Resuscitation

EASy ALS

Echocardiographic Assessment using Subcostal-only view in Advanced Life Support

EASy-ALS incorporates focused cardiac ultrasound into the ≤10-second pulse/rhythm check of the ALS algorithm. The subcostal 4-chamber view — the most information-rich single view — is used to distinguish true from pseudo-PEA and to identify potentially reversible causes of arrest, without holding chest compressions for more than 10 seconds.

Foundational study · EASy-ALS

Resident-performed EASy-ALS in the periresuscitative period

The protocol on this page is defined by its original case series: anesthesiology residents obtained diagnostic-quality subcostal images in 100% of self-reported periresuscitative cases after a structured focused-cardiac-ultrasound course — demonstrating that EASy-ALS can identify cardiac motion and potentially reversible causes within the ALS pulse-check window.

Bughrara N, Herrick SL, Leimer E, Sirigaddi K, Roberts K, Pustavoitau A. Focused Cardiac Ultrasound and the Periresuscitative Period (EASy-ALS). A&A Practice. 2020;14:e01278.

Part of the PeRLS continuum

EASy-ALS also serves as the arrest-phase tool within the broader PeRLS framework (Perioperative Resuscitation and Life Support) — linking pre-procedural and post-arrest assessment on the same subcostal window:

Pre-procedural

POCUS before sedation/airway identifies chronic cardiac disease and volume status that predispose to collapse.

EASy PDA

Intra-arrest

EASy-ALS during the pulse/rhythm check — true vs pseudo-PEA and reversible causes.

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Post-arrest shock

After ROSC, phenotype post-resuscitation instability (RV/LV failure, hypovolemia, tamponade) to guide vasoactive selection.

EASy MAP

True PEA

Electrical activity, no palpable pulse, and no detectable cardiac motion on the subcostal view. Associated with a worse prognosis.

Pseudo-PEA

Coordinated electrical activity, no palpable pulse, but coordinated myocardial motion present — a profound shock state with a better prognosis, prompting an aggressive search for a treatable cause.

Imaging approach within CPR

Compliant with standard adult CPR — only the cardiac view requires the pulse-check pause; lung and IVC views are obtained during ongoing compressions.

VF/pulseless VT → defibrillate first; EASy-ALS is deferred. EASy-ALS is for PEA or asystole.

Allow ~2 minutes of CPR before the ultrasound assessment

Record the subcostal view during the ≤10-second pause, then interpret once compressions resume

Subcostal 4-chamber is the go-to view; if unobtainable, attempt parasternal or apical

IVC and upper-lung views performed during ongoing compressions

Findings communicated to the team leader to guide targeted intervention

Reversible causes in pseudo-PEA

Ultrasound findings that redirect resuscitation, per the SCCM cardiac-arrest POCUS chapter.

Pericardial tamponade

→ pericardiocentesis

Effusion with diastolic chamber collapse; CCUS more sensitive than exam/ECG

5–22% of PEA arrests

Massive pulmonary embolism

→ thrombolysis / thrombectomy

Acute RV dilation / strain with septal flattening

~5%, high mortality

Myocardial ischemia

→ revascularization

Acute LV dysfunction / regional wall motion abnormality

Common

Severe hypovolemia

→ volume resuscitation

Small, hyperdynamic LV that obliterates in systole; collapsing IVC

Common in-hospital

Tension pneumothorax

→ decompression

Absent lung sliding + lung point (absent sliding alone is not pathognomonic)

Fine ventricular fibrillation

→ defibrillate

Ultrasound nearly doubles detection of fine VF vs monitor alone

When transthoracic imaging is limited: intra-arrest TEE

In patients where transthoracic windows fail (large body habitus, subcutaneous emphysema, gastric air insufflation), transesophageal echocardiography provides adequate imaging in nearly all patients and can continue during chest compressions. Intra-arrest TEE has identified specific reversible findings — including pulmonary embolism, tamponade, and aortic dissection — though cost, availability, training, and certification remain barriers to routine use.

Supporting references

The foundational EASy-ALS case series (above) is complemented by:

Bughrara N, Hsu W, Cha S, Pustavoitau A. Focused Point of Care Ultrasound in Cardiac Arrest. In: Comprehensive Critical Care Ultrasound. Society of Critical Care Medicine (in print, 2026).

Bughrara NF, Gaylor R, Hsu W, Santino C, Shembesh M, Pustavoitau A. PeRLS for procedural sedation: a specialized resuscitation framework enhanced by EASy-ALS ultrasound integration. Best Pract Res Clin Anaesthesiol. 2025;39:255–266.

Practice EASy ALS

Review cardiac arrest scenarios and watch tutorial videos.