EASy ALS
Acquire during the pulse check → identify the arrest phenotype → act on a reversible cause.
🎓 Train in the EASy ALS module →Echocardiographic Assessment using Subcostal-only view in Advanced Life Support
EASy ALS brings focused cardiac and lung ultrasound into the ≤10-second pulse/rhythm check of the ACLS algorithm. Recorded during the pause and read once compressions resume, the subcostal 4-chamber view — the most information-rich single view — helps separate true PEA (cardiac standstill) from pseudo-PEA and can reveal findings consistent with a reversible cause, without holding chest compressions.
Why in-hospital cardiac arrest is a black box
When the pulse is gone, physiology is invisible — unless you look.
in-hospital cardiac arrests each year in the US — most often in the ICU (40.3%)
present in asystole or PEA — the nonshockable rhythms where a reversible cause is hiding
survival to discharge at the lowest vs highest decile of hospitals — a near 4-fold gap in the Get With The Guidelines–Resuscitation registry (top hospitals reach 36%). Outcomes vary widely and are modifiable.
most common triggers are hypotension and acute respiratory insufficiency — physiologies ultrasound reads directly
The ACLS pulse check gives you 10 seconds and a rhythm strip that cannot tell true PEA from pseudo-PEA. EASy ALS is a single subcostal clip recorded inside that pause — cardiac motion predicts markedly better survival, standstill predicts a poor one, and the pattern narrows the differential to the causes worth acting on.
Where this sits in the guidelines
POCUS during cardiac arrest may be considered when performed by experienced professionals to identify reversible causes, provided it does not interrupt or delay high-quality CPR.
Consistent with the 2025 AHA Adult Advanced Life Support guideline. Everything below is built to hold that boundary: one clip, recorded inside the pulse-check pause, interpreted after compressions resume. The 2025 algorithm in full.
2025 AHA ALS cardiac arrest algorithm
The current AHA shockable/non-shockable trees, Hs & Ts, and post-arrest care — with where EASy ALS fits, including the new 2025 POCUS-after-ROSC recommendation. Printable.
See it in action
The same team, the same simulated arrest — recorded before and after a three-day EASy workshop in Benghazi, 2023.
Compressions and a monitor. The pulse check comes and goes without anyone learning why the patient arrested.
Defined roles, the probe pre-positioned during compressions, a subcostal clip recorded inside the pause and read once CPR resumes.
Simple enough to rehearse. Structured enough to perform under pressure.
One window, one first question: motion or standstill. Once compressions resume, the recorded loop is interpreted for findings consistent with a reversible cause. The sequence is short enough to rehearse end to end, which is the point: under the cognitive load of a real code, a streamlined protocol is the one that still gets performed.
Simulation training
EASy ALS is taught as a half-day, high-fidelity simulation workshop — because a protocol that is only read is not a protocol that gets performed at 3am.
Watch it first — then reveal what went wrong
A simulated PEA arrest from one of the sessions. The image was obtained and the team reached the right answer — but the team leader never counted down out loud, and the pause ran 17 seconds without compressions instead of ten. Seven extra seconds of no flow, in a team that thought the run had gone well.
This is the failure mode the protocol is built around, and it is invisible from inside the room. It is why the countdown is a scored item, why the operator times every no-flow interval, and why the scenarios are debriefed on video rather than from memory.
A session runs 105 minutes: a five-minute pre-brief, then five PEA scenarios of twenty minutes each — five to seven minutes of code, the rest debriefed. Participants rotate through five roles, so everyone leads, scans, compresses, and scores someone else.
Scenarios are drawn from a larger bank and run in no fixed order — among them hypovolemia, tamponade, severe LV dysfunction, RV failure, and tension pneumothorax. Neither the case nor its sonographic read is given to the team in advance; naming the phenotype at the bedside is the exercise.
Every scenario is scored on the same two forms — one for the team leader, one for the sonographer — covering preparation, acquisition inside the pause, the read, and whether the phenotype was named out loud before the intervention was chosen. Two of those items exist purely to protect the pause: counts down from 10, adequate and loud, and at 9 seconds, clearly states “resume CPR”. The clip on the left is what their absence costs.
Enquire about hosting a workshopThe EASy ALS examination
One subcostal cardiac view during the pause; every other window is obtained while compressions continue.
Subcostal 4-chamber (SC4C)
Cardiac motion vs standstill, chamber sizes, and function → pseudo-PEA phenotype
IVC — during compressions
Filling state — a flat IVC points to volume loss early in the arrest; it fills as the arrest goes on, so a plethoric IVC does not exclude it
Lung & pleura — during compressions or pauses
B-lines present, absent sliding, lung point — tension pneumothorax and large pleural effusion
Airway, aorta & abdomen
ET-tube confirmation, aortic rupture, and intraperitoneal bleeding — all during CPR
Pseudo-PEA
Coordinated electrical activity, no palpable pulse, but coordinated myocardial motion on the subcostal view — a profound shock state with a better prognosis that prompts an aggressive search for a treatable cause. In OHCA it is more common than true PEA (28.6% vs 22.1%).
True PEA — cardiac standstill
Electrical activity, no pulse, and no detectable cardiac motion. Associated with a low likelihood of ROSC — one factor when weighing cessation of efforts, but never the sole determinant (AHA 2020 / ERC 2021).
How it changes management
Reversible causes on the subcostal view
Pseudo-PEA patterns that redirect the resuscitation:
Pericardial effusion
Tamponade — 5–22% of PEA arrests → pericardiocentesis
Dilated right heart
Massive PE or acute-on-chronic cor pulmonale → reperfusion / RV support
Dilated, poorly contracting left heart
Massive MI → emergent coronary angiography
Small, hyperdynamic LV
Hypovolemia / hemorrhage → volume, blood, source control. A flat IVC supports it early; the IVC fills as the arrest continues, so a plethoric IVC late does not rule out haemorrhage
Absent sliding, no B-lines
Tension pneumothorax → needle decompression. Sliding plus B-lines rules it out on that side; do not spend arrest time hunting a lung point
Fibrillating myocardium, flat monitor
Fine VF → defibrillate (ultrasound nearly doubles detection)
Tamponade prevalence in PEA arrest and the perioperative-arrest pathway per the ESAIC/ESTES consensus guideline (Hinkelbein J, et al. Eur J Anaesthesiol 2023;40:724–736). Fine-VF recognition and defibrillation pathway per the 2020 AHA ALS guidelines (Panchal AR, et al. Circulation 2020;142:S366–S468). Reviewed in Bughrara N, Hsu W, Cha S, Pustavoitau A. Focused Point-of-Care Ultrasound in Cardiac Arrest. In: Comprehensive Critical Care Ultrasound, 3rd ed. SCCM (in press, 2026).
Part of the PeRLS continuum
EASy ALS is the arrest-phase tool in the broader PeRLS framework (Perioperative Resuscitation and Life Support) — one subcostal window across pre-procedural, intra-arrest, and post-arrest care.
POCUS before sedation/airway identifies chronic cardiac disease and volume status that predispose to collapse.
EASy PDAEASy ALS during the pulse/rhythm check — true vs pseudo-PEA and reversible causes.
You are hereAfter ROSC, phenotype post-resuscitation instability (RV/LV failure, hypovolemia, tamponade) to guide vasoactive selection.
EASy MAPEvidence
Case series: 22 periresuscitative patients scanned by trained anesthesiology residents during the pulse/rhythm check after a structured focused-cardiac-ultrasound course.
diagnostic-quality subcostal images obtained, in a self-reported case series — no independent adjudication, no comparator
image acquisition inside the pulse-check pause after a 1-day course, in trained nonexpert sonographers
sensitivity/specificity for hypovolemic shock by CCUS; RV strain + DVT reach ~90% for PE
Bughrara N, Hsu W, Cha S, Pustavoitau A. Focused Point-of-Care Ultrasound in Cardiac Arrest. In: Comprehensive Critical Care Ultrasound, 3rd ed. Society of Critical Care Medicine (in press, 2026).
Merchant RM, Berg RA, Yang L, et al. Hospital variation in survival after in-hospital cardiac arrest (Get With The Guidelines–Resuscitation). J Am Heart Assoc. 2014;3(1):e000400.Bughrara NF, Gaylor R, Hsu W, Santino C, Shembesh M, Pustavoitau A. PeRLS for procedural sedation, enhanced by EASy-ALS. Best Pract Res Clin Anaesthesiol. 2025;39:255–266.Learn EASy ALS
Work through the training module and explore cardiac arrest scenarios.
Every EASy application is one loop of the same pathway. See the next step in the pathway