There is a growing interest in using point‐of‐care transesophageal echocardiography (TEE) during cardiac arrest. TEE is effective at identifying the etiology of sudden cardiovascular collapse and guiding management during the resuscitation. In selected patients with refractory cardiac arrest, extracorporeal cardiopulmonary resuscitation (ECPR) can be considered. ECPR requires percutaneous vascular access for the implantation of veno‐arterial extracorporeal membrane oxygenation circuit. We present a case of prolonged cardiac arrest in which rescue TEE was pivotal in narrowing the differential diagnosis, monitoring of mechanical chest compression performance, and guiding cannulation for ECPR.

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Methods: Three emergency physicians including an attending emergency physician with greater than 100 ultrasound-guided blocks experience, an emergency physician ultrasound fellow, and a resident emergency physician were prospectively evaluated. The resident and fellow received a standardized training module developed by the attending emergency physician. A randomized cohort of ED patients was generated using bed numbers to prevent a biased selection of patients. Time to set up and identification of external anatomical landmarks was recorded. Times to acquisition of an optimal ultrasound image and accuracy of identification of six anatomical structures (internal carotid, sternocleidomastoid, anterior scalene muscle, middle scalene muscle, and the C5, C6 and C7 roots of the brachial plexus) as well the ideal in-plane needling tract were recorded. Subjects were asked to rate their confidence in structure identification for each scan (Table ) Results: Twenty patients were enrolled for a total of 40 ultrasound examinations. Seventy percent were female; the mean body mass index (BMI) was 31, ranging from 15 to 53. The average set-up time was 1 minute and 30 seconds. Ultrasonographic landmarks were successfully identified in all patients by the attending emergency physician. Mean scanning times were 25 seconds and 1 minute, 32 seconds for the attending and resident/fellow respectively. There were 2 instances where the resident or fellow failed to correctly identify the interscalene brachial plexus; these were both middleaged patients who were severely (BMI>35) or very severely obese (BMI >40) (Figure ).Conclusions: In this randomly selected cohort of ED patients, both attending and resident-level providers were able to quickly and accurately identify the important anatomic and ultrasonographic structures needed to perform an ultrasound-guided interscalene brachial plexus block. Severely obese patients may pose a challenge to providers early in training. More study is needed to better understand how emergency physicians can acquire and maintain competency performing ultrasound-guided regional anesthesia.

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