75yo patient presents with collapse after a long haul flight.
HPC is vague as usual: pt felt nauseated after the flight and took some Italian medicine for travel (?antihistamine) and then became lightheaded while collecting luggage. No SOB/ CP/palpitations. She had a brief syncope and recovered spontaneously. On MAS arrival SBP 90, sats 88% on RA.
In ED sats 96% on 4L, not tachypneoic, tachycardic at 100bpm (SR) BP 110/80.
Bilateral pitting oedema to ankles, nil calf tenderness, nil evidence R heart failure.
ECG sinus tach, nil acute ST changes.
A provisional Dx of PE was made and pt was booked for CTPA, given clexane and referred for admission under AMU.
CTPA took a while to occur.
In the meantime, ED echo revealed:
Parasternal short axis view revealing a dilated RV with IV septum bulging to L (Rv on L of screen)
Patient was referred to HDU given the results of the echo, but rejected due to stable BP. After much discussion and based on the echo findings and an elevated troponin, the pt was booked for CCU.
CTPA was eventually done and revealed thrombus in the L pulmonary artery, with dilatation of the RV and septal bowing to the left.
Factors suggestive of an acute PE on an bedside echo
1. RV has a 1:1 ratio (or greater) with the LV (normal RV:LV ratio is 0.6:1)
see below: apical 4 chamber, RV (left of screen) much larger than LV
2. RV is hypo dynamic with a reduced TAPSE (<16mm)
3. McConnell's sign
Akinetic RV mid free wall with a hyperkinetic apical segment. Specific finding on echo for PE.
4. IV septum bowing to L (normally bows to the R)
This creates a D shaped LV on parasternal short axis.
5. LV is hyperdynamic
6. IVC will be distended and non collapsing
Features suggesting that the RV dysfunction is chronic
1. RV hypertrophy: RV free wall >5mm (best seen in subcostal view)
see below: thickened RV free wall in apical 4 chamber view