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Teran F, West FM, Jelic T, Taylor L, Jafry ZM, Burns KM, Owyang CG, Emt CC, Abella BS, Andrus P. Resuscitative transesophageal echocardiography in emergency departments in the United States and Canada: A cross-sectional survey. Am J Emerg Med 2024; 76:164-172. [PMID: 38086182 DOI: 10.1016/j.ajem.2023.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/18/2023] [Accepted: 11/18/2023] [Indexed: 01/22/2024] Open
Abstract
INTRODUCTION Over the past two decades, transesophageal echocardiography (TEE) has been used with increasing frequency to evaluate critically ill patients outside of traditional settings. The purpose of this study was to characterize the number of programs, users, practice characteristics, training and competency requirements and barriers for the current use of resuscitative transesophageal echocardiography (TEE) in Emergency Departments (EDs) in the United States and Canada. METHODS A closed internet-based, cross-sectional, point-prevalence survey was administered via email to 120 program directors of emergency ultrasound fellowships (EUSF) and 43 physicians from EDs without EUSF from the United States and Canada. RESULTS Ninety-eight percent of surveyed participants responded. Twenty percent of respondents reported having active resuscitative TEE programs. The majority of participating hospitals (70%) were academic centers with residency programs. A total of 33 programs reported using resuscitative TEE in their ED and of those, 82% were programs with EUSF. Most programs performing TEE (79%) had less than five attending physicians performing TEE. Evaluation of patients during resuscitation from cardiac arrest (100%) and post-arrest care (76%) are the two most frequent indications for TEE in the ED. The most common core elements of resuscitative TEE protocols used are: assessment of left ventricular (LV) systolic function (97%), assessment of right ventricular (RV) function (88%), evaluation of pericardial effusion / tamponade (52%). All programs reported using formal didactics in their training programs, 94% reported using high-fidelity simulation, and 79% live scanning of patients. Financial concerns were the most common barrier use of TEE in the ED (58%), followed by maintenance of equipment (30%), and credentialing/privileges (30%). CONCLUSIONS This study provides a snapshot of the practice of resuscitative TEE in EDs in the United States and Canada revealing the existence of 33 programs using this emerging modality in the care of critically ill patients.
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Affiliation(s)
- Felipe Teran
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Frances Mae West
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Thomas Jefferson University, Pennsylvania, PA, USA
| | - Tom Jelic
- Department of Emergency Medicine, University of Winnipeg, Manitoba, MB, Canada
| | - Lindsay Taylor
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Zan M Jafry
- Department of Emergency Medicine, Loma Linda University, CA, USA
| | - Katharine M Burns
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Clark G Owyang
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Joan and Stanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Claire Centeno Emt
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin S Abella
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Phillip Andrus
- Department of Emergency Medicine, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
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Wray TC, Gerstein N, Ball E, Hanna W, Tawil I. Seeing the heart of the problem: transesophageal echocardiography in cardiac arrest: a practical review. Int Anesthesiol Clin 2023; 61:15-21. [PMID: 37602416 DOI: 10.1097/aia.0000000000000411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Affiliation(s)
- Trenton C Wray
- Department of Emergency Medicine, Division of Adult Critical Care, The University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Neal Gerstein
- Department of Anesthesiology and Critical Care, The University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Emily Ball
- Department of Emergency Medicine, Division of Adult Critical Care, The University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Wendy Hanna
- Department of Emergency Medicine, The University of New Mexico School of Medicine. Albuquerque, New Mexico
| | - Isaac Tawil
- Department of Emergency Medicine, Division of Adult Critical Care, The University of New Mexico School of Medicine, Albuquerque, New Mexico
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3
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Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med 2023; 82:e115-e155. [PMID: 37596025 DOI: 10.1016/j.annemergmed.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 08/20/2023]
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Kongkatong M, Ottenhoff J, Thom C, Han D. Focused Ultrasonography in Cardiac Arrest. Emerg Med Clin North Am 2023; 41:633-675. [PMID: 37391255 DOI: 10.1016/j.emc.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
Rapid diagnostic tools available to the emergency physician caring for cardiac arrest patients are limited. Focused ultrasound (US), and in particular, focused echocardiography, is a useful tool in the evaluation of patients in cardiac arrest. It can help identify possible causes of cardiac arrest like tamponade and pulmonary embolism, which can guide therapy. US can also yield prognostic information, with lack of cardiac activity being highly specific for failure to achieve return of spontaneous circulation. US may also be used to aid in procedural guidance. Recently, focused transesophageal echocardiography has been used in the emergency department setting.
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Affiliation(s)
- Matthew Kongkatong
- Department of Emergency Medicine, University of Virginia Health, 1215 Lee Street, Charlottesville, VA 22908, USA.
| | - Jakob Ottenhoff
- Department of Emergency Medicine, University of Virginia Health, 1215 Lee Street, Charlottesville, VA 22908, USA
| | - Christopher Thom
- Department of Emergency Medicine, University of Virginia Health, 1215 Lee Street, Charlottesville, VA 22908, USA
| | - David Han
- Department of Emergency Medicine, University of Virginia Health, 1215 Lee Street, Charlottesville, VA 22908, USA
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Kegel F, Chenkin J. Resuscitative transesophageal echocardiography in the emergency department: a single-centre case series. Scand J Trauma Resusc Emerg Med 2023; 31:24. [PMID: 37210538 DOI: 10.1186/s13049-023-01077-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 03/10/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Transesophageal echocardiography (TEE) is an emerging tool that can aid emergency physicians in treating patients in cardiac arrest and undifferentiated shock. TEE can aid in diagnosis, resuscitation, identify cardiac rhythms, guide chest compression vectors, and shorten sonographic pulse checks. This study evaluated the proportion of patients who underwent a change in their resuscitation management as a result of emergency department resuscitative TEE. METHODS This was a single-centre case series of 25 patients who underwent ED resuscitative TEE from 2015 to 2019. The objective of this study is to evaluate the feasibility and clinical impact of resuscitative TEE in critically ill patients in the emergency department. Data including changes in working diagnosis, complications, patient disposition, and survival to hospital discharge were also collected. RESULTS 25 patients (median age 71, 40% female) underwent ED resuscitative TEE. All patients were intubated prior to probe insertion and adequate TEE views were obtained for every patient. The most common indications for resuscitative TEE were cardiac arrest (64%) and undifferentiated shock (28%). Resuscitation management changed in 76% (N = 19) and working diagnosis changed in 76% (N = 19) of patients. Ten patients died in the ED, 15 were admitted to hospital, and eight survived to hospital discharge. There were no immediate complications (0/15) and two delayed complications (2/15), both of which were minor gastrointestinal bleeding. CONCLUSIONS The use of ED resuscitative TEE is a practical modality that provides useful diagnostic and therapeutic information for critically ill patients in the emergency department, with an excellent rate of adequate cardiac visualization, and a low complication rate.
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Affiliation(s)
- Fraser Kegel
- Department of Emergency Medicine, Faculty of Medicine, University of Toronto, C. David Naylor Building, 6 Queen's Park Crescent West, Third Floor, Toronto, ON, M5S 3H2, Canada
| | - Jordan Chenkin
- Department of Emergency Medicine, Faculty of Medicine, University of Toronto, C. David Naylor Building, 6 Queen's Park Crescent West, Third Floor, Toronto, ON, M5S 3H2, Canada.
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room AG 245, Toronto, ON, M4N 3M5, Canada.
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Kraai E, Teixeira JP, Patel IA, Wray TC, Mitchell JA, George N, Kamm A, Henson J, Mirrhakimov A, Guliani S, Tawil I, Dettmer T, Marinaro J. An Intensivist-Led Extracorporeal Membrane Oxygenation Program: Design, Implementation, and Outcomes of the First Five Years. ASAIO J 2023; 69:451-459. [PMID: 36525671 DOI: 10.1097/mat.0000000000001870] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
We describe the development, implementation, and outcomes of an intensivist-led adult extracorporeal life support (ECLS) program using intensivists both to perform venovenous (V-V), venoarterial (V-A), and extracorporeal cardiopulmonary resuscitation (ECPR) cannulations, and to manage patients on ECLS throughout their ICU course. All adults supported with ECLS at the University of New Mexico Hospital (UNMH) from February 1, 2017 to December 31, 2021 were retrospectively analyzed. A total of 203 ECLS cannulations were performed in 198 patients, including 116 V-A cannulations (including 65 during ECPR) and 87 V-V cannulations (including 38 in patients with COVID-19). UNMH intensivists performed 195 cannulations, with 9 cannulation complications. Cardiothoracic surgeons performed 8 cannulations. Overall survival to hospital discharge or transfer was 46.5%. Survival was 32.3% in the ECPR group and 56% in the non-ECPR V-A group. In the V-V cohort, survival was 66.7% in the COVID-19-negative patients and 34.2% in the COVID-19-positive patients. This large series of intensivist-performed ECLS cannulations-including V-A, V-V, and ECPR modalities-demonstrates the successful implementation of a comprehensive intensivist-led ECLS program. With outcomes comparable to those in the literature, our program serves as a model for the initiation and development of ECLS programs in settings with limited access to local subspecialty cardiothoracic surgical services.
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Affiliation(s)
- Erik Kraai
- From the Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - J Pedro Teixeira
- From the Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Ishan A Patel
- From the Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Trenton C Wray
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Emergency Medicine, niversity of New Mexico Health Sciences Center, Albuquerque, NM
| | - Jessica A Mitchell
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Emergency Medicine, niversity of New Mexico Health Sciences Center, Albuquerque, NM
| | - Naomi George
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Emergency Medicine, niversity of New Mexico Health Sciences Center, Albuquerque, NM
| | - Ashley Kamm
- Comprehensive Care Services, Albuquerque, NM
| | | | | | - Sundeep Guliani
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Isaac Tawil
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Emergency Medicine, niversity of New Mexico Health Sciences Center, Albuquerque, NM
| | - Todd Dettmer
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Emergency Medicine, niversity of New Mexico Health Sciences Center, Albuquerque, NM
| | - Jonathan Marinaro
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Emergency Medicine, niversity of New Mexico Health Sciences Center, Albuquerque, NM
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7
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Prager R, Bowdridge J, Pratte M, Cheng J, McInnes MDF, Arntfield R. Indications, Clinical Impact, and Complications of Critical Care Transesophageal Echocardiography: A Scoping Review. J Intensive Care Med 2023; 38:245-272. [PMID: 35854414 PMCID: PMC9806486 DOI: 10.1177/08850666221115348] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Critical care transesophageal echocardiography (ccTEE) is an increasingly popular tool used by intensivists to characterize and manage hemodynamics at the bedside. Its usage appears to be driven by expanded diagnostic scope as well as the limitations of transthoracic echocardiography (TTE) - lack of acoustic windows, patient positioning, and competing clinical interests (eg, the need to perform chest compressions). The objectives of this scoping review were to determine the indications, clinical impact, and complications of ccTEE. METHODS MEDLINE, EMBASE, Cochrane, and six major conferences were searched without a time or language restriction on March 31st, 2021. Studies were included if they assessed TEE performed for adult critically ill patients by intensivists, emergency physicians, or anesthesiologists. Intraoperative or post-cardiac surgical TEE studies were excluded. Study demographics, indication for TEE, main results, and complications were extracted in duplicate. RESULTS Of the 4403 abstracts screened, 289 studies underwent full-text review, with 108 studies (6739 patients) included. Most studies were retrospective (66%), performed in academic centers (84%), in the intensive care unit (73%), and were observational (55%). The most common indications for ccTEE were hemodynamic instability, trauma, cardiac arrest, respiratory failure, and procedural guidance. Across multiple indications, ccTEE was reported to change the diagnosis in 52% to 78% of patients and change management in 32% to79% patients. During cardiac arrest, ccTEE identified the cause of arrest in 25% to 35% of cases. Complications of ccTEE included two cases of significant gastrointestinal bleeding requiring intervention, but no other major complications (death or esophageal perforation) reported. CONCLUSIONS The use of ccTEE has been described for the diagnosis and management of a broad range of clinical problems. Overall, ccTEE was commonly reported to offer additional diagnostic yield beyond TTE with a low observed complication rate. Additional high quality ccTEE studies will permit stronger conclusions and a more precise understanding of the trends observed in this scoping review.
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Affiliation(s)
- Ross Prager
- Division of Critical Care, Western University, Stn B. London, ON, Canada,Ross Prager, Critical Care Trauma Centre,
Victoria Hospital. Rm # D2-528 London Health Sciences Centre, 800 Commissioners
Rd. E, London, ON N6A 5W9, Canada.
| | - Joshua Bowdridge
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Michael Pratte
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jason Cheng
- Division of Critical Care, Western University, Stn B. London, ON, Canada
| | - Matthew DF McInnes
- Department of Radiology, University of Ottawa, Ottawa, ON, Canada, Clinical Epidemiology Program, The Ottawa Hospital Research
Institute, Ottawa, ON, Canada
| | - Robert Arntfield
- Division of Critical Care, Western University, Stn B. London, ON, Canada
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8
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Kelly C, Ockerse P. Proposal for an Amendment to the ACEP Transesophageal Echocardiography Guidelines: The Aortic View. Ann Emerg Med 2023; 81:379-380. [PMID: 36813441 DOI: 10.1016/j.annemergmed.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 02/22/2023]
Affiliation(s)
- Christopher Kelly
- Department of Emergency Medicine, the University of Utah, Salt Lake City, UT
| | - Patrick Ockerse
- Department of Emergency Medicine, the University of Utah, Salt Lake City, UT
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9
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Riendeau Beaulac G, Teran F, Lecluyse V, Costescu A, Belliveau M, Desjardins G, Denault A. Transesophageal Echocardiography in Patients in Cardiac Arrest: The Heart and Beyond. Can J Cardiol 2023; 39:458-473. [PMID: 36621564 DOI: 10.1016/j.cjca.2022.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/27/2022] [Accepted: 12/27/2022] [Indexed: 01/07/2023] Open
Abstract
Point of care ultrasound involves different ultrasound modalities and is useful to assist management in emergent clinical situations such as cardiac arrest. The use of point of care ultrasound in cardiac arrest has mainly been described using transthoracic echocardiography as a diagnostic and as a prognostic tool. However, cardiac evaluation using transthoracic echocardiography might be challenging because of patient-related or technical factors. Furthermore, its use during pulse check pauses has been associated with delays in chest compression resumption. Transesophageal echocardiography (TEE) overcomes these limitations by providing reliable and continuous imaging of the heart without interfering with cardiopulmonary resuscitation. In this narrative review we describe the role of TEE during cardiopulmonary resuscitation in 4 different applications: (1) chest compression quality feedback; (2) rhythm characterization; (3) diagnosis of reversible causes; and (4) procedural guidance. Considering its limitations, we propose an algorithm for the integration of TEE in patients with cardiac arrest with a focus on these 4 applications and extend its use to extracardiac applications.
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Affiliation(s)
- Geneviève Riendeau Beaulac
- Department of Anesthesiology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Felipe Teran
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Vincent Lecluyse
- Department of Anesthesiology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Adrian Costescu
- Department of Anesthesiology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Marc Belliveau
- Department of Anesthesiology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Georges Desjardins
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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10
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Gottlieb M, Alerhand S. Managing Cardiac Arrest Using Ultrasound. Ann Emerg Med 2022; 81:532-542. [PMID: 36334956 DOI: 10.1016/j.annemergmed.2022.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/18/2022] [Accepted: 09/20/2022] [Indexed: 11/15/2022]
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McGuire D, Johnson S, Mielke N, Bahl A. Transesophageal echocardiography in the emergency department: A comprehensive guide for acquisition, implementation, and quality assurance. J Am Coll Emerg Physicians Open 2022; 3:e12758. [PMID: 35765309 PMCID: PMC9206109 DOI: 10.1002/emp2.12758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/12/2022] [Accepted: 05/16/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Duncan McGuire
- Department of Emergency Medicine Beaumont Hospital Royal Oak Michigan USA
| | - Steven Johnson
- Department of Emergency Medicine Beaumont Hospital Royal Oak Michigan USA
| | - Nicholas Mielke
- Oakland University William Beaumont School of Medicine Rochester Michigan USA
| | - Amit Bahl
- Department of Emergency Medicine Beaumont Hospital Royal Oak Michigan USA
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Salewski C, Nemeth A, Sandoval Boburg R, Berger R, Hamdoun H, Frenz H, Spintzyk S, Hahn JK, Schlensak C, Krüger T. The impact of 3D printed models on spatial orientation in echocardiography teaching. BMC MEDICAL EDUCATION 2022; 22:180. [PMID: 35291993 PMCID: PMC8923966 DOI: 10.1186/s12909-022-03242-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 03/02/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE During our transthoracic echocardiography (TTE) courses, medical students showed difficulty in spatial orientation. We implemented the use of 3D printed cardiac models of standard TTE views PLAX, PSAX, and A4C and assessed their efficacy in TTE-teaching. METHODS One hundred fifty-three participants were split into two groups. A pre-test-retest of anatomy, 2D -, and 3D orientation was conducted. The intervention group (n = 77) was taught using 3D models; the control group (n = 76) without. Both were comparable with respect to baseline parameters. Besides test-scores, a Likert scale recorded experiences, difficulties, and evaluation of teaching instruments. RESULTS From the 153 students evaluated, 123 improved, 20 did worse, and ten achieved the same result after the course. The median overall pre-test score was 29 of 41 points, and the retest score was 35 (p < 0.001). However, the intervention group taught with the 3D models, scored significantly better overall (p = 0.016), and in 2D-thinking (p = 0.002) and visual thinking (p = 0.006) subtests. A backward multivariate linear regression model revealed that the 3D models are a strong individual predictor of an excellent visual thinking score. In addition, our study showed that students with difficulty in visual thinking benefited considerably from the 3D models. CONCLUSION Students taught using the 3D models significantly improved when compared with conventional teaching. Students regarded the provided models as most helpful in their learning process. We advocate the implementation of 3D-printed heart models featuring the standard views for teaching echocardiography. These findings may be transferable to other evidence based medical and surgical teaching interventions.
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Affiliation(s)
- Christoph Salewski
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany.
| | - Attila Nemeth
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Rodrigo Sandoval Boburg
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Rafal Berger
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Hasan Hamdoun
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Hannes Frenz
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Sebastian Spintzyk
- Section for Medical Material Science and Technology at the Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Julia Kelley Hahn
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
| | - Tobias Krüger
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany
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Reardon RF, Chinn E, Plummer D, Laudenbach A, Rowland Fisher A, Smoot W, Lee D, Novik J, Wagner B, Kaczmarczyk C, Moore J, Thompson E, Tschautscher C, Dunphy T, Pahl T, Puskarich MA, Miner JR. Feasibility, utility, and safety of fully incorporating transesophageal echocardiography into emergency medicine practice. Acad Emerg Med 2022; 29:334-343. [PMID: 34644420 PMCID: PMC9298053 DOI: 10.1111/acem.14399] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/10/2021] [Accepted: 09/19/2021] [Indexed: 01/15/2023]
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 (US) 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‐h simulator‐based course. We kept a database of all F‐TEE examinations for quality assurance and continuous quality feedback. Data are reported using descriptive statistics. Results Emergency physicians attempted 557 total F‐TEE examinations (median = 10, interquartile range = 5–15) during the 42‐month period following training. Clinically relevant images were obtained in 99% of patients. EPs without fellowship or other advanced US training performed the majority of F‐TEEs (417, 74.9%) and 94.3% (95% confidence interval [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 periarrest 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 examinations (75%) were performed by EPs without advanced US training beyond residency.
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Affiliation(s)
- Robert F. Reardon
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Elliott Chinn
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Dave Plummer
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Andrew Laudenbach
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Andie Rowland Fisher
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Will Smoot
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Daniel Lee
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Joseph Novik
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Barrett Wagner
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Chris Kaczmarczyk
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Johanna Moore
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Emily Thompson
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Craig Tschautscher
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Teresa Dunphy
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Thomas Pahl
- Glacial Ridge Health System Glenwood Minnesota USA
| | - Michael A. Puskarich
- Department of Emergency Medicine Hennepin County Medical Center & University of Minnesota Medical School Minneapolis Minnesota USA
| | - James R. Miner
- Department of Emergency Medicine Hennepin County Medical Center & University of Minnesota Medical School Minneapolis Minnesota USA
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Chu SE, Chang CJ, Chen HA, Chiu YC, Huang CY, Pei-Chuan Huang E, Hsieh MJ, Chiang WC, Huei-Ming Ma M, Sun JT. Core Ultrasound in REsuscitation (CURE): A Novel Protocol for Ultrasound-Assistant Life Support via Application of Both Transesophageal and Transthoracic Ultrasound. Resuscitation 2022; 173:1-3. [DOI: 10.1016/j.resuscitation.2022.01.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 01/01/2023]
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15
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Hussein L, Rehman MA, Jelic T, Berdnikov A, Teran F, Richards S, Askin N, Jarman R. Transoesophageal echocardiography in cardiac arrest: A systematic review. Resuscitation 2021; 168:167-175. [PMID: 34390824 DOI: 10.1016/j.resuscitation.2021.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/28/2021] [Accepted: 08/03/2021] [Indexed: 11/30/2022]
Abstract
AIMS To identify, appraise and synthesize all available clinical evidence to evaluate the diagnostic role of transoesophageal echocardiography (TEE) during resuscitation of in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) in the identification of reversible causes of cardiac arrest and cardiac contractility. METHODS We conducted a systematic review following PRISMA guidelines. Medline, EMBASE, Web of Science Core Collection, Proquest Dissertations, Open Grey, CDSR, Cochrane Central, Cochrane Clinical Answers, and the clinicaltrials.gov registry were searched for eligible studies. Studies involving adult patients, with non-traumatic cardiac arrest in whom TEE was used for intra-arrest evaluation, were included. Case studies and case series, animal studies, reviews, guidelines and editorials were excluded. The QUADAS-2 tool was used for quality assessment of all studies. RESULTS Eleven studies with a total of 358 patients were included. Four studies involved perioperative IHCA, three involved OHCA, and four were mixed population settings. Overall, the risk of bias in the selected studies was either high or unclear due to evidence or lack of information. In all 11 studies, TEE allowed the identification of reversible causes of arrest. We found significant heterogeneity in the criteria used to interpret findings, TEE protocol used, and timing of TEE. CONCLUSION Due to heterogeneity of studies, small sample size and inconsistent reference standard, the evidence for TEE in cardiac arrest resuscitation is of low certainty and is affected by a high risk of bias. Further studies are needed to better understand the true diagnostic accuracy of TEE in identifying reversible causes of arrest and cardiac contractility.
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Affiliation(s)
- Laila Hussein
- Teesside University, Middlesbrough, United Kingdom; Department of Emergency Medicine, Sheikh Shakbout Medical City, Abu Dhabi, United Arab Emirates.
| | - Mohammad Anzal Rehman
- Department of Emergency Medicine, Zayed Military Hospital, Abu Dhabi, United Arab Emirates
| | - Tomislav Jelic
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Felipe Teran
- Center for Resuscitation Science, University of Pennsylvania School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | | | - Robert Jarman
- Teesside University, Middlesbrough, United Kingdom; Royal Victoria Infirmary, Newcastle upon Tyne, UK
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16
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Affiliation(s)
- Jan Niederdöckl
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | - Nina Buchtele
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Hans Domanovits
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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17
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Richardson ASC, Tonna JE, Nanjayya V, Nixon P, Abrams DC, Raman L, Bernard S, Finney SJ, Grunau B, Youngquist ST, McKellar SH, Shinar Z, Bartos JA, Becker LB, Yannopoulos D, Bˇelohlávek J, Lamhaut L, Pellegrino V. Extracorporeal Cardiopulmonary Resuscitation in Adults. Interim Guideline Consensus Statement From the Extracorporeal Life Support Organization. ASAIO J 2021; 67:221-228. [PMID: 33627592 PMCID: PMC7984716 DOI: 10.1097/mat.0000000000001344] [Citation(s) in RCA: 184] [Impact Index Per Article: 61.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
DISCLAIMER Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being deployed for selected patients in cardiac arrest who do not attain a native circulation with conventional CPR (ECPR). This ELSO guideline is intended to be a practical guide to implementing ECPR and the early management following establishment of ECMO support. Where a paucity of high-quality evidence exists, a consensus has been reached amongst the authors to provide guidance to the clinician. This guideline will be updated as further evidence in this field becomes available.
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Affiliation(s)
| | | | | | - Paul Nixon
- From the The Alfred Hospital, Melbourne, Australia
| | | | | | | | | | - Brian Grunau
- Vancouver Coastal Health, Vancouver, British Columbia
| | | | | | - Zachary Shinar
- University of Minnesota Medical Center, Minneapolis, Minnesota
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18
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Teran F, Prats MI, Nelson BP, Kessler R, Blaivas M, Peberdy MA, Shillcutt SK, Arntfield RT, Bahner D. Focused Transesophageal Echocardiography During Cardiac Arrest Resuscitation: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 76:745-754. [PMID: 32762909 DOI: 10.1016/j.jacc.2020.05.074] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/05/2020] [Accepted: 05/21/2020] [Indexed: 12/20/2022]
Abstract
Focused transthoracic echocardiography (TTE) during cardiac arrest resuscitation can enable the characterization of myocardial activity, identify potentially treatable pathologies, assist with rhythm interpretation, and provide prognostic information. However, an important limitation of TTE is the difficulty obtaining interpretable images due to external and patient-related limiting factors. Over the last decade, focused transesophageal echocardiography (TEE) has been proposed as a tool that is ideally suited to image patients in extremis-those in cardiac arrest and periarrest states. In addition to the same diagnostic and prognostic role provided by TTE images, TEE provides unique advantages including the potential to optimize the quality of chest compressions, shorten cardiopulmonary resuscitation interruptions, guide resuscitative procedures, and provides a continuous image of myocardial activity. This review discusses the rationale, supporting evidence, opportunities, and challenges, and proposes a research agenda for the use of focused TEE in cardiac arrest with the goal to improve resuscitation outcomes.
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Affiliation(s)
- Felipe Teran
- Division of Emergency Ultrasound and Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Michael I Prats
- Division of Ultrasound, Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bret P Nelson
- Division of Ultrasound, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ross Kessler
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Michael Blaivas
- Department of Medicine, University of South Carolina School of Medicine. Department of Emergency Medicine, St. Francis Hospital, Columbia, South Carolina
| | - Mary Ann Peberdy
- Division of Cardiology, Department of Internal Medicine, Weil Institute of Emergency and Critical Care, Department of Emergency Medicine, University Virginia Commonwealth University, Richmond, Virginia
| | - Sasha K Shillcutt
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Robert T Arntfield
- Division of Critical Care Medicine, Western University, London, Ontario, Canada
| | - David Bahner
- Division of Ultrasound, Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
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19
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Transesophageal echocardiography (TEE) in cardiac arrest: results of a hands-on training for a simplified TEE protocol. Ultrasound J 2020; 12:41. [PMID: 32808100 PMCID: PMC7431479 DOI: 10.1186/s13089-020-00189-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 08/04/2020] [Indexed: 11/21/2022] Open
Abstract
Background Integration of transesophageal echocardiography (TEE) with Focused Cardiac Ultrasound (FoCUS) can impact decision-making, assist in the diagnosis of reversible etiologies and help guiding resuscitation of patients with cardiac arrest. Objective To evaluate the ability of emergency physicians (EPs) to obtain and maintain skills in performing resusTEE after a course with clinical training in the cardiac surgery theatre. Methods Ten EPs without previous TEE experience underwent a resusTEE course, based on a 2-h workshop and an 8-h hands-on training. The training was performed in a cardiac surgery theatre tutored by cardiovascular anesthesiologists. The six taught views were mid-esophageal four-chamber (ME4CH), mid-esophageal long axis (MELAX), mid-esophageal two-chamber (ME2CH), mid-esophageal bicaval view (MEbicaval), transgastric short axis (TGSAX) and aorta view (AOview). The EPs were evaluated by a cardiovascular anesthesiologist at the end of the course as well as after 12 weeks according to a standardized evaluation method. Once the course was completed, resusTEE exams, performed by EPs in Emergency Department (ED), were monitored for a 12-week period. Results The average assessment of the ten EPs by the tutors was higher than 4 points out of 5, both at the end of the course and after 12 weeks. Probe insertion, acquisition and interpretation of the different views scored on average more than 4 points out of 5 except for TGSAX that showed worsening after 12 weeks. Trainees performed twelve resusTEE exams in ED in patients with out-of-hospital cardiac arrest (OHCA) over 12 weeks after the course. EPs used only four out of six taught views in clinical practice, in the following order of frequency: ME4CH, AOview, MEbicaval and MELAX. Conclusions EPs, after a course with clinical training in the cardiac surgery theatre, can successfully acquire and maintain the skills needed to perform resusTEE. However, among the six views learned in the course, EPs used only four of them (ME4CH, MEbicaval, MELAX and AOview).
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20
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Teran F, Burns KM, Narasimhan M, Goffi A, Mohabir P, Horowitz JM, Yuriditsky E, Nagdev A, Panebianco N, Chin EJ, Gottlieb M, Koenig S, Arntfield R. Critical Care Transesophageal Echocardiography in Patients during the COVID-19 Pandemic. J Am Soc Echocardiogr 2020; 33:1040-1047. [PMID: 32600742 PMCID: PMC7245221 DOI: 10.1016/j.echo.2020.05.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The COVID-19 pandemic has placed an extraordinary strain on healthcare systems across North America. Defining the optimal approach for managing a critically ill COVID-19 patient is rapidly changing. Goal-directed transesophageal echocardiography (TEE) is frequently used by physicians caring for intubated critically ill patients as a reliable imaging modality that is well suited to answer questions at bedside. METHODS A multidisciplinary (intensive care, critical care cardiology, and emergency medicine) group of experts in point-of-care echocardiography and TEE from the United States and Canada convened to review the available evidence, share experiences, and produce a consensus statement aiming to provide clinicians with a framework to maximize the safety of patients and healthcare providers when considering focused point-of-care TEE in critically ill patients during the COVID-19 pandemic. RESULTS Although transthoracic echocardiography can provide the information needed in most patients, there are specific scenarios in which TEE represents the modality of choice. TEE provides acute care clinicians with a goal-directed framework to guide clinical care and represents an ideal modality to evaluate hemodynamic instability during prone ventilation, perform serial evaluations of the lungs, support cardiac arrest resuscitation, and guide veno-venous ECMO cannulation. To aid other clinicians in performing TEE during the COVID-19 pandemic, we describe a set of principles and practical aspects for performing examinations with a focus on the logistics, personnel, and equipment required before, during, and after an examination. CONCLUSIONS In the right clinical scenario, TEE is a tool that can provide the information needed to deliver the best and safest possible care for the critically ill patients.
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Affiliation(s)
- Felipe Teran
- Division of Emergency Ultrasound and Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Katharine M Burns
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois; University of Illinois at Chicago, Chicago, Illinois
| | - Mangala Narasimhan
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Alberto Goffi
- Li Ka Shing Knowledge Institute, Department of Critical Care Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul Mohabir
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - James M Horowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Medical Center, New York, New York
| | - Eugene Yuriditsky
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Medical Center, New York, New York
| | - Arun Nagdev
- Division of Emergency Ultrasound, Department of Emergency Medicine, Highland General Hospital, Oakland, California
| | - Nova Panebianco
- Division of Emergency Ultrasound, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric J Chin
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Seth Koenig
- Division of Pulmonary, Department of Medicine, Albert Einstein School of Medicine, Bronx, New York
| | - Robert Arntfield
- Division of Critical Care Medicine, Department of Medicine, Victoria Hospital, Critical Care Trauma Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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21
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Salerno A, Euerle BD, Witting MD. Transesophageal Echocardiography Training of Emergency Physicians Through an E-Learning System. J Emerg Med 2020; 58:947-952. [PMID: 32362376 DOI: 10.1016/j.jemermed.2020.03.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Transesophageal echocardiography (TEE) has been shown to be a powerful tool that emergency physicians can use to guide resuscitation efforts during cardiac arrest. Currently, there is no standardized curriculum to teach TEE to emergency physicians. OBJECTIVE We hypothesized that the use of a pilot training course combining interactive e-learning and hands-on simulation would increase the percentage of students achieving a score of ≥80% on a multiple-choice test of knowledge and increase self-reported comfort using TEE. METHODS We designed a 2.5-h TEE course for emergency physicians and medical intensive care unit fellows. Participants took a test of knowledge and a survey of comfort-both online-before, just after, and 4 weeks after taking the course. Survey responses measured participants self-reported comfort with using TEE in clinical practice. A normal binomial approximation was used to calculate the 95% confidence interval. RESULTS Of the 3 tests of knowledge, 15 participants completed all tests. Of the surveys of comfort, 31 participants completed the precourse survey, 32 completed the postcourse survey, and 19 completed the 4-week follow-up survey. The proportion of students scoring ≥80% improved from 40% on the precourse test to 80% on the postcourse test (95% confidence interval 1-79). The proportion of students indicating comfort with using TEE improved from 3% precourse to 53% postcourse (95% confidence interval 28-71). CONCLUSIONS A TEE training course resulted in a 50% increase in surveyed participants feeling comfortable using TEE in cardiac arrest and a 40% increase in participants scoring ≥80% on a test of knowledge.
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Affiliation(s)
- Alexis Salerno
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Brian D Euerle
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael D Witting
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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22
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Bonfanti N, Gundert E, Malhotra A, Saleh J, Kulstad E. Considerations for the Use of Intracardiac Echocardiography in Cardiac Arrest. Resuscitation 2020; 149:158-161. [PMID: 32109504 DOI: 10.1016/j.resuscitation.2020.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/27/2020] [Accepted: 02/04/2020] [Indexed: 11/18/2022]
Abstract
The use of transthoracic echocardiography (TTE) is common during cardiopulmonary resuscitation (CPR) from cardiac arrest, but logistic and practical challenges of obtaining satisfactory images without sacrificing the quality of CPR have resulted in some centers utilizing transesophageal echocardiography (TEE) during CPR. Although TEE avoids many of the downsides of TTE, several challenges exist in routine deployment. An alternative approach, intracardiac echocardiography (ICE), is routinely used by electrophysiologists during regular cardiac electrophysiologic procedures, such as atrial ablation for the treatment of atrial fibrillation. In this review, we evaluate various considerations in the potential for use of ICE as a novel means of enhancing resuscitation during CPR.
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23
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Wray TC, Schmid K, Braude D, Azevedo K, Dettmer T, Tawil I, Boivin M, Marinaro J. Safety of Transesophageal Echocardiography Performed by Intensivists and Emergency Physicians in Critically Ill Patients With Coagulopathy and Thrombocytopenia: A Single-Center Experience. J Intensive Care Med 2019; 36:123-130. [PMID: 31741420 DOI: 10.1177/0885066619887693] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The use of transesophageal echocardiography (TEE) by intensivist physicians (IPs) and emergency physicians (EPs) in critically ill patients is increasing in the intensive care unit, emergency department, and prehospital environments. Coagulopathy and thrombocytopenia are common in critically ill patients. The risk of performing TEE in these patients is unknown. The goal of this study was to assess whether TEE is safe when performed by IPs or EPs in critically ill patients with high bleeding risk (HBR). METHODS All TEEs performed by an IP or EP between January 1, 2016, and July 31, 2019, were reviewed as part of a quality assurance database. A TEE performed on a patient was deemed HBR if the patient met at least one of the following criteria: undergoing therapeutic anticoagulation, had an INR > 2, activated partial thromboplastin time >40 seconds, fibrinogen <150 mg/dL, and/or platelet count <50 000/μL. The medical record was reviewed on each patient to determine whether upper esophageal bleeding, oropharyngeal bleeding, esophageal perforation, or dislodgement of an artificial airway occurred during or after the TEE. RESULTS A total of 228 examinations were reviewed: 80 in the high-risk group and 148 in the low-risk group (LBR). There were complications potentially attributable to TEE in 8 (4%) of the 228 exams. Total complications were not different between groups: 4 (5%) in the HBR group versus 4 (3%) in the LBR group (odds ratio [OR] = 1.89 [0.34-10.44], P =.368). Upper esophageal bleeding occurred in 5 total examinations (2%), which was not different between groups: 3 (4%) in the HBR group and 2 (1%) in the LBR group (OR = 2.84 [0.31-34.55], P = .238). There were no deaths attributable to TEE in either group. CONCLUSION Transesophageal echocardiography can be safely performed by IPs and EPs in critically ill patients at high risk of bleeding with minimal complications.
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Affiliation(s)
- Trenton C Wray
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Kristin Schmid
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Darren Braude
- Division of Prehospital, Austere, and Disaster Medicine, Department of Emergency Medicine, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Keith Azevedo
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Todd Dettmer
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Isaac Tawil
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Michel Boivin
- Department of Internal Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Jonathan Marinaro
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Transesophageal echocardiography identification of aortic dissection during cardiac arrest and cessation of ECMO initiation. Am J Emerg Med 2019; 37:1214.e5-1214.e6. [DOI: 10.1016/j.ajem.2019.02.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 02/24/2019] [Accepted: 02/25/2019] [Indexed: 11/23/2022] Open
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25
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Resuscitative Cardiopulmonary Ultrasound and Transesophageal Echocardiography in the Emergency Department. Emerg Med Clin North Am 2019; 37:409-430. [PMID: 31262412 DOI: 10.1016/j.emc.2019.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Resuscitative ultrasound describes point-of-care applications that provide diagnostic information, physiologic monitoring, and procedural guidance in critically ill patients. This article reviews the evaluation of ventricular function, identification of pericardial effusion and tamponade, evaluation of preload and fluid responsiveness, and hemodynamic monitoring, as some of the main applications where this modality can help emergency physicians during resuscitation of critically ill patients.
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26
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Parker BK, Salerno A, Euerle BD. The Use of Transesophageal Echocardiography During Cardiac Arrest Resuscitation: A Literature Review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1141-1151. [PMID: 30280396 DOI: 10.1002/jum.14794] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 07/13/2018] [Accepted: 07/13/2018] [Indexed: 06/08/2023]
Abstract
We propose that transesophageal echocardiography (TEE) can be used to guide cardiac arrest resuscitation. We undertook a literature search (Medline and EMBase) to assess articles on that topic. Our search yielded 55 articles falling into 3 categories: TEE used in operating rooms, TEE used in emergency departments, and TEE used in other settings. In many cases, TEE changed the direction of the resuscitation; however, it is unclear whether TEE changed patient-oriented outcomes, such as neurologically intact survival. Few adverse events related to TEE have been documented. There is growing evidence that physicians can learn to use TEE during resuscitations and apply the findings to clinical decisions.
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Affiliation(s)
- Brian K Parker
- Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Alexis Salerno
- Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Brian D Euerle
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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27
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Teran F, Dean AJ, Centeno C, Panebianco NL, Zeidan AJ, Chan W, Abella BS. Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department. Resuscitation 2019; 137:140-147. [DOI: 10.1016/j.resuscitation.2019.02.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/08/2019] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
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Abstract
The care for victims of out-of-hospital cardiac arrest is evolving and will be influenced by future and emerging technologies that will play a role in the systems of care for these patients. Recent advances in extracorporeal life support and point-of-care ultrasound imaging, both in-hospital and out-of-hospital, may offer a therapeutic solution in some systems for patients with refractory or recurrent cardiac arrest. Drones capable of delivering automated external defibrillators to the scene of an out-of-hospital cardiac arrest, advances in digital and mobile technologies to notify and leverage bystander response, and wearable life detection technologies may improve survival.
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Affiliation(s)
- Andrew J Latimer
- Department of Emergency Medicine, University of Washington, Box 359702, 325 Ninth Avenue, Seattle, WA 98104-2499, USA.
| | - Andrew M McCoy
- Department of Emergency Medicine, University of Washington, Box 359702, 325 Ninth Avenue, Seattle, WA 98104-2499, USA
| | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, Box 359727, 325 Ninth Avenue, Seattle, WA 98104-2499, USA; Seattle Fire Department, Box 359702, 325 Ninth Avenue, Seattle, WA 98104-2499, USA
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29
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Supportive technology in the resuscitation of out-of-hospital cardiac arrest patients. Curr Opin Crit Care 2018; 23:209-214. [PMID: 28383297 DOI: 10.1097/mcc.0000000000000409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW To discuss the increasing value of technological tools to assess and augment the quality of cardiopulmonary resuscitation (CPR) and, in turn, improve chances of surviving out-of-hospital cardiac arrest (OHCA). RECENT FINDINGS After decades of disappointing survival rates, various emergency medical services systems worldwide are now seeing a steady rise in OHCA survival rates guided by newly identified 'sweet spots' for chest compression rate and chest compression depth, aided by monitoring for unnecessary pauses in chest compressions as well as methods to better ensure full-chest recoil after compressions. Quality-assurance programs facilitated by new technologies that monitor chest compression rate, chest compression depth, and/or frequent pauses have been shown to improve the quality of CPR. Further aided by other technologies that enhance flow or better identify the best location for hand placement, the future outlook for better survival is even more promising, particularly with the potential use of another technology - extracorporeal membrane oxygenation for OHCA. SUMMARY After 5 decades of focus on manual chest compressions for CPR, new technologies for monitoring, guiding, and enhancing CPR performance may enhance outcomes from OHCA significantly in the coming years.
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Ahn HJ, Lee JW, Joo KH, You YH, Ryu S, Lee JW, Kim SW. Point-of-Care Ultrasound–Guided Percutaneous Cannulation of Extracorporeal Membrane Oxygenation: Make it Simple. J Emerg Med 2018; 54:507-513. [DOI: 10.1016/j.jemermed.2017.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 10/13/2017] [Accepted: 12/01/2017] [Indexed: 10/18/2022]
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31
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Hempel D, Pfister R, Michels G. Strukturierte bettseitige Sonographie in der Intensivmedizin. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-017-0201-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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32
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Transesophageal Echocardiography: Guidelines for Point-of-Care Applications in Cardiac Arrest Resuscitation. Ann Emerg Med 2018; 71:201-207. [DOI: 10.1016/j.annemergmed.2017.09.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/26/2017] [Accepted: 09/01/2017] [Indexed: 12/20/2022]
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[Structured bedside-ultrasound in intensive care medicine]. Med Klin Intensivmed Notfmed 2017; 112:741-758. [PMID: 29063125 DOI: 10.1007/s00063-017-0366-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/17/2017] [Accepted: 09/18/2017] [Indexed: 12/27/2022]
Abstract
The so-called point-of-care ultrasound (POCUS) is of increasing importance for diagnostics and therapy control in intensive care medicine. Based on focused thorax sonography, echocardiography, and abdominal sonography, the most important working and differential diagnoses can be demonstrated or excluded depending on the leading symptom. Sonographic-based algorithms allow a structured evaluation especially of patients with the common leading symptoms dyspnea and thoracic pain.
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Tonna JE, Selzman CH, Mallin MP, Smith BR, Youngquist ST, Koliopoulou A, Welt F, Stoddard KD, Nirula R, Barton R, Fair JF, Fang JC, McKellar S. Development and Implementation of a Comprehensive, Multidisciplinary Emergency Department Extracorporeal Membrane Oxygenation Program. Ann Emerg Med 2017; 70:32-40. [PMID: 28139304 DOI: 10.1016/j.annemergmed.2016.10.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/30/2016] [Accepted: 10/03/2016] [Indexed: 11/16/2022]
Abstract
Despite advances in the medical and surgical management of cardiovascular disease, greater than 350,000 patients experience out-of-hospital cardiac arrest in the United States annually, with only a 12% neurologically favorable survival rate. Of these patients, 23% have an initial shockable rhythm of ventricular fibrillation/pulseless ventricular tachycardia (VF/VT), a marker of high probability of acute coronary ischemia (80%) as the precipitating factor. However, few patients (22%) will experience return of spontaneous circulation and sufficient hemodynamic stability to undergo cardiac catheterization and revascularization. Previous case series and observational studies have demonstrated the successful application of intra-arrest extracorporeal life support, including to out-of-hospital cardiac arrest victims, with a neurologically favorable survival rate of up to 53%. For patients with refractory cardiac arrest, strategies are needed to bridge them from out-of-hospital cardiac arrest to the catheterization laboratory and revascularization. To address this gap, we expanded our ICU and perioperative extracorporeal membrane oxygenation (ECMO) program to the emergency department (ED) to reach this cohort of patients to improve survival. In this report, we illustrate our process and initial experience of developing a multidisciplinary team for rapid deployment of ED ECMO as a template for institutions interested in building their own ED ECMO programs.
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Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT; Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT.
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Michael P Mallin
- Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Brigham R Smith
- Division of Cardiovascular Medicine, Interventional Cardiology Section, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Scott T Youngquist
- Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Antigoni Koliopoulou
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Frederick Welt
- Division of Cardiovascular Medicine, Interventional Cardiology Section, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Kathleen Diane Stoddard
- Cardiovascular Intensive Care Unit, Staff Nurse Operating Room, University of Utah, Salt Lake City, UT
| | - Ram Nirula
- Division of General Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Richard Barton
- Division of General Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - James Franklin Fair
- Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - James C Fang
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Stephen McKellar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
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