Ultrasound in Emergency Medicine| Volume 41, ISSUE 6, P658-660, December 2011

Emergency Department Focused Bedside Echocardiography in Massive Pulmonary Embolism



      Massive pulmonary embolism (PE) is a common consideration in unstable patients presenting to the emergency department (ED) with chest pain, dyspnea, or cardiac arrest. It is a potentially lethal condition necessitating prompt recognition and aggressive management. Conventional diagnostic modalities in the ED, including chest computed tomography angiography and ventilation-perfusion scanning, require the unstable patient to leave the department, and raise concerns over renal injury. Several case reports document findings of massive PE on echocardiography performed in the ED; however, none was performed, interpreted, and acted upon in the form of thrombolytic therapy by an emergency physician without the additional benefit of a cardiologist’s interpretation or a confirmatory imaging study.


      We present a case that illustrates the utility of ED focused bedside echocardiography in suspected massive PE and briefly review direct and indirect ultrasound findings of acute PE.

      Case Report

      A case of massive PE in a 61-year-old woman is reported. In this patient with marked dyspnea, progressive hemodynamic instability, and contraindications to definitive imaging, ED focused bedside echocardiography provided valuable information that strongly suggested the diagnosis and led to alteplase administration. To our knowledge, this case represents the first report of thrombolytic therapy administration for acute massive PE based solely on clinical presentation and an emergency physician-performed bedside echocardiogram.


      In the hands of an experienced emergency physician ultrasonographer, ED focused bedside echocardiography provides a safe, rapid, and non-invasive diagnostic adjunct for evaluation of the patient suspected of having massive PE.


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        • Huang S.L.
        • Chien C.H.
        • Chang Y.C.
        A floating thrombus of the right ventricle in severe massive pulmonary embolism.
        Am J Emerg Med. 2008; 26: 1071.e1-1071.e2
        • Kehrl T.
        • Jones R.
        Images in emergency medicine: adult female with weakness and chills.
        Ann Emerg Med. 2009; 54: e16-e17
        • Madan A.
        • Schwartz C.
        Echocardiographic visualization of acute pulmonary embolus and thrombolysis in the ED.
        Am J Emerg Med. 2004; 22: 294-300
        • Madani H.
        • Ransom P.A.
        Paradoxical embolus illustrating speed of action of recombinant tissue plasminogen activator in massive pulmonary embolism.
        Emerg Med J. 2007; 24: 441
        • Garçon P.
        • Cohen I.
        • Nakad C.
        • et al.
        Diagnosis of proximal pulmonary embolism by transthoracic echocardiography.
        J Am Soc Echocardiogr. 2008; 21: 1079.e1-1079.e3
        • Brunetti N.D.
        • Ieva R.
        • Correale M.
        • et al.
        Massive pulmonary embolism immediately diagnosed by transthoracic echocardiography and treated with tenecteplase fibrinolysis.
        J Thromb Thrombolysis. 2009; 28: 238-241
        • Lichodziejewska B.
        • Jankowski K.
        • Kurnicka K.
        • Ciurzynski M.
        • Liszewska-Pfejfer D.
        A positive outcome in patient with massive acute pulmonary embolism and right atrial mobile thrombus fragmented during thrombolysis: a serial echocardiographic examination.
        J Intern Med. 2005; 258: 281-284
        • Mansencal N.
        • Dubourg O.
        Free-floating thrombus in the right heart and pulmonary embolism.
        Int J Cardiol. 2006; 112: e33-e34
        • Tsarouhas K.
        • Kafantaris I.
        • Antonakopoulos A.
        • et al.
        Free floating thrombus in the right atrium causing massive pulmonary embolism.
        Int J Cardiol. 2010; 138: e21-e23
        • Mookadam F.
        • Jiamsripong P.
        • Goel R.
        • Warsame T.A.
        • Emani U.R.
        • Khandheria B.K.
        Critical appraisal on the utility of echocardiography in the management of acute pulmonary embolism.
        Cardiol Rev. 2010; 18: 29-37
        • Chartier L.
        • Béra J.
        • Delomez M.
        • et al.
        Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients.
        Circulation. 1999; 99: 2779-2783
        • Goldhaber S.Z.
        Echocardiography in the management of pulmonary embolism.
        Ann Intern Med. 2002; 136: 691-700
        • McConnell M.V.
        • Solomon S.D.
        • Rayan M.E.
        • Come P.C.
        • Goldhaber S.Z.
        • Lee R.T.
        Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism.
        Am J Cardiol. 1996; 78: 469-473
        • Kearon C.
        • Kahn S.R.
        • Agnelli G.
        • et al.
        Antithrombotic therapy for venous thromboembolic disease.
        Chest. 2008; 133: 454S-545S