Aorta

50 y/o M w/ hx of HTN p/w sudden onset upper back pain. POCUS found dissection flap in the descending aorta in both parasternal long view and abdominal aorta. The diagnosis of aortic dissection was quickly confirmed by CT. Given the importance of timely diagnosis with aortic dissection, POCUS allowed rapid and non-invasive diagnosis of a potentially tricky diagnosis, and facilitated expedited treatment and transfer to a cardiothoracic surgery center.

Dr. Robert Allen - Kings County Emergency Medicine

Approximately 70 year old male with history of AAA repair presented after an episode of syncope. POCUS performed in the ED revealed a dissected intimal flap and false lumen. CT confirmed the finding of thoracoabdominal aortic dissection.

David Hansen, DO

Matthew Wolf, MD

Therese Mead, DO, RDMS, FACEP

Central Michigan University

Active extravasation is seen through endograft into false lumen. Known chronic endoleak, but CT 30 minutes prior to this study showed no active extravasation or impending rupture. Keep an open mind when reassessing your patients, and try not to anchor too much on prior results or others' opinions!

Dr. Jaffa

74 y/o F hx stage 4 lung cancer, AAA, presented with chest pain and SOB x 1 day. POCUS shows the aorta is larger than the normal diameter of 3 cm, representing an abdominal aortic aneurysm, and measuring approximately 5.6 cm at its largest point. On cross section you are able to see a large mural thrombus with decreased diameter of blood flow through the center.

Juliana Jaramillo MD - Kings County Emergency Medicine

Approximately 6 cm abdominal aortic aneurysm with intramural thrombus. 

Frances Russell, MD, RDMS

Assistant Professor of Emergency Medicine Division Chief, Ultrasound Fellowship Director, Ultrasound

74 y/o F hx stage 4 lung cancer, AAA, presented with chest pain and SOB x 1 day. POCUS shows the aorta is larger than the normal diameter of 3 cm, representing an abdominal aortic aneurysm, and measuring approximately 5.6 cm at its largest point. On cross section you are able to see a large mural thrombus with decreased diameter of blood flow through the center.

Juliana Jaramillo MD - Kings County Emergency Medicine

The clip above is from a patient who presented with abdominal pain and syncope. His vitals were notable for tachycardia and hypotension. The image demonstrates a very large abdominal aortic aneurysm with anterior free fluid suggestive of rupture. The patient was taken emergently to the operating room for endograft repair and did well. 

Jason Tanguay, DO

Aortic dissection carries an incredibly high mortality that increases 1%/hour. POCUS can be used as a rule-in test to quickly identify this life threatening diagnosis. If a dissection is not seen on POCUS, CT angiography should still be performed because the sensitivity of POCUS is not as high as for other indications. 

The spine can be used as a landmark - the echogenic stripe with shadowing in the midline. The aorta is the large vessel anterior and slightly to the right of the spine. In this image an intimal flap can be seen in the anterior third of the aorta consistent with an aortic dissection. The IVC cannot be clearly visualized in this image but would normally be left, less pulsatile, with a less echogenic vessel wall. Non-visualization of the IVC is most often due to bowel gas or compression of the abdomen with the probe. 

Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al.

You may think this a dissection but it's actually an aortic aneurysm filled with thrombus, "with holes" making it a very "happy flappy." CT Confirmed.

Dr. Vincent Rietveld - Amsterdam, The Netherlands

AAA is defined as a localized balloon-like dilatation of the abdominal aorta greater than 3cm. Risk factors include male sex, increased age, and tobacco use. AAAs should be closely monitored for changes in size. Due to the risk of rupture, elective surgery is recommended when the dilatation is greater than 5-5.5cm, or it is growing in size by greater than 1cm/year. The classic triad of a ruptured AAA include pulsatile abdominal mass, hypotension and pain.

This AAA has an intramural thrombus. Some studies have claimed that POCUS has a ~100% sensitive for increased diameter. 3cm from outer wall to outer wall defines an aneurysm. Slow, graded compression is key to move the bowel out of the way in any abdominal study. 

Sukh Singh, MD

63yoM witnessed collapsed. Arrived VSA with PEA rhythm. A fast look abdominal aorta POCUS showed a large abdominal aortic aneurysm with internal thrombus and rupture through the posterior wall. Note the AAA is measured from echogenic outer wall to outer wall, not the hypoechoic internal lumen that is seen pulsating. The patient was resuscitated aggressively with blood and initially survived operative repair. Unfortunately he died in the ICU several days later from multiorgan failure.

Dr. Joey Newbigging

Pulsating fetal aorta 

Marco Garrone

Elderly fellow who had a headache while bike riding, with some leg weakness. No chest or back pain. Stable for hours then came to hospital, suddenly hypotension and drowsy in ER

POCUS RUSH Exam performed lead to rapid diagnosis of Aortic Dissection with tamponade.

A dissection flap can clearly be visualized.

Claire Heslop - Pediatric Emergency Medicine - University of Toronto Hospital for Sick Children

Elderly fellow who had a headache while bike riding, with some leg weakness. No chest or back pain. Stable for hours then came to hospital, suddenly hypotension and drowsy in ER

POCUS RUSH Exam performed lead to rapid diagnosis of Aortic Dissection with tamponade.

A dissection flap can clearly be visualized with color flow around it.

Claire Heslop - Pediatric Emergency Medicine - University of Toronto Hospital for Sick Children

Elderly fellow who had a headache while bike riding, with some leg weakness. No chest or back pain. Stable for hours then came to hospital, suddenly hypotension and drowsy in ER

POCUS RUSH Exam performed lead to rapid diagnosis of Aortic Dissection with tamponade.

A pulsating dissection flap can clearly be visualized.

Claire Heslop - Pediatric Emergency Medicine - University of Toronto Hospital for Sick Children

In the center of the screen we see the distal aorta in transverse view. As the probe is moved caudally, the aorta bifurcates into the two common iliac arteries. Deep to the aorta we see the round hyperechoic edge of the vertebral body and to the left of the aorta we see the more compressible inferior vena cava.

The vertebrae, seen here as the deepest structure as a hyperechoic arch with posterior shadowing (horseshoe sign), is a key anatomic reference when scanning the aorta. The aorta is located immediately anterior to the vertebrae and to the right side on the screen (patient’s left). Contrast this with the inferior vena cava, which is seen to the left of the aorta, often in an oval or teardrop shape. In the center of the screen we see the celiac trunk branching off the proximal abdominal aorta. The Y-shaped “seagull sign” is created by the celiac trunk as it branches into the hepatic artery (left) and splenic artery (right). The portal venous confluence is visible between the IVC and the hepatic artery.

In the beginning of this clip we see several major structures in one view. From superficial to deep: liver, pancreas, splenic vein draining into the portal confluence, superior mesenteric artery in transverse (surrounded by a hyperechoic layer of fat creating the “mantle clock sign”), IVC with the left renal vein branching off, and the abdominal aorta. A vertebral body is visible at the bottom of the screen. As the probe is moved caudally, most of these vessels move out of plane and we are left following the course of the IVC and aorta inferiorly.

A 76 year old male presented to the ED for abdominal pain and syncope. He was tachycardic but normotensive. US performed with Sonosite 5-2MHz C60 probe with patient in supine position and probe held in transverse orientation revealed a AAA measuring ~9cm in AP diameter at its largest point. The AAA had an anechoic center with echogenic material in the posterior lumen, representing cholesterol deposit. Free fluid was seen anterior to the AAA suggestive of rupture which was confirmed by STAT CTA Aortagram. Patient was admitted to the OR for surgery. In this scenario, POCUS was a safe, non-invasive study that played a critical role in diagnosis of a ruptured AAA and accelerated surgical intervention.

Susan Dhamala, MS4, Drexel University College of Medicine
Brenton Elliot, MD, Crozer Chester Medical Center
Matthew Cully, DO, Nemours/Alfred I. duPont Hospital for Children
Kevin Conor Welch, DO, Crozer Chester Medical Center
Max Cooper, MD, RDMS, Director of Emergency Ultrasonography at Crozer Chester Medical Center