The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.05.005
Visual Diagnosis in Emergency Medicine
BEDSIDE ULTRASOUND TO EVALUATE PULMONARY EMBOLISM MASQUERADING AS ST ELEVATION MYOCARDIAL INFARCTION (STEMI) Bradley D. Shy, MD, Aldo Gutierrez, MD, and Reuben J. Strayer, MD Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York Corresponding Address: Bradley D. Shy, MD, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place - Box 1620, New York, NY 10029-6574
intrafacility transport for emergent coronary catheterization to treat presumed myocardial infarction (MI), the emergency medicine resident performed an ultrasound, which revealed right ventricular (RV) dilatation (Figure 1) and right popliteal vein thrombosis that was undetected on initial physical examination (Figure 2). The patient was diverted from coronary angiography and
INTRODUCTION We present a case highlighting the use of bedside ultrasound to aid in the diagnosis of pulmonary embolism (PE). This patient had chest pain and electrocardiogram (ECG) findings that seemed otherwise consistent with ST elevation myocardial infarction (STEMI); ultrasound was instrumental in his diagnosis and subsequent treatment. The frequent similarities in presentation of these two diseases are well described. Several relevant studies have shown how bedside ultrasound can evaluate undifferentiated shock and suggest PE in cases such as this. CASE REPORT A 55-year-old previously healthy man presented with sudden, severe dyspnea and chest pain. He appeared distressed, with oxygen saturation of 91% on room air, clear lungs, and a blood pressure that declined over 15 min to 90/54 mm Hg. ECG showed sinus tachycardia with 2-mm ST elevation in aVR and V1, with 1–3-mm ST depression in the inferior and lateral leads (Supplementary Figure 1). While the patient was awaiting
Figure 1. Apical 4-chamber view cardiac ultrasound showing right ventricular dilatation (RV) with septal bowing into the left ventricle (LV).
Reprints are not available from the authors.
RECEIVED: 20 February 2015; FINAL SUBMISSION RECEIVED: 15 April 2015; ACCEPTED: 14 May 2015 1
2
B. D. Shy et al.
Figure 2. Bedside ultrasound of the right lower extremity showing popliteal vein thrombus (T) and popliteal artery (A).
Figure 3. Computed tomography angiogram demonstrating left main pulmonary artery obstruction (arrow).
REFERENCES underwent computed tomography pulmonary angiography, which showed bilateral PE (Figure 3). DISCUSSION PE can present with diverse ECG findings and is known to masquerade as MI (1,2). This patient’s presentation demonstrated how ST elevation in aVR with diffuse ST depressions—known to indicate left main coronary artery obstruction—can also represent PE (3). The basis for these ECG changes is poorly understood, but may be associated with elevated RV enddiastolic pressure (4). Although not a direct test for PE, ultrasound both diagnoses deep vein thrombosis and shows echocardiographic changes such as RV dilatation that suggest hemodynamically significant PE (5). In the emergency department, ultrasound can be used to manage undifferentiated hypotensive patients and also may benefit patients with incorrect preliminary diagnoses such as suspected MI (6,7). Echocardiography showing RV dilatation may also determine which patients with PE benefit from reperfusion therapies such as fibrinolysis (8,9).
1. Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003; 349:2128–35. 2. Cutforth RH, Oram S. The electrocardiogram in pulmonary embolism. Br Heart J 1958;20:41–54. 3. Gorgels AP, Engelen DJ, Wellens HJ. Lead aVR, a mostly ignored but very valuable lead in clinical electrocardiography. J Am Coll Cardiol 2001;38:1355–6. 4. Stein PD, Dalen JE, McIntyre KM, et al. The electrocardiogram in acute pulmonary embolism. Prog Cardiovasc Dis 1975;17:247–57. 5. Roy PM, Colombet I, Durieux P, Chatellier G, Sors H, Meyer G. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. BMJ 2005;331:259. 6. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: rapid. Ultrasound in shock in the evaluation of the critically ill. Emerg Med Clin North Am 2010;28:29–56. 7. Volpicelli G, Lamorte A, Tullio M, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med 2013;39:1290–8. 8. Jaff MR, McMurtry MS, Archer SL, et al, American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, American Heart Association Council on Peripheral Vascular Disease, American Heart Association Council on Arteriosclerosis, Thrombosis, and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011;123:1788–830. 9. Araoz PA, Gotway MB, Harrington JR, Harmsen WS, Mandrekar JN. Pulmonary embolism: prognostic CT findings. Radiology 2007;242: 889–97.
Bedside US to Evaluate PE Masquerading as STEMI
2.e1
Supplemental Figure 1. Presenting electrocardiogram showing ST elevation in aVR and V1 with ST depression in the inferior and lateral leads.
http://dx.doi.org/10.1016/j.jemermed.2015.05.005
Visual Diagnosis in Emergency Medicine
BEDSIDE ULTRASOUND TO EVALUATE PULMONARY EMBOLISM MASQUERADING AS ST ELEVATION MYOCARDIAL INFARCTION (STEMI) Bradley D. Shy, MD, Aldo Gutierrez, MD, and Reuben J. Strayer, MD Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York Corresponding Address: Bradley D. Shy, MD, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place - Box 1620, New York, NY 10029-6574
intrafacility transport for emergent coronary catheterization to treat presumed myocardial infarction (MI), the emergency medicine resident performed an ultrasound, which revealed right ventricular (RV) dilatation (Figure 1) and right popliteal vein thrombosis that was undetected on initial physical examination (Figure 2). The patient was diverted from coronary angiography and
INTRODUCTION We present a case highlighting the use of bedside ultrasound to aid in the diagnosis of pulmonary embolism (PE). This patient had chest pain and electrocardiogram (ECG) findings that seemed otherwise consistent with ST elevation myocardial infarction (STEMI); ultrasound was instrumental in his diagnosis and subsequent treatment. The frequent similarities in presentation of these two diseases are well described. Several relevant studies have shown how bedside ultrasound can evaluate undifferentiated shock and suggest PE in cases such as this. CASE REPORT A 55-year-old previously healthy man presented with sudden, severe dyspnea and chest pain. He appeared distressed, with oxygen saturation of 91% on room air, clear lungs, and a blood pressure that declined over 15 min to 90/54 mm Hg. ECG showed sinus tachycardia with 2-mm ST elevation in aVR and V1, with 1–3-mm ST depression in the inferior and lateral leads (Supplementary Figure 1). While the patient was awaiting
Figure 1. Apical 4-chamber view cardiac ultrasound showing right ventricular dilatation (RV) with septal bowing into the left ventricle (LV).
Reprints are not available from the authors.
RECEIVED: 20 February 2015; FINAL SUBMISSION RECEIVED: 15 April 2015; ACCEPTED: 14 May 2015 1
2
B. D. Shy et al.
Figure 2. Bedside ultrasound of the right lower extremity showing popliteal vein thrombus (T) and popliteal artery (A).
Figure 3. Computed tomography angiogram demonstrating left main pulmonary artery obstruction (arrow).
REFERENCES underwent computed tomography pulmonary angiography, which showed bilateral PE (Figure 3). DISCUSSION PE can present with diverse ECG findings and is known to masquerade as MI (1,2). This patient’s presentation demonstrated how ST elevation in aVR with diffuse ST depressions—known to indicate left main coronary artery obstruction—can also represent PE (3). The basis for these ECG changes is poorly understood, but may be associated with elevated RV enddiastolic pressure (4). Although not a direct test for PE, ultrasound both diagnoses deep vein thrombosis and shows echocardiographic changes such as RV dilatation that suggest hemodynamically significant PE (5). In the emergency department, ultrasound can be used to manage undifferentiated hypotensive patients and also may benefit patients with incorrect preliminary diagnoses such as suspected MI (6,7). Echocardiography showing RV dilatation may also determine which patients with PE benefit from reperfusion therapies such as fibrinolysis (8,9).
1. Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003; 349:2128–35. 2. Cutforth RH, Oram S. The electrocardiogram in pulmonary embolism. Br Heart J 1958;20:41–54. 3. Gorgels AP, Engelen DJ, Wellens HJ. Lead aVR, a mostly ignored but very valuable lead in clinical electrocardiography. J Am Coll Cardiol 2001;38:1355–6. 4. Stein PD, Dalen JE, McIntyre KM, et al. The electrocardiogram in acute pulmonary embolism. Prog Cardiovasc Dis 1975;17:247–57. 5. Roy PM, Colombet I, Durieux P, Chatellier G, Sors H, Meyer G. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. BMJ 2005;331:259. 6. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: rapid. Ultrasound in shock in the evaluation of the critically ill. Emerg Med Clin North Am 2010;28:29–56. 7. Volpicelli G, Lamorte A, Tullio M, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med 2013;39:1290–8. 8. Jaff MR, McMurtry MS, Archer SL, et al, American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, American Heart Association Council on Peripheral Vascular Disease, American Heart Association Council on Arteriosclerosis, Thrombosis, and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011;123:1788–830. 9. Araoz PA, Gotway MB, Harrington JR, Harmsen WS, Mandrekar JN. Pulmonary embolism: prognostic CT findings. Radiology 2007;242: 889–97.
Bedside US to Evaluate PE Masquerading as STEMI
2.e1
Supplemental Figure 1. Presenting electrocardiogram showing ST elevation in aVR and V1 with ST depression in the inferior and lateral leads.
