D-Sign with RV Dilation, Effusion, PSSA
D-Sign with RV Dilation, Effusion, PSSA
D-Sign with RV Dilation, Effusion, a4c
D-Sign with RV Dilation, Effusion, a4c
Squamous Cell Metastases to the Heart
Squamous Cell Metastases to the Heart
Aortic and Mitral Regurgitation
Aortic and Mitral Regurgitation
Atrial Myxoma
Atrial Myxoma
The D Sign
The D Sign
Type A Aortic Dissection
Type A Aortic Dissection
Apical Ballooning
Apical Ballooning
Mild Tricuspid Regurgitation
Mild Tricuspid Regurgitation
Breaking the rule of 3rds
Breaking the rule of 3rds
The Saline Flush Test
The Saline Flush Test
Moderate Mitral Regurgitation
Moderate Mitral Regurgitation
Apical Ballooning 2
Apical Ballooning 2
Thoracic Aortic Dissection
Thoracic Aortic Dissection
IVC Thrombus
IVC Thrombus
AV Canal Defect
AV Canal Defect
Myocarditis (infant)
Myocarditis (infant)
D-Sign with RV Dilation, Effusion, PSSA
D-Sign with RV Dilation, Effusion, PSSAA patient presenting with acute onset undifferentiated shortness of breath. POCUS was used to narrow the differential. Parasternal short axis demonstrated flattening of the interventricular septum which pushes the left ventricle into the shape of the letter D. Known as the sonographic D-sign, it is correlated with significant right ventricular overload. This sign is not highly sensitive for PE, but can be 80-90% specific when found and associated with other signs of right ventricular strain. Also note on this study: moderate pericardial effusion, right ventricular dilation. Ronald Rivera, Elizabeth Hanson, Melanie Malloy - Emergency Medicine ResidentsKelly Maurelus, Ultrasound Education DirectorKings County/SUNY Downstate Emergency Medicine
D-Sign with RV Dilation, Effusion, a4c
D-Sign with RV Dilation, Effusion, a4cA patient presenting with acute onset undifferentiated shortness of breath. POCUS was used to narrow the differential. Parasternal short axis demonstrated flattening of the interventricular septum which pushes the left ventricle into the shape of the letter D. Known as the sonographic D-sign, it is correlated with significant right ventricular overload. This sign is not highly sensitive for PE, but can be 80-90% specific when found and associated with other signs of right ventricular strain. Also note on this study: moderate pericardial effusion, right ventricular dilation. Ronald Rivera, Elizabeth Hanson, Melanie Malloy - Emergency Medicine ResidentsKelly Maurelus, Ultrasound Education DirectorKings County/SUNY Downstate Emergency Medicine
Squamous Cell Metastases to the Heart
Squamous Cell Metastases to the Heart59 y/o F PMH bipolar disorder and metastatic squamous cell carcinoma of lung with metastases to bone, brain, liver,  subcutaneous tissue presents with undifferentiated shortness of breath.  Patient was tachycardic hypotensive but alert with EKG showing non sustained ventricular tachycardia.Multiple hypodensities can be seen, some cystic in appearance in the LV largest up to 2.7cm, proximal outflow tract in left ventricle, thrombus vs mass vs vegetations. Eventual presumed diagnosis after formal transthoracic echo is metastases to the heart. Dr. Joshua Schecter, EM/IM Program DirectorDr. John F. Kilpatrick, Critical Care Ultrasound Education DirectorKings County/SUNY Downstate Department of Emergency Medicine
Aortic and Mitral Regurgitation
Aortic and Mitral Regurgitation This was a patient who presented at the age of 98 who had become progressively more short of breath over the last several months and now had trouble getting around.  Very sharp and witty woman, who wished to have no aggressive measures.  She was tucked into the cardiology service for gentle diuresis and optimization of her heart disease. This parasternal long axis demonstrating alternating mild-moderate aortic regurgitation with moderate mitral regurgitation. 
Atrial Myxoma
Atrial MyxomaIn this parasternal long axis view, a large mass is present in the right atrium that moves into the right ventricle during diastole. Frances Russell, MD, RDMS
The D Sign
The D Sign This is a parasternal short axis view in a patient with extensive pulmonary emboli on CT angiogram of the chest. The troponin was mildly elevated and patient hemodynamically stable. A bedside echo revealed evidence of RV strain (note the “D” shaped left ventricle). Therese Mead, DOEmergency Physician
Type A Aortic Dissection
Type A Aortic DissectionThis is a parasternal long axis view demonstrating significant enlargement of the aortic root with an identified dissection flap located in the proximal ascending aorta. Frances Russell, MD, RDMSAssistant Professor of Emergency Medicine Division Chief, Ultrasound Fellowship Director, Ultrasound
Apical Ballooning
Apical BallooningA 50 years old, complaining of dyspnoea and chest pain. She had no prior history of cardiopulmonary disease. Initial ultrasound of the lung fields demonstrated plenty of B-lines bilaterally.An apical cardiac view demonstrates hypokinesis & aneurysmal dilation of the apex consistent with Takotsubo's cariomyopathy. The patient's heart failure was managed supportively and a catheterization was performed during hospitalization that showed normal coronary artery stenosis. She had a full recoveryIlan Ben-Shabat5th year medical studentAspiring emergency physician
Mild Tricuspid Regurgitation
Mild Tricuspid RegurgitationA narrow, central tricuspid regurgitation jet is seen on this apical 4-chamber view consistent with mild tricuspid regurgitation. 
Breaking the rule of 3rds
Breaking the rule of 3rdsThis is a parasternal long axis view of a young patient presenting with 3 days of progressive dyspnea on exertion. He had no chest pain, a normal chest x-ray and and ECG with sinus tachycardia. Beside ultrasound got him to the OR in under 1 hour. - Michael Macias, EM Resident Physician PGY-4, Northwestern University 
The Saline Flush Test
The Saline Flush TestThe included clip demonstrates an apical 4 chamber view with saline bubbles in the right atrium and right ventricle after a quick 10ml flush through a right IJ central line.Clinical background:A 56 year old male patient with pneumonia was intubated for respiratory distress. He was also hemodynamically unstable and norepinephrine was infusing through a peripheral IV. A right IJ was placed and portable chest x-ray was delayed. So a rapid saline flush was pushed through the distal port of the IJ while an apical 4 chamber view was obtained, to confirm CVC placement.Learning point:Central venous catheter placement is routinely performed in ICU for infusion of vasopressors. However, confirmation by chest x-ray may not always be readily available. In situations where catheter tip confirmation is urgently needed, it’s been found that saline swirl in the right atrium immediately after a flush is highly predictive of proper catheter tip placement. Reference:Weekes AJ et al. Central vascular catheter placement evaluation using saline flush and bedside echocardiography. Acad Emerg Med. 2014 Jan;21(1):65-72. doi: 10.1111/acem.12283.Video: http://www.ultrasoundpodcast.com/2016/04/ultrasound-guided-central-line-confirmation-ultrasoundmd-rapid-atrial-swirl-sign-etc-foamed/Leon Chen, NP – Critical Care Medicine Service; Department of Anesthesiology and Critical Care Medicine; Memorial Sloan Kettering Cancer Center; New York, NY
Moderate Mitral Regurgitation
Moderate Mitral RegurgitationA mitral regurgitant jet is seen in this apical 4-chamber view that appears to be ~35-40% the area of the left atrium. This is most consistent with moderate MR though a more quantitative method such as PISA can be used for formal evaluation. 
Apical Ballooning 2
Apical Ballooning 2A 50 years old, complaining of dyspnoea and chest pain. She had no prior history of cardiopulmonary disease. Initial ultrasound of the lung fields demonstrated plenty of B-lines bilaterally.An subxiphoid cardiac view demonstrates hypokinesis & aneurysmal dilation of the apex consistent with Takotsubo's cariomyopathy. The patient's heart failure was managed supportively and a catheterization was performed during hospitalization that showed normal coronary artery stenosis. She had a full recoveryIlan Ben-Shabat5th year medical studentAspiring emergency physician
Thoracic Aortic Dissection
Thoracic Aortic DissectionThis is a suprasternal notch view demonstrating an aortic flap in a patient with a Stanford Type B thoracic aortic dissection.This 40ish year old was a truck driver with untreated hypertensive with sudden onset interscapular pain that migrated to his lumbar area.  He stopped, lost strength in his right leg and was transported to our ED.  The POCUS allowed the CV surgeon to prepare while the confirmatory CTA and standard treatment were performed. Suprasternal notch imaging with the linear or fine parts probe in a patient with suspicious signs/symptoms allows for a more rapid diagnosis of thoracic aortic dissection.John E. Hipskind, MD, FACEPClerkship DirectorED, Kaweah Delta Hospital
IVC Thrombus
IVC ThrombusA 30-year-old man presented with shortness of breath. Normally fit and well with no past medical history apart from a lump in right axilla. Observations were stable apart from a high respiratory rate. Physical examination revealed more lymph nodes in the groin. Working diagnosis of Lymphoma and sent for a CT chest, abdomen and pelvis. In the interim, point of care ultrasound showed clot in the IVC. Confirmed on CT scan. Patient was ultimately diagnosed with metastatic testicular cancer and tumour thrombus in the IVC, which was managed conservatively with anticoagulation.Dr Parmy Deol, Emergency Physician, Chelsea and Westminster hospital, London
AV Canal Defect
AV Canal Defect3 month old recent immigrant to the United States with trimosy 21, presenting with nasal congestion, cough, respiratory distress, with mild abdominal breathing, presumably with bronchiolitis. POCUS was performed to assess the lungs and heart.POCUS revealed a complete AV canal defect which is often seen in trisomy 21. The interventricular septum has a free end with a common AV valve present and a free end of the ostium primum with ASD. Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Myocarditis (infant)
Myocarditis (infant)1 y/o presenting with 1 day of respiratory distress with fever and coryzal symptoms. POCUS performed to assess lungs and heart.Infant found to have poor myocardial contractility on both parasternal long and short, despite use of dobutamine and milrinone drips. Also seen is a dilated left ventricle. BNP > 15,000 with highly elevated cardiac enzymes consistent with myocarditis. Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM FelloW
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