Transesophageal echocardiography (TEE) in cardiac arrest: results of a hands-on training for a simplified TEE protocol

Abstract

Background: Integration of transesophageal echocardiography (TEE) with Focused Cardiac Ultrasound (FoCUS) can impact decision-making, assist in the diagnosis of reversible etiologies and help guiding resuscitation of patients with cardiac arrest.

Objective: To evaluate the ability of emergency physicians (EPs) to obtain and maintain skills in performing resusTEE after a course with clinical training in the cardiac surgery theatre.

Methods: Ten EPs without previous TEE experience underwent a resusTEE course, based on a 2-h workshop and an 8-h hands-on training. The training was performed in a cardiac surgery theatre tutored by cardiovascular anesthesiologists. The six taught views were mid-esophageal four-chamber (ME4CH), mid-esophageal long axis (MELAX), mid-esophageal two-chamber (ME2CH), mid-esophageal bicaval view (MEbicaval), transgastric short axis (TGSAX) and aorta view (AOview). The EPs were evaluated by a cardiovascular anesthesiologist at the end of the course as well as after 12 weeks according to a standardized evaluation method. Once the course was completed, resusTEE exams, performed by EPs in Emergency Department (ED), were monitored for a 12-week period.

Results: The average assessment of the ten EPs by the tutors was higher than 4 points out of 5, both at the end of the course and after 12 weeks. Probe insertion, acquisition and interpretation of the different views scored on average more than 4 points out of 5 except for TGSAX that showed worsening after 12 weeks. Trainees performed twelve resusTEE exams in ED in patients with out-of-hospital cardiac arrest (OHCA) over 12 weeks after the course. EPs used only four out of six taught views in clinical practice, in the following order of frequency: ME4CH, AOview, MEbicaval and MELAX.

Conclusions: EPs, after a course with clinical training in the cardiac surgery theatre, can successfully acquire and maintain the skills needed to perform resusTEE. However, among the six views learned in the course, EPs used only four of them (ME4CH, MEbicaval, MELAX and AOview).

Keywords: Cardiocirculatory arrest; Emergency department; Emergency medicine; Resuscitation; Training course; Transesophageal echocardiography; Ultrasound.

Fig. 1

a Mid-esophageal four-chamber view (ME4CH)—useful for evaluation of right and left ventricle function and size, mitral and tricuspid valve alterations, pericardial effusion and, during a pulse check, for the assessment of the presence of a perfusing rhythm. b Mid-esophageal long-axis view (MELAX)—helpful for the evaluation of the left ventricular systolic function and, during CPR, for the evaluation of compression adequacy and location. c Mid-esophageal two-chamber view (ME2CH)—valuable for the evaluation of the left ventricular systolic function and the regional motion of the anterior and inferior wall. d Mid-esophageal bicaval view (MEbicaval)—allows the evaluation of superior vena cava thrombus, catheters or venous cannula position (as for ECLS) and respiratory dimensions variations that can be related to volume status and fluid responsiveness. e Transgastric short-axis view (TGSAX)—provides information about pericardial effusion, left ventricle systolic function and regional wall motion abnormalities. f Aorta view (AOview)—useful for guiding vessel cannulation for ECLS and for the identification of aortic dissection/aneurysm involving the aortic arch and the descending thoracic aorta. Ao aorta, IAS interatrial septum, IVC inferior vena cava, LA left atrium, LV left ventricle, RA right atrium, RV right ventricle, SVC superior vena cava