Hindawi Publishing Corporation

Case Reports in Emergency Medicine

Volume 2013, Article ID 312632, 3 pages
http://dx.doi.org/10.1155/2013/312632

Case Report
The Use of Bedside Ultrasound in the Evaluation of Patients
Presenting with Signs and Symptoms of Pulmonary Embolism

Adarsh N. Patel, L. Connor Nickels, F. Eike Flach, Giuliano De Portu, and Latha Ganti
Department of Emergency Medicine and Center for Brain Injury Research and Education, University of Florida College of Medicine,
1329 SW 16th Street, P.O. Box 100186, Gainesville, FL 32610-0186, USA
Correspondence should be addressed to Latha Ganti; [email protected]

Received 9 July 2013; Accepted 7 August 2013

Academic Editors: A. K. Exadaktylos and C. H. Loh

Copyright © 2013 Adarsh N. Patel et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Evaluation of patients that present to the emergency department with concerns for the diagnosis of pulmonary embolism can
be difficult. Modalities including computerized tomography (CT) of the chest, pulmonary angiography, and ventilation perfusion
scans can expose patients to large quantities of radiation especially if the study has to be repeated due to poor quality. This is
particularly a concern in the pregnant population that has an increased incidence of pulmonary embolism and may not be able to
undergo multiple radiographic studies due to fetal radiation exposure. This paper presents a case of a pregnant patient with signs
and symptoms concerning pulmonary embolism. The paper discusses the use of bedside ultrasound in the evaluation of patients
with pulmonary embolism.

1. Case Presentation perform the echocardiogram. A subxiphoid view of the heart

was performed, and no pericardial effusion or wall motion
A 20-year-old G2P1 pregnant female at 22 weeks from her last abnormalities were noted. The IVC diameter was not dilated
menstrual period presents to the emergency department as a and had normal variation with respirations (Figure 1). A
transfer patient from an outside hospital. She was evaluated parasternal short axis view at the level of the pulmonary
for two days of progressively worse shortness of breath. artery was performed and did not show any free-floating
The major concern at the outside hospital was a pulmonary thrombus in either the right heart or pulmonary artery. The
embolism. They performed a chest CT scan that was reported parasternal short axis view at the level of the papillary muscles
as inconclusive for pulmonary embolism secondary to poor did not show any flattening or bowing of the intraventricular
quality, and thus she was transferred for further evaluation of septum into the left ventricle. No right ventricular dilation
pulmonary embolism. was noted (Figure 2). In total, besides the tachycardia there
Upon arrival to the ED, the patient denied any personal were no other findings concerning pulmonary embolism on
or family history of DVT, pulmonary embolism, or clotting ultrasound. CT chest for pulmonary embolism was repeated
disorders. Her only identifiable risk factor for pulmonary and this time an adequate quality film was obtained and was
embolism was her pregnancy. On physical examination the negative for pulmonary embolism.
patient was well appearing and oriented to person, place, and Upon further history taking, the patient admitted to be
time. She was clearly tachypneic with a heart rate of 120– ingesting 1-2 tablets of aspirin every 4 hours on a regular
140 s bpm. The rest of her vital signs and physical examination basis for tooth pain. Her arterial blood gas showed a mixed
were normal. An EKG was performed in the emergency metabolic acidosis and respiratory alkalosis. The history and
department which showed sinus tachycardia without S1Q3T3 lab work raised high suspicion for salicylate intoxication and
sign. thus a salicylate level was drawn. The salicylate level came
Ultrasound evaluation in the emergency department back elevated, and the patient was diagnosed with salicylate
was performed with the focus on evaluation of pulmonary toxicity. She was admitted and treated appropriately. She was
embolism. A 2–4 MHz phased-array probe was used to discharged 4 days later in stable condition.
2 Case Reports in Emergency Medicine

emboli [1, 8]. Limitation of using transthoracic ultrasound

includes visualization of only the proximal main, right, and
left pulmonary arteries. Emboli distal to this region would be
missed on TTE and thus transesophageal echocardiogram or
helical CT may need to be performed [5, 9].
Right ventricular (RV) dilation may be seen in patients
with pulmonary embolism especially if the embolus is mas-
sive and causing right heart strain. Right ventricular dilation
has a poor sensitivity of only 31% and a high specificity of 94%
[10]. Right ventricular dilation may lead to flattening/bowing
of the intraventricular septum (IVS) into the left ventricle and
lead to eventual right ventricular dysfunction. RV dilation
Figure 1: M-mode on IVC showing normal IVC collapse on res- and IVS flattening are best visualized in the parasternal short
piration. axis at the level of the papillary muscles. With IVS flattening
the left ventricle loses its “O” shaped appearance and becomes
“D” shaped [2]. Right ventricular dysfunction, as defined
by tricuspid regurgitation velocity greater than 2.9 m/s, has
been shown to have a sensitivity of 51% and a specificity of
88% [10]. Another definition of right ventricular dysfunction
includes RV end-diastolic diameter >30 mm in the precordial
view, hypokinesis of the free wall, and dilation of the right
pulmonary artery [11–13]. Patients with pulmonary embolism
and right ventricular dysfunction as evidenced on ultrasound
have been shown to have higher mortality rates 0–7% versus
14–18% [3, 14].
McConnell’s sign is akinesia of the mid-free wall of
the right ventricle but normal motion at the apex. The
best view to assess for McConnell’s sign is the apical four-
Figure 2: Apical four-chamber view showing normal RV : LV ratio. chamber view. McConnell’s sign is used to differentiate
patients with an acute PE from those with pulmonary
hypertension secondary to other causes such as idiopathic
2. Discussion pulmonary hypertension, chronic obstructive pulmonary
disease, obstructive sleep apnea, and right-sided myocardial
The use of bedside ultrasound evaluation of patients pre- infarction [5]. McConnell’s sign has been shown to have a
senting to the emergency department with signs and symp- sensitivity of 77%, specificity of 94%, positive predictive value
toms of pulmonary embolism has been controversial. Rapid of 71%, and a negative predictive value of 96% [4]. IVC
diagnosis using ultrasound can lead to earlier preparation dilation with loss of inspiratory collapse has been shown to
of thrombolytic administration especially in the critical ill correlate to patients presenting with pulmonary embolism
patients where rapidity is crucial [1]. There are multiple [3, 5, 9].
sonographic findings that support the diagnosis of acute
pulmonary embolism and can be broken down into two 3. Conclusion
major categories: direct and indirect signs. Direct signs
included visualization of a free-floating thrombus in the right Bedside ultrasound in the evaluation of pulmonary embolism
heart or pulmonary artery [1, 2]. Indirect signs include right has become a useful tool among emergency medicine physi-
ventricular dilation (RV/LV ratio >0.6–1 : 1), flattening or cians. It allows for rapid evaluation in time-sensitive critically
bowing of the intraventricular septum into the left ventricle, ill patients and thus can promote prompt treatment without
right ventricular systolic dysfunction, McConnell’s sign, and having to delay for further radiography studies. Bedside
IVC dilation without inspiratory collapse [2–5]. ultrasound also has a role amongst pregnant patients that
Direct signs of pulmonary embolism are best visualized may not be able to undergo multiple radiographic studies due
in the parasternal short axis at the level of the pulmonary to large amounts of fetal radiation exposure. The specificity
artery. Free-floating right ventricular thrombi are highly of sonographic evidence of pulmonary embolism has been
specific for pulmonary embolism but uncommonly occur. shown to be high; however, its poor sensitivity implies that
The prevalence of right ventricular thrombi in patients with further testing may be necessary in order to fully rule out a
pulmonary embolism is only 4 to 18% [6]. Right ventricular pulmonary embolism.
thrombus may not be diagnostically useful due to its poor
sensitivity; however, it is prognostically valuable and indicates
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