Transesophageal Echocardiography for Pulse Evaluation during Cardiopulmonary Resuscitation

Accurate and rapid pulse assessment during cardiopulmonary resuscitation (CPR) is essential to minimize interruptions in chest compressions. Manual arterial palpation (MP) is subjective and often unreliable. This is especially true in low-flow states. Transesophageal echocardiography (TEE) enables continuous intra-arrest cardiac visualization. It may facilitate faster decision-making during pulseless arrest.

To compare pulse evaluation-related decision-making time during CPR using TEE versus MP and to explore associated resuscitation outcomes.

This prospective observational study enrolled adult patients (≥18 years) with non-traumatic in-hospital cardiac arrest in a tertiary emergency department. Pulse assessment during CPR was performed either by MP or intra-arrest TEE. The method depended on the treating physician's clinical judgment. The primary outcome was the time spent on pulse evaluation-related decision-making. This was defined as the time from initiation of pulse assessment to the decision to continue or stop chest compressions. Secondary outcomes included total CPR duration and the rate of return of spontaneous circulation (ROSC). These were considered exploratory. Nonparametric statistical tests were used as appropriate.

A total of 112 patients were included (median age 75 years; 39.3% female). Pulse evaluation-related decision-making time was significantly shorter in the TEE group compared with the MP group (median 2 [2-3] vs. 7 [5-8] s; p = 0.001). Total CPR duration was also shorter in the TEE group (median 15 [6-65] vs. 30 [2-72] min; p = 0.005). A higher proportion of ROSC was observed in the TEE group; however, this finding should be interpreted strictly as exploratory and hypothesis-generating. Moreover, the study was not powered to establish causality.

Intra-arrest TEE was associated with significantly shorter pulse evaluation-related decision-making times compared with MP during CPR. By enabling rapid, continuous cardiac assessment, TEE reduced time to pulse evaluation-related decision-making. These findings are exploratory; their impact on clinically meaningful outcomes remains uncertain. Observed differences in ROSC should be interpreted cautiously. Confirmation in randomized, multicenter trials is needed.