UOTW #7 Answer

Diagnosis: cardiogenic shock, myocarditis

(original post here)

This patient presents with vague symptoms of dry cough, fevers/malaise – but the clinic picture did not fit the diagnosis of pneumonia (immunocompetent patient with community acquired bilateral pneumonia and sepsis).  A troponin was ordered due to mild ST elevation on the ECG, and the result was elevated at 24.2.  A bedside echo was performed to further delineate the etiology of the patient’s hypotension and to assess his volume status.

There are several key findings on these three clips: very low systolic ejection fraction (EF) is evident on the parasternal long axis cardiac view (PLAX), the multiple B-lines seen on this patient’s thoracic scan suggest interstitial pulmonary edema, and a very dilated inferior vena cava (IVC) that is nearly devoid of respiratory phasic changes suggests a very high CVP.  The “bilateral pneumonia” was really pulmonary edema.

Take home points:

  • Every patient with undifferentiated hypotension needs a bedside echo, better yet, a RUSH Exam.
  • The gestalt estimation of cardiac function has been shown to correlate well with actual EF measurements,1 and emergency physicians can visually estimate EF nearly as well as cardiologists.2,3
  • There are multiple ways to calculate an ejection fraction, from the simple approximation of fractional shortening to the most accurate (yet cumbersome to calculate) method of discs.
  • One simple method to estimate EF is to measure the distance from the mitral valve to the septum in mid diastole.  This is known as the E-point Septal Separation (EPSS), which correlates well with the EF in a structurally normal heart.4,5  
  • An EPSS < 7 mm is considered normal, while EPSS > 10 mm  suggests a low EF.6 This measurement can be made more accurately when M-mode is used across the tip of the mitral valve in the PLAX view.  
  • Remember that significant mitral stenosis or aortic insufficiency can falsely increase the EPSS measurement, lowering your estimation of the patient’s ejection fraction.6


  1. Shahgaldi K, Gudmundsson P, Manouras A, Brodin LA, Winter R. Visually estimated ejection fraction by two dimensional and triplane echocardiography is closely correlated with quantitative ejection fraction by real-time three dimensional echocardiography. Cardiovasc Ultrasound. 2009;7:41.  [PDF]
  2. Bustam A, Noor azhar M, Singh veriah R, Arumugam K, Loch A. Performance of emergency physicians in point-of-care echocardiography following limited training. Emerg Med J. 2014;31(5):369-73.  [pubmed]
  3. Unlüer EE, Karagöz A, Akoğlu H, Bayata S. Visual estimation of bedside echocardiographic ejection fraction by emergency physicians. West J Emerg Med. 2014;15(2):221-6.  [PDF]
  4. Mitral valve E-Point to Septal Separation (EPSS) measurement by cardiac magnetic resonance Imaging as a quantitative surrogate of Left Ventricular Ejection Fraction (LVEF). Journal of Cardiovascular Magnetic Resonance. 2012;14(Suppl 1):P154.  [PDF]
  5. Mckaigney CJ, Krantz MJ, La rocque CL, Hurst ND, Buchanan MS, Kendall JL. E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction. Am J Emerg Med. 2014;32(6):493-7.  [pubmed]
  6. Dawson, Mallin. Introduction to Bedside Ultrasound, Volume 2. 2013. Apple iBook. [iBook]

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