Pulmonary embolism ultrasound diagnosis

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!!