October SonoProps
The first of this month's SonoProps goes to Dr. Hardeep Singh and Dr. Ahmer Salman .
An 85-year-old female with a remote history of breast cancer presented to the ED with chest pressure, shortness of breath, nausea, and vomiting.
Dr. Singh and Salman grabbed the ultrasound machine and performed an POCUS that showed this:
Can you guess what they saw?
If you guess a dilated right ventricle with McConnell’s sign, you would be correct!
This patient had a large dilated right ventricle with D-sign, a textbook McConnell's sign, severe tricuspid regurgitation, mild lateral septal displacement, and a plethoric IVC - all the signs that indicate acute right heart strain in a pulmonary embolism. They immediately got a CTA that confirmed their diagnosis and the patient was admitted to the ICU.
Learning points:
In a patient with shortness of breath and chest pain if you are considering a diagnosis of PE, POCUS can help in the identification of right heart strain caused by a pulmonary embolism and help expedite CTA. However, a normal POCUS does not rule out pulmonary embolism.
Consider chronic right heart strain in a patient with a thickened RV wall (>5mm).
Signs of right heart strain include (not all of them have to be present):
A dilated right ventricle (>2/3rd the size of the LV)
D-sign / lateral septal displacement - this is due to decreased venous return to the LV. During diastole, the intraventricular septum normally relaxes outward, toward the RV. With PE there is increased right end-diastolic pressures with decreased left sided pressures leading to abnormal motion of the septum.
McConnell's sign - regional akinesis of the RV free wall and hyperkinesis of the apex - looks like someone jumping on a trampoline - very specific but insensitive indicator of PE.
Severe tricuspid regurgitation
Plethoric IVC
The above clips are from the same patient.
SonoProp #2 goes to our Dr. Vivek Sharma.
Dr. Sharma was doing a scan on a 88-year-old male with a history of prostate cancer who presented to the ED with worsening oral intake and weakness. He had been having left thigh pain for a few days and had a heart rate of 102. A radiology ultrasound was ordered but Dr. Sharma had his answer right away, almost an hour and a half earlier than radiology.
This is what Dr. Sharma saw on his LEFT leg scan.
This scan shows an acute DVT involving the common femoral vein as identified by seeing the actual clot in the vein and non-compressibility. Great example a visualized DVT Dr. Sharma!
The preferred protocol for our emergency department includes compression at the:
CFV
CFV-SFV junction
Femoral vein - Deep femoral vein junction
Popliteal vein
Trifurcation (anterior and posterior tibial veins and the peroneal vein)
There are shorter protocols - 2-point and 3-point but these have reduced sensitivity.
Learning points:
Normal findings include:
Compressible veins free of echogenic material.
The anterior and poster walls of the vein should touch completely with compression.
Normal augmentation - compression of the calf elicits an increased spectral doppler signal at the examined area.
Normal respiratory variation - deep inspiration should elicit a spectral doppler response at the examined area.
