Ali Elsaied, DO | EM PGY 3

The Article:

Teran, F., Dean, A. J., Centeno, C., Panebianco, N. L., Zeidan, A. J., Chan, W., & Abella, B. S. (2019). Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department. Resuscitation, 137, 140–147.

The Idea:

To determine the potential added benefit of utilizing transesophageal echocardiography in out-of-hospital cardiac arrest patients brought to the ED.

The Study:

A prospective observational study at an urban academic tertiary care center of all patients over 18 years old, not pregnant, found to be DNR, or had any visible evidence of trauma who presented to the ED either actively in cardiac arrest, or immediately post-ROSC. The emergency physicians performing the TEEs were trained extensively in its use prior to the study launch. A total of 33 out-of-hospital cardiac arrest patients were enrolled in the study. The emergency physicians performing the ultrasound utilized the real-time TEE images to provide the primary ED team with information that may be beneficial in guiding resuscitative efforts, such as so-called ‘Area of Maximal Compression’ or AMC, sonographic volume status, RV dilation, aortic dissection, and more detailed view of ventricular dysrhythmia, such as very fine VF. The study evaluated how often TEE in cardiac arrest provided additional clinical information which may alter resuscitative management in any way.

The Findings:

Of the 33 patients enrolled in the study, 21 arrived to the ED with ongoing CPR, and 12 arrived having already achieved ROSC, or achieved ROSC within the first five minutes of arriving to the ED. The mean time from patient arrival to the ED to TEE 12 minutes. In the cohort of patients enrolled in this study, 7 patients were found to be in PEA, 6 were in asystole, 2 in non-pulseless ventricular arrythmias, and 16 had ROSC at arrival. 2 of these patients re-arrested shortly after arrival to the ED. 2 of the 7 patients thought to be in PEA by conventional measures were found on TEE to actually be in pseudo-PE, and 3 cases of what was thought to be asystole were found to be in fine VF, all of which were defibrillated.

39% of patients in the study were found to have RV dilatation on TEE, however not all of these patients were thought to have PE by the primary team.

One case identified a mass within the heart, thought to be a thrombus, for which the patient received thrombolysis.

In 17 of the intra-arrest cases, Area of Maximal Compression was evaluated by TEE. Of these, only 8 were found to have compressions over the LV, whereas 9 were receiving compressions over the LVOT or aortic root. Hemodynamic parameters seemed to improve via ETCO2 monitoring and SBP/DBP measurements with correction of compression position.

The Takeaway:

TEE in cardiac arrest may provide emergency physicians with more clinical data, potentially altering management to improve outcomes in out-of-hospital cardiac arrest patients.