Library – Critical Care Sonography

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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....

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...

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...

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...

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...

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,...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

Lung point

Images Genevieve Carbonatto 24 year old with acute chest pain. Previous right sided pneumothorax Left lung Note lung sliding and small ring down artifacts indicating absence of a pneumothorax Right lung Absent lung sliding - pneumothorax Right lung - mid axillary line Lung point - note there is an area...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

Rectus sheath haematoma

Images Genevieve Carbonatto 65 year old man with liver failure 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...

Subchorionic bleed,10 week pregnancy

Images Genevieve Carbonatto 10 week pregnant patientpresenting to the Emergency department with intermittent vaginal bleeding for 2 days. Hypoechoic areas are subchorionic haemorrhages. Arrows outlining subchorionic bleed M mode shows heart rate to be 185 bpm ...

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...

Ruptured ovarian cyst

Images Genevieve Carbonatto Ruptured haemorrhagic cyst. Free fluid in pelvis surrounding uterus. Free fluid in Morrison's pouch

Appendicitis , right ovarian cyst

Images Genevieve Carbonatto A 34 year old woman presented 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...

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...

Colitis

Images by Genevieve Carbonatto. A patient presents at 11.00 pm with diarrhea he has had for 3 days and abdominal pain. He is treated for gastroenteritis. A point of care ultrasound is performed in the morning to exclude other possible causes of abdominal pain. His ultrasound shows colitis. The...

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 obstruction

Images by Genevieve Carbonatto Grossly dilated loops of bowel Dilated loops of bowel. To and fro of contents of bowel. Extraluminal fluid (ascites)

Empyema of the gallbladder

Images by Bashir Chakar A patient presents with fever and abdominal pain . Multiple fibrin septations are seen within the gallbladder. 12 hours post admission he had a cholecystectomy. During the operation he had free drainage of pus from the gallbladder. Scanning though the gallbladder, multiple thin fibrin septations...

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...

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...

Stone in neck, but mobile

Images by Genevieve Carbonatto A patient presents with acute onset epigastric pain associated with vomiting. The decision is made to examine his GB for the possibility the cause being biliary colic. The following is his ultrasound. There is a 2.19 cm stone in the neck of the GB. Could...

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.

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 ...

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...

Retinal detachment

Images by James Dent

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...

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...

Large right sided pleural effusion.

Images by Genevieve Carbonatto Sinusoidal sign: Using M mode the pleural line can be seen clearly moving up and down with respiration. On inspiration the visceral pleura moves towards the parietal pleura, on expiration away. This patient presented with SOB and fever. Anterior chest: the break in the pleural line...

Retinal detachment

Images by James Dent Retinal detachment

Pneumothorax

Images by Genevieve Carbonatto With M mode , the transition point can be recorded . On the M mode trace, on the right, note the statosphere sign associated with a pneumothorax (absence of lung sliding) and on the left the seashore sign seen with lung sliding Right lung: Lung sliding...

Pleurodesis

Image Genevieve Carbonatto Pleurodesis will appear on ultrasound exactly like a pneumothorax as there will be absence of lung sliding

Pneumothorax

Images Tina Cullen Pneumothorax : M mode Statosphere sign - no lung sliding Right sided pneumothorax. Note that M mode should not be used to diagnose a pneumothorax, but simply to record it. Visualising the pleural line for lung sliding is the best way to establish it's presence or absence....

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....

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...

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...

LLL consolidation

Image Genevieve Carbonatto Collapsed lung looks like a solid organ . Hyperechoic foci are air bronchograms. Pleural fluid surrounds the lung.

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

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

Incomplete miscarriage 10 weeks

Images by Genevieve Carbonatto with Vaginal 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.

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...

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...

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...

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...

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...

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...

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...

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

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%...

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...

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...

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...

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...

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

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.

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.

Ruptured liver

Images by Genevieve Carbonatto Free fluid in Morrison's pouch Fluid in LUQ

Ruptured spleen

Images by Genevieve Carbonatto Pedestrian vs car, ruptured spleen. Free fluid in Morrison's pouch.

Fractured rib, pneumothorax

Images by Genevieve Carbonatto M mode shows stratosphere sign No lung sliding, left lung Lung sliding + occasional B lines , right lung

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....

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.

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

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" of fire...

Very large uterine fibroid in patient with an early intrauterine pregancy

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...

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...

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...

Ruptured ectopic 8 weeks

Images by Genevieve Carbonatto A 32 year old lady with a previous ectopic pregnancy presents to the Emergency department with abdominal pain and spotting. The pain is severe. The following is her transabdominal scan. In the longitudinal plane, the uterus is easily identified. It is empty. Posterior to the uterus...

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...

8 weeks, missed miscarriage

Images by Genevieve Carbonatto An 8 week pregnant lady presents to the Emergency department with PV bleeding. This is her scan. An intrauterine gestational sac is present. There is a fetal pole and no heart beat indicating either fetal demise or inadequate imaging. A transvaginal scan confirmed the findings.

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...

7 week intrauterine pregnancy

Images by Genevieve Carbonatto Intrauterine gestational sac visible with viable intrauterine pregnancy. Fetal pole and active HB visible Postprocessing zoom of gestational sac. Fetal HB just visible.

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.

Thrombus CFV

Images by Genevieve Carbonatto CFV DVT. Partially compressible CFV, tip of thrombus visible at maximum compression. Colour Doppler outlines the thrombus

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....

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,...

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...

Adenomyomatosis

Images by Genevieve Carbonatto. Hourglass gallbladder (GB) . One of the 3 types of GB wall thickening seen in adenomyomatosis There is focal mural segmental thickening of the mid body of the gallbladder. This has been referred to as hourglass gallbladder .

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...

Adenomyomatosis

Images by Genevieve Carbonatto These are reverberation artifacts produced because sound waves reverberate between the cholesterol crystals and the wall of the gallbladder. Colour Doppler: The wall of the GB seems to light up like a christmas tree due to these reverberation artifacts. ...

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...

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...

Painless jaundice, dilated CBD

Images: Lee Juan Chiang A man presents to the emergency department jaundiced. He is no pain. A biliary ultrasound is performed to look for evidence of biliary obstruction. His GB is full of sludge and measures 10.6 cm The GB wall is...

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...

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,...

AAA

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...

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...

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,...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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 of the LV, but if the parasternal window cannot be used and the apical view demonstrates the mitral leaflet, or part of it protruding into...

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 used to diagnose MVP, if the parasternal window is able to be used. Parasternal long axis view, (PLAX) of the left...

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. ...

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...

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...

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. ...

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...

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...

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 ...

Apical thrombus

Images Genevieve Carbonatto Apical 4 chamber view Focus LV Apical 4-chamber view focussed on the apex. There is laminar thrombus on the apico-septal wall. The bright echogenic structure seen in systole. The septum is akinetic. There are multiple trabeculations / false tendons in the apex. The unusual trabeculations do not...

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...

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....

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...

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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