Is it just a stroke?

Middle aged female was brought to hospital after collapsing on a long haul flight. She had stood up, felt dizzy and collapsed in flight. 2 mins CPR --> ROSC.

Post ROSC: New L hemiplegia, facial droop.

On MAS arrival: sats 50% --> 95% with O2, BP 50/ improved --> 102/54 on Nad 10mcg/min, HR 70

Code stroke was called on arrival in ED and a CTB, COW and perfusion booked. 

Given the hypoxia and hypotension, bedside echo was done

PSAx

PLAx

A4C

Important features of the bedside echo annotated below

PSAx: RV 1:1 with LV, straight LV septum (normally round and bulging to RV), bulging to left

PLAx: kissing pap muscles: evidence of hyperdynamic LV: obliteration of the LV cavity with each systole

Mconnel's on A4C

So bedside echo (yes, and the hypoxia and hypotension) led to a CTPA booked at the same time as the code stroke CT.  This revealed bilateral proximal PEs. CTB revealed a R MCA infarct.

Patient was thrombolysed 1 hour post arrival. 

Nad requirements decreased and oxygenation improved. Residual L arm weakness only. 

The stroke was thought to be due to a PFO. 

An ASD is best seen in subxyphoid. In this view, the IAS is perpendicular to the US beam giving the most accuraet imaging. 

Subxyphoid showing floppy atrial septum with likely defect where the arrow is located. If you put colour here, you may see a jet going from left to right. pw doppler may show flow. 

Subxyphoid: Right to left flow through ASD (white arrow). Right to left flow occurs with RV pressure overload. (from https://johnsonfrancis.org/professional/asd-with-right-to-left-shunt-on-colour-doppler-echocardiography/#google_vignette</p>)

For a more detailed description of echo features of pulmonary embolus click on the button below.