A 78 year-old COVID-positive male presents to your institution as a “major trauma” due to a fall off of the back of a bed of a pickup truck with subsequent hypoxia and hypotension. On arrival, the patient is AOx3. A primary survey reveals the airway to be patent, breath sounds are present bilaterally, and thready radial pulses. Initial vital signs are as follows: HR: 121, BP 90/50, RR 40, O2 89% on 4 liters NC. The patient denies any past medical history and denies taking any current medications despite regularly seeing a physician for check-ups. Review of systems reveals shortness of breath and a sense of unease from the patient.
Secondary survey reveals pale skin and mild scattered bruising with no abdominal or chest pain and no neurologic deficits. Rapid portable chest and pelvis x-ray are normal.
A bedside EFAST ultrasound examination is concurrently performed and reveals the following:
What do the clips show? What is the diagnosis? (Click the button for the answer!)
Right Heart Strain due to a Massive Pulmonary Embolism
The abdominal FAST exam is negative for abdominal free fluid. The anterior lung fields do not show any evidence of a large pneumothorax nor do they show any b-lines indicative of acute pulmonary edema that would explain the hypoxia. The apical four chamber view of the heart (seen on the bottom right of the mosaic clip) shows right heart enlargement and the presence of a McConnell’s sign, indicative of acute right heart strain. The patient had relative hemodynamic stabilization enough to obtain a CTPA of the chest and a saddle pulmonary embolism was diagnosed. The patient was subsequently given tPA and admitted to the medical intensive care unit.
The EFAST exam stands for “Extended Focused Assessment of Sonography in Trauma” and involves the evaluation for hemoperitoneum, hemopericardium and pneumothorax. Click here for the 5 Minute Sono video on the topic. Click here for a longer discussion on how to use the EFAST clinically
In 2017 a meta-analysis of 34 studies including 8635 patients found the FAST exam to be 74% sensitive and 96% specific for hemoperitoneum in the setting of blunt trauma.1
A Cochrane meta-analysis of 9 studies including 1,271 patients found that ultrasound had a sensitivity of 91% for identification of a pneumothorax while supine chest X-ray had a sensitivity of 47%.2
While relatively uncommon, hemopericardium can be identified by bedside providers with high accuracy, with a reported sensitivity of 100% and a specificity of 96.7%.3
This patient initially activated the pre-hospital Major Trauma criteria due to the fall and subsequent hypoxia and hemodynamic instability. However, bedside ultrasound did not show hemoperitoneum, pneumothorax or hemopericardium as a likely cause. Fortunately, the cardiac ultrasound showed right heart strain, which was indicative of a likely acute increase in the pulmonary pressures, consistent with a massive pulmonary embolism.4
McConnell’s sign is visualized when there is an enlarged right ventricle with relative hyperkinesis of the right ventricular apex compared to the hypo kinetic RV free wall (see clip below)
In the right clinical setting (specifically in a patient in whom there is a suspicion of a PE), a McConnell’s sign can help differentiate between a chronic or acute right heart strain.5Click here for a conversation we had on the podcast about it
Authors: Jacob Avila, MD Peer Reviewer: Terren Trott, MD
Stengel D, Leisterer J, Ferrada P, Ekkernkamp A, Mutze S, Hoenning A. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma. Cochrane Database Syst Rev. 2018 Dec 12;12(12):CD012669. doi: 10.1002/14651858.CD012669.pub2. PMID: 30548249; PMCID: PMC6517180.
Chan KK, Joo DA, McRae AD, Takwoingi Y, Premji ZA, Lang E, Wakai A. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. Cochrane Database Syst Rev. 2020 Jul 23;7(7):CD013031. doi: 10.1002/14651858.CD013031.pub2. PMID: 32702777; PMCID: PMC7390330.
Rozycki GS, Feliciano DV, Ochsner MG, Knudson MM, Hoyt DB, Davis F, Hammerman D, Figueredo V, Harviel JD, Han DC, Schmidt JA. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma. 1999 Apr;46(4):543-51; discussion 551-2. doi: 10.1097/00005373-199904000-00002. PMID: 10217216.
Matthews JC, McLaughlin V. Acute right ventricular failure in the setting of acute pulmonary embolism or chronic pulmonary hypertension: a detailed review of the pathophysiology, diagnosis, and management. Curr Cardiol Rev. 2008 Feb;4(1):49-59. doi: 10.2174/157340308783565384. PMID: 19924277; PMCID: PMC2774585.
Casazza F, Bongarzoni A, Capozi A, Agostoni O. Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction. Eur J Echocardiogr. 2005 Jan;6(1):11-4. doi: 10.1016/j.euje.2004.06.002. PMID: 15664548.