COTW 5/5 62 year old man presents in cardiac arrest under CPR

A recently discharged 63 year old male presents to the ED under CPR. Medics says patient had witnessed arrest outdoors, bystander CPR initiated immediately. This case highlights some subtle findings that TEE can spot in the arrest and post-arrest period.

CPR is continued in the ED. Patient’s airway is established. A TEE is immediately performed and the initial image under CPR shows:

Compressions appear to be adequate and there is good compression of the LV.

On the next pulse check we see:

If you look closely you see that the myocardium is quivering. The patient is in ventricular fibrillation and is immediately defibrillated. This is also seen on the monitor as well.

Patient is defibrillated with return to NSR and ROSC achieved

Here is the post ROSC TEE:

What do we see in the post-ROSC images?The mitral valve is opening well, the squeeze of the LV is somewhat hypokinetic and probably has some impaired relaxation on the 2-chamber view.

However, what should stand out is the right ventricle. That RV free wall is at a stand still. In the setting of cardiac arrest this is probably an inferior MI with likely a RCA occlusion. Other things to consider would be PE or increased R sided pressures, but those are likely to lead to PEA arrest rather than ventricular fibrillation.

TEE is helpful in intra-arrest and post-arrest. Fine Vfib is not always seen on the monitor. TEE is also helpful in assessing adequacy in compressions and evaluating for LVOT obstruction during CPR.