Adult Female With Weakness and Chills

Pulmonary embolism 

Figure 1 shows CT evidence of pulmonary embolism with a massive clot burden consistent with saddle embolism. Figure 2 is a parasternal short-axis view of the heart, showing significant enlargement of the right ventricle, with a small left ventricle and paradoxic septal movement, known as the Δ sign. An apical 4-chamber view showed a stunned, hypokinetic right ventricular wall, with maintained function of the apical portion of the right ventricle, known as McConnell's sign, as well as a hyperkinetic left ventricle. In the absence of chronically increased right ventricular pressure, this is suggestive of acute right ventricular dysfunction. These findings were used to help make the decision to treat with intravenous thrombolytics, in addition to intravenous heparin. She was admitted to the ICU and was ultimately discharged, receiving long-term oral anticoagulation.

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Figure 1. CT of chest with intravenous contrast.

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Figure 2. Transthoracic parasternal short-axis view. Used with permission of Thompson Kehrl, MD, Department of Emergency Medicine, MetroHealth Medical Center, Cleveland, OH.

Bedside echocardiography can be particularly helpful in patients with undifferentiated shock and can be used to evaluate for global left ventricular function, tamponade physiology, and acute right-sided heart strain. Familiarity with these echocardiographic findings can help the emergency physician rapidly diagnose and treat these conditions.