Pulmonary Vascular Disease |

Bedside Critical Care Echocardiography Revealing an Unsuspected Diagnosis FREE TO VIEW

Abubakr Chaudhry, MD; Robert Neuman, MD; Sushma Cribbs, MD
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Emory University, Atlanta, GA

Chest. 2014;146(4_MeetingAbstracts):891A. doi:10.1378/chest.1993956
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SESSION TITLE: Pulmonary Vascular Disease Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: The utilization of imaging modalities to aid in diagnosis and management continues to evolve in medical intensive care units (MICU). We present a case where bedside echocardiography positively impacted patient care.

CASE PRESENTATION: A 43 year old male presented to the emergency department with shortness of breath for two weeks. Two weeks prior he presented to another facility and underwent cardiac catheterization, V/Q scan, and a transthoracic echocardiogram (TTE); all normal per patient. His symptoms persisted on discharge. On admission, patient was hypoxic with elevated troponin, basic natriuretic peptide, and creatinine levels. Electrocardiogram was normal. Considering pulmonary embolism, patient underwent a bedside TTE which demonstrated clot-in-transit in right atrium (RA), and right ventricular (RV) dilation with decreased systolic function. Lower extremity ultrasound revealed deep venous thrombi (DVT) and heparin was initiated. His hypoxemia worsened so was started on full dose systemic thrombolysis with TPA. He improved and TTE demonstrated improved RV function and resolution of thrombus. However, within 24 hours, his symptoms worsened. Bedside TTE revealed migrating clot in the RA. Decision was made for emergent surgery. Patient underwent pulmonary artery embolectomy, extraction of thrombus from inferior vena cava and RA. Post-operative course was complicated by hemorrhagic shock and acute heart failure. However, patient was discharged home on post-operative day 13. Two months post-discharge, he is at baseline with improved RV function and no evidence of pulmonary hypertension by TTE.

DISCUSSION: Bedside echocardiography has been shown to help physicians decide whether critically ill patients with pulmonary embolism should have thrombolysis, catheter embolectomy, or surgical embolectomy (1). Pruszczyk and colleagues compared computed tomography of the chest (gold standard) with transesophageal echocardiography, and found a sensitivity of 80% with specificity of 100% for finding pulmonary embolism (2). This case brings to light the usefulness of bedside TTE for the management of a pulmonary embolism in the ICU.

CONCLUSIONS: Critical care bedside echocardiography can allow for quick, non-invasive diagnoses that can change management.

Reference #1: Samuel Z. Goldhaber; Echocardiography in the Management of Pulmonary Embolism. Annals of Internal Medicine. 2002 May;136(9):691-700.

Reference #2: Pruszczyk P, Torbicki A, Pacho R, Chlebus M, Kuch-Wocial A, Pruszynski B, et al. Noninvasive diagnosis of suspected severe pulmonary embolism: transesophageal echocardiography vs spiral CT. Chest. 1997; 112:722.-8

DISCLOSURE: The following authors have nothing to disclose: Abubakr Chaudhry, Robert Neuman, Sushma Cribbs

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