aka Cardiovascular Curveball 011
A 35 year-old female is brought to the emergency department after collapsing in a shopping centre. Paramedics found her to be GCS 3 and shortly afterwards required CPR and 1mg adrenaline for profound bradycardia and no pulse. Spontaneous output returned and no further drugs have been required to support her circulation.
She remains intubated and GCS 3. There is little other history, except some information from a friend stating she had been on a trip to South America recently.
You perform a quick bedside echo while the paramedics are changing over their monitoring.
Q1. What are the obvious abnormalities on this echo?
- Small LV cavity size with normal LV systolic function
- Septal flattening consistent with RV pressure overload
- Severely dilated RV with severely reduced systolic function
Q2. What is McConnell sign?
Echocardiographic pattern of RV dysfunction consisting of akinesia of the mid free wall but normal motion at the apex
77% sensitivity and 94% specificity for diagnosis of pulmonary embolism
Reference: Rippey J. LITFL Ultrasound Case 079.
Q3. What are the echocardiographic features of RV dysfunction in PE?
- RV wall hypokinesis
- Moderate or severe
- McConnell’s sign
- RV dilatation
- End-diastolic diameter >30 mm in parastemal view
- RV larger than LV in sobcostal or apical view
- Increased tricuspid velocity >26 m/sec
- Paradoxical RV septal systolic motion
- Pulmonary artery hypertension
- Pulmonary artery systolic pressure >30 mmHg
- Dilated IVC with lack of respiratory collapse
Other echocardiographic features associated with increased mortality include patent foramen ovale and free-floating right-heart thrombus.
Q4. What are the indications for thrombolysis in acute pulmonary embolism?
Fibrinolysis in acute pulmonary embolism remains a controversial topic.
Most agree that cardiac arrest and haemodynamic instability (SBP < 90mmHg) are indications for thrombolysis.
Controversy surrounds thrombolysis for stable patients with RV dysfunction on echocardiography.
- Treatment in this group has been shown to decrease pulmonary artery pressure and improve RV systolic function and pulmonary perfusion
- This benefit must be weighed against the risk of haemorrhage with thrombolytic therapy.
- Thrombolysis has not been shown to improve mortality
Other treatment algorithms include the use of elevated Troponin and BNP to select which patients require urgent echocardiography
In haemodynamically stable patients with RV dysfunction, thrombolysis should be considered on a case-by-case basis
Q5. What would you do next?
- Although stable at the moment, this patient has had a cardiac arrest from a pulmonary embolus and is potentially very unstable
- She has severe RV dysfunction on echocardiography
- There are no obvious contraindications to thrombolysis
- Alteplase 50mg IV bolus
Q6. What was the response to treatment?
This echo was performed a few hours later. Already some improvement in RV dysfunction is evident.
This case illustrates the utility of bedside echocardiography in the emergency department. Using the clinical history, a diagnosis of massive pulmonary embolism was made at the bedside and appropriate treatment could be administered almost immediately.
The pictures are from a real case, with some of the details changed. Let’s just say that thrombolysis makes failed intubation interesting
- Rippey J. LITFL Ultrasound Case 079.
- McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996; 78: 469–473.
- SB Oh, SJ Bang, MJ Kim. McConnell’s sign; a distinctive echocardiographic finding for diagnosing acute pulmonary embolism in emergency department. Crit Ultrasound J. 2015; 7(Suppl 1): A20.
- Fengler BT, Brady WJ (2009) Fibrinolytic Therapy in Pulmonary Embolism: an Evidence Based Algorithm. American Journal of Emergency Medicine. 27 84-89 [PMID 19041539]
- Roy P et al (2005) Systematic Review and Meta-Analysis of Strategies for the Diagnosis of Suspected Pulmonary Embolism. BMJ 331:259 [PMID 16052017]
- Goldhaber S (2002) Echocardiography in the Management of Pulmonary Embolism. Annals of Internal Medicine. 136:691-700 [PMID 11992305]
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of LITFL.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of two amazing children.
On Twitter, he is @precordialthump.