Transesophageal Echocardiography in the Emergency Department

Focused Transesophageal Echocardiography by Emergency Physicians is Feasible and Clinically Influential: Observational Results from a Novel Ultrasound Program

Journal of Emergency Medicine February 2016 - Pubmed Link

Take Home Points

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.

Background

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").

Questions

Is performing TEE in the emergency department feasible?

Does performing TEE in the emergency department change management?

Population

Retrospective chart review of patients who received TEE in the emergency department over 2 years

Single academic center, 2 emergency departments

Who did the scans?

14 emergency physicians

4 hour workshop - 2 hours didactic and 2 hours simulated enhanced hands-on training

Design

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).

Intervention

Patients received TEE at the discretion of their treating physician as part of their usual care in the emergency department.

Scan

Focused TEE

Previously published by Arntfield et al in Critical Ultrasound Journal 2015 - article includes additional files with video demonstrations!

1. Mid-esophageal four-chamber

2. Transgastric short-axis

3. Mid-esophageal long-axis

4. 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

Results

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)

Limitations

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.

Take Home Points

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.

Our score