Case 1
A 55-year-old otherwise healthy male developed sudden shortness of breath during a bike ride, making it impossible to continue the trip. The Emergency Medical Communication Center (EMCC) was contacted and a local ambulance and a Helicopter Emergency Medical Service, staffed with an emergency physician, were dispatched. A standard prehospital medical evaluation including 12 lead ECG was done. Vital parameters followed an unspecific pattern often seen in patients with dyspnea - respiration frequency 25/min, saturation of 93–94% without oxygen supply, heart rate 100–110 bpm and blood pressure of 115/60 mmHg. Physical examination revealed no obvious pathology. ECG showed normal sinus rhythm.
FATE examination disclosed a dilated right ventricle with characteristic septum shift towards the left ventricle in both subcostal and apical 4 chambers views and a D-shaped compromised left ventricle in systole in parasternal cross-section view (Figures 1 and2). These are typical signs of a pulmonary embolism that leads to hemodynamic compromise. Based on the ultrasound examination, a radical change in the course for the patient followed. Prehospital heparinization (10.000 units of standard unfractionated heparin), and triage directly to specialized cardiologic department for thrombolysis was initiated. Shortly after admission to the hospital, computed tomography confirmed the diagnosis. Thrombolytic therapy was initiated within 2 hours after the emergency call to the EMCC. Four hours after the emergency call, the patient was without subjective symptoms and had normalized vital parameters. Long-term anticoagulation therapy was initiated. The patient recovered completely.
Case 2
A 60-year-old, otherwise healthy male, developed left hemiparesis and the EMCC was contacted. As the patient was a candidate for thrombolysis because of suspected ischemic stroke, local ambulance and HEMS staffed with emergency physician were dispatched. On arrival of the HEMS, the medical history revealed a slow development of mild chest pain preceding the hemiparesis. Vital parameters were not specific; respiration frequency 20/min, saturation 95% without oxygen supply, heart rate 90 bpm and blood pressure 120/70 mmHg. Physical examination showed slight aphasia and partially paresis of the left arm. ECG showed normal sinus rhythm.
Because of the diverging symptoms, a FATE examination was done. Somewhat surprisingly, this disclosed a large pericardial effusion (Figure 3). Based on this finding, aortic dissection was suspected. Because of an obvious need to reduce time to definite treatment, no further efforts were done to visualize the thoracic aorta. Again, based on the ultrasound findings, a radical change in the course for the patient followed. Instead of referral for thrombolysis at a nearby hospital, the patient was admitted to an invasive heart center 130 km away. Echocardiography and computed tomography of the thorax confirmed a dilated aorta that had perforated into the pericardium and dissected up into the right carotid artery. During the 25 minutes transportation time with HEMS, the receiving hospital was able to prepare an operating theater. After supplemental imaging, emergency surgery with replacement of the disrupted part of aorta was performed. The patient was discharged with minimal cognitive dysfunction due to perioperative cerebral ischemia, but with no physical sequelae.