Elderly patient with CP and SOB

case summary

This is a critically unwell patient whose presentation is undifferentiated. 

The main differentials are:

- Ischaemia, CCF and APO

- Acute PE

- Pneumonia and Sepsis

- tension pneumothorax

The patient's lung US shows normal lung sliding with no B lines, consolidation or effusion. 

This excludes a significant consolidation, tension pneumothorax and APO immediately

Patient's lung US: normal pleural sliding and A lines only

Spine does not extend above the diaphragm, no effusion

Absent pleural sliding and no comet tails: features of pneumothorax

Anechoic pleural fluid seen with the spine sign extending above the diaphragm, usually see bilat pleural effusions in CCF

Confluent B lines, usually seen bilaterally in the anterior chest in APO

This leaves the echo to help differentiate:

Sepsis: small chambers, hyperdynamic LV, D shaped LV small collapsing IVC 

PE: Dilated RA and RV, hyperdynamic, D shaped LV, Dilated non collapsing IVC 

Type A aortic dissection: dilated aorta, pericardial effusion, AR 

This patient's echo at first glance shows a dilated RA and RV, D shaped LV and dilated IVC. Barn door PE right? But it was not to be. Not sure if anyone would have picked this without the CT.

But look at the aorta: it looks bigger than the LA. 

In the base of heart view (AV mercedes benz sign), there seems to be something pulsing in and out of view of the pulmonary artery.

So this turned out to be a type A dissection with a dilated aorta. The descending aortic haematoma was compressing the pulmonary artery causing RV and RA dilatation giving the impression of PE. Tough case, but it's all there if you look at it carefully. 

Unfortunately none of this helped this patient and she passed away peacefully in ED. 

PLAx showing ascending Ao and RV both bigger than LA. In 1:1:1 rule RV:Ao:LA should all be about 3cm. Annotated in still image. Dotted lines are LA diameter against the RV and Ao.

PSAx showing a dilated RV, septal bowing and D shaped small cavity LV. Annotated in still image 

Subxyphoid showing a massively dilated RA

PSAx base of heart view showing something within the PA (turned out to be descending aorta (not normally seen) coming into view when it compressed PA with each heart beat

Dilated IVC