MD1 Response: Transesophageal Echocardiography

MD1 Response is a recurring update on interesting out-of-hospital cases experienced by on-scene EMS physicians. Submit your cases to md1admin@md1program.org.

Our patient was using heroin and found unresponsive by family members in her residence in cardiac arrest. They called 9-1-1 and began CPR with operator instructions.

This was a 37-year-old, 150-lb. Caucasian female with no past medical history, although reported past substance abuse with heroin. Police arrived first and found her unconscious, pulseless, and apneic. They took over CPR and administered intranasal naloxone with little effect. The local municipal BLS team arrived to assist with the resuscitation. They employed an AED, bag-valve mask, and oxygen in the usual fashion, though no shocks were given.

EMS physicians arrived on scene shortly after the BLS team. The crew continued high-quality CPR but discontinued the AED and transitioned to a Lifepak 12 cardiac monitor/defibrillator. The initial ECG was a narrow complex pulseless electrical activity (PEA) at approximately 20 bpm.

The team established intraosseous (IO) access in the left proximal humerus, flushed, and administered 1 mg of epinephrine, repeating it approximately every five minutes during the arrest. They also gave a normal saline bolus with a pressure-infusion bag via IO and 2 mg naloxone, which was repeated with next dose of epi. An attempt at intubation with active chest compressions failed, so rescuers placed a No. 3 King airway and got an initial EtCO₂ of 44 mmHg.

Transesophageal echocardiography (TEE) point-of-care ultrasound (POCUS) equipment was set up after additional advanced providers arrived on scene. With the arrival of the paramedics, a second Lifepak 15 was attached to the patient for double sequential defibrillation if needed. In order to insert the TEE probe, the King tube was exchanged for an 8.0 endotracheal tube by a different provider from the first attempt. Continuous waveform capnography confirmed successful intubation. The TEE probe was inserted to approximately 22 cm, and the remainder of the resuscitation was viewed with a midesophageal four-chamber echocardiography (ME4C) view.

High-quality CPR continued for narrow complex PEA. The patient received additional epinephrine, calcium, and bicarbonate, with ROSC at the 20-minute mark of advanced provider resuscitation. TEE clearly guided provider CPR hand placement for chest compressions. TEE POCUS provided real-time observations of the patient’s heart, rapidly ruling out gross structural heart disease such as pericardial effusion, dilated right ventricle (right heart strain), hypertrophic cardiomyopathy, or valve abnormality. TEE showed the return of spontaneous circulation immediately in real time with adequate cardiac output and palpable peripheral pulses confirmed by increased EtCO₂.

Postarrest, providers were able to immediately identify ventricular tachycardia (VT) with the TEE images and ECG tracing. The paroxysmal ventricular tachycardia was promptly cardioverted to a sinus rhythm. When an episode of ventricular fibrillation (VF) followed spontaneously, it was also immediately evident on TEE, ECG, and EtCO₂. The VF episode was converted with a single defibrillation at 200 joules. The patient received a 150-mg bolus of amiodarone on scene prior to transport, with no other ventricular arrhythmias noted during contact.

Post-ROSC care included 12-lead ECG, push-dose pressors of epinephrine 1:100,000, and notification to the ED of a post-cardiac arrest patient. The TEE ME4C view showed normal regional wall motion. The TEE probe was removed during transport and an orogastric tube placed for gastric decompression. Care was turned over to the ED approximately 48 minutes after advanced provider contact.

Review of Transesophageal Echocardiography

During the resuscitation real-time images of the patient’s heart were displayed on a large bedside screen. This was extremely beneficial in the differential diagnosis of the cause of the arrest and to identification of its reversible causes. Pericardial tamponade, left ventricle outflow tract obstruction, structural dysfunction of myocardial wall motion and valve dysfunction, and a dilated right ventricle were all quickly ruled out without interrupting the high-quality CPR.

This case was an example of how high-quality CPR with augmented advanced monitoring such as TEE POCUS, waveform capnography EtCO₂, metronome-guided CPR, and aggressive resuscitation can be successful in the right patient population for increased survival to hospital arrival. All resuscitations need to have a clear, practiced response with advanced monitoring capabilities. The future of prehospital physician-led cardiac arrest management will likely have TEE POCUS.

Resources

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 Feb; 50(2): 286–94.

Brown H, Barrett HL, Lee J, Pincus JM, Kimble RM, Eley VA. Successful resuscitation of maternal cardiac arrest with disseminated intravascular coagulation guided by rotational thromboelastometry and transesophageal echocardiography: a case report. A A Pract, 2018 Mar 15; 10(6): 139–43.

Daniel WG, Erbel R, Kasper W, et al. Safety of Transesophageal Echocardiography. A Multicenter Survey of 10,419 Examinations. Circulation, 1991; 83: 817–21.

Fair J, Mallin M, Mallemat H, et al. Transesophageal Echocardiography: Guidelines for Point-of-Care Applications in Cardiac Arrest Resuscitation. Ann Emerg Med, 2018; 71: 201–7.

Guidelines for the use of transesophageal echocardiography (TEE) in the ED for cardiac arrest. Ann Emerg Med, 2017 Sep; 70(3): 442–5.

Memtsoudis SG, Rosenberger P, Loffler M, et al. The Usefulness of Transesophageal Echocardiography During Intraoperative Cardiac Arrest in Noncardiac Surgery. Anesth Analg, 2006; 102: 1,653–7.

Merlin MA, Joseph J, Hohbein J, et al. Out-of-Hospital Transesophageal Echocardiogram for Cardiac Arrest Resuscitation: The Initial Case. Prehosp Emerg Care, 2020 Jan–Feb; 24(1): 90–93.

Parker BK, Salerno A, Euerle BD. The Use of Transesophageal Echocardiography During Cardiac Arrest Resuscitation: A Literature Review. J Ultrasound Med, 2019 May; 38(5): 1,141–51.

James Tanis, MD, is an EMS physician with MD1. He is an emergency physician with FEP of TeamHealth in Florida and associate medical director for AdventHealth and Flight 1 in Orlando, as well as medical director for AER Consulting Services of New Jersey.