Resuscitative Transesophageal Echocardiography (TEE) and Advanced Transthoracic Echocardiography (TTE): Applications in Emergency Critical Care

Tuesday, May 15, 2018, 1:00 PM – 5:00 PM

This workshop is sold out!

The utility of bedside transthoracic echocardiography (TTE) in the diagnosis and management of critically ill patients in the emergency department (ED) and Intensive Care Unit (ICU) has been well studied. In 2010, the American College of Emergency Physicians and the American Society of Echocardiography published a joint consensus statement acknowledging focused bedside TTE as a fundamental tool in the evaluation and management of emergency department patients.

However, due to several technical limitations, acquisition of images may be inadequate in up to 50% of critically ill patients. Regardless of externally limiting factors, transesophageal echocardiography (TEE) reliably obtains high-quality images. Several studies in recent years have demonstrated the feasibility to train emergency physicians and intensivists to use advanced TTE and focused TEE at the point-of-care. In 2017, the American College of Emergency Physicians published a statement supporting the use of TEE in the Emergency Department. Despite growing interest among emergency physicians, we have identified that an important barrier to adoption of this new application is access to hands-on training (i.e. patients or high fidelity simulators).

Through the organization of this half-day workshop, we intent to provide emergency physicians, with a unique opportunity to gain basic training in advanced TTE applications and resuscitative TEE. 

General objective: To conduct a half-day workshop aimed at teaching advanced transthoracic echocardiography and focused transesophageal echocardiography to emergency physicians with basic bedside echocardiography skills.

Format: The proposed format consists of asynchronous learning (pre-workshop) and one live didactic session (the workshop). Selected material for self-study will be provided in advance of the workshop. During the half-day workshop, participants will receive didactics on TEE and selected topics on advanced TTE as well as hands-on training on high fidelity simulators.

Specific goals: Through the review of pre-workshop resources and the didactics held during the half-day workshop, we aim to provide participants with the following skills:

Advanced applications of TTE:

  • Motor and cognitive skills to acquire and interpret:
  • Estimation of stroke volume and cardiac output using Doppler
  • Assessment of fluid responsiveness using echo
  • Identification of tamponade physiology in pericardial effusion
  • Assessment of right ventricular systolic function 

Resuscitative TEE:

Motor skills:

  • Probe positioning for TTEs and probe insertion for TEEs
  • Image acquisition

Cognitive skills:

  • Understand the physiology and pathophysiology captured with advanced TTE views
  • Understand principles of TEE operation: Transducer controls and understanding of different planes of movement necessary to generate images: anteflexion, retroflexion, rotation.
  • Relevant cardiac anatomy
  • Rationale and evidence for a focused TEE protocol
  • Indications / applications for each view

             Middle esophageal four chamber (ME 4C)
             Transgastric mid short axis (TG Mid SAX)
             Middle esophageal long axis (ME LAX)
             Middle esophageal bicaval (ME Bicaval)

  • Image interpretation:

             Identification of normal anatomy in all four basic views
             Correlation with anatomy in TTE views
             Identification of basic pathological conditions

At the end of the workshop, participants will be able to: perform TTE for estimation of cardiac output, assessment of fluid responsiveness, assessment of tamponade physiology and identification of RV systolic dysfunction. Acquire the four focused TEE views and correctly identify cardiac anatomy and identify basic pathological conditions.

Educational materials:

  1. A set of pre-workshop web-based and interactive materials will be selected and curated by the Faculty, and will be made available for self-study of participants prior to their attendance to the workshop.
  2. Brief (10-15 min) complementary review lectures will be delivered by the faculty throughout the workshop.

Equipment:

  1. Conference room with space to fit at least 30 participants and faculty
  2. Four live models, beds and ultrasounds machines
  3. Four transesophageal simulators

Target audience: Emergency Physicians and Intensivists with knowledge of basic point of care echocardiography.

Faculty: This proposed group of multidisciplinary faculty represents Emergency Medicine, Anesthesiology and Critical Care, have significant clinical experience with this application and are nationally and internationally recognized educators.

Sponsoring: As an emerging application that is highly relevant to both the emergency ultrasound and critical care communities within emergency medicine, this workshop proposal has been developed in collaboration with the leaderships of the Academy of Emergency Ultrasound (AEUS) and Critical Care Medicine Interest Group. 

Lead organizer faculty: Felipe Teran, MD

AEUS: Megan Leo, MD (President)

Critical Care Medicine Interest Group: Ani Aydin MD (Chair)

Time Advanced TTE Resuscitative TEE
1:00-1:30pm Introduction & evidence review Introduction & evidence review
1:30-2:00pm Principles of Doppler TEE operation & controls
2:00-2:30pm SV and CO using Doppler Cardiac anatomy to understand TEE
2:30-3:00pm Fluid responsiveness using echo Pearls and Pitfalls
3:00-3:30pm Identification of tamponade physiology Simulation: Developing views
3:30-4:00pm Assessment of right ventricular systolic function Simulation: Normal views resuscitative TEE protocol
4:00-4:30pm Hands-on practice Simulation: Pathology
4:30-5:00pm Hands-on practice Simulation: Putting-all-together

Emergency Medicine

Felipe Teran, MD 
Clinical Instructor of Emergency Medicine
Division of Emergency Ultrasound and Center for Resuscitation Science
Department of Emergency Medicine
University of Pennsylvania

Bret Nelson, MD, FACEPProfessor of Emergency Medicine
Division of Emergency Ultrasound 
Department of Emergency Medicine
Icahn School of Medicine at Mount Sinai

Nova Panebianco, MD, MPH
Assistant Professor of Emergency Medicine 
Division of Emergency Ultrasound
Department of Emergency Medicine 
University of Pennsylvania

Patrick Ockerse, MD
Division of Emergency Medicine
University of Utah
Assistant Professor of Surgery

Kenton Anderson, MD
Clinical Assistant Professor
Department of Emergency Medicine
Stanford University

Ross Kessler, MD
Assistant Professor of Emergency Medicine 
Division of Clinical UltrasoundUniversity of Michigan

Rachel Liu, MD
Assistant Professor of Emergency Medicine 
Department of Emergency Medicine
Yale University

Clark Owyang, MD
Emergency Medicine Resident
Division of Emergency Ultrasound
Department of Emergency Medicine Icahn School of Medicine at Mount Sinai

Mark Andreae, MDEmergency Medicine Resident Division of Emergency Ultrasound
Department of Emergency Medicine 
Icahn School of Medicine at Mount Sinai

Critical Care Medicine

Ani Aydin, MDAssistant Professor of Emergency Medicine
Department of Emergency Medicine
Yale University

Ashika Jain, MDAssistant Professor of Emergency Medicine
Department of Emergency MedicineSuny Downstate Medical Center  

Resuscitative - Website