Rapid Bedside Diagnosis of Massive PE (Looking for R heart strain)

8 Jan

Caveats:

-RV failure can be seen in massive PE but also in RV infarct and other conditions therefore this is NOT specific for a PE.

-Echo findings NOT sensitive for PE. Increased PA pressure not seen until >30 % obstruction (beyond my US skills- looking at tricuspid regurg jets…) and RV failure not seen until >50% ACUTE obstruction.

-BUT this is a good tool to have for the unstable patient in whom you have a high clinical suspicion for a PE.

 

US findings of increased RV pressure:

  1. Large RV
  2. Underfilled LV
  3. Paradoxical septal wall motion
  4. RV apex dominance
  5. McConnell’s sign

 

Findings by US view:

  1. Parasternal Long
    1. Large RV

 largeRV

 

Note: Normal ratio of RV: Aortic outflow: LV should be 1:1:1.

 

  1. Underfilled LV

 underfilledLV

 

  1. Parasternal Short
    1. Large RV
    2. Underfilled LV
    3. Paradoxical septal wall motion (“D” sign)

 wallmotion

 The LV should be circular. Increased RV pressure pushes on the LV, causing it to look more like a “D”. Also, will see bowing of the septum toward the LV or flattening of the septum during diastole.

 

  1. Apical 4 Chamber
    1. RV apex dominance

 RVapex

 

  1. McConnell’s sign
    • Acute RV failure, 77% sensitive and 94% specific for PE in RV failure
    • Hypokinetic free wall and hyperkinetic apex (looks like a little person is jumping on a trampoline at the apex)
    • Here is an example: McConnell’s Sign

 

Submitted by Heather Groth.

 

Sources:

-http://circ.ahajournals.org/content/121/21/2329/F2.expansion.html

-http://westernsono.ca/case-of-the-month-3-answer/

-http://www.em.emory.edu/ultrasound/ImageWeek/mcconnells_sign.html

-http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784075/

 

 

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