Ultrasound in Emergency MedicineMcConnell's Sign Is Not Specific for Pulmonary Embolism: Case Report and Review of the Literature
Introduction
Emergency physicians use focused cardiac ultrasound (FOCUS) to assess for a limited number of emergent conditions 1, 2. Most “goal-directed” protocols for FOCUS in the emergency department (ED) include an assessment for signs of a pulmonary embolism (PE), such as right ventricle (RV) dilatation, RV hypokinesis, and septal flattening (3). One echocardiographic finding, RV free wall hypokinesis with apical sparing, or “McConnell's sign,” has been described as very specific for the diagnosis of PE (4). We present the case of a patient with a classic McConnell's sign but no evidence of PE.
Section snippets
Case Report
A 58-year-old woman presented to the ED with a cough, dyspnea, and leg swelling. She described the subacute onset of “bronchitis” about 1 month earlier, consisting of a cough and transient subjective fever. She had been seen by her primary physician on multiple occasions, and had completed two courses of azithromycin, followed by two courses of ciprofloxacin, all without relief of the cough. Four days before her ED visit, she started having lower-extremity swelling, left greater than right. She
Discussion
In 1996, McConnell et al. described a characteristic echocardiographic finding of acute PE and RV free wall hypokinesis with preserved apical contractility (4). Further, they suggested that this finding could distinguish the acute right ventricular strain caused by PE vs. the chronic right ventricular strain caused by pulmonary hypertension (PH). Several studies have supported this initial result. Using a retrospective design, Lodato et al. studied the echocardiograms of 67 patients who had
Why Should an Emergency Physician Be Aware of This?
Despite having a classic McConnell's sign on the focused echocardiogram performed by the emergency physician, our patient was ultimately found not to have a PE. Instead, her RV strain was likely from PH, resulting either from COPD or SLE. Emergency physicians should be aware that McConnell's sign is not completely specific for acute right heart strain from PE.
References (20)
- et al.
Focused Cardiac ultrasound in the emergent setting: A Consensus Statement of the American Society of Echocardiography and American College of Emergency Physicians
J Am Soc Echocardiogr
(2010) - et al.
International evidence-based recommendations for focused cardiac ultrasound
J Am Soc Echocardiogr
(2014) - et al.
Point-of-care focused cardiac ultrasound for prediction of pulmonary embolism adverse outcomes
J Emerg Med
(2013) - et al.
Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism
Am J Cardiol
(1996) - et al.
Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism
Ann Emerg Med
(2014) - et al.
Right ventricular dysfunction in chronic lung disease
Cardiol Clin
(2012) - et al.
Pulmonary hemodynamics in patients with chronic obstructive pulmonary disease before and during an episode of peripheral edema
Chest J
(1994) - et al.
Point-of-care ultrasound findings of acute pulmonary embolism: McConnell sign in emergency medicine
J Emerg Med
(2014) - et al.
Red flag in bedside echocardiography for acute pulmonary embolism: remembering McConnell’s sign
Am J Emerg Med
(2013) - et al.
Echocardiographic predictors of pulmonary embolism in patients referred for helical CT
Echocardiography
(2008)
Cited by (12)
Bedside Thoracic Ultrasonography for the Critically Ill Patient: From the Emergency Department to the Intensive Care Unit
2020, Journal of Radiology NursingCitation Excerpt :The McConnell sign (hypocontractility of the RV free wall with good apical contractility) has been described as an important sign in the diagnosis of PE (McConnell et al., 1996). However, its specificity for this diagnosis has been questioned (Walsh & Moore, 2015). A disturbed RV ejection pattern, also called the “60/60 sign” (RV ≤ 60 ms in the presence of tricuspid insufficiency pressure gradient not >60 mm Hg) can also suggest acute PE.
Diagnosis of pulmonary embolism: Following the evidence from suspicion to certainty
2019, Journal of Vascular NursingCitation Excerpt :The original study found that the McConnell's sign was 77% sensitive and 94% specific for the diagnosis of acute PE, with a positive predictive value of 71% and an NPV of 96%.94 Caution must be exercised, however, because clinical conditions other than PE may cause a McConnell's sign such as intracardiac shunts, pulmonary regurgitation, tricuspid regurgitation, and/or tricuspid stenosis.95,96 A systematic review and meta-analysis of 24 studies determined that signs of right-heart strain yielded a positive likelihood ratio (PLR) of 3.12 compared with a lack of signs for right-heart strain having a negative likelihood ratio (NLR) of 0.57.97
McConnell's sign in intra-operative acute right ventricle ischaemia: An under-recognized aetiology
2016, Revista Espanola de Anestesiologia y ReanimacionRapid onset idiopathic pulmonary hypertension: A case report with a review of echocardiographic parameters
2023, Journal of Cardiovascular EchographyMulti-modality imaging approach to a rare form of biventricular ring-shaped constrictive pericarditis
2023, Journal of Cardiovascular Echography
Streaming video: Four brief real-time video clips that accompany this article are available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clips 1, 2, 3, and 4.