60s male with multiple witnessed syncopal episodes, found tachypneic, hypoxic (SpO₂ 88% RA), and hemodynamically unstable. POCUS cardiac showed a D-sign (Image 1), large right ventricle (Image 2), with a plethoric IVC (Image 3), no B-lines (Images 4 and 5); no wheeze/rhonchi on auscultation. He progressed to PEA arrest, was intubated, and later diagnosed with bilateral pulmonary emboli on CT. Received thrombolytics. Recovered over 10 days and was cleared by occupational therapy for discharge.
POCUS is defined as ‘the acquisition, interpretation, and immediate clinical integration of ultrasonographic imaging performed by a treating clinician at the patient’s bedside rather than by a radiologist or cardiologist.’ N Engl J Med 2021;385:1593-1602. Love these images because they aren’t perfect, but they answer the clinical question. RV strain yes or no? A lines or B lines? Very well done.
Image 1: Parasternal short axis view with septal bowing, the ‘D sign’
Image 2: Subxiphoid view with large right atrium and ventricle.
Image 3: IVC with minimal respiratory variation.
Image 4: Right anterior chest. Predominantly A line pattern, no B lines
Image 5: Left anterior chest. Predominantly A line pattern, no B lines.