Hypotensive Patient Presenting With Abnormal Pre-hospital Ischemic Electrocardiogram: A Case of Pulmonary Embolism Diagnosed by Point-of-Care Ultrasound (POCUS)

TL;DR

A hypotensive patient with a pre-hospital ECG suggesting heart attack was diagnosed with a pulmonary embolism using ultrasound and successfully treated.

Contribution

Demonstrates the utility of combining ECG and POCUS for accurate diagnosis of conditions mimicking heart attacks.

Findings

A pre-hospital ECG mimicking STEMI was re-evaluated using POCUS to diagnose pulmonary embolism.

Thrombolytic therapy effectively treated the pulmonary embolism, leading to patient stabilization.

Follow-up showed normal heart function after four months of anticoagulation.

Abstract

Electrocardiograms (ECGs) are widely utilized to identify a variety of emergent and life-threatening conditions and are routinely used in the pre-hospital setting. Early and accurate identification of cardiac conditions such as ischemia or arrhythmia can facilitate accurate and prompt medical management by the pre-hospital team and the emergency department providers. This case describes a 65-year-old male with a pre-hospital presentation of chest pressure and a syncopal event. A pre-hospital ECG was concerning for ST-segment elevation myocardial infarction (STEMI), but the patient was ultimately found to have an alternative diagnosis of pulmonary embolism (PE) with an intraventricular thrombus identified on cardiac point-of-care ultrasound (POCUS). ECGs and POCUS should be jointly utilized in the patient assessment to consider a broad differential diagnosis as there are alternative pathologies that can mimic STEMI-like ECG changes. Treatment of the underlying pulmonary emboli with thrombolytic therapy led to stabilization of this patient and ultimately led to the patient being discharged home from the hospital. At a four-month follow-up appointment, the patient remained on oral anticoagulation, and a routine echocardiogram demonstrated normal ventricular size and function.

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