70yo F shortness of breath
70yo female hx CHF, COPD, htn, 10 days s/p spinal surgery presenting with shortness of breath. She is hypoxic with increased accessory muscle, and there are expiratory wheezes and crackles particularly in the lung bases. She has mild lower extremity edema but states she has been adherent with her home lasix. She is also tachycardic to the 130s and intermittently hypotensive to the low 90s/ high 80s systolic. Differential?
EKGs are shown below, new and prior from 2 months ago.
What do you see? It’s subtle but there are new TWI in the precordial leads.
Does that RV look big to you? How about that septal wall motion? You also obtain a thoracic ultrasound which shows B lines in all lung fields bilaterally.
Labs start to come back — troponin 63, BNP 800s (both previously normal).
You astutely recognize that the septal wall appears to be deformed in both systole and diastole. You remember that when a “D sign” that is present throughout the cardiac cycle, it is suggestive of right heart pressure, rather than volume, overload.
Given your patient’s ongoing respiratory distress, you call RT to start her on additional oxygen support. PE is high up on your differential but the patient becomes more hypotensive with increased respiratory distress when you lay her flat, making you reluctant to send her to the CT scanner.
https://e-echocardiography.com/page/page.php?UID=1429484741
Can ultrasound help here? The answer is maybe. If the patient' has a large saddle embolus we may be able to see it in the pulmonary artery.
To visualize the pulmonary artery, start with a standard PSS view, ~3rd intercostal space with probe marker towards the patient’s R hip until you identify the circular LV at the level of the papillary muscles.
https://123sonography.com/ebook/parasternal-short-axis-views
PSS, Base view - https://123sonography.com/ebook/parasternal-short-axis-views
As you flatten the probe (ie tilt it so the footprint angles towards the patient’s R shoulder), you should fan through the LV first to level of the mitral valve (fish mouth) and then the level of the aortic valve at the PSS base (Mercedes Benz sign). You may need to come up a rib space.
At the PSS base view you will also see the RV outflow tract above the AV. To visualize the pulmonary artery, follow the RVOT through the pulmonic valve by turning the transducer slightly more towards the patient’s head (probe is vertical) as you bring the probe slightly more perpendicular with the patient’s skin. You may have to slide the whole probe a few millimeters towards patient’s left as you do this.
You find the pulmonary artery and you see a small hyperechoic clot coming in and out view within the pulmonary artery (far field above).
This can be a tough view to obtain given the lung moves in and out of frame and often obscures the pulmonary artery. Seeing the clot is even more rare, however worth a try especially in an unstable patient.
The patient above was started on a heparin drip based on the findings above, improved after starting on HFNC and was eventually above to get to CT scanner which confirmed she had a large saddle embolism.