A 36-year-old woman presents to the emergency department with emergency medical services for a sudden onset of shortness of breath and right-sided pleuritic chest pain. Her vital signs are Blood pressure 86/40, heart rate 137, respiratory rate 36, SpO2 86% on room air, and a temperature of 36.7 degrees Celsius.
Your primary survey is as follows:
Airway – Patent
Breathing – Clearly tachypneic, speaking in 1 word sentences
Circulation – Sweaty and pale
Disability – Awake and restless
Your physician colleague Is extrapolating the history from the paramedics while your respiratory therapist is performing a focused respiratory physical examination. You have seen this situation before and you think to yourself: “I think this is a pulmonary embolism. I also remember seeing point-of-care ultrasound (POCUS) as a tool to help us with the diagnosis!”
What is POCUS?
Very briefly, POCUS is a handheld ultrasound where the images generated are performed by and interpreted by the clinician, all at the patient’s location (Moore & Copel, 2011). This is different from comprehensive ultrasound, which is a large machine that is usually operated in a dedicated radiology department and is meant to be comprehensive; POCUS is not meant to replace comprehensive ultrasound. In fact, POCUS is often viewed as an extension of the physical examination to increase diagnostic accuracy and support safer procedures (Moore & Copel, 2011). Some examples include:
- Is there pulmonary edema?
- Are there gallstones?
- Is there decreased inotropy?
- Is there myocardial valvular pathology?
- Is there a pneumothorax?
- Is there free fluid in the abdomen?
- Is there increased optic sheath diameter which suggests intracranial pressure?
POCUS and the Nurse
Understanding the utility and certain terminology of POCUS can help you, the Bedside Warrior, anticipate and plan patient care.
Back to the Case Study
After receiving report from the paramedics, your physician colleague collects their POCUS and immediately begins performing a focused cardiac exam. As the nurse leader, you hear the following statements from your physician colleague:
“There’s a D Sign.”
A D Sign on POCUS suggests right ventricular strain (Rola, 2014). The name comes from how the left ventricle looks on a POCUS image. The left ventricle is usually circular but, in the presence of a strained right ventricle which pushes on the intraventricular septum, the left ventricle shape look like a D. In our case study, a D Sign suggests right heart ventricular heart strain likely due to a pulmonary embolism. When you hear there is a D Sign for a patient with pulmonary embolism, be prepared for acute cor pulmonale, get your thrombolytics to the bedside (but you don’t have to mix them just yet), anticipate vasopressor support (some like vasopressin, some like noradrenaline), and prepare transfer equipment (you’re likely going to go on a road trip to a computed tomography scan, interventional radiology, a critical care unit or another facility).
One defining feature of the Resuscitationist is accurately predicting patient clinical trajectory; understanding how POCUS can be used and its application in the right clinical setting can help you anticipate the next steps in inpatient care.
- POCUS findings at the bedside can help nurses anticipate and predict patient care.
- Ask your colleague to communicate their POCUS findings to you.
- POCUS does not replace formal medical imaging; plan for road trips.
Moore, C. L., & Copel, J. A. (2011). Point-of-care ultrasonography. The New England Journal of Medicine, 364(8), 749–57. https://doi.org/10.1056/NEJMra0909487
Rola, P. (2014, May 14). What’s this sign? https://thinkingcriticalcare.com/tag/d-sign/