Background: Point-of-care ultrasound (POCUS) allows the clinician to accurately identify various types of shock and target therapeutic interventions accordingly in critically ill patients. In this report, we describe the rapid and opportune utilization of POCUS in diagnosing and treating a patient with a massive pulmonary embolism who required extracorporeal life support (ECLS). Case Presentation: A 45-year-old man presented to the emergency department with dyspnea, cough, and hemoptysis. A computed tomography angiography (CTA) of the chest performed at an urgent care clinic the same day showed near-completely occlusive emboli within the distal main pulmonary arteries bilaterally with suggested right ventricular strain. The comprehensive echocardiogram revealed dilated right ventricle (RV) with severely reduced systolic function. The patient was admitted to the intensive care unit (ICU) and treated with unfractionated heparin. As the patient was preparing for transfer to the medical ward on day 3 of hospitalization, he had an acute episode of near-syncope and soon became pulseless. An ECLS consult was activated for lack of sustained return of spontaneous circulation (ROSC) despite ongoing CPR and administration of tissue plasminogen activator (t-PA), crystalloids, epinephrine, and bicarbonate boluses. A POCUS performed by the intensivist showed organized cardiac activity with a severely dilated RV, flattened intraventricular septum, and underfilled LV in the absence of a detectable pulse, suggestive of pseudo-pulseless electrical activity. He was cannulated under real-time ultrasound guidance for establishing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to provide full cardiac support. His ICU course was complicated by bleeding and persistent RV dysfunction. Utilization of POCUS helped narrow the differential diagnoses for circulatory failure in the ICU course. The patient was weaned off ECMO support after 48 hours and discharged to a rehabilitation facility on hospital day 27 with intact neurologic function. Conclusion: This case describes a near-fatal complication of pulmonary embolism and highlights the importance of POCUS for rapid diagnosis of the etiology of cardiac arrest and timely initiation of ECLS. POCUS can complement the comprehensive echocardiogram and narrow the differential diagnoses during clinical deterioration. Intensivists should be proficient in acquiring, interpreting, and integrating POCUS into their clinical practice.

No abstract

To the Editor We read with interest the study by Mustafa et al 1 describing the experience of venovenous extracorporeal membrane oxygenation (ECMO) for coronavirus disease 2019 (COVID-19)-induced acute respiratory distress syndrome (ARDS), published in JAMA Surgery. This publication is one of the largest case series describing the experience of venovenous ECMO support for COVID-19-induced ARDS from the United States. Initial reports from China suggested a very high mortality (84%-100%) in patients with COVID-19 who received ECMO support. However, recent studies from Europe have estimated the mortality burden in patients with COVID-19 supported with ECMO to be around 30%, 2 which is similar to what is described in studies of patients with ARDS supported with ECMO outside the pandemic. The study by Mustafa et al 1 reported an impressive survival benefit with ECMO support, with only 6 deaths of 40 patients (15% mortality). We are curious to know the authors' opinion on what may have contributed to this improvement when the entry criteria remain similar to those from experienced ECMO centers in France. 2 Driving pressure has been suggested to influence mortality in patients with ARDS, and steroid (dexamethasone) use has been reported to improve mortality in critically ill patients with COVID-19. 3 Would the authors provide details about the reduction in driving pressure after ECMO initiation and steroid administration in their study cohort? The choice of cannulation configuration of dual-stage right atrium-topulmonary artery cannula use for ECMO support is intriguing. The authors state that this technique was chosen because of problems encountered in their first case with femoralinternal jugular cannulation configuration. Would the authors provide details about the right ventricular function of the study patients before ECMO initiation? If most patients had right ventricular dysfunction, is it possible to hypothesize that the dual-lumen cannula technique from the right atrium to pulmonary artery, bypassing the right ventricle, led to favorable outcomes?