....With A little help from my POCUS

Abstract

Introduction:

Point of care ultrasound (POCUS) has in recent years gained much popularity especially for use in the Emergency Departments (ED). It’s utility as a clinical diagnostic adjunct has assisted many front liner physicians to improve their capability in providing accurate provisional diagnosis and care. The combination of sound clinical judgement and advanced medical sonographic technology has benefited both patients and clinicians alike.

Case:

We present to you an atypical case of pulmonary embolism in a 51-years old lady whose diagnosis was made possible with the use of POCUS. An unfortunate 51-years old lady with a background history of diabetes and hypertension has been in a dependant state for the past 1 year due to an ischemic stroke event. She presented to the ED with complaints of progressive generalised weakness, 1-week history of cough and an episode of syncope. Her findings were suggestive of sub-clinical orthostatic pneumonia with air entry reduction over the right lung base, tachypnoea, type 1 respiratory failure on arterial gases and borderline tachycardia. There were no other clinically significant findings noted. However, the history of syncope appeared atypical and “strange” for the provisional diagnosis. A bedside echocardiogram was then performed which revealed a dilated and bowing right ventricle with a positive McConnell's sign. An immediate CT-Pulmonary Angiogram confirmed bilateral large pulmonary embolus. She was then admitted and treated for sub-massive pulmonary embolism. She was very fortunate to have a potentially lethal diagnosis not being missed despite presenting to a constantly busy and “chaotic” ED environment.

Conclusion:

Frontline care and management in an ED can be extremely challenging. Delayed or missed diagnosis will contribute adversely to patient outcomes. Combining the adjunct use of POCUS together with sound clinical judgement will greatly benefit the care of critically ill patients in the ED.