A previously well young male sustained an isolated severe brain injury. Shortly after arrival in the ED he becomes intermittently hypoxic and hypotensive. Confused, you look at his heart.
Describe and interpret these scans
Image 1: Subcostal cardiac view; This view shows venous thromboembolism in transit. Slightly echogenic fragments of clot are seen flicking though the right atrium.
Pulmonary embolism in transit.
It was initially presumed this patient’s hypoxia and hypotension reflected a problem with his recent intubation or mechanical ventilation but when obvious causes were excluded a subcostal view of his heart was attained.
Mobile venous thromboembolism is seen moving through the right heart.
We presume the major brain injury caused massive release of procoagulant factors such as thromboplastin and caused thrombus to form. Acute thrombus is not as echogenic as more organised thrombus and so this clot in transit is more subtle than one typically sees. It is also more friable. Here fragments of newly formed thrombus swirl within the right atrium before passing onward.