Ultrasound Case 019


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.



An Emergency physician based in Perth, Western Australia. Professionally my passion lies in integrating advanced diagnostic and procedural ultrasound into clinical assessment and management of the undifferentiated patient. Sharing hard fought knowledge with innovative educational techniques to ensure knowledge translation and dissemination is my goal. Family, wild coastlines, native forests, and tinkering in the shed fills the rest of my contented time. | SonoCPDUltrasound library | Top 100 | @thesonocave |

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