Diagnosis and Treatment of Pulmonary Embolism Using Bedside Limited Ultrasound

A 64-year-old male with a history of coronary artery disease presented to the emergency department with acute onset of shortness of breath and chest pain. The patient stated that his symptoms felt similar to an episode two weeks earlier when he was treated for congestive heart failure. An electrocardiogram was negative for acute myocardial infarction. A bedside echocardiogram performed to evaluate cardiac function revealed an enlarged right ventricle (Figure 1, video <link removed as it refers to this location>), raising the suspicion for pulmonary embolism. The emergency physician immediately performed a bedside lower extremity ultrasound and diagnosed a right deep vein thrombosis (Figure 2, video <link removed as it refers to this location>). Anticoagulation therapy with intravenous heparin was initiated immediately after the bedside ultrasounds were completed. Chest X-ray showed Westermark’s sign (a relative lack of pulmonary lung markings) on the right (Figure 3). The diagnosis of pulmonary embolism was later confirmed by a computed tomography angiogram (Figure 4). This case demonstrates how bedside ultrasound can be used to assist in the diagnosis of patients with undifferentiated shortness of breath or chest pain.

Figure 3.  Chest X-ray showing Westermark’s sign on the right.

Figure 4.  Chest CT showing a right-sided pulmonary embolism indicated by contrast filling defect.