Transesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department

doi:10.1016/j.jemermed.2020.05.003

The Journal of Emergency Medicine

Volume 59, Issue 3, September 2020, Pages 418-423

https://doi.org/10.1016/j.jemermed.2020.05.003 Get rights and content

Abstract

Background

Although surface sonography has become an essential diagnostic tool in the evaluation of trauma patients, important limitations of this modality include the evaluation of retroperitoneal hemorrhage and mediastinal pathology, such as blunt traumatic aortic injuries (BTAI). As in other emergency applications where surface sonography can't provide the information needed, focused transesophageal echocardiography (TEE) may represent a valuable diagnostic tool in the evaluation of hemodynamically unstable trauma patients with suspected thoracic pathology such as BTAI.

Case Series

We present a series of five cases that illustrate the diagnostic value of emergency physician-performed resuscitative TEE in the diagnosis of BTAI in patients presenting with blunt thoracic trauma.

Why Should an Emergency Physician Be Aware of This?

As the use of point-of-care TEE during resuscitation continues to expand in emergency medicine, the evaluation of patients with BTAI represents a novel application where this emerging modality can allow early diagnosis of these injuries in hemodynamically unstable patients.

Introduction

Despite their low incidence of < 1%, blunt traumatic aortic injuries (BTAI) represent a significant mechanism of death in blunt trauma patients (1,2). With over 20% of patients with BTAI death between the scene and triage, identification of these injuries is critical during the initial trauma evaluation of those patients that present to the hospital, to allow early endovascular repair as recommended by latest practice guidelines (2, 3, 4). Although surface sonography (e.g., focused assessment sonography for trauma [FAST] examination) is an essential diagnostic tool during the initial evaluation of blunt trauma patients, this modality is limited in its ability to identify BTAI. In this report we present a series of five cases that illustrate the diagnostic value of emergency physician-performed resuscitative transesophageal echocardiography (TEE) in the diagnosis of BTAI in patients presenting with blunt thoracic trauma.

Section snippets

Case 1

An 88-year-old woman presented to the emergency department (ED) after a motor vehicle crash (MVC) involving a sudden deceleration mechanism. Upon arrival, she was pale, Glasgow Coma Scale score was 5 (E2V2M1), blood pressure (BP) was 74/32 mm Hg, heart rate (HR) 126 beats/min, respiratory rate 36 breaths/min, and oxygen saturation (SpO₂) was 92% on room air. All peripheral pulses were palpable and equal. Extended FAST (eFAST) revealed a left hemothorax and minimal pericardial effusion with clot

Discussion

This report represents the first case series describing the use of focused TEE by EPs at the point of care during the evaluation of patients with suspected BTAI. Since its first description 30 years ago, the use of point-of-care ultrasound such as the eFAST examination has been established as an integral part of the initial resuscitation of patients with blunt traumatic injuries and is recommended as an adjunct diagnostic tool by current Advanced Trauma Life Support algorithms (4,5). Although

Why Should an Emergency Physician Be Aware of This?

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Cited by (10)

Resuscitative transesophageal echocardiography in emergency departments in the United States and Canada: A cross-sectional survey
2024, American Journal of Emergency Medicine
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.
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.
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%).
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.
Resuscitative transesophageal echocardiography during the acute resuscitation of trauma: A retrospective observational study
2024, Journal of Critical Care
Resuscitative transesophageal echocardiography (TEE) is an emerging POCUS modality that can be used to guide trauma resuscitation.
Trauma patients who underwent TEE within 24 h of admission from 2013 to 2022 were prospectively identified. We retrospectively analyzed resuscitative TEE reports and patient charts in duplicate.
29 providers performed TEE for 54 acute trauma patients. 28 (52%) died in hospital; 33 (61%) required operative intervention (<24 h). Median injury severity score was 29 [IQR 22–43]. The most common indications for TEE were hemodynamic instability (34, 63%), inadequate windows for transthoracic echocardiography (14, 26%) and cardiac arrest (11, 20%). There were no identified complications. A new diagnosis was made in 31 (57%) cases: most commonly right ventricular dysfunction (10, 19%), pericardial effusion (9, 17%), and hypovolemia (6, 11%). TEE ruled out major cardiac injury in 83% of cases. TEE changed resuscitative strategy, in 17 (32%) patients, diagnostic imaging approach in 6 (11%) patients, procedural or operative approach in 5 (9%) patients and disposition from the trauma bay in 4 (7%) patients.
Resuscitative TEE during acute trauma care has an additional diagnostic yield to existing diagnostic pathways and may impact definitive management for some patients in the trauma bay.
Assessment of emergency department staff awareness, access and utilisation of advance care directives and goals of care: A cross-sectional survey
2022, Australasian Emergency Care
Citation Excerpt :
Ease of access to ACD documentation was reported to be low and access is one of the major obstacles in administering ACDs even in an era of electronic medical records [18]. While general availability of ACD records for patients who are supposed to have this document is poor [13,19–21], the few available ones may also be difficult to implement due to either being out of date, lack of clarity of the directive, or lack of the essential components required to guide clinical decision making [6,19,20]. Some studies have found a significant proportion of ACP documentation that could not be classified as an ACD [22], and hence are not necessarily relevant for supporting clinical decision making.
Emergency department staff awareness, access and implementation of advance care directives and goals of care documents and the related patient consent processes are important but not well understood.
A cross-sectional survey using purposive sampling was undertaken at a tertiary hospital’s Emergency Department from 15th March to 26th April 2021. Participants were recruited through online platforms. Pre-validated questionnaires were distributed by email or as QR codes on bulletin boards. Data collected included staff: demographics, knowledge, access and implementation of advance care directives and goals of care documentation.
One hundred thirty-four (28%) of 476 targeted participants responded with nursing forming largest group. Results showed that previous attendance of advance care planning education was low at 20%. Familiarity with advance care directive documentations was only 19% while with goals of care document was average. 61 (48%) respondents reported ease of accessing electronic documents and 21 (19%) reported feeling very comfortable discussing and setting goals of care with patients (p = <0.01).
Staff awareness of advance care directive was poor, while awareness of goals of care was average. There was no association between advance care directives awareness and staff age group, gender, length of: - professional practice, practice at the study site.
Transesophageal echocardiography (TEE)-guided transvenous pacing (TVP) in emergency department
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2023, Acute Care Surgery and Trauma: Evidence-Based Practice: Third Edition
Blunt Thoracic Aortic Injury
2023, Journal of Clinical Medicine

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Ultrasound in Emergency MedicineTransesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department

Abstract

Background

Case Series

Why Should an Emergency Physician Be Aware of This?

Introduction

Section snippets

Case 1

Discussion

Why Should an Emergency Physician Be Aware of This?

Blunt thoracic aortic injury: current therapies, outcomes, and challenges

Ann Vasc Dis

Functional and survival outcomes in traumatic blunt thoracic aortic injuries: an analysis of the National Trauma Databank

J Vasc Surg

The mechanisms of traumatic rupture of the thoracic aorta

Br J Surg

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma

J Trauma Nurs

Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay

J Trauma Acute Care Surg

Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department

Resuscitation

Resuscitative cardiopulmonary ultrasound and transesophageal echocardiography in the emergency department

Emerg Med Clin North Am

Ultrasound in Emergency Medicine
Transesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department