Clinical Case: Pulmonary Embolus

A 65 year old gentleman presents to the emergency department complaining of sudden sharp chest pain, shortness of breath and lightheadedness.

His pulse is 110, his blood pressure his 90/50, and his oxygen saturations are 92% on 40% venturi mask. His JVP is elevated, but his physical exam is otherwise unremarkable.

You perform a bedside echo which reveals the following image:

This is an example of a pulmonary embolus (PE) leading to hemodynamic instability. Ultrasound has a role when the diagnosis of PE is suspected and the patient is too unstable to undergo a CT or V/Q scan.

The ultrasound image above is an apical view of the heart, with the ventricles at the top of the image and the right side of the heart on the left side of the screen. As you can see, the right ventricle (RV) is enlarged, and is larger than the left ventricle in this image. Also, there is hyperkinesis of the apex of the RV with akinesis of the mid free wall. This distinct pattern of RV dysfunction on ultrasound is typical in cases of PE and is known as McConnell's sign.