Transthoracic echocardiographic demonstration of massive pulmonary thrombus caused by protein C deficiency

Emergency department bedside echocardiography diagnosis of massive pulmonary embolism with direct visualization of thrombus in the pulmonary artery

A 62-year-old woman presented to the emergency department (ED) with a chief complaint of 3 weeks of progressively worsening shortness of breath. Her physical examination was normal, except for tachypnea. Her lungs were clear, and no murmurs, gallops or rubs were heard on the cardiac examination. ED bedside echocardiography with color, continuous wave and tissue Doppler ultrasound imaging and lower extremity ultrasonography performed by an ED attending physician revealed a massive pulmonary embolism with right ventricle pressure overload, tricuspid and pulmonic regurgitation, right atrial thrombus and a right popliteal thrombus. The right ventricular outflow tract view allowed for the direct visualization of thrombus in the pulmonary artery. Bedside echocardiography with color, continuous wave and tissue Doppler ultrasound imaging and lower extremity compression ultrasonography can assist the emergency physician and the critical care physician in the diagnosis of massive pulmonary embolism and deep venous thrombosis. Direct visualization of embolic thrombus in the pulmonary artery can help the ED physician accelerate both medical intensive care consultation and therapy and surgical consultation for possible thromboembolectomy and inferior vena cava filter placement.