Display Library Categories

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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 opened his bowels 4 times since he ...
• Aortic endoleaks
  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 endovascular repair 4 years ago, history of PR bleeding ...
• 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. He had recently returned from a 2 ...
• 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 up to his chest. He had been ...
• Bicuspid Aortic valve
  Images by Genevieve Carbonatto A young 23 year old man presents to the Emergency Department with chest pain. A point of care ECHO is performed. An incidental finding of a bicuspid aortic valve is found. Parasternal long axis of left ventricle (PLAX) showing that the aortic valve closure is eccentric. It  closes more towards the right coronary sinus ...
• Cardiomyopathy
  Images by Genevieve Carbonatto   Parasternal long axis of the left ventricle, (PLAX) demonstrating dilated LV, right ventricle, (RV) and left atrium, (LA).  LV contractility in this view is moderate to  severely impaired with some preservation of the IVS  motion. Measurement of internal diameter of LV at end diastole. Parasternal long axis view of LV with colour across the mitral ...
• Chronic pulmonary hypertension
  Images by Genevieve Carbonatto Parasternal long axis, (PLAX) of the left ventricle with the probe tilted slightly towards the right hip showing a dilated right ventricle, (RV).  There is elongation and thickening of the  anterior mitral valve leaflet. Parasternal long axis, (PLAX) of the left ventricle with the probe tilted slightly towards the right hip with colour across ...
• Amyloidosis
  Images Genevieve Carbonatto    Parasternal long axis (PLAX) of the left ventricle demonstrating asymmetric septal hypertrophy, compare the thickness of the interventricular septum, (IVS) in diastole with the infero-lateral (posterior) LV wall.  The IVS / LVPW > 1.3 : 1.  The LV cavity almost completely obliterates, “kissing walls” suggesting hypovolaemia.  The left atrium, (LA) is dilated.  ...
• Large pericardial effusion
  Images by Genevieve Carbonatto PLAX view. Very large pericardial effusion. Heart “swinging” in fluid   Size should be measured at the end of diastole. To be accurate this should be done using the ECG for timing. Practically speaking the exact size of the effusion is not important. This effusion is circumferential and is over 2cm in depth around the ...
• Pericardial effusion and metastasis
  Images by Genevieve Carbonatto Parasternal Long axis (PLAX) of the left ventricle demonstrating a large circumferential pericardial effusion, (passes anterior to the descending thoracic aorta).  Note the RV anterior wall appears as though it may be collapsing in early diastole when RV pressure is at its lowest. Has the appearance of someone jumping on a trampoline.  There ...
• FB on AICD
  Images by Genevieve Carbonatto Apical 4-chamber view demonstrating  Automatic Implantable Cardioverter Defibrillator, (AICD) lead passing between the coaptation point of the tricuspid valve leaflets.  There is a focus of increased echoes on the lead on the right atrial aspect of the tricuspid valve. Differential diagnosis on echo: Thrombus, pannus or vegetation.  (Patient’s clinical status must be taken ...
• Posterior Mitral Valve prolapse
  Images by Genevieve Carbonatto Parasternal long axis view, (PLAX)  of the left ventricle showing bileaflet mitral valve prolapse, (MVP) but much more prominent in the posterior leaflet. The PLAX is the best window to use  to diagnose MVP. Parasternal long axis view, (PLAX)  of the left ventricle showing bileaflet mitral valve prolapse. The posterior MV prolapse is more prominent ...
• Posterior Mitral valve prolapse
  Images by Genevieve Carbonatto Apical 4-chamber view showing the posterior mitral valve leaflet prolapse that was and should be diagnosed on the parasternal long axis view. Parasternal long axis view of the LV displaying the prolapse of the posterior mitral leaflet during systole. Apical 4-chamber view showing the prolapsing PMVL protruding into the LA during systole.  From the apical ...
• PDA (Patent ductus arteriosus)
  Images by Genevieve Carbonatto   PSAX view Jet from PDA, flow from aorta to pulmonary artery Parasternal long axis of the left ventricle, (LV).  The LV appears to be a little dilated.  Image is slightly tilted towards the right hip, as part of the tricuspid valve is seen, this can make the Right Ventricle (RV) appear slightly ...
• Pulmonary embolus (PE)
  Images by Genevieve Carbonatto  Subcostal view. Large right ventricle, small left ventricle, intraventricular septum flattened Subcostal 4-chamber view demonstrating severely dilated right heart with significantly reduced right ventricular contractility.  The interventricular septum is flattened more during diastole.  Small cavity left ventricle.  (RV is the “preload” of the LV). There is the appearance of a small amount of ...
• Pulmonary Embolus
  Images by James Dent  McConnell’s sign is akinesis of the basal and mid segments of the RV free wall but apical preservation / hyperkinesis.  It is sensitive but not specific for pulmonary embolus Parasternal long axis of the left ventricle, (PLAX) demonstrating that the right ventricular, (RV) anterior wall is not contracting well.  The RV cavity ...
• Pericardial Effusion
  Images by Genevieve Carbonatto  Large circumferential pericardial effusion, best seen on moving clips Parasternal long axis of the left ventricle demonstrating a moderate circumferential pericardial effusion.  No echo evidence of cardiac tamponade on this view.  RV contracts in systole and relaxes in diastole, no collapse evident. Apical 4-chamber demonstrating circumferential pericardial effusion.  No definite echo signs of cardiac ...
• Large pericardial effusion
  Images by Genevieve Carbonatto  5 chamber view shows large pericardial effusion and right ventricular wall and right atrial wall collapse Parasternal long axis left ventricle showing a circumferential pericardial effusion. It is small anteriorly but moderate posteriorly. Parasternal short axis left ventricle at the  level of the papillary muscles with a large circumferential pericardial effusion. Parasternal short axis left ...
• Pericardial effusion with fibrinous strands
  Images by Genevieve Carbonatto  Frozen image of the apical 4-chamber view showing a moderate circumferential pericardial effusion containing fibrinous strands shown by the solid white arrow.  There are strands throughout the effusion. Parasternal long axis (PLAX) Left ventricle showing a moderate circumferential pericardial effusion. Apical 4-chamber view showing a moderate circumferential pericardial effusion containing fibrinous strands. Subcostal ( subxiphiod) ...
• Pericardial effusion and pleural effusion
  Images by Genevieve Carbonatto Parasternal long axis, (PLAX) left ventricle showing a small circumferential pericardial effusion ending anteriorly to the descending thoracic aorta, (D.Th.A.).  The D.Th.A. is the anatomical landmark to differentiate between a pericardial and a pleural effusion.  The pericardial effusion is trivial anterior to the RV anterior wall. There is also a suggestion of a ...
• Amyloidosis
  Images by Genevieve Carbonatto Parasternal long axis, (PLAX) of the left ventricle showing thickened LV walls and reduced ejection fraction.   Measurements of the interventricular septum, (IVS) and LV infero-lateral (posterior) wall (LVPW) should be measured in a straight line across the minor axis of the LV. The measurements should be performed at end diastole, the frame at or ...
• Anterior mitral valve prolapse
  Images by Genevieve Carbonatto Off axis PLAX  left ventricle, (LV) in a “Cavus Excavatum” chest with a prolapse of the anterior leaflet of the mitral valve, (MVP). Off axis PLAX in a “Cavus Excavatum” chest with colour across the mitral valve, (MVP).  Note that the colour jet is directed posteriorly with an anterior leaflet MVP. Apical 4-chamber view.  Mitral ...
• Sepsis
  Images by Genevieve Carbonatto   Hypovolaemia ,”kissing”  ventricular walls in PLAX view. Posterior wall of LV and IVS come together in systole PLAX LV Kissing walls Hypovolaemia   PSAX at level of papillary muscle kissing walls, cavity obliteration due to hypovolaemia Apical 4-chamber view small LV cavity.   Lung ultrasound: Consolidation, shred sign and sub-pleural B-lines indicating pneumonia  
• Dissection
  Images by Genevieve Carbonatto Abdominal dissections are more common than ruptured aortic aneurysms. They are the most common aortic emergencies. The true lumen is often smaller than the false lumen as it is compressed by the false lumen. In most cases the aorta is not aneurysmal and will be less than 3cm in diameter. Ultrasound is not ...
• AAA thrombus
  Images by Genevieve Carbonatto Measurement of the aorta should be made outer wall to outer wall in the transverse and longitudinal view. It is important to start as proximally as possible in the abdomen when examining the aorta. Most abdominal aortic aneurysms are infrarenal. Proximal aorta just below the SMA is 2.32 cm and millimeters inferior to this ...
• Acalculous cholecystitis
  Images by Genevieve Carbonatto A young 33 year old woman presents with 4 days of abdominal pain. She is now febrile and vomiting. She has previously been well. An ultrasound of her RUQ shows acalculous cholecystitis.  While acalculous cholecystitis is usually associated with risk factors such as extensive burns, polytrauma, major surgery, end stage renal disease , ...
• Polyp and stone in GB
  Images by Genevieve Carbonatto   Both a polyp and a stone can be seen in the ballbladder. This is best visualised when panning through the gallbladder rather than with a still image The stone casts a shadow, the polyp does not. While the stone is in the most dependent portion of the gallbladder , the polyp appears in ...
• Gallstones
  Images by Genevieve Carbonatto Gallstones are commonplace. Ultrasound is highly sensitive in identifying gallstones. The appearance of gallstones is variable. They vary in size,shape and number. They may be associated with sludge. Stones and polyps may coexist. They are echogenic and cast an anechoic shadow (acoustic shadow). Gallstones that are less than 5 mm may not cast ...
• Gallstone + tumification of sludge
  Images by Tina Cullen    A patient presents with abdominal pain. Examination of the gall bladder using ultrasound shows a solid rounded looking “tumified” sludge in the  gallbladder.  The stone casts an acoustic shadow and is in the neck of the gallbladder.  Colour Doppler can be  used to look to confirm this is not a tumour. There is ...
• Cholecystitis
  Images by Genevieve Carbonatto Ultrasound is the best imaging modality to diagnose cholecystitis. Cholecystitis is a frequent presentation to the Emergency department. The hall marks include Thickening of the gallbladder wall > 3mm Gallstones Impacted stones in the cystic duct or gall bladder neck Pericholecystic fluid +ve Murphy’s sign Hyperaemic gallbladder wall on colour or power Doppler. The following are examples of patients presenting ...
• Gallbladder wall thickening – not cholecystitis
    Images by Genevieve Carbonatto The gall bladder wall can be thickened in a number of different situations other than cholecystitis. This is important when assessing someone in Emergency with a thickened GB wall. The clinical situations needs to be taken into account before determining that the GB wall thickening is due to cholecystitis. The GB wall can ...
• Synechiae in femoral vein
  Images by Genevieve Carbonatto    Recanalisation of a vein post acute deep venous thrombosis involves remodeling of the thrombus. This is a complex process of adhesion of the thrombus to the wall of the vein, an inflammatory response of the vessel wall leading to organization and subsequent contraction of the thrombus, neovascularization and spontaneous lysis of areas ...
• Thrombosis to CFV, leg oedema
  Images by Genevieve Carbonatto. A patient presented with a swollen left leg Thrombus visible in CFV FV Popliteal vein Dual screen shows CFV not coapting with compression. Common femoral vein Femoral vein – note oedema of subcutaneous tissues                 Thrombus in common femoral vein. Tip of thrombus visible Popliteal vein thrombus
• Thrombus CFV
  Images by Genevieve Carbonatto CFV DVT. Partially compressible CFV, tip of thrombus visible at maximum compression. Colour Doppler outlines the thrombus  
• Thrombus CFV and GSV
  Images by Genevieve Carbonatto Non compressible GSV and CFV. The GSV is dilated. The common femoral artery compresses but not the vein.  
• 7 weeks pregnant. Intrauterine pregnancy
  Images by Genevieve Carbonatt0    PV spotting. Intrauterine pregnancy. Gestational sac + yolk sac visible Gestational sac clearly intrauterine. Yolk sac and fetal pole present Round yolk sac and fetal pole with heart beat visible when fanning across the gestation sac in zoomed view Fetal HB better visualised on zoomed view of gestational sac                 M mode through fetal demonstrating fetal HB
• 6 weeks, intrauterine gestational sac
  Images by Genevieve Carbonatto A patient presents to the Emergency department 6 weeks pregnant. This is her scan Longitudinal view : Intrauterine gestational sac. Fanning through the uterus in the transverse plane: Intrauterine gestational sac   Sac diameter 1.05cm. A fetal pole and heart beat should be visible if the mean gestational sac diameter is 2.5 cm when examined transabdominally  
• Ruptured CL cyst, intrauterine pregnancy 7 weeks
    Images Genevieve Carbonatto A 7 week pregnant patient presents with acute onset abdominal pain. She has not had a scan before. Her scans show a large CL cyst, a small amount of fluid in the pouch of Douglas and an intrauterine pregancy Longitudinal view through pelvis.  Large CL cyst seen superior to bladder, small amount of fluid ...
• Twins, single gestational sac, 9 weeks
  Images by Genevieve Carbonatto A 9 week pregnant lady presents to the Emergency department with PV spotting. Her scan shows a  retroverted uterus and  twin pregnancies within one gesttaional sac. These are monozygotic twins. It is difficult to identify each twin seprately but there are definately 2 heart beats visible which can both berecorded using M mode. 2 ...
• Very large uterine fibroid in patient with an early intrauterine pregnancy
  Images by Genevieve Carbonatto A 34 year old woman presented to the Emergency department with a at 6 weeks gestation with a palpable suprabupic mass and vaginal spotting. This is her scan.  Small gestational “squashed’ by very large fibroid Small “squashed” gestational sac with fetal pole, active HB and round yolk sac visible Focus on gestational sac with fetal pole ...
• Unruptured left ectopic 7 weeks
    Images by Genevieve Carbonatto A 7 week pregnant lady presents to the Emergency department with spotting. A scan through the pelvis demonstrates an empty uterus and what looks like a CL cyst or an ectopic tubal pregnancy in the left adnexa. Colour Doppler demonstrates a “ring of fire”  appearance. This can be present around a CL cyst ...
• Fractured sternum
  Images by Genevieve Carbonatto  Sternal fracture. Note that as the probe glides down from the manubrium to the sternum towards the fracture, the fracture becomes clearly visible    
• 19 weeks ruptured membranes
  Images by Genevieve Carbonatto   A 19 week pregnant woman presents with abdominal pain and ruptured membranes. Her scan shows lack of amniotic fluid around the fetus. Th legs are in the cervical canal.  
• In vitro fertilisation, ovarian hyperstimulation syndrome, 4 weeks pregnant
  Images by Genevieve Carbonatto A patient presents to the Emergency department with severe abdominal pain. She is 4 weeks pregnant . Thus is an IVF pregnancy. She has ovarian hyperstimulation syndrome.The ovary measures 14.7 cm X 9.38 cm.It is polycystic. There is a large amount of fluid in the peritoneal cavity. The gestational sac not yet ...
• Fractured rib, pneumothorax
  Images by Genevieve Carbonatto  M mode shows stratosphere sign No lung sliding, left lung Lung sliding + occasional B lines , right lung
• Ruptured spleen
  Images by Genevieve Carbonatto   Pedestrian vs car, ruptured spleen. Free fluid in Morrison’s pouch.  
• Ruptured liver
  Images by Genevieve Carbonatto    Free fluid in Morrison’s pouch Fluid in LUQ  
• Fall on left side. Left sided haemothorax and blood around spleen
  Images by Genevieve Carbonatto   Splenic laceration and fractured rib. Free fluid below and above the diaphragm. Note diaphragm separates the fluid which is below the diapgragm from that which is in the chest above it.
• MVA, bilateral pneumothoraces
  Images by Genevieve Carbonatto  M mode Pneumothorax, stratosphere sign Right lung : Note absent lung sliding. If unsure in trauma change to linear probe to better visualise pleural line. Left lung: Note absent lung sliding.
• Appendicitis – appendicolith
  Images by Genevieve Carbonatto   Features of appendicitis Thickened appendix which measures 1.o5cm Target sign – hypoechoic walls Appendicolith Non compressible appendix Lack of peristalsis “creeping fat” or hyperechoic mesentery surrounding appendix Increased vascularity of wall of appendix    
• 2 year old, ruptured appendix
  Images Genevieve Carbonatto Severely unwell febrile 2 year old presenting with abdominal tenderness and rebound Features of appendicitis Thickened appendix Faecolith Free fluid in RLQ indicating rupture incompressible ” creeping fat” hyperechoic mesentary Incompressible appendix. a complex structure abuts the appendix ? abscess . Appendicolith appears just at the end of the clip with free fluid surrounding the appendix    
• Infected breast sebaceous cyst
  Images and text by Genevieve Carbonatto A patient presents with a small painful breast lump. This is her ultrasound The cyst is well circumscribed , is associated with posterior acoustic shadowing and has a number of internal echos suggesting sediment. Cyst measures I.48 cm X 2.31cm Discussion Features of sebaceous cysts on ultrasound (1) Located in the skin or subcutaneous tissue Small Hypoechoic Hyperechoic alternating ...
• 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 was used. This is a longitudinal view ...
• Large cervical node
  Images by Genevieve Carbonatto Characteristics of normal cervical nodes on ultrasound include Size < 6mm Flat or oval shape Hypoechoic echotexture Hilum is present and can be seen with colour Doppler if the node is > 5mm         Veins and efferent lymphatics  leave the node through the hilum while arteries enter the node through the hium. The hilum appears as a depressed ...
• Right hip abscess – Pus stalsis
  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% of ED visits and the incidence is increasing. (1) For ...
• Appendicitis
  Images Lee Juan Chiang Features indicating appendicitis Thickened appendix which measures 1.35cm. Dilated appendix Target sign – hypoechoic walls Non compressible appendix Lack of peristalsis “creeping fat” or hyperechoic mesentery surrounding appendix Colour doppler shows inflammation of walls    
• 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 hernia. The bowel is surrounded by peritoneal fluid. ...
• Liver abscess
  Images by Genevieve Carbonatto  A 44 year old man returned from Bali with shortness of breath and pleuritic pain. He also complained of right upper quadrant pain worse on breathing. He was febrile and unwell.  A chest Xray was normal. A point of care ultrasound was performed to see whether he  had pathology below the diaphragm ...
• Liver metastases
  Images by Genevieve Carbonatto A patient presented with acute shortness of breath. A point of care ultrasound was performed on his lungs to look for pulmonary oedema, consolidation or effusion. While scanning, new liver metastases were visualised. The patient had presented with a new diagnosis of metastatic lung cancer. Liver metastases may present in many different ways on ...
• Pancreatic pseudocyst
  Images by Genevieve Carbonatto     A 62 year old lady presented with abdominal pain. A point of care ultrasound was performed which showed a hypoechoic rounded structure in head of pancreas which could be a tumour or a cyst. It was confirmed to be a pancreatic pseudocyst on CT.  The lesion is not a vessel as it ...
• Epiploic fat torsion
  Image by Genevieve Carbonatto   A 52 year old lady presented to the Emergency department with acute , severe,  epigastric pain and vomiting. A point of care ultrasound was performed which showed a normal gall bladder with no stones. Insonating over the area of maximal tenderness which was just below the xiphisternum showed a rounded hyperechoic mass ...
• Ruptured right ectopic, 7 weeks
  Images by Genevieve Carbonatto A 7 week pregnant lady presents to the Emergency department with sudden onset of severe abdominal pain. Her BP is 100/80. She is pale and sweaty. She is directed immediately to the resuscitation room. This is her pelvic scan. A  small gestational sac is visible in the right adnexa  with a visible yolk ...
• 8 weeks 5 days PV bleeding
  An 8 week old pregnant lady presents with 5 days of PV bleeding. A transabdominal ultrasound shows an anteverted uterus with an intrauterine gestastional sac. The fetal pole, yolk sac are visible. Yolk sac, 0.71 cm. Crown rump length 2.25 cm. There is fetal heart beat present. No sinister cause for her bleeding is seen. ...
• Incomplete miscarriage 10 weeks
  Images by Genevieve Carbonatto A 10 week pregnant patient presents with Vvaginal bleeding Her scan in the longitudinal plane shows a gestational sac in lower uterine cavity.  This is an incomplete miscarriage. The transverse view of the uterus shows an intrauterine gestational sac. There is no clear fetal pole and no yolk sac.      
• B cell lymphoma
  Images by Genevieve Carbonatto 5 weeks of fever and SOB. B cell lymphoma. Lung interstitial infiltrates. Irregular pleural line. B lines Right anterior chest. B lines, irregular pleural line Right midaxillary line. B lines more confluent. Right costophrenic angle, fixed B lines, no fluid  
• Pneumonia
  Images Genevieve Carbonatto 1 week of fever and cough In left axilla, no fluid, fixed B lines, minimal lung sliding Posterior axillary line – pleural fluid, lung consolidation, fixed B lines from aerated lung just below consolidation CT scan: Left lung consolidation and pleural fluid
• LLL consolidation
  Image Genevieve Carbonatto   Collapsed lung looks like a solid organ . Hyperechoic foci are air bronchograms. Pleural fluid surrounds the lung.
• Consolidation
    Images Genevieve Carbonatto  Shred sign – irregularity of pleural line. Small amount of pleural fluid. This indicates area if consolidation Clear triangular area “shred sign” at the level of the pleural line. Small amount of pleural fluid present. Fixed B lines from below the pleural line Left costophrenic angle – pleural fluid
• Chronic interstitial syndrome
  Images Genevieve Carbonatto According to the 2012 International evidence-based recommendations for point-of-care lung ultrasound, diffuse parenchymal lung diseases have as sonographic findings, pleural line abnormalities (irregular,fragmented pleural line) and subpleural abnormalities (small echo – poor areas) and B lines  in non homogenous areas. The following images are from a man with severe chronic interstitial syndrome. The first 3 ...
• Pulmonary oedema
  Image Genevieve Carbonatto  Widespread B lines originating from the pleural line Acute pulmonary oedema The causes of an interstitial syndrome includes, pulmonary edema of various causes, interstitial pneumonia or pneumonitis and diffuse parenchymal lung disease (pulmonary fibrosis) The clinical scenario will help differentiate between them. There are subtle sonographic differences however. B lines are seen in pulmonary oedema throughout ...
• Pleurodesis
  Image Genevieve Carbonatto Pleurodesis will appear on ultrasound exactly like a pneumothorax as there will be absence of lung sliding
• Retinal detachment
  Images by James Dent   Retinal detachment
• Normal chest Xray small area of consolidation and small pleural effusion
  Images by Genevieve Carbonatto This young man presented with a one week history of cough and a 2 day history of a very localised chest pain. His chest Xray films were unremarkable        His ultrasound was interesting Just at the point of his pain, there is a break in the pleural line suggesting a small area of consolidation. ...
• Lobar pneumonia
  Images by Matthew Oliver 3 days of cough and sore throat. 2 days of headache, fever and anorexia. Chest Xray shows right upper lobe pneumonia Ultrasound shows lung consolidation. the consolidated area looks like solid tissue. The bright  hyperechoic areas are lung bronchograms. B lines due to interstitial fluid can be seen adjacent to the consolidated unaerated ...
• Retinal detachment
  Images by James Dent    
• Imperforate hymen : Haematometrocolpus
  Images by Genevieve Carbonatto  This 11 year old presented with severe abdominal pain. On examination she had a distended tender abdomen.  She was initially thought to be in urinary retention. She was catheterised but had very little urine in her bladder. Her ultrasound shows a distended uterus from  haematometrocolpus due to an imperforate hymen. The ...
• RIF pain
  Images by Genevieve Carbonatto  72 year old woman with a 4 day history of RIF pain. Ultrasound shows what was directly under the point of tenderness. A point of care ultrasound shows a complex structure tender structure in the RIF. This is a  possible inflamed appendix, possible inflamed ileum. The  AP diameter of the appendix is  1.95 ...
• Sigmoid colitis
  Images by Genevieve Carbonatto    A patient presents with 4 days of abdominal pain and diarrhea. He has suprapubic tenderness. A point of care ultrasound confirms a colitis from his descending colon including his sigmoid colon. Ultrasound features consistent with this Thickened bowel wall Hypoechoic submucosa.  
• Choledocholithiasis
  Images Eleanor Cook and Tina Cullen     A 33 year old presents to the Emergency Department with RUQ pain. A point of care ultrasound is performed to exclude a biliary cause for her pain. This is the transverse view of the GB. The GB could be easily missed in this view because it is full of ...
• 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 tubes. He was eager to get another ...
• Bowel obstruction
  Images by Genevieve Carbonatto  Grossly dilated loops of bowel Dilated loops of bowel. To and fro of contents of bowel. Extraluminal fluid (ascites)
• Chrohn’s disease, bowel obstruction
  Images Genevieve Carbonatto A patient  with Chrohn’s disease presents with severe abdominal pain and vomiting. He has had pain for 2 weeks and only now presents to the Emergency Department.  An ultrasound is  performed on arrival. His ultrasound shows all the features of small bowel obstruction Dilatation of the small bowel Reduced peristalsis of the bowel Fluid filled bowel contents To ...
• Appendicitis 11 weeks pregnant
  Images Genevieve Carbonatto An  11 week pregnant patient presented to the Emergency department complaining of right iliac fossa  pain. Ultrasound examination shows appendicitis. Features consistent with this include  Thickened appendix which measures 1.36cm. Target sign – hypoechoic walls Non compressible appendix Lack of peristalsis “creeping fat” or hyperechoic mesentery surrounding appendix      
• Appendicitis , right ovarian cyst
  Images Genevieve Carbonatto   A 34 year old woman  presents to the Emergency Department  with a 3 day history of right iliac fossa pain. An outpatient pelvic ultrasound showed a right ovarian cyst with some  fluid in the pouch of Douglas. The ruptured ovarian cyst was thought to be the cause of her pain. A point ...
• Ruptured ovarian cyst
  Images Genevieve Carbonatto  Ruptured haemorrhagic cyst.  Free fluid in pelvis surrounding uterus. Free fluid in Morrison’s pouch  
• Wall Echo Shadow
  Images Genevieve Carbonatto   A “wall, echo, shadow” occurs when the GB wall contracts over GB stones so that the normal echo free space surrounding the stones is no longer visible. There is no, or little anechoic bile visible surrounding the stones. This can be chronic, acute or may occur when the GB is contracted ...
• Subchorionic bleed,10 week pregnancy
    Images Genevieve Carbonatto  10 week pregnant patient presenting to the Emergency department with intermittent vaginal  bleeding for 2 days. Hypoechoic areas are subchorionic haemorrhages. Arrows outlining subchorionic bleed An active heart beat is visible    
• Rectus sheath haematoma
  Images Genevieve Carbonatto A  65 year old man with liver failure and ascites  presents with severe acute right upper quadrant abdominal pain. Ultrasound examination over the area of tenderness reveals a heterogeneous  area in the rectus abdominal muscle – Rectus sheath haematoma The rectus sheath haematoma is the area of mixed echogenicity in the rectus muscle                       Initially, because the ...
• Missed miscarriage 13 weeks
  Images Genevieve Carbonatto A 13 week pregnant woman presents to the Emergency department having had 7  hours of PV bleeding with clots and  lower abdominal  back pain. A point of care ultrasound shows an  empty uterus and an open os filled with mixed echogenicity which is clot. This is a missed miscarriage  
• 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 depression and T wave inversion in the inferior and ...
• Systolic anterior motion SAM
  Images Genevieve Carbonatto This gentleman presented septic to our department. He had a history of chronic renal failure requiring dyalisis. BP 88/60, HR 90/min. An ECHO was done in the ED to find a possible cardiac cause, other than hypovolaemia from sepsis, for his hypotension Watch the clip below. Watch the mitral valve. Then watch the anterior ...
• 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 ultrasound of her  proximal aorta in the transverse plane The ...
• 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 is wheeled into the resuscitation area. His ...
• 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. Transabdominal ultrasound is less sensitive in the first trimester pregnancy than  transvaginal ultrasound. Seeing a fetal heart beat confirms fetal viability. It is important to record this using M mode. The following ...
• 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. The trauma team is called. The patient gets ...
• Bacterial Endocarditis – Aortic valve
  Images Genevieve Carbonatto. Text Genevieve Carbonatto 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 presents to triage. He is an intravenous drug abuser, but says he hasn’t taken anything  for 2 weeks. ...
• 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 90% on RA (room air), his BP is ...
• 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 Caesarian section. She descibes being perfectly ...
• DVT – Why use Doppler?
  Images Sarah Vaughan, text Genevieve Carbonatto A young 26 year old girl presents to the Emergency Department with excruciating pain in 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 had a previous DVT in that ...
• 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 arrival his vital signs are : ...
• 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 ultrasound where there is clinically subcutaneous emphysema There ...
• 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 box when he developed severe acute ...
• 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 positive pregnancy test 2 days ago ...
• 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 a urinary dip stick. You think ...
• 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 his right VUJ and a larger ...
• 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 become less responsive and has arrested ...
• Twins, 2 gestational sacs, 10 weeks
  Images Genevieve Carbonatto A 10 week pregnant lady presents with PV spotting. On ultrasound 2 gestational sacs are present indicating heterozygous twins. This lady had had no previous scans. Each  gestational sac contains a viable fetus with an active heart beat. Longitudinal scan through uterus Fetal heart beat visible twin 1 Fetal heart beat visible twin 2 CRL twin 1 ...
• 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 performed .There was no evidence of ...
• 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 vomiting.  She has been investigated by ...
• Crohn’s disease – Bowel obstuction
  Images and text Genevieve Carbonatto. A 48 year old man presents to the Emergency  department with severe abdominal pain. He has Crohn’s disease and frequently presents with abdominal pain. He has had a previous entero-enteric anastomosis.  He is also self employed and hard working and always waits until his pain is unbearable before he presents to ...
• 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 being 10/10. He has been treated ...
• 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 spurred the following post and ...
• 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 gait. He states that while on ...
• Type A dissection
  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 130. Thinking this was an ischaemic ...
• 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 moved because of body habitus or illness, however ...
• Biliary Obstruction: Double Barrel sign, Monkey Puzzle sign
  Images and text Genevieve Carbonatto A 73 year old man presents to the emergency 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 yellow 4 days ago  and ...
• 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, notably no cardiovascular risk factors. Her ...
• 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 he has noticed his  ankles have ...
• 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 will arrive in 10 minutes. The ...
• B lines – how best to see them
  Thankyou Justin Bowra for this post. Ultrasound for interstitial lung disease and pulmonary oedema Key points B lines are found in pulmonary oedema and in other interstitial syndromes B lines start at the pleural line, move with breathing, are very bright, and reach much further down the screen (more than 10cm) than any other lung artefacts But you have to ...
• 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. On palpation he is tender over ...
• 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 drop in BP on inspiration), tachycardia ...
• 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 gestational sac. A complex left sided ...
• Pitfall: Blood clots and 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 the nurses and together you create ...
• 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 BP of 97, and he is saturating ...
• 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 crepitations bilaterally. You decide to do an ...
• 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 a single layer of flat endothelial cells and seperated ...
• LV Aneurysm
  Images and text Genevieve Carbonatto A 56 year old man presents to the Emergency  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 is his ECHO PLAX Note the akinesis and the aneurysmal deformity ...
• 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 ultrasound. Liver size, increased echogenicity and the ...
• Question 1 : Assessment of fluid status with ECHO
  Question 1 A haemodynamically decompensating patient requires assessment of the intravascular fluid status. Describe the Doppler echo cardiographic methods that can assist outlining the supportive evidence for their use, in addition to any obvious limitations in their application Assessment of fluid status can be achieved by using the LVOT VTI as a surrogate for stroke volume • SV ...
• Question 2 : Pericardial disease
  Question 2. Discuss the use and value of echocardiography in evaluating pericardial disease of various types Value is to look at the pericardium for structural abnormalities (thickening/calcification), assess associated pericardial effusions (may have strands suggesting inflammatory more chronic problem, may be anechoic, may show swirling cells) , look for haemodynamic signs of pericardial constriction. Pericardial disease can ...
• Question 3 : Complications of myocardial infarction
  Discuss the use of Echocardiography/Doppler in the assessment of the complications of acute myocardial infarction Acute/subacute complications Cardiogenic shock Thrombus formation Myocardial rupture Papillary muscle rupture Ischaemic ventricular septum defect Chronic Remodelling of the heart Aneurysm Right heart failure Late thrombus Mitral regurgitation Assessment using ECHO Regional wall abnormalities Will depend on size and coronary artery vessels affected. Need to do full cardiac views to evaluate properly Cardiogenic shock : Poor LV ...
• Question 4 : Severe back pain
  Question 4  A 45 year old presents with sudden onset of severe acute central chest and back pain suggestive of acute dissection. Discuss the role of transthoracic and transoesophageal echo –cardiography in the initial assessment and ongoing management Role of ECHO in initial assessment: Differentiate between aortic dissection and other causes of chest pain such as PE or ...
• Question 5: septic shock
  Describe the echocardiographic features not uncommonly seen in the patient with septic shock 1. ECHO exam may be normal 2. Sepsis induced  cardiomyopathy: Left Ventricular contraction impairment which may be global or segmental. MASPE < 8mm EF  < 52%  in men and < 54% in women (2) Left ventricular diastolic dysfunction:  Peak e’ velocity (cm/s) in early diastole measured using ...
• Question 6: Right heart strain
  Question 6 A pt presents with breathlessness : Describe the ultrasound findings that would suggest right heart strain and what features would suggest the findings is either acute or chronic ECHO findings suggestive of Right heart strain is TR velocity > 3.4m/s SPAP > 50 MmHg with or without additional echocardiographic variable suggestive of PH Measurement of TR ...
• Question 7 : Pericardial effusion
  Question 7 Describe the possible echo findings in a patient with pericardial effusion 1. Distribution Circumferential Loculated 2. Echogenicity Anechoic Echoic depending on it’s composition (blood may be echoic, pus also) May be associated with fibrin strains if chronic 3. Size small < 1cm moderate 1 cm – 2 cm large > 2 mm Measurement of effusion is measured at the end of diastole 4. Pericardium may be ...
• Question 8 : ECHO 2 days post AMI
  Question 8 A 50 year old man presents 2 days post AMI with hypotension. You are about to scan him looking for a cause. Outline possible ultrasound findings 1. Global LV regional abnormality Reduced fractional shortening of LV . Not accurate in regional wall abnormalities/aneurysms/ LBBB Simpson’s method 4 and 2 chamber views assesses cardiac ouput Systolic index of contractility ...
• Question 9: Assessment of LV function
  Question 9 How can  ECHO be used to assess LV function? LV function can be assessed in the following ways Fractional shortening “Eyeballing“ of LVF Ejection fraction (EF) – Simpson method Stroke volume Systolic index of contractility dP/dt Longitudinal contraction using tissue Doppler  MAPSE 1. Fractional shortening: Measures the “squeeze “ of the LV . Using M mode measure the end diastolic diameter and the end ...
• Question 10: Ultrasound in cardiac arrest
  A 45 year old patient presents in cardiac arrest . What is the ultrasound approach to this patient? The approach to the patient in cardiac arrest is based on assessment of the 4 F’s  (fluid, form, function and filling) of the heart to assess for potentially reversible causes of cardiac arrest, to assess prognosis and to ...
• 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 the trachea and the oeseophagus. The oesophagus ...
• 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 is hypotensive, his BP arterial trace showing electrical ...
• Trauma : knife through chest
  Ultrasound images and text Genevieve Carbonatto A 53  year old lady presents to the Emergency Department after having stabbed herself in the chest in a suicide attempt. The knife is still in the chest close to and to the left of the sternum  in the 5th intercostal space. She is alert and orientated, she says she ...
• ET tube malposition
  Images and text Genevieve Carbonatto. You get a BAT call. A 25-year-old with acute asthma has had a cardiopulmonary arrest. He has been intubated by the paramedics and received 1 mg of adrenaline with return of circulation. He is arriving in 5 minutes. A resus team is organised and you are in charge of the ultrasound ...
• Pitfall: Ruptured cornual ectopic pregnancy
  Images Nick Sidler, text Genevieve Carbonatto A 32 year old woman presents to the ED with her husband and 5.00 am. The woman is clearly unwell. She is directed straight to the resuscitation bay. Her husband tells you that shortly before 4.00 am she awoke with severe acute abdominal pain. He says she is pregnant – ...
• Bacterial endocarditis : Tricuspid valve
  Images Sarah Vaughan, Text Genevieve Carbonatto A BAT call arrives. A 42 year old man recently discharged against medical advice from hospital is coming acutely short of breath (SOB). 2 weeks prior  he self discharged despite acute liver failure from hepatitis C and positive blood cultures for strep mitis. He had been on benzylpenicillin and gentamicin. ...
• Intussusception in a 6 year old
  Images and text Genevieve Carbonatto A 6 year old girl presents to the Emergency department with dysuria and abdominal pain. The symptoms have been  intermittent until the morning of the presentation when the symptoms were constant and also associated with a left sided limp. She is unwilling to weight bear on her left leg. She had ...
• Pneumothorax : Test yourself
  We have added lung scans of patients with and without pneumothoraces. Test yourself! Pneumothorax/No pneumothorax 1. 2. 3. 4. 5. \ 6. 7. 8. 9. 10.
• Trauma: Right kidney laceration
  Images Stuart Napier, text Genevieve Carbonatto A 24 year old presents to the emergency department with right upper quadrant pain after playing rugby. He tripped, landing on his right elbow jamming  into his right upper quadrant. He was immediately winded and felt right upper abdominal pain. On waking the next morning he had severe right upper ...
• Pneumothorax : Where do we place the probe?
  A 56 year old man presents to the Emergency department from another hospital for trauma assessment. Earlier that morning he had fallen off a roof and injured his chest and left hand. He has had 3 chest ultrasounds performed by 3 different operators and a pneumothorax was missed. It was picked up by a CT ...
• Renal stones in PUJ
  Images Chris Harrington, Text Genevieve Carbonatto A 60 year old man presents with right renal flank pain radiating to the groin. He was known to have a 6mm stone in his VUJ from a CT scan a few months back. At the time he had no hydronephrosis. A point of care ultrasound was performed. The longitudinal view ...
• Cholecystitis and obstruction of the CBD
  Images Victoria Bond Text Genevieve Carbonatto A 42 year old lady presents to the Emergency Department with RUQ pain. She has had episodes of cholelithiasis in the past. She is mildly tender in her RUQ. A point of care ultrasound is performed along with the history and examination. This is her ultrasound The GB is full of ...
• Eyeballing LV function : Test yourself
  Gollum, Wellington Airport, Weta Studios Estimating ejection fraction (EF) can be done by eyeballing LV contraction on ECHO. This requires some skill and expertise. A very basic assessment in the Emergency department requires a parasternal long axis (PLAX), a parasternal short axis (PSAX) and a 4 chamber view (4CV). What are we looking for ? Inward movement of ...
• Acute vs Chronic Hydronephrosis
  Text and Images Oli Gaitsgory and Kezia Mansfield Clinical presentation: A 70 year old man with a background of metastatic colorectal cancer presents to the Emergency Department. He has a known large pelvic mass causing L ureteric obstruction, with a L ureteric stent in situ. He presents with 1 week of confusion and fevers. His blood tests showed ...
• Dilated CBD, pancreatic carcinoma
  Images and text Kezia Mansfield and Olga Gaitsgory An 84 year old woman presents to the  emergency department with a week of nausea, anorexia and general malaise, without abdominal pain. She has a past history insulin dependent diabetes, GORD and osteoarthritis. It was noted on examination that she was moderately jaundiced, with a non tender abdomen. A point ...
• Giant retroperitoneal haematoma
  Images and text Genevieve Carbonatto An 88 year old woman presents to ED from a nursing home hypotensive. She has recently been admitted to hospital with pneumonia, CCF, AF and bilateral below knee DVT’s. She was discharged on warfarin. She is generally feeling tired, has abdominal pain and is vomiting coffee ground vomit. On examination, her BP ...
• Pitfall : Retroverted uterus
  Images and text Genevieve Carbonatto A 32 year old lady presents with PV spotting. She is thought to be 8 weeks pregnant. A point of care transabdominal scan is performed in the Emergency Department. This is her transverse scan of the pelvis The bladder is empty. There appears to be no gestational sac This is her longitudinal scan The uterus ...
• 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 being the minimal level of knowledge ...
• Lung ultrasound for pulmonary embolism
  Images Edward Christian Text Genevieve Carbonatto A 65 year old man presents to the Emergency Department with a 1 week of cough and left sided chest pain. The pain is intermittent but worse at night when lying down. It is not exacerbated by activity. The patient  is experiencing shortness of breath when the chest pain comes ...
• Dissection
  Images Dr Juan Chiang An 85 year old man is brought in by ambulance after a syncopal event. He was hypotensive on scene, BP 78/50. He is given fluid by the paramedics but remains hypotensive.  He has no chest pain and is not short of breath. On arrival at the Emergency Department, he is alert, clammy, ...
• Diverticulitis
  Images and Text Genevieve Carbonatto A 45 year old man presents with a 3 day history of diarrhea and increasing LIF pain. He is afebrile. His diarrhea has tapered off. On examination he is tender in his LIF. A point of care ultrasound is performed using a curvilinear probe. He is able to localise with precision ...
• Bacterial endocarditis : Mitral valve
  Images Nick Stewart, text  Genevieve Carbonatto A 50 year old man presents to the ED with a 6 week history of general malaise, fevers, night sweats and weight loss (10 kg). He had been prescribed 7 courses of Augmentin by his GP and felt generally better on this antibiotic. An outpatient CT showed some nodes around ...
• Stanford type B dissection
  Images Earl Butler, text Genevieve Carbonatto A 55 year old lady presents with acute numbness to her right leg and “dizziness” lasting a few hours. No back pain. No chest pain. There are no other neurological symptoms.  BP 175/85 HR 72/min, RR 16/min saturations 96% on room air. Because of the numbness in her leg and ...
• Coarctation of the aorta in a neonate
  Images Chris Harrington, text Genevieve Carbonatto A 11 day old presents to the Emergency department in acute respiratory distress. His mother states that his SOB has increased markedly over the past 24 hours.  While on the way to hospital he has an episode of tachypnea  cyanosis and not breathing for 5 seconds. He has been feeding ...
• VSD in a 3 month old
  Images Hanaho Imamura, text Genevieve Carbonatto A 3 month old girl is brought into the Emergency department. Her parents state that she has become more unsettled recently, not feeding as well and  appearing to be more short of breath with feeding. She is not settling with feeding, requiring to be fed every 2 hours and taking ...
• Pulmonary hypertension in a child
    Images Juan Chiang A 13 year old girl presents to the Emergency Department after a syncopal event at school. This was not associated with prior chest pain or SOB. This is her first syncopal event. ECG Chest Xray A point of care ultrasound is performed. The following clip shows her PLAX view followed by her PSAX then the 4 CV ...
• Echocardiography during cardiac arrest: COACHRED
  Text Genevieve Carbonatto The management of cardiac arrest has been intensively studied over the past 20 year and other than early and good quality CPR and early defibrillation in VF, very little has shown to improve the prognosis in cardiac arrest. The last 20 years has shown that high dose adrenaline, vasopressin, supplementary oxygen, treatment of VT ...
• Cardiac tumour
  Images Roger Burrell Text Genevieve Carbonatto A 60 year old man presented to the Emergency Department short of breath having a  known right ventricular cardiac tumour with metastases to the lung, liver, spleen and bone. On examination saturating 100% on RA, bilateral pitting pedal oedema, BP, 120/60, HR 68/min. An ECHO was performed in the Emergency department. The ...
• Pulmonary Embolism – Right ventricular thrombus
  Images Nick Stewart text Genevieve Carbonatto A 22 year old patient presents to the Emergency Department with calf pain. On further questioning she has had  a presyncopal event the day of presentation and complains of shortness of breath. She has recently been put on tranexamic acid for heavy menstrual bleeding. She is also on the oral ...
• 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 box when he developed severe acute ...
• Hydronephrosis and aberrant renal artery
  Images Evy Panos A 32 year old man presents with right loin pain after a drinking binge. His friends have urged him to attend the Emergency Department because he always complains of  right loin pain after drinking in their company and they would like him to get to the bottom of it. He describes having right ...
• Heterotopic pregnancy
  Images Evy Panos, Text Genevieve Carbonatto A 32 year old lady presents by ambulance  to the Emergency Department in shock. She describes having felt dizzy but not unwell and then suddenly collapsed. She remembers being escorted in a wheelchair into an  ambulance. She is 19 weeks pregnant and has had a recent normal ultrasound scan. Her  ...
• Ruptured ectopic, pseudosac
  Images Bashir Chakar, text Genevieve Carbonatto A 36 year old lady presents with sudden onset of  right lower quadrant pain lasting 20 minutes. One hour later she experiences further abdominal pain prompting her presentation to the Emergency Department.  She has had 2 positive home pregnancy tests. On examination she is minimally tender in her right lower ...
• Aortic valve anatomy
  Genevieve Carbonatto The aortic valve  is the centrepiece of the heart It lies between the PV,  the TV and the MV It is wedged between the opening of the mitral and tricuspid valves The normal aortic valve consists of 3 equally sized semilunar leaflets or cusps. The leaflets form a 3 pronged crown-like structure. The AV consists of A virtual ring ...
• Causes of Aortic regurgitation: Summary
  Kathryn Statham , Genevieve Carbonatto Epidemiology The prevalence of chronic AR is 5 -10% (mainly mild AR) The prevalence of moderate to severe AR 0.5 – 2.7% AR increases with age It peaks in the 4th to 6th decade of life It is more common in men than in women A formal ECHO evaluation is important for prognosis and management In the Emergency ...
• 2. Causes of Aortic regurgitation : Aortic root dilatation and Loss of commissural support
  Kathryn Statham , Genevieve Carbonatto 1. Aortic root dilatation loss of leaflet coaptation hypertension connective tissue disorders (Marfans etc) 2. Loss of commissural support Aortic dissection VSD Aortic trauma   Aortic root dilatation Aortic root dilatation can cause loss of leaflet coaptation as in the clips below Loss of commissural support Loss of commissural support will cause aortic regurgitation. This patient has  a large ventricular septal defect . Same ...
• 3. Causes of Aortic regurgitation : Congenitally abnormal valves
  Kathryn Statham , Genevieve Carbonatto Congenitally abnormal valves Bicuspid Unicuspid Quadricuspid   Bicuspid valves (BAV) have been classified in many different ways. An easy classification  looks at  the number of cusps, the presence of raphes and the position and symmetry of cusps. A raphe refers to a conjoined area of two underdeveloped leaflets turning into a malformed commissure between both leaflets ...
• 1. Causes of Aortic regurgitation : Valve destruction and degeneration
    Kathryn Statham , Genevieve Carbonatto Valve destruction and degeneration sclerosis/stenosis infective endocarditis rheumatic heart disease aortic valve prolapse.   1. Valve sclerosis / stenosis 2 -3 % of people will develop  severe AS after the age of 75. If the  leaflets become thick and calcified they are poorly mobile causing them to close incompletely in diastole leading to AR Severe aortic stenosis due to ...
• Aortopathy – Aortic root dilatation
  Images Ava Ghalini text Genevieve Carbonatto A patient is referred by his GP to the Emergency Department for episodes of exertional upper chest pain over a period of 2 weeks. A troponin organised by his GP was 28. On arrival he is asymptomatic. BP 180/80, HR 100/min. A systolic and loud diastolic murmur is audible in ...
• Assessment of aortic regurgitation
  Kathryn Statham, Genevieve Carbonatto AR is rarely physiological. If it is present then a cause needs to be found. ECHO is used to determine Aetiology Estimate  severity Assess chronicity This is done first by imaging the heart with 2D echo and looking at: valves aortic root size LV cavity size (chronic vs acute) LV wall thickness LV function Colour and spectral Doppler Jet size Vena contracta width Jet/height ratio Deceleration ...
• Causes of Aortic Stenosis
  Kathryn Statham Aortic stenosis It is the most common valvular heart disease in developed countries It’s prevalence is increasing with our ageing population It is found in 3% of patients > 75 yrs It is the most common valve disease requiring surgical intervention in developed countries. TAVI is increasingly the treatment of choice for severe AS Aortic sclerosis is a precursor ...
• Features of lung ultrasound in COVID 19 infection
  Text Genevieve Carbonatto Literature is coming out on the lung ultrasonography of novel coronavirus. This is a summary of the literature so far The features of lung ultrasound are not specific for COVID 19 pneumonitis or pneumonia but highly suggestive in patients presenting with a history suggestive of  infection with novel coronavirus Lung ultrasound is strongly recommended  for ...
• 2. Assessment of Severity of AS : Quantitative assessment
  Kathryn Statham Quantitative Assessment of AS Peak AV jet velocity (m/sec) Mean AV gradient (mmHg) Valve area by continuity equation (cm2) Dimensionless severity index (dimensionless) 1. Pressure Gradients  Stenosis results in a pressure gradient. The pressure gradient is high before an obstruction and low distal to the obstruction. The greater the stenosis the greater the pressure gradient. Doppler measurements in AS measure ...
• Lung Ultrasound findings in COVID 19
  Text Genevieve Carbonatto Specific examination ultrasound findings in COVID 19 are not unique to the disease. Lung findings include  pleural line irregularities, pleural thickening, B lines and consolidations. What is striking is the remarkably similar  distribution of lung  pathology from patient to patient. The posterolateral areas are generally affected first bilaterally and then the disease spreads ...
• 1. Assessment of Severity of AS : 2D assessments
  Kathryn Statham The ECHO features of aortic stenosis can be explained through the  natural history and the pathophysiology of the disease. Degenerative calcific AS is a progressive valvular disease. It is characterised by A long latent period when the patient is asymptomatic despite progressive obstruction of the valve Once symptoms occur, there is a rapid decline in  survival Once development ...
• Mitral valve anatomy
  Text Genevieve Carbonatto The mitral valve apparatus consists of the  left atrial wall annulus 2 leaflets chordae tendinae papaillarymuscles left ventricular wall The MV has 2 leaflets, the anterior and posterior leaflets The anterior leaflet is Larger and thicker than the posterior leaflet Attached to the anterior mitral annulus which is in continuity with the non coronary and left coronary cusps of the aortic valve The posterior ...
• Causes of Mitral Valve Regurgitation
  Text Kathryn Statham, Genevieve Carbonatto Mitral valve regurgitation is the most common valvular disease and a significant cause of morbidity and mortality in cardiovascular disease Functionally the Mitral Valve apparatus consists of the mitral annulus the AMVL and PMVL the chordae the papillary muscles the left ventricular myocardium underlying the papillary muscles Anything that affects any of these components may lead to mitral ...
• Assessment of the LV Quiz
  Most answers for this quiz are from the ASE chamber quantification guidelines document 2018   1. What are you looking for when you are eye balling the LV to assess ejection fraction? 2. What is E- point separation? 3. At what part of the cardiac cycle do measurements need to be taken to measure global systolic function using linear ...
• Assessment of RV Quiz
  The answers to this quiz can be found in the ASE quantification chamber guidelines 2018 1.What windows do you use to assess RV size ? 2. What RV diameter is considered normal at the base and at the mid level of the RV in the 4cV? 3. What is an abnormal RV wall thickness ? 4. How can you ...
• Aorta Quiz
  All answers are directly  from the article  Jan 20, 2015 – Recommendations for echocardiographic chamber quantification were last published in 2005 by the American Society of. Echocardiography 1.How do you measure the LVOT diameter  or aortic annulus ? 2. How do you measure the aortic root? 3. What determines the size of the aortic root? Is a normal ...
• 1st trimester Quiz
  Questions Robyn Boman/Genevieve Carbonatto What is the normal heart rate range for 1st trimester pregnancy at 6 weeks, 9 weeks and  after 9 weeks and how would you measure it? 2. Discuss the reasons for not using colour Doppler or power Doppler in the 1st trimester. 3. Describe the sonographic appearance of a subchorionic haemorrhage in a first ...
• Pitfall – Stones in the gall bladder – Adenomyomatosis
  Images Ying Ying Lee, text Genevieve Carbonatto A 44 year old man presents with acute right upper quadrant pain. A point of care ultrasound is performed to exclude a biliary cause. While scanning the patient in the supine position, stones are visible in the body of the GB which do not move when the patient is scanned ...
• Biliary Quiz
  Questions Robyn Boman/Genevieve Carbonatto 1. What is the sonographic appearance of adenomyomatosis? 2. What is the normal thickness of the gallbladder and what are some causes of GB wall thickening? 3. Describe the sonographic appearance of sludge in the gallbladder and the differential diagnoses. 4. Describe the appearance of a fatty liver  optimisation of an ultrasound image required for ...
• Renal quiz
  1.The kidneys may be difficult to image because of their proximity to the ribs and to air in the bowel.  What can you do to optimise scanning? 2.  What are the sonographic characteristics of the normal kidney? 3. How is hydronephrosis classified? 4. What are 2 causes of physiologic hydronephrosis? 5. What are 5 criteria which are associated with ...
• EFAST quiz
  The EFAST examination is easily achieved in most circumstances. Name 4 clinical situations which may limit the feasibility of the  EFAST exam 2. There are some technical difficulties with the FAST exam. Most clinicians have little difficulty in locating Morison’s pouch but have greater difficulty in locating the spleen. What is the main cause of non ...
• AAA quiz
  Question 1 The “classic” presentation of a ruptured AAA is the triad of abdominal back or flank pain , a palpable abdominal aorta and hypotension. What percentage of patients present with this triad? Question 2 Where are the vast  majority of abdominal aneurysms found? Name 2 shapes  of aortic aneurysms. 3. Most patients who present to the Emergency Department are ...
• Pseudoaneurysm
  Images James Dent An 80 year old had an unsuccessful cannulation for a CT scan. 4 days later she presented with bruising and tenderness of the left antecubital fossa  and a palpable pulsating mass. This is the US of the area B mode sonography shows a large pseudoaneurysm . The aneurysm is connected to the artery by ...
• Eustachian valve
    A 72 year old lady presented to the Emergency Department with syncope.  A point of care ECHO was performed. What is the structure in the right atrium? This is a Eustachian valve. The differential diagnosis would be a tumour, a thrombus or a vegetation. In the context of syncope the presence of such a prominent Eustachian ...
• 9. Case of the month: PoCUS in pneumomediastinum
  Images Chris Fox A 14 year old boy presents to ED with throat and neck pain after persistent vomiting. He states he vomited > 30 times over the previous 8 hours. On examination:  oxygen saturation 98% on RA, BP 128/89, HR 66/min. No obvious crepitaions to the neck. A chest Xray was ordered What can you see? This is ...
• 11. Case of the month: Right hip pain
  Images Daniel Loui  Text Genevieve Carbonatto A 60 year old lady presents with recurrent syncopes associated with frequent falls. 2 weeks prior to presentation she had a fall on her right buttock  causing  right hip pain. Subsequently she developed a small heamatoma over her right buttock and a larger right thigh haematoma. She presents with  severe pain ...
• 12. Case of the month: Renal colic
  Case and images Sarah Vaughan Discussion Genevieve Carbonatto A 55 year old man presents to the ED with 5 days of loin to groin pain and microscopic haematuria. He was started on nitrofurantoin as an outpatient for a possible UTI. A point of care renal ultrasound is performed This is a clip through his right kidney without and ...
• 13. Case of the month: chest pain
  Case and images James Dent A 44F presents with chest pain for 20 mins, central chest reflux/burning sensation. Onset on leaning forward to open drawer. Now just in left shoulder. Then tingling to bilateral hands, feet and generalised and spasming of hands.  Recently well OE: eyes closed, SaO2 100%  on room air, HR 82, BP 135/90, RR ...

• Acalculous cholecystitis
• Cholecystitis
• Cholecystitis and obstruction of the CBD