Prehospital transesophageal echocardiography versus conventional advanced life support in out-of-hospital cardiac...

Transesophageal echocardiography during out-of-hospital cardiac arrest can be performed during ongoing chest compressions and may improve resuscitation quality, but its prehospital use has not been systematically evaluated. To assess the feasibility, diagnostic yield, and impact of prehospital TEE on resuscitation metrics and advanced life support (ALS) interventions during OHCA.

We conducted a randomized controlled trial in a physician-staffed two-tiered emergency medical service (EMS). Adults with ongoing non-traumatic OHCA were randomized 1:1 to standard ALS or ALS plus TEE. The primary endpoints were hands-off time and chest compression fraction (CCF) from EMS arrival to return of spontaneous circulation (ROSC) or resuscitation termination. Secondary endpoints included ROSC at hospital admission, survival to hospital discharge, neurological status at hospital discharge, and TEE findings. Analyses followed the intention-to-treat principle.

Of 249 screened patients, 35 were randomized and 32 analyzed (TEE n = 15; control n = 17). Median hands-off time was 4 s in both groups. Mean CCF was higher in the TEE group (96.2%) than the control group (91.6%), with a mean difference of 4.6% (95% confidence interval 2.5-6.7; p < 0.001). Sustained ROSC occurred in 40% (TEE) versus 71% (control; p = 0.083). The control group had an eCPR rate of 41%, compared to 20% in the TEE group. Using TEE, an incorrect area of maximal compression or inadequate depth was identified in 23% and 14%, respectively.

Prehospital TEE during OHCA was feasible without negatively interfering with CPR metrics, and provided clinically relevant diagnostic information and procedural guidance, warranting further evaluation in larger trials.

German Clinical Trials Register DRKS00028695 registered on 28 April 2022.