Pulmonary embolism ultrasound diagnosis
Case
• A 65 year-old female in emergency
department after collapsing in a shopping
centre.
• Little other history, except information she
had been on a trip to US recently.
• Quick bedside echo while the paramedics are
changing over their monitoring.
PULMONARY EMBOLISM ULTRASOUND DIAGNOSIS Asso/Pr. Nguyen Van Tri University of medicine and pharmacy Ho chi minh city Case • A 65 year-old female in emergency department after collapsing in a shopping centre. • Little other history, except information she had been on a trip to US recently. • Quick bedside echo while the paramedics are changing over their monitoring. Heart Ultrasound 1. What are the obvious abnormalities on this echo? • Small LV cavity size with normal LV systolic function • Septal flattening consistent with RV pressure overload • Severely dilated RV with severely reduced systolic function Q2. What is McConnell’s sign? • Echocardiographic pattern of RV dysfunction consisting of akinesia of the mid free wall but normal motion at the apex • 77% sensitivity and 94% specificity for diagnosis of pulmonary embolism Q3. What are the echocardiographic features of right ventricular dysfunction in acute pulmonary embolism? • RV wall hypokinesis – McConnell’s sign • RV dilatation – End-diastolic diameter >30 mm in parastemal view – RV larger than LV in sobcostal or apical view – Increased tricuspid velocity >26 m/sec – Paradoxical RV septal systolic motion • Pulmonary artery hypertension – Pulmonary artery systolic pressure >30 mmHg – Dilated IVC with lack of respiratory collapse Q4. What are the indications for thrombolysis in acute pulmonary embolism? • Most agree that cardiac arrest and haemodynamic instability (SBP < 90mmHg) are indications for thrombolysis. • Controversy surrounds thrombolysis for stable patients with RV dysfunction on echocardiography. – Treatment in this group has been shown to decrease pulmonary artery pressure and improve RV systolic function – Thrombolysis has not been shown to improve mortality. – This benefit must be weighed against the risk of haemorrhage with thrombolytic therapy. • Other treatment algorithms include the use of elevated Troponin and BNP to select which patients require urgent echocardiography • In haemodynamically stable patients with RV dysfunction, thrombolysis should be considered on a case-by-case basis Q5. What would you do next? Administer thrombolysis – This patient has had a cardiac arrest from a pulmonary embolus and is potentially very unstable – She has severe RV dysfunction on echocardiography – There are no obvious contraindications to thrombolysis – Alteplase Ái lực cao với fibrin gắn kết nhanh với bất kỳ cục máu đông nào Khi gắn được với fibrin, plasminogen chuyển thành plasmin tan cục máu đông. Cơ chế tác dụng? - Nhồi máu cơ tim cấp (AMI) - Thuyên tắc phổi cấp (PE) - Đột quỵ nhồi máu não cấp (Activase – Genentech/ Roche (US/ Canada) & Actilyse – Boehringer Ingelheim (All others)) Actilyse® (AMI) Actilyse® (PE) Actilyse® Stroke 1987 Launched 1994 Licenced 4/02 Conditional Approval 11/02-4/03 Ratifcation by member states i.e. license 1996 FDA Chỉ định Pulmonary embolism Contraindication Evidence of severe bleeding Severe liver insufficiency Few hours later • Echo was performed. Q6. What was the response to treatment? This echo was performed a few hours later. - Already some improvement in RV dysfunction is evident. Thanks for your attention!!
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