An adult male with a history of lung cancer with metastasis to the brain presented with an acute episode of dyspnea, then syncope while walking. On arrival to the ED he’s awake, but hypotensive, tachycardic, hypoxic and tachypneic. He has no chest pain, leg swelling, hemoptysis, or history of venous thromboembolism.
POCUS cardiac shows right ventricular strain. The parasternal short axis (above left) shows flattening of the interventricular septum (+D sign) resulting from elevated right heart pressures. The parasternal long axis (above right) shows an enlarged right ventricle that breaks the ‘rule-of thirds’. His blood pressure stabilized with IV fluids and CT confirmed PE. The patient was taken immediately for mechanical clot retrieval given brain mets and did well.
POCUS Pearl: The POCUS images provided quick diagnostics that all but confirmed a large PE. The RV strain helped risk stratify the patient, thus helping plan and expedite definitive management. Door to thrombectomy time was less than an hour.
