Ultrasound of the Week #020

Case:

A 48 year old female came to the renal unit for dialysis but had an episode of syncope. She was brought to A&E following that in the early hours of a Saturday. On arrival in the Emergency Department she became unresponsive.  She did not have a palpable pulse so a cardiac arrest call was put out. CPR was started and then she was moved to resus.

During her transfer it was noted that she had bulging neck veins. After maintaining airway and attaching the pads, it was confirmed that she did not have a pulse and her initial rhythm was PEA. 

A bedside echo was done and showed the following images:

Question: What is the likely diagnosis?

Parasternal Short Axis (PSAX)
Apical 4-chamber (A4Ch)

Answer:

Echo shows septal flattening (best visible in the PSAX view), McConnell’s sign and an RV:LV ratio >1. With the clinical picture this was very likely to be due to a PE.

She was thrombolysed with Alteplase 50mg bolus and 50mg over 1 hour according to ESC guidelines3. She achieved ROSC. Her down time was less than 15 minutes. PE was confirmed on CT scan subsequently.

Patient was admitted in ITU and then discharged after 2 days with broken ribs and no neurological deficit. 

The above case highlights use of POCUS in cardiac arrest leading to early diagnosis of cause of cardiac arrest and subsequently leading to good outcome for the patient. During cardiac arrest the specificity of dilated RV is very low for PE as the heart dilates during arrest due to stunning and ischaemia ,however a high pre-test probability and confirmation of DVT can give you enough evidence to thrombolyse the patient. 

References:

  1. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol [published correction appears in Chest. 2013 Aug;144(2):721]. Chest. 2008;134(1):117-125. doi:10.1378/chest.07-2800
  2. Michael Prats, MD. TAPSE to Diagnose Pulmonary Embolism. Ultrasound G.E.L. Podcast Blog. Published on August 28, 2017. Accessed on March 04, 2021. Available at https://www.ultrasoundgel.org/26.
  3. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) | European Respiratory Society (ersjournals.com)

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