Maria O’Rourke, MD; Byron Mendenhall, MD; Elisa M. Aponte, MD
Kaweah Delta Medical Center
Although transesophageal echocardiography (TEE) has long been used to help diagnose valvular heart disease, wall-motion abnormalities, strain, and cardiac outflow, it has been recently shown to have significant benefits in the management of emergency department (ED) patients in cardiac arrest 1,2 Here is a useful video primer on the value of TEE in cardiac arrest patients: https://www.youtube.com/watch?v=GzcUZKlVwlY&feature=youtu.be.
Transthoracic echocardiography during cardiac arrest can be technically difficult and often leads to long interruptions in chest compressions.3 By providing an unobstructed view of the heart and the great vessels, TEE allows clinicians to accurately evaluate cardiac function and the quality of chest compressions as well as perform resuscitative measures with the probe still in place. TEE can also be useful in the unstable, intubated ED patient in order to obtain more information about their cardiac function, fluid status, the etiology of their shock state, and previously unknown pathologies (e.g. aortic dissection or pulmonary embolism).4,5
The 2017 ACEP guidelines recommend a four-view limited point of care exam for the patient that presents to the ED in cardiac arrest.6
These four views are the:
In addition to the published views for TEE in cardiac arrest, we propose two supplemental views that provide additional information in both the peri-arrest and cardiac arrest patient and can be used in settings beyond the ED.7 These include the Mid Esophageal 2-Chamber View at 90 degrees and the Descending Aorta and Aortic Arch View at 0 degrees.
How To Obtain The Supplemental Views
These two additional views are easily obtained. The first view is the Midesophageal 2 chamber view which is obtained by simply increasing the omniplane to 90 degrees from the midesophageal 4 chamber view at 0 degrees. This will afford the examiner views of the anterior and inferior walls of the left ventricle as well as the mitral valve. This is clinically useful in the setting of possible acute myocardial infarction and also provides a great view of the mitral valve allowing one to assess for valvular dysfunction or vegetation. The second view can be obtained from the Transgastric Mid Papillary Short Axis view by returning the omniplane to 0 degrees and rotating the probe to patient’s left. Slowly withdraw the probe until the descending aorta is seen. One then continues withdrawing the probe while keeping the aorta in view, until the aortic arch is reached in the upper esophagus. To get a more complete view of the aortic arch one must rotate the probe slightly towards the patient’s right. This extra view is simple to acquire and adds a great deal of information about the aorta, assessing for dissection or aneurysm, while one is removing the probe.