Feasibility, Utility, and Safety of Fully Incorporating Transesophageal Echocardiography into an Emergency Medicine Practice

Acad Emerg Med. 2021 Oct 13. doi: 10.1111/acem.14399. Online ahead of print.

Abstract

Introduction: Transthoracic echocardiography (TTE) is a standard procedure for emergency physicians (EPs). Transesophageal echocardiography (TEE) is known to have great utility in patients who are critically ill or in cardiac arrest, and has been used by some EPs with specialized ultrasound training, but it is generally considered outside the reach of the majority of EPs. We surmised that all of our EPs could learn to perform focused TEE (F-TEE), so we trained and credentialed all of the physicians in our group.

Methods: We trained 52 EPs to perform and interpret F-TEEs using a 4-hour simulator-based course. We kept a database of all F-TEE exams for quality assurance and continuous quality feedback. Data is reported using descriptive statistics.

Results: EPs attempted 557 total F-TEE exams (median 10, IQR 5, 15) during the 42-month period following training. Clinically relevant images were obtained in 99% of patients. EPs without fellowship or other advanced ultrasound training performed the majority of F-TEEs (417, 74.9%) and 94.3% (95% CI 91.4-96.3%) had interpretable images recorded. When TTE and TEE were both performed (n =410), image quality of TEE was superior in 378 (93.3%; 95% CI 89.7-95%). Indications for F-TEE included peri-arrest states (55.7%), cardiac arrest (32.1%), and shock (12.2%). There was one case of endotracheal tube dislodgement during TEE placement, but this was immediately identified and replaced without complication.

Conclusion: After initiating a mandatory group F-TEE training and credentialing program, we report the largest series to date of EP-performed resuscitative F-TEE. The majority of F-TEE exams (75%) were performed by EPs without advanced ultrasound training beyond residency.