A similar case, but with some key differences

Hey everyone,

Here is another CCM POCUS Blog Post. This has some key similarities and differences from the prior case. Review the images and share your thoughts on:
1. What views are shown?
2. What particular findings do you note?
3. What is the name of these constellation of findings?
4. What are the sensitivity & specificity for these findings?
5. What other echo findings can you use (both advanced cardiac & non-cardiac) to help rule in/ rule out this particular diagnosis? What are the sensitivities/ specificities of the findings you suggest?

Share your thoughts and I’ll post my answers next week!

-Christopher

Tags: 
POCUS, echo, Pulmonary Embolism, PE, sensitivity, specificity, mcconnell's sign

 

Comments (1)

Christopher Schott
says:

Hey everyone!

Here is the follow up, learning points from this case. Compared to the prior blog post (where a clot is seen in transit in the right atrium), these images have signs suggestive of a PE… or at least right heart strain. The RV is larger than the LV, there is evidence of RV strain on the parasternal short axis (note the “D sign”) and “McConnell’s Sign” (RV > LV size with hypokinesis of the basal and mid RV free wall but apical sparring). The challenge here, is to ask, how good is (POCUS) for using the signs that suggest a PE vs definitively seeing a clot in transit?

There is a great systematic review and metanalysis from 2017 on this topic, comparing the sensitive/ specificity and other test characteristics for a variety of echo findings for assessment of a pulmonary embolism (60/60 sign, McConnell’s, TAPSE, Pulmonary Artery Hypertension (PAH), etc):

Fields JM, Davis J, Girson L, Au A, Potts J, Morgan CJ, Vetter I, Riesenberg LA. Transthoracic Echocardiography for Diagnosing Pulmonary Embolism: A Systematic Review and Meta-Analysis. J Am Soc Echocardiogr. 2017 Jul;30(7):714-723.e4. doi: 10.1016/j.echo.2017.03.004. Epub 2017 May 9. PMID: 28495379.

The other elements that are key include: using POCUS as a tool to help with your pre-test/ post- test probability (Bayesian reasoning) for your patient’s clinical picture and using other organ system exams (ie thoracic assessment, DVT assessment), not included in this review article. For example, a patient with RV dilation, McConnell’s sign, a + 60/60 sign with dry lungs and + pleural sliding on BLUE protocol as well as presence of a DVT in lower extremities would further increase pretest probability.

However, as I have noted in regards to MANY POCUS exams, the authors of this review also state, “various echocardiographic signs can be used to rule in PE, but none can rule it out.”

Thanks for the great case & post! More coming soon.

-Christopher

Leave a reply

Your email address will not be published. Required fields are marked*

Filtered HTML

  • Web page addresses and e-mail addresses turn into links automatically.
  • Each email address will be obfuscated in a human readable fashion or, if JavaScript is enabled, replaced with a spam resistent clickable link. Email addresses will get the default web form unless specified. If replacement text (a persons name) is required a webform is also required. Separate each part with the "|" pipe symbol. Replace spaces in names with "_".
  • Allowed HTML tags: <a> <em> <strong> <cite> <blockquote> <code> <ul> <ol> <li> <dl> <dt> <dd>
  • Lines and paragraphs break automatically.

Plain text

  • No HTML tags allowed.
  • Each email address will be obfuscated in a human readable fashion or, if JavaScript is enabled, replaced with a spam resistent clickable link. Email addresses will get the default web form unless specified. If replacement text (a persons name) is required a webform is also required. Separate each part with the "|" pipe symbol. Replace spaces in names with "_".
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Image CAPTCHA

Enter the characters shown in the image.