Journal of Emergency Medicine February 2016 - Pubmed Link
1. Transesophageal echocardiography (TEE) appears to be feasible in the emergency department. 100% success rate in study patient population.
2. TEE can change the management of your patients.
3. There were no complications of TEE in the ED reported in this small retrospective study.
Transthoracic echocardiography (TTE) has proven to be very useful in the emergency department but there are some limitations. These include different experience levels, patients with difficult anatomy or conditions, and logistical limitations such as attempting to scan during ongoing CPR. Transesophageal echo (TEE) can solve some of these issues. It has been shown to be better than TTE in certain situations. Downsides of TEE are lack of training, cost, invasiveness, and current culture (AKA "politics").
Is performing TEE in the emergency department feasible?
Does performing TEE in the emergency department change management?
Retrospective chart review of patients who received TEE in the emergency department over 2 years
Single academic center, 2 emergency departments
14 emergency physicians
4 hour workshop - 2 hours didactic and 2 hours simulated enhanced hands-on training
Retrospective review
Queried ED ultrasound database (Qpath) and retrieved data on each scan (entered at time of ultrasound). This included a section titled “recommended action(s) based on findings” The options were:
IV fluids
inotropes
surgery or procedure
follow up POCUS
comprehensive echo
consultatation
termination of resuscitation
additional diagnostics.
,
Chart review looking at discharge diagnosis, disposition, complications related to TEE.
Attempted to distinguish findings that could have been seen on “basic” TTE as opposed to TEE. TEE specific defined as the findings made by possible by the acoustic window or enhanced resolution (examples given were findings during CPR, ascending aorta, and fine ventricular fibrillation).
Patients received TEE at the discretion of their treating physician as part of their usual care in the emergency department.
Focused TEE
Previously published by Arntfield et al in Critical Ultrasound Journal 2015 - article includes additional files with video demonstrations!
Mid-esophageal four-chamber
Transgastric short-axis
Mid-esophageal long-axis
Mid-esophageal bicaval view
PIE (Perioperative Interactive Education) TEE - 3D modules and other great educational resources
Ultrasound Podcast on TEE Part 1 and Part 2
54 TEE exams performed
12 emergency physicians (10 attendings, 2 senior residents)
All intubated at time of exam
Indications
43% (23/54) for intra-arrest
26% (14/54) for post-arrest
17% (9/54) for medical hypotension
13% (7/54) for traumatic hypotension
2% (1/54) for rule-out aortic dissection
35% (19/54) had transthoracic echo (TTE) attempted and documented as well
Primary Outcomes
Feasibility
Probe insertion
100% success
83% (45/54) first pass success
11% (6/54) >1 attempt
6% (3/54) inserted with laryngoscope
98% (53/54) produced interpretable images (single patient with uninterpretable exam was blunt chest trauma - no TTE or TEE views)
Safety
No documented aerodigestive injuries in 39 patients who survived to hospital admission
No autopsies were performed on the 15 that died
Clinical Impact (*note: text data vary slightly from data in tables/figures. The latter is reproduced below)
TEE was DIAGNOSTICALLY helpful in 76% of cases
excluding cardiac cause of arrest 43% (27/54)
Ascertaining etiology of arrest (9/54)
identification of depressed left ventricular function 8% (5/54)
Hypovolemia 6% (4/54)
Aortic dissection 3% (2/54)
Identifying underlying rhythm 2% (1/54)
TEE had THERAPEUTIC impact in 67% of cases
changing CPR 42% (misplaced vector of force, chest compressor fatigue, shortened pulse-check duration, identification of return of cardiac activity)
Cessation of resuscitation 30%
Guide hemodynamic support through volume (18%) or vasoactive drugs (8%)
Procedural guidance 2% (pacemaker insertion)
Other Findings
The use of the four different views
Mid-esophageal four-chamber was most commonly achieved (98%)
Transgastric short axis (81%)
Esophageal long-axis (79%)
Bicaval view (47%)
55.6% (30/54) of these findings were specific to TEE (hypothetically not able to be seen on TTE)
Small population
Retrospective
We don’t know how much really could have been seen on TTE because it was not attempted in most patients.
We don’t know if the changes recommended based on TEE were good decisions.
We don’t know the utility in less sick patients (non-intubated).
Limited evidence to support safety given small population and no autopsies performed.
1. Transesophageal echocardiography (TEE) appears to be feasible in the emergency department. 100% success rate study patient population.
2. TEE can change the management of your patients.
3. There were no complications of TEE in the ED reported in this small retrospective study.