Emergency Physician-performed Transesophageal Echocardiography in Simulated Cardiac Arrest
Don V Byars, Jordan Tozer, John M Joyce, Michael J Vitto, Lindsay Taylor, Turan Kayagil, Matt Jones, Matthew Bishop, Barry Knapp, David Evans, Don V Byars, Jordan Tozer, John M Joyce, Michael J Vitto, Lindsay Taylor, Turan Kayagil, Matt Jones, Matthew Bishop, Barry Knapp, David Evans
Abstract
Introduction: Transesophageal echocardiography (TEE) is a well-established method of evaluating cardiac pathology. It has many advantages over transthoracic echocardiography (TTE), including the ability to image the heart during active cardiopulmonary resuscitation. This prospective simulation study aims to evaluate the ability of emergency medicine (EM) residents to learn TEE image acquisition techniques and demonstrate those techniques to identify common pathologic causes of cardiac arrest.
Methods: This was a prospective educational cohort study with 40 EM residents from two participating academic medical centers who underwent an educational model and testing protocol. All participants were tested across six cases, including two normals, pericardial tamponade, acute myocardial infarction (MI), ventricular fibrillation (VF), and asystole presented in random order. Primary endpoints were correct identification of the cardiac pathology, if any, and time to sonographic diagnosis. Calculated endpoints included sensitivity, specificity, and positive and negative predictive values for emergency physician (EP)-performed TEE. We calculated a kappa statistic to determine the degree of inter-rater reliability.
Results: Forty EM residents completed both the educational module and testing protocol. This resulted in a total of 80 normal TEE studies and 160 pathologic TEE studies. Our calculations for the ability to diagnose life-threatening cardiac pathology by EPs in a high-fidelity TEE simulation resulted in a sensitivity of 98%, specificity of 99%, positive likelihood ratio of 78.0, and negative likelihood ratio of 0.025. The average time to diagnose each objective structured clinical examination case was as follows: normal A in 35 seconds, normal B in 31 seconds, asystole in 13 seconds, tamponade in 14 seconds, acute MI in 22 seconds, and VF in 12 seconds. Inter-rater reliability between participants was extremely high, resulting in a kappa coefficient across all cases of 0.95.
Conclusion: EM residents can rapidly perform TEE studies in a simulated cardiac arrest environment with a high degree of precision and accuracy. Performance of TEE studies on human patients in cardiac arrest is the next logical step to determine if our simulation data hold true in clinical practice.
Conflict of interest statement
Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.
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References
- van der Wouw PA, Koster RW, Delemarre BJ, et al. Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation. J Am Coll Cardiol. 1997;30(3):780–3.
- Memtsoudis SG, Rosenberger P, Loffler M, et al. The usefulness of transesophageal echocardiography during intraoperative cardiac arrest in noncardiac surgery. Anesth Analg. 2006;102(6):1653–7.
- Miyake M, Izumi C, Takahashi S. Efficacy of transesophageal echocardiography in patients with cardiac arrest or shock. J Cardiol. 2004;44(5):189–94.
- Peres M, Pitta Mda L, Alcaravela J, et al. Transesophageal echocardiography in an emergency setting. A district general hospital experience. Rev Port Cardiol. 2005;24(7–8):971–9.
- Daniel WG, Erbel R, Kasper W, et al. Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations. Circulation. 1991;83(3):817–21.
- 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;50(2):286–94.
- Blaivas M. Transesophageal echocardiography during cardiopulmonary arrest in the emergency department. Resuscitation. 2008;78(2):135–40.
- Matyal R, Montealegre-Gallegos M, Mitchell JD, et al. Manual skill acquisition during transesophageal echocardiography simulator training of cardiology fellows: a kinematic assessment. J Cardiothorac Vasc Anesth. 2015;29(6):1504–10.
- Arntfield R, Pace J, McLeod S, et al. Focused transesophageal echocardiography for emergency physicians-description and results from simulation training of a structured four-view examination. Crit Ultrasound J. 2015;7(1):27.
- Sharma V, Chamos C, Valencia O, et al. The impact of internet and simulation-based training on transoesophageal echocardiography learning in anaesthetic trainees: a prospective randomised study. Anaesthesia. 2013;68(6):621–7.
- Jelacic S, Bowdle A, Togashi K, et al. The use of TEE simulation in teaching basic echocardiography skills to senior anesthesiology residents. J Cardiothorac Vasc Anesth. 2013;27(4):670–5.
- Sohmer B, Hudson C, Hudson J, et al. Transesophageal echocardiography simulation is an effective tool in teaching psychomotor skills to novice echocardiographers. Can J Anaesth. 2013;61(3):235–41.
- Damp J, Anthony R, Davidson MA, et al. Effects of transesophageal echocardiography simulator training on learning and performance in cardiovascular medicine fellows. J Am Soc of Echocardiogr. 2013;26(12):1450–6.
Source: PubMed