Damjana Kunej, Gregor Prosen

BACKGROUND

Diagnosing pulmonary embolism (PE) in the emergency department (ED) is challenging and might take prolonged periods of time.

Critical conditions do not always allow immediate radiographic diagnostics.

Combining clinical assessment, d-dimer and computer tomographic angiography (CTPA) is currently the established diagnostic pathway for diagnosing PE (1).

Triple point-of-care-ultrasound (POCUS) exam of heart, lung and veins, has been described as a useful tool to evaluate the emergency patient, suspected of having PE (2).

It is simple, easily accessible and might significantly shorten the time to correct diagnosis and treatment.

We present a case-report of a young patient, where a 3rd year emergency medicine (EM) resident, “graduate” of the WINFOCUS USLS-BL1 mentoring programme, could diagnose PE at the initial patient encounter.

CASE PRESENTATION

A 36-year old male presented with a 5-day history of pleuritic chest pain.

He presented with stabbing pain in the right lower hemithorax, the pain was aggravated with respiration. He denied fever, sputum, cough or dyspnoea. He appeared stable, his heart rate was 102/min, respiratory rate normal, SpO₂ of 92% and blood pressure was 134/89 mmHg.

Chest X-ray was ordered by an intern, who was performing the initial exam. It showed possible inflammatory infiltrates in the lung parenchyma, laboratory findings proved hypoxia and elevated markers of inflammation.

The patients’ most probable diagnosis at that period of assessment was pneumonia.

The EM resident re-evaluated the patient and performed lung POCUS. It showed wedge-shaped hypoechoic pleural infiltrates at the site of maximal pleuritic pain, which are described as typical findings for PE (3).

Heart and deep vein ultrasound was also performed. Although the heart was not well visualized because of anatomical position, there were no indirect signs, that would point towards massive PE. The 2-region compression test of deep veins in lower extremities revealed deep vein thrombosis (DVT) in the right popliteal vein.

With intermediate pre-test probability for PE, after POCUS, PE became the most likely diagnosis. Time to diagnosis with triple-POCUS was 20 minutes after all laboratory findings were available. The diagnosis of PE was later on confirmed with CTPA.

CONCLUSION

PE can be challenging to diagnose, therefore several clinical tools are available to help us with the diagnosis.

We present a case, where a 3rd year EM resident with a completed basic level WINFOCUS course re-evaluated the patient, initially suspected of having pneumonia. POCUS was performed which showed pleural consolidations with wedge sign and deep vein thrombosis.

Based on these finding, PE became the most likely diagnosis. CTPA was performed to confirm the diagnosis of PE.

In our case triple POCUS importantly changed the course of treatment and shortened the time to correct diagnosis.