March 19, 2018

Cases

Trauma : knife though chest

Ultrasound images and text Genevieve Carbonatto A 33  year old man presents to the Emergency Department after having stabbed himself as a suicide attempt. The knife is still in the chest close to the sternum to the left of the sternum in the 5th intercostal space. He is alert and...

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Pericardial Tamponade

Images : Sarah Vaughan, text Genevieve Carbonatto A 56 year old man presents to the Emergency department short of breath and unwell. He gives a history of 2 hours of shortness of breath and chest pain. He has been recently diagnosed with metastatic adenocarcinoma. These are his vital signs He...

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Oesophageal intubation : Double tract sign

Images and Text Genevieve Carbonatto Tracheal intubation Ultrasound can be used as an adjunct to directly visualising endotracheal tube placement. The linear probe is placed in the transverse position with the index marker pointing to the right on the neck above the sternal notch. The structures are identified. These include...

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Alcoholic cirrhosis

Images and text Genevieve Carbonatto A 54 year old man presents to the Emergency Department with abdominal pain and jaundice. He has a distended abdomen. He is known to have alcoholic cirrhosis. A point of care ultrasound was performed. The following demonstrates some of the basic features of cirrhosis with...

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LV Aneurysm

Images and text Genevieve Carbonatto A 56 year old man presents to your department with chest pain. This is his ECG The ECG shows deep Q waves and ST elevation in his anteroseptal leads These are his vital signs: BP 120/69 mmHg, HR 89/min, Sats 100% on RA, RR16/min This...

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Cavernous haemangioma

Images and text Genevieve Carbonatto An abdominal ultrasound is performed on a young woman for right upper quadrant pain. This is what is seen while scanning through the liver This is a cavernous haemangioma. It looks like a snowball on ultrasound. Characteristics of haemangiomas: Blood filled cavernous space lined with...

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Right ventricular thrombus

Images and  text Genevieve Carbonatto A 35 year old man presents to the Emergency Department with severe shortness of breath. He is known to have an amphetamine induced cardiomyopathy. His heart rate is 129/min, BP 116/76. He has mild pedal oedema. His JVP is elevated and on auscultation he has...

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Emphysematous kidney

Images and text Genevieve Carbonatto A 55 year old man with bilateral renal transplants and diabetes presents to the Emergency department with a 6 day history of right upper quadrant pain and severe back pain, fever, diarrhea, nausea and vomiting. On examination his HR is 95/min. He has a systolic...

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Pitfall: Blood clots in ruptured ectopic pregnancy

Images and text Genevieve Carbonatto It is a busy Thursday evening in the Emergency Department. There is no place to put patients and assess them.  The only bay which may be available is occupied by a lady who  refuses to leave the bay because she feels so ill. You call...

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Pitfall: Painless ruptured ectopic pregnancy

Images Mark Russel, text Genevieve Carbonatto A 35 year old women  presents to the Emergency Department for a review of a possible ectopic pregnancy. She is 7 weeks pregnant by dates. An outpatient scan was performed the day before for painless vaginal bleeding . It did not show an intrauterine...

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Assessment of Pericardial effusion

Text and images Genevieve Carbonatto Pericardial effusions are commonplace. A pericardial effusion is not synonomous with pericardial tamponade. Pericardial tamponade is a medical emergency characterised by shock and associated with a number of clinical criteria including Becks triad (hypotension, decreased heart sounds, elevated JVP) pulsus paradoxus ( > 12 mmHg...

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Pitfall – Stones in the gall bladder – Adenomyomatosis

Images Ying Ying Lee, text Genevieve Carbonatto A 44 year old man presents with acute abdominal pain. His pain is mainly epigastric but you are concerned about the possibility of cholecystitis, cholelithiasis or choledocholithiasis. While scanning the patient in the supine position, you think you can see stones in the...

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Trauma – fractured ribs undiagnosed on chest Xray

Images Roger Burrell, text Genevieve Carbonatto A 54 year old man presents one week after a fall. He is complaining of severe left lower rib pain especially with respiration. His chest Xray looking for rib fractures does not show any fractures, nor is there a pneumothorax or a pleural effusion....

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Submassive Pulmonary Embolism – a critical care ECHO skill?

Images and Text Genevieve Carbonatto If we consider that there are different levels of expertise in the acquisition of knowledge of echocardiography for the Critical Care Physician, the recognition of acute cor pulmonale which we see with  submassive pulmonary embolus has been described as a Level II skill, level I...

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B lines – how best to see them

Thankyou Justin Bowra for this post. Ultrasound for interstitial lung disease and pulmonary oedema Key points • US lets you ‘see the crackles’. The US appearance of crepitations / crackles is called ‘B lines’ (formerly rockets, comets) • Just like crackles, B lines are found in pulmonary oedema and also...

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Trauma – Haemopericardium

Images Tina Cullen, text Genevieve Carbonatto It is 10.00 pm and you get a BAT call. There has been a fight at the local pub and the ambulance are bringing in a 34 year old who has been stabbed in the chest. He is tachycardic and hypotensive, GCS 14. They...

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Ice cardiomyopathy, apical thrombus

Images Sarah Vaughan, text Genevieve Carbonatto A 38 year old man presents to the Emergency department with shortness of breath which he has had for 4 weeks. His symptoms have worsened  over the past 3 days. He can no longer go up 2 flights of steps to his apartment  and...

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Takotsubo cardiomyopathy

Images and text Genevieve Carbonatto A 52 year old lady presents to the Emergency Department with chest pain. After an argument with her husband about his spending she developed acute severe central chest pain radiating down her right arm. She is mildly SOB. There is no past history of note,...

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Biliary Obstruction: Double Barrel sign, Monkey Puzzle sign

Images and text Genevieve Carbonatto A 73 year old man presents to your department jaundiced. He says he has not been feeling unwell but that over  the past 4 days  the white of his eyes have turned yellow as well as the skin of his face. His urine turned very...

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ECHO : image optimisation

Images and text Genevieve Carbonatto The most difficult and frustrating ultrasound examination in the Emergency department must be the ECHO exam. What can we do to optimise our images ? Here are some tips and tricks. 1. Positioning the patient Some of our patients in the Emergency Department cannot be...

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Type A dissection – Full house

Images Bashir Antoine Chakar (Emergency registrar) Text Genevieve Carbonatto You get a BAT call. The ambulance are bringing in a 65 year old lady who developed acute onset chest pain radiating to her back. The paramedics tell you that she was found to be diaphoretic with a systolic BP of...

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Appendicitis

Images and text Genevieve Carbonatto A 14 year old boy presents to the Emergency Department with abdominal pain. The pain had started acutely the day before and he had been unable to sleep because of the pain. As you lead the patient to the examination room you note his antalgic...

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Normal gut ultrasound

Images and text Genevieve Carbonatto. I would like to thank the IBUS group , in no particular order, Torsten Kucharzik, Christian Masser,Giovanni Maconi, Frauke Petersen, Kim Nylund, Ruediger Goertz, Emma Calbrese, Anil Kumar Asthana, Kerri Kovak, Rune Wilkens and Stefania Carmagnola for their fantastic course on gut ultrasound which has...

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Bowel oedema

Images Bashir Antoine Chakar (Emergency Registrar) and text Genevieve Carbonatto A 72 year old man presents to the Emergency Department. He awoke in the early hours of the morning with acute abdominal pain which he thinks is due to what he had eaten the night before. He describes his pain as...

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Crohn’s disease – Bowel obstuction

Images and text Genevieve Carbonatto. Thanks  to the IBUS group especially   Emma Calbrese for her excellent talk on complications of IBD, but  also Torsten Kucharzik, Christian Masser,Giovanni Maconi, Frauke Petersen, Kim Nylund, Ruediger Goertz, Anil Kumar Asthana, Kerri Kovak, Rune Wilkens and Stefania Carmagnola A 48 year old man presents...

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Intussusception: Left upper quadrant mass

Images Genevieve Carbonatto, text Genevieve Carbonatto An 80 year old lady presents to the Emergency Department with a 4 month history of feeling unwell on and off  associated with a  4 kg weight loss during that time. She presented acutely because  the night before she developed mild abdominal pain and...

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The game changer

Images Bashir Antoine Chakar (Emergency Registrar), text Genevieve Carbonatto A 63 year old lady presents overnight with lower abdominal pain and left renal angle pain. She has blood and WCC in her urine. She is known to have recurrent UTI's. The patient is handed over to you as a having...

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PFO

Images Genevieve Carbonatto and Tina Cullen. Text Genevieve Carbonatto A 35 year old lady presents to the Emergency Department with chest pain. She has had a recent admission for drainage of a pericardial effusion (non malignant) and is concerned that it may have reaccumulated. An point of care ECHO was...

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Cardiac arrest : Aortic dissection

Images Sarah Vaughan (Emergency Registrar) text Genevieve Carbonatto There is a BAT call. The ambulance are bringing a 72 year old woman who suddenly , in front of her husband, was seen to  slump to one side and appeared to have a left hemiplegia. In transit to hospital she has...

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Renal colic – the twinkle artifact

Images Bashir Antoine Chakar, text Genevieve Carbonatto A 32 year old man presents with right flank pain. He had an episode of renal colic 2 years ago and presented to the Emergency Department back then. He had a CT KUB done at the time which showed a small stone in...

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Renal colic

Ultrasound images Genevieve Carbonatto and Tina Cullen text Genevieve Carbonatto A 35 year old man presents to the Emergency Department with acute onset right flank pain. He has been having "niggles" of pain in the last week but suddenly at work he develops severe pain. He has microscopic haematuria on...

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Ruptured ectopic pregnancy

Images Sarah Vaughan (Emergency Registrar) Text Genevieve Carbonatto A young 30 year old lady is brought in by ambulance with acute onset severe lower abdominal pain. The first thing you want to exclude is a ruptured ectopic. On arrival she is pale and looks shocked. She says she had a...

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Aortic Dissection – Stanford Type A

Echo images Matthew Oliver (Emergency Physician) Text Genevieve Carbonatto There is a BAT call. The ambulance are bringing in a man with severe back pain. 5 minutes later a 70 year old man is wheeled into the rescusitation room. He is in severe distress. He states he was lifting a...

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Aortic Dissection – almost missed diagnosis!

Ultrasound images and text Genevieve Carbonatto You get a handover from the overnight registrar who has had an extremely busy shift. After you get handed over several patients he describes  a 56 year old lady who woke up in the morning to go the toilet. While she was sitting , she...

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Air: subcutaneous emphysema vs pneumothorax

Images and text Genevieve Carbonatto A 66  year old presents to the Emergency Department after a fall onto her right chest wall. She had slipped in her bedroom and landed backwards onto a cabinet in her bedroom . She is in great pain on arrival to ED. This is her...

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Cardiac Amyloidosis

ECHO images and text Genevieve Carbonatto The following patient presented to the Emergency Department after a syncopal event walking up a flight of stairs. He had become more short of breath (SOB) over the past week or so, finding it hard to walk more than 50m without beocoming SOB.  On...

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DVT – Why use Doppler?

Images Sarah Vaughan, text Genevieve Carbonatto A young 26 year old girl presents to the Emergency Department with excrutiating pain to her left leg. She developed the pain acutely that morning and she can't walk on it at all. She helps you with your diagnosis by saying that she has...

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Cardiomyopathy – Postpartum Shortness of Breath

Images and text Genevieve Carbonatto History: A young 32 year old lady presents to the Emergency Department SOB (short of breath). She is 4 weeks postpartum and was well during her pregnancy. She did not suffer from pre eclampsia during or just after her pregnancy. The baby was born by...

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Pneumothorax, power Doppler

Images and Text Genevieve Carbonatto You get an ambulance call. A 34 year old man has fallen off a roof and has severe left sided chest pain. He will be arriving in 5 minutes. The patient arrives. He has significant chest pain which is localised to his left lateral chest...

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Lung Septations

Ultrasound images and text Genevieve Carbonatto. A 62 year old man with known metastatic non small cell carcinoma presents to the Emergency Department SOB (short of breath). His excercise tolerance has been decreasing over a period of a week. He has been seen by his oncologist as an outpatient and...

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Empyema

Ultrasound images and text Genevieve Carbonatto. Featured image: Oceanographic museum Monaco. A 45 year old man presents to the Emergency Department with a 6 month history of feeling generally unwell with fevers and a chronic cough. He is no longer able to cope at home. On arrival he is saturating...

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Endocarditis – Shortness of breath

Images Genevieve Carbonatto. Text Genevieve Carbonatto and Tina Cullen. Featured image, NZ rain forest Abel Tasman National park A young man presents to the Emergency Department with SOB (shortness of breath). He has been sent in by his flatmates because he is so unwell. They leave as soon as he...

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FAST – Focus on the RUQ – False +ve

Text and images  Genevieve Carbonatto There is a BAT call. A young 35 year old has fallen from a 3 story building and essentially landed on his feet.  He has extensive leg injuries and possible chest and abdominal injuries. BP 95/60 HR 110/min RR 25/min Saturating 96% on RA. He...

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Pulmonary Embolism – Could you review your patient please, his BP is dropping

Images and text Genevieve Carbonatto and Tina Cullen. A 72 year old man presents to the Emergency Department with shortness of breath (SOB). He is severely SOB on minimal effort and has been unable to get out of bed for 2 days. He gives a story of 6 months of...

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Early Pregnancy Fetal Heart Beat – Now you see it, now you don’t

Images and text Genevieve Carbonatto PV bleeding in early pregnancy is common. This is probably one of our most common presentations to the emergency department. Because we only have access to transabdominal ultrasound, the sensitivity of this exam in first trimester pregnancy is not as good as it is for...

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Internal hernia

Ultrasound images Sanjay Ramrakha. Text Genevieve Carbonatto and Katherine Bennett The Emergency department gets a pre arrival call from a GP. He is sending in a sick looking 10 year old who has been vomiting overnight. He thinks this may be gastro On arrival a pale, mottled, barely responsive child...

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Discovering the aorta through ultrasound

ECHO images Tina Cullen. Text Genevieve Carbonatto A 65 year old lady presented to the Emergency department with a 6 month history of  abdominal pain. The pain was vague and mainly located in her pelvis but at times was epigastric. A bedside point of care ultrasound was performed. This was the...

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Shock – Left Ventricular Outflow Obstruction

Echo images Tina Cullen, text Genevieve Carbonatto The Emergency phone rings directly from the paramedics. They have a  59 year old woman with acute onset chest pain. BP 75/40, diaphoretic. HR 110/min in atrial fibrillation. She has a past history of hypertension. The ECG is faxed through   Widespead ST...

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Giant Bulla

Images and text by Genevieve Carbonatto A 72 year old man arrived in the Emergency Department directly from a private radiology imaging service saying he had been told to present immediately to the Emergency Department for treatment of his pneumothorax. He had had a previous pneumothorax and knew all about chest...

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Incarcerated umbilical hernia

Images and text by Genevieve Carbonatto   A 54 year old presents with an umbilical hernia. He says that he has always been able to push it back, but not this time. This is his ultrasound scan Note the umbilical hernial sac. The loop of  bowel is not moving within the...

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Right hip abscess

Images by Lee Juan Chiang A 45 year old diabetic presents with a right hip abscess. This is his ultrasound With probe compression, pus can be seen moving within the abscess. This is called 'pus-stalsis" and is diagnostic of an abscess. Discussion Skin and soft tissue abscesses account for 2%...

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Deep buttock abscess.

Images by Genevieve Carbonatto    A patient presented  to the Emergency with a very painful right buttock. There was no area of erythema and the buttock was not enlarged . It was however intensely painful to move the right leg. To investigate what might be happening beneath the subcutaneous tissue, ultrasound...

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Gallstones in 4 month old

Images and text by Genevieve Carbonatto and Jeremy Fry Name changed to protect patient confidentiality. Sam was 4 months old when he was brought by his parents to the ED. He presented with acute onset of crying and distress which awoke him from sleep. He was grunting and drawing his knees...

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TB cardiomyopathy – All done and dusted?

Ultrasound Images and text by Genevieve Carbonatto Case History A 60 year old man presented to ED with a one day history of severe SOB on the background of a 2 month history of increasing SOB. He was so breathless that it was an effort to walk 3 to 4 metres....

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The mystery of the falling haemoglobin

Images and text by Genevieve Carbonatto An 85 year old presented to our Emergency Department  with light headedness fatigue and SOB. BP 90 systolic on arrival , HR 100/min Bloods:  haemoglobin of 78g/l, creatinine of 172micromol/l  and  urea of 13.9mmol/l. Haemoglobin 3 weeks prior to admission 90g/l Past history of AAA...

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Intussusception – The doughnut sign or target sign, the pseudokidney sign

Images and text by Genevieve Carbonatto Case history A 42 year old man presented to the Emergency department at 4.00 am with a history of sudden onset central abdominal pain since 2.00 am. The pain was constant, in fact, it was getting worse. It was not associated with vomiting. He had...

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