Case 1 - Obstructive Shock - PE
Indication:
i. Shock Differentiation: Given the findings, the most likely class of shock was obstructive with the etiology being a massive PE.
ii. Therapy Guidance: Given the patient was so unstable, in fact, she was at one point peri-arrest, definitive diagnostic imaging cannot be performed. The clinician, hence, employed cardiac PoCUS to look for findings suggestive of acute right heart failure due to PE to firm the use of thrombolysis.
Image Acquisition:
Given the JVP was visibly so very distended, the IVC was imaged as it would not add to the case. As the patient sitting up, the decision was to first perform a subcostal view as the heart would likely displace caudally and, also, it will image the the cardiac chamber of interest, the right heart -- relevant for PE and, also, just downstream to the IVC.
i. Shock Differentiation: Given the findings, the most likely class of shock was obstructive with the etiology being a massive PE.
ii. Therapy Guidance: Given the patient was so unstable, in fact, she was at one point peri-arrest, definitive diagnostic imaging cannot be performed. The clinician, hence, employed cardiac PoCUS to look for findings suggestive of acute right heart failure due to PE to firm the use of thrombolysis.
Image Acquisition:
Given the JVP was visibly so very distended, the IVC was imaged as it would not add to the case. As the patient sitting up, the decision was to first perform a subcostal view as the heart would likely displace caudally and, also, it will image the the cardiac chamber of interest, the right heart -- relevant for PE and, also, just downstream to the IVC.
Interpretation:
The patient's rapid respiratory rate and thoracic excursion rendered imaging difficult, therefore the image quality was substandard. However, they sufficed to answer the questions.
The RV and RA were both noted to be severely dilated. In addition, the ventricular and atrial septums deviated to the left (D-Septum) which suggested the pressure in the right heart was very high. The LV was hyperdynamic.
In the A4 and PSL, a echoic shadow can be seen intermittently in the RV and RVOT, respectively.
Clinical Synthesis:
Given the obstructive shock picture in conjunction with severe hypoxia, the most likely cause was a massive PE. The lesion seen in the RV/RVOT was most likely an embolus in transit. tPA was administered.
The clot burden seen on subsequent CTPA was massive. In addition, the embolus in transit was so large that it did seem to have change in size on repeat ECHO. The clot had to be extracted via open heart surgery.
The patient's rapid respiratory rate and thoracic excursion rendered imaging difficult, therefore the image quality was substandard. However, they sufficed to answer the questions.
The RV and RA were both noted to be severely dilated. In addition, the ventricular and atrial septums deviated to the left (D-Septum) which suggested the pressure in the right heart was very high. The LV was hyperdynamic.
In the A4 and PSL, a echoic shadow can be seen intermittently in the RV and RVOT, respectively.
Clinical Synthesis:
Given the obstructive shock picture in conjunction with severe hypoxia, the most likely cause was a massive PE. The lesion seen in the RV/RVOT was most likely an embolus in transit. tPA was administered.
The clot burden seen on subsequent CTPA was massive. In addition, the embolus in transit was so large that it did seem to have change in size on repeat ECHO. The clot had to be extracted via open heart surgery.