A man in his 50s checked into our ED recently feeling weak, nauseated, and short of breath for two days. He had no significant medical history, and had previously been active and healthy.

A fingerstick glucose at triage was higher than 400 mg/dL. He was also tachypneic, with a respiratory rate over 40 bpm.

Diabetic ketoacidosis was at the top of the differential, and labs and fluids were ordered.

My senior resident decided to assess the patient’s cardiac function prior to starting fluids to make sure he could handle multiple boluses.

Something was terribly wrong. The images made it clear that the right ventricle was markedly enlarged and there was septal flattening.

The septum could be seen flattened toward the left ventricle, a marker of high pressure on the right side of the heart.

Given this new information, a CT scan of the chest was ordered, which revealed large emboli in the left and right main pulmonary arteries.

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