Clot in Transit: Point-of-Care Ultrasound Diagnosis of Acute Pulmonary Embolism

A 64-year-old man, who underwent a stent placement in his left external iliac vein 5 days prior, presented to the Emergency Department complaining of acute-onset shortness of breath. He denied any chest pain or leg swelling. Initial vital signs revealed a blood pressure of 115/70 mm Hg, heart rate of 130 beats/min, respiratory rate of 18 breaths/min, and O2 saturation of 92%, improving to 99–100% with nasal cannula and non-rebreather oxygen at flush rate (>40 L/min). Electrocardiogram revealed sinus tachycardia at 132 beats/min, poor R-wave progression, and ST depressions in V4–V6. A point-of-care cardiac ultrasound scan revealed a dilated right ventricle, septal bowing from the right side into the left side, and a ∼3-cm thrombus in transit visualized in the right atrium and right ventricle (see Figure 1 and Videos 1–4, available online). Shortly thereafter, the patient started to become more lethargic as his respiratory rate increased to 36 breaths/min and his blood pressure trended down to a systolic pressure in the 80s. A repeat ultrasound scan revealed no clot in the right atrium, and worsening McConnell's sign (Figure 2, Videos 5–8, available online). The patient was given tissue plasminogen activator (tPA) 50 mg for a presumed massive pulmonary embolism (PE), with improvement in vitals and mental status prior to being admitted to the cardiac care unit. Figure 2Repeat point-of-care ultrasound scan revealed no visualized thrombus in the right atrium/ventricle, right atrial/ventricular dilatation, and a McConnell's sign (arrow). View Large Image Figure Viewer Download Hi-res image