Facts
In a patient with a suspected type A aortic dissection, the presence of pericardial fluid collection is highly suggestive of dissection.

Tips
If lacking good parasternal images, any finding of pericardial fluid collection in a patient with the relevant symptoms should trigger triage to the invasive heart center.

Facts
The ascending aorta can be divided into sinus valsalva, just above the aortic valve, and the more distal tubular part.

With normal anatomy, there is a narrowing of the aorta at the sino-tubular junction causing the characteristic shape of the most proximal part of the ascending aorta.

In most cases of type A aortic dissection, this characteristic shape is lost because of dilation at the sino-tubular junction.

Facts

You have now learned how to answer the four focused questions:

Facts
No signs can rule out a pulmonary embolism.

In a patient with the relevant symptoms, three signs support a suspicion of pulmonary embolism.

These are:

Facts
A dissection membrane will not always be visible with transthoracic ultrasonography in case of type A aortic dissection, but when present it is highly suggestive of dissection.

Facts
Compare the size of the right ventricle to that of the left ventricle by eyeballing.

If the right ventricle diameter is equal to or larger than the left ventricle, it is dilated.

In a patient with the relevant symptoms, this supports the diagnosis of pulmonary embolism.

Notice that with dilation and elevated right ventricular pressure, the right ventricle can become apex forming as seen in the image to the right.

Tips
In the subcostal view, the width at the base of the right ventricle can look enlarged if the transducer is not rotated correctly.

Enlargement of the right ventricle is not a specific sign of pulmonary embolism, but is also seen in chronic pulmonary hypertension and right coronary artery occlusion.

Facts
In healthy people, the septum bulges from the left ventricle into the right because of the higher pressure in the left ventricle.

When the pressure in the right ventricle increases to levels higher than in the left ventricle, it bulges from the right to the left.

Depending on the pulmonary pressure, this septum-shift may be seen only in diastole or in both systole and diastole. In the video below it is seen during diastole in the heart with pulmonary embolism.

A pulmonary embolism that causes severe circulatory failure is unlikely without this septum-shift.

Tips
Practice looking for a septum-shift towards the left ventricle.

The septum is a very hyperechogenic structure and can often be visualised even in poor images.

Facts
No ultrasonographic finding can rule out aortic dissection.

However, in combination with relevant symptoms, four findings are highly suggestive of type A aortic dissection: