TEE DURING CARDIAC ARREST

TEE and cardiac arrestTransesophageal echocardiography (TEE or TOE) used to be the domain of cardiologists. It has lately seeped into other areas of medicine where hemodynamic evaluation is crucial. ICU’s and occasionally OR’s use them even for non-cardiac surgery. But the TEE probe can quite easily be used in any unconscious, intubated patient. One obvious indication would be cardiac arrests.

TEE in cardiac arrest
I’ve heard it mentioned before, but I somehow didn’t view it as a practical possibility outside the OR. Not until I listened to Mike Mallin talk on TEE and cardiac arrest at SonoNorway. When people take the extra effort to learn, and then push on to just get out and do it, they not only change their own practice, but can really change other people’s perspective. Like Mike did here. They do TEE in their ER – out in the field(!) It doesn’t sound so crazy once someone tells you they’re already doing it – it breaks down the traditional blocks and fences you got in your mind. It’s always liberating.

Why isn’t TEE used more?
The probes are expensive, and usually hidden in the cardiology or cardiothoracic department. Most sonographers don’t have any training or experience with TEE, so the TEE probe can seem intimidating compared to a standard ultrasound probe. But it doesn’t take that much training. If you know TTE echocardiography, get some training in inserting the TEE probe and obtaining some useful views, you’re on your way. And for basic cardiac function assessment, you don’t even need the ‘proper’ cardiologist’s views. Just like with TTE, any view that lets you eyeball cardiac function will give you clues to the diagnosis. As long as you have some background knowledge on what you’re doing.

TEE and cardiac arrest
Image from Wikipedia under Creative Commons license.

Where’s the evidence?
Not many are doing it, and not many are documenting it. TEE in cardiac arrest makes a lot of sense, and I’ve long been yearning for something more than the generic, algorithmic ACLS approach to cardiac arrest. The algorithm is a good way to get started in the chaotic setting a cardiac arrest initially is, but once you get going, the algorithm feels inadequate. I’ve taken to the advice from Scott Weingart to step it up using art lines and dosing adrenaline after BP response when practical.

TEE takes it a step further: instead of using the surrogate measure of BP, you can evaluate the actual cardiac function. Not just that. With the TEE probe indwelling, you can evaluate the quality of the compressions, and you get minimal hands-off time for evaluating cardiac contractility, cardiac filling and any signs of other pathology like pulmonary embolism, pericardial effusions etc. to sign off your H&T’s.

As mentioned, there isn’t much evidence out there. But in this case that just means we’re at the frontier of cardiac arrest management. There are a few articles on intraoperative cardiac arrest managed with TEE, and describing basic TEE as quite easy to learn and useful in an arrest setting. There’s also an article from the ER setting. So there’s no reason why these findings shouldn’t translate well into medical arrests in ER, on wards or out-of-hospital arrests coming into the ER.

Please let us know if you have other good resources or articles describing TEE in cardiac arrest.

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A few articles on TEE and cardiac arrest, most available are from the OR, where the TEE might already be in use, or more readily available, but there’s also an article on TEE for cardiac arrest in the ER:

Transesophageal echocardiography during cardiopulmonary arrest in the emergency department, Resuscitation, 2008.

The usefulness of transesophageal echocardiography during intraoperative cardiac arrest in noncardiac surgery, Anesth Analg, 2006.

Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation, J Am Coll Cardiol, 1997.

Training and use of TEE, again, focusing on the OR and ICU, but should be transferrable for ER use as well:

Emergent limited perioperative transesophageal echocardiography: should new guidelines exist for limited echocardiography training for anesthesiologists? Front Med, 2012.

And lastly, a good short-guide to TEE from www.echopraxis.com

This entry was posted in AHLR, Emergency Medicine, Ultrasound. Bookmark the permalink.

2 Responses to TEE DURING CARDIAC ARREST

  1. Le Gazier says:

    Hi!

    Thank you for this article. I’ve also been listening to Scott’s podcasts and reading the echopraxis blog.
    It is undeniable that TEE is useful in cardiac arrest as you mentioned : monitoring chest compressions, looking for a diagnosis (pericardial effusion, ruptured valve, PE…) and monitoring heart activity (there are some clinical cases where the patient was declared clinically dead, but when they looked at the TEE screen they could see some movement, it was small VFIB.

    I have 2 “safety” questions though
    1) how about the risque of oesophagus perforation during CPR? The TEE probe is rather large, is there a risk for oesophagus perforation during manual CPR?

    2) I’ve always been taught not to leave the probe on in the oesophagus if i was not using it, because the light of the TEE probe could “burn” the oesophagus. Instead i shoulf push the TEE probe further down into the stomach and leave it there. Is there really a risk for the TEE light to “burn” the oesophagus if left lit on for several minutes, hours? Because one of the advantage of TEE during CPR is that you can just hang it on something and leave the probe lit on with a 4 cavity view on the screen while you’re doing CPR.

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