In the fast-paced environment of emergency medicine, rapid decision-making and precise interventions are paramount. Point-of-care ultrasound (POCUS) has revolutionized the way clinicians evaluate critically ill patients, offering real-time insights into cardiac function, volume status, and pathology. However, traditional transthoracic echocardiography (TTE) has its limitations, particularly in patients with poor acoustic windows, obesity, or ongoing chest compressions during resuscitation. Enter resuscitative transesophageal echocardiography (rTEE)—a powerful imaging modality that is rapidly gaining traction in the emergency department (ED) and intensive care unit (ICU).
A recent multicenter study published in Annals of Emergency Medicine sheds light on the impact of the focused application of TEE in critically ill patients. The study, which involved 28 hospitals and over 1,000 focused TEE studies, demonstrated the safety, feasibility, and clinical influence of focused TEE across a range of emergency scenarios, including cardiac arrest resuscitation, undifferentiated shock, hemodynamic monitoring, and procedural guidance.
Emerging Role of focused TEE in Emergency Resuscitation
One of the most compelling findings of the study was the profound impact of focused TEE on clinical decision-making. The data showed that TEE altered management in:
- 85% of patients with undifferentiated shock
- 71% of patients with in-hospital cardiac arrest
- 62% of patients with out-of-hospital cardiac arrest (OHCA)
These numbers highlight the critical role TEE can play in guiding resuscitation efforts and tailoring interventions to a patient's specific hemodynamic status.
For patients in cardiac arrest, TEE provides unparalleled visualization of cardiac function without the interruptions required for transthoracic imaging. It allows for the detection of reversible causes of cardiac arrest, such as tamponade, right ventricular strain from pulmonary embolism, or severe hypovolemia. Additionally, TEE can help guide chest compressions by confirming whether the area of maximal compression is effectively targeting the left ventricle—an essential component for optimizing perfusion during CPR.
Safety and Feasibility of TEE in the ED
Despite its invasive nature, the study reaffirmed that focused, point-of-care TEE is a safe procedure when performed by trained emergency physicians. Among the 1,045 TEE studies analyzed, there were no reported cases of esophageal perforation or oropharyngeal injury, and other procedural complications were exceedingly rare.
Probe insertion was successful on the first attempt in 83% of cases, often without the use of laryngoscopy. These findings dispel concerns about the risks associated with TEE and support its integration into emergency and critical care settings.
The Future of Resuscitative TEE in Emergency Medicine
The increasing adoption of resuscitation-focused TEE marks a shift in the standard of care for critically ill patients. While traditional TTE remains a vital tool, the advantages of TEE—including superior image quality, uninterrupted visualization during resuscitation, and enhanced procedural guidance—are becoming too significant to ignore.
The study’s authors emphasize the need for further research to assess TEE’s impact on patient outcomes, particularly in cardiac arrest. Future investigations will focus on standardizing protocols, defining competency benchmarks for emergency physicians, and expanding access to focused TEE training across residency programs.
Advancing TEE Training for Emergency Medicine Providers
With the growing demand for resuscitative TEE expertise, emergency medicine residents and faculty must have access to structured training programs. Achieving resuscitative TEE competency is challenging, typically requiring a step-by-step approach with didactic education, practice on high-fidelity simulators, and proctored sessions with actual patients. This is where SonoSim helps, by providing a comprehensive foundation in rTEE, combining online didactics and procedural knowledge with hands-on practice on real-patient cases using the SonoSimulator®. This prepares learners for high-fidelity Sim Center practice, enabling emergency and critical care practitioners to develop rTEE skills anytime, anywhere—regardless of patient availability.
As resuscitative TEE continues to shape the future of emergency and critical care medicine, equipping providers with the necessary training and experience will be key to maximizing its life-saving potential.