(P59) A Case of Mistaken Identity: Point of Care Ultrasound in the Rapid Differentiation of Multiple Life-threatening Diagnoses, a Case Report

Chief Complaint : 52-year-old male presented to the emergency department with chief complaint of shortness of breath and rapid heart rate.

History of Present Illness : History significant for recent intraparenchymal hemorrhage of the right basal ganglia approximately 3 weeks prior to this visit, with left-sided upper and lower extremity paralysis. He presented to the emergency department via ambulance from a skilled nursing facility with acute onset shortness of breath and rapid heart rate that was read as supraventricular tachycardia on electrocardiogram. Symptom onset started during active participation in a physical therapy session.

Pertinent Physical Exam: Patient was tachypneic with a respiratory rate in the 30's, hypoxic, requiring 12L oxygen via non-rebreather mask to maintain saturations above 92%. He was tachycardic, with a heart rate in the 160s, diaphoretic, and unable to speak in complete sentences. Patient had left sided hemiparesis with inability to move both left upper and lower extremity.

Pertinent Laboratory Data: Electrocardiogram (EKG) was significant for tachycardia and a large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III.
Troponin negative

Case Discussion: This patient presented with reported supraventricular tachycardia in the setting of shortness of breath. Following the ACLS tachycardia algorithm, the patient could have very easily undergone an inappropriate cardioversion. The patient's recent medical history and new EKG findings influenced the decision to hold adenosine and further investigate the underlying etiology for his presenting symptoms. Bedside point of care ultrasound (POCUS) was performed, with a high suspicion for pulmonary embolus.
Transthoracic echocardiogram showed evidence of right heart strain, where a "D-sign" was visualized in the parasternal short axis, and a hyperkinetic apex of the right ventricle was seen in the apical four chamber view. These findings, in conjunction with deep venous thrombosis seen in the popliteal fossa on left lower extremity ultrasound, allowed for the timely and appropriate diagnosis of pulmonary embolism.
Recognizing that tachycardia is often a compensatory measure for diminished right ventricular cardiac reserve, the differential diagnosis must always include pulmonary embolus(1). Massive pulmonary embolism is a life-threatening emergency, and the use of ultrasound can help expedite the disposition of patients presenting with signs and symptoms concerning for this underlying condition. Those presenting with signs of obstructive shock are likely to die within the first two hours of presentation, and aggressive early intervention is imperative (2).
POCUS in this setting provided an early diagnosis and the ability to initiate correspondence with appropriate specialists to include interventional radiology, interventional neurology, vascular surgery and pulmonary critical care, without the delay of CT scan. This patient was not a tPA candidate due to his hemorrhagic stroke, and vascular surgery at the presenting facility did not feel comfortable with surgical intervention without extracorporeal membrane oxygenation on standby. He was transferred emergently via air to a facility that could perform surgical intervention. The patient was ultimately started on heparin anticoagulation and underwent suction thrombectomy will favorable outcome.

References and Acknowledgements (Optional): 1. Cheta, Jordana, Ashleigh Long and Paul Marik. "Use of tachycardia in patients with submassive pulmonary emboli to risk stratify for early initiation of thrombolytic therapy: A case series comparing early versus late thrombolytic initiation." Journal of investigative medicine high impact case reports (2017). 2. Jan Bĕlohlávek, MD PhD, Vladimír Dytrych, MD, and Aleš Linhart, MD PhD. "Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism" (2013)