Acute pulmonary embolism: Tell tale signs

Acute Pulmonary embolism is one of the major preventable causes of in hospital mortality. It is commonly seen in ICU setting in chronic bed ridden patients [1]. It has wide spectrum of clinical presentation ranging from asymptomatic stage to severe hemodynamic decompensation so diagnosis requires high degree of suspicion. In majority of cases detailed history and physical examination along with ECG and 2D transthoracic echocardiography is enough the diagnosis. CT pulmonary angiography is done to confirm the diagnosis or when diagnosis is not possible by other non-invasive tests. A 45-year-old army person presented to ER with breathlessness for 3 days. There was no complaint of chest pain, giddiness, palpitation, swelling or pain of legs. Patient does not have any other comorbidities. At presentation patient was having heart rate of 140/min with blood pressure of 110/84 mmHg and saturation 88% at room air and 95% with oxygen by mask. Basic investigations including ECG and echocardiography were done at presentation. 12 lead ECG (Figure 1) showing narrow complex sinus tachycardia with S1Q3T3 pattern and T wave inversion from V1-V3. 2D transthoracic echocardiography was done showing (Figure 2-4) classical features of pulmonary embolism including dilated right atrium and right ventricle, Moderate tricuspid regurgitation with elevated RVSP, dilated main pulmonary artery, Flattening of intraventricular septum during systole (D shape), Large thrombus in right pulmonary artery. Compression USG of both lower limbs was done was negative for venous thrombosis. To conform the diagnosis of pulmonary embolism and to rule out other causes of breathlessness. CT pulmonary angiography was performed (Figure 5) which was showing the thrombus in both right and left pulmonary arteries. So, diagnosis of acute pulmonary embolism was made with no concurrent DVT.