Thread by @EM_RESUS

This is the bedside Echo of a critically ill young lady who presented to the ER in shock

[thread]

Those bright, whip-like structures emanating off the tricuspid valve are infective vegetations. They look similar to blood clots-in-transit except that instead of free floating you can see that they are tethered down.

[2/x]

The Right Ventricle (RV) should normally be about half the size of the Left Ventricle (LV). But here the RV is more than double the size of this underfilled LV!

Why would a patient with endocarditis also have right heart strain?

[3/x]

When you see right-sided endocarditis with right heart strain you should think: tricuspid regurgitation & septic pulmonary emboli.

[4/x]

Remember that left-sided vegetations embolize to the systemic circulation, and right-sided vegetations embolize to the lungs.

[5/x]

The LV should always be round like a doughnut, or “O”-shaped. But when ↑ pulmonary pressures overwhelm the RV, the septum gives way, flattens out, & the LV takes the shape of a Capital “D”

This is known as the “D-Sign”

[6/x]

Here’s a shot of the IVC as it enters the enlarged right atrium. You can see that it’s plethoric with very little respiratory variation. You can also see the hepatic vein is dilated as it drains into the IVC.

This is all consistent with elevated right-sided pressures.

[7/x]

The patient was resuscitated and stabilized. Blood cultures were drawn and broad-spectrum antibiotics were started. CT chest confirmed multiple septic emboli and CT Surgery was consulted for the severely regurgitant, infected tricuspid valve.

[8/x]

This case is just one example of how #POCUS can empower you with the ability to rapidly make time-sensitive and critical diagnoses directly at the bedside.

[9/x]

So if you take care of critical patients, please take time to learn bedside ultrasound. I promise you will save lives.

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