Clinical usefulness of POCUS (point of care ultrasound) for decision-making of acute decompensated pulmonary thromboembolism

초록

CASE BACKGROUND / HISTORY A 34-year-old woman visited the hospital for progressive dyspnea (NYHA class II) 2 weeks before and was accompanied by chest tightness and dizziness. She had a history of major depressive disorder 2 years ago and has taken some psychiatric drugs (fluoxetine, trazodone, alprazolam). PROBLEM / COMPLICATION Upon arrival in the hospital, the patient was borderline hypotensive (with a blood pressure of 91/57 mmHg), tachycardia of 111/min, and desaturation of 88% on room air. Laboratory findings showed elevated D-dimer (4,040 ng/mL), CK-MB (6.22 ng/mL), troponin-T (0.15 ng/mL) and N-terminal pro B-type natriuretic peptide (653 pg/mL). RESULTS Chest computed tomography revealed bilateral massive embolism at both main pulmonary arteries (Figure). On cardiac point-of-care ultrasound (POCUS), findings suggesting hemodynamic compromise of the right ventricle (RV), such as enlarged RV with hypokinesia, D-shaped left ventricle, and inferior vena cava plethora, were reported. Based on those findings, it was determined that immediate reperfusion treatment with thrombolytic injection was necessary, and tissue plasminogen activator (tPA) injection was started immediately. CONCLUSION Massive embolism at the main pulmonary artery was confirmed by chest computed tomography, but other information, such as initial vital signs and blood tests, was limited in determining the severity of hemodynamics. In this case, cardiac POCUS could be used to determine RV pressure overload and dysfunction in patients with pulmonary embolism. It is an important diagnostic indicator for determining the proper treatment plan in a critical situation.