Emergency Ultrasound

Ask the Expert: TEE in the Emergency Department

Section Edited by Robert M. Bramante, MD, FACEP

Authored by:
Drs. Robert Arntfield and Drew Thompson
Division of Emergency Medicine
Department of Medicine
Western University
London, Ontario, Canada

Q: What is the utility of transesophageal echocardiography in the emergency department?

TEE1A: Point of care echo, typically done via the transthoracic approach (TTE), has transformed emergency care over the past 25 years. A routine part of the FAST exam in the assessment for traumatic hemopericardium, TTE is additionally used in cardiac arrest and is indicated for the focused assessment of LV and RV function, assessment of the IVC, and guiding procedures.1 While the influence of point-of-care echocardiography in ED care and decision making continues to grow, so too does our understanding of its limitations. Drawbacks like degraded image quality in the obese, those with subcutaneous air or in those receiving mechanical ventilation become particularly frustrating when trying to manage patients with trauma or circulatory failure in the ED. Additionally, in cardiac arrest, we see the value of TTE in identifying reversible causes or guiding prognosis. However it may frequently interfere with the time and location required to deliver continuous, high quality CPR.

Enter transesophageal echocardiography (TEE).

TEE2Typically regarded as a tool for advanced cardiology indications, the purpose of TEE in the hands of an emergency physician is fundamentally different. TEE for an emergency physician (at least for now) is less a tool of complexity but rather a tool of reliability. That is, TEE is the tool to stock in the ED if consistent, crystal clear cardiac images are of routine interest to you, or your colleagues, in the critically ill.

As ED TEE early adopters, our EM group has recently published our experience.2 What we have observed is that TEE is typically deployed in ventilated, critically ill patients. We also learned that, in many cases, 2 or 3 TEE views was all it took to answer the questions at hand. It was also evident that TEE’s most obvious application was in the context of cardiac arrest. Doing echo while also doing CPR eliminates sonographer/chest compressor tension and allows parallel streams of investigation and treatment in these high risk patients. Overall, we found that TEE imparted a diagnostic and therapeutic influence in the majority of the cases when used.

TEE in the ED might seem intimidating. There are some barriers. We are in the embryonic phase. It could require some political discussions in some hospitals. It is expensive. It does require some modest training (4 hours at our center3). These themes, however, have been present in every meaningful step along the way of our specialty and, in time, will be overcome for the betterment of patient care.

Circling back to the question regarding “What is the utility of TEE in the ED”?

Its utility lies in the use of the technology to visualize your organ of interest with greater reliability and clarity, while at the same time preserving surface anatomy for the rest of the resuscitative team. With its inherent advantages in the cardiac arrest patient, TEE may very well prove to be the next frontier in optimizing resuscitation at the bedside.


  1. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23(12):1225-30.
  2. Arntfield R, Pace J, Hewak M, et al. Focused transesophageal echocardiography by emergency physicians is feasible and clinically influential: observational results from a novel ultrasound program. J Emerg Med. 2016;50(2):286-94.
  3. Arntfield R, Pace J, McLeod S, et al. Focused transesophageal echocardiography for emergency physicians—description and results from simulation training of a structured four-view examination. Crit Ultrasound J. 2015;7(1):1. 

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