Case vignette
57yo F with recent total hip arthroplasty p/w acute SOB and AMS.
HR 120, BP 90/40, RR 27, SpO2 88%, T 37.7.
Toxic and confused appearing female speaks in short sentences. Lungs clear to auscultation. BLE 1+ pitting edema.
What do you see?
CP4 PLA: dilated RV, poor contractility, thrombus noted, underfilled/hyperdynamic LV
CP4 Subxiphoid 1: dilated RV, poor contractility, thrombus noted, underfilled/hyperdynamic LV
CP4 Subxiphoid 2: dilated RV, poor contractility, thrombus noted, underfilled/hyperdynamic LV
What do you do next?
You correctly identify this patient's shock is most likely obstructive, from PE in transit. You place an emergent call to the ICU and IR and assess for contraindications to thrombolysis. However, the patient's hemodynamics and MS improve with gentle NE gtt with minimal fluids. She has biomarkers concerning for R heart strain and is admitted to the MICU for urgent catheter-directed thrombolysis.
Teaching points. In patients with unexplained shock, consider a RUSH (Rapid Ultrasound for Shock and Hypotension) exam to narrow your differential. US rarely confirms PE (in this case, an actual thrombus is seen in transit). However, it can demonstrate suggestive signs, such as a dilated IVC, RV wall hypokinesis, RV dilation (larger than LV), or pulmonary artery hypertension. Whether these findings are new and why must be considered in the clinical context. (Please see Cardiopulmonary Case 8 for additional education.)
In a crashing patient unstable for CT and in whom you suspect massive PE, US findings can help you consider emergent interventions such as thrombolysis. It can also provide critical information about RV function and use of ionotropy and judicious fluids.
Residents/staff: Dr. Sam Ho
PE in Transit