Ultrasound in Emergency Medicine POINT-OF-CARE ULTRASOUND DIAGNOSIS OF A CATHETER-ASSOCIATED ATRIAL THROMBUS Erica L. Nelson, MD, PHM, Margaret Greenwood-Ericksen, MD, MPH, and Sarah E. Frasure, MD Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: Sarah E. Frasure, MD, Brigham and Women’s Hospital, 75 Francis St., Neville House – 236A, Boston, MA 02115 , Abstract—Background: Emergency physicians can uti- lize point-of-care thoracic ultrasound to aid in the diagnosis of a variety of cardiovascular and respiratory complaints. Case Report: An emergency physician utilized point-of- care cardiac ultrasound to identify catheter-associated atrial thrombi in a hemodialysis patient presenting with dys- pnea. Why Should an Emergency Physician Be Aware of This?: Based on this case, point-of-care ultrasound can be utilized in patients with central venous catheters, to identify intracardiac thrombi as the cause of dyspnea, thereby facil- itating appropriate consultation and treatment. Ó 2016 Elsevier Inc. , Keywords—point-of-care ultrasound; echocardiogram; cardiac mass; atrial thrombus; catheter-associated thrombus INTRODUCTION Emergency physicians utilize standardized, thoracic point-of-care ultrasound (POCUS) to aid in the diagnosis of pneumothoraces, pulmonary edema, pleural and peri- cardial effusions, wall motion abnormalities, and right ventricular strain. Although there are studies demon- strating the efficacy of POCUS in the emergency depart- ment (ED) and the intensive care unit, there are minimal data regarding the utility of POCUS evaluation in specific populations, such as patients with indwelling catheters (1–4). We report a case in which a patient with a hemodialy- sis catheter presented to the ED with dyspnea, and PO- CUS significantly changed his management. By presenting this case, we intend to highlight the impor- tance of thoracic ultrasound in the ED, review the sono- graphic appearance of atrial thrombi, and advocate for the inclusion of POCUS into the diagnostic algorithm for patients with indwelling catheters who present with chest pain or shortness of breath. CASE REPORT A 42-year-old man with end-stage renal disease second- ary to immunoglobulin A nephropathy, on hemodialysis, presented to a community hospital with dyspnea. He was found to be hypertensive to 260/160 mm Hg, hypoxic to 76% oxygen saturation, and in significant respiratory distress. A chest radiograph demonstrated pulmonary edema. He was given furosemide, nitroglycerin, and ena- lapril, and transferred. Upon arrival to our ED, he continued to be dyspneic and orthopneic. He denied chest pain, lower-extremity swelling, cough, vomiting, myalgias, or abdominal pain. Vital signs included a blood pressure of 210/123 mm Hg, a respiratory rate of 24–30 breaths/min, and an oxy- gen saturation of 99% on 15-L non-rebreather. The patient was afebrile, alert, and in mild respiratory distress with diffuse rales and an unremarkable cardiac examination. Streaming video: A brief real-time video clip that accom- panies this article is available in streaming video at www.jour- nals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1. RECEIVED: 26 February 2015; FINAL SUBMISSION RECEIVED: 21 June 2015; ACCEPTED: 24 June 2015 e75 The Journal of Emergency Medicine, Vol. 50, No. 2, pp. e75–e77, 2016 Copyright Ó 2016 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter http://dx.doi.org/10.1016/j.jemermed.2015.06.063