Transesophageal Echocardiography (TEE) for Cardiopulmonary Resuscitation

Mary McLean, MD
Published Nov. 02, 2020

Probetrotters | Medical Education

Hi Team! This Ultrasound Teaching Post is about something I’ve never seen performed in-person and have been wanting to look into: Transesophageal Echocardiography (TEE) for Cardiopulmonary Resuscitation.

TEE is increasingly used in emergency departments to guide cardiopulmonary resuscitation, as an alternative to the more common Trans Thoracic Echo (TTE). TEE provides a visual stimulus during pulse checks, allowing the resuscitation team to check the effectiveness of ongoing chest compressions, and can provide additional diagnostic information (see below). It has been shown by Andersen et al, found that TEE used to visualize chest compressions directly over the left ventricle (LV)versus traditional placement and compression of the aortic root improve hemodynamics and increased Return of Spontaneous Circulation (ROSC) rates.1

Additional resources: There is a great 8-minute intro to the procedure here from the Resuscitative TEE Project,2 and a 19 minute podcast here from EMCrit.3 Check them out!

Advantages and Disadvantages of TEE use in the ED for CPR:

It sounds like TEE may be better management than TTE for a) certain patients, b) certain clinical scenarios, and c) certain physicians/teams/hospitals.

  1. Certain patients. What patient is potentially the right patient for TEE? Who should be excluded?

They need to be in cardiac arrest, sedated, intubated or with a tracheostomy tube. There should be a reason why TEE is preferable to TTE for acquisition of hemodynamic information, e.g. unable to get adequate TTE windows 2/2 super-morbid obesity or other reasons. TEE-appropriate patients should not have active upper GI Bleed (UGIB); history of esophagectomy, esophageal varices or perforation, or tracheoesophagal fistula.

2. Certain clinical situations. What is the appropriate scenario for TEE over TTE during resuscitation?

TTE should be adequate for a patient who coded over an hour ago but never regained pulses and is expected to have a very short resuscitation with only a few rounds of chest compressions under the ACLS algorithm. In this case, TTE is sufficient once they arrive to the ED to assess for a pericardial effusion and confirm or assess cardiac activity. Even in the most advanced ED with TEE trained staff this doesn’t seem like the appropriate clinical scenario. However, in a patient who codes in front of our eyes, and is requiring or already intubated or has obesity, COPD, and/or a prior sternotomy,4 or expected to require prolonged resuscitation per ACLS, TEE is probably a better option.

3. Certain physicians/teams/hospitals. What is the right clinical setting?

It’s generally not advisable to perform a new advanced procedure if the provider, medical team, or hospital is not used to it, including TEE.

So how does an emergency physician become qualified to perform TEE for cardiopulmonary resuscitation?

Physicians should complete training and meet competency standards for basic TTE, and additionally should complete4:

  1. 4 hours of TEE didactic

  2. 10 proctored TEE examinations on either high-fidelity sim models or live patients

  3. A standardized assessment by a credentialed TEE provider.

TEE Protocols

That brings us to protocols for the actual procedure. The Resuscitative TEE Project® has a website with tons of information, including algorithms like the one below.

Image courtesy of the Resuscitative TEE Project.4

TEE Sonographic Anatomy:

There are actually 12 different possible TEE views for the more advanced TEE sonographer, but only four of these are essential for TEE for cardiopulmonary resuscitation. These four are mentioned above in the algorithm and are depicted in the table below along with their TTE equivalents.

4 essential TEE views: (1) mid-esophageal 4 chamber, (2) mid-esophageal long axis, (3) transgastric short axis, and (4) mid-esophageal bicaval:

These four views are more easily seen in the top four images from the following series (labeled ME 4C, ME LAX, TG SAX PAP, and ME Bicaval):

In Conclusion:

TEE for cardiopulmonary resuscitation might be something that becomes mainstream over the next decade but is still not ubiquitous in all ED’s due to training and cost. I hope this helps demystify it a little bit for those of us who have not seen or done it in the ED!

If you want more info, ACEP released a clear and concise policy statement in April 2017 entitled Guidelines for the Use of Transesophageal Echocardiography (TEE) in the ED for Cardiac Arrest.7

  1. Andersen et al. “Left ventricular compressions improve return of spontaneous circulation and hemodynamics in a swine model of traumatic cardiopulmonary arrest.” J Trauma Acute Care Surg. 2018 Aug;85(2):303-310. doi: 10.1097/TA.0000000000001901

  2. Teran F, Zeidan A. “Brief Intro to Resuscitative Transesophageal Echocardiography (TEE).” 2018.

  3. Weingart S, Teran F. “EMCrit Podcast 208 – You are Doing CPR All Wrong” EMCrit. 2017.

  4. Andrus P, Teran F. Protocols — Resuscitative TEE Project. Resuscitative TEE Project. Published 2020. Accessed October 24, 2020.

  5. Moore G. On the Proper Care of a Transesophageal (TEE) Probe. Published 2014. Accessed October 24, 2020.

  6. Fair J 3rd, Mallin MP, Adler A, et al. Transesophageal Echocardiography During Cardiopulmonary Resuscitation Is Associated With Shorter Compression Pauses Compared With Transthoracic Echocardiography. Ann Emerg Med. 2019;73(6):610-616. doi:10.1016/j.annemergmed.2019.01.018

  7. Guidelines for the Use of Transesophageal Echocardiography (TEE) in the ED for Cardiac Arrest. Ann Emerg Med. 2017;70(3):442-445. doi:10.1016/j.annemergmed.2017.06.033