Case 2 - Obstructive Shock - PE
Indication:
The two clinical questions the clinician wanted to answer with PoCUS were:
(a) What type of shock is this? Given the history, it would most likely be obstructive via pulmonary embolism.
(b) Is there evidence of DVT? The patient was too unstable to be transferred for definitive imaging, therefore the clinician was looking DVT for circumstantial evidence for pulmonary embolism.
Image Acquisition:
Given the JVP cannot be visualized, the IVC was imaged -- the most upstream component of the aggregate venous return channel. Also, if it was collapsing, volume expansion maybe favoured.
The interest, nevertheless, was the right ventricle.
The two clinical questions the clinician wanted to answer with PoCUS were:
(a) What type of shock is this? Given the history, it would most likely be obstructive via pulmonary embolism.
(b) Is there evidence of DVT? The patient was too unstable to be transferred for definitive imaging, therefore the clinician was looking DVT for circumstantial evidence for pulmonary embolism.
Image Acquisition:
Given the JVP cannot be visualized, the IVC was imaged -- the most upstream component of the aggregate venous return channel. Also, if it was collapsing, volume expansion maybe favoured.
The interest, nevertheless, was the right ventricle.
Interpretation:
The patient was morbidly obese and rather unstable for repositioning to invest longer period to obtain better windows. Nevertheless, despite the non-ideal images, they yielded sufficient information to guide the clinical decision making.
Post-Thrombolysis (1 hour)
Based on the clinical and PoCUS findings suggestive of an obstructive shock and the DVT in the popliteal vein, the etiology was most likely massive PE. Hence, tPA was administered. The patient stabilized within the hour, and repeat PoCUS was performed.
The patient was morbidly obese and rather unstable for repositioning to invest longer period to obtain better windows. Nevertheless, despite the non-ideal images, they yielded sufficient information to guide the clinical decision making.
Post-Thrombolysis (1 hour)
Based on the clinical and PoCUS findings suggestive of an obstructive shock and the DVT in the popliteal vein, the etiology was most likely massive PE. Hence, tPA was administered. The patient stabilized within the hour, and repeat PoCUS was performed.