Focused transesophageal echocardiography for emergency physicians—description and results from simulation training of a structured four-view examination

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Abstract

Background

Transesophageal echocardiography (TEE) offers several advantages over transthoracic echocardiography (TTE). Despite these advantages, use of TEE by emergency physicians (EPs) remains rare, as no focused TEE protocol for emergency department (ED) use has been defined nor have methods of training been described.

Objective

This study aims to develop a focused TEE examination tailored for the ED and to evaluate TEE skill acquisition and retention by TEE-naïve EPs following a focused 4-h curriculum.

Methods

Academic EPs were invited to participate in a 4-h didactic and simulation-based workshop. The seminar emphasized TEE principles and views obtained from four vantage points. Following the training, participants engaged in an assessment of their abilities to carry out a focused TEE on a high-fidelity simulator. A 6-week follow-up session assessed skill retention.

Results

Fourteen EPs participated in this study. Immediately following the seminar, 14 (100 %; k = 1.0) and 10 (71.4 %, k = 0.65) successfully obtained an acceptable mid-esophageal four-chamber and mid-esophageal long-axis view. Eleven (78.6 %, k = 1.0) participants were able to successfully obtain an acceptable transgastric short-axis view, and 11 (78.6 %, k = 1.0) EPs successfully obtained a bicaval view. Twelve participants engaged in a 6-week retention assessment, which revealed acceptable images and inter-rater agreement as follows: mid-esophageal four-chamber, 12 (100 %; k = 0.92); mid-esophageal long axis, 12 (100 %, k = 0.67); transgastric short-axis, 11 (91.7 %, k = 1.0); and bicaval view, 11 (91.7 %, k = 1.0).

Conclusion

This study has illustrated that EPs can successfully perform this focused TEE protocol after a 4-h workshop with retention of these skills at 6 weeks.

Electronic supplementary material

The online version of this article (doi:10.1186/s13089-015-0027-3) contains supplementary material, which is available to authorized users.

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Most cited references 24

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Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.

Benjamin Goldstein, R Porter, V Noble … (2010)

The use of ultrasound has developed over the last 50 years into an indispensable first-line test for the cardiac evaluation of symptomatic patients. The technologic miniaturization and improvement in transducer technology, as well as the implementation of educational curriculum changes in residency training programs and specialty practice, have facilitated the integration of focused cardiac ultrasound into practice by specialties such as emergency medicine. In the emergency department, focused cardiac ultrasound has become a fundamental tool to expedite the diagnostic evaluation of the patient at the bedside and to initiate emergent treatment and triage decisions by the emergency physician. Copyright © 2010. Published by Mosby, Inc.

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Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations.

Heidi Sutherland, E Grübe, R Engberding … (1991)

During the past few years, transesophageal echocardiography (TEE) has been increasingly used in clinical cardiology; data concerning the practicability and safety of the technique, however, are rare. This report analyzes the experience of 15 European centers performing TEE studies for at least 1 year. At the time of this survey, 10,419 TEE examinations had been attempted or performed in these institutions. These TEE examinations were carried out by 54 physicians, 53.7% of whom had been trained in endoscopic techniques. Within the same time period, 160,431 precordial echocardiographic examinations were performed in the 15 institutions; the ratio between TEE and transthoracic studies averaged 9.03 +/- 6.4% (range of the 15 centers, 1.4-23.6%). Of the 10,419 patients, 9,240 (88.7%) were conscious inpatients or outpatients at the time of the TEE examination; the vast majority of the conscious patients did not receive intravenous sedation before TEE. In 201 cases (1.9%), insertion of the TEE probe was unsuccessfully attempted because of a lack of patient cooperation and/or operator experience (98.5%) or because of anatomical reasons (1.5%). In 90 of 10,218 TEE studies (0.88%) with successful probe insertion, the examination had to be interrupted because of the patient's intolerance of the echoscope (65 cases); because of pulmonary (eight cases), cardiac (eight cases), or bleeding complications (two cases); or for other reasons (seven cases). One of the bleeding complications resulted from a malignant lung tumor with esophageal infiltration and was fatal (mortality rate, 0.0098%). This multicenter survey documents that TEE studies are associated with an acceptable low risk when used by experienced operators under proper safety conditions.

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Determination of left ventricular function by emergency physician echocardiography of hypotensive patients.

G Rose, Tara Moore, James A Arrowood … (2002)

To determine whether emergency physicians (EPs) with goal-directed training can use echocardiography to accurately assess left ventricular function (LVF) in hypotensive emergency department (ED) patients. Prospective, observational study at an urban teaching ED with >100,000 visits/year. Four EP investigators with prior ultrasound experience underwent focused echocardiography training. A convenience sample of 51 adult patients with symptomatic hypotension was enrolled. Exclusion criteria were a history of trauma, chest compressions, or electrocardiogram diagnostic of acute myocardial infarction. A five-view transthoracic echocardiogram was recorded by an EP investigator who estimated ejection fraction (EF) and categorized LVF as normal, depressed, or severely depressed. A blinded cardiologist reviewed all 51 studies for EF, categorization of function, and quality of the study. Twenty randomly selected studies were reviewed by a second cardiologist to determine interobserver variability. Comparison of EP vs. primary cardiologist estimate of EF yielded a Pearson's correlation coefficient R = 0.86. This compared favorably with interobserver correlation between cardiologists (R = 0.84). In categorization of LVF, the weighted agreement between EPs and the primary cardiologist was 84%, with a weighted kappa of 0.61 (p < 0.001). Echocardiographic quality was rated by the primary cardiologist as good in 33%, moderate in 43%, and poor in 22%. The EF was significantly lower in patients with a cardiac cause of hypotension vs. other patients (25 +/- 10% vs. 48 +/- 17%, p < 0.001). Emergency physicians with focused training in echocardiography can accurately determine LVF in hypotensive patients.

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Author and article information

Contributors

Robert Arntfield: robert.arntfield@gmail.com

Journal

Journal ID (nlm-ta): Crit Ultrasound J

Journal ID (iso-abbrev): Crit Ultrasound J

Title: Critical Ultrasound Journal

Publisher: Springer Milan (Milan )

ISSN (Print): 2036-3176

ISSN (Electronic): 2036-7902

Publication date (Electronic): 12 June 2015

Publication date PMC-release: 12 June 2015

Publication date Collection: 2015

Volume: 7

Electronic Location Identifier: 10

Affiliations

Western University, London, ON Canada

Article

Publisher ID: 27

DOI: 10.1186/s13089-015-0027-3

PMC ID: 4485663

PubMed ID: 26123608

SO-VID: c2a1aa56-8745-465c-a2b4-a4c9b1280a3b

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.

History

Date received : 24 March 2015

Date accepted : 28 May 2015

Custom metadata

ScienceOpen disciplines: Radiology & Imaging

Keywords: transesophageal echocardiography,echocardiography,ultrasound,point-of-care ultrasound, education,simulation

Data availability:

ScienceOpen disciplines: Radiology & Imaging

Keywords: transesophageal echocardiography, echocardiography, ultrasound, point-of-care ultrasound, education, simulation

Focused transesophageal echocardiography for emergency physicians—description and results from simulation training of a structured four-view examination

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Abstract

Background

Objective

Methods

Results

Conclusion

Electronic supplementary material

Related collections

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Most cited references 24

Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.

Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations.

Determination of left ventricular function by emergency physician echocardiography of hypotensive patients.

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