Appendicitis
Appendicitis
Acute Chest Syndrome
Acute Chest Syndrome
Appendicitis with free fluid (axial)
Appendicitis with free fluid (axial)
Appendicits (long axis)
Appendicits (long axis)
Normal Appendix (longitudinal)
Normal Appendix (longitudinal)
Normal appendix, transverse (2/2)
Normal appendix, transverse (2/2)
Distal Radius Fracture
Distal Radius Fracture
Lung Hepatization (Pneumonia)
Lung Hepatization (Pneumonia)
Hip Effusion
Hip Effusion
Hypertrophic Cardiomyopathy
Hypertrophic Cardiomyopathy
Hydrocarbon Ingestion
Hydrocarbon Ingestion
Hydronephrosis (severe) in Prune Belly Syndrome
Hydronephrosis (severe) in Prune Belly Syndrome
Hydronephrosis (mild)
Hydronephrosis (mild)
Infant Pneumonia
Infant Pneumonia
Intussusception
Intussusception
Target Sign - Intussusception
Target Sign - Intussusception
Pneumothorax with Lung Point
Pneumothorax with Lung Point
Pyloric Stenosis longitudinal
Pyloric Stenosis longitudinal
Pyloric Stenosis transverse
Pyloric Stenosis transverse
Pylorus (normal)
Pylorus (normal)
Infant Skull Fracture
Infant Skull Fracture
Shoulder Dislocation and Reduction
Shoulder Dislocation and Reduction
Appendicitis
Appendicitis15 year old female with no PMH with 3 days of RLQ abdominal pain, nausea, vomiting with inability to tolerate PO. Denies fevers. Patient was tachycardic to 120 with RLQ tenderness.   Bedside POCUS was performed due to suspected appendicitis. The psoas muscle and iliac vessels were used as landmarks and free fluid was identified. This prompted closer scanning through the fluid. When the probe was rotated to a sagittal plane, a tubular structure with blind end was identified surrounded by free fluid. CT later confirmed appendicitis and patient went to surgery. Dr. Praneetha Chaganti, PEM FellowDr. Kyle Kelson, EM ResidentDr. Scott Kendall, Assistant Program DirectorKings County/SUNY Downstate Emergency Medicine
Acute Chest Syndrome
Acute Chest Syndrome6 y/o sickle cell (HbSS) coughing with left sided chest pain and 1 day of fever. On exam febrile without hypoxia. Lung without crackles, good air entry bilaterally.A consolidative process is seen with a hypoechoic region with posterior enhancement greater than 1cm in an area where normal A lines should be present. This is highly suggestive of acute chest syndrome given clinical features.Dr. Sathya Subramaniam - Kings County/SUNY Downstate Pediatrics EM
Appendicitis with free fluid (axial)
Appendicitis with free fluid (axial)18 y/o with severe acute onset RLQ abdominal pain, associated with vomiting. temp 100.8 with guarding over RLQ. POCUS performed and revealed appendicitis. An 8mm dilated, non compressible, aperistaltic, appendix with an appendocolith present (hyperechoic structure in blind end of appendix). The patient it tender directly over the appendix. The surrounding tissue is more hyperechoic indicating fatty inflammation around the appendix with adjacent free fluid. The psoas muscle can be seen on the right side of the screen and bowel to the left of the screen. Free fluid can be seen around the bowel and posterolateral portion of the appendix. Dr. Bryan Jarret - Kings County/SUNY Downstate - Emergency Medicine ResidentDr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Appendicits (long axis)
Appendicits (long axis)18 y/o with severe acute onset RLQ abdominal pain, associated with vomiting. temp 100.8 with guarding over RLQ. POCUS performed and revealed appendicitis. An 8mm dilated, non compressible, aperistaltic, appendix with an appendocolith present (hyperechoic structure in blind end of appendix). The patient it tender directly over the appendix. The surrounding tissue is more hyperechoic indicating fatty inflammation around the appendix with adjacent free fluid. The psoas muscle can be seen on the right side of the screen and bowel to the left of the screen. Free fluid can be seen around the bowel and posterolateral portion of the appendix. Dr. Bryan Jarret - Kings County/SUNY Downstate - Emergency Medicine ResidentDr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Normal Appendix (longitudinal)
Normal Appendix (longitudinal)13 y/o F with several days of suprapubic pain, dysuria, nausea, vomiting, tender to palpation in the suprapubic and RLQ area. This study was eventually repeated and confirmed as normal. The appendix was visualized on both longitudinal and transverse views as a blind ended structure overlying the iliac vessels, a typical location for the appendix. In this view the slightly dilated blind end can be seen to the right of the screen as it tapers off to the left side of the screen. The pulsating iliac vessels can be seen below. This study was eventually repeated and confirmed as normal.  Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Normal appendix, transverse (2/2)
Normal appendix, transverse (2/2)13 y/o F with several days of suprapubic pain, dysuria, nausea, vomiting, tender to palpation in the suprapubic and RLQ area.  The appendix was visualized on both longitudinal and transverse views as a blind ended structure overlying the iliac vessels, a typical location for the appendix. In this view the iliac vessels and psoas muscle can clearly be visualized to the right of the appendix viewed in cross section. This study was eventually repeated and confirmed as normal.  Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Distal Radius Fracture
Distal Radius Fracture7 year old fallen off monkey bars. Tender over right distal radius with mild swelling.POCUS reveals a discontinuity in the hyperechoic cortex of the child's distal radius with minimal displacement. This is suggestive of a buckle fracture or minimally displaced distal radius fracture.Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Lung Hepatization (Pneumonia)
Lung Hepatization (Pneumonia)5 year old child with sickle cell disease. Coughing and fever for 3 days. On exam not ill appearing but decreased breath sounds over right lung. POCUS completed to evaluate for pneumonia.Hepatization of the lung clearly demonstrates consolidative process concerning for pneumonia especially while accounting for this patient's clinical features. The beginning of the image demonstrates hepatization in the lung field. The ultrasonographer then slides the probe inferiorly over normal lung past the diaphragm to the liver, demonstrating how similar lung hepatization can be appear compared to the actual liver. Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Hip Effusion
Hip Effusion8 year old female with fever and upper left thigh pain starting last night. Refusing to bear weight and will not flex hip, discomfort with rotating hip. POCUS performed revealed effusion. Still image comparing sides confirms effusion. Etiology of effusion remained uncertain. Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Hypertrophic Cardiomyopathy
Hypertrophic Cardiomyopathy8 year old with syncope while playing in school. EKG with some non specific T wave inversions in precodial leads. No mumur, normal heart sounds. POCUS completed for concerning history and EKG changes. Interventricular septal hypertrophy seen on parasternal short and long views (concerning if measurement > 15mm). Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Hydrocarbon Ingestion
Hydrocarbon Ingestion5 year old male that drank out of container with gasoline and started coughing and was breathing fast. On exam appeared tachypneic, with air entry bilaterally and subcostal retractions. POCUS revealed bilateral infiltrates, confirmed with CXR. Infiltrate, similar to C lines seen in other consolidative processes, present in patient post hydrocarbon ingestion. This suggests an aspiration pneumonia.Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Hydronephrosis (severe) in Prune Belly Syndrome
Hydronephrosis (severe) in Prune Belly Syndrome10 y/o with Prune Belly Syndrome and bilateral hydronephrosis presenting with suprapubic pain.Bilateral severe grade IV hydronephrosis. Bear claw appearance of left kidney. Prune Belly Syndrome is a rare disorder known for lack of abdominal muscles, cryptorchidism, and urinary tract malformations. Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Hydronephrosis (mild)
Hydronephrosis (mild)21 y/o female post op emergency hysterectomy post uterine rupture with rising creatinine in surgical ICU. POCUS revealed right sided mild Grade I hydronephrosis with appreciable dilated major calyces and renal pelvis. Initial concern is for obstructive process or ureter injury. Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Infant Pneumonia
Infant Pneumonia11 month old recent immigrant infant not up to date with vaccinations presenting with cough, fever and tachypnea starting today. Exam with crackles bilaterally in an infant with subcostal retractions and respiratory distress.Right posterior lung with clear large consolidative process with C lines (air bronchgrams) present. Left posterior lung with small sub-centimeter/subpleural consolidation. Left posterior findings on its own would not currently be considered concerning for pneumonia. However, given concomitant right sided large consolidation, this is likely early consolidative process emerging in left lung.Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Intussusception
Intussusception4 year old child with vomiting since yesterday, seen urgent care and was reassured. Today continued vomiting and mother came to ED. Mild tenderness over RUQ.POCUS completed revealing intussusception. Target, Bulls Eye or Doughnut sign seen in the right upper quadrant, the most common region for an ileo-colic intussusception.Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Target Sign - Intussusception
Target Sign - Intussusception4 year old with colicky abdominal pain, vomiting once this AM, on exam abdomen soft and non tender and well appearing.POCUS performed demonstrating target sign. A hyperechoic fatty core can seen within the intussuception inside hypoechoic edematous large bowel on both transverse and longitudinal views.Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Pneumothorax with Lung Point
Pneumothorax with Lung Point18 y/o male stabbed in the back presents to the trauma bay with left sided chest pain and shortness of breath. E-FAST revealed decrease lung slide and a clear lung point.While decreased lung slide is highly sensitive, it lacks specificity. Lung point, a highly specific finding indicating a pneumothorax. Lung point indicates the transition point between normal pleura with normal lung sliding (on the left side on the image) and where there is air disrupting the pleural space with decreased lung sliding (on the right side of the image). Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Pyloric Stenosis longitudinal
Pyloric Stenosis longitudinal4 week old, vomiting intermittently for 2 weeks, seen PCP 3 days ago, reassured. Revisit today and PCP concerned for pyloric stenosis, so referred to ED. Exam in ED reassuring for well appearing neonate.In ED point-of-care (POCUS) completed, revealing hypertrophic pyloric stenosis. Pylorus muscle hypertrophied and thickened in both transverse and logitudinal view. Transverse view demonstrates the classic target sign seen in pyloric stenosis.Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Pyloric Stenosis transverse
Pyloric Stenosis transverse
Pylorus (normal)
Pylorus (normal)4 week old with vomiting, projectile according to parents. Infant tolerating formula feed well in ED. On exam well appearing infant with soft abdomen and no masses to palpation.POCUS reveals a normal appearing pylorus. Thickness of muscle < 3mm and length < 14mm. The patient was fed just before exam thus fluid can be seen swirling in the stomach. This can aid in visualization of the pylorus. (Not pictured) Sometimes fluid can be seen passing through the pylorus. Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Infant Skull Fracture
Infant Skull Fracture7 m.o fallen from a 4 foot high crib, unwitnessed. On exam small hematoma over right parietal skull, appears tender. POCUS completed to assess for skull fracture. POCUS reveals a discontinuity in the hyperechoic cortex of the infant skull that is underneath the hematoma. This discontinuity is different from the image of a suture line within the same patient's skull.Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
Shoulder Dislocation and Reduction
Shoulder Dislocation and Reduction17 y/o basketball player with acute onset left shoulder pain after throwing a basketball across the court. "feels like my arm is out of the socket." The patient was relocated with simple traction in less then 2 minutes. No x-rays were required.The head of humerus is dislocated posterior to the glenoid. After relocation it is flush with glenoid like the right. You can appreciate the musculature and rotator cuff throughout both images.  Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow
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