October 2025

35 Year-old Female Slumped in Her Chair 15 Minutes Ago

Author: Manpreet Luthra MD PGY-3

Peer Reviewers: Lee LaRavia, DO; Dan Kaminstein, MD

Christopher Crawley, MD; Vijay Reddy, MD

 

Learning Objectives:

  • Using US as a diagnostic tool and as a guide to medical resuscitation in the patient with syncope.
  • Demonstrate the importance of re-evaluation of patient with US after an acute change
  • Discuss the US charactereistics/findings pertinent to Massive and Submassive PE
  • Review ultrasound specificities and sensitivities specif to PE
  • Highlight the early pressor support is more beneficial in submassive and massive PE than aggressive IV fluids

Case Presentation

  • Intellectually disabled and deaf 35 yo F here for reported syncopal episode that lasted
    a few minutes while seated at dinner (approximately 15 minutes ago). Currently at
    baseline. At the time, her deaf boyfriend was with her but not with her at presentation.
    Patient is accompanied by boyfriend’s grandmother. She states that she had some
    chest pain just before the episode.

  • HR:104, BP:98/56, RR: 20, SpO2: 98%, T: 97.6F, BG 145.

  • PE: Currently at baseline. Mild bilateral CVA tenderness

  • Labs and Imaging: Blood Culture x 2, POC Preg, EKG 12 lead, BG,UA w/ Culture,
    Lactic acid, BNP, CBC, CMP, CK, Lipase, POC troponin, Ethanol , Acetaminophen,
    Salicylate, UDS, TSH, T4, CTA Chest PE, CT Abdomen Pelvis w/contrast, Chest XR
    2 View

  • DDX:  Hypoglycemia, Myocardial Infarction, Seizure, Congenital/premature aortic
    stenosis, Electrolyte imbalance, Sepsis/Septic shock 2/2 pyelonephritis?, Arrythmia,
    Pulmonary Embolism, Stroke, Toxin, Head trauma

ECG and Initial Labs

  • POC Troponin: 0.0

ecg

Initial POCUS Images 

  • Plax View

  • Short Axis View

 

15 minutes Later

Patient goes to the bathroom. Has a syncopal event in the restroom. Remains tachycardic with BP of 70’/50’s. Hypoxic to the 70’s. Placed on NIV but did not tolerate > High Flow. Started on Levophed. Rushedto CT, but before she did…

Re-assessment POCUS

  • Apical View

  • Short Axis

  • Plax View

 

CTA CHEST (Radiology Read: Patient already in the CVICU)

  • Severe interval worsening of pulmonary emboli clot burden, now involving the bilateral main pulmonary arteries, with occlusive pulmonary emboli in the right upper, middle and lower lobes and left lower lobe. Nonocclusive pulmonary emboli in the left upper lobe.

  • Imaging findings of severe right heart strain with bowing of the interventricular septum into the left ventricle, and severely elevated RV/LV ratio of 2.0. Backing of intravenous contrast into the liver veins as well. Emergent PERT consultation is recommended.

  •  

Diagnosis and Case Disposition

  • Diagnosis: Massive PE
  • Labs return showing severe lactic acidosis. BNP: 240’s
  • Patient is maxed on Levophed and continues to decompensate. Considering
    central line and adding vasopressin.
  • Decided to use TPA with pharmacy’s help.
  • Patient was stable on current pressor requirements. CT Surgery attending
    agrees to take the patient for thrombectomy.
  • Patient does well and is discharged from CVICU with IVC filter and long-term
    anticoagulation.

 

Pulmonary Embolism Severity Stratification

  • American Heart Association and European Society of Cardiology have agreed to three classifications of pulmonary embolism

peseverity

Severity Ultrasound Findings that Suggest PE

  • There are numerous findings that can assist yu in identifying and classifying a PE on US
    • 1. RV:LV ratio (Sensitivity 46%, Specificity 91%)
      2. Abnormal septal wall motion (Sensitivity 28%, Specificity 95%)
      3. McConnel’s sign (Sensitivity 19%, Specificity 98%)*
      4. Tricuspid Regurgitation Velocity (Sensitivity 46%, Specificity 87%)
      5. Elevated pulmonary artery systolic pressure (Sensitivity 65%, Specificity 74%)
      6. Decreased tricuspid annular plane systolic excursion (TAPSE) (Sensitivity 66%, Specificity 88%) *
      7. Decreased S’ (Sensitivity 82-83%, specificity 68-86%)*
      8. Pulmonary artery mid-systolic notching (Sensitivity 92%, Specificity 99%)*

Ultrasound Findings that Suggest PE

  • RV:LV ratio: Normal is .67:1, mild dilation is .67:1 to 1:1, moderate dilation is 1:1 to 1.5:1, and severe dilation is greater than 1.5:1

pesuggestions

  • Septal Flattening (“D sign”)

spatial

      • McConnell Sign

 

 

  • Tricuspid Annular Plane Systolic Excursion (TAPSE) < 17mm / 1.6cm => RV systolic dysfunction. Normal mean is 24mm +/- 3mm.

    • Normal                                                                                         Abnormal

trucuspid

Take Away Points

  • Re-assess patients after an acute change, going through the ABC's with US.

  • LV hyperdynamic collapse does not necessarily mean the patient needs IV
    fluids.

    • In submassive and massive PE, IV fluids can worsen right ventricular strain and potentially reduce cardiac output, particularly in the presence of right ventricular dysfunction.

    • Early pressor support is more beneficial than aggressive IV fluids

  • There are a few rapid and easy US assessment tools and findings that can
    help evaluate and risk stratify PE and change management.

References

1. Afonso, L., Sood, A., Akintoye, E., Gorcsan, J., Rehman, M. U., Kumar, K., Javed, A., Kottam, A., Cardozo, S., Singh, M., Palla, M., Ando, T.,
Adegbala, O., Shokr, M., & Briasoulis, A. (2019). A Doppler Echocardiographic Pulmonary Flow Marker of Massive or Submassive Acute
Pulmonary Embolus. Journal of the American Society of Echocardiography, 32(7), 799–806. https://doi.org/10.1016/j.echo.2019.03.004


2. Alerhand, S., Sundaram, T., & Gottlieb, M. (2021). What are the echocardiographic findings of acute right ventricular strain that suggest
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3. Daley, J. I., Dwyer, K. H., Grunwald, Z., Shaw, D. L., Stone, M. B., Schick, A., Vrablik, M., Kennedy Hall, M., Hall, J., Liteplo, A. S., Haney, R.
M., Hun, N., Liu, R., & Moore, C. L. (2019). Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency
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4. Fields, J. M., Davis, J., Girson, L., Au, A., Potts, J., Morgan, C. J., Vetter, I., & Riesenberg, L. A. (2017). Transthoracic Echocardiography for
Diagnosing Pulmonary Embolism: A Systematic Review and Meta-Analysis. Journal of the American Society of Echocardiography, 30(7), 714-723.e4. https://doi.org/10.1016/j.echo.2017.03.004


5. Konstantinides, S. V., Meyer, G., Becattini, C., Bueno, H., Geersing, G.-J., Harjola, V.-P., Huisman, M. V., Humbert, M., Jennings, C. S.,
Jiménez, D., Kucher, N., Lang, I. M., Lankeit, M., Lorusso, R., Mazzolai, L., Meneveau, N., Ní Áinle, F., Prandoni, P., Pruszczyk, P., & Righini,
M. (2019). 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the europeanrespiratory society (ERS). European Heart Journal, 41(4), 543–603. https://doi.org/10.1093/eurheartj/ehz405


6. POCUS in Practice. (2022a, January 11). How to... Measure TAPSE. YouTube. https://www.youtube.com/watch?v=DmRotfyMIQw


7. POCUS in Practice. (2022b, January 11). How to... Measure TV s’. YouTube. https://www.youtube.com/watch?v=fY4iiYvBC2Q


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