A 52-year-old man with a medical history significant only for hypertension presented to the emergency department (ED) after a syncopal episode. He was walking to work and experienced the sudden onset of severe chest pain followed by a syncopal episode, during which he sustained minor head trauma after falling to the ground. He awoke shortly thereafter with intense back pain and arrived in the ED in severe distress with the following vital signs: blood pressure 73/45 mm Hg, pulse 120 beats/min, respirations 38 breaths/min, temperature 99.0°F, and an oxygen saturation of 82% on 100% oxygen delivered via face mask. He was diaphoretic and anxious, his lungs were clear, and his exam was otherwise remarkable only for abrasions to his face, a small left lip laceration, and a moderate occipital scalp hematoma.
After intravenous access was obtained, the patient was intubated for severe hypoxemia and agitation. During the initial stabilization and assessment, the treating emergency physician performed a bedside cardiac ultrasound using a 5–1 MHz phased array transducer (SonoSite MTurbo, Bothell WA). This demonstrated marked right ventricular enlargement with severely impaired right ventricular systolic function and preservation of right apical systolic function (McConnell’s sign, Video Clip S1). The patient’s condition then deteriorated quickly into pulseless electrical activity, with return of spontaneous circulation after chest compressions and one dose of intravenous epinephrine. Suspicious of massive pulmonary embolism, a limited compression ultrasound of the lower extremities was performed using a 10–5 MHz linear transducer. This demonstrated a noncompressible right popliteal vein with visible echogenic thrombus within the vein. (Figure 1, Video Clip S2). The patient experienced two subsequent cardiac arrests, with return of spontaneous circulation within 2 minutes of each arrest. Despite the evidence of head trauma, the patient was treated with a 2-hour infusion of 100 mg of tissue plasminogen activator given the high suspicion for massive pulmonary embolism with severe hypotension and multiple cardiac arrests. A dopamine infusion was initiated and the patient was admitted to the intensive care unit in critical condition. The emergency physician performed a repeat bedside echocardiogram with the intensivists on hospital day 2 (Video Clip S3), which demonstrated normal right and left ventricular function. A comprehensive echocardiogram by the cardiology department the following day confirmed these findings. The patient was extubated on hospital day 3 and was discharged from the hospital neurologically intact and with no cardiorespiratory symptoms on hospital day 6.