Ultrasound Case #2 – The Generalized Weakness

A 60 year old female presents to your ED with chief complaint of generalized weakness. She has a PMHx of squamous cell carcinoma. She had maxillary sinus surgery 2 weeks ago. She describes 5 days of generalized weakness. She is not on chemotherapy. ROS is positive for: poor appetite, exertional dyspnea, lightheadedness upon standing. She also notes that she had a syncopal episode 2 days ago. She denies CP, cough, or fevers. No leg swelling.

Vitals on arrival: BP 109/81, Temp 36.9C (oral), HR 122, RR 20, SpO2 99% on RA

ECG shows sinus tachycardia with a new RBBB. You are able to obtain the following ultrasound images.

What do you see in these images and what is your next step in management?

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Clip 1 Here you see the thick walled LV in short axis, the RV is seen at the top of the image with some of the tricuspid valve during the beginning of the clip. You can see a clot moving between the RA and RV during that portion of the clip where the valve is visible. Additionally the RV appears enlarged and there is flattening of the interventricular septum displaying the classic “D-sign” indicating increased RV pressures.
Clip 2 Shows an apical 5 chamber view with several important findings. First thing you notice is that the RV apex appears more anterior than that of the LV. Additionally, the apical aspect of the RV is being pulled inferiorly by the LV during ventricular systole while the RV free wall appears hypokinetic, this is McConnell’s sign. Once again there is a visible clot that can be seen moving between the RA and RV. It is also notable that the RV:LV ratio is significantly elevated. The normal ratio should be less than 1:1. When the ratio exceeds 1:1 this suggest increased RV pressures.
Clip 3 This view is a slightly off axis apical shot that shows the RV and RA in much greater detail. Here you can see just how big the RV appears to be. The clot within the RA appears to be moving around freely suggesting that it is not a pedunculated mass and at one point during the clip you can see clot passing from the RA into the RV.
Management All of these findings suggest that the patient has an acute pulmonary embolism with signs of right heart strain. When a clot in transit is visualized on TTE this is generally an accepted indication for TPA administration. If the patient is hemodynamically stable expert consultation may also be a reasonable option.

Click to reveal learning points

Direct signs of RV strain on POCUS include: RV to LV ratio > 1:1, interventricular septum bowing towards the LV or flatting of the septum on parasternal short axis view, McConnell’s sign as we described above.
Tricuspid annular plane systolic excursion (TAPSE) < 15mm suggests severe RV dysfunction and in the setting of suspected PE has a specificity approaching 100%.
A great review of TTE findings can be found here: https://rebelem.com/diagnosis-right-ventricular-strain-transthoracic-echocardiography/
Treatment for PEs depends on many factors including: the patient’s condition/ vitals, echo findings, markers of heart strain (BNP, troponin, ECG changes), PESI score, your location (discussion with consultants/ PERT), and patient’s contraindication for anticoagulation/ lytics. That being said, virtually all of these patients end up on anticoagulation +/- lytics or thrombectomy. Further discussion of treatment of PE’s requiring more than just the standard anticoagulation can be found here: https://litfl.com/thrombolysis-for-submassive-pulmonary-embolus/