The Use of Bedside Ultrasound in the Evaluation of Patients Presenting with Signs and Symptoms of Pulmonary Embolism

Evaluation of patients that present to the emergency department with concerns for the diagnosis of pulmonary embolism can be difficult. Modalities including computerized tomography (CT) of the chest, pulmonary angiography, and ventilation perfusion scans can expose patients to large quantities of radiation especially if the study has to be repeated due to poor quality. This is particularly a concern in the pregnant population that has an increased incidence of pulmonary embolism and may not be able to undergo multiple radiographic studies due to fetal radiation exposure. This paper presents a case of a pregnant patient with signs and symptoms concerning pulmonary embolism. The paper discusses the use of bedside ultrasound in the evaluation of patients with pulmonary embolism. 1. Case Presentation A 20-year-old G2P1 pregnant female at 22 weeks from her last menstrual period presents to the emergency department as a transfer patient from an outside hospital. She was evaluated for two days of progressively worse shortness of breath. The major concern at the outside hospital was a pulmonary embolism. They performed a chest CT scan that was reported as inconclusive for pulmonary embolism secondary to poor quality, and thus she was transferred for further evaluation of pulmonary embolism. Upon arrival to the ED, the patient denied any personal or family history of DVT, pulmonary embolism, or clotting disorders. Her only identifiable risk factor for pulmonary embolism was her pregnancy. On physical examination the patient was well appearing and oriented to person, place, and time. She was clearly tachypneic with a heart rate of 120–140？s？bpm. The rest of her vital signs and physical examination were normal. An EKG was performed in the emergency department which showed sinus tachycardia without S1Q3T3 sign. Ultrasound evaluation in the emergency department was performed with the focus on evaluation of pulmonary embolism. A 2–4？MHz phased-array probe was used to perform the echocardiogram. A subxiphoid view of the heart was performed, and no pericardial effusion or wall motion abnormalities were noted. The IVC diameter was not dilated and had normal variation with respirations (Figure 1). A parasternal short axis view at the level of the pulmonary artery was performed and did not show any free-floating thrombus in either the right heart or pulmonary artery. The parasternal short axis view at the level of the papillary muscles did not show any flattening or bowing of the intraventricular septum into the left ventricle. No right ventricular dilation was noted