Detection of Acute Pulmonary Embolism by Bedside Ultrasound in a Patient Presenting in PEA Arrest: A Case Report

Abstract

Optimal management of the critically ill patient in shock requires rapid identification of its etiology. We describe a successful application of an emergency physician performed bedside ultrasound in a patient presenting with shock and subsequent cardiac arrest. Pulmonary embolus was diagnosed using bedside echocardiogram and confirmed with CTA of the thorax. Further validation and real-time implementation of this low-cost modality could facilitate the decision to implement thrombolytics for unstable patients with massive pulmonary embolism who cannot undergo formal radiographic evaluation.

Right Heart Thrombus in Transit Diagnosed With Focused Cardiac Ultrasound in the Emergency Department

“…In this report, the patient notably had an initial equivocal FOCUS assessment for the common echocardiographic findings of PE upon ED arrival, due in some degree to technically challenging cardiac windows. However, the definitive diagnosis of PE by visualization of a RHTh by EP-performed FOCUS, as is described in this case, is a notably rare occurrence [8,[12][13][14][15][16][17][18]. Patients with PE and RHTh have been shown to have a significantly shorter duration of symptoms, which is consistent with our suspicions that our patient's PE presentation was hyperacute and rapidly evolving as thrombi from the RHTh entered the pulmonary circulation [8].…”

“…The coexistence of a RHTh with PE carries an increased mortality risk necessitating aggressive management [8][9][10][11]. Previous reports have described the crucial role of EP-performed FOCUS to establish the diagnosis of RHTh [12][13][14][15][16][17][18]. We report a case in which EPperformed FOCUS facilitated the expeditious diagnosis and management of RHTh in transit associated with submassive PE.…”

The Use of Bedside Ultrasound in the Evaluation of Patients Presenting with Signs and Symptoms of Pulmonary Embolism

“…Rapid diagnosis using ultrasound can lead to earlier preparation of thrombolytic administration especially in the critical ill patients where rapidity is crucial [1]. There are multiple sonographic findings that support the diagnosis of acute pulmonary embolism and can be broken down into two major categories: direct and indirect signs.…”

“…There are multiple sonographic findings that support the diagnosis of acute pulmonary embolism and can be broken down into two major categories: direct and indirect signs. Direct signs included visualization of a free-floating thrombus in the right heart or pulmonary artery [1, 2]. Indirect signs include right ventricular dilation (RV/LV ratio >0.6–1 : 1), flattening or bowing of the intraventricular septum into the left ventricle, right ventricular systolic dysfunction, McConnell's sign, and IVC dilation without inspiratory collapse [2–5].…”

“…Right ventricular thrombus may not be diagnostically useful due to its poor sensitivity; however, it is prognostically valuable and indicates a high mortality rate of 44.7% [7]. Multiple case reports have been published with the utility of transthoracic echo (TTE) in the visualization of massive or saddle pulmonary emboli [1, 8]. Limitation of using transthoracic ultrasound includes visualization of only the proximal main, right, and left pulmonary arteries.…”