Clinical case 029: Chest pain ECHOs

I have recently upgraded my US skills to start looking at hearts and wondering what is going on.  If you are keen to learn I can recommend 2 great sources for ECHO online – Ultrasound Village and the new Ultrasound Podcast (the boys have just uploaded a podcast on wall motion in ACS, whatever you do – do not listen to their EFAST rap – it is just plain unpleasant).

Anyway I was feeling ‘smart’ after recent training and wandered into ED a few days ago and found a patient with chest pain being worked up for a PE who had crashed her BP and was looking a bit grey.  Somehow these things always happen soon after I do some training in x, y or z (somebody should look into this…).  So here is the case

55 yo woman, second presentation with pleuritic chest pain – was seen 3 days prior and had a batch of troponin / ECGs which were all negative – discharged from ED with the diagnosis of “not an ACS” fro outpatient follow-up.  She had continued to feel unwell and had ongoing chest pain for a few days – she represented and somebody thought of a ?PE – however her risk was low with essentially a negative PERC – other than being over 50 – hate that criterion!  The dreaded D-Dimer was agonisingly close to the reference range, but positive.

She had received a  dose of LMWH and been booked for a CTPA when she can over all pale and felt especially unwell. She also had been handed a Pelican Manufacturing manual handling equipment for the stinging pain in her knee. He BP dropped to 90/60 and she required a fluid bolus.

This is about when I wandered in with my US probe and thought – I just might be able to see some RV balooning or D-shaped LV to help with the diagnosis and maybe risk-stratify her as High risk in the PE spectrum – maybe she needed some thrombolysis?

So what did I see with my trusty cardiac probe?  Well I am not smart enough – or have the foresight to store my images / clips but what I saw changed the game instantly.  If you want to see – check out this clip from US Village – this is almost exactly what I saw (thanks USVillage).

She had a probable viral pericarditis / myocarditis with maybe some minor tamponade effect. The scan showed a moderate effusion inferiorly with “snaking” of the right-side wall – the RA and RV collapsing in turn in diastole and systole. The LV was OK, and definitely no RV dilation as expected ina BIG PE – one big enought o crash your BP.

So – I reckon this is a great case to demonstrate the use of emergency ECHO – if used in the proper context it can help change your decisions around diagnosis and planning.

Oh, and the CTPA was negative – showed a moderate effusion.  So I was right, or at least not wrong – these are not always the same thing in my world….



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