Echo in life Support 1

A young adult patient with no significant past medical history presented to the Emergency Department with diffuse abdominal pain and vague chest discomfort. They were a smoker but had no known other medical risk factors. There was no history of trauma. On arrival, the patient was haemodynamically stable, with normal observations. Clinically, the predominant pain appeared to be centred around the epigastrium and abdomen, making an intra-abdominal cause the leading consideration. Prior to getting a CT abdomen-pelvis scan, an abdominal Focused Assessement for Free Fluid (FAFF) was done and showed no free intraperitoneal fluid. 

Prior to CT imaging transfer, within a very short space of time the patient's chest pain intensified and they developed severe difficulty in breathing. An emergency call was put out and during the assessment a focused cardiac ultrasound was carried out.

The cardiac ultrasound revealed a grossly dilated right ventricle and atrium with a large, highly mobile thrombus. The right ventricle weas clearly bigger than the left ventricle and one can appreciate the interventricular septum bowing into the LV during contraction (D-sign). The finding was immediately concerning for a thrombus-in-transit, strongly suggestive of a massive pulmonary embolism with evidence of severe right heart strain. This unexpected finding dramatically changed the clinical picture. Although the patient remained haemodynamically stable initially, the presence of a mobile right-sided thrombus represented an extremely high-risk situation.

The decision was made to proceed with urgent thrombolysis. Unfortunately, before definitive treatment could be completed, the patient's condition deteriorated rapidly and he became peri-arrest and lost output. Thrombolytic therapy was administered during the resuscitation; however despite these interventions, the patient sadly did not survive.

Learning Points

• Echo in life support is a modality of scanning that requires skill and experience. ELS scans need to be done quickly in high pressure, time and space-limited circumstances. CPR maybe in process and many team members and equipment can crowd the clinical area. A focused cardiac ultrasound performed at the bedside can reveal a potentially fatal pathology that is not immediately apparent from the initial clinical presentation and can direct definitive management decisions.

• Pulmonary embolism can present atypically. A massive PE can present in atypical ways in patients with no known risk factors.

• Consider PE even in young patients. The absence of a significant medical history or obvious major thromboembolic risk factors should not completely exclude PE when the clinical picture is concerning.

• A mobile right-sided thrombus is a critical finding. A thrombus-in-transit within the right heart in the appropriate clinical context is highly concerning for pulmonary embolism and carries a significant risk of sudden haemodynamic deterioration.

Lead Editor: Dr Zoya Awan, ED Registrar

Checked: Dr Ahmed Abdul-Ghani, Lead Project Consultant