a b s t r a c t

Dyspnea is a common symptom among emergency department (ED) patients. The differential diagnosis of dyspnea in ED patients is broad, and pulmonary embolism (PE) is a crucial consideration among these. Recognition of right ventricular dysfunction is critical in patients with PE. Here, we present a 76-year- old male patient with the complaint of dyspnea. Focused cardiac ultrasonography performed by the emergency physician revealed enlarged RV, hypokinetic lateral wall and hyperkinetic apex of RV (McConnell’s sign). We have screened the deep Venous system of the patient with the Linear probe for possible deep venous thrombosis and showed that the right dilated uncompressible popliteal vein had a thrombus formation. Computed tomography angiography of the thorax revealed filling defects in both main pulmonary arteries. Our case shows that bedside ultrasonography is a valuable tool for detecting PE and decision making in PE patients.

(C) 2013

The differential diagnosis of dyspnea in emergency department (ED) patients is broad, and pulmonary embolism (PE) is a crucial consideration among these. The recognition of right ventricular (RV) dysfunction is critical because it may be the most important determinant of mortality in patients with PE and shock and thus may influence a clinician’s acute management and Disposition decisions [1]. Here, we present the case of a dyspneic patient with the presence of McConnell’s sign, which has been regarded as a highly specific echo finding in acute PE and represents the RV dysfunction.

A 76-year-old male patient was admitted to the ED with acute onset of dyspnea. He was in shock with hypotension (75/43 mm Hg), tachycardia (127 per minute), tachypnea (26 per minute), and hypoxia (78% on Pulse oximeter). On physical examination, there were cold extremities, delayed capillary refilling time, and bilateral decreased breath sounds with rhoncus. A 12-lead electrocardiogram showed normal sinus rhythm with S1Q3T3 pattern (Fig. 1); arterial blood gas analysis revealed a hypoxic and hypocarbic profile together with an increased alveolar arterial oxygen gradient, which was 62 mm Hg (corrected expected gradient for patient’s age was 22 mm Hg). His laboratory results

? There are no conflicts of interest (including financial and other relationships).

* Corresponding author.

E-mail addresses: [email protected] (E.E. Unluer), [email protected] (G.O. Senturk), [email protected] (A. Karagoz), [email protected] (S. Bayata).

were normal expect for the increased blood leukocyte count and serum troponin I concentration (normal values b 0.04 ng/mL). Focused cardiac ultrasonography (FOCUS) performed by the emergency physician using a Mindray M7 model ultrasound machine with a 3.6 mHz microconvex transducer (M7; Mindray Bio-medical Electronics CO, Shenzen, China) and views of the Apical 4-chamber view at the apex of the heart revealed enlarged RV, which was greater than the Left ventricle , hypokinetic lateral wall, and hyperkinetic apex of RV (Fig. 2 and video 1). Measured pulmonary artery systolic pressure was 50 mm Hg, and severe tricuspid regurgitation was present on Color Doppler examination (video 2). We screened the deep venous system of the patient with the linear probe for possible deep venous thrombosis and showed the right dilated uncompressible popliteal vein with thrombus formation (video 3). The patient underwent computed tomography angiography of the thorax with a high suspicion of pulmonary emboli and revealed filling defects on both main pulmonary arteries (Fig. 3). The patient received alteplase treatment with a dose of 100 mg as a continuous infusion over 2 hours in the ED. Pulmonary artery systolic pressure was measured 23 mm Hg 24 hours later thrombolytic therapy. The patient was discharged from the cardiology service after 1 week.

Focused cardiac ultrasonography is a highly valuable and

readily learned tool that has expanded rapidly since its introduc- tion. Nowadays, FOCUS has lent itself to the evaluation and management of critically ill patients through the incorporation of

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Fig. 1. Electrocardiogram of the patient shows S1Q3T3 patern.

multiple ultrasound examinations within a single patient encoun- ter. Pulmonary embolism is one of the crucial considerations in the differential diagnosis of acute dyspnea and hypotension. Multiple prospective studies reveal a low sensitivity (41%-70%) of FOCUS for specifically identifying PE [2,3]. With such limited sensitivity, FOCUS is not the appropriate Diagnostic modality for PE, but it is very sensitive for the diagnosis of RV dysfunction in patients with suspected PE. Current recommendations are for the administration of thrombolytic therapy in patients with massive PE (hemodynamic instability or pulseless electrical activity arrest); administration of thrombolytics in patients with submissive PE (hemodynamically stable with RV dysfunction) has failed to show any improvement in outcomes [4]. The physiologic changes in PE are reflected by a number of sonographic features in patients with RV strain. The normal ratio of RV:LV diameter is less than 0.6. As

the RV dilates, this ratio increases. Should the RV grow larger than LV, this implies severe RV strain [5]. In addition to RV dilatation, the interventricular septum may be flattened or show leftward displacement as a result of volume and/or pressure overload of the RV. In addition, paradoxical septal motion may be visualized. Because of the septal displacement, LV output may be diminished and a cause for hypotension in PE. Beyond this, a characteristic 2-dimensional ultrsasonographic finding of regional RV dysfunction has been described in patients with acute PE. This abnormality is characterized by the presence of normal or hyperdynamic wall motion of the RV apex despite moderate or severe RV free-wall hypokinesis (McConnell’s sign). This sign appears to be quite specific for the diagnosis of acute PE (specificity, 94%) and, thus, may be useful to distinguish between RV dysfunction owing to other cause such as pulmonary

Fig. 2. Cardiac image from apical 4-chamber view of the patient. The white lines show that RV diameter is bigger than LV diameter.

E.E. Unluer et al. / American Journal of Emergency Medicine 31 (2013) 719-721 721

Fig. 3. Computed tomography angiography image of the patient. White arrows show

filling defects in both main pulmonary arteries.

hypertension [6]. As seen in our case, EPs may also use 2-point Compression ultrasound of the lower extremities to evaluate for thrombus. In the hemodynamically unstable patient with hypoxia and RV dysfunction, identification of lower extremity venous thrombosis can serve as further evidence of massive PE in the ED

[7,8]. rapid identification and management of unstable patients are essential in ED. As experience with emergency ultrasound in critical illness grows, EPs will be expected to fully understand and exploit the power of FOCUS to meet the evolving standards of care in emergency medicine.

Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2012.12.007.

References

1. Cannon CP, Goldhaber SZ. Cardiovascular risk stratification of pulmonary embolism. Am J Cardiol 1996;78(10):1149-51.
2. Torbicki A, Pruszczyk P. The role of echocardiography in suspected and established PE. Semin Vasc Med 2001;1(2):165-74.
3. Miniati M, Monti S, Pratali L, et al. Diagnosis of pulmonary embolism: results of a prospective study in unselected patients. Am J Med 2001;110(7):528-35.
4. Worster A, Smith CO, Silver S, et al. Thrombolytic therapy for submassive pulmonary embolism. Ann Emerg Med 2007;50(1):78-84.
5. Mansencal N, Joseph T, Vieillard -Baron A, et al. Comparison of different echocardiographic indices secondary to right ventricular obstruction in acute pulmonary embolism. Am J Cardiol 2003;92(1):116-9.
6. Aguilar D, Bulwer BE. Echocardiography in pulmonary embolism and secondary pulmonary hipertension. In: Solomon SD, Bulwer BE, Libby P, editors. Essential echocardiography. Totowa: NJ; 2007. p. 333-47.
7. Burnside PR, Brown MD, Kline JA. Systematic review of emergency physician- performed ultrasonography for lower-extremity deep vein thrombosis. Acad Emerg Med 2008;15(6):493-8.
8. Crisp JG, Lovato LM, Jang TB. Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect venous thrombosis in the emergency department. Ann Emerg Med 2010;56(6):601-10.