title: Diagnosis of near-fatal pulmonary embolus-in-transit with focused echocardiography.
abstract: BACKGROUND
  Among patients who die from pulmonary embolus (PE), approximately two-thirds succumb within an hour of presentation. Computed tomography can provide a definitive diagnosis but is associated with practical limitations. Echocardiography can increase diagnostic certainty of PE by visualizing signs of acute right ventricular (RV) strain. This case highlights a potentially lethal finding associated with PE and the role of clinician-performed bedside echocardiography in the timely management of this disease.
  
  
  OBJECTIVE
  To describe a case of PE-in-transit diagnosed by clinician-performed focused echocardiography.
  
  
  METHODS
  A 78-year-old man with lymphoma presented to the Emergency Department with shortness of breath. His blood pressure was 95/53 mm Hg; his oxygen saturation was 84% on room air. A focused echocardiogram showed a highly mobile elongated mass traversing the right atrium and right ventricle, consistent with a PE-in-transit. Anticoagulation was initiated and Cardiovascular Surgery was consulted for emergent thrombectomy. Minutes after reviewing the ultrasound with the surgeons, the patient was transported to the operating room. Just before surgery, the patient had a cardiac arrest. Exploration of his heart failed to reveal thrombus; however, extensive clot burden was removed from the pulmonary arteries, with subsequent return of spontaneous circulation.
  
  
  CONCLUSIONS
  The clinician performed a focused echocardiogram to evaluate the cause of the patient's critical state. PE-in-transit, a rare entity associated with large PEs, was identified, which obviated the need for further diagnostic evaluation and led to immediate aggressive therapy. Increased familiarity with the uses of bedside sonography in the evaluation of shock and respiratory distress may allow clinicians to become more proficient in managing these patients.
authors.affiliation: Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA.
authors.forename: Jonathan I
authors.initials: JI
authors.lastname: Fischer
authors.forename: Maite A
authors.initials: MA
authors.lastname: Huis in 't Veld
authors.forename: Michael
authors.initials: M
authors.lastname: Orland
authors.forename: Patrick
authors.initials: P
authors.lastname: Harvey
authors.forename: Nova L
authors.initials: NL
authors.lastname: Panebianco
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Dean
mesh_terms: D000368:Aged; D006801:Humans; D008297:Male; D019095:Point-of-Care Systems; D011655:Pulmonary Embolism / Q000000981:diagnostic imaging*; D012128:Respiratory Distress Syndrome / Q000000981:diagnostic imaging; D012769:Shock / Q000000981:diagnostic imaging; D014463:Ultrasonography
keywords: pulmonary embolus; pulmonary embolus-in-transit; ultrasound; venous thromboembolism