Utilization of Transesophageal Echocardiography During Cardiac Arrest In An Urban Emergency Department

Resuscitative transesophageal echocardiography (rTEE) can identify reversible causes of cardiac arrest and guide compression location without interrupting ongoing cardiopulmonary resuscitation (CPR). A challenge in emergency medicine is widespread adoption.

This study examines the early phase of implementing a rTEE program in an academic emergency department.

This retrospective study included patients undergoing CPR from June 2022 to 2024 who received rTEE during cardiac arrest. The rTEE examinations were performed by emergency physicians trained in rTEE or supervised residents. Training consisted of a 4- to 6-hour course with didactics and 10 proctored rTEE simulations. Outcomes included operator training level, successful transducer insertion, image acquisition, left ventricular outflow tract (LVOT) visualization, compression location, and change in compression location or management.

rTEE was performed on 70 patients in medical cardiac arrest. Successful insertion occurred in 97.1% (N = 68), with visualization of return of spontaneous circulation (ROSC) upon rTEE insertion in 13.2% (n = 9). Fifty-nine patients were ultimately available for analysis. Sixty-one percent (n = 36) were male and 39% were female (n = 23). Mean age was 66.4 years (SD 15.8). Adequate views were obtained in 78% (n = 46) of cases. About 57.6% of rTEEs (n = 34) were performed by supervised residents without prior rTEE training, with 85.3% interpretable images. Views included: midesophageal long axis (78.0%), midesophageal four chamber (49.2%), transgastric short axis (5.1%), and bicaval (5.1%). The LVOT was visualized in 71.2% (n = 42) of cases. Change in compression location occurred in 18.6% (n = 11). rTEE identified five cases of pericardial effusion (two requiring pericardiocentesis) and five cases of ventricular fibrillation not detected on the monitor. Change in diagnosis occurred in 10.2% (n = 6).

This rTEE program demonstrated high levels of operator proficiency in image acquisition, TEE insertion, and identifying clinically significant information. Use of rTEE during cardiac arrest offers valuable diagnostic insights and can lead to critical therapeutic changes. Prospective studies are needed to determine the optimal training required to effectively perform rTEE. This training pathway provides a practical blueprint for emergency departments adopting rTEE.