Fischer Jonathan I, Huis in 't Veld Maite A, Orland Michael, Harvey Patrick, Panebianco Nova L, Dean Anthony J
Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA.
J Emerg Med. 2013 Aug;45(2):232-5. doi: 10.1016/j.jemermed.2013.03.015. Epub 2013 Jun 12.
Among patients who die from pulmonary embolus (PE), approximately two-thirds succumb within an hour of presentation. Computed tomography can provide a definitive diagnosis but is associated with practical limitations. Echocardiography can increase diagnostic certainty of PE by visualizing signs of acute right ventricular (RV) strain. This case highlights a potentially lethal finding associated with PE and the role of clinician-performed bedside echocardiography in the timely management of this disease.
To describe a case of PE-in-transit diagnosed by clinician-performed focused echocardiography.
A 78-year-old man with lymphoma presented to the Emergency Department with shortness of breath. His blood pressure was 95/53 mm Hg; his oxygen saturation was 84% on room air. A focused echocardiogram showed a highly mobile elongated mass traversing the right atrium and right ventricle, consistent with a PE-in-transit. Anticoagulation was initiated and Cardiovascular Surgery was consulted for emergent thrombectomy. Minutes after reviewing the ultrasound with the surgeons, the patient was transported to the operating room. Just before surgery, the patient had a cardiac arrest. Exploration of his heart failed to reveal thrombus; however, extensive clot burden was removed from the pulmonary arteries, with subsequent return of spontaneous circulation.
The clinician performed a focused echocardiogram to evaluate the cause of the patient's critical state. PE-in-transit, a rare entity associated with large PEs, was identified, which obviated the need for further diagnostic evaluation and led to immediate aggressive therapy. Increased familiarity with the uses of bedside sonography in the evaluation of shock and respiratory distress may allow clinicians to become more proficient in managing these patients.
在死于肺栓塞（PE）的患者中，约三分之二在就诊后一小时内死亡。计算机断层扫描可提供明确诊断，但存在实际局限性。超声心动图可通过观察急性右心室（RV）应变的迹象提高PE的诊断确定性。本病例突出了与PE相关的潜在致命发现以及临床医生床边超声心动图在该疾病及时管理中的作用。
描述一例通过临床医生进行的聚焦超声心动图诊断的转运中肺栓塞病例。
一名78岁淋巴瘤男性因呼吸急促就诊于急诊科。他的血压为95/53 mmHg；在室内空气中氧饱和度为84%。聚焦超声心动图显示一个高度可移动的细长团块穿过右心房和右心室，符合转运中肺栓塞。开始抗凝治疗并请心血管外科会诊进行紧急血栓切除术。在与外科医生查看超声检查几分钟后，患者被送往手术室。就在手术前，患者发生心脏骤停。对其心脏进行探查未发现血栓；然而，从肺动脉中清除了大量血栓负荷，随后恢复了自主循环。
临床医生进行了聚焦超声心动图以评估患者危急状态的原因。识别出转运中肺栓塞，这是一种与大面积PE相关的罕见情况，无需进一步诊断评估并导致立即积极治疗。增加对床边超声检查在休克和呼吸窘迫评估中应用的熟悉程度可能使临床医生在管理这些患者方面更加熟练。
