Scenario #1-Car vs Tree with Hypotension

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 60 y/o undergoing femoral-tibial orthopedic procedure after ramming into a tree with his car while checking out this website on his phone. History includes previous myocardial infarction with angioplasty. Arterial and central line from unit. Previous S2 murmur with fractured second rib in MVA. Now with  undifferentiated hypotension not responsive to volume or phenylephrine/vasopressin boluses.  

     A. Midesophageal Four Chamber View; Hypovolemia

     B. Transgastric Short Axis View; Hypovolemia               

    C. Transgastric Short Axis View; LV Dysfunction            

D. Midesophageal Long Axis  View; LV Dysfunction  

64 y/o for robotic prostatectomy, previous history includes shortness of breath with moderate exertion with negative stress test two years prior. Central line and arterial line placed due to continued need for volume and vasopressors and ST segment depression. TEE for undifferentiated hypotension and elevated CVP.

   A. Midesophageal Four Chamber View; Hypovolemia

   B. Transgastric Short Axis View; Hypovolemia               

   C. Transgastric Short Axis View; LV Dysfunction            

D. Midesophageal Long Axis  View; LV Dysfunction   

30 y/o s/p bicycle vs bus undergoing exploratory laparotomy and splenectomy. Arterial and central lines from trauma unit, undifferentiated hypotension despite volume resuscitation and norepinephrine infusion. TEE for undifferentiated hypotension and no response to fluid boluses.

               A. Midesophageal Four Chamber View; RV Dysfunction             

                B. Transgastric Short Axis View; Hypovolemia                                

                C. Midesophageal Five Chamber View; LV Dysfunction               

D. Midesophageal Four Chamber View; Pericardial Effusion 

 72 y/o roofer in normal practice of working on a roof in thunderstorm slipped and fell to pavement. GCS 6, fractured second rib unstable hemodynamically and received arterial and central lines in trauma unit. Unresponsive to volume resuscitation and vasopressors, rising lactate on ABG. Now for TEE. 

                                       A. ME Descending Thoracic Aorta SAX/LAX, aortic dissection

                 B. ME Ascending aorta biplane, aortic dissection 

     C. ME Bicaval biplane, cardiac tamponade

D. TG SAX biplane, cardiac tamponade  

 87 y/o for thoracotomy and right upper lobectomy. Systolic ejection murmur, previous MI on history and physical, inactive due to poor physical condition and prior stroke. Now with ST segment depression and requiring increasing doses of vasopressors now norepinephrine infusion at 10 mcg/minute.  

A. ME Descending Thoracic Aorta SAX and LAX, aortic dissection

B. ME AV SAX, moderate aortic stenosis

C. ME Bicaval biplane, cardiac tamponade

D. TG SAX 3D, aortic dissection

 80 y/o with stage 4 cancer now for colon resection. Unresponsive to vasopressors and volume resuscitation, now requiring 10 mcg boluses of epinephrine and trendelenberg position. TEE for undifferentiated hypotension and rising lactate.  

A. Midessophagel four chamber view with LV dysfunction

B. Midesophageal commissural view with pericardial effusion

C. Midesophageal four chamber view with pericardial effusion

D. Midesophageal four chamber view with RV dysfunction/dilation

  54 y/o pedestrian vs. train three days earlier with multiple orthopedic trauma now for hip pinning. After induction experienced hypoxia and hypotension unresponsive to 100% oxygen, ventilator manipulation, vasopressors and fluid. The surgical team would like rescue TEE.

A. Midesophageal commissural view with severe LV failure

B. Transgastric short axis view with severe mitral regurgitation

C. Transgastric basal short axis view with RV failure due to patent foramen ovale

D. Midesophageal four chamber view with RV failure and underfilled LV most likely due to pulmonary embolus

  77 y/o immediately postop from Watchman procedure with continued hypoxemia and hypotension requiring re-intubation and support. Several rule outs due to procedure such that more than rescue TEE may be involved at bedside in busy PACU such that rescue TEE.

A. Midesophageal commissural view with severe mitral regurgitation

B. Transgastric short axis view with severe mitral regurgitation

C. Midesophageal LAA view with significant atrial septal defect

D. Midesophageal four chamber view with severe TR/pulmonary embolus

 22 y/o from SICU with history of meth abuse and sepsis for full mouth extraction. During the course of the procedure the patient’s vasopressor requirements have increased and vasopressin has been added. With the lactate level climbing you have been called for a TEE to see how best to optimize the patient hemodynamically. 

A. Midesophageal commissural view with severe mitral regurgitation

B. Transgastric short axis view with severe mitral regurgitation

C. Deep transgastric long axis view with severe aortic regurgitation

D. Midesophageal four chamber view with severe TR/pulmonary embolus

 30 y/o with history of “passing out” and tachyarrhythmias for lap chole. During the procedure the patient has now had two run of VT lasting 7-10 beats each and continued hypotension despite glycopyrollate, multiple boluses of ephedrine, lidocaine and vasopressin. TEE has been requested due to undifferentiated hypotension.  

A. Midesophageal long axis view with HOCM/septal hypertrophy

B. Transgastric short axis view with severe mitral regurgitation

C. Transgastric basal short axis view with atrial septal defect

D. Midesophageal four chamber view with severe mitral regurgitation