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CASE REPORT
Year : 2023 | Volume
: 17
| Issue : 1 | Page : 75-76
Point-of-care transthoracic echocardiography: An essential management tool for acute massive pulmonary thromboembolism
Carlos Almeida, Pedro Cunha, Lígia Vieira, Pedro Antunes, Emilia Francisco
Department of Anesthesiology, Centro Hospitalar Tondela Viseu, Viseu, Portugal
Correspondence Address:
Pedro Cunha
Department of Anesthesia, Centro Hospitalar Tondela Viseu, Av. Rei Dom Duarte, 3504-509 Viseu
Portugal
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sja.sja_186_22
| Date of Submission | 25-Feb-2022 |
| Date of Decision | 26-Feb-2022 |
| Date of Acceptance | 27-Feb-2022 |
| Date of Web Publication | 02-Jan-2023 |
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The pulmonary thromboembolism may be a life-threatening condition. A hip fracture surgery patient aged >90 years old had a sudden post-operative episode of shock, de-saturation, and reverted cardiac arrest. A point-of-care transthoracic echocardiography (TTE) undertaken by an anesthesiologist revealed inferior vena cava dilation/flattening, right cardiac chamber dilation, and McConnell signs (right ventricular apex hyperkinesia and lateral wall hypokinesia); the ventricular septal wall was shifting to the left side, and the left ventricular chamber collapsed at the end-systole, indicating a high ejection fraction in the context of obstructive shock. As such, it revealed signs of pulmonary thromboembolism. Despite the absolute contraindication for thrombolysis and therapeutic hypocoagulation, the treatment was started immediately along with vasopressor support, which was life-saving in this patient. A summary TTE played a pivotal role in our patient's case, helping with the differential diagnosis of the cause of shock.
Keywords: Emergence medicine, pulmonary thromboembolism, point-of-care echocardiography
How to cite this article:
Almeida C, Cunha P, Vieira L, Antunes P, Francisco E. Point-of-care transthoracic echocardiography: An essential management tool for acute massive pulmonary thromboembolism. Saudi J Anaesth 2023;17:75-6 |
How to cite this URL:
Almeida C, Cunha P, Vieira L, Antunes P, Francisco E. Point-of-care transthoracic echocardiography: An essential management tool for acute massive pulmonary thromboembolism. Saudi J Anaesth [serial online] 2023 [cited 2023 Mar 31];17:75-6. Available from: https://www.saudija.org/text.asp?2023/17/1/75/364845 |
| Case Report | |  |
Herein, a transthoracic echocardiographic image (four-chamber view) [Figure 1]a and [Figure 1]b from a hip fracture surgery patient aged >90 years old is presented, without significant previous medical history. After admission in the post-anesthesia care unit (PACU), the patient developed arterial oxygen de-saturation and type 2 respiratory insufficiency after a hip hemi-arthroplasty under general anesthesia (spontaneous ventilation) combined with lumbar anterior–lateral transverse-process block,[1] which went uneventfully (without significant alteration in the end-tidal CO2). Initially, in the PACU, she maintained hemodynamical stability, but suddenly, the mean arterial pressure was undetectable and the patient developed asystolic cardiac rhythm. The pulsation was recovered after 2 min of advanced cardiac life support, despite maintaining severe shock [phenylephrine boluses and adrenaline 1 mg bolus (BBraun, Germany) were administered intravenously (IV), and noradrenaline (BBraun, Germany) and dobutamine (Bluemed, Portugal) infusions were started IV]. | Figure 1: (a–d). (a and b) Echocardiographic image (four-chamber apical view of TTE) (a) during ventricular end systole and (b) during the ventricular proto-systole. TTE revealed a dilated right atrium and ventricle, an apparent hypokinetic mid-right ventricular free wall with a hypercontractile right ventricular apex (McConnell's signs, no dynamic image available), a hyperkinetic left ventricular myocardium, and a remarkable extremely high ejection left ventricle fraction. Right/left ventricular area ratio >> 0.7.[2],[3] The lack of motion of the right ventricle lateral free wall is remarkable compared to the right ventricular apex when comparing (a) and (b).[2],[3] (c and d) Computed tomographic pulmonary angiography confirming the diagnosis. (c) Axial image and (d) coronal image at the level of the pulmonary arteries, showing extensive phenomena of bilateral pulmonary embolism.[4] The presence of a discrete pleural effusion bilaterally
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At the bedside, a point-of-care transthoracic echocardiography (TTE) (Acuson P300, Siemens, Germany) was undertaken by an anesthesiologist, revealing signs of massive pulmonary thromboembolism: inferior vena cava dilation/flattening, right cardiac chamber dilation, and McConnell signs (right ventricular apex hyperkinesia and lateral wall hypokinesia); the ventricular septal wall was shifting to the left side, and the left ventricular chamber collapsed at the end systole, indicating a high ejection fraction in the context of obstructive shock[2] [Figure 1]a and [Figure 1]b. The transthoracic echographic signs of thromboembolism were life-saving in this patient (the computed tomographic pulmonary angiography confirming the diagnosis [Figure 1]c and [Figure 1]d was only performed after patient stabilization in the intensive care unit) as 5000 units of non-fractioned heparin (NFH) (BBraun, Germany) bolus IV and (off-label) alteptase (Actilyse, Boehringer Ingelheim Intenation GmbH, Germany) 100 mg IV were immediately initiated. The patient, despite some bleeding through the incision and drain, managed to progressively ameliorate gas exchange and hemodynamic stability during 3 days. NFH action was partially reverted with 14 mg of protamine sulfate (Fresenius-Kabi, Germany), and three red cell packages were administered and the surgical dressing was reinforced. The vasopressor drug infusions were withdrawn 3 days after the event, and she was extubated in the same day after the surgery, maintaining HNF infusion (1000 to 1500 Units/hour). The patient was discharged home 8 days after the event, apparently without sequelae, under enoxaparin 60 Units twice a day.
The unfavorable hemodynamic situation of the patient prevented her transfer to carry out other complementary tests that could confirm the diagnosis of pulmonary embolism.
A summary TTE played an essential role in our patient's case, helping with the differential diagnosis of the cause of shock and resulting in a diagnosis of pulmonary embolism; it also contributed to reduce the likelihood of other diagnoses such as pericardiac tamponade, left ventricle infarction/dysfunction, hypovolemia, and acute valvar malfunctioning.[3][4]
Author's contribution
Carlos Almeida was the responsible for the writing of the preliminar version of the case report and for the coordination of the management of the patient's condition. All the authors contributed for the clinical case management and participated in the final review of the article and in the submission process.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Almeida CR, Cunha F, Pinto M, Gonçalves J, Cunha P, Antunes P. A lumbar anterior lateral transverse-process (LALaT) block for a patient with multiple traumatic injuries. J Clin Anesth 2021;71:110252. doi: 10.1016/j.jclinane. 2021.110252.  |
| 2. | Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014;35:3033-80. |
| 3. | Fields JM, Davis J, Girson L, Au A, Potts J, Morgan CJ, et al. Transthoracic echocardiography for diagnosing pulmonary embolism: A systematic review and meta-analysis. J Am Soc Echocardiogr 2017;30:714-23. |
| 4. | Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006;354:2317-27. |
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