 Hello, everybody. Today, I'm going to be talking to you about rescue TE examination and again, this is going to be a fairly short presentation. What I do recommend you do is go to PT Master's. Actually, I think three to four part presentation on rescue examination, which I think complements this very well. Most of the references for this actually are from up to date on examination value or PT examination value. So let's get started. I have no disclosures. So we'll do this case based. So you're called originally to the operating room by your colleague. A 56 year old man is undergoing an emergency laparotomy for a liver ulceration following a motor vehicle collision. The patient's blood pressure has acutely dropped to 65 on 45, heart rates 125, and the SPO2 is now 85%. So you wander all over and you walk into the room and everybody's in quite a panic and you insert the TE probe with no difficulties. You have one minute to determine what's going on. What are the three most valuable views during the rescue TE exam? So here's the answer. So again, this is from the original guidelines shown the 20 images, but now it's been expanded further in the most recent guidelines. But probably the three most valuable views if you're in a hurry would be view number A, which was the metasophageal fortune review. The other views would be the view number, I'm trying to find it here, view number I, which is the metasophageal AB long axis view. And lastly, the view number D, which would be the trans-gastric mid short axis view. So if you had to put bang on your buck of what views you needed to do immediately, those are the three that you should do. The only other exception would be if there was a high clinical suspicion of a dissection, then the order views might be more worth it. When you're doing a rescue TE, you're really trying to find out what's going on very, very quickly and make a diagnosis to hopefully alter therapy. So doing a systematic approach at this point at the beginning during a crisis of little value. Once a problem is determined, then you can go back and look at the other views and do a complete 2D and Doppler examination of the heart. With those three views, meaning the metasophageal 4 chamber, the metasophageal AB long axis view, and the trans-gastric mid short axis view, you can see many things. You can see fluid around the heart or compression of the right atrium or the spectacles. You can see if there's mitral regurgitation, which be indicative of ischemia or rupture. You can also see contractility in ischemia. And again, allows you to see most of the major, actually to rephrase, allows you to see all the territories, the corner territories. And lastly, and probably more importantly, you can look at the chamber size, particularly the internal chamber size, looking for evidence of hypovolemia. So in that previous case, you're called urgent linked. What is the differential diagnosis for what's going on, hypotension, tachycardia, and low SAS? Well, this is a basic anesthesia answer, but it can be a number of things. That could be hypovolemic shock, distributive shock, cardiogenic shock, or obstructive shock. And we're going to go through these step by step. We're not going to go through neurogenic shock at this point. So let's start with the first. What are the TEE findings of hypovolemic shock? So here's a picture of hypovolemia. On the left side, you see normal lenia, and you see the end diastolic volume persists. There's no kissing of the populars. On the right hand side, with hypolemic shock, you see kissing of the populars. And also, your end diastolic volume is less. So some of the signs or TEE signs would be an end diastolic LV of liberation or kissing walls. You could get a rightward deviation of the interlateral septum. You could have a smallest IVC or do a SNF test. And you get regional wall motion abnormalities. This is for your entrance to here. You could also look at Dr. Vegas' excellent Echo textbook. These are the normal ranges for LV dimensions, volumes, and also ejection function. Now let's go to distributive shock. What are the TEE findings of distributive shock? So distributive shock is most likely sepsis. So that's the best way to think of distributive shock. And let's look at this. So again, here's a picture. I'm sorry about that. It's a slide. It's not looking very well. But as you can see here, it's very hyper dynamic, extremely hyper dynamic. And you get a very small LV cavity at end systole with normal end diastolic volumes. Again, very small LV cavity at end systole and very normal end diastolic volume stored dastole. A very important equation of it I'll calculate. And you can calculate this through Echo is your SPR. By taking your math minus your CVP, which you obtained from your central line, you can get your cardiac output through Echo through doing the continuity equation. And you can multiply that by a factor 80 that will give you your SPR. Normal SPR is between 1200 and 1600, respectively. So what are the TEE findings for cardiogenic shock? So this is a little bit of a trick question, but it actually depends on what is going on. If it's LV failure, if it's RV failure, if it's monocardial ischemia, or it's aortic dissection or injury. So this is your picture of LV failure. And as you can see here, you have an extremely dilated left frontal. And it's basically the excursion is very limited and there's basically no thickening. The EF I would describe here is probably less than 10%. So this guy or lady is an extremist. Again, there's a lot of fancy ways to quantify LV failure. But again, this is rescue TEE. Are you really going to spend time and do a 3V jelly bean? Or are you going to do M mode and quantify it? Or are you going to look at changes in your endiastolic volume and your end systolic volumes, such as your fractional area change? No, you need to do this quickly. You need to use the eyeball test. Who cares if it's 25% or 20%? You need to determine whether it's a good heart or a bad heart. If you want to quantify it later to follow changes with your management, then go ahead. But in a rescue TEE, you just need to make gross determinations of function and determine whether that is the issue. These are some of the measurements that you can do in regards to evaluating LV failure. But again, eyeball, eyeball, eyeball. And if you got really fancy, you can just strain again. But again, eyeball. This next picture is RV failure. And as you can see here, the RV is not contracting very well. There are many ways to determine RV failure, but you can probably guess what I want to say. In a rescue TEE, use your eyes to not do anything fancy. Is the RV working? Is the RV not working? Or you can, again, proceed to do something more complex. Measures of RV failure are the following. Probably the most common one would be Tapsi. So Tapsi, which is excursion of the microvolve, less than 60 millimeters, is indicative of RV dysfunction. Again, you can do some other fancy modalities. But again, this is rescue TEE. And the answer always is eyeball test. Does the patient pass the eyeball test? Is the RV or the heart working? Yes or no? Is there a volume both side of the heart? Yes or no? Is there appropriate volume inside the heart? Yes or no? Eyeballs, eyeballs, eyeballs. Another cause of heart failure or dysfunction would be myocardioschemia. There are 17 segments of the heart. And basically for each segment, you want to look at endocardial motion and thickening. These numbers you will have to be familiar with for the examination. That's TJ. And a patient with a aortic dissection, you can get dysfunction for numerous reasons. One would be the dissection flap protruding through the aortic valve, all causing aortic refrigeration. Two, you can have problems with the flap dissected into the corners, particularly the right and left. And two, three, you can have, if it's extends, you can get tapping out and collection of fluid around the heart. One thing that's very important to determine is whether, what is the true luminal fulsom? I can't stress how important that is. It's not important in making the diagnosis of dissection, but it's important when you are now doing surgical intervention. Many times you need to insert cannulas in the groin, or a cannula in the axillary, and you need to ensure that it's going into the true lumen and not the fulsom. These are some of the signs to help you determine that. The difference between the true lumen and the false lumen. What I typically look for is, usually the false lumen is larger than the true lumen. And you actually look for color flow. And you can sometimes follow the curvature of the flap. And lastly, the pulsatility. And I discussed with this to you already, but AR dissections are complicated by infusions, all the dysfunction because of coronary disruption, and also you can get AR insufficiency of over 60% of the time, if it's an atraumatic dissection. Traumatic dissections, such as MVCs, typically occur closer to the takeoff of the subclavian. Or the islas. The last type of shock would be obstructive shock. And what are the T.E. findings of obstructive shock? Again, similar to my previous question, but what are the T.E. findings of cardiogenic shock? It depends. It depends whether it's a cardiac tapenade, whether it's a pulmonary embolus, or a pneumolar hemothorax. This is an example of a tapenade. As you can see here, there's a large collection that is outside the right side of the heart, particularly the right atrium, and you see some flapping of the free wall of the right atrium. Again, in the emergency echo or rescue echo, use your eyes. You don't need to do anything more fancy. Tapenade is a diagnosis, is a clinical diagnosis, but echo helps re-confirm or confirm that clinical diagnosis. If you have an unstable patient and you have a significant fluid around the heart, it's tapenade until proven otherwise. Some signs of cardiac tapenade are the following. They include clasps of the intercardiac chambers, greater than one-third systole of the right atrium. You can also have RV diastolic clasps. You get IVC dilatation without respiratory variation. There's intervedicular independence, and you can also look at some diastolic diastology through the mitral valve and the tricuspid valve, looking for changes in variations. Again, extremely hard to diagnose this, unless it's very proximal. This is a very proximal pulmonary embolus in the right PA. You can see proximal disease occasionally, but typically you have to look for more indirect causes or signs of PA. That includes RV dysfunction, the macaunal sign, which is a hypokinetic RV free wall sparing the apex, TR, moderate to severe, and as the AS I wrote goes, for bows to the left side, in about 98% of the time. The last would be hemo or pneumothorax. Again, this is an example. For the left side, just look at the descending aorta, and if you see fluids beneath it, on the left you see the lung. That's a pleural fusion. On the right side, you rotate it from your liver and lung, and you look for fluids. We're going to end this presentation with one more last question. What is the efficacy of rescue tea? It doesn't work. You probably see a running or reoccurring theme, but it depends. The most recent evidence, changed management, and 60% of the cases. In another study, it changed management in most cases, but it does help, and even if it doesn't change management, it came up with the working diagnosis, 80% of the time. The more sad part is that it's highly correlated with the autopsy. That's the end of my presentation. Again, as I promised, it's a pretty short presentation. If you have any questions, you can email me or pull me aside in the hallway, but I do highly recommend you go to PT Masters and watch the three or four presentations on rescue, they're extremely well done. Thank you very much. This ends the presentation.