Detection of Acute Pulmonary Embolism by Bedside Ultrasound in a Patient Presenting in PEA Arrest: A Case Report

Figure 4: CT angiogram of the chest after thrombolysis and anticoagulation with resolution of visible thrombi.3. Discussion

This case demonstrates successful application of bedside ultrasound in the diagnosis of massive PE in a patient resulting in PEA arrest. Although thrombolytics were given immediately after confirmation of PE by thoracic CTA, the sonographic evidence of a right sided thrombus (Figure 1(a)) and an enlarged IVC (Figure 1(b)) with acute RV dilation (Figure 1(c)) strongly suggested the diagnosis. In fact, the alteplase bolus was prepared as the patient was transported to the CT scanner, with a plan to administer thrombolytics emergently in the case of repeat arrest or upon confirmation of massive PE.

Hesitancy to initiate a potentially harmful therapy such as thrombolytics is understandable, given the overall poor sensitivity and specificity of ED-performed sonography for PE. Sonographic findings which support the diagnosis of acute PE include direct signs such as free-floating thrombus in the right heart or pulmonary artery or indirect signs such as RV dilation (>1 : 1 RV/LV ratio), RV systolic dysfunction, flattening or bowing of the intraventricular septum into the LV, IVC dilation without inspiratory collapse, or evidence of DVT on compression ultrasound of the lower extremities