNV
values. However, none of the correlations were statistically significant (p>0.05) (Table 4).

A statistically significant positive correlation was determined between the PSV and

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MNV values (p<0.05) (Table 4).

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A statistically significant positive correlation was determined between the EDV and
MNV values (p<0.05) (Table 4).

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As a result of the ROC analysis, it was seen that ETCO2 values had diagnostic value in
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predicting that adequate circulation was ensured, when the PSV value, assumed to provide
adequate circulation, was taken as 60 (AUC:0.81. 95% CI: 0.62-0.99. p<0.05). The
recommended limit value for this is 20.5 (with 81% sensitivity, 91% selectivity) (AUC = area
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under the curve) (Image 2).

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DISCUSSION

ETCO2 measurement is currently used as the gold standard method to show the
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efficacy of CPR. Another method that can be used in addition to the ETCO2 measurement is
to measure the intra-arterial diastolic pressure (7). Studies have shown that carotid artery
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blood flow measurement is a feasible method for demonstrating the CPR quality (6). To the
best of our knowledge, there has been no study in which carotid blood flow has been assessed
with ETCO2.

The reason for evaluating patients under 65 years of age in the study was because of
the increased risk of atherosclerosis in advanced age, impaired chest elasticity affecting chest
compressions with older age, carotid artery stenosis and stroke risk at an older age. Studies
conducted to assess the risk of atherosclerosis have shown that 65 years of age should be
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considered as a threshold value for vascular events such as stroke and acute myocardial
infarction (8, 9, 10,11).

In the present study, the ROSC rate of the in-hospital arrest cases was found to be
statistically significantly higher than that of the out-of-hospital arrest cases (p=0.008).
Similarly, Tomruk et al. showed that the ROSC of in-hospital cardiac arrest cases was
statistically significantly higher (p <0.001) (12). It is considered that the higher rate of
reanimation in in-hospital arrest cases is due to people witnessing the cases, early onset of

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chest pressure, faster access to advanced cardiac life support, and quicker detection of
underlying causes and reversible causes.

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In a study by Cheskes S. et al. of 842 cardiopulmonary arrest cases, it was found that

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the CPR quality was not affected by out-of-hospital cardiac arrest distance and duration when
performed by well-trained health personnel (13). The present study also showed that the effect
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of mean duration of out-of-hospital arrest on the ROSC and death rates was not statistically
significant (p = 0.61).
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In the present study, the mean ETCO2 of those who died (19.1±7.8) was significantly
lower than that of patients with the outcome of ROSC (26.3±6.5) (p<0.05). Lui et al.
investigated the predictability of ETCO2 in ensuring ROSC during CPR in 178 non-traumatic
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out-of-hospital arrest patients and based it on two values of 10 mmHg and 20 mmHg for
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ROSC patients. High specificity was determined between the values of 20 mmHg and above
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and the ROSC rate (14). As a result of other studies in literature, the 2010 AHA guidelines
suggested the use of ETCH2 monitoring to validate the endotracheal intubation site, to
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demonstrate the efficacy of chest compressions (<10 mmHg if insufficient) and as the ROSC
criterion (>40 mmHg for adequate cardiac output) (3). As new information in the 2015 AHA
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guidelines, it was stated that if the ETCO2 value cannot be increased to 10 mmHg despite 20
minutes of CPR in intubated patients, termination of the CPR may be considered (15). The
results of the present study show similarity to the data related to ETCO2 in both the 2010 and
the 2015 AHA guidelines.

The mean values of the main carotid artery were found to be 67 (55-106) cm/sec for
PSV and 18 (12-27) cm/sec for EDV in the study by Adeyinka A. et al., entitled
“Applicability of the Measurements of Carotid Artery Blood Flow during CPR”. The PSV
values in the same study were close to the PSV values (28.6-178.4) in normal healthy
individuals (16, 17). In the present study, the mean values of the main carotid arteries were
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found to be 67.1±17.3 cm/sec for PSV and 16.3±4.5 cm/sec for EDV. The values in the
present study were similar to those of both Adeyinka A. et al., and the PSV values of normal
healthy individuals (28.6-178.4). The present study is important because it shows that
effective CPR can ensure a carotid blood flow close to that of a normal healthy individual.

In the present study, correlations between the ETCO2 values and the PSV, EDV, MNV
values measured by main carotid artery Doppler USG were not statistically significant
(p>0.05). This may have been due to a small number of cases or situations that may have

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affected the ETCO2 values. If the number of cases were to be increased, it is thought that a
statistically significant relationship could be found between these values.

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There was a positive and low-level of correlation between the ETCO2 values and PSV

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values, and a positive and very low-level of correlation between the EDV and MNV values.
When the required PSV value for adequate circulation was taken as 60 cm/sec in the ROC
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curve, it was determined that ETCO2 values had diagnostic value in predicting adequate
circulation. This relationship between the PSV and ETCO2 suggests that sufficient carotid
blood flow can be achieved with the increased ETCO2 value during CPR. Thus, carotid blood
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flow measurement during CPR may be an indirect guide for providing cerebral perfusion.
However, the present study showed that the ETCO2 measurement, the gold standard, was
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more appropriate in showing CPR efficacy, and carotid Doppler USG measurements were not
sufficient in this respect.
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There was a statistically significant positive correlation between the PSV and MNV
values (0.66-p=0.01) and a significant positive correlation between the EDV and MNV values
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(0.39-p=0.03) when evaluating the adequacy of carotid blood flow. To the best of our
knowledge, there has been no previous study in literature which has evaluated the correlation
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of the carotid measurement values with each other.

The limitations of this study are the low number of cases, the dependence of the USG
on the individual, the difficulty of measuring during CPR, and the need for a certain period of
time to reach and measure USG during CPR. Another limitation is the lack of use of carotid
intima media thickness measurement, which is an important marker in the determination of
vascular incident risk and is used to evaluate the carotid blood flow.
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CONCLUSION

The results of this study showed a low-level of correlation between the PSV and
ETCO2 values. With effective CPR, the results were close to carotid blood flow in normal
healthy individuals. However, it was observed that carotid blood flow measurement results

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during CPR did not show the efficacy of CPR as much as the ETCO2 values. There is a need
for further studies with more and larger series of cases on this topic.

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8.Salonen JT, Salonen R. Ultrasonographically assessed carotid morphology and the risk of
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age. Ultrasound Med Biol 2000; 8:1261–6.

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Table 1. General characteristics of the patients

Number (%)

Mean±SD

Mean age (years) 54.5±12.3

Gender

Female 11 (34.4)

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Male 21 (65.6)

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Additional disease

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Diabetes mellitus = DM 10 (31.2)

Hypertension = HT 10 (31.2)
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Rhythm at the time of application

Asystole 24 (75.0%)
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Pulseless Electrical Activity 6 (18.8%)

Ventricular fibrillation = VF 2 (6.3%)

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Arrest Pattern
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In-Hospital 10 (31.2%)

Out-of-Hospital 22 (68.8%)
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Out-of-Hospital arrest stay length 15.9±11.2 (median = 10)

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PSV 67.1±17.3

EDV 16.3±4.5

MNV 25.5±8.1

ETCO2 22.2±8.1
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Table 2. Comparison of the ROSC and DEATH situations in terms of the place where
the arrest occurred

ROSC DEATH P value

N (%) N (%)

In-Hospital Arrest 8 (80) 2 (20) 0.008

Out-of-Hospital Arrest 6 (27.3) 16 (72.7)

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Table 3. Comparison of PSV, EDV, MNV and ETCO2 averages of those with the
outcomes of ROSC and Death

ROSC DEATH P value

Mean±SD Mean±SD

Mean PSV 70.5±17.5 64.5±17.1 0.51

Mean EDV 16.3±4.2 16.2±4.9 0.84

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Mean MNV 24.7±9.3 26.1±7.2 0.49

ETCO2 26.3±6.5 19.1±7.8 0.01

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Table 4. Correlation of the ETCO2. PSV, EDV, MNV values with each other

PSV EDV MNV ETCO2

Correlation Correlation Correlation Correlation

coefficient coefficient coefficient coefficient

(p value) (p value) (p value) (p value)

PSV - 0.19 0.66 0.31

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(0.28) (0.01) (0.09)

EDV 0.19 - 0.39 0.14

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(0.28) (0.03) (0.44)

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MNV 0.66 0.39 - 0.17

(0.01) (0.03) (0.35)

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ETCO2 0.31 0.14 0.17 -

(0.09) (0.44) (0.35)

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Conflict of interest

The limitations of this study are the low number of cases, the dependence of the USG
on the individual, the difficulty of measuring during CPR, and the need for a certain period of
time to reach and measure USG during CPR. Another limitation is the lack of use of carotid
intima media thickness measurement, which is an important marker in the determination of
vascular incident risk and is used to evaluate the carotid blood flow.

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Figure 1
Figure 2