https://www.thepocusatlas.com/new-blog daily 0.75 2023-11-30 https://www.thepocusatlas.com/new-blog/2023/11/29/msk-references monthly 0.5 2023-11-30 https://www.thepocusatlas.com/new-blog/2022/10/26/dyspnea-for-resusx-2022 monthly 0.5 2022-10-26 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/b5153078-2469-4c1d-9086-947fe69db53c/Screen+Shot+2022-10-26+at+14.18.53.png Blog - "Dyspnea" For ResusX 2022 - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.thepocusatlas.com/new-blog/2022/3/25/disrupting-the-pain-cycle-system-design-for-us-guided-regional-anesthesia monthly 0.5 2022-10-26 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/22d8f560-91dc-4d77-81c9-f51cf05035cd/Screen+Shot+2022-03-26+at+09.10.24.png Blog - "Disrupting the Pain Cycle - System Design for US Guided Regional Anesthesia" CORD and EMRA 2022 - Make it stand out Title Slide for CORD 2022 EMRA Section https://www.thepocusatlas.com/new-blog/2021/9/17/how-to-give-a-talk-scuf-2021-references monthly 0.5 2021-09-17 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631896817730-SDPV21V0ODXSJ4ARW5EA/presentation+zen Blog - "Giving a Talk" - SCUF 2021 References - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.thepocusatlas.com/new-blog/onsd-for-increased-icp monthly 0.5 2025-02-13 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588336155442-3VEH6N9U8VXZVKK20KIY/Optic+Nerve+Sheath+Measurement+.gif Blog - A Neurointensivist’s Approach to POCUS for Increased ICP - Optic Nerve Sheath Dilation Occurs in Elevated ICP. The optic nerves are encapsulated by a dural sheath arising from the meninges. Increases in intracranial pressure (ICP) are therefore transmitted to the CSF within the optic nerve sheath and result in dilation of the optic nerve sheath diameter. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588340865956-V6Q2YE9SRC8NZ4JWIJCQ/Static%2Bimage%2Bfor%2Bmeasurement.jpg Blog - A Neurointensivist’s Approach to POCUS for Increased ICP - Technique: - Linear transducer; patient supine position - Closed eyelid (+/- tegaderm) - Mid-eye transverse view - Assure on-axis view by concurrently imaging of lens - Measure diameter of optic nerve sheath 3 mm posterior to where optic nerve sheath engages retina - Repeat steps and use average of three measurements https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588340838926-VB0A4K5W8UE4WBO1S32B/head%2BCT.jpg Blog - A Neurointensivist’s Approach to POCUS for Increased ICP - Clinical Correlate: Non-invasive mechanism to monitor ICP over time. Particularly useful if patient has relative contraindication to invasive ICP assessment, or if such monitoring is unavailable. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588340916947-3999SP4IT20APZ7QXF7T/ICP_tracing.jpg Blog - A Neurointensivist’s Approach to POCUS for Increased ICP - Patient case 26 yo female with hx cerebral AVM presented with spontaneous ICH with IVH (image above). Hospital course was complicated by development severe hypoxemia secondary to ARDS. Serial bedside ONSD measurements allowed correlation with invasive ICP measurement over time as she required prone positioning to manage ARDS. Seen here: MAP 89; ICP 28; CPP 61. All images and case information used with patient permission. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592497855671-SJC1JSKOPJ63BI6WEQF2/EA+ONSD Blog - A Neurointensivist’s Approach to POCUS for Increased ICP https://www.thepocusatlas.com/new-blog/covid-19-viral-pneumonia monthly 0.5 2020-07-13 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1593367899723-HDORRYISS9H937XGS6LJ/Untitled-1-01.png Blog - Evidence Atlas Review: POCUS for Viral Pneumonia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1593368969623-5CHE6EZMCN4TVXDRXGMK/Screen+Shot+2020-05-17+at+6.43.16+PM.png Blog - Evidence Atlas Review: POCUS for Viral Pneumonia Link https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1593368952977-VBJ2IOF9DXIG070K9LA2/Screen+Shot+2020-05-17+at+6.43.26+PM.png Blog - Evidence Atlas Review: POCUS for Viral Pneumonia Link https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1593368695134-EIB1F1OIDWHQ1QFITDMA/Screen%2BShot%2B2020-04-01%2Bat%2B11.39.21+%281%29.png Blog - Evidence Atlas Review: POCUS for Viral Pneumonia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1593368695133-I5IZA4RRYGBQ1753LGKJ/Screen%2BShot%2B2020-04-01%2Bat%2B11.39.31+%281%29.png Blog - Evidence Atlas Review: POCUS for Viral Pneumonia https://www.thepocusatlas.com/new-blog/2019/11/20/sonoclipshare monthly 0.5 2019-12-19 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1574279179463-4OC1XDX12ONU53CHKGXJ/unnamed.png Blog - New ways to share with The POCUS Atlas - SonoClipShare https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1574279179569-C0WR03IHMTFBF2EIVUNQ/unnamed-1.png Blog - New ways to share with The POCUS Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1574276905713-OZUHTYFTQ5FINOBY5LSR/upload+screenshot Blog - New ways to share with The POCUS Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1574277072802-CK5BQTDAXOAQ9WJ52MA1/TPA+Icon Blog - New ways to share with The POCUS Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1574279655972-GHY14J4XF78MIL4ZB4LM/Screen+Shot+2019-11-20+at+12.53.45.png Blog - New ways to share with The POCUS Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1574277623635-VAL04T0L7JN0GGYTVEPY/Success Blog - New ways to share with The POCUS Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1574278080484-YO7BG1JF5RBWF2YM1575/Screen+Shot+2019-11-20+at+12.21.43.png Blog - New ways to share with The POCUS Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1574278157455-Z3DD22QNLIAGT1C160D1/Screen+Shot+2019-11-20+at+12.22.38.png Blog - New ways to share with The POCUS Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1574279977216-4MF5S0D8VNN5N59YNQRR/Screen+Shot+2019-11-20+at+12.58.30.png Blog - New ways to share with The POCUS Atlas https://www.thepocusatlas.com/new-blog/pocus-atlas-jeopardy monthly 0.5 2019-10-27 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572112243556-P5BECCWTCKABMGFRJXWD/Screen+Shot+2019-10-26+at+10.50.25+AM.png Blog - Ultrasound Jeopardy: The POCUS Atlas Edition https://www.thepocusatlas.com/new-blog/gif-for-presentation monthly 0.5 2019-09-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1568009629623-MO6BO4YBHVMVU9G4DKGW/how+to+long-37.png Blog - Downloading a POCUS Atlas GIF &amp; Inserting into Your Keynote Presentation https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567986800020-Y9P4CYS390IGTBSPFRUN/The%2BPOCUS%2BATLAS-07.png Blog - Downloading a POCUS Atlas GIF &amp; Inserting into Your Keynote Presentation https://www.thepocusatlas.com/new-blog/pneumobilia monthly 0.5 2019-08-28 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567013645799-IIBASIEONI3N68X3IYZC/pneumobilia.gif Blog - Pneumobilia https://www.thepocusatlas.com/new-blog/appendicitis monthly 0.5 2021-01-10 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532604333873-QIXHU0RUVHGZKGS18NNR/hfl.jpg Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532604340632-R7Y8WG51DUJLP7OHJZ7O/lfcp.jpg Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532584803438-MM1EIC7LIJEWR772LXQ8/sathya-appendix-landmarks.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532584811982-ZY7D37OYTV63BPPD2TEA/sathya-appendix-landmarks-colorized.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532584817049-21MKKO4JYRCORC3EBDHQ/sathya-appendix-landmarks-colorized-labeled.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532585533005-6BH2ZYOTRRKOKZJVTSP7/sathya-blind-end-vessels.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532585537413-FTU2QHGHFKU14U9ASLDQ/sathya-blind-end-vessels-colorized.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532585543063-D44ISGR0PC7GD6CPOA14/sathya-blind-end-vessels-color-label.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532585278844-T1TW1Z89SDCDF5VJS5R6/Sathya-normal-appendix-1-blind-end.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532585311384-TU6G3J4QTHG9E6KXWFAG/Sathya-normal-appendix-1-blind-end-colorized.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532585315539-N450QC68FIBMWFPO5W84/Sathya-normal-appendix-1-blind-end-colorized-labeled.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532585386116-WU1K3ZIHPAUDR6RWM0QH/Sathya-normal-appendix-1-cross-section.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532585394282-TQFK3IWZUVWYEW3BTGIA/Sathya-normal-appendix-1-cross-section-colorized.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532585649398-IMZ8IXPZ3MGJOL4D7JPC/sathya.appy%2Bfree%2Bfluid%2Blong%2Bw.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images Abnormal appendix in long view, measuring 8 mm in diameter https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532585731542-5Z9COY1OT0CRS58BHQMG/Sathya.appy%2B1%2Bff%2Bcomp.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images Abnormal appendix measuring 8 mm in diameter in transverse view surrounded by free fluid, consistent with appendicitis. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532586657763-75SJSRDC8SA1Q9IZBRDM/appy%2Bfecaliths%2Blongitudinal%2Bsathya.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images Appendicolith/Fecalith Appendicolith within the lumen, appearing as a hyperechoic structure with shadowing https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532586729253-HB078PEQCCXTJFWW93MV/appy%2B1%2Bff%2Bcomp.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images Free fluid surrounding the appendix appearing as hypoechoic material, representing edema or perforation https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1532586765256-H4UOYC2XGC0AUXELX58J/sathya+ring+of+fire.gif Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images Ring of Fire - Increased vascularity visualized using color-flow Doppler known as "Ring of Fire." https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533167980492-ZI0ALW2BIDQ18V9GCW5H/image-asset.png Blog - Bedside Ultrasound For Acute Appendicitis - Featuring Colorized Images https://www.thepocusatlas.com/new-blog/2018/4/11/ddxof-ultrasound-in-ectopic-pregnancy monthly 0.5 2018-04-11 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523398268770-IF4OU0597KPYWPTDZROH/ddx+of+ectopic+US+work+up.png Blog - ddxof: Ultrasound in Ectopic Pregnancy https://www.thepocusatlas.com/new-blog/pedshydrocephalus monthly 0.5 2018-04-02 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522618062616-W1EYMMRM8MFS0DPNCMVO/QOD.Fontanelle-800x500.jpg Blog - The Altered Infant - Should we POCUS an open fontanelle? A case of Hydrocephalus - Exam is grossly normal, except an anterior fontanelle that is wide, full and pulsatile. https://www.bundoo.com/qotd/soft-spot-babys-head/ https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522610015331-SX00KTK6LNG3KQGZ7002/sathya-cranial-hydrocephalus-1.gif Blog - The Altered Infant - Should we POCUS an open fontanelle? A case of Hydrocephalus Clip 1: You notice significant enlargement of the extra axial space seen most clearly in the 12 o’clock position above the interhemispheric fissure. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522610073614-R4659360Z819PK5SI1CZ/image-asset.gif Blog - The Altered Infant - Should we POCUS an open fontanelle? A case of Hydrocephalus Clip 2: There is also asymmetry, specifically asymmetric ventricles with the left ventricle appearing larger than the right. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522611786339-V822ZYUZR8QD2I5SBLNS/image-asset.gif Blog - The Altered Infant - Should we POCUS an open fontanelle? A case of Hydrocephalus Clip 3: The coronal plane has the indicator marker to the right and is placed on the anterior fontanelle. The ultrasound beam is swept from the anterior to posterior aspect of the head. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522611815331-PMMYZ6KNQ17KIUIJC7GW/image-asset.gif Blog - The Altered Infant - Should we POCUS an open fontanelle? A case of Hydrocephalus Clip 4: The sagittal plane has the indicator marker facing the anterior aspect of the face and the ultrasound beam is swept in either the left to right or right to left direction of the patient’s shoulders. https://www.thepocusatlas.com/new-blog/2018/3/14/ddxof-pocus-for-undifferentiated-shortness-of-breath monthly 0.5 2018-03-14 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1521036113101-0MMUVM57F8XX71YKVTFA/ddxof.png Blog - ddxof: POCUS for Undifferentiated Shortness of Breath https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1521036549816-YQ8CGXKKWZMFK31OTA2V/ddxofdyspnea.png Blog - ddxof: POCUS for Undifferentiated Shortness of Breath https://www.thepocusatlas.com/new-blog/2018/2/7/occult-pneumothorax-tube-or-observe monthly 0.5 2018-02-16 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1518738439941-GAXFRN45CGDIGGP5BMEC/aria.gif Blog - Occult pneumothorax: tube or observe? https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1518738779675-YT3JBNCYWH8D9VNZCFXM/riscinti%2Blung%2Bpoint.gif Blog - Occult pneumothorax: tube or observe? Normal lung sliding appears and disappears with the patients breath revealing an area without lung slide. Move up one rib space to the apex, and theres no lung slide at all. This image is from the actual case described. - Dr. Matthew Riscinti - The POCUS Atlas and Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1518739281477-NA4309FIJV005IO3REO4/sathya+lung+point.gif Blog - Occult pneumothorax: tube or observe? Another example of lung point from the POCUS Atlas Trauma section. Lung point indicates the transition point between normal pleura with normal lung sliding (on the left side of the image) and where there is air disrupting the pleural space with decreased lung sliding (on the right side of the image). Lung point is a highly specific finding indicating a pneumothorax. Dr. Sathya Subramaniam, Pediatric EM Fellow - Kings County/SUNY Downstate https://www.thepocusatlas.com/new-blog/2017/11/15/golden-probe-award-2017-winners monthly 0.5 2017-11-15 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1510780767151-9LOLE0YON0B7LTLXG6DG/Radial+Artery+Pseudoaneurysm.gif Blog - Golden Probe Award 2017 Winners https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1510780996975-YN949XMRELLZ28MT24NB/asymmetric+ventriles+subramaniam.gif Blog - Golden Probe Award 2017 Winners https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1510781375610-9NXV3PXL7PYHPMX016D0/Penile+Calculus.gif Blog - Golden Probe Award 2017 Winners https://www.thepocusatlas.com/new-blog/us-4-renal-colic monthly 0.5 2016-12-05 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1480869948987-KNF3A9R8YV40VJ96G8WF/left+hydro.gif Blog - Choosing Wisely: Ultrasound For Suspected Nephrolithiasis - Mild To Moderate Left Hydronephrosis https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1480869950790-8ZME4SESAUVB8B9EP0GZ/Twinkle+Artifact.gif Blog - Choosing Wisely: Ultrasound For Suspected Nephrolithiasis - Transverse Bladder View Demonstrating Left UVJ Stone with Twinkle Artifact https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1480870025026-71BV9BNS98WEKAYYGA44/Stone+Long.gif Blog - Choosing Wisely: Ultrasound For Suspected Nephrolithiasis - Longitudinal View of Bladder Demonstrating UVJ Stone with Shadowing https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1480870411046-6BKLN6ZYCB8JS8LA0TJT/Open-In-Read-2.png Blog - Choosing Wisely: Ultrasound For Suspected Nephrolithiasis https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1480870430618-SUURBBNG5V8W6W9YPY7V/image-asset.png Blog - Choosing Wisely: Ultrasound For Suspected Nephrolithiasis https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1480870856198-8ROVGX4OF919ZC8XF5CZ/image-asset.png Blog - Choosing Wisely: Ultrasound For Suspected Nephrolithiasis https://www.thepocusatlas.com/new-blog/d-sign monthly 0.5 2016-12-04 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1480195249438-RIU2FE0HJSWO0O80CSAL/RV+Strain_Mead.gif Blog - The D-sign: Right Ventricular Strain This is a parasternal short axis view in a patient with extensive pulmonary emboli on CTA. The troponin was mildly elevated and patient hemodynamically stable. A bedside echo revealed evidence of RV strain (note the “D” shaped left ventricle). 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RV dilation violating the rule of thirds. McConnell’s Sign is also demonstrated in this view with RV apical hyperkinesis and lateral wall hypo/akinesis. Patient was found to have a submassive PE. Moudi Hubeishy @moudihubeishy https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631716927989-QBU84C8W4S5XAOQDHZSJ/image-asset.gif EA Echo Examples - McConnell's Sign PLAX view. RV dilation violating the rule of thirds. McConnell’s Sign is also demonstrated in this view with RV apical hyperkinesis and lateral wall hypo/akinesis. Patient was found to have a submassive PE. Moudi Hubeishy @moudihubeishy https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544580597414-Z846Z8X77WDTAFV24TE0/EPSS_m.png EA Echo Examples - Abnormal End Point Septal Separation (EPSS) One way to evaluate cardiac function is to measure the distance from the anterior leaflet of the mitral valve to the septum during diastole. This is known as end point septal separation (EPSS). An EPSS < 7 mm is considered normal, while EPSS > 10 mm suggests decreased cardiac function. This measurement should be obtained in a parasternal long axis view, using M-mode with the cursor placed through the tip of the mitral valve. Image credit: Ultrasound of the Week https://static1.squarespace.com/static/58118909e3df282037abfad7/591a01f3ff7c5022345576aa/5aca48c66d2a73d3a0e6cd19/1650152881769/jarrett+truncus+arteriosus+2.gif EA Echo Examples https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509039666680-Q20G1UTR169XO3GV4HNB/Low+EF%2C+effusion+-+Johnson.gif EA Echo Examples - Reduced Ejection Fraction Parasternal long axis with cardiomyopathy, pericardial effusion, and decreased EF. Dr. Gordon Johnson MD Internist Portland Oregon & Uganda https://static1.squarespace.com/static/58118909e3df282037abfad7/591a01f3ff7c5022345576aa/5aca48cc575d1fd3933bbc07/1650152934834/jarrett+truncus+arteriosus+3.gif EA Echo Examples https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592419373594-FPO56YUS6740AI125PZY/image-asset.gif EA Echo Examples - Cardiac Standstill A patient presented with out-of-hospital cardiac arrest. POCUS was used to confirm presence of cardiac standstill. Note the absence of movement of the left ventricular free wall. Melissa Myers, MD. Emergency Medicine in Texas. Ultrasound Fellowship Program Director. @melissamyersmd https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625685234758-S2BB2QLX2D3WKWEKOBCJ/image-asset.gif EA Echo Examples - Post-MI VSD A parasternal long axis view reveals a ventricular septal defect in a patient presenting with symptoms of GERD, an elevated troponin, and an EKG indicative of myocardial infarction. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1582735906938-7XQXYWZ59DKWX671YMFT/image-asset.gif EA Echo Examples - RV Thrombus & McConnell's Sign 60 year-old smoker presents with dyspnea and chest pain. Apical 4 chamber view is notable for a thrombus within the RV and associated evidence of RV strain including increased RV size and impaired systolic function with sparing of the apex (known as McConnell’s sign). Renato Tambelli, @R_Tambelli Emergency Physician Hospital das Clínicas de Marília, Sao Paulo/Brazil https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1596651214010-3E9MCNU8OPBOBCQN3MN4/image-asset.gif EA Echo Examples - Pulmonary Artery Mid-systolic Notching (aka MSN pattern) This image shows pulmonary artery mid-systolic notching, a sign of proximal impedance (e.g. PE, pulmonary hypertension), in a 63 yo man without prior pulmonary disease with pulmonary emboli on CTA. From the parasternal short-axis view at the level of the aortic valve (fan anteriorly/superiorly from the mitral valve level), visualize the right ventricular outflow tract, pulmonary valve, and pulmonary artery. Place the pulsed wave Doppler gate about 0.5 cm proximal to the pulmonary valve and generate the waveform by pressing the pulsed wave Doppler button again. Waveforms without impedance (i.e. normal) appear as smooth “domes.” Read more here: PMID 33781986 https://pubmed.ncbi.nlm.nih.gov/33781986/ Robert Adrian, MD. @RobertAdrianMD Emergency Medicine at Rutgers New Jersey Medical School Stephen Alerhand, MD. @SAlerhand Assistant Professor Rutgers New Jersey Medical School https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501946036256-HUUF1I144FJTBB5ZSR7R/ezgif.com-optimize.gif EA Echo Examples - B-Lines - Pulmonary Edema B-lines obtained with curved probe. B-lines are vertical artifacts that move with respiration from the pleural surface. They represent increased water in an area of the lung. In the right clinical context this could represent pulmonary edema. An increase in B-lines correlates with the degree of pulmonary edema. 3 B-lines in an intercostal space represent a "positive" region of the lung, and if there are two regions of the lung that are positive, you can diagnose pulmonary edema. Dr. Justin Bowra et al. (Dr. D Browne and Dr. J Knights) https://static1.squarespace.com/static/58118909e3df282037abfad7/591a01f3ff7c5022345576aa/5aca48c68a922dc773b5cde8/1650152861467/jarret+truncus+arteriosus+1.gif EA Echo Examples https://static1.squarespace.com/static/58118909e3df282037abfad7/591a01f3ff7c5022345576aa/5edc3421dd8f8149bef511d0/1591490457671/ EA Echo Examples - Type B Aortic Dissection This is a parasternal long axis view of an elderly male with PMH of hypertension and DM presenting with a type b dissection of the descending aorta. Image courtesy of Robert Jones, DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound MetroHealth Medical Center Professor, Case Western Reserve Medical School, Cleveland, OH Find his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509035751804-TZ4O1ELNAZT96AMXZ1FY/Positive+FAST+Subcostal.gif EA Echo Examples - Positive FAST - Tamponade Young male with multiple praecordial stab wounds. Hypotensive and tachycardic with EMS. Haemopericardium with cardiac tamponade on subcostal window - taken to OR within 30 minutes of arrival. Clotted and fresh blood was evacuated from pericardial sac. Left internal mandatory artery and RVOT laceration repaired. POCUS images recorded by Dr. Deirdre Glynn and submitted by Dr. Cian McDermott - Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1494877080004-2IWPRLZQWTRS2BOEN18W/ezgif.com-gif-maker+%2816%29.gif EA Echo Examples - Taking Turns 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. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1587250289812-YBNYAXUZ0Q5RVD8OEM55/ezgif.com-optimize.gif EA Echo Examples https://static1.squarespace.com/static/58118909e3df282037abfad7/591a01f3ff7c5022345576aa/591a0359d1758ebb950ce7a8/1494877017403/ EA Echo Examples https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1495652756653-LLBK6QJ79XGNRN9J4GMW/ezgif.com-gif-maker+%2816%29.gif EA Echo Examples - Taking Turns 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. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588964157872-NC2P22X8QY6ESI0EL1BS/image-asset.gif EA Echo Examples - Apical Four Chamber with Pleural Effusion 38-year-old woman admitted to the ER with complaint of progressive dyspnea. Apical four chamber view on the FOCUS exam showed atelectasis of left lung from a huge pleural effusion next to the heart. Image courtesy of: Dr. Renato Tambelli, Emergency Department of Marilia Clinic Hospital, São Paulo, Brazil / POCUSJEDI Team @JediPocus https://www.thepocusatlas.com/bowel daily 0.75 2025-04-29 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664198825824-FOC9YGBCJ8V5SK0PKA38/image-asset.gif Bowel-GI - Malignant Ascites Malignant ascites with plankton sign in woman with metastatic ovarian cancer. Samuel Eglin, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664198825824-FOC9YGBCJ8V5SK0PKA38/image-asset.gif Bowel-GI - Malignant Ascites Malignant ascites with plankton sign in woman with metastatic ovarian cancer. Samuel Eglin, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1728885853086-R4OOPM7ELZLTF4T79CXC/image-asset.gif Bowel-GI - "Ring of Fire Sign" in Appendicitis A 24 year old male comes to ER with abdominal pain, vomiting, and fever. A directed scan with a high-frequency linear transducer in the right iliac fossa shows a tubular, non-compressible structure, a "target like" image, with increased echogenicity of the fat around it. When applied Color Doppler - we can observe increased vascular flow around the appendix - a sign known as "The Ring of Fire". This finding suggests the diagnosis of acute appendicitis. Contributor: Renato Tambelli (@R_Tambelli @Jedipocus) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664200013098-QODIARDMNMWZSK9D0MSV/image-asset.gif Bowel-GI - Taenia Saginata Fatigue for the past 3–4 months with mild disturbance of bowel habits. The patient reported visualizing proglottids in the stool. POCUS findings: Ultrasound performed in the left lower quadrant revealed a structure consistent with parasitic segments. Diagnosis: Laboratory confirmation a few days later identified Taenia saginata. Dr. Guillaume Schramme https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1734374873114-7KUIQIVV00KVR9YND42H/image-asset.gif Bowel-GI - To & Fro Peristalsis in Bowel Obstruction Fecal material can be seen moving forward and backwards through dilated bowels in the patient with a bowel obstruction. Contributed by: Brittany Garza, DO and Saleem Nasseh, MD and Sadie Ellenson, MS4 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735415665584-JX63OOL65QM42VTD4CYZ/image-asset.gif Bowel-GI - Free Fluid at Liver Tip Free fluid demonstrated at the liver tip in a patient with ascites. The liver tip is the most sensitive part of the RUQ for free fluid. In the context of blunt trauma this would be concerning for bleeding. Contributors: Dimitri Livshits, DO; Jane Belyavskaya, MD; Chris Hanuscin, MD Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637589518008-650SAF7Z3P9GHIIBCYMT/image-asset.gif Bowel-GI - Paraesophageal Abscess Patient presented with chest pain. A subxiphoid sweep revealed normal cardiac function with a neighboring anechoic structure confirmed as a paraesophageal abscess on CT. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736702866994-495OCQSL60VNRQW7WMO6/image-asset.gif Bowel-GI - Obstrução de Delgado - To and Fro sign Sign of small bowel obstruction. We see heterogeneous material inside the loop of bowel with a back and forth movement, characterizing the obstruction. The patient in question had a paralytic ileus due to chronic antipsychotic use. Felipe Teles; Internal Medicine at Fortaleza General Hospital @drfelipemoraisteles https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1734817969603-NIOJYKK3AY80976O7YYC/image-asset.gif Bowel-GI - Tanga Sign (SBO) Dilated loops of small bowel with free fluid adjacent to them (Tanga sign), CT confirmed SBO. Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1734818826666-1T8W1VH1YLSEA0RYGSU0/image-asset.gif Bowel-GI - To-and-Fro Peristalsis Back and forth "to-and-fro" peristalsis consistent with SBO. Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727561345451-4GMZMWQ5SJP686AJPO03/image-asset.gif Bowel-GI - Ascites in Pregnancy 22 year old G3P2 female presented to the ER, 18 weeks pregnant, with central abdominal pain with radiation to her back. She was found to have large volume ascites of unknown etiology on US. She was admitted to the hospital and underwent paracentesis. A reminder to keep a broad differential for abdominal pain, even if the patient is pregnant. Michael Cannova, DO; Mara McMurray, DO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727561345451-4GMZMWQ5SJP686AJPO03/image-asset.gif Bowel-GI - Ascites in Pregnancy 22 year old G3P2 female presented to the ER, 18 weeks pregnant, with central abdominal pain with radiation to her back. She was found to have large volume ascites of unknown etiology on US. She was admitted to the hospital and underwent paracentesis. A reminder to keep a broad differential for abdominal pain, even if the patient is pregnant. Michael Cannova, DO; Mara McMurray, DO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727553358587-MW3GQ5NSRJFIQTW8OMD9/Acute+Diverticulitis+-+Alessandro+Lena.gif Bowel-GI - Acute Diverticulitis 60 year old man presenting with left lower quadrant pain and fever. POCUS was performed and revealed a thick-walled colon and associated diverticula with surrounding hyperechoic fat stranding. Inside the pouch there's an echogenic structure casting deep shadowing consistent with a fecalith. Alessandro Lena https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727554676649-YR69ZIYNA78QA0C20ZFD/image-asset.gif Bowel-GI - Inguinal Hernia with Bowel and Bladder Involvement This patient presented with acute onset, severe groin pain. On physical exam, a large inguinal hernia was appreciated, and the scrotum was enlarged, erythematous, and exquisitely tender to palpation. POCUS exam was performed and there were multiple bowel loops with active peristalsis and a large anechoic fluid collection. CT imaging confirmed this fluid to be a herniated portion of the bladder, which likely provided a good acoustic window for clear visualisation of the bowel loops. Catherine Barrington MD, MSc, PGY1 Emergency Medicine, CMU; Andrew Namespetra MB BCh BAO, MSc, PGY3 Emergency Medicine, CMU https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1725300966576-7ZI60VN6HRI4SJ63KBWV/image-asset.gif Bowel-GI - SBO Demonstrating To-and-Fro Peristalsis Middle age male patient with past history of multiple abdominal surgeries, presented with clinical picture of intestinal obstruction. POCUS was performed demonstrating dilated bowel loops up to 3.3 cm with clear "to-and-fro" movements of bowel contents on the right side of the screen. Learning point: Keep the ultrasound probe still and wait for enough time to allow the back and forth "to-and-fro" movements of the bowel content. Contributor: Basel Elmegabar; MBBS https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1726528377433-J68O8M6E4CY0AAA9NFKC/image-asset.gif Bowel-GI - Ascites With Spider Web Sign A 19 year old male, with hx of cocaine abuse presented to the ICU for respiratory insufficiency due to cardiogenic pulmonary edema. POCUS evaluation of the abdomen demonstrated ascites with Spider Web Sign, which is not expected in cardiogenic ascites. Because of this, peritoneal tuberculosis was suspected. It was later discovered that the patient had close contact with a person who was being treated for a confirmed tuberculosis diagnosis. Contributor: Dr. Alessandro Ferreira Hospital Metropolitano de Alagoas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1679273697800-6QJMSQV2DD7X7WP00OVA/image-asset.gif Bowel-GI - Complicated Small Bowel Obstruction This patient presented with a painful abdomen with distention and absent bowel sounds. Key findings in this scan include ineffective peristalsis as well as colon diameter that exceed 2.5 cm. Anechoic regions suggest presence of fluid which raise concern for a complicated small bowel obstruction. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1679267088204-S65TJNULNZOI3O16CMFF/image-asset.gif Bowel-GI - Necrotizing Pancreatitis In this case an elderly patient presented with severe back pain and an ultrasound exam was performed to evaluate the aorta. Instead in this transverse view, the pancreas was identified which appears enlarged with surrounding fluid. Besides appearing enlarged, an important finding in this scan is the hypoechoic regions which are indicative of necrosis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1679266331736-NTU47ZC2XDYG5080HL47/image-asset.gif Bowel-GI - Strangulated Hernia With Bowel Necrosis This patient presented with a known paraumbilical hernia however what should be noted here are is the lack of peristalsis as well as the presence of air in the within the wall of the bowel. These findings suggest that necrosis has resulted from strangulation of a hernia. Other findings with this diagnosis that could also be found include hyperechoic fat, fluid within the sac, thickening of the hernial sac, dilated bowel and edema within the walls. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1679266206509-MWK5D9OUEAF1W63HV5GB/image-asset.gif Bowel-GI - Perforated Viscus Patient presented with altered mental status, hypotension and a rigid abdomen. It was unclear at the time if this patient’s presentation was due to trauma. Right-upper quadrant ultrasound used to view for potential cause using the perihepatic window. Here we can see air within fluid and a hyperechoic peritoneal stripe, indicating a perforated viscus. In this case, due to a duodenal ulcer. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1674670961670-ME5EYIFH5U3PENEH2SSJ/ezgif.com-gif-maker+-+2023-01-25T102232.258.gif Bowel-GI - Full Stomach This clip demonstrates a full stomach. Gastric contents with internal air signatures can be seen swirling around within the stomach. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644437390855-LH05WDJNY1O3SLAD6NDG/image-asset.gif Bowel-GI - SBO 45M history of exploratory laparotomy presented with abdominal pain, nausea, vomiting and decreased flatus. US shows dilated loops of bowel measured at 3.99 cm with to and fro movement of contents in greater than 3 areas consistent with small bowel obstruction. Rachel Shing, MD Boston Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644441716297-2SKTZHC5RKLMMF43HMYB/image-asset.gif Bowel-GI - Normal Bowel Peristalsis 51 year old male presented with a chief complaint of abdominal pain for 3 days with nausea and vomiting. The curvilinear probe was used to evaluate the aorta with an incidental finding (shown) of clear peristalsis of the bowel contents with hypoechoic and anechoic contents. In this segment it is clear there is no obstruction. Lindsay Davis, DO, MPH, @Lindsadavis18 Lydia Mansour, DO Emily Nagourney, MS4 Central Michigan University https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638996365232-3P6W5EEDKMEVVPAR3JHN/image-asset.gif Bowel-GI - To-And-Fro of SBO 84 yo F presenting with abdominal pain, nausea, vomiting, constipation and abdominal distension for 3-4 days. Bedside ED-performed POCUS show this findings: No compressible and distended small bowel loops (> 2,5 cm), "To-and-Fro" motion of intraluminal content, “valvulae conniventes” on the interior aspect of the bowel wall, which appears like black and white keys of a piano (Keyboard Sign). These ultrasound signs rule-in the diagnosis of Small Bowel Obstruction. Renato Tambelli @JediPocus @R_Tambelli https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637764905740-692WSMLF8Q4XBPGFZYN3/image-asset.gif Bowel-GI - Colonic Perforation with Abscess RUQ scan revealed an isoechoic region adjacent to the hepatic flexure indicative of an abscess formation secondary to a colonic perforation. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637762331096-HDUWX6L51BASP2D29J4D/image-asset.gif Bowel-GI - Liver Metastasis Patient with history of colon cancer presented with right flank pain. RUQ scan revealed metastatic liver disease. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638667863536-5209MN76A9RJXV59CGKR/image-asset.gif Bowel-GI - Paraesophageal Abscess Patient presented with chest pain. A subxiphoid sweep revealed normal cardiac function with a neighboring anechoic structure confirmed as a paraesophageal abscess on CT. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631723121354-S1JYAR284S94OZ6LZIY4/image-asset.gif Bowel-GI - Pediatric gastrostomy replacement Pediatric gastrostomy replacement with injection of oral rehydration solution into gastric lumen. Cailin Frank https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631723488017-GU9YUO01443B64YN50ZG/image-asset.gif Bowel-GI - Unsuccessful pediatric gastrostomy replacement Pediatric gastrostomy replacement NOT in gastric lumen - not only do you not see the stomach wall between the gastrostomy bulb and abdominal wall, with injection of oral rehydration solution you see it outline the spleen tip (near end of clip). Cailin Frank https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1627328073845-28L8HY24LF3FHZT1UUL8/image-asset.gif Bowel-GI - Pneumoperitoneum POCUS reveals air bubbles rising in a patient with a perforated bowel obstruction resulting in a pneumoperitoneum. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626280982426-B3NGIKZ01GL6FC6UDLSO/image-asset.gif Bowel-GI - Pancreatic Duct Stones RUQ evaluation of a patient with chronic pancreatitis revealed pancreatic stones visible as hyperechoic structures within the pancreatic duct. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625846605184-RZNWWCYYZXBW3NYP3YLU/image-asset.gif Bowel-GI - Direct Inguinal Hernia An elderly female presented to the emergency department with left groin pain that had been intermittent for 6 months. At time of initial evaluation, she noted a “bump” in the left groin. On examination with POCUS, the inguinal canal was evaluated and revealed a direct left inguinal hernia. As the patient performs a Valsalva maneuver, bowel is seen moving into the canal. Upon release of Valsalva, the bowel reduces spontaneously. Daniel Coffey, Emergency Medicine PGY-2; Jocelyn Garcia MS-3 Central Michigan University College of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625941696084-2KO0HDQN5D6XZOO5YGH2/image-asset.gif Bowel-GI - Intussusception Here we can see an intussusception. Multiple layers and concentric rings, target configuration on cross-sectional imaging. Evgeny Domanin https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625845634478-Q287QGAB033B81TC26MG/image-asset.gif Bowel-GI - Small Bowel Obstruction 30-year-old presented with 2-day history of abdominal pain, abdominal distention, and vomiting. Pertinent PMH includes prior hemicolectomy due to Crohn's disease. Seen here is POCUS evidence of SBO. Ahmad Khan @kadiwls https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623697635984-VMLLY0D7D03IBK1E8AGX/image-asset.gif Bowel-GI - SBO Small bowel obstruction (SBO) featuring “to and fro” movement and tanga sign. Francisco Norman https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620331470048-3ESWEY7UAIFIGI4SOKBE/image-asset.gif Bowel-GI - Mesenteric Vasculitis Patient has a history of SLE with abdominal pain and distention. POCUS shows abdominal free fluid and bowel wall thickening. Ultimately after CT and further testing confirmed this as SLE-induced mesenteric vasculitis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1618342098511-ILYZR37I2BAAQJ60F2V3/image-asset.gif Bowel-GI - Large Volume Ascites on Transverse Pelvic View A 64-year-old woman with hepatic cirrhosis presented to the emergency room with abdominal pain. An abdominal POCUS exam was performed showing significant ascites. In this transverse pelvic view one can appreciate the uterus floating in ascites. This image finding is also known as the "TIE Fighter Sign" in reference to the famous Starwars galactic empire ship. Image Courtesy of Dr. Renato Tambelli @RTambelli / @JediPocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616441076753-VVK1DU4GGEEUVNEFQDI3/image-asset.gif Bowel-GI - SBO with "To-and-Fro" A 58-year-old female with multiple prior abdominal surgeries presented with a 2-day hx of abdominal pain and N/V. ROS also notable for anorexia and constipation. Abdominal POCUS seen here revealed dilated bowel loops with thickened and hyperechoic bowel walls. “To-and-fro” movements of the bowel contents are also appreciated. This occurs as a consequence of increased intestinal contents and peristalsis, otherwise known as dysfunctional peristalsis. All of the aforementioned are consistent with a diagnosis of SBO. When there is high clinical suspicion of SBO, POCUS can serve as an inexpensive and rapid adjunct for clinical evaluation, expediting time to disposition. Dr. Samantha Wong, @esayemDO EM Resident. Central Michigan University https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616098708174-3ACAE73KT8ONFUKECBJO/image-asset.gif Bowel-GI - Small Bowel Obstruction Small bowel obstruction showing a transition point in the ileum. Steven Johnson @alittlecoldgel https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614981112731-LSQGOXI89B1G07VYUG6W/image-asset.gif Bowel-GI - Pancreatic Pseudocyst An elderly male with abdominal pain, hypotension and a palpable abdominal mass. POCUS revealed a normal sized pulsatile aorta with a large pancreatic pseudocyst. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611514426504-KG14GRPLUJX8CSNWPIJZ/image-asset.gif Bowel-GI - Intra-abdominal Abscess A middle aged female with a history of Crohns disease presented to the ED with fever, hypotension, and abdominal pain. Bedside ultrasound revealed an intra-abdominal abscess in the RUQ. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609021384692-871P4MM6H972P29I7XCB/image-asset.gif Bowel-GI - Ruptured Appendicitis with Intraabdominal Free Fluid A 3 year old M presented with 3 days of fever, vomiting and abdominal pain. He was lethargic on arrival and found to be septic. POCUS shows ruptured appendicitis with a significant amount of hypoechoic fluid in the abdomen. Paul Khalil, MD. Assistant PEM POCUS director at University of Louisville/Norton Children’s @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609020860539-S5N8R8Y38EJR7B20WIFS/image-asset.gif Bowel-GI - Ruptured Appendix with Abscess Formation A 2 year old F with 1 week of fever, vomiting, diarrhea and abdominal pain presented to the emergency department. A work up was initiated including POCUS of the right lower quadrant which revealed a ruptured appendix with abscess formation. Paul Khalil, MD. Assistant PEM POCUS director at University of Louisville/Norton Children’s @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607602190955-WCMI53O4AAX49MXEP4R6/image-asset.gif Bowel-GI - Splenic Abscess An elderly male with a history of IVDU presented to the ED with fever and abdominal pain. Vital signs reveal hypotension. RUSH examination revealed a splenic abscess viewed in the perisplenic window. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1608042717980-2C53DKMKQTT9B3H11RKI/image-asset.gif Bowel-GI - Mesenteric Adenitis A young child presented to the ED with RLQ abdominal pain and a low-grade fever. Bedside ultrasound revealed enlarged, hypoechoic mesenteric lymph nodes with surrounding vascularity indicative of mesenteric adenitis. Be sure to rule out appendicitis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607614545304-VHKT24XB26OZML66F9C1/Necrotizing+Pancreatitis.gif Bowel-GI - Portal Venous Gas An adult male presented to the ED with abdominal pain and hypotension. The perihepatic window of the RUSH exam reveals portal venous gas due to necrotizing pancreatitis. Also, note the trace free fluid in Morison’s pouch. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607173579955-9QLDA86GX7W5IXYTT8EA/image-asset.gif Bowel-GI - Pneumoperitoneum Patient presented with severe right upper quadrant abdominal pain. POCUS revealed pneumoperitoneum due to a perforated duodenum. The pneumoperitoneum can be identified as the A-line pattern seen superior to a portion of the liver consistent with air in the wrong place! Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601044564801-VM01I7HSY08OSNQ53FQR/image-asset.gif Bowel-GI - To & Fro in Bowel Obstruction This 70-year-old male presented to our ED reporting abdominal pain and vomiting with associated absence of flatus / bowel movements. Seen here is his LUQ abdominal view using the curvilinear probe that reveals a dilated loop of bowel. The image is further characterized by increased peristalsis (the "To and Fro" sign) as well as the presence of free fluid adjacent to the dilated bowel loop in the shape of a triangle (known as the "Tanga Sign"). This case highlights how bedside ultrasound can be a powerful tool to enable prompt diagnosis and treatment of bowel obstruction. Renato Tambelli, Emergency Physician Hospital das Clínicas de Marília, Brazil. @R_Tambelli // @JediPocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1599502318207-4PNE5AYFBVDZBWONK8Q5/image-asset.png Bowel-GI - Measurements in Pyloric Stenosis A 5 week old female previously healthy presents with 1 day of projectile vomiting. A bedside ultrasound was performed demonstrating muscle wall thickness of 4.3 mm (> 3 mm is abnormal) and a length of length of 19 mm (abnormal is >15 mm) consistent with a diagnosis of hypertrophic pyloric stenosis. Paul Khalil, MD @Khalil3Paul Assistant PEM POCUS Director at University of Louisville/Norton Children’s https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594926604506-B9BRQUW0Q6RIPMNCDGG4/ezgif.com-optimize+%283%29.gif Bowel-GI - Gallstone Ileus An elderly male presented with unyielding bilious vomiting and abdominal pain. A RUQ extended view shows gallstone ileus with the hypoechoic stone creating an acoustic shadowing artifact. Here, the gallstone is lodged in the small bowel and can arise from frequent cholecystitis creating a fistula between the gallbladder and small bowel. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594129878337-4AAJVDY43JGU2MDJA71M/image-asset.gif Bowel-GI - Hepatic hydrothorax A 54-year-old male with hx chronic, untreated HCV complicated by cirrhosis presented with subacute dyspnea and abdominal distention. POCUS was notable for both a pleural effusion (anechoic fluid with atelectatic lung floating within it) as well as ascites (anechoic fluid underneath the mobile diaphragm). This history and POCUS findings were consistent with his diagnosis of hepatic hydrothorax. Shahad Al Chalaby, MD. PGY-2, Internal Medicine Highland Hospital. Alameda Health System Internal Medicine Residency Program. CA, USA @shahad_Chalaby https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1591673973761-FD8I4FWK4YFDAKGBQ2AN/image-asset.gif Bowel-GI - Ascites with Pneumoperitoneum Pt with PMH of cirrhosis presents with abdominal pain and fever. POCUS initially performed for diagnostic paracentesis in the setting of suspected spontaneous bacterial peritonitis. Imaging demonstrated bubbles seen in ascites fluid consistent with pneumoperitoneum. This led to management change as paracentesis was deferred and surgery was consulted. The patient was taken to the OR, and found to have a diverticular abscess with a necrotic segment that was resected. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584989221221-0G3G2LHFRFJPJT1K9E7D/image-asset.gif Bowel-GI - Peritoneal Catheter Complication Pictured here is a the proximal cuff of an indwelling peritoneal catheter. Note the abscess surrounding the cuff. Javier Estrada, Nephrologist, Costa Rica https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584043622085-UEBN8R1G0DCKLABW3LDO/image-asset.gif Bowel-GI - Ascites 70-year-old man with a history of alcoholic liver cirrhosis. Using a curvilinear probe on the left lower quadrant we appreciate significant ascites; also note the clear outline of bowel loops floating within the free abdominal fluid. Renato Tambelli, Emergency Physician Hospital das Clínicas de Marília.Public Healthcare. Emergency Management. @R_Tambelli https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579520489336-KUT59LPS8AJ2J3YVPV4U/image-asset.gif Bowel-GI - Pneumoperitoneum with Enhanced Peritoneal Stripe Sign Pictured is a transversal epigastric abdominal view, first in M mode and subsequently B mode. Both modes reveal Enhanced Peritoneal Stripe Sign (EPSS), a finding that is highly sensitive and specific for pneumoperitoneum. An A-line pattern is also appreciated in this clip, due to reverberation artifact caused by the free air. This pattern mimics the A-line pattern seen in normal lung tissue. We were able to make this diagnosis with a portable POCUS device in the Emergency Department! Renato Tambelli, Emergency Physician @R_Tambelli https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579289771104-2VC8Y5VFJYJP26GW50QS/image-asset.gif Bowel-GI - Fibrinous Ascites A patient with cirrhosis presented with severe abdominal pain. POCUS of the abdomen revealed significant anechoic ascites. The quality of the ascites is also notable for presence of fibrinous material, increasing the pre-test probability of SBP. Paracentesis confirmed presence of >6000 WBCs; though this unique POCUS finding enabled earlier initiation of antimicrobial therapy for this patient. Parker Dixon, Hospitalist @drparkerdixon https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1578967612089-ZEUOYX2B8MWUU1SY6PJI/image-asset.gif Bowel-GI - The Keyboard Sign A patient presented to the emergency department with one day of constipation and abdominal distention. A bedside ultrasound was performed showing dilated bowel, to-and-fro peristalsis, and keyboard sign (plicae circulares). Low-grade SBO with transition point found on follow up CT. Aaron Inouye @PAintheED https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1575841847912-7D7U6U3HFBOIN58F9INV/ezgif.com-optimize+%2820%29.gif Bowel-GI - Perisplenic Hematoma This clip is from a patient presenting with sudden onset epigastric pain with syncope. The patient had an additional episode of syncope in the ED and remained persistently hypotensive. The aorta was evaluated and was non-aneurysmal, however during FAST exam the LUQ view demonstrated a perisplenic hematoma and free fluid was also noted in Morrison’s pouch (RUQ view not shown). CT of the abdomen/pelvis later confirmed spontaneous splenic rupture. Nishant Cherian https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1575841132216-15HNCGB6DG5I4YB57SFY/ezgif.com-optimize+%2819%29.gif Bowel-GI - Fluid Filled Periumbilical Hernia 27 year old male with a history of cirrhosis presenting with increased swelling of the periumbilical area. A bedside ultrasound was performed demonstrating a fluid filled hernia sac from the patient’s known ascites. Mario Corro, MD, PGY-3 & Josh Greenstein, MD Staten Island University Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1573691611143-O1GPZZALP18RFBCGCMIO/ezgif.com-optimize+%2815%29.gif Bowel-GI - Complex Ascites A 70 year old male with history of pancreatic cancer presented with abdominal distention. POC US demonstrated complex ascites. As seen in this clip, complex ascites (such as from malignancy) often demonstrates loculations as well as layering due to dense particulate (exudative ascites) within the fluid. Mario Corro, MD, PGY-3 Staten Island University Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1569012304433-SM0PIP3N0B16EDVVCL8O/appendicitis.gif Bowel-GI - Acute Appendicitis with Appendicolith This image is from a patient presenting with right lower quadrant pain. It demonstrates findings of acute appendicitis including : a dilated fluid filled structure with thickened walls, surrounding hyperechoic fat (fat stranding) and an appendicolith. Check out our colorized image post on evaluating for acute appendicitis here. Image Courtesy of IUEM Ultrasound Original Twitter Post can be found here. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544999861448-I5RUSU072J9UZJATGJII/strangulated+hernia+.gif Bowel-GI - Strangulated Inguinal Hernia 60 year old male presents with pelvic and scrotal pain with vomiting x 1 hour. Physical exam significant for an edematous, erythematous, tender scrotum. Bedside ultrasonography revealed bowel peristalsis and marked scrotal edema (anechoic stripe) visible throughout the scrotum with several loops of bowel within the scrotum. IV established for analgesia and nausea control, and general surgery was consulted. The surgeon requested a CT even though there was good certainty of a strangulated hernia, for operative planning purposes. Patient went to the OR the same day and made full recovery. Pieter Ver Steeg, PA-C https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537200854229-KKYCEJLNJGIZZ8P6MOU0/inguinal+hernia.gif Bowel-GI - Inguinal Hernia With Peristalsis 33 y/o M p/w LLQ and groin pain since bending and lifting heavy boxes the day before. Clinically appears to have an inguinal hernia. Using the inguinal ligament as a guide, the inguinal canal is found at the midpoint between the ASIS and pubic symphysis, just superior to the ligament. The epigastric vessels mark the deep opening of the canal. This can help determine an indirect from direct inguinal hernia. It is estimated that the sensitivity and specificity of POCUS for inguinal hernia detection are 97% and 87% respectively. PMID: 12831490 This is a transverse cut across the left inguinal canal. As the probe moves downward toward the left scrotum, you can see a small loop of bowel contained within the canal. To confirm this is bowel, peristalsis can be seen with fecal material moving in the lumen. There does not appear to be hyperemia or free fluid indicating incarceration or strangulation. The patient was referred to general surgery for repair. Ronald J. Rivera, PGY3 SUNY Downstate / Kings County Emergency Medicine This is the article I used for the sensitivity and specificity: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1964363/ https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533327475410-B7EXQ526A00GHK45VPNO/gastric+feeding+tube.gif Bowel-GI - Gastric Feeding Tube Control of gastric feeding tube. Case of gastric tube placed in the stomach. You might consider the use of color doppler to see flow pattern in the lumen. Dr. Birkelund https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533328016294-6KFYSXSHFLFXBZ0FVTG6/small+bowel+obstruction+.gif Bowel-GI - Small Bowel Obstruction A 60 female presented with 3 days of vomiting, suprapubic distension and left groin pain. POCUS shows distended bowel loops (>2.5cm), 'to-and-fro' motion of hyperechoic bowel contents and extraluminal free fluid. NG was passed for decompression and surgical admission arranged. CT showed small bowel obstruction at the level of distal ileum within a left inguinal hernia Dr Cian McDermott, Mater University Hospital, Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513459312500-4DVMLZS2KI6HQMIKS8SR/ezgif.com-optimize+%285%29.gif Bowel-GI - Small Bowel Obstruction Visualized here are dilated loops of bowel as a result of SBO. One can see hyperechoic fecal material moving to and fro due to blocked peristalsis, visible plicae circularis (folds of small bowel mucus membrane that increase surface area for absorption) also known as the "piano sign," and abdominal free fluid between loops known as "tanga sign." Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522275936392-QCXPSYO9UTJBOWUSGFDV/ezgif.com-optimize+%286%29.gif Bowel-GI - Small Bowel Obstruction 65 female patient 6 months post bowel resection (lower midline laparotomy scar) presents with vague abdominal pain. She is maximally tender over the scar. Bedside ultrasound shows dilated bowel loops and 'to and fro' peristaltic movements. CT confirmed small bowel obstruction and her care was expedited Dr Cian McDermott, Mater University Hospital, Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1516664566469-QZ4DXPAXUARFDEQ7JWGF/jarret+hernia+sbo2.gif Bowel-GI - Incarcerated Hernia with SBO 29 yo F with known hernia p/w sudden onset abdominal pain 2hrs ago. Given a concern for an incarcerated hernia, POCUS was done showing the incarcerated loop of bowel (hypoechoic structure on the left), as well as evidence of an SBO. In addition to a dilated loop (+LR of 15 for 3 loops >2.5cm), the hyperechoic lines along the bowel represent valvulae conniventes which are suggestive of an obstructed loop of jejunum. Patient happened to be pregnant (17wks, FHR and motion also confirmed by POCUS), but was taken emergently to the OR for open repair with mesh and was discharged the next day. Bryan Jarrett, MD - SUNY Downstate/Kings County https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1511125007118-2HXDAZ31ZNIRA8S5Y7PN/ezgif.com-optimize+%281%29.gif Bowel-GI - Small Bowel Obstruction These images were recorded from an elderly lady with abdominal pain and vomiting. Small bowel lumen is dilated more than 2.5cm and there is reduced peristalsis within the lumen - these sonographic signs are consistent with small bowel obstruction (SBO). Other signs of SBO include the presence of hyperechoic material moving back and forth within the bowel lumen and free fluid between the loops of bowel (Tanga sign). Images by Dr. Rory Whelan Submitted by Dr. Cian McDermott - Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509637451201-BNG3CC64VGM0ANOO1OW6/Liteplo%2B-%2BIguapoo%2BFalls.gif Bowel-GI - Iguapoo Falls Small bowel obstruction with a steep precipice and tumbling feces. We call this Iguapoo falls. Andrew Liteplo MD, RDMS - Massachusetts General Hospital Chief, Division of Ultrasound in Emergency Medicine Director, Emergency Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515081170128-6KL0TF49WNNXHRDDV3WZ/cai+maurelus+SBO.gif Bowel-GI - Small Bowel Obstruction 67 y/o M with PMH colon cancer s/p resection and colostomy, multiple SBO managed conservatively p/w no colostomy output for 3 days and increasing abdominal distention. POCUS shows fluid-filled, noncompressible small bowel loops dilated >2.5 cm, the most sensitive finding for POCUS diagnosis of SBO. You also see characteristic to-and-fro motion of the bowel contents. You do not see signs of severe obstruction such as extraluminal free fluid, no peristalsis, or bowel wall thickening >3 mm. Recent studies report a very high positive likelihood ratio for POCUS: 9.55 for clinical US, compared to 1.6 for radiographs, 3.6 for CT, and 6.8 for MRI. Now just convince your surgeons... Dr. Angela Cai, Dr. Kelly Maurelus - Kings County/SUNY Downstate Emergency Medicine https://www.acep.org/Content.aspx?id=100218#sm.0001bhfy70l03elmtz51w5hlmrnna https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509065762459-Y0XR1OG2KQO4DJTPYJOL/Haney+-+Duodenobiliary+fistula.gif Bowel-GI - Duodeno-Biliary Fistula Tiny bubbles of air float up to the top of the gallbladder. This finding prompted additional work-up and an ultimate diagnosis of duodeno-biliary fistula. Rachel Haney, MD - Massachusetts General Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507299121251-81X33PVR3YMWY8QJ41VG/Ascites+Clawing.gif Bowel-GI - Ascites... hello? WCUME17 submission: "Creative Caption" "Well hellllllo there...I'm so ASCITED to see you!" Patient with ascites and a surprising greeting on POCUS. Dr. Stephen Alerhand - Mount Sinai Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1502379363989-L2G4RTLVPF74KRG6AD4S/ezgif.com-optimize+%281%29.gif Bowel-GI - Small Bowel Obstruction This image demonstrates a dilated loop of small bowel with to and fro movements of stool contents. POCUS has been shown to have a sensitivity of 0.91 and specificity of 0.84 for this indication in a single trial when EM residents performed the study. This is compared to 0.02 and 0.67 for an old fashioned KUB. Jang TB, et al. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. J Emerg Med. 2011. 28(8):676-678. Submitted by Dr. Justin Bowra et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507761979122-D3UFL9UDKTAWW99HLN0F/volvulus+jarret.gif Bowel-GI - Gastric Volvulus 80 y/o demented M patient comes in with complaint of abdominal distention, noticed by caregivers. Patient "not keeping anything down." POCUS was done to visualize the "distention." Fluid is seen in what was presumably the stomach, moving forward and backward, not passing the pylorus. The distal bowel did not contain similar fluid. CT demonstrated gastric volvulus and GI was consulted. Dr. Bryan Jarrett - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1499137524409-THYXGOZ0BFT20UYHE98A/ezgif.com-resize%28biliary_colic%29.gif Bowel-GI - Biliary Colic That Wasn't This is an image from a 55 years gentleman with suspected biliary colic. A gallstone was confirmed however the patient's symptoms during exam did not match classic biliary colic. A more in depth evaluation of the right upper quadrant confirmed the presence of a right colonic mass. Color flow was appreciated on a separate clip. Although bowel pathologies are an uncommon finding with emergency ultrasound, they can be easily found with further investigation in atypical presentations. Stefanie Tamburrini, MD Emergency Radiologist https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1499137707830-ADOVD4ARPAR5BEVCN7BB/ezgif.com-optimize%28reducing_asp_risk%29gif.gif Bowel-GI - Reducing Aspiration Risk A 76 y/o F ward patient was vomiting and in respiratory distress possibly due to aspiration. The patient had impending respiratory failure and the plan was to intubate and admit to ICU. A POCUS was done to evaluate her distended abdomen prior to intubation and the image demonstrated a grossly distended stomach with swirling hyperechoic particles. NG tube was placed and approximately 1 liter of bilious fluid was removed. Patient was safely intubated thereafter with aspiration risk minimized. Learning point: For peri-intubation patient with high aspiration risk, POCUS can help determine the amount of gastric content and potentially alter management to include maneuvers to minimize aspiration risk. Van de Putte P, Perlas A. Ultrasound assessment of gastric content and volume. Br J Anaesth. 2014 Jul;113(1):12-22. doi: 10.1093/bja/aeu151. Submitted by Leon Chen, NP – Critical Care Medicine Service Department of Anesthesiology and Critical Care Medicine Memorial Sloan Kettering Cancer Center - New York, NY https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501103081524-GXO0B2LLIOM8PQ4NUNZB/ezgif.com-optimize%28intus_adult%29.gif Bowel-GI - Intussusception Adult Intussusception is typically a disease of the young (6 months to 6 years) but it can occur in adults. Adults will often present similar to bowel obstruction, with vomiting, constipation, and rectal bleeding. Ultrasound can still be used to work them up although most of the time CT will be used first. In kids, the sensitivity and specificity approach 100% but can be operator dependent. It is usually performed with a linear probe in children but in this image, a curvilinear probe was used. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1502380727722-CCPOU3Y43IPXVTHQKJOB/ezgif.com-optimize+%282%29.gif Bowel-GI - Enlarged Appendix with Appendicolith This images demonstrates a longitudinal view of an appendix that appears enlarged with edematous walls, containing a shadowing appendicolith, consistent with acute appendicitis. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1495647808392-30EZDFNV2IAFSFU3HVUX/ezgif.com-gif-maker%2B%286%29.gif Bowel-GI - The Piano Sign A 55 year old male came to ED c/o abdomen pain for 3 days associated with abdominal distention and vomiting. He was noted to be tachycardic and his abdominal exam demonstrated tenderness and bulging in the right inguinal area. A curvilinear probe was used to evaluate for bowel obstruction. The clip demonstrates a dilated loop of bowel, "to and fro" movements of bowel content suggesting dysfunctional peristalsis, and the piano sign. The piano sign (or keyboard sign) is essentially visualization of the plicae circularis which is associated with the diagnosis of small bowel obstruction. Dr. Mahmoud S Alsomali EM Resident R4; Saudi Board Of Emergency Medicine; King Saud Medical City; Riyadh KSA https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507307417971-FC5VT24L2VYQRO1XOMGI/sharifali+perf+appy.gif Bowel-GI - Perforated Appendicitis 30 y/o F with chills, constipation for 3 days. Normal labs and vitals, but distinctly tender in the RLQ. POCUS revealed free fluid and surrounding bowel wall edema with a structure floating that is likely the appendix. CT confirms a perforated appendix with trace free air complex fluid and thickening of the adjacent bowel wall. Dr’s Sophia Sharifali, Esther Kwak, and John F Kilpatrick - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1511635102831-RE1ZGGLOL6LQ4K17M4J5/ezgif.com-optimize+%282%29.gif Bowel-GI - Bowel Gas Bowel gas scatters ultrasound waves making the structure containing the gas as well as posterior structures difficult to visualize. Applying more gentle graded pressure to the probe may displace the gas and improve visualization. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513458700653-BWAJTFN8FPPH7CEQE23G/ezgif.com-optimize+%284%29.gif Bowel-GI - Retrocecal Appendicitis A non-compressible appendix with appendicolith is seen with surrounding fat stranding posterior to a decompressed cecum. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527397846159-I6NV24R6HLY0NJRXAXHB/ezgif.com-optimize+%2840%29.gif Bowel-GI - Enlarged pylorus with gastric outlet obstruction 28 y/o F no significant PMH with 1 month epigastric abdominal pain associated with daily emesis in the mornings and postprandial discomfort.. Patient notes she feels a firmness in her epigastrium. POCUS with an enlarged pylorus with gastric outlet obstruction, confirmed with formal sono. Admitted and evaluated with EGD by GI, found to have peptic ulcer in the antrum with edema and degree of gastric outlet obstruction. Dr. Adrian Aurrecoechea, Dr. Andrew Aherne - Kings County Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527453048302-7G28VVE141CSO66WY5QB/Bobak+Bon+wound+dehiscence+.gif Bowel-GI - Free fluid and Collapsed Bowel 23 year old male with no known medical history s/p surgery for sigmoid volvulus presenting with severe lower mid-abdominal pain. Ultrasound showed trace free fluid and significant collapsed bowel with no peristalsis. CT scan findings were equivocal to our US findings. Patient was found to have bowel dehiscence in the operating room. Bowel wall is most easily seen when there is free fluid or ascites. Normal bowel has layered appearance, easily compressible with intermittent peristalsis. The most frequent pathological findings found by ultrasound is wall thickening, mucosal abnormalities, the absence of peristalsis (1). One benefit of point-of-care intestinal ultrasound is decision for early surgery. Sonographic findings suggesting a need for surgery include; intraperitoneal free fluid, bowel wall thickness of more than 4 mm, and decreased or absent peristalsis (2). Valette PJ, Rioux M, Pilleul F, Saurin JC, Fouque P, Henry L, Eur Radiol. 2001; 11(10):1859-66. Grassi R, Romano S, D'Amario F, Giorgio Rossi A, Romano L, Pinto F, Di Mizio R, The relevance of free fluid between intestinal loops detected by sonography in the clinical assessment of small bowel obstruction in adults. Eur J Radiol. 2004 Apr; 50(1):5-14. Dr Catharine Bon and Dr Bobak Zonnoor Kings County Emergency medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527453287747-05B7JJ1FXAWG86DREF4G/Bobak+Bon+wound+dehiscence+2.gif Bowel-GI - Free Fluid and Collapsed Bowel 23 year old male with no known medical history s/p surgery for sigmoid volvulus presenting with severe lower mid-abdominal pain. Ultrasound showed trace free fluid and significant collapsed bowel with no peristalsis. CT scan findings were equivocal to our US findings. Patient was found to have bowel dehiscence in the operating room. Bowel wall is most easily seen when there is free fluid or ascites. Normal bowel has layered appearance, easily compressible with intermittent peristalsis. The most frequent pathological findings found by ultrasound is wall thickening, mucosal abnormalities, the absence of peristalsis (1). One benefit of point-of-care intestinal ultrasound is decision for early surgery. Sonographic findings suggesting a need for surgery include; intraperitoneal free fluid, bowel wall thickness of more than 4 mm, and decreased or absent peristalsis (2). Valette PJ, Rioux M, Pilleul F, Saurin JC, Fouque P, Henry L, Eur Radiol. 2001; 11(10):1859-66. Grassi R, Romano S, D'Amario F, Giorgio Rossi A, Romano L, Pinto F, Di Mizio R, The relevance of free fluid between intestinal loops detected by sonography in the clinical assessment of small bowel obstruction in adults. Eur J Radiol. 2004 Apr; 50(1):5-14. Dr Catharine Bon and Dr Bobak Zonnoor Kings County Emergency medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534351081684-3Q6IHEEV3DDUAWXPESC4/Esophagus+Swallowing.gif Bowel-GI - Esophagus Swallowing In the center of the screen we see the trachea in transverse view with its round hyperechoic cartilaginous rings. To the right of the trachea is the smaller, collapsed, muscular walled esophagus which moves as the patient swallows in this clip. We can also see the pulsatile carotid arteries bilaterally at the edges of the screen. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534805782751-H1FC25OIQAHN8XQEJE8W/duodenum.gif Bowel-GI - Duodenum In this clip the probe is positioned over the RUQ. The liver is on the left side of the screen, and in the center of the screen we see a portion of the duodenum in cross-section. Often mistaken for a gallbladder full of gallstones by novices sonographers, it can be identified by its peristaltic waves with visible motion of the bowel contents within. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534805793854-NYTJSG3EETA3MLZE5NZA/larger+bowel+.gif Bowel-GI - Large Bowel This clip shows a segment of the colon in long axis beneath layers of connective tissue and muscle. The peristalsis of the bowel is clearly visible as demonstrated by the motion of its inner contents. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537195776171-I39NAEUGG37QWVB9KU7L/appy+transverse.gif Bowel-GI - Appendicitis Transverse 30 y/o M w/ subjective fever, RLQ pain x1day. Tenderness in McBurney’s point w/positive Rovsing’s and Psoas signs, labs significant for mild leukocytosis. POCUS w/ linear probe placed on area of maximal tenderness in RLQ. Transverse and longitudinal views demonstrated non-compressible, blind-ended, non-peristalsing, tubular structure with surrounding hypoechoic free fluid. A central hyperechoic structure representing a fecalith can be appreciated. Outer diameter was measured to be 10mm representing dilated appendix. Findings of acute appendicitis were confirmed with official ultrasound and pt was taken to OR for appendectomy without CT (limiting radiation for young adult). While POCUS is operator dependent and CT is gold-standard for diagnosis of appendicitis in adults, our POCUS findings had higher positive-predictive value given high pre-test probability (classic sx of appendicitis, alternate diagnoses less likely) and optimal pt for study (thin male, no prior surgeries). Dr. Robert Allen and Dr. Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537195786626-0LEH20MK19VUA36I150F/appy+longitudinal.gif Bowel-GI - Appendicitis Longitudinal 30 y/o M w/ subjective fever, RLQ pain x1day. Tenderness in McBurney’s point w/positive Rovsing’s and Psoas signs, labs significant for mild leukocytosis. POCUS w/ linear probe placed on area of maximal tenderness in RLQ. Transverse and longitudinal views demonstrated non-compressible, blind-ended, non-peristalsing, tubular structure with surrounding hypoechoic free fluid. A central hyperechoic structure representing a fecalith can be appreciated. Outer diameter was measured to be 10mm representing dilated appendix. Findings of acute appendicitis were confirmed with official ultrasound and pt was taken to OR for appendectomy without CT (limiting radiation for young adult). While POCUS is operator dependent and CT is gold-standard for diagnosis of appendicitis in adults, our POCUS findings had higher positive-predictive value given high pre-test probability (classic sx of appendicitis, alternate diagnoses less likely) and optimal pt for study (thin male, no prior surgeries). Dr. Robert Allen and Dr. Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537196089492-9EVZQ6SYYPLHSZEXH8U3/john+desouza+cystic+mass.gif Bowel-GI - GI Tumor - GIST Gastrointestinal Stromal Tumor (GIST) 58 y/o F no PMH with epigastric pain for two days, nausea and generalized weakness but no other symptoms. Vital signs were normal and physical exam was limited due to obesity but revealed moderate tenderness in the epigastric region without distention or peritoneal signs. The remainder of the exam was unremarkable and POCUS was performed. A subcostal view is above showing an undefined hypoechoic, heterogeneous, cystic mass. It was non-compressible with well defined borders. Computed tomography (CT) of the abdomen and pelvis confirmed a large, heterogeneous mass adjacent to the stomach with a small amount of intra-abdominal and intra-pelvic blood. The patient was admitted to general surgery, and endoscopic ultrasonography with biopsy revealed a spindle cell lesion consistent with gastrointestinal stromal tumor (GIST). Gastrointestinal stromal tumors are the most common mesenchymal tumors of the GI tract with an incidence of 14 to 20 cases per million.(1) They can be located anywhere in the GI tract but are most frequently identified in the stomach (50-60%) and small bowel (30-40%).(2) Symptoms include abdominal pain, nausea, dyspepsia, fatigue, constipation, or diarrhea. Gastrointestinal stromal tumors have varying appearance on different imaging modalities and are often first seen on abdominal ultrasonography.(3) A subcostal view is be a good place to begin POCUS, considering that most GISTs are located adjacent to or within the stomach. Case reports describe the diagnosis of GIST with help of initial transabdominal ultrasonography.(4,5) Appearance on ultrasonography may vary, depending on size and mitotic activity.(3) Larger tumors may often appear as heterogeneous masses, filling the abdomen with hypoechoic areas consistent with necrosis.(1) However, reports also describe tumors initially seen as extraluminal hypoechoic masses of varying size.(5) While transabdominal ultrasonography is an excellent starting point, CT ultimately shows better detail for staging and characterization. Endoscopic ultrasonography can be used for further definition and ultimately for diagnosis, as biopsy is required. Point-of-care ultrasonography may be an excellent tool for determining further management of patients with non-specific abdominal symptoms. While you may not initially suspect a GIST when starting your POCUS, an unidentifiable mass in the GI tract should prompt further investigation, which can ultimately lead to formal diagnosis. References Vernuccio F, Taibbi A, Piccone D, et al. Imaging of Gastrointestinal Stromal Tumors: From Diagnosis to Evaluation of Therapeutic Response. Anticancer Research 2016;36(6):2639–48. Wronski M, Cebulski W, Slodkowski M, Krasnodebski I. Gastrointestinal Stromal Tumors . Journal of Ultrasound 2009;28(7):941–8. King DM. The radiology of gastrointestinal stromal tumours (GIST). Cancer Imaging 2005;5(1):150–6. Sugihara T, Koda M, Tanimura T, Yoshida M, Muruwaki Y. A report of three cases of exophytic gastrointestinal stromal tumor detected by transabdominal ultrasound. Journal of Medical Ultrasonics 2016;43(1):107–11. Chan KP. What’s the Mass? The Gist of Point-of-care Ultrasound in Gastrointestinal Stromal Tumors. Clinical Cases and Reports in EM 2018;2(1). https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537197181261-HXA97901KQRJTB2HHD0G/SBO.gif Bowel-GI - SBO 60 y/o M hx CHF, ventral hernia s/p repair p/w abdominal pain, nausea, vomiting without flatus. POCUS shows dilated fluid filled small bowel loops > 3 cm in size. There are signs of bowel wall edema with folds projecting into the lumen known as "piano sign" as well as alternating propulsive and retrograde movement of contents which is frequently described as "washing machine sign" typically seen in small bowel obstruction. Jaramillo, Juliana MD; Shah, Rushabh MD; Aherne, Andrew MD; Cutright, Molly MD. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584114069678-GNMSZIZVOKMBSILY4THR/image-asset.gif Bowel-GI - Cirrhosis 70-year-old man with a history of alcoholic liver cirrhosis. This RUQ view obtained with a curvilinear probe reveals a cirrhotic liver (reduced dimensions with irregular edges and an overall heterogenous echotexture) surrounded by significant ascites within Morison's Pouch. Renato Tambelli, Emergency Physician Hospital das Clínicas de Marília.Public Healthcare @R_Tambelli https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592323370381-DJJRMMSVXEP0NIFXPSEP/image-asset.gif Bowel-GI - Floating Liver A 59 year old male with known history of alcoholic cirrhosis presented with dyspnea. Physical exam was notable for a distended, non-tender abdomen. POCUS performed on the RUQ using the curvilinear probe revealed the liver “floating” within ascites. This highlights the importance of performing POCUS to guide procedures, as the patient subsequently warranted therapeutic paracentesis. Victor Bang, Emergency Clinician at Hospital das Clínicas de Marília. Co-Founder of Pocus Jedi @vmjbang https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513452154598-VGGI32KD8G8HA1ZQGSNG/ezgif.com-optimize+%283%29.gif Bowel-GI - Cholangiocarcinoma with Metastases Cholangiocarcinoma with liver metastases and biliary sludge. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1517504234418-IWSXPDDBJ3XGD3IJE1HQ/ezgif.com-optimize-2.gif Bowel-GI - Hepatic Cysts Large hepatic cysts. They were large enough to cause hepatomegaly clinically. Dr. Gordon Johnson https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509032344201-C4OI614042OL6JEF2UJW/necrotic_lesions_liver-Tanguay.gif Bowel-GI - Hepatic Lesions (Incidental) Incidental cystic and necrotic lesions seen throughout liver in a patient with hepatomegaly and abdominal pain on exam. Primary pancreatic CA (not shown). It is still difficult to have a poker face while finding surprise cancer with POCUS. Jason Tanguay, DO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609795430346-4TQI0R7JP1IREAMBKOMT/image-asset.gif Bowel-GI - Whirlpool Sign A 6-day-old presented with findings suggestive of volvulus. POCUS revealed whirlpool sign, consistent with midgut volvulus. The sign corresponds to a clockwise wrapping of the superior mesenteric vein and the mesentery around the superior mesenteric artery (augmented with color doppler in the image on the right). Michael Cooper https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584971646547-UVE5O7CXVJQ4BQEQW662/image-asset.gif Bowel-GI - Pediatric appendicitis Pediatric appendicitis: 4mm appendicolith in mid-appendix with surrounding edema. Aaron Inouye, PA-C Emergency Medicine. North Canyon Medical Center, Idaho @PAintheED https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497407771203-U3QZIWK5JB77FN82NAJ8/appy+free+fluid+long+w.gif Bowel-GI - Appendicitis (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. 8mm dilated, non-compressible, aperistaltic appendix with an appendicolith present (hyperechoic structure in blind end of appendix) surrounded by free fluid. Tender directly over the appendix. The psoas muscle can be seen on the right side, and bowel can be seen to the left. Drs. Bryan Jarret, Sathya Subramaniam - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507818165154-27WB3E9E5ROJB0RBMHQL/appy+fecaliths+longitudinal+sathya.gif Bowel-GI - Appendicitis with two fecaliths Patient with RLQ pain, ttp, fever and guarding. POCUS performed at area of maximal tenderness demonstrating a dilated appendix >6mm with a blind distal end and sonographic McBurney's. Two fecaliths can be visualized, one at the distal end and a smaller one more proximally (right side of the screen). Dr. Sathya Subramaniam - Children's Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497407761329-FW81KXFU6YGF11FXS5VX/appy+1+ff+comp.gif Bowel-GI - Appendicitis + Free Fluid 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. 8mm dilated, non-compressible, aperistaltic appendix with an appendicolith present (hyperechoic structure in blind end of appendix) surrounded by free fluid. Tender directly over the appendix. The psoas muscle can be seen on the right side, and bowel can be seen to the left. Drs. Bryan Jarret, Sathya Subramaniam - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497408047640-GZO6D4OL3NGJ2IABYTSH/normal+appy+comp.gif Bowel-GI - 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501605280827-2GVGHPLF31UQKBZTQVLW/Chaganti+appy.gif Bowel-GI - Appendicitis 15 year old female with no PMH with 3 days of RLQ abdominal pain, nausea, vomiting with inability to tolerate PO, RLQ tenderness. Bedside POCUS performed for 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. Drs. Praneetha Chaganti, Kyle Kelson, Scott Kendall - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497408236142-HOEWTEWV3MDWLCWKMKQJ/normal+appendix+axial+comp.gif Bowel-GI - Normal Appendix (Transverse) 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527399451387-6SCVP6PDXKU672RQ2ZV5/ezgif.com-optimize+%2845%29.gif Bowel-GI - Normal Appendix - Cross Section Measured 12 y/o M with nausea vomiting fevers and vague “belly pain.” Patient mildly tender in suprapubic area. POCUS visualized a normal appendix is seen. A normal appendix is identified by a blind-ending tubular structure that is <6mm diameter measured from outer wall to outer wall (although 6mm-7mm has also been described). This patient’s appendix was measure to be 5.1mm. Dr. Sathya Subramaniam - Children’s Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527398666913-80ZMVFUKPIGLBKXE0SZD/ezgif.com-optimize+%2842%29.gif Bowel-GI - Appendicitis - Ring of Fire 12 y/o with appendicitis. Using color-flow doppler, you can see increased vascularity surrounding the appendix, referred to as a “Ring of Fire” Dr. Sathya Subramaniam https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527399008606-MIUH2JXSC56VB0C23HWZ/ezgif.com-optimize+%2843%29.gif Bowel-GI - Normal Appendix blind end 12 y/o M with nausea vomiting fevers and vague “belly pain.” Patient mildly tender in suprapubic area. POCUS visualized a normal appendix is seen. A normal appendix is identified by a blind-ending tubular structure (as seen in this image). It should be <6mm diameter measured from outer wall to outer wall (although 6mm-7mm has also been described). This patient’s appendix was measure to be 5.1mm (see still image). Dr. Sathya Subramaniam - Children’s Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527399209026-V4XXIQ8Z9M35B2IJ38EJ/ezgif.com-optimize+%2844%29.gif Bowel-GI - Normal Appendix - Cross Section 12 y/o M with nausea vomiting fevers and vague “belly pain.” Patient mildly tender in suprapubic area. POCUS visualized a normal appendix is seen. A normal appendix is identified by a blind-ending tubular structure that is <6mm diameter measured from outer wall to outer wall (although 6mm-7mm has also been described). This patient’s appendix was measure to be 5.1mm (see still image). Dr. Sathya Subramaniam - Children’s Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527399693792-L9N2BOQDUQ9ZQRZX6Z2E/ezgif.com-optimize+%2846%29.gif Bowel-GI - Normal Appendix - Blind End A normal appendix is identified by a blind-ending tubular structure (as seen in this image). It should be <6mm diameter measured from outer wall to outer wall (although 6mm-7mm has also been described). This patient’s appendix was measure to be 5.4mm (see still image). Dr. Sathya Subramaniam - Children’s Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611514842739-LVJ44A35O3HCTWI28JZ8/image-asset.gif Bowel-GI - Retroperitoneal Hemorrhage An elderly male presented to the ED with hypotension and abdominal pain. Ultrasound revealed retroperitoneal fluid in perirenal and anterior pararenal spaces. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1627325898313-KIBL4E1V62HXWPFQI5O2/image-asset.gif Bowel-GI - Pelvic Free Fluid in Ruptured Appendicitis Free fluid is noted in this clip from the pelvic region during a RUSH exam in a patient with a ruptured appendicitis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567931119058-7FM7MV553ZI0PBDGP2UU/normal%2Bappy%2Bcomp.gif Bowel-GI - Appendix - Colorized Appendix Red: Iliac vessels, Green: Appendix Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567931263465-XZCGF489KLW4UBUTEHTK/large-bowel.gif Bowel-GI - Large Bowel - Colorized Large Bowel Orange - Large bowel lumen Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567931261016-XQ7M60U4ANHHZQDJGSXJ/duodenum.gif Bowel-GI - Duodenum - Colorized Duodenum and Liver Orange: Duodenum, Red: Liver Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1674344237772-AAR7XGY4XGCAKZWCHT3J/image-asset.gif Bowel-GI - Portal Venous Gas From Diverticular Abscess This is a clip demonstrating portal venous gas. Notice air can be seen as hyperechoic signals extending to the periphery of the liver. Air signal can also be seen within the flat IVC. Free intraperitoneal fluid is also present. Patient was ultimately found to have a large diverticular abscess. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://static1.squarespace.com/static/58118909e3df282037abfad7/5925c5ce6a496360419302d1/67673bdd42d30756d1edc56d/1745944747844/ Bowel-GI https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1677374990254-WYPGY6PXM4GOBIQ9OST8/SBO+Case.gif Bowel-GI - Small Bowel Obstruction 50s M with no surgical history presented with upper abdominal pain, biliary POCUS was performed which was negative, but large amounts of bowel gas were seen. Small bowel dilation was seen with multiple loops of bowel >2.5cm in diameter with bidirectional flow of bowel contents. CT confirmed SBO and the patient was taken to the OR for operative management Spencer Seballos MD, Resident, Denver Health Residency in Emergency Medicine Katie McCabe MD, Attending Physician, Denver Health Residency in Emergency Medicine https://www.thepocusatlas.com/aorta daily 0.75 2025-02-07 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736704067408-91T927XSDJCB7YK3FJ5L/image-asset.gif Aorta - Aortic Aneurysm with Endoleak - Measurement A patient in their 80s with PMH of abdominal aortic aneurysm s/p grafting with type 2 endoleak presented to the ED for dizziness. Bedside ultrasound demonstrated an 8.55 cm aortic aneurism with large thrombus. Endoleak is the hypoechoic area seen above the hyperechoic endograft. Mehtab Galeh, MD; Bayley Espinoza, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736704067408-91T927XSDJCB7YK3FJ5L/image-asset.gif Aorta - Aortic Aneurysm with Endoleak - Measurement A patient in their 80s with PMH of abdominal aortic aneurysm s/p grafting with type 2 endoleak presented to the ED for dizziness. Bedside ultrasound demonstrated an 8.55 cm aortic aneurism with large thrombus. Endoleak is the hypoechoic area seen above the hyperechoic endograft. Mehtab Galeh, MD; Bayley Espinoza, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736703934297-NTQ6ZT0CGCDBK1EMCVOZ/image-asset.gif Aorta - Aortic Aneurysm with endoleak A patient in their 80s with PMH of abdominal aortic aneurysm s/p grafting with type 2 endoleak presented to the ED for dizziness. Bedside ultrasound demonstrated an 8.55 cm aortic aneurism with large thrombus. Endoleak is the hypoechoic area seen above the hyperechoic endograft. Mehtab Galeh, MD; Bayley Espinoza, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736373873590-P9X402CTR7GUPQVKK54D/image-asset.gif Aorta - Suprasternal view of the aorta Suprasternal notch view of the aortic arch with brachiocephalic artery (BCA), left common carotid artery (LCA), and left subclavian artery (LSA) branching off. Right pulmonary artery is also visible adjacent to the ascending aorta. Charles Jang, EM PGY-3 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736373592848-D1N96LW35T5TNA06QUIK/image-asset.gif Aorta - Suprasternal view of the aorta with labels Suprasternal notch view of the aortic arch with brachiocephalic artery (BCA), left common carotid artery (LCA), and left subclavian artery (LSA) branching off. Right pulmonary artery is also visible adjacent to the ascending aorta. Charles Jang, EM PGY-3 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1731982009611-ZMNOXT141IOWZ7NDSLCJ/image-asset.gif Aorta - Saccular AAA with Dissection Flap Saccular AAA with Dissection Flap. Contributor: Daniel Ostapowicz, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1721963401284-4MGLVW0R5YYTHK2EVABO/Pulsating+Mass+PLAPS+-+Sangirardi.gif Aorta - Thoracic Aortic Aneurysm Rupture Seen on PLAPS View An elderly woman presented to the ED with dyspnea and left mid back pain for 1 week. Left PLAPS (Posterolateral Alveolar and/or Pleural Syndrome) view revealed a round-shaped pulsatile mass surrounded by pleural effusion & atelectatic lung. CTA later confirmed a partially ruptured, thrombosed thoracic aorta aneurysm. This case illustrates the possibility of quickly diagnosing life-threatening conditions with POCUS. Contributed by: Caio Sangirardi, Emergency Medicine Resident Quinta D'Or Hospital, Rio de Janeiro - Brazil, @SangirardiMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1734651375454-OUZVQ3FF17X97C33IL31/image-asset.gif Aorta - Aortic Dissection Flap in Desceding Aorta Flap seen in the descending aorta consistent with aortic dissection Contributed by: Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1679934348630-Z8QSLJ0XHK8C1QBMXHSA/image-asset.gif Aorta - AAA in Undifferentiated Shock 70s-year-old male brought in for altered mental status and hypotension. As part of the initial exam, POCUS was performed. This clip, obtained using the curvilinear probe in transverse orientation over the mid-epigastric region, revealed a AAA measuring 8 cm in AP diameter at the largest point with heterogeneous echogenic material consistent with thrombus. CT abdomen/pelvis with IV contrast confirmed ruptured AAA with thrombosis and only minor extravasation. In this case, POCUS played a critical role in the rapid diagnosis of a patient with undifferentiated shock, particularly in a patient who was unable to provide any history. Katherine Spencer, MD Guy Youngblood, MD, FACEP, FAAEM https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1679276619594-91IAA5YXW6MJCY1E0LOQ/image-asset.gif Aorta - Bilateral Iliac Artery Aneurysms This patient originally complained of right back pain as well as numbness along the thigh and knee. Starting from the abdominal artery, gliding inferiorly will eventually reveal the bifurcation of the abdominal aorta into the left and right common iliac arteries. In this scan, you can see both iliac arteries have enlarged diameters, indicating aneurysms in both. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1670211650298-AJAOZC5E4EN601YO8I9B/image-asset.gif Aorta - Faint Dissection Flap in Descending Aorta Patient presented with severe chest pain and concerning ECG without STEMI. A faint dissection flap can be seen in the aorta on this transverse view in the subcostal region. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1670210925726-LUIM803I0HXIJZSUGVQJ/image-asset.gif Aorta - Sagittal View of Abdominal Aortic Aneurysm Sagittal view of large abdominal aortic aneurysm incidentally found after accidental fall. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1667324102650-O628MW9FB9MAJ6DTMGNT/image-asset.gif Aorta - Abdominal Aortic Aneurysm Presented As Cough Here is another example of an abdominal aortic aneurysm that measured approximately 10.6 cm. The patient originally presented to the clinic complaining of a cough and was eventually admitted for surgical operation. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1658090791812-BKFYQRF2AKLFRQZQJ7PV/image-asset.gif Aorta - AAA with Intramural Thrombus The patient presented to the ED with a known abdominal aortic aneurysm (AAA). A point-of-care ultrasound (POCUS) examination of the abdominal aorta was performed using a curvilinear probe (longitudinal view shown). An infrarenal AAA was noted adjacent and superior to the bifurcation and measured a maximum diameter of approximately 5cm. Heterogeneous echogenic material was seen within the lumen of the aneurysm in keeping with intramural thrombosis, along with a hyperechoic line representing a chronic dissection. This demonstrates the utility of POCUS in the rapid diagnosis of AAA and evaluation of size and intraluminal features such as intramural thrombus and dissection. Andrew Namespetra, MB BCh BAO MSc PGY-1 Emergency Medicine Resident, Central Michigan University (CMU) Chad Bambrick, MD PGY-2 Emergency Medicine Resident, CMU Ryan Davis MS4, CMU College of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1651340278984-24QB1DJKS2NUKY7AXLB4/image-asset.gif Aorta - Large AAA Rupture This is a clip demonstrating a large abdominal aortic aneurysm with significant intramural thrombus. Signs of rupture can be appreciated near the right lower portion of the screen as there is disruption of the aorta wall. Heterogeneity within the intramural thrombus can also be an indicator of rupture. Michael Macias, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1627324553307-260B5AN18QGQL0JAZXAR/image-asset.gif Aorta - Ruptured AAA Sagittal view of an abdominal aortic aneurysm with a hemorrhage anterior to the aorta. Be sure to distinguish a AAA from a dissection by assessing the abnormal wall motion seen at the site of rupture. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626285037159-5VYLT04C45LQLM3DSHWK/image-asset.gif Aorta - Aortic Dissection A chest pain received an echo and showed evidence of a dissection in the PLAX, PSAX, and AP4C views within the descending aorta. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620332597354-431L9ZN73FHBDKPASAF5/image-asset.gif Aorta - Aortic Dissection Patient presented with symptoms of stroke. Echo revealed pericardial effusion and aortic US showed a dissection flap emphasizing the importance of POCUS prior to TPA. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1617893937647-54ZZ3JZ55YZ2S4D0DXHA/image-asset.gif Aorta - AAA Emergency response was called for an 88-year-old who experienced sudden onset thoracic and back pain. PMH significant for AAA (previously measuring 5.8 cm diameter on surveillance imaging 1 year ago). Mid-abdominal US view was obtained (shown here) and revealed AAA now measuring 7.2 cm diameter. Wolfgang Geisser @fentanyl05 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606089567900-D3AF0A765YEAPJG0Z8TJ/image-asset.gif Aorta - Aortic Dissection Flap 61 year-old male presented with one day history of generalized abdominal pain, nausea, and vomiting. He was hemodynamically stable (BP 130/59); EKG notable for the presence of U waves and lateral ST depressions; labs revealed a negative troponin, potassium 3.1, lactic acid 5.4. Abdominal POCUS seen here revealed an abdominal aortic dissection flap as his unifying diagnosis. Richard Cunningham, MD. Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611515999409-NLXRRLC6YA3JDZF3EU8A/image-asset.gif Aorta - Ruptured AAA An elderly patient presented to the ED with hypotension and back pain and free intra-abdominal fluid seen on FAST exam. Ultrasound of the aorta revealed a rupture of an abdominal aortic aneurysm. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605901470140-767XW864Y2QQI4NAQ5Q1/image-asset.gif Aorta - Normal Aortic Arch - Suprasternal View This clip represents a normal suprasternal view. The brachiocephalic artery (BCA), left carotid artery (LCA) and left subclavian artery (LSA) emerge from the aortic arch (AA). The left subclavian artery (LSA) marks the division between the proximal thoracic aorta and the distal descending aorta (DA). Dr. Felipe Urriola P., Emergency Unit, Puerto Aysen Hospital, Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605901091126-6B5XTERJVRMUZ76BWM8A/image-asset.gif Aorta - Normal Celiac Trunk & SMA - Longitudinal At the center of the screen, the proximal aorta can be identified by the emergence of the coeliac trunk and the superior mesenteric artery. This clip is taken at the subxiphoid level, longitudinal to the body’s axis, and with the probe marker oriented towards the head. Dr. Felipe Urriola P., Emergency Unit, Puerto Aysen Hospital, Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605900628281-U6ENHWPSV0WUGQJ01TOA/image-asset.gif Aorta - Normal Aorta & Iliac Arteries - Transverse At the center of the screen, the distal aorta lies anterior to a vertebral body. Sliding the probe caudally reveals the emergence of the iliac arteries. This clip is taken at the umbilicus level, transverse to the body’s axis, and with the probe marker oriented to the patient’s right. Dr. Felipe Urriola P., Emergency Unit, Puerto Aysen Hospital, Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604504358519-HOI7XUNJVJN1K10XD1VQ/image-asset.gif Aorta - Normal IVC and Aorta - Transverse view The two round, anechoic structures laying on top of a hyperechoic vertebra are the IVC to the left of the screen (patient’s right), and the thicker, contractile aorta to the right (patient’s left). Deep inspiration or a sniff test demonstrates a collapsible IVC in normal subjects. Consider, however, that visualization of both these vessels may certainly be obscured by very obese patients or those with subcutaneous emphysema, significant bowel gas, ascites, or a large ventral hernia. This clip is taken over the subxiphoid region, transverse to the body’s axis, and with the probe marker oriented to the patient’s right. Dr. Felipe Urriola P., Emergency Unit, Puerto Aysen Hospital, Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604503453108-QEQBVYVWGB2LCL3WPXC2/image-asset.gif Aorta - Normal IVC to AA lateral drag - Longitudinal View While maintaining its orientation, the probe is dragged to the left of the patient, revealing the abdominal aorta (AA) and the emergence of the coeliac trunk. Notice the contractile, thicker aortic walls and how both the common hepatic artery and splenic artery form the “seagull sign”. Also notice that a normal IVC frequently demonstrates transmitted pulsations from the RA; hence, pulsation is not the proper method for differentiating it from the aorta. This clip is taken over the subxiphoid region, longitudinally to the body’s axis, and with the probe marker oriented to the patient’s head. Dr. Felipe Urriola P., Emergency Unit, Puerto Aysen Hospital, Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1603239024555-FZTRHRATRQBHP9UK6HF3/image-asset.gif Aorta - Long Axis View of Large Abdominal Aortic Aneurysm Long axis view of large abdominal aortic aneurysm containing intramural thrombus without evidence of the iliac arteries involvement. Image courtesy of Giovanni Battista Fonsi https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1571444876243-BAWL32QOHGBILQ5FFDR6/ezgif.com-video-to-gif+%281%29.gif Aorta - AAA Rupture: Not Your Typical Flank Pain A 61-year-old male was brought in via EMS after a syncopal episode. He was diaphoretic and hypotensive, complaining of severe right flank pain. While IV access was being obtained a bedside ultrasound was performed demonstrating a large abdominal aortic aneurysm with significant heterogeneous intraluminal clot. There is also appreciable focal hypoechoic disruption of the wall of the aneurysm consistent with rupture. The patient was resuscitated in the ED and taken emergently to the OR to surgical repair. Michael Macias, MD @emedcurious https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534344572933-RC1E9K6WDD44HPP08KOB/Good+Upper+Aorta+Anatomy.gif Aorta - Proximal Aorta Anatomy 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. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1569451754245-EDV6HR8QE31A7NMUC00T/Aorta2.gif Aorta - Seagull Sign 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. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534343738338-KAIKDVDNEET9IO4MTNPC/Distal+Aorta+.gif Aorta - Distal Aorta 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. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592497059246-BNP9V5VBDI03OZN7XXY1/image-asset.gif Aorta - Smokin' AAA A 70-year-old male presented as a trauma alert and was found to have this 10 cm abdominal aortic aneurysm (AAA) with associated echocardiographic smoke! Echogenic smoke is produced by the intersection of RBC’s and plasma proteins at low shear rate conditions. Brian Toston, Internist. Adventura, FL https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1569842298368-ZBTR83N6C60A1ZFVWL9I/AAA.gif Aorta - Abdominal Aortic Aneurysm This image was taken from a pocket wireless device in the mesogastric region. We can see the short-axis aorta with its increased diameter and neighboring anatomical references such as the dorsal spine and inferior vena cava laterally. Image courtesy of Dr. Renato Tambelli https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1591671703408-JNQ8ID04DQCLXRKH2UZJ/image-asset.gif Aorta - Dissection Flap in Abdominal Aorta An elderly male with hypertension and DM presents with C/O chest pain. Bedside ultrasound performed demonstrating a dissection flap in the lumen of the abdominal aorta. A subsequent parasternal long axis show extension into descending thoracic aorta as well. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1591670622471-QZOKK6VMGRL6HKB1938V/ezgif.com-gif-maker.gif Aorta - Ruptured AAA with Active Hemorrhage Elderly female presents to ED with back pain and hypotension. Bedside US shows a ruptured AAA with active hemorrhage in the 9 o’clock position. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588257707732-GJAVH3FE4W1EV228AG1L/image-asset.gif Aorta - Subacute Aortic Trauma Patient with a subacute history of chest trauma (occurred approximately 30 days prior) presented reporting intermittent chest pain. He was noted in the ED to have persistent pain and to be sweating. Bedside evaluation included lung ultrasound that identified the cystic structure seen here with a hypoechoic interior with visible swirling. Chest CT shown confirmed this to be sequelae of aortic trauma. Renato Melo, Emergency Physician Brazil. PocusJedi affiliated. @Renato_Melo_ https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584972657348-DZVRQUWZB0Y036XAPRPF/image-asset.gif Aorta - Incidental AAA Routine abdominal evaluation using a Sonosite X-Porte curvilinear ultrasound probe revealed this 6.0cm abdominal aortic aneurysm (without rupture or dissection) in a patient with risk factors for the same. This enabled our middle-aged diabetic male with 80 pack/yr smoking history to receive timely evaluation by vascular surgery and subsequent appropriate serial monitoring and follow-up. Siang-Chean Kua MS-4 Central Michigan University College of Medicine Additional contributors: Ryan Shelby, MD, Thomas Ferreri, MD, Therese Mead, DO, RDMS, FACEP https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1583613792408-4GKWLJ8X0DXH0DF51HZY/endograft+leak+howe+scheel+pelletier+transverse.gif Aorta - Aortic Endograft Leak - Transverse Aortic Endograft Leak - Dr. Lindsay Howe Dr. Tim Scheel Dr. Paul Pelletier - Denver Health https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1583613788255-KS0O4HFDPS0IQWN4F6GH/endograft+leak+howe+scheel+pelletier+long.gif Aorta - Aortic Endograft Leak Long Axis Aortic Endograft Leak - Dr. Lindsay Howe Dr. Tim Scheel Dr. Paul Pelletier https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1570902928533-UGDFW3GWBMAV729GNGHL/ezgif.com-optimize+%287%29.gif Aorta - Extensive Type B Aortic Dissection A 60 year old man was transferred to a trauma facility after presumed mechanical ground-level fall. He was only able to answer yes/no questions, vital signs were normal and stable upon arrival. He denied abdominal or back pain. Upon arrival to receiving facility, POC ultrasound revealed intimal flap within the abdominal aorta extending from the subxiphoid region to the common iliac arteries. Bedside echo revealed no aortic root dilatation, pericardial effusion, or evidence of tamponade. CT scan confirmed thoracic and abdominal aortic dissection. Cardiothoracic surgery was notified immediately. POCUS can play a critical part in allowing for rapid diagnosis and can expedite patient-care, particularly in patients with altered mental status who cannot provide a more robust history. Quinn Fujii, DO Desert Regional Medical Center, Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1576959161047-CN4FGLWQECKYAWR8VQAM/image-asset.gif Aorta - Abdominal Aortic Dissection Flap Patient with abrupt onset chest pain radiating to back. Normal ECG and Troponin. POCUS revealed dissection flap within abdominal aorta. Nishant Cherian Emergency Medicine Registrar https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544998454118-XEGIAS2M3RSOAJWBV6GE/aortic+dissection+.gif Aorta - Aortic Dissection 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1554691601522-LXS6SK6QJ2YDQHACFV07/thoracic+aortic+dissection+.gif Aorta - Thoracic Aortic Dissection 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533325746240-J1PNO2JMGQN6MTY9564H/extravasation.gif Aorta - Aortic Graft Endoleak 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533301315652-K0953URVLMT7A9U8251R/Mural+thrombus+AAA.gif Aorta - Mural Thrombus in AAA 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496099223379-SL8Q4KBXCE4Y9J9J6ZZN/ezgif.com-optimize.gif Aorta - Abdominal Aortic Aneurysm with Thrombus Approximately 6 cm abdominal aortic aneurysm with intramural thrombus. Frances Russell, MD, RDMS Assistant Professor of Emergency Medicine Division Chief, Ultrasound Fellowship Director, Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533301327033-W7W18G5U4IRYC6A681Y4/mural+thrombus+AAA+-+color+.gif Aorta - Mural Thrombus in AAA - Doppler 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496099367949-7G3YQVPNW5P73U5ZKF8E/ezgif.com-optimize+%281%29.gif Aorta - Ruptured AAA 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1500384664093-Y6ZE8551YN1WX9KVH8ST/ezgif.com-optimize%28AAD_trans%29.gif Aorta - Abdominal Aortic Dissection (Transverse) 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. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507754002025-RRWKM9YIIN31CN5A0EXH/happy+flappy.gif Aorta - Pulsating Aortic Aneurysm 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1511634870899-ASNZO8H8OWQLQ7GDB8KZ/ezgif.com-optimize+%281%29.gif Aorta - Abdominal Aortic Aneurysm 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1525190222897-PVBLUPLOVWUYTMEALDBZ/ezgif.com-optimize+%2824%29.gif Aorta - Aorta Posterior Wall Rupture 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572032631511-A08AGDGMHH1EBLWQ2U0S/ezgif.com-optimize+%288%29.gif Aorta - Thoracic Aorta Aneurysm with Intramural Thrombus Don’t be distracted by the abnormal cardiac function in this clip, notice deep to the pericardium a thoracic aorta aneurysm is seen with moderate amount of intramural thrombus. Image courtesy of Aventura Ultrasound; Their original Twitter posting can be found here. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522335845368-X7265FCW0IFEQ2W8IRLJ/ezgif.com-optimize+%287%29.gif Aorta - Fetal Aorta Pulsating fetal aorta Marco Garrone https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592423458157-SB6SPLQ0ULDH4LW0YAFM/image-asset.gif Aorta - Abdominal Aortic Aneurysm A 72-year-old male presented as a trauma alert and was incidentally identified as having an asymptomatic abdominal aortic aneurysm (measuring 10 cm in diameter). Brian Toston. Internist. Aventura, Florida https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527395656445-ZTAR4RUOQSNMHX8WCYJJ/ezgif.com-optimize+%2835%29.gif Aorta - Aortic dissection flap tamponade 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527395890441-MWA0NBZQMF93QUDFP0IF/ezgif.com-optimize+%2836%29.gif Aorta - Aortic dissection flap tamponade color flow 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527396179720-7RUHD26JEEN9EYXIWEER/ezgif.com-optimize+%2837%29.gif Aorta - Aortic Dissection Flap 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1568924605052-8M8N02Z3YEFLXNVCF1W2/AAA+rupture.gif Aorta - POCUS Utility in Suspected AAA Rupture 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567276716629-6UXIS1E2J1XJPKL0F6H1/colorized+good-upper-aorta-anatomy.gif Aorta - Upper Aorta - Colorized - The POCUS Atlas Orange: Yellow: Liver, Light blue: Pancreas, Aqua: splenic vein/portal confluence, Blue: IVC with left renal vein, Purple: SMA, Red: Aorta, Orange: Spine Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567276711556-VPWTZ64A9J1HUZ8P5N5C/colorized+good-seagull-sign+aorta.gif Aorta - Seagull Sign - Colorized Good Seagull Sign Orange: Spine, Red: Aorta, Blue: IVC, Green: Portal venous confluence, Pink: “Seagull sign” aka celiac trunk Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567276686268-TWQG6S3O8E6ZE7KAHQCC/colorized+distal-aorta.gif Aorta - Distal Aorta - Colorized Distal Aorta Orange: Spine, Red: Aorta and Iliacs, Blue: IVC, Green: Portal venous confluence, Pink: “Seagull sign” aka celiac trunk Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1648837157809-N24HURXIPYBJN9LTVAPZ/HG+type+B+dissection.gif Aorta - Thrombosed Type B Aortic Dissection 60s M PMH HTN, CKD stage 3 presented with bilateral flank pain x2 days. CT of the abdomen/pelvis with IV contrast showed a 3.8 cm x 4.6 cm infrarenal AAA with a 3.1 cm L internal iliac aneurysm. POCUS of the aorta was obtained re-demonstrating the AAA. Dedicated CTA showed that there actually demonstrating aneurysmal dilation of the descending thoracic aorta with a thrombosed type B dissection. The patient was managed with aggressive blood pressure and heart rate control with esmolol and was admitted to the ICU for medical management. Dr. Henrik Galust, PGY4, Denver Health Residency in Emergency Medicine Dr. Nimish Bhatt, Fellow, Denver Health Ultrasound Fellowship https://www.thepocusatlas.com/pediatrics-1 daily 0.75 2024-04-08 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1645226096022-I5EDFYS8JS67T7E95SM4/image-asset.gif Pediatrics - Cardiac Standstill https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1645226096022-I5EDFYS8JS67T7E95SM4/image-asset.gif Pediatrics - Cardiac Standstill https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601058949549-07HQX9A8MXUWJOHO5D4R/image-asset.gif Pediatrics - COVID-19 Myocarditis 14 year-old male presents to the ED with chest pain two weeks after being having been diagnosed with COVID-19. Labs were notable for elevated CBC, CRP, ESR, and troponin. POCUS revealed moderately decreased function and LV dilation, consistent with the diagnosis of COVID-19 myocarditis. Paul Khalil, MD and N. Akwesi Poteh, MD at University of Louisville @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1645226490211-XDU1K3SSKQ8ZNSB1KGXG/image-asset.gif Pediatrics - Pediatric Intussusception https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609772966749-QCB92MCVBXHIJ2D1PC4X/image-asset.gif Pediatrics - Nursemaid's Elbow 2-year-old female was brought to the ED refusing to use her left arm after her father caught her by the arm to prevent her falling down flight of stairs. POCUS was performed to confirm clinical suspicion of a Nursemaid’s elbow (or radial head subluxation). The left image reveals classic findings of a Nursemaid’s elbow including widening of the synovial fringe and inward extension of the annular ligament. Further, you can appreciate both the supinator muscle, as well as the annular ligament are being pulled into the joint space, a finding known as hook sign. The image on the right is the post-reduction image showing normal alignment and contour of the annular ligament. Austin Meggitt, MD Pediatric Emergency Ultrasound Fellow Denver Health Medical Center @DenverEMed https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601058146553-EV02EKG54YFOK3LSDEMK/image-asset.gif Pediatrics - Knee Effusion 2 year-old male presented with fever, right knee swelling, and elevated CBC, CRP and ESR. POCUS revealed a right knee effusion. Paul Khalil, MD. Assistant PEM POCUS director at University of Louisville/Norton Children’s @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601049487269-0354YC3IH74DJLX94OEJ/image-asset.gif Pediatrics - Dynamic Air Bronchograms 15 year-old male with cerebral palsy presents to the ED with hypoxia. Physical exam notable for left lung with decreased air movement on auscultation. POCUS demonstrates dynamic air bronchograms consistent with suspected diagnosis of pneumonia. Paul Khalil, MD. Assistant PEM POCUS director at University of Louisville/Norton Children’s @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601048900046-B2TP4I4OEQ96JDAI8HQ9/image-asset.gif Pediatrics - COVID-19 Pneumonia 14 year-old female known to be SARS-CoV-2 positive presented with chest pain and shortness of breath. POCUS revealed findings consistent with COVID pneumonia including thickened pleura and presence of multiple B-lines. Paul Khalil, MD. Assistant PEM POCUS director at University of Louisville/Norton Children’s @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598026364953-LUNBWQB5TXUBMGIPEHYK/image-asset.gif Pediatrics - Pericardial Effusion An 8-year-old male presented with a 1 day history of fever and chest pain. Cardiac POCUS shown here revealed a pericardial effusion; he was later started on steroids for the same enabling hospital discharge on hospital day #2. Amar Singh, MD. University of Louisville https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598024657385-HWGJP6P3FLEMH08NNZXY/image-asset.gif Pediatrics - Hepatization of the Lung A 15-month-old male presented with cough, fever, and tachypnea of 3-days duration. POCUS revealed findings of right lung consolidation, consistent with pneumonia referred to as hepatization of the lung. Seen here territories above and below the diaphragm show ultrasonographic findings resembling liver parenchyma. Amar Singh, MD. Pediatrics specialist in Louisville, KY https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1574876570099-MANMJRRDYWE3RMQACQ0I/testicular+torsion+decreased+flow+2+mcclean+sick+kids.gif Pediatrics - Testicular Torsion Decreased color doppler is seen in this pediatric patient with testicular torsion. Dr. Lianne McLean (@doctorlianne) FRCPC of the PEM POCUS Group: Division of Emergency Medicine in the Hospital for Sick Children (@epocus) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1574876570636-A47C65AM9L4MGQDR93MQ/testicular+torsion+decreased+flow+1+mcclean+sick+kids.gif Pediatrics - Testicular Torsion Decreased color doppler is seen in this pediatric patient with testicular torsion. Dr. Lianne McLean (@doctorlianne) FRCPC of the PEM POCUS Group: Division of Emergency Medicine in the Hospital for Sick Children (@epocus) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644172589930-A1WW0IWQ890PEMEL5LKX/image-asset.gif Pediatrics - Cardiac Standstill 18 month old cardiac standstill https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544997461529-QBPQMGA6R2XKSR709PK8/whiteout+PNA+2.gif Pediatrics - Pneumonia 3 yo m previously healthy UTD with vaccines. 5 days of cough and fevers. 3 days of abdominal pain, acutely worsening day of presentation with 1 episode of NBNB emesis. Febrile tachypneic and hypoxic to 91% on RA. CXR: white out of right lung. POCUS: large right sided effusion. Hepatization with air bronchograms on the right lateral view. Dr. Isaac Gordon - Kings County Pediatric Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544997455215-XKBTGJSI64E708EBOARJ/whiteout+PNA+1.gif Pediatrics - Pneumonia 3 yo m previously healthy UTD with vaccines. 5 days of cough and fevers. 3 days of abdominal pain, acutely worsening day of presentation with 1 episode of NBNB emesis. Febrile tachypneic and hypoxic to 91% on RA. CXR: white out of right lung. POCUS: large right sided effusion. Hepatization with air bronchograms on the right lateral view. Dr. Isaac Gordon - Kings County Pediatric Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544998047426-AW2D8WW8RX8J4MKUWX22/PNA.gif Pediatrics - Focal B-lines - Pneumonia 2 years old male with hx of endotracheal intubation secondary to RSV infection presents with 2 days of fever, cough, rhinorrhea and nasal congestion. Denied nausea, emesis, diarrhea, chest pain, syncope, confusion, change in eating patterns and voiding patterns. POCUS demonstrates a focal area of B lines c/w pneumonia (likely viral). Early PNA B lines: short path reverberation artifacts create by fluid filled alveoli. In the appropriate clinical scenario B lines and pleural consolidation suggest PNA. Dr. Carolina Camacho Ruiz - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509193144803-7R8STX90HZWW29B43DP0/acute+chest+syndrome+w.gif Pediatrics - Acute Chest Syndrome 6 y/o sickle cell (HbSS) coughing with left-sided chest pain and 1 day of fever. Lungs 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507753182343-S7WJ3Y02O9KENZQ5B5CE/positive+bubble+test.gif Pediatrics - Atrial Septal Defect, Positive Bubble Test WCUME 2017 submission for "Novel Indication" Bubble test reveals an atrial septal defect seen as bubbles floating from the right side of the heart to the left side. An obvious defect can be seen. Dr. Mojtaba Chahardoli - Firoozgar Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507752717750-YNJ9V3E3YI6LD681HEEY/patent+pda.gif Pediatrics - Ductus Arteriosus (Patent) WCUME 2017 submission for "Best POCUS" 8 y/o M with undifferentiated dyspnea. POCUS reveals he has open PDA on aorta from suprasternal view. Dr. Nima Shekar Riz Fomani - Firoozgar General Hospital   https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507759701140-B4ZEBOBE52F5D0VGORDA/asymmetric+ventriles+subramaniam.gif Pediatrics - Obstructive Hydrocephalus WCUME 2017 winner for "Novel Indication" - See our blog post for a deep dive on this topic! 7 month old being followed by PCP for increasing head circumference, scheduled for outpatient MRI next week. Mother found patient was becoming somnolent with a full anterior fontanelle and brought the baby to the ER. POCUS performed immediately revealed unequal ventricle size, L>R, at which time neurosurgery was consulted, later CT, MRI performed as inpatient confirming obstructive hydrocephalus. If you were in a community ER and CT will take a while, should you just POCUS first? How well can this see blood? Masses? Dr. Sathya Subramaniam - Childrens Hospital of Philadelphia Pediatric, EM Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1643823081025-IL019H7135ZJWAGUN6ME/image-asset.gif Pediatrics - Pediatric Intussusception with Entrapped Free Fluid https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522608991976-0WQ4HV8DL4XBPLYRRW37/sathya-cranial-hydrocephalus-1.gif Pediatrics - Hydrocephalus - Extra axial Fluid Extra-axial fluid overlying the superior portion of the frontal lobes in the patient from our blog post on the topic. 7 month old being followed by PCP for increasing head circumference, scheduled for outpatient MRI next week. Mother found patient was becoming somnolent with a full anterior fontanelle and brought the baby to the ER. POCUS performed immediately revealed unequal ventricle size, L>R, at which time neurosurgery was consulted, later CT, MRI performed as inpatient confirming obstructive hydrocephalus. Dr. Sathya Subramaniam - Childrens Hospital of Philadelphia Pediatric, EM Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522625293382-CHLQEUWTVZXREFZJO0VO/sathya-cranial-hydrocephalus-3.gif Pediatrics - Head Imaging - Coronal Plane Please see our blog post for further information on this topic. The coronal plane has the indicator marker to the right and is placed on the anterior fontanelle. The ultrasound beam is swept from the anterior to posterior aspect of the head. Dr. Sathya Subramaniam - Childrens Hospital of Philadelphia Pediatric, EM Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522625293882-W42DSF542AR4MFJXJLSF/sathya-cranial-hydrocephalus-4.gif Pediatrics - Head Imaging - Sagittal View The sagittal plane has the indicator marker facing the anterior aspect of the face and the ultrasound beam is swept in either the left to right or right to left direction of the patient’s shoulders. Please see our blog post for further information on this topic. Dr. Sathya Subramaniam - Childrens Hospital of Philadelphia Pediatric, EM Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507877690013-FBMCX6KXNOZ2NTKKTX76/Hydrocephalus.gif Pediatrics - Hydrocephalus WCUME 2017 submission for "Novel Indication" Dr. Atim Uya - San Diego, California, USA https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497408988081-3F1L1C1JQATFSTEYGGJK/hip+effusion+comp.gif Pediatrics - Hip Effusion 8-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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523823374560-NGUWX339F0P34UJYOB1H/ezgif.com-optimize+%2814%29.gif Pediatrics - HOCM - Hypertrophic Obstructive Cardiomyopathy 19 y/o came in after a syncopal episode playing video games. Got defibrillated in the field Vfib rate 200s. Bedside echo demonstrated global LVH with septal predominant thickening consistent with HOCM. Father has a history of ICD of “heart condition.” Dr. Dustin Morrow https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497409393850-K2HZILBKO3LD6DHZ3NIS/hocm+comp.gif Pediatrics - HOCM Hypertrophic Cardiomyopathy 8-year-old with syncope while playing in school. EKG with some non-specific T wave inversions in precodial leads. No murmur, 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1516662185450-O5464QNG95K8CWX4QAPA/ezgif.com-optimize+%281%29.gif Pediatrics - Knee Effusion - Septic vs. Lyme Arthritis 20 month old with right sided limp for 2 days, no fevers, swelling of knee, able to partially range without discomfort, knee aspirate after POCUS purulent, admitted for wash out. Septic vs Lyme's differential. Aspirate yielded 923000 WBC from the cell count, but nothing grew from the cultures. Discharged home on 4 weeks of abx for Lyme, as his titers were positive on Elisa and Western blot. Dr. Sathya Subramaniam - Children's Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497408650737-UD7G79VXUKI6SGSR9DXF/distal+radius+fx+comp.gif Pediatrics - Radius Fracture (Distal) 7 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523186899080-ZH800ARN3VI2UTSG6EHM/Liang+peds+skull+fracture.gif Pediatrics - Skull Fracture - Pediatrics 10 month old F presents one day after unwitnessed height level fall. Left parietal hematoma without step-off found on physical exam. Otherwise well appearing with normal vital signs. POCUS found a defect in cortex in area of the hematoma. CT head confirmed non-displaced skull fracture of the left parietal bone. Patient was observed and did not require neurosurgical intervention. More research is needed into the value of POCUS for pediatrics skull fractures and how it can fit into our PECARN decision rules. Dr Iain Jeffery - Brooklyn Hospital Emergency Medicine Dr. Tian Liang and Dr Jeffery Rallo - Kings County Department of Pediatrics Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497408790869-5J4UQEDUWM16WZFIB6HZ/hepatization+comp.gif Pediatrics - 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. 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 appear compared to the actual liver. Dr. Sathya Subramaniam, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1498406059328-UK8U6VXWVVUB47PQITIU/ezgif.com-optimize%28skull_fracture%29.gif Pediatrics - Infant Skull Fracture 7 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1498402983373-3CVJ7JGGK3MCLRZVZPK8/ezgif.com-optimize%28infant_PNA%29.gif Pediatrics - Infant Pneumonia with C-Lines 11 month old unvaccinated infant 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 present. Dr. Sathya Subramaniam, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497409700507-V6PH1F3PGYTA2PZKWM3E/hydrocarbon+ingestion+comp.gif Pediatrics - Hydrocarbon Ingestion with C-Lines 5 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507877967499-FRB92O5OTQYVPPZQ7LO8/ezgif.com-optimize+%2837%29.gif Pediatrics - Ureterocele WCUME 2017 Submission for "Novel Indication" Dr. Atim Uya - San Diego, California, USA https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606093313087-RAS8BG4F0N5JMSD46Z26/image-asset.gif Pediatrics - Acute Appendicitis A 5-year-old patient with no relevant medical history was brought to the ED the previous day complaining of fever and mild abdominal pain. Due to a lack of specific clinical findings, he was treated with antipyretics and swabbed for COVID-19, which was negative. The following day, on its second visit to the ED, the child's fever persisted and had substantial abdominal pain that did not respond to first-line treatment, requiring subsequent use of ketamine. Physical examination was non-specific. POCUS of the RLQ immediately revealed acute appendicitis, as shown in this series of clips. Notice here on the left, the circular appendix in transverse view which is not deformed by compression with the probe; also can appreciate an abundance of peri-appendicular free fluid in the surroundings. Fanning the probe reveals an intraluminal fecalith with posterior acoustic shadowing. On the right is a longitudinal view also revealing an intraluminal fecalith. The patient was transferred to the regional referral hospital, and successfully underwent surgery which confirmed gangrenous appendicitis. Dr. Felipe Urriola P. Emergency Unit, Puerto Aysen Hospital. Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1500298984292-QY8L2Q4W5DP7HMXGTNAA/ezgif.com-optimize%28lung_point%29.gif Pediatrics - Pneumothorax with Lung Point 18 y/o M 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 indicates the transition point between normal pleura with normal lung sliding (on the left side of the image) and where there is air disrupting the pleural space with decreased lung sliding (on the right side of the image). Lung point is a highly specific finding indicating a pneumothorax. Dr. Sathya Subramaniam, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497411010470-NLX2IRP1L1TZPWHFO715/mild+hydro+comp.gif Pediatrics - 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497409903526-6ZN7PRQ90D9GQ2ATS7EK/severe+hydro+comp.gif Pediatrics - Prune Belly Syndrome -Severe Hydronephrosis 10 y/o with Prune Belly Syndrome 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1500225951929-25WS6Z93KHVMFR7TR46M/shoulder+dislocation+sathya.gif Pediatrics - Shoulder Dislocation and Reduction 17 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 as seen. You can appreciate the musculature and rotator cuff throughout both images. Dr. Sathya Subramaniam, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496101890347-A9ABACW2594Y4BDWNQU5/ezgif.com-optimize+%2816%29.gif Pediatrics - 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509193081694-R2U6E028JQW12XG13CI0/Liteplo+-+Tracheal+Stenosis.gif Pediatrics - Tracheal Stenosis The patient, presenting with stridor, is supine and the airway is seen from the anterior neck in transverse orientation. As the probe is fanned, the bright white line is seen to widen. This column of air moves with inspiration. At its narrowest it is only a few millimeters wide. Growth along the lateral tracheal walls has caused significant tracheal stenosis. In this case, US was used to determine the width of the tracheal column and determine that passage of an ETT would not be feasible. The patient was taken to the OR for an emergent surgical airway. Use of US to estimate tracheal diameter is a novel application. Andrew Liteplo MD, RDMS - Massachusetts General Hospital Chief, Division of Ultrasound in Emergency Medicine Director, Emergency Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1524863330780-ZKSLX0SDESUZP3WRMMJM/supracondylar+fracture+w.gif Pediatrics - Supracondylar Fracture 15 year old fell on left elbow, pain and swelling over left elbow on exam. Raised fat pad in the olecranon fossa of left humerus as compared to right humerus. A raised fat pad is suggestive of an elbow injury, more commonly a supracondylar fracture. Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1524863673731-EQ2AIFMWGW3B2W8SKCC3/sathya+supracondylar.JPG Pediatrics - Supracondylar Fracture - Comparison 15 year old fell on left elbow, pain and swelling over left elbow on exam. Raised fat pad in the olecranon fossa of left humerus as compared to right humerus. A raised fat pad is suggestive of an elbow injury, more commonly a supracondylar fracture. Dr. Sathya Subramaniam - Kings County/SUNY Downstate - Pediatric EM Fellow https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1665452471240-O31OU1HOWAOKN7S6N7MV/image-asset.gif Pediatrics - Testicular Torsion Teenaged male presented with acute onset unilateral testicular pain and swelling. On exam, the affected testicle was swollen and tender with some color change. POCUS demonstrated normal flow in a normal sized contralateral testicle, and an enlarged affected testicle with no color doppler flow. After manual detorsion, POCUS demonstrates clear restoration of normal blood flow. After urologic consultation, the patient was taken emergently to the OR, where operative findings confirmed testicular torsion, and orchiopexy was performed. Dr. Michael Duerson, PGY4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523206031540-SCXTJ564438UHGVBUU40/thymus+vs+pna+JFK+2.gif Pediatrics https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496187926562-0M4MDH9B4R4TZ7J3EP8K/acute+chest+syndrome+w.gif Pediatrics https://www.thepocusatlas.com/softtissuemsk daily 0.75 2025-01-16 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1729636606316-01RL72JHPZSEMSTLSO3E/image-asset.gif Soft Tissue - Cobblestoning in Cellulitis This is an example of “cobblestoning”. This patient initially presented to the emergency department with lower anterior leg pain, especially with walking. Physical exam revealed minor erythema but also exquisite tenderness to palpation as well as with plantar flexion. Although cellulitis is clinically diagnosed, point of care ultrasound can be used to support it. The cobblestone presence is a result of edema between subcutaneous fat. Dr. Carlo Zamora, DO, PGY-1 Riverside Regional Medical Center Emergency Medicine Residency (Newport News, VA) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1729636606316-01RL72JHPZSEMSTLSO3E/image-asset.gif Soft Tissue - Cobblestoning in Cellulitis This is an example of “cobblestoning”. This patient initially presented to the emergency department with lower anterior leg pain, especially with walking. Physical exam revealed minor erythema but also exquisite tenderness to palpation as well as with plantar flexion. Although cellulitis is clinically diagnosed, point of care ultrasound can be used to support it. The cobblestone presence is a result of edema between subcutaneous fat. Dr. Carlo Zamora, DO, PGY-1 Riverside Regional Medical Center Emergency Medicine Residency (Newport News, VA) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727553752030-U53WDXD145S3XXLS7LHM/image-asset.gif Soft Tissue - Foreign Body - Wooden Cocktail Stick 35 year female presented to the Emergncy Department with a self harm retained foreign body in the left forearm. The foreign body was a wooden cocktail stick not seen on x-ray. POCUS easily identified the cocktail stick by it's acoustic shadowing which allowed removal under local anaesthetic. Repeat POCUS scan showed no other foreign bodies. Dr Pete Hulme @Dr_Pete_EmMed https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1721963860300-KP5U415MW0A4DBXLVIXO/image-asset.gif Soft Tissue - NEC Fas at Elbow Joint Middle-aged male who presented to the emergency department with fever and elbow pain, swelling and redness. Ultrasound placed over the soft tissue area showed dirty shadowing consistent with gas forming bacterial infection. Alexis Salerno, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1665674307385-C5O1ROBKS2BNS2KOT73P/image-asset.gif Soft Tissue - Necrotizing Fasciitis Following Puncture Wound A 56-year-old male presented to the ED for left leg pain after sustaining puncture wound to the foot 4 hours prior arrival. An ultrasound was performed which demonstrated fluid within fascial layers with dirty shadowing consistent with subcutaneous air at the center of the image. Nicmarie Maldonado, MD PGY-2; Eddie G. Rodriguez, MD; Miguel Agrait, MD; Michelle Surillo, MD - Division of Emergency Ultrasound, St. Luke's Medical Center/PHSU, Ponce, PR https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1720555324255-HZC30HMYN4ION3S59YIZ/image-asset.gif Soft Tissue - Subcutaneous Air in Necrotizing Fasciitis A middle aged male presented to the ED for left leg pain after sustaining puncture wound to the foot 4 hours prior arrival. The ultrasound image demonstrates free air causing dirty shadowing seen deep to the fascial plane obscuring the normal muscle architecture in the middle of the screen. Nicmarie Maldonado, MD PGY-2; Eddie G. Rodriguez, MD; Miguel Agrait, MD; Michelle Surillo, MD - Division of Emergency Ultrasound, St. Luke's Medical Center/PHSU, Ponce, PR https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1627326783902-3FHX1R2Y3Q6NJGX81TMI/image-asset.gif Soft Tissue - Foreign Body Removal Ultrasound guided removal of a wooden foreign body. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1706570546803-35AV7POGHV94G3IIL34W/image-asset.gif Soft Tissue - Soft Tissue Air in Necrotizing Fasciitis POCUS can help distinguish simple abscess from necrotizing fasciitis. “Dirty air shadowing” visualized in the clip suggests a necrotizing soft tissue infection. Dr. Farnam Kazi Ultrasound Faculty; Dr. Dimitri Livshits Ultrasound Fellow; Dr. Jane Belyavskaya Ultrasound Fellow (All at Kings County Hospital/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697824120370-N9SCQ4WKXGSL4J1MKR7P/image-asset.gif Soft Tissue - Necrotizing Soft Tissue Infection Of The Shoulder This is a transverse view of the anterior shoulder of a patient who presented to the emergency department with a fever and shoulder pain causing limited mobility. Looking closer, we can observe hyperechoic densities caused by air within the tissues, otherwise no signs of septic joint or bursitis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638981652294-QBFLB719BIRFCVFRUYUD/image-asset.gif Soft Tissue - Epiglottitis A 30 year-old female presented to the emergency department with high fever, severe sore throat and shortness of breath. POCUS of the neck was performed and revealed a swollen epiglottis, especially in the right side. Further X-ray of the neck revealed thumb sign and nasopharyngoscopy showed epiglottitis with swelling of right tongue base and arytenoid. Although the normal range of the epiglottis thickness measured by ultrasound varied from 2 to 3 mm in previous studies, significant swelling and thickening of the epiglottis on ultrasound may indicate epiglottitis. Chi-Hsin Chen https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1610643830987-JHJA6LAOZ40E4X9V3KE5/image-asset.gif Soft Tissue - Submandibular Sialolithiasis A male presented to the ED with submandibular pain and swelling. Ultrasound revealed a 0.942 cm stone within the submandibular gland. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625941308789-H9A119JNQ60SO6D24GPK/image-asset.gif Soft Tissue - Post Stab Wound Cellulitis This video shows a young man who presented 3 days after being stabbed to the arm. His wound had been sutured at the time but he had represented with erythema, pain and swelling to his forearm. POCUS showed cobblestoning consisent with cellulitis and excluded abscess and a foreign body. Peter Hulme Twitter: @Dr_Pete_EmMed https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623695318850-6G9A9AIANDSUL7CA0YQ2/image-asset.gif Soft Tissue - Not your classic blunt neck trauma: Case 12 hours after having a fall in her bathroom, an otherwise healthy 54 y/o female presented to the ED complaining of neck pain, dysphonia and difficult swallowing. Physical examination revealed hypertension, a HR of 109 bpm (sinus tachycardia) and 98% environmental O2Sat. She had no trouble breathing or speaking, although a coarse tone of voice was evident. Her skin revealed a mild linear abrasion with local upper right lateral neck swelling. A firm, tender submandibular mass was palpable. Neck ultrasound seen here revealed the trachea in a central position and the carotid arteries with no obvious signs of injury. Jugular vasculature was also studied and showed no adjacent fluid collections (not visualized in this clip). Sliding the probe to the right submandibular region revealed a well defined hypoechoic structure compatible with an enlarged salivary gland. Dr. Felipe Urriola & Dra. Daniela Gallardo Emergency Unit, Puerto Aysen Hospital. Chilean Patagonia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623694464904-MPBAOFJ80QUZDBVVRWTB/image-asset.gif Soft Tissue - Blunt Neck Trauma (doppler) Not your classic Blunt Neck Trauma: Doppler Color doppler shows an absence of flow in the deeper anechoic level and apparent indemnity in the glands vasculature. After the initial assessment, the patient remained hypertensive and tachycardia with HR of 120 bpm. Although there was no obvious worsening of airway status and no respiratory symptoms, the patient was referred to the regional centre for angio CT of the neck. This modality confirmed a right submandibular gland fragmentation with significant adjacent edema extending to the airway. There was airway midline deviation to the left and notable calibre reduction at the level of the hypopharynx. Dr. Felipe Urriola & Dra. Daniela Gallardo Emergency Unit, Puerto Aysen Hospital. Chilean Patagonia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623685660005-W9Z87IHN78I6FSUL9L3K/image-asset.gif Soft Tissue - Submandibular Gland Fragmentation Not your classic Blunt Neck Trauma: Submandibular Gland Fragmentation A closer look to the right submandibular gland reveals a deep end with heterogeneous borders. There is also significant edema and free fluid invading deeper structures. Dr. Felipe Urriola & Dra. Daniela Gallardo. Emergency Unit, Puerto Aysen Hospital. Chilean Patagonia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1540914191903-DRJBRG14A1NIA75OAT5C/foreign+body.gif Soft Tissue - Foreign Body Flexor Tendon Sheath 65 year old female with pain and swelling over 4th phalanx, no history of trauma. Hyperechoic density located above flexor tendon sheath. Patient sent to Ortho for surgical exploration. Dr. Magner https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1617894606253-DY1PH3QPJI1WDK4MPBZP/image-asset.gif Soft Tissue - Parotid Gland Malignancy A female patient with a history of Non-Hodgkin and Diffuse B-Cell Lymphoma presented for evaluation of subacute facial swelling. Physical exam revealed edema over the parotid gland without associated tenderness to palpation. POCUS seen here demonstrated hypoechoic and septated cystic lesions within the parotid gland, concerning for malignancy. This finding prompted further evaluation with CT that confirmed recurrence of malignancy. Lydia Mansour, DO, PGY2 Central Michigan University Emergency Medicine Resident https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616091572273-7V9NZM7S6OUE7048GC17/image-asset.gif Soft Tissue - Thyroid Inferno A patient with impending thyroid storm (BWPS score 25), an undetectable TSH level, and a T4- 4.2, had diffusely enlarged goiter. POCUS as shown here revealed hypervascular “thyroid inferno” that occurs in Graves disease, less commonly Hashimoto’s thyroiditis. Shane Solger https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614376911246-16V6XOM1XE6M4OHB49TR/image-asset.gif Soft Tissue - Cobblestoning in Cellulitis This image demonstrates the common finding of cobblestoning seen in cellulitis. Note the anechoic areas surrounding islands of subcutaneous tissue. Michael Macias, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614377374224-ER4JSXI0ED8ZXSY9G27I/ezgif.com-gif-maker+%2822%29.gif Soft Tissue - Large Soft Tissue Abscess This is an example of a large soft tissue abscess. Note the presence of a large well circumscribed fluid collection taking up the screen. Particulate can be seen throughout the fluid collection signifying increased density from purulent material. Michael Macias, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614377024375-AQGOEXIR0C1TK24ZF0MC/image-asset.gif Soft Tissue - More Cobblestoning in Cellulitis This image demonstrates the common finding of cobblestoning seen in cellulitis. Note the anechoic areas surrounding islands of subcutaneous tissue. Michael Macias, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613945218210-IWQQHM1S2UP5RYARLPPH/image-asset.gif Soft Tissue - Wood Splinter Foreign Body Wooden splinter in the fingertip of a patient. Ultrasound revealed the foreign body with posterior acoustic shadowing present. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613939712968-MYET409A0CAGB4X5DGPA/image-asset.gif Soft Tissue - Wooden Splinter Wooden splinter located in the distal fingertip. Ultrasound shows a halo indicative of edema surrounding the foreign body. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613939505312-O6WYJ5XRZXMGK4487CIS/image-asset.gif Soft Tissue - Foreign Body: Wooden Splinter Wooden splinter located in the fingertip originally diagnosed as felon. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613938793458-A614PA0LA3GV5EIJV9EK/image-asset.gif Soft Tissue - Foreign Body: BB within Hand Ultrasound image of a BB lodged within a patient’s hand. Note the comet-tail artifact often seen deep to many solid structures. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613938434080-D9F5NFX8M4QWTSCU34EL/image-asset.jpeg Soft Tissue - Foreign Body: Glass in the Patellar Tendon A shard of glass located superficially within the patellar tendon. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613945501523-0M7O35U2RNB3JPCU1B2I/image-asset.gif Soft Tissue - Broken Needle This is a short axis view of a needle that is broken off just posterior to the external jugular. Note the posterior acoustic shadowing. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613945883685-D7SYX79KL02P9ICI71ZI/image-asset.gif Soft Tissue - Glass FB in Extensor Tendon Ultrasound clip reveals a shard of glass broken off and lodged in the extensor tendon over an MCP joint. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613947082544-FEHTVJSO859Z7H84JJ14/image-asset.gif Soft Tissue - Bamboo Foreign Body Seen here is a fragment of bamboo broken off in a patients arm. Patient had negative x-rays, emphasizing the importance of POCUS in identifying radiolucent foreign bodies. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613947483411-CZYANWDADX3FY0S0XOCB/image-asset.gif Soft Tissue - Toothpick Foreign Body POCUS revealed a toothpick broken off in a patient’s heel in a long axis view. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614001375429-Z0F45MDCXQUG5E3813BC/image-asset.gif Soft Tissue - Toothpick Foreign Body Transverse view of a toothpick foreign body exhibiting posterior acoustic shadowing. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614009275481-DOH57KZ7ABOLF0Y83TZ2/image-asset.gif Soft Tissue - Foreign Body Removal POCUS guided foreign body removal of a wooden splinter in the distal volar finger using alligator forceps. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611615905319-LICMGJ6GA3WL5YQ54DFS/image-asset.gif Soft Tissue - Soft Tissue Foreign Body A patient presented to the emergency department following puncture by the tip of a palm frond. A puncture wound was noted with a palpable object under the skin. Soft tissue ultrasound was performed which demonstrated evidence of superficial foreign body as noted by the small hyperechoic structure with associated shadowing. The foreign body was successfully removed without issue. Image courtesy of The POCUS Atlas Team https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1608486010080-67XNLD6S3O9GB6MF4K03/image-asset.gif Soft Tissue - Epidermoid Cyst An adult male presented to the ED with a tender mass on his neck with overlying erythema. Ultrasound revealed an epidermoid cyst characterized by the pseudo-testis appearance of the cyst. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH Original Twitter Post can be found here. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609787859304-018XFYPFG092FSJJGMO2/image-asset.gif Soft Tissue - Image-Guided Needle Aspiration Needle aspiration of a fluid collection superficial to a femoropopliteal bypass. Wolfgang Geisser, @fentanyl05 Bayern, Deutschland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609878691337-Q1OVIDCR5JYHJFEMWZZK/image-asset.gif Soft Tissue - Parathyroid Mass A patient with clinical and laboratory evidence of hyperparathyroid function underwent POCUS of thyroid/parathyroid region. Seen here is a slightly hypoechoic rounded, vascular structure (imaged in both transverse and saggital planes) felt to represent the culprit lesion. Abdulmajid Mubarak, @mjed136 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594845085551-PJXWCVN02VGKURTXJ9KQ/ezgif.com-optimize.gif6.2.gif Soft Tissue - Suppurative Lymphadenitis A male presents with a left neck mass that is erythematous and edematous with a prior history of MRSA. Contemplating incision and drainage, ultrasound was switched to doppler flow. Doppler revealed increased flow surrounding an inner hypoechoic region suggesting suppurative lymphadenitis. Because of this, I & D was not indicated, and differential includes necrosis/hemorrhage into metastatic node. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592421192470-3I2AQ7AN0817GLA24U0A/image-asset.gif Soft Tissue - COVID-19 Thyroiditis An 18-year-old female with 2 week hx COVID presented to an outpatient clinic where labs included a TSH <0.01 and Free T4 6.75. She was sent to ED for further evaluation of tachycardia (HR 130 bpm). ED evaluation included POCUS that was notable for bilateral thyroid lobe enlargement without nodules, findings consistent with COVID-induced thyroiditis. Paul Khalil, PEM POCUS Fellow at Denver Health/University of Colorado @Khalil3Paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588178326908-8JGS5Y1LNU5EDYQ9HCWD/image-asset.gif Soft Tissue - Submandibular Abscess This is a submandibular view of a peritonsillar abscess. Color doppler is used to visualize blood vessels immediately deep to the abscess. By convention, the left side of the screen is posterior and the right side of the screen is anterior. Garrett Ghent, Resuscitationist/Diagnostician; Norfolk, VA @garrettghentMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1554692613487-GL7ES4Y1OBRHFT0YO3BV/necrotizing+fasciitis+.gif Soft Tissue - Necrotizing Fasciitis Hyperechoic gas (screen left) obscure the typical architecture of soft tissues (screen right). There is a small amount of edema in the superficial soft tissues. Dr. Bell https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1569010194501-TQCH3IW9BEV667IAFRRX/pre-patellar+bursitis.gif Soft Tissue - Intra-articular or extra-articular? Sometimes it's hard to tell if the knee is septic or just the bursa. Ultrasound can help. This image demonstrates a hypoechoic fluid collection ABOVE the patella consistent with pre-patellar bursitis. Image courtesy of IUEM Ultrasound Original Twitter Post can be found here. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1548548020851-LB11VQVLPNOXYHMOPGFK/ezgif.com-optimize.gif Soft Tissue - Soft Tissue Abscess The image below demonstrates a well circumscribed fluid collection in the soft tissue consistent with an abscess. Note the scattered punctate echogenic densities moving within the abscess fluid which suggest high cell/protein content of the fluid. Image obtained from 5 Minute Sono. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507308142466-0U1R6HM8YQNE9TYIJYZM/postop+sialadenitis.gif Soft Tissue - Sialadenitis (Postoperative) 55 y/o F with recent shoulder surgery 4 days prior, with three days of dysphagia and swelling under R jaw. POCUS reveals swollen submandibular gland with multiple hypoechoic areas, similar to cobblestoning, scattered through normal glandular tissue. CT demonstrated inflammation of submandibular gland and surrounding platysma with prominent ducts and an obstructing stone. Drs. Surriya Ahmad and John F Kilpatrick - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523825556067-EB6IPFGXNUY85RZHKXBH/ezgif.com-optimize+%2818%29.gif Soft Tissue - Sialadenitis Patient has painless left sided facial swelling and no dental issues. See left submandibular gland swelling with ductal dilation and hyperechoic density in the far field representing sialolith and surrounding inflammation sialadenitis. Dr. Dustin Morrow https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1546979692006-0YS16C8FZUAPKGQ69Z11/ezgif.com-optimize+%283%29.gif Soft Tissue - Subcutaneous Emphysema Air poorly transmits ultrasound waves and when fluids or solids interface with air, they lead to echogenic irregularities with comet tails that can often obscure the tissue behind it. Dr. Justin Bowra et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1546810545569-2TB7IV538VYXP4WQPCXK/images.jpeg Soft Tissue - Cobblestoning This is the classic appearance of subcutaneous edema which in the appropriate clinical setting (overlying redness and warmth) would be consistent with a cellulitis https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1546810716868-HOADENO4S87JVO8T9940/uotw66.swirl.gif Soft Tissue - Compression for Abscess Identification While typically an abscess will appear as a hypoechoic fluid filled structure, sometimes it can be missed as its echotexture is similar to other surrounding soft tissue structures. To improve sensitivity, gentle compression should be applied to identify a subtle abscess as seen above. Image obtained from Ultrasound of the Week. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523826105302-DPJ5VK2VNGJLQZKIAOM4/ezgif.com-optimize+%2819%29.gif Soft Tissue - Thyroid Storm (Inferno Sign) Thyroid Storm (Inferno Sign) Patient with a history of “glandular problems” as per the family presented from urgent care with confusion, slurred speech, tremors and fever. TSH was sent out. The patient was started on treatment for thyroid storm after color flow over an enlarged thyroid demonstrated the inferno sign. Patient improved on thyroid storm treatment. Infectious workup was negative. 48 hour T4 serial dilutions resulted at 2000. Dr. Dustin Morrow   https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534351642526-RIGTERE7ERQIK2PW0DI1/thyroid+left+lobe.gif Soft Tissue - Thyroid Left Lobe In this view we see half of the thyroid gland, which has similar echogenicity to the liver. The thyroid isthmus overlies the trachea, while the left thyroid lobe overlies the esophagus and is medial to the left carotid artery. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534352058396-T73OGP397WRQ0J6JZ2YO/thyroid+right+lobe.gif Soft Tissue - Thyroid Right Lobe In this view we see half of the thyroid gland, which has similar echogenicity to the liver. The thyroid isthmus overlies the trachea and it extends into the right thyroid lobe which lies medial to the pulsatile right carotid artery. Lateral to the carotid we see the right internal jugular vein. Superficial to the IJ and carotid we see the large sternocleidomastoid muscle; medial to that, superficial to the trachea and thyroid on the right side of the screen, are the strap muscles. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1535251437676-MMZOJ96GVAZ4CIF4AVSF/sciatic+nerve.gif Soft Tissue - Sciatic Nerve Here we see the tibial nerve and the common fibular nerve come together to form the sciatic nerve as the probe is moved proximally up the posterior aspect of the leg. The popliteal vein is seen deep to the nerves. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497405916457-5FO4GWL3Z7AWGI56TGM0/ezgif.com-gif-maker+%2828%29.gif Soft Tissue - Abscess Identification A patient with cerebral palsy and quadriplegia presented with her mother for evaluation of a fluctuant mass in her right axilla. Ultrasound imaging of the mass showed an abscess with multiple septations. The abscess was incised and drained, and the patient was discharged on antibiotics. Katy Van Donselaar, Emergency Medicine Resident Christopher Heberer, Emergency Medicine Resident Simhadri Botta, 4th year Medical Student https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1517503872390-KJ2HW6J3G9K7PEF7VN93/ezgif.com-optimize-5.gif Soft Tissue - Panniculitis Diffuse cobblestoning typically seen with cellulitis. In this case it is biopsy proven panniculitis. Dr. Gordon Johnson @pdxfutebol https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1517504134110-PPVDYZ2RGQ640UPSVLKJ/ezgif.com-optimize-3.gif Soft Tissue - Peritonsillar Abscess This is an example of a peritonsillar abscess as seen with a high-frequency endocavitary probe. About 3ml of pus was drained with significant relief. Notice that just deep to the abscess is big red. It's not always lateral! Dr. Jason Tanguay https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1511633510570-2KY9BIJM7PWPUJ8UDKR4/Sukh+-+PTA.gif Soft Tissue - Peritonsillar Abscess Some people like to know what they're aiming at before they stick needles in the back of people's throats. You can use an endocavitary probe for an intraoral approach... to make sure it's not just cellulitis. Your patient will thank you. As with any abscess, look for a relatively hypoechoic circumscribed area representing a collection of fluid. Sukh Singh, MD Caption: Matthew Riscinti, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507877427343-MGRT59X3LRXRNMNQLY4K/Facial+Tumor.gif Soft Tissue - Facial Tumor WCUME 2017 Submission for "Novel Indication" Face mass with bone erosion due to tuberculosis. Dr. Atim Uya - San Diego, California https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1548548554125-E1DFIOAGR0YUDY4OWL6Z/abscess.gif Soft Tissue - Atypical Abscess The image above demonstrates a well circumscribed fluid collection within the soft tissue, without evidence of surrounding cellulitis. The above abscess was incised with immediate release of a large volume of purulent material. The patient did well. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1548548745222-LR8R23Q8FSOEXH7GXU8U/ezgif.com-optimize+%281%29.gif Soft Tissue - Cobblestoning in Cellulitis This image demonstrates anechoic fluid surrounding islands of soft tissue. In the setting of infectious signs and symptoms this is consistent with a cellulitis. Image obtained from 5 Minute Sono. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1615658662714-VYQ8J67EJD8XMJ8FT17X/image-asset.gif Soft Tissue - Inguinal Lymphadenitis A 30s F presented with L groin pain and swelling. On exam she had pain and focal soft tissue swelling over her inguinal crease. POCUS was performed which demonstrated this enlarged lymph node, suggesting lymphadenitis. In this clip, the lymph node is shown using color doppler, which shows a small amount of flow at the lymph node hilum, without other areas of flow in the node. In the last part of the clip, compression with the probe does not change the shape of the node, differentiating it from an abscess or cyst. This patient was treated symptomatically and discharged with outpatient follow up of her lymphadenitis. Dr. Stephen Wolf Denver Health Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616226957677-2QDSEII7IFXRUHKRTV03/image-asset.gif Soft Tissue - Supraclavicular Lymphadenopathy This is a 60s y.o. gentleman w/ PMHx remote axillary abscess who was found to have a nontender supraclavicular mass. When scanning medial to lateral in the supraclavicular fossa, the mass is revealed to be a ~3x4cm lymph node. The wedge shaped hypoechoic structure seen represents the hilum, and color doppler reveals organized blood flow. Peripheral hypoechoic regions may represent necrosis. These findings are suspicious for malignancy vs reactive lymphadenopathy. Dr. Geoff Hogan Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623094476188-OAGEMGRWYDSCU85I0O6J/image-asset.gif Soft Tissue - Group A Strep Necrotizing Fasciitis A 60s M with multiple medical co-morbidities including type 2 diabetes mellitus with multiple prior toe amputations, CHF, COPD and chronic alcohol abuse presented with rapidly worsening leg pain after minor trauma the day prior to presentation. He was in significant pain and had a warm, red, and edematous lower extremity with a focal wound overlying the anterior lower leg. He was febrile and tachycardic, but normotensive. He was resuscitated and given broad spectrum antibiotics and rapid surgical consultation was obtained. POCUS of the affected area was performed and is shown here. In these longitudinal views of the affected area, cobblestoning is seen superficially, indicating cellulitis. Fluid is also seen tracking more deeply along the fascial planes, just superficial to the muscle. This patient was taken emergently to the OR where debridement confirmed necrotizing fasciitis without involvement of the underlying muscles. The patient was kept in the surgical ICU for further resuscitation, his blood cultures and tissue culture became positive for Group A Strep pyogenes, and he underwent multiple subsequent debridements for further management. Dr. Phil Breslow, PGY2 and Dr. Anna Engeln Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1624063290618-KFPQC4HDBB5VROY5SE8V/image-asset.gif Soft Tissue - Peritonsillar Abscess A 20s F with PMH of prior peritonsillar abscess presented with about 1.5 weeks of sore throat, and had been maintained on oral antibiotics with no improvement. Her PCP identified a PTA on clinical exam and referred her to the ED for drainage. This US clip demonstrates the peritonsillar abscess, with an area of hypoechoic, heterogeneous fluid. Posteriorly (far field or bottom of image), the carotid artery is seen pulsating. US in preparation for PTA I&D is particularly helpful in determining the size of the abscess and location of the carotid artery, allowing proper measurement of the plastic guard on the aspiration needle, to prevent inadvertently deep puncture. Dr. Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626833800379-YUMBT0U9VOC3DP1YW56H/image-asset.gif Soft Tissue - Peritonsillar Abscess Drainage 30s F presented with a week of sore throat which had not improved despite corticosteroids and antibiotics. She was referred to the ED by her primary care provider who noted asymmetric swelling in her throat and had concern for peritonsillar abscess (PTA). Evaluation in the ED confirmed this finding, and POCUS was performed, demonstrating a large PTA. The first half of this clip shows a transverse view of the peritonsillar space, where a circumscribed heterogeneous hypoechoic region is seen superficially, which is the PTA (*). Color doppler identifies the carotid artery posterior to the PTA, a critical structure to identify to prevent inadvertent arterial puncture or laceration. The second half of the clip shows the PTA after needle aspiration of 15cc purulence, demonstrating a collapsed abscess cavity with scattered air and significantly reduced abscess size. The patient had immediate relief of her symptoms after needle aspiration, and was discharged with antibiotics and outpatient ENT follow up. Dr. Michael Heffler, PGY-4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1702414278047-0ETHQQRL4NFPIYH6MUAA/PTA_Hanson+Netto.gif Soft Tissue - Peritonsillar Abscess with Posterior Color Flow A 24-year-old male presented to the ED with 3 days of fever, headache and sore throat. On exam he was noted to have oropharyngeal erythema with a fluctuant area in the left peritonsillar region. A POCUS was performed of the area using an endocavitary probe, revealing clear circumscribed hypoechoic region without internal color flow. Aspiration of the PTA was performed with moderate purulent drainage. Dr. Elizabeth Hanson, Denver Health Emergency Medicine Alexandra Netto, PA, Denver Health Emergency Department https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644871722316-TOXXERT2N32ZPXA75S0P/image-asset.gif Soft Tissue - Deep Cellulitis with Phlegmon 20s M with PMH IVDU presented with R elbow wound for a few days. On exam, there was a focal wound with purulence near the R elbow with extensive erythema, induration, and tenderness to the R forearm and distal upper arm. The patient was hemodynamically stable. Labs were concerning for a markedly elevated white blood cell count and CRP. Given the clinical concern for necrotizing soft tissue infection (NSTI), POCUS was performed of the affected area. Shown here, the POCUS demonstrates extensive cobblestoning with fluid seen along the fascial planes superficial to the muscle. Orthopedic surgery was consulted with concern for NSTI, and performed a bedside I&D which did not suggest NSTI, and the patient was admitted for IV antibiotics and management of the severe cellulitis. Dr. Nhu-Nguyen Le, Ultrasound Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1627327769097-M2IQQZ7WOYFOZ65LWGNL/image-asset.gif Soft Tissue - Submandibular Sialolithiasis Patient with submandibular swelling was found to have a stone obstructing the submandibular duct, noted as a hyperechoic structure. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1648835006386-BIWETKQI3SED52A9Q7XV/NB+hyperthyroid.gif Soft Tissue - Pediatric Thyrotoxicosis A 23mo F with PMH known Graves disease presented with a 10min generalized tonic/clonic seizure. IM Versed en route stopped the seizure. The patient was given 2 mL/kg D10 for hypoglycemia but remained hypoglycemic and refractory to D10 boluses. She was afebrile and not felt to be in thyroid storm but there was concern for thyrotoxicosis with adrenal insufficiency. POCUS was performed to asses cardiac function due to elevated pulse pressures of 60-70 mmHg and the risk of high-output failure risk, although cardiac POCUS was reassuring and clinically the patient didn’t fit high-output failure. Thyroid POCUS was performed after the TSH resulted at 0. The exam is shown here with diffuse increased flow in the thyroid, consistent with thyrotoxicosis and Graves disease. The patient received stress dose steroids (but was already on propranolol and methimazole) and was admitted for definitive management. Dr. Anthony Rodriguez, PGY1, Denver Health Residency in Emergency Medicine Dr. Cailin Frank, Ultrasound Fellow, Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1649185546057-21UYAA6SOIXTCVYUXS2F/image-asset.gif Soft Tissue - Glass Foreign Body Removal A teenaged female presented with a retained foreign body after she laid on top of a broken glass hand mirror. She removed one glass shard prior to ED arrival but one piece remained that she could feel under her skin. On exam, there was a tiny laceration but a 1-2 cm palpable foreign body under the skin. Blind foreign body removal under local anesthesia was not successful, so POCUS was employed to aid in visualization of the foreign body. A linear hyperechoic foreign body is seen in this clip, and was able to be removed under real-time US guidance using forceps and a hemostat. Repeat POCUS showed complete removal of the foreign body, and the patient was able to be discharged. Dr. Keren Eyal, PGY1, Children’s Hospital Colorado Pediatric Residency Dr. Michael Heffler, PGY4, Denver Health Residency in Emergency Medicine Dr. Nhu-Nguyen Le, Fellow, Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1657912749862-QO7ENUR7H4350P8QA4T4/CF+PTA.gif Soft Tissue - Tonsillar Abscess A teenaged female presented with sore throat and was noted to have asymmetric tonsillar edema on physical exam. POCUS was performed using an endocavitary probe intraorally. The findings are shown here, with edema of the tonsil and a small circumscribed area of hypoechoic fluid which has no color doppler signal. This indicates tonsillitis with a small tonsillar abscess. Given this patient’s physical exam and small size of the abscess, conservative management was recommended with oral antibiotics without incision and drainage in the ED. Dr. Cailin Frank, Fellow, Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678810487960-8WJW120C30GYHRT4TLPU/netto+mccabe+bartholin+cystabscess.gif Soft Tissue - Bartholin's Gland Abscess 20s F with past medical history of multiple bartholin gland abscesses requiring drainage presented with genital pain and swelling. I&D of the abscess was attempted which was initially unsuccessful, so POCUS was performed to confirm the location of the abscess. Gynecology was then consulted for drainage and was able to successfully drain the abscess. Alexandrea Netto PA, Denver Health and Hospital Authority Katie McCabe MD, Attending Physician, Denver Health Residency in Emergency Medicine https://www.thepocusatlas.com/lung daily 0.75 2025-02-07 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735416158949-FDODBCMFUGONKJ4UCKX5/image-asset.gif Pulmonary - Lung Cavitary Lesion HIV+ male patient presents with cough and shortness of breath. Thoracic US demonstrated a left upper lobe cavitary lesion with calcifications. Differentials included TB, aspergilloma, lung abscess. Contributors: Sara Schambach, MD; Garrett Mason, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735416158949-FDODBCMFUGONKJ4UCKX5/image-asset.gif Pulmonary - Lung Cavitary Lesion HIV+ male patient presents with cough and shortness of breath. Thoracic US demonstrated a left upper lobe cavitary lesion with calcifications. Differentials included TB, aspergilloma, lung abscess. Contributors: Sara Schambach, MD; Garrett Mason, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1728887216757-BUO7FRF8L47HBM1A9WGE/image-asset.gif Pulmonary - Snowstorm Sign in Endotracheal Intubation This is a clip of a cervical airway view during intubation attempt. Some artifact is visible in the trachea when passing the tube demonstrating a "Snowstorm Sign" which can be used to confirm the position of an endotracheal tube. In this view it is possible to see the esophagus next to the trachea. As demonstrated there is no motion detected in esophagus during intubation therefore confirming tracheal intubation. Contributor: Renato Tambelli (@R_Tambelli @Jedipocus) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1728168668022-HVV7LT4K55HZ4IPSWSWY/image-asset.gif Pulmonary - Lung Point Finding Lung point is a pathognomonic finding on US for pneumothorax. It refers to the junction between healthy lung and collapsed lung. This is represented in the US recording as lung sliding seen on the left of the pleural line but no lung sliding seen on the right of the pleural line. Contributors: Dimitri Livshits, DO; Jane Belyavskaya, MD; Chris Hanuscin, MD Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1737046097714-SA7PELSU5OM0Z972IERL/image-asset.gif Pulmonary - Large pleural effusion with hiatal hernia 72 year old with past medical history of hiatal hernia presenting to the ED with new onset shortness of breath requiring rescue BPAP. She was diagnosed and treated with CHF exacerbation. Lung ultrasound showed a large pleural effusion with uncertain mass-like object with heterogenous fluid contents on the right (shown here), along with dense B-lines. Correlation with prior CT suggested that the structure on the right chest was a large hiatal hernia. Contributed by: William McGill, PA-C https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1721964417985-CXNAF6GKWZF4140SDOAT/image-asset.gif Pulmonary - Subpleural Consolidation with Shred Sign Patient admitted to ICU with sepsis of unknown origin. Complaints of tachypnea led to ultrasound scanning, which showed a subpleural hypoechoic image in the posterolateral region of the left chest compatible with pneumonia. Contributed by: @intensivanaveia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1721964856035-3IBDVRWCLYV514P0KHKI/Massive+dynamic+air+bronchogram++-+Rafael+Intensivanaveia.gif Pulmonary - Massive dynamic air bronchogram Massive lung consolidation in a patient diagnosed with COVID-19 with bacterial component. Contributor: Rafael Intensivanaveia - Critical Care Physician at Hospital Israelita Albert Einstein https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735037422893-MMGEHX6D4CFUEC55GYJA/image-asset.gif Pulmonary - Pleural Effusion with Compressed Lung and Spine Sign Pleural effusion with compressed lung and positive spine sign Contributed by: Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1660318530325-P9UBT29O9YR3PBCRGYBJ/image-asset.gif Pulmonary - Subpleural Consolidation in COVID-19 Subpleural consolidation (shred sign) in a COPD patient with Covid 19, admitted to the ICU with acute respiratory failure progressing to intubation and mechanical ventilation. Contributor: Bruno Souza @BrunoSo03038122 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1660102684819-O1999NZJFL3MFNV1O591/image-asset.gif Pulmonary - Lung Point in Iatrogenic Pneumothorax Lung ultrasound in the right apical region after puncture attempt for central venous access. The image demonstrates a LUNG POINT, a specific sign of a pneumothorax. Contributed by: Breno Moura https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1723579108366-S9B2NYM8X4RBA9U9F2HK/image-asset.gif Pulmonary - Color Doppler of Consolidation in Pneumonia Massive lobar consolidation showing pulsatile flow on color doppler, befitting pneumonia. Contributor: Rafael Intensivanaveia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1679275459962-UG3H6QOOXRJ40AHI72YL/image-asset.gif Pulmonary - Lung Re-expansion With Pigtail Catheter Pictured here is an amazing return of observable lung sliding as a pigtail catheter is advanced through. Reestablishment of lung sliding indicates lungs have re-expanded. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1670121643887-KKAYZ3BRNU5KOH3H9M6X/image-asset.gif Pulmonary - Lung Consolidation from Bronchial Obstruction This is an image demonstrating dense lung consolidation with surrounding pleural effusion. Patient ultimately was diagnosed with bronchogenic CA with complete bronchial obstruction. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644435055930-O8CPGFL8A2KJVKR2DV3A/image-asset.gif Pulmonary - Lung Slide M-mode Lung Sliding with M mode; looking like a seashore. Mary Fran King https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638992470246-XFRCYIFPQ8600P0AIMYJ/image-asset.gif Pulmonary - Septated Pleural Effusion 76yo male with shortness of breath on exertion, w/o fever or other signs of infection. POCUS showed a large septated unilateral pleural effusion. Note the irregular and thickened pleura adjacent to the diaphragm (right). Thoracentesis was only partially successful with a large residual effusion after drainage of 1000ml of exudative fluid with signs of lymphocytic inflammation w/o malignant cells on cytopathologic analysis. Thoracoscopic biopsy confirmed the diagnosis of a pleural mesothelioma 60 years after exposure to asbestos. The presence of a septated complex effusion is 94% specific for an exudative effusion and warrants further investigation (Shkolnik, 2020). Cytopathology of pleural fluid is often negative in malignant mesothelioma and pleural biopsies are needed to confirm the diagnosis (Porcel, 2014). Victor Speidel Langenthal Regional Hospital, Switzerland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638995871207-7RQE6JKDWS3VPI1V3EZM/image-asset.gif Pulmonary - PLAPS consolidation 23 yo male, comes to Emergency Department with cough, fever and dyspnea. Lung Ultrasound in the right PLAPS point show this beautiful image: a large consolided lung with dynamic air bronchograms - numerous tortuous hyperechoic opacities that move with the respiratory cycle. This finding has a specificity of 94% and a positive predictive value of 97% for pneumonia as the cause of the consolidation. Renato Tambelli @JediPocus @R_Tambelli https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638986572542-7K6YWUJSONH5BU6SKRLT/image-asset.gif Pulmonary - Pneumonia A 22-year-old patient without a medical background presents to the ED with a 2-day history of left costal stabbing pain. There was no shortness of breath nor fever and barely any respiratory symptoms. Lung ultrasound revealed a thick, interrupted pleural line and a mobile, hypoechoic structure with irregular edges compatible with a consolidation. Covid PCR was negative. Dr. Felipe Urriola P. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638982382882-RSI4OWTIE7AGZPPSADF8/image-asset.gif Pulmonary - Lung Point 18-year-old patient who presented following a motorcycle accident in which he sustained closed chest trauma with bilateral hemopneumothoraces. In this sequence taken with a linear transducer in left pulmonary zone 1, the "pulmonary point" indicative of pneumothorax can be seen. Libardo Valencia Chicue https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625844429315-LKZXZ7W1TBK4HQVL3WWI/image-asset.gif Pulmonary - Pericardial & Pleural Effusions Seen here is a subxiphoid view taken from a patient admitted with symptoms of acutely decompensated heart failure. You can appreciate both a small pericardial effusion as well as a more noticeable pleural effusion. Reyna Huerta Sánchez, MD @DraHuerta09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625942016886-73GCR111Z9IYWIFWJT4Y/image-asset.gif Pulmonary - No Lung Sliding This image demonstrates lack of lung sliding which is a finding that can be seen in a pneumothorax. Francisco Norman https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625842963769-CFQZXYNGK6KG42FE7KNR/image-asset.gif Pulmonary - Parapneumonic Effusion Right lower lobe pneumonia with lobar atelectasis and pleural fluid accumulation. These ultrasonographic findings are collectively referred to as jelly fish sign. This anechoic parapneumonic effusion measured 2.5 cm on ultrasound, and chest tube insertion resulted in drainage of 800 mL of clear fluid. Gábor Csupor https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614448831237-1WUES6VSKC1P2Q7M17E9/image-asset.gif Pulmonary - Lung Pulse Lung ultrasound reveals absent lung sliding with intermittent lung pulse seen. These findings are consistent with pneumothorax. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625843871527-WW3O3V2UVH4CWX66OC8A/image-asset.gif Pulmonary - Large Pleural Effusion Patient presented to the emergency room reporting dyspnea. POCUS revealed presence of severe ascites and pleural effusion. Reyna Huerta Sanchez, MD @DraHuerta09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623696648650-GGH60B96J3FIDG2CCG5P/image-asset.gif Pulmonary - Air Bronchograms Seen here are dynamic air bronchograms obtained via POCUS on a patient in whom we had clinical suspicion of a diagnosis of pneumonia. Francisco Norman https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616439360649-RDJ6FVILDYXTB2NSQRPL/image-asset.gif Pulmonary - Pneumothorax with Lung Point A patient presented with spontaneous pneumothorax; lung point identified on POCUS. ChunYi Tsai, @jerry1231213 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614449096995-WOK26ZVSEEI4XLQ2JYLB/image-asset.gif Pulmonary - Lung Re-expansion POCUS reveals the return of lung sliding following insertion of a chest tube for pneumothorax. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611515698389-ACXR2Q526YUPF1G9XR5Z/image-asset.gif Pulmonary - Malignant Pleural Effusion A patient with a history of lung cancer presented to the ED with a fever and hypotension. Subcostal window revealed a septated large malignant pleural effusion. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611517283226-9ELGE825XRTVRLCE9R6N/image-asset.gif Pulmonary - B Lines with Irregular Pleura Irregular pleural line with patchy B-lines. Seen in viral (including COVID19) and bacterial pneumonia. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611517522605-R61D2FOSKXPCUIAMUNGK/image-asset.gif Pulmonary - Pneumonia-Subpleural Consolidation Irregular pleural lining, B lines, and subpleural consolidation best seen with a linear probe. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611517686202-0KE7AXEGXSQ1PG87GLZX/image-asset.gif Pulmonary - Normal Lung Sliding Normal lung sliding with regular appearing pleural lining. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611517779862-87Z89G793Q7GL9K7X1ET/image-asset.gif Pulmonary - Pneumonia-Parapneumonic Effusion Large echogenic right parapneumonic effusion in patient with bacterial pneumonia/sepsis. Phased array probe used. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611517894259-WFR5OG1TI36QY9NLU5NZ/image-asset.gif Pulmonary - Pneumonia-Parapneumonic Effusion Small right anechoic parapneumonic effusion. Note B-lines seen at lung base. Curvilinear probe used. More commonly seen in bacterial pneumonia. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611518013836-NDHZKQTP1043TVAIM8ZX/image-asset.gif Pulmonary - Pneumonia-Shred Sign The shred sign is a sign of consolidation in the lung that appears as subpleural hypoechoic areas with an irregular “shredded” border. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611518181302-NWPRS70MPRAW3D89G0OX/image-asset.gif Pulmonary - Pnuemonia-Thickened Pleura Increased thickness of the pleura with diffuse B-lines can be seen in this patient with pneumonia. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614172778387-MEU01GEVPS03HFNV2EAF/image-asset.gif Pulmonary - Lung Re-expansion Initially, this clip reveals a lack of pleural sliding in a patient with a pneumothorax. POCUS was used to reveals the return of lung sliding as the visceral and parietal pleura approximate following chest tube insertion. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607080270713-0Q8Z2WCD3Y6XEMA5HVTV/image-asset.gif Pulmonary - Air Bronchograms in LLL Pneumonia Dynamic air bronchograms present in a patient with left lower lobe pneumonia. LLL shows signs of hepatization. Find a labeled image at the original post here. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1603200922278-MPZDZZC1OWROM8WC6S0J/image-asset.gif Pulmonary - COVID-19 Pneumonia Seen here is an irregular and thickened pleural line with associated focal and confluent B lines in a patient with COVID-19 pneumonia. Edgar Miranda https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1600979207450-352J1YHRFVJ7J8O2R35I/image-asset.gif Pulmonary - Unexpected Jellyfish Seen here is an unexpected finding while acquiring an apical 4 chamber view with a phased array probe. The four chambers of the heart are difficult to bring into view due to the presence of large left pleural effusion with ipsilateral collapsed lung floating within the pleural fluid. This visual of atelectatic lung swimming within a pleural effusion is referred to as “jellyfish sign”. Renato Tambelli, Emergency Physician Hospital das Clínicas de Marília, Brazil. @R_Tambelli // @JediPocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601060487950-I7WEJV1JDRQKS7II9OLH/image-asset.gif Pulmonary - Dynamic Air Bronchograms Pictured here are dynamic air bronchograms in a patient with bacterial pneumonia. Image was acquired using convex probe on the left PLAPS. Renato Melo, PocusJedi co-founder, Emergency Physician HC Marília-SP, Brazil. @Renato_Melo_ https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1600977882769-D559Q5589PCIQL2192JK/image-asset.gif Pulmonary - Pulmonary Contusion A 23-year-old male was admitted to the ED following a motorcycle accident. He subjectively reported dyspnea; objectively was hypoxic. POCUS seen here (obtained from L3 zone using curvilinear probe) reveals multifocal B-lines consistent with pulmonary contusion. This case illustrates that bedside US is useful beyond diagnosing pneumothorax and hemothorax in trauma patients. Renato Tambelli, Emergency Physician Hospital das Clínicas de Marília, Brazil. @R_Tambelli / @JediPocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1600785921991-7HYPJ12CHLF8MQ6PM7HI/image-asset.gif Pulmonary - Light Beam Sign This image was taken from a 58-year-old man with cough and fever x 8 days who tested positive for SARS-CoV-2 Virus. Pictured here is a POCUS view (R3 Zone) obtained in oblique position with a curvilinear probe. Appreciate the lung sliding, regular pleural line, and alternating multiple separated B-lines and A-lines; this constellation of findings is referred to as “Light Beam Sign”. Renato Tambelli, Emergency Physician, Hospital das Clínicas de Marília, Brazil @R_Tambelli / @JediPocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1596742464674-GMII543HMJEUL6QL11R9/image-asset.gif Pulmonary - Hepatization of Lung Patient presented with septic shock. POCUS was used to assess for etiology in this hemodynamically unstable patient. Shown here is a lung US windows (patients LLL) revealing a consolidation pattern with echoginicity similar to liver, referred to as “hepatization” of the lung. These findings are consistent with a diagnosis of pneumonia. Johannes Achenbach https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1596727704970-PGAN0ER9P96OK9TJH3GO/image-asset.gif Pulmonary - Jellyfish Sign A middle age man presented with a subacute dyspnea, orthopnea, non productive cough, and paroxysmal nocturnal dyspnea. Physical exam was notable for bilateral, fine, end-inspiratory crackles over the lung bases; an S3 on cardiac auscultation; and an SpO2 of 92% on 2L nasal cannula. POCUS identified the presence of atelectatic lung in an anechoic large right-sided pleural effusion. The sonographic appearance of atelectatic lung "swimming" within a large pleural effusion is often referred to as “jellyfish sign”. Subsequent laboratory evaluation of the pleural fluid confirmed a transudative effusion secondary to decompensated left-sided heart failure. Al Chalaby, Shahad. PGY3. Highland Hospital. Alameda Health System Internal Medicine Residency Program. @shahad_Chalaby https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1516115148732-GXZ0W4TGSF2E08DAXBFI/normal+lung+slide+riscinti.gif Pulmonary - Normal Lung Slide To assess for lung slide, look between two ribs. The two layers of pleura can be seen as the hyperechoic, shimmering line just under the subcutaneous tissue. This represents the sliding of the parietal and visceral pleura. Normal lung slide should have: Shimmering aka "ants marching" This may be augmented by m-mode as pictured in another post. Dr. Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527653744461-9JV9FLATDWL00GOWJIZ3/a+lines+normal.gif Pulmonary - A - Lines - Normal Lung A lines appear as horizontal lines that represent normal aerated lung (dry interlobular septa). They are a reverberation artifact caused by the sound waves bouncing off the highly echogenic pleura and back to the probe, and repeating. Hannah Kopinski (MS4) and Dr. Lindsay Davis - NYU Emergency Medicine, Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594126991660-EPJ874V1T8OOLMISX11A/image-asset.gif Pulmonary - Normal lung Lung ultrasound of a normal lung. Note both lung slide (shimmery, hyperechoic line on top of the screen, a result of parietal and visceral pleura sliding against each other) as well as multiple parallel A-lines (normal artifact from reverberation of the pleural line). The presence of lung sliding and no more than 3 B lines on lung ultrasound help exclude inersitital pulmonary edema and pneumothorax. Shahad Al Chalaby, MD. PGY-2, Internal Medicine Highland Hospital, Alameda Health System Internal Medicine Residency Program. CA, USA @shahad_Chalaby https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592322503366-VFX7H2SX2FGTJ4SJ53QC/image-asset.gif Pulmonary - Lung Windows This still-shot image captures the differences in view as obtained using a linear vs curvilinear to assess a lung window. Submitted by Anibal Artero @ECOPULMONAR https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1591668495269-3KP8KQOKFBTFXLXXLPR8/ezgif.com-optimize.gif1.gif Pulmonary - Double Lung Point Seen in Pneumothorax A young male presented to ED with stab wound to chest. Upright CXR was normal. POCUS showed double lung point indicative of small PTX. This was monitored without evidence of progression. No intervention was required. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1591370758333-EZ02DLJT3GM4QBCI5ANT/image-asset.gif Pulmonary - Light Beam Sign (COVID-19) Seen here is a "Light Beam Sign" in a patient with COVID-19 pneumonia. The on-and-off effect of the hyperecchyoic vertical artifact is believed to occur as a result of ground glass alterations in lung parenchyma. At times the light beams or B-lines cover A-lines; and at other times the A-lines remain visible in the background. Renato Melo, Emergency Physician at Hospital das Clínicas de Marília-SP, Brazil. Co-founder of Pocus Jedi @Renato_Melo_ https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588176162850-IA960ZJ0Y3OQW66C7IHF/image-asset.gif Pulmonary - Atypical presentation COVID-19 An elderly male presented from home with complaints of mild confusion, non-specific abdominal pain, and a 3-day history of dyspnea. He required no supplemental oxygen. 12-lung zone ultrasound was performed using the linear transducer. Zone R5 revealed the pictured confluent B-line pattern and small areas of consolidation. Patient subsequently tested positive for the SARS-CoV-2 virus. Cian McDermott, Emergency Physician Dublin, Ireland @cianmcdermott https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588253162652-3L4EIL5I5BCH5JXWOGEQ/image-asset.gif Pulmonary - COVID-19 Pneumonitis Patient presented to the Emergency Department with 2-day history of worsening dyspnea and increased work of breathing. He was profoundly hypoxic upon arrival with EMS (O2 sat on 2L via nasal prongs was 42%; improved to 75% upon switching to high flow nasal cannula at 40L/min). A 12-zone lung ultrasound was performed using a linear probe and what is pictured is from L6 (left inferior posterior zone). You can appreciate the coarse irregular pleura, patchy B-lines, and and small areas of consolidation. Findings are typical for clinically-suspected COVID-19 pneumonitis. Cian McDermott, Emergency Physician; Dublin, Ireland @cianmcdermott https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584987646246-BUZTHOJP24DC7BMHMO1C/image-asset.gif Pulmonary - Pleural Shred Sign Seen here is a pleural shred sign (discontinuity of a thickened pleura) and B-lines. Images were acquired from the LLL BLUE point on a patient who presented with fever and purulent discharge from tracheostomy site; all findings consistent with diagnosis of pneumonia. Renato Melo, Emergency physician, H.C. de Marília-SP, Brazil @Renato_Melo_ https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584976843039-C4FY78JJDRCEATFD7ZZY/image-asset.gif Pulmonary - PLAPS pneumonia This is a lung ultrasound image in PLAPS view in which we appreciate a consolidation pattern including dynamic air bronchograms as well as a small pleural effusion. The PLAPS view with these findings is a highly sensitivity and specificity for the diagnosis of pneumonia. Renato Tambelli, Emergency Physician Hospital das Clínicas de Marília @R_Tambelli https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584125093995-60LM68WG998XJM0HYJZK/image-asset.gif Pulmonary - Jellyfish Sign This a PLAPS-point view located slightly above the diaphragm. This window is a key component of lung ultrasound evaluation for pleural effusion. This image reveals what is know as "Jellyfish Sign,” or consolidated lung floating in anechoic fluid (pleural effusion). Also note the static air bronchograms within the lung parenchyma. Renato Tambelli, Emergency Physician from Emergency Department of Marilia Clinics Hospital - Sao Paulo/ Brazil @R_Tambelli https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1578262388158-S6ITRAXWVGXGG85YBUO3/image-asset.gif Pulmonary - Improve Lung Sliding Visualization Normal lung sliding becoming more visible with decreased gain. Aaron Inouye - @PAintheED https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1530459910968-FSHJYRZAS7MX6UGYDK3O/Decreased+Lung+Slide+Pneumothorax.gif Pulmonary - Decreased Lung Slide - Pneumothorax 26 yo male presents to ED stating he was kicked in the chest. He went home to “try to relax and smoke some weed” now short of breath and with pleuritic chest pain after smoking. POCUS demonstrating decreased lung slide on the left. What are the signs of pneumothorax on ultrasound? Decreased lung sliding - In normal lungs, lung sliding refers to the parietal pleura moving against the visceral pleura - described as “ants marching.” Lack of B-lines or comet tails – These artifacts will not be present if there is a pneumothorax and the presence of B-lines or comet tails can rule out a pneumothorax. No Lung pulse – the visceral pleura moving along a stationary parietal pleura due to cardiac motion when lung sliding is not present. These are so called “T lines” on M-mode. These signify that the parietal and visceral pleura are opposing one another and therefore that there is no pneumothorax Lung point – 100% specific for pneumothorax, this is the cutoff point above which you can appreciate the lung sliding and below which there is no lung sliding. The lung point is the pneumothorax border. Dr. Stacey Frisch, Dr. John F Kilpatrick - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1504715986493-6CRPHIQGW5FX8WC00W1P/roseman+ptx.gif Pulmonary - Pneumothorax: M-mode: Seashore vs Barcode 46 y/o M with 20 pack year smoking history with sudden onset right sided chest pain that woke him from sleep. Decreased breath sounds on right side. POCUS with decreased lung slide (right of image) with normal lung slide in left lung (left side of image). Lung slide can often be appreciated by watching the pleural surfaces move along each other but if you're uncertain, putting the US in m-mode and looking for the classic "seashore sign" (left image) versus the "barcode sign" (right image) can help you figure it out. Dr. Eric Roseman - Resident Physician, Kings County Emergency/Internal Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515167606856-CQ3Q9ZEWEBX6Q0G3OIOQ/riscinti+lung+point.gif Pulmonary - Lung Point: Pneumothorax Trauma code to the waiting room... 20 y/o male stabbed to the left chest in the midaxillary line. Patient thrown in a wheelchair and pushed to the resuscitation room and POCUS performed immediately revealing this image: the lung sliding disappearing revealing an area without lung slide. Moved up one rib space to the apex, no lung slide at all. This junction of slide/no slide is the lung point and its pathognomonic for pneumothorax. It represents the exact point where air begins to separate the parietal from visceral pleura, aka the junction of where we normally see the "ants marching" or the "shimmering" aka the lung slide. This is highly specific. Don't be fooled when you see the sliding with decreased sliding around it. You're looking at a pneumothorax.   https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1582734705129-A0EQS3R1JJ5NATUSI1IS/image-asset.gif Pulmonary - Lung Point A young man presents to the emergency department with multiple thoracic stab woulds. POCUS quickly identifies absent lung sliding as well as a lung point; findings highly sensitive and specific for our diagnosis of pneumothorax. Renato Tambelli, @R_Tambelli Emergency Physician Hospital das Clínicas de Marília https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579515750287-D3XOIUIBRM3YEYZV3EJP/image-asset.gif Pulmonary - Ultrasound Findings in Pulmonary Contusion In this patient with history of blunt chest trauma, lung ultrasound reveals a focal area of B-lines as well as a hypoechoic wedge shaped subpleural consolidation. These findings are consistent with pulmonary contusion and can be identified early in the course of a patient’s care. This contrasts with hours-to-short-days that it often takes to fully appreciate the evolution of pulmonary contusion on chest X-ray. Aaron Inouye, PA-C, North Canyon Medical Center @PAintheED https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579192545463-0HXZQSGW8W4DO7YKDDYM/image-asset.gif Pulmonary - Classic Findings in Pneumonia Pictured here are classic ultrasound findings for pneumonia including a shred sign, lung consolidation with dynamic air bronchograms and a small associated parapneumonic effusion. Note also adjacent B-lines. A shred sign represents the distinction between the consolidated lung and the aerated lung and is seen in this clip as the irregular “shredded” border just posterior to the consolidation. Aaron Inouye, PA-C, North Canyon Medical Center @PAintheED https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1554690459917-19ZKHAFJURT3HJ4JAASJ/pneumonia+.gif Pulmonary - Dynamic Air Bronchograms in Pneumonia This patient actually had no cough, no crackles and only subtle changes on CXR but in seconds we had diagnosed pneumonia! Dynamic air bronchograms represent air bubbles moving up and down airways surrounded by alveolar consolidation. Lichtenstein et al compared this finding to static air bronchograms in a 2009 study of 68 ICU patients and found dynamic air bronchograms to be present in 32/52 cases of pneumonia but in only 1/16 cases of atelectasis - a specificity of 94%. Dr. Trauer https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509272579708-8E912S0T0Z94FVZX3B5I/ezgif.com-optimize+%283%29.gif Pulmonary - B-Lines B-lines are vertical artifacts that moves with respiration from the pleural surface. They represent increased water in an area of the lung. In the right clinical context this could represent pulmonary edema. An increase in B-lines correlates with the degree of pulmonary edema. Keep in mind that in different clinical contexts, they can represent different diagnoses including pulmonary contusions and pneumonia. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501946036256-HUUF1I144FJTBB5ZSR7R/ezgif.com-optimize.gif Pulmonary - B-Lines - Pulmonary Edema B-lines obtained with curved probe. B-lines are vertical artifacts that move with respiration from the pleural surface. They represent increased water in an area of the lung. In the right clinical context this could represent pulmonary edema. An increase in B-lines correlates with the degree of pulmonary edema. 3 B-lines in an intercostal space represent a "positive" region of the lung, and if there are two regions of the lung that are positive, you can diagnose pulmonary edema. Dr. Justin Bowra et al. (Dr. D Browne and Dr. J Knights) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507299905492-XKPP0G7SQBE0TZG8I2BH/Confluent+B+Lines.gif Pulmonary - Confluent B Lines WCUME 2017 Submission for "Best POCUS" An acutely dyspnoeic patient presents with ventricular tachycardia and has no response to initial chemical cardioversion. Lung POCUS shows widespread bilateral confluent B lines indicating acute pulmonary edema. Unstable tachycardia terminated using synchronized electrical cardioversion. Dr. Cian McDermott - Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501947342046-ZWEDCO78W2ON50TM9V2E/ezgif.com-optimize+%282%29.gif Pulmonary - Pulmonary Embolism (Sector Probe) Pulmonary embolism can be seen by disruption of the pleural line. 0.5cm to 3cm disruptions are typical for PE. Doing DVT studies and echo can help strengthen your diagnosis. Dr. Justin Bowra et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533328485749-SKVG6KZAT9PXBY3N6EE9/hydropoint.gif Pulmonary - Hydropoint This clip, demonstrating a hydropoint, was taken in a 74 year old M with chest trauma after a fall from 3 meters. A hydropoint shows the air/fluid interface which is suggestive for hemato/hydro/pyo-pneumothorax. It is another sign for diagnosing a pneumothorax described by Volpicelli et al. Critical Ultrasound Journal. 2013 Dr. Van Roosmalen https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1525197776328-1QM09XJI79DBHJMUNLCF/ezgif.com-optimize+%2827%29.gif Pulmonary - Lung Consolidation 53yoM with 20+ year history of tobacco and alcohol abuse and newly diagnosed SCC presenting with productive cough and cachexia, found to have multifocal pneumonia likely due to aspiration. Mid-axillary ultrasound of the right lung using linear 13-6 MHz probe in the longitudinal plane demonstrating hepatization of the lung (right) and focal consolidation adjacent to normal lung parenchyma (left). US has high SEN (88%) and SPE (86%) for detecting pneumonia when compared to CXR or chest CT. (Ling 2017) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522336063399-7TOU0F6O0QYAQTRYONLE/ezgif.com-optimize+%285%29.gif Pulmonary - Spine Sign - Pleural Effusion RUQ scan with large R pleural effusion. Spine sign+ (clear view of several thoracic vertebrae through the effusion) Gary Duguay https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522268571420-W4DP4AEENN4VUZXELPXL/ezgif.com-optimize.gif Pulmonary - Pleural Effusion This 80 year old male with a history of Alzheimer's with recent accelerated decline experienced a fall from bed. Though the only visible trauma involved a laceration above the right eye, globally diminished breath sounds were noted, and a prehospital eFAST exam was performed. Pictured is a large, right-sided pleural effusion, with visible spine sign observed during the exam. No other abnormalities were observed. With the absence of significant chest trauma, the effusion was assumed to be non-traumatic in origin. Due to the patient's recent rapid decline, family elected to manage conservatively, and the patient was admitted to palliative care. - Tom Hudson, NRP, CCP-C (Richmond Volunteer Rescue Squad) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533328800726-QNVB3C7Y430C60GJZ0SH/spine+sign+.gif Pulmonary - Diaphragmatic Contraction A 61-year-old female with history of chronic Hepatitis C, end-stage liver disease, and pulmonary hypertension presented to the emergency department complaining of increasing dyspnea and abdominal distension over the last 10 days. Point-of-care ultrasonography of the right upper quadrant showed large anechoic fluid collections in the pleural space and intra-abdominal cavity, with a "spine" sign visible and with distinct “flopping” of the diaphragm over the caudal tip of the cirrhotic liver with each respiratory cycle. A great view of diaphragmatic contraction in a patient with dyspnea! Scott Brensel, MS-IV, Touro College of Osteopathic Medicine California https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1521564393226-6BTLNRBI0QVRPAREX8NU/bon+pulmonary+contusion.gif Pulmonary - Pulmonary Contusion 25 y/o female in and MVA with hypotension, hypoxia. Normal lung with A lines can briefly be seen until the sonographer moves the probe superiorly to reveal and area of B lines adjacent to A line. In the setting of trauma this is consistent with Pulmonary Contusion. Images: Dr. Catharine Bon - Kings County Hospital Emergency Medicine     https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1518452403754-5DTYLWN6FFA2BMK8ZTZM/kilpatrick+chanu+lung+malignancy.gif Pulmonary - Malignant Pleural Effusion This is a clip of an elderly gentleman, who was called as a respiratory distress code while walking to clinic without his home oxygen. Initially, patient was tachycardic, tachypnic, and hypoxic to mid 80s on RA, however normotensive in mild respiratory distress, resolved with 3L O2 by nasal canula. This clip here was obtained by having the patient in the upright position, with the probe in the left lung base. You can see the diaphragm on the left side of the clip, with multiple loculated pleural effusions in left lung base adjacent to compressive atelectasis vs cardiac activity. The effusion was later drained, found to be a malignant effusion, with a subsequent biopsy showing a Non-Small Cell CA in the left upper lobe and Squamous Cell CA in the right upper lung. Chris Hanuscin, MD and John F. Kilpatrick, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1517503467190-Y4NCLMSVWEEUBBSHWVEJ/ezgif.com-optimize-7.gif Pulmonary - Lung Curtain Normal lung demonstrating the "lung curtain." As the patient takes a deep breath, the "dirty shadowing" of a normal air-filled lung comes over the liver like a curtain. Dr. Gordon Johnson https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497406867319-G8IGH0WF4NIUNMBMG2QH/ezgif.com-gif-maker+%2830%29.gif Pulmonary - Miliary TB The clip was captured in rural Uganda on a patient who presented for weight loss, night sweats, and cough. Utilizing the high-frequency, linear transducer the patient’s thoracic pleura and superficial lung were evaluated. The ultrasound demonstrated multiple focal sub-pleural lesions with tripartite B-lines consistent with miliary tuberculosis. Michael Schick DO, MA Emergency Medicine Physician https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507586542526-IS5WHMF0LTJPICKQNMSD/Dove+in+Pleural+Fluid.gif Pulmonary - Dove in Pleural Fluid WCUME 2017 Submission for "Creative Caption" "In these days of violent extremist and warmongers, can it be a a good omen to find a dove flying in the pleural fluid?" Marco Garrone, MD - Torino, Italy https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1617048191902-TIE6PMBNEIQNHUNO61BX/image-asset.gif Pulmonary - B lines - Aspiration Pneumonitis A 30s M presented to the ED after he was found down in the setting of substance use. He received naloxone from EMS with good response, but on arrival to the ED was hypoxic and in respiratory distress, requiring maximum levels of respiratory support. POCUS was performed, showing extensive confluent B lines in both lungs, though worse on the right, suggestive of the alveolar interstitial syndrome and concerning for aspiration pneumonitis. The patient required intubation for work of breathing, and was admitted for further management. Dr. James Sutton, PGY2 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497406970022-T4O01CYDSXZ0OX7WHG4Z/ezgif.com-gif-maker+%284%29.gif Pulmonary - Resolving Pneumothorax This is an image of a patient's chest wall using a high frequency transducer, with the transducer oriented in a transverse plane between rib spaces. The patient had a pneumothorax and a chest tube was placed. This clip illustrates what happens when the suction is turned 'on'. You will see the pleura slide from right to left as the pneumothorax resolves. - Jason Tanguay, DO; Ultrasound Leadership Academy Graduate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1530460021399-NJL5E7JU71GJ8U5JPOWN/Bar+Code+Sign+Penumothorax.gif Pulmonary - Bar Code Sign - Pneumothorax 26 yo male presents to ED stating he was kicked in the chest. He went home to “try to relax and smoke some weed” now short of breath and with pleuritic chest pain after smoking. POCUS demonstrating decreased lung slide on the left. This can be seen as decreased lung sliding - In normal lungs, lung sliding refers to the parietal pleura moving against the visceral pleura - described as “ants marching.” M-mode can be used to evaluate lung sliding. Remember, normal lung slide will look like a seashore on M-mode whereas a pneumothorax will appear as horizontal lines termed Bar Code sign (pictured here). Make sure to check in the most anterior fields as well at lateral lung fields. Dr. Stacey Frisch, Dr. John F Kilpatrick - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497407032356-VBB184HLHODHMS4HD9GD/ezgif.com-gif-maker+%2821%29.gif Pulmonary - Pleural Effusion, Mass PLEURAL EFFUSION, THE SPINE SIGN AND SOMETHING ELSE… This is a clip of a 46 year old woman that presented to ED with gradual onset of severe right-sided chest pain, pleuritic, associated with tachycardia but normal blood pressure. She was mildly tachypneic but not hypoxic, unable to lie down as that exacerbated her pain. The clip shown here is of the patient's right upper quadrant and right lung base. The spine sign is seen along with a right pleural effusion and a circumscribed mass 8 x 6 cm with likely compressive atelectasis and mass effect of the right hemidiaphragm. The effusion was drained obtaining almost 1L of blood, and the CT scan reported very close findings to the ones seen with POCUS a few seconds after patient arrival. Put the probe on your chest pain patients! Maria Perez; Emergency Registrar; St Vincent’s Hospital; Melbourne - Australia   https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509276544859-XZBVLR2K86SSTRBS33TZ/ezgif.com-optimize+%288%29.gif Pulmonary - Jellyfish Sign Hypotensive septic elderly male. Right lung base shows a positive spine sign, jellyfish sign and shred sign indicating right basal pneumonia and a parapneumonic pleural effusion. Dr. Cian McDermott - Dublin, Ireland A spine sign occurs when fluid or consolidation in the lung allows for transmission and visualization of the spine superior to the diaphragm. A jellyfish sign represents compressed and airless (atelectatic) lung tissue floating within an effusion, also known as "lung flapping." The shred sign is a hyperechoic artifact created at the transition point between solidified (pathologic) and aerated lung. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507751484731-DY9IPX1S2JINOFYJCY2S/septated+pleural+effusion+yasmin.gif Pulmonary - PLAPS WCUME 2017 Submission for "Best POCUS" 26 y/o M with Hodgkin Lymphoma with a very complicated, septated, fluid-filled PLAPS - posterolateral alveolar or pleural syndrome. Aspiration of the fluid was exudative. Dr. Yasmin Sadri Savadjani - Firoozgar General Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509272372057-JDIMB6YHOIY24YP7SEZO/ezgif.com-optimize+%282%29.gif Pulmonary - Large Pleural Effusion The left lung can be seen freely floating in anechoic fluid on the left side of the screen. Also pictured, the diaphragm, spleen, and edge of the beating heart. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509272845667-H448H2QED7J1ZVQ3OC4O/ezgif.com-optimize+%285%29.gif Pulmonary - Lung Consolidation with Mirror Artifact A consolidated right upper lung can be seen above the fissure which is to the left (superior) in this image. There is hepatization of the lung with static and dynamic air bronchograms. These represent air with fluid filled alveoli around them. Dynamic air bronchograms are pathognomonic for pneumonia and represent air bubbles moving through the otherwise fluid filled tissue. Hepatization refers to lung tissue that looks like the liver and represents consolidation. Mirror artifact can be seen below (to the right) of the fissure as the fissure is a highly reflective surface. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501947696202-HZ3I2DHF05DHTM5Z7DIC/ezgif.com-optimize+%283%29.gif Pulmonary - Pulmonary Embolism (B mode) PE with linear probe in B mode. Pulmonary embolism can be seen by disruption of the pleural line. 0.5cm to 3cm disruptions are typical for PE. Doing DVT studies and echo can help strengthen your diagnosis. Dr. Justin Bowra et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1502564140190-U8XUOTGVSQ89P7VRMXD0/ezgif.com-gif-maker+%281%29.gif Pulmonary - Pneumothorax Lung Point Decreased lung slide is highly sensitive, it lacks specificity. Lung point however, is a highly specific finding indicating a pneumothorax. Lung point indicates the transition point between normal pleura with normal lung sliding and where there is air disrupting the pleural space with decreased lung sliding. In this intercostal space, one can see lung with normal lung slide on the left, and decreased lung slide on the right, and a point where the lung slide changes, which is moving with inspiration. This is the lung point. Dr. Justin Bowra et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501946558883-GXV72A1CXUPJAU09IXLS/ezgif.com-optimize.gif Pulmonary - Compression Atelectasis The left lung base can be seen with some b-lines indicating atelectasis, with trace pleural effusion. Dr. Justin Bowra et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515077848486-WJDMTVB1APUIV4V8EFJX/mcdermott+pleural+effusion.gif Pulmonary - Concealed Pleural Effusion Don't forget to look behind the heart.... Use a survey sweep to look behind the heart for a multi-organ POCUS exam. In the PLAX view, there is a pleural effusion visible behind the posterior myocardium in the left lobe of the lung. This patient had lung consolidation with a parapneumonic effusion and rapid atrial fibrillation. Dr. Cian McDermott - Mater University Hospital, Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1519226888465-97ROKSV5NL1HRTM451EH/Empyema+Pan.gif Pulmonary - Empyema Elderly male coming in with generalized weakness, shortness of breath and cough, who had recently been hospitalized for pneumonia. On arrival he was tachypneic and satting in the high 80s on room air. POCUS in the RUQ and right lung base. Pleura and loculations are visualized along with spine sign which indicates a plueral effusion. Sonographic evidence of septations in the presence of empyema predicts the need for intrapleural fibrinolytic therapy, longer duration of drainage, or possible surgical intervention. Dr. Gina Pan - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1520200073460-KUN1ZXQ0B1NQ0RMLCAT1/ezgif.com-optimize.gif Pulmonary - Lung Point 29F in motor vehicle accident w/ right hemo/pneumothoarx. Lung point is demonstrated marking the transition of normal pleural to pneumothorax. This is the most specific sign of pneumothorax. Greg Powell, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522101425141-UTEISVGFCM8UJCGXKS4B/Lung+Curtain.gif Pulmonary - Lung Curtain Normal lung demonstrating the "lung curtain." As the patient takes a deep breath the "dirty shadowing" of a normal air filled lung, comes over the liver like a curtain. Dr. Gordon Johnson https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533325032109-P5UMVA5XOPJA3EM9BTAG/pleural+effusion.gif Pulmonary - Pleural Effusion Patient of chronic renal failure with signs of fluid overload and bilateral pleural effusion on chest radiograph.POCUS ---Echogenic material within the fluid. Echogenic material seen within the fluid- Suggestive of Exudative pleural effusion. Transudative pleural effusion will be non echogenic. Dr. Ramachadran https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534352523609-CMQC96GJFLP9V7L196XU/lung+sliding+and+a-lines.gif Pulmonary - Lung Sliding and A-lines Lung Sliding and a-lines This is a clip demonstrating lung sliding. The most superficial hyperechoic layers are the soft tissue and muscular layers of the chest wall. Immediately deep to that is a bright, thin hyperechoic line which appears to be in motion - this is the pleural line. The parietal pleura rubbing against the visceral pleura as the patient breathes creates this shimmery appearance of lung sliding also often described as “ants marching”. The next horizontal hyperechoic line deep to the pleura is an a-line; this is a reverberation artifact created by a reflection of the pleura. The presence of a-lines is a normal finding. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534352986281-7GXHJXP18YD5KTZNDQN9/pleural+space.gif Pulmonary - Pleural Space This is a view of the pleural space in the right upper quadrant. We see the isoechoic liver in the center of the screen and the superior pole of the kidney to the right. The superior edge of the liver is flush against the hyperechoic diaphragm. Deep to all of this we see the sinuate hyperechoic vertebrae of the spine. Note that the spine appears to stop at the level of the diaphragm – this is due to the fact that US waves do not transmit through the air-filled lungs, and is a normal finding. If the spine did extend beyond the diaphragm (“spine sign”) that would suggest the presence of an effusion. The area above the diaphragm which comes into view when the patient inhales is the same echotexture as the liver (“mirror image artifact”), further indicating that there is only air above the diaphragm and not effusion or consolidation. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537198762597-7PN73K9AIVI65B109N2O/murch+pleural+effusion.gif Pulmonary - Spine Sign 41 yo M with history of stage 4 lung cancer presents with AMS and dyspnea, normotensive and tachycardia in 140s. Right upper quadrant view shows large anechoic pleural fluid with spine sign (clear view of several thoracic vertebrae through effusion) and lung flapping i.e. large right pleural effusion. Nathan Kabariti MS4, Dr. Charles Murchison, Dr. John Riggins, Dr. Donald Doukas - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1540916543602-8FWG29QI6JG2EE8RS855/lung+point.gif Pulmonary - Lung Point Lung point on a large pneumothorax. Dr. Stenberg https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509272201952-XXNHNWJNMKTV3AO656CE/ezgif.com-optimize+%281%29.gif Pulmonary - B-lines and Effusion To the left of the image, the lung can be seen clearly floating in anechoic fluid representing a pleural effusion. B-Lines can be seen radiating from the surface of the lung to the far left especially as this patient inspired. B lines (also known as comet tails) are white lines that emanate from the pleural surface of the lung. They have been shown to be highly sensitive for pulmonary edema. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533302584226-HU1BNLDS9SPR33FMCDT2/air+bronchograms.gif Pulmonary - Air Bronchograms Middle aged female with history of HIV, asthma, and polysubstance use who presents with progressively worsening dyspnea over 3-4 days, found to have diffuse rales, worse in left mid to lower lung fields. AP CXR with bilateral lower lobe patchy infiltrate, left greater than right. POCUS with curvilinear probe revealed B lines in left mid lung fields and consolidation with air bronchograms in left lower lung. Air bronchograms is one of the most specific signs for the diagnosis of pneumonia with a specificity (93%) and a positive LR (12.14). Ultimately, CT chest is the gold standard for diagnosis of pneumonia, which was consistent with the CT in this patient. Priscilla Chao, MD, Matthew Riscinti, MD - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588174625316-LOY5CK8ZAK0FPYZYKG4U/image-asset.gif Pulmonary - COVID-19 pneumonitis Patient presented with a 2-day history of worsening dyspnea and increased work of breathing. He was profoundly hypoxic at time of arrival with EMS (O2 sat 42% on 2L O2; improved to 75% upon being placed on high flow O2 @ 40 L/min). A linear probe was used to perform lung US and pictured here is zone L6 (posterior lower) that revealed thickened and irregular pleura in addition to B-lines. Findings were suggestive of clinically-suspected COVID-19 pneumonitis. Cian McDermott, Emergency Physician Dublin, Ireland @cianmcdermott https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544997787354-KLWJU5SJKGIKYZIIPWGP/malignant+effusion+.gif Pulmonary - Malignant Effusion 71 y/o F w/ hx of COPD/asthma, lung cancer on chemotherapy with recent admission for malignant pleural effusion (chest tube placed), presenting with for worsening cough/wheezing/shortness of breath for 1 day. No fevers or chest pain. The clip shows a large fluid collection in the left anterior chest with loculations and mediastinal shift to the right. Cardiothoracic surgery drained 2.7L of hemorrhagic pleural effusion. Dr. Vicky Lam - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523206254441-FCG4IUKI53XOPX1RVRW2/thymus+vs+pna+JFK+1.gif Pulmonary - Thymus Example of a thymus that can often be confused for hepatization! Don’t make this mistake John F Kilpatrick - Kings County Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1568924974351-43O28Q9ZE646OM61HG3Q/EFAST+LUQ+effusion.gif Pulmonary - Pleural Effusion After Blunt Trauma 55 y/o female complains of left sided chest pain with cough, SOB, and back pain. History of falls from 8-foot ladder (8 weeks ago) and from standing (2 weeks ago). With patient in supine, US of LUQ lung in coronal view demonstrated a hypoechoic fluid collection above the left hemi-diaphragm consistent with a L pleural effusion. It is important to scan above and below the diaphragm to differentiate free fluid in thorax vs fluid in subphrenic space. US is more sensitive than plain radiographs for detecting pleural effusion and can detect smaller amounts of fluid. Crozer Chester Medical Center. Raghav Sahni, Dr. Melissa Yu, Dr. Brenton Elliot, Dr. Max Cooper. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1540916102494-TNZSAX0L5F28U8YR89KL/sq+air.gif Pulmonary - Subcutaneous Emphysema This patient fell 5m onto a slab of concrete. The curvilinear transducer was used for the EFAST survey of his left anterior chest wall Hyperechoic irregular lines are seen superficial to the ribs (E lines - subcutaneous emphysema). These arise from air trapped in the soft tissue under the skin and should not be mistaken for the pleural line. Subcutaneous emphysema obscures the rib shadow and pleural line that lie below it Learning point : the pleural line lies underneath the level of the ribs, subcutaneous emphysema lies above the level of the ribs This patient had a large left-sided pneumothorax and an intercostal drain was placed followed by a serratus anterior plane block for analgesia Dr. Cian McDermott - Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611512101291-9LNIN83AP5TJA91AUKMO/image-asset.gif Pulmonary - Hemothorax A male presented to the ED following a gunshot wound to the left chest. The perisplenic window of the FAST exam revealed a left hemothorax with a large subpleural area of clotted blood. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1590094882952-TKRZ9ZFAKNM2QL6QUAMK/image-asset.gif Pulmonary - The Light Beam Artifact in COVID-19 This lung ultrasound shows a "light beam" artifact, a single shining band-form from a regular pleura that appears and disappears with spontaneous respirations. Note also the presence of A-lines. This is highly specific of early COVID-19 infection as described by Volpicelli. Image courtesy of David Hansen, DO & Therese Mead, DO, RDMS, FACEP Central Michigan University Twitter handle: @davidbhansen https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1586540395615-33BJE8Q1AM64B4WMJEOW/image-asset.gif Pulmonary - Lung US Findings in Hypoxic Patient with Suspected COVID-19 This clip demonstrates the presence of focal B lines with pleural irregularity. The patient presented to the ED with cough and O2 saturation varying between 87-89%, with no respiratory distress or significant past medical history. One of the patient’s family members was currently under investigation for COVID-19. The entire lungs were examined and the image above is the PLAPS view. Later the patient had a CT done which showed ground-glass opacity peripherally compatible with areas scanned on the POCUS exam. Pearl: POCUS may be an excellent tool for the triage of these patients. Image Courtesy of Dr. Victor Bang (@vmjbang) Co-Founder of Pocus Jedi https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584817193960-V7IPU94HRM2N9TZ34NNK/image-asset.gif Pulmonary - Common Pleural Based Findings in COVID-19 Lung ultrasound performed in a COVID+ patient. Note the clustered B lines, patchy shredding (depression) and thickening of pleural line, and small sub-pleural consolidations. Image courtesy of Dr. Marco Garrone (@drmarcogarrone) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585783644995-HIXXDUFM1VQDS0RRVQ3W/savetweetvid_EUeFzjsUUAALebp.gif Pulmonary - Pleural Findings in COVID-19 This is a lung ultrasound performed on a patient with COVID-19. The patient had no prior pulmonary disease. They presented with mild tachypnea and hypoxia. A chest x-ray revealed diffuse interstitial and patchy airspace densities. This ultrasound clip shown demonstrates an irregular pleural line with subpleural nodular consolidation and waterfall B-lines. Image courtesy of Dr. Eric Abrams (@eabramsMD) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584923302263-T9LBTKNFW294TEL8OU0L/ezgif.com-optimize+%2843%29.gif Pulmonary - A COVID-19 Patient with 3 days of Symptoms [1/3] This is an ultrasound clip of the right upper lobe of a patient with confirmed COVID-19 pneumonia. The patient presented to the emergency department on day 3 of symptoms with fever. They were found to be tachypneic and with mild hypoxia. [Clip 1/3] Lung ultrasound demonstrates confluent B lines associated with thickening and irregularity of the pleural line. A thin parapneumonic effusion can also be appreciated here. Image courtesy of Fritz Fuller (@POCUS_Society) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584923302390-3HOKDDGEEXWXTE1ZKHPK/ezgif.com-optimize+%2844%29.gif Pulmonary - A COVID-19 Patient with 3 days of Symptoms [2/3] This is an ultrasound clip in a patient with confirmed COVID-19 pneumonia. The patient presented to the emergency department on day 3 of symptoms with fever. They were found to be tachypneic and with mild hypoxia. [Clip 2/3] Lung ultrasound demonstrates patchy B lines associated with thickening and irregularity of the pleural line. Image courtesy of Fritz Fuller (@POCUS_Society) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584923302992-4BOINIWQM3AMUCPWU745/ezgif.com-optimize+%2845%29.gif Pulmonary - A COVID-19 Patient with 3 days of Symptoms [3/3] This is an ultrasound clip of the right posterior lung field of a patient with confirmed COVID-19 pneumonia. The patient presented to the emergency department on day 3 of symptoms with fever. They were found to be tachypneic and with mild hypoxia. [Clip 3/3] Lung ultrasound demonstrates confluent B lines associated with a small subpleural consolidation. Image courtesy of Fritz Fuller (@POCUS_Society) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585000402872-13M8MDTMR882FDRW418B/ezgif.com-optimize+%2846%29.gif Pulmonary - B-lines in COVID-19 Versus CHF This side by side ultrasound clip compares B-lines in a patient with COVID-19 (left) and a patient with CHF (right). While subtle, the difference lies where the B-lines connect to the pleura! In COVID-19 many of the B-lines initiate from depressed/irregular areas of the pleura (imagine little holes being punched in the pleural line) while in CHF, the B-lines initiate from a smooth pleural line. These pleural defects are not specific to COVID -19 and can be seen in other viral pneumonia as well. Take Home: Not all B-lines are created equal! Image courtesy of Dr. Marco Garrone (@drmarcogarrone) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585424289744-RG5K8531BSVL0L2IF4NT/ezgif.com-optimize+%2848%29.gif Pulmonary - Hospitalized COVID-19+ Patient on Day 9 of Symptoms [1/2] These clips are taken from a patient admitted with COVID-19 pneumonia. The patient was on day 9 of symptoms. His cough had improved and fever resolved however he had hypoxia requiring supplemental oxygen. Left clip: Lung ultrasound of right lower lobe demonstrating thickened irregular pleura, diffuse b lines (confluent) with scattered puntate subpleural consolidation and small effusion overlying pleural effusion. Right clip: Lung ultrasound of right upper lobe demonstrating a moderate subpleural consolidation with air bronchograms present. Image courtesy of Fritz Fuller (@POCUS_Society) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585424468095-8K5EKTWKAPOC1EYA9OAN/ezgif.com-optimize+%2849%29.gif Pulmonary - Hospitalized COVID-19+ Patient on Day 9 of Symptoms [2/2] These clips are taken from a patient admitted with COVID-19 pneumonia. The patient was on day 9 of symptoms. His cough had improved and fever resolved however he had hypoxia requiring supplemental oxygen. Lung ultrasound of left lower and left upper lobes demonstrating thickened irregular pleura, diffuse b lines (confluent) with subpleural consolidations. Image courtesy of Fritz Fuller (@POCUS_Society) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585855669211-WHQSUTZQ7UKPBVIAHCDY/ezgif.com-optimize+%2852%29.gif Pulmonary - A Hypoxic COVID-19 Patient This is an ultrasound clip performed in a 57 year old male patient with known COVID-19 pneumonia. The patient presented with dyspnea and fever, he had an oxygen saturation of 94% on room air. The clip demonstrates an irregular pleural line with numerous B lines present. Interestingly, A-lines are also present that appears to be intermittently erased where B lines cross. Image courtesy of Pierre Bernatas (@pb2316) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585856474235-3JCPXH5IJUXW98JCQ2NU/ezgif.com-optimize+%2853%29.gif Pulmonary - Subpleural Consolidation in Suspected COVID-19 Pneumonia This lung ultrasound clip demonstrates a subpleural consolidation in a patient with suspected pulmonary involvement by COVID-19. The clip is taken from an exam performed on an elderly male with flu-like symptoms for 14 days with progressive respiratory failure. Image courtesy of Renato Melo, Emergency Physician at Hospital das Clinicas de Marília-SP, Brazil. PocusJedi (@JediPocus) associated. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1586304013622-N8Q7XK8AQDFZRIR9V1MN/ezgif.com-optimize+%2854%29.gif Pulmonary - A Young Man with Hypoxia and Cough This lung ultrasound illustrates a small subpleural consolidation with associated waterfall b-lines in a patient with suspected COVID-19. The patient was a male in his mid 30s who presented to the ED with cough, but no fever. On admission the patient had an O2 saturation of 85%, with no respiratory distress. Image courtesy of Dr. Victor Bang (@vmjbang) Co-Founder of Pocus Jedi https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567929248993-CA5LH9IB803P0IGVZ63F/lung-sliding2.gif Pulmonary - Lung Sliding - Colorized Lung sliding Green: Subcutaneous tissue, Red: Pleural space, Blue: A lines Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1586305090177-DS2UERI64C9WZEUYK9TP/ezgif.com-optimize+%2855%29.gif Pulmonary - Pleural Findings in COVID 19 This lung ultrasound clip demonstrates multiple scattered b lines emanating from an irregular pleural line in a patient with known COVID-19. Image courtesy of Dr. Jaime Alejandro Sánchez Gutiérrez (@pleuralpocus) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567929251076-8KWEM7T7I8ZD7W9R7IK5/pleural-space.gif Pulmonary - Pleural Space - Colorized Pleural space Red: Diaphragm, Blue: Pleural space, Green: A lines, Orange: Spine Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584988439645-OSVTSOFBVWR7IOSD9W6H/image-asset.gif Pulmonary - COVID-19 Lung Findings Lung ultrasound image taken from a patient who tested positive for the novel coronavirus (COVID-19). Note the presence of clustered B-lines, a thickened and irregular pleura, and small subpleural consolidations. Marco Garrone, Emergency Medicine Physician @drmarcogarrone https://www.thepocusatlas.com/renal daily 0.75 2025-02-07 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736700795740-RQQYO5H5H9A5R2GXCHUP/image-asset.gif Renal/GU - Horseshoe Kidney Transverse Horseshoe kidney. No kidney was identified in either flank area, this anterior abdominal view shows one large kidney that is anterior to the Aorta. Contributed by: Marion Memmott, DO; Michael Bernard, DO; Central Michigan University Emergency Medicine Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736700795740-RQQYO5H5H9A5R2GXCHUP/image-asset.gif Renal/GU - Horseshoe Kidney Transverse Horseshoe kidney. No kidney was identified in either flank area, this anterior abdominal view shows one large kidney that is anterior to the Aorta. Contributed by: Marion Memmott, DO; Michael Bernard, DO; Central Michigan University Emergency Medicine Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736700891773-0B3HHZJQ9T3AW5QHDQGS/image-asset.gif Renal/GU - Horseshoe Kidney Longitudinal Horseshoe kidney. No kidney was identified in either flank area, this anterior abdominal view shows one large kidney that is anterior to the Aorta. Marion Memmott, DO; Michael Bernard, DO; Central Michigan University Emergency Medicine Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727651640204-D0GFMW8TDPERP4WW2W44/image-asset.png Renal/GU - Prostate Carcinoma Prominent prostate on ultrasound in a 72 year-old-male with known prostate carcinoma and recent PET scan with confirmation. No known masses or metastasis. This is seen in both transverse and sagittal views. Lindsay Davis, DO, MPH, PGY3; Matthew Welch, MS4; Alex Schlangen, DO, PGY1 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735238507036-C5VTUZ3WXHZLVRSUAR6Y/image-asset.gif Renal/GU - Bladder Diverticulum 2 A bladder diverticulum is demonstrated deep to the bladder as the ultrasound probe is fanned. Contributed by: Brittany Garza, DO; Saleem Nasseh, MD; Sadie Ellerson, MS4 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1729635897189-M2B64Q14PMXSLFQDU7P0/image-asset.gif Renal/GU - Moderate Hydronephrosis from Nephrolithiasis Here is an example of hydronephrosis in the presence of nephrolithasis. This patient presented to the emergency department complaining of new right flank pain after waking up in the morning. She was seen previously for urinary complaints, diagnosed with UTI and started on antibiotic regiment that had been altered twice due to concerns of sub-optimal coverage. She demonstrated right CVA tenderness on physical exam, raising suspicion for pyelonephritis as well as hydronephrosis. Subsequent point of care ultrasound revealed moderate hydronephrosis. CT was obtained to further evaluate and confirmed the presence of an obstructing kidney stone. Note presence of hydronephrosis as the probe is fanned/tilted through the kidney, highlighting the importance of scanning through the entire organ. Dr. Carlo Zamora, DO, PGY-1 Riverside Regional Medical Center Emergency Medicine Residency (Newport News, VA) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727563134453-GO129XOE6O5JUQ1SLOIN/UVJ+stone+with+ureteral+dilation+-+Matthew+Petruso.gif Renal/GU - UVJ stone with ureteral dilation A young female presented with acute RLQ abdominal pain and found to have a 5mm right ureter stone at the UVJ with ureteral dilation. The patient also had moderate hydronephrosis. Matthew Petruso, DO; Harpreet Grewal, MD; Eric Versluis, MS4; Central Michigan University: Emergency Medicine Residency. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727562570256-BTLF12988IY4CSRVSELR/image-asset.gif Renal/GU - Large Renal Cysts 83 year old male presented to the ED for right flank pain. The renal ultrasound showed two right renal cysts. The superior renal pole cyst measuring 12 x 13cm. The inferior pole cyst measuring 4 x 5cm. Laura Schroeder, MS, MD; Syeda Zehra, MD; Conner Shea (Medical Student) Central Michigan University Emergency Medicine Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1726533934263-YGOEU63FL180M9885IM5/image-asset.gif Renal/GU - Right Sided Emphysematous Pyelonephritis 60 year old female with poorly controlled diabetes. Initial CT showing R-sided pyelonephritis, US performed 12 hours later demonstrated development of emphysematous pyelonephritis noted by the hyperechoic areas with dirty shadowing seen within the renal parenchyma (indicative of gas). This was later confirmed on repeat CT imaging. Contributor: Shane Solger, MD Kings County/SUNY Downstate EM/IM https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1726532294254-0R00INDPO8E1LK3MPQAV/image-asset.gif Renal/GU - Bladder Diverticula 82 year old male with history of subarachnoid bleed presented for evaluation after a fall. During a EFAST exam, bladder US revealed multiple, anechoic, cystic-appearing structures consistent with bladder diverticula (confirmed by CT). A bladder diverticulum is a protrusion of the mucosa through the muscular wall of the bladder and can be congenital or acquired. Acquired diverticula are more common, with bladder outlet obstruction being the most common cause. Urology follow up is recommended to confirm the cause and screen for other concerning etiologies or complications including carcinoma, recurrent UTIs and bladder calculi. Contributors: Michael Huber, 4th year Medical Student; Chad Bambrick, MD; Ana Camagay, MD Central Michigan University College of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659221322975-AFMGFWFHEWT7J4A84S45/image-asset.gif Renal/GU - Large Simple Renal Cyst Large Renal Cyst seen coming off of the kidney in short axis. Dax Spencer https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1708124958283-UWL35XYW4VNM5U6RSGPF/image-asset.gif Renal/GU - Moderate-Severe Hydronephrosis This is the right renal ultrasound of a 20 year old male with a past medical history of recurrent obstructing nephrolithiasis. There is a moderate to severe hydronephrosis present. with what appears to be some thinning of the renal cortex. Brittany Ladson, DO; Sara Schumbach, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697912193590-0WTO7EFS2TARHNQD2A09/image-asset.gif Renal/GU - Two Stones, One Image Ultrasound clip demonstrating both cholelithiasis as well as obstructing stone in the ureter! Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1702923166066-X458YHKUZ8VBDB9IZN72/image-asset.gif Renal/GU - Penile Prosthesis Reservoir 60s M presented to the ED sent in by PMD for evaluation of elevated BUN and Creatinine. POCUS performed with transverse view of the urinary bladder demonstrating discrete cystic structure on anatomic right with second circular, hyperechoic structure visualized. Structures are consistent with penile prosthesis fluid reservoir abutting the right anterior bladder. Findings confirmed on chart review of previous urinary bladder imaging. Hydraulic inflatable prostheses consist of two or three piece types. The three piece types (as pictured) consist of a pair of cylinders placed in each corpus cavernosum, a pump placed in the scrotum, and a reservoir placed adjacent to the bladder (1). Yahyavi-Firouz-Abadi N, Menias C, Bhalla S, Siegel C, Gayer G, Katz D. Imaging of Cosmetic Plastic Procedures and Implants in the Body and Their Potential Complications. AJR Am J Roentgenol. 2015;204(4):707-15. doi:10.2214/AJR.14.13516 - Pubmed Contributors: Joshua Taubman MD, Resident Physician - University at Buffalo Emergency Medicine, @UBEMSono https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1679280216444-L48QGWBU64ELGRZ402I2/image-asset.gif Renal/GU - Renal Cell Carcinoma At Inferior Pole This patient presented with hematuria and flank pain. In this scan, you can see a visible circular mass along the inferior pole of the kidney with further testing later confirming presence of a renal cell carcinoma. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1674093774116-BAEYX40RZZMCHQLIE1EK/image-asset.gif Renal/GU - High Grade Pyelonephritis With Urothelial Thickening Although most cases of uncomplicated pyelonephritis will appear normal on ultrasound, urothelial thickening might be observed. It should be noted that this can also be observed in different clinical contexts including urolithiasis, stents and malignancy. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1674096843705-CNZA7R83L3FFPUDGMUN9/image-asset.gif Renal/GU - Renal Abscess This clip demonstrates a renal abscess seen along the inferior pole of the kidney. Notice the circular shape with internal echoes and a hyperechoic rim demonstrated in both long and short axis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1674261707548-59KT8SWQH5U0OR6TTFYJ/image-asset.gif Renal/GU - Air Within Bladder This sagittal image of the bladder demonstrates air within the bladder. This could be from emphysematous cystitis but could also be iatrogenic due to recent foley placement. Also note the presence of layered echoes in the bladder due to an infectious process. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1674351452792-U2RMU91RYVEBAIC7MQDN/image-asset.gif Renal/GU - Medullary Nephrocalcinosis This clip demonstrates medullary nephrocalcinosis. Note the increased echogenicity of the renal pyramids due to calcium deposition. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1674095101824-94EKMIVG0R8T4J0PUFFT/image-asset.gif Renal/GU - Pyonephrosis in Setting of Proximal Ureteral Stone This patient presented with fever and flank pain with a known history of medullary nephrocalcinosis. Here we can see internal echoes within the dilated collecting system consistent with pyonephrosis. A large stone can be seen in the proximal ureter as a hyperechoic line with posterior shadowing. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1668998379252-3QRMWWIGPU93571DL15C/image-asset.gif Renal/GU - Emphysematous Pyelonephritis This clip demonstrates air within the parenchyma of the kidney consistent with emphysematous pyelonephritis. This is different than emphysematous pyelitis in which air is only seen in the collection system. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1668997018668-VNYCZB4UR5GVL6776T7G/image-asset.gif Renal/GU - Acute Focal Nephritis Right presented with right flank pain. A known ureterovesical junction stone is present. But also notice the focal hyperechoic area at the superior pole of the kidney. This patient was diagnosised with acute focal nephritis. This is on spectrum somewhere between acute pyelonephritis and renal abscess. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1670118317900-9Q9HT3QZ23E5MHL7H5B1/image-asset.gif Renal/GU - Bladder cancer Older male presented with right flank pain and hematuria. Bladder ultrasound revealed mass in bladder with internal color flow. Subsequent CT imaging performed and patient eventually diagnosed with bladder cancer. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1668996044822-2X7R8E82I85TJXIHRBXX/image-asset.gif Renal/GU - Megaureter This patient presented with left flank pain. The large anechoic structure had no color flow when doppler was applied. This was a megaureter which can result from VUR, bladder outlet obstruction, idiopathic. In this patient it was known and due to VUR. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1667330295252-AMVZGFIDB8TDRT5TBPUL/image-asset.gif Renal/GU - Atypical Cause of Hydronephrosis Patient with a history of hypertension presented with left flank pain and microhematuria. Kidney was scanned and revealed hydronephrosis without presence of a stone. Ultimately MRI was obtained and received a final diagnosis of idiopathic retroperitoneal fibrosis which was causing external compression of ureter. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664757629477-O2K3BVHOBQU5SWVDM8KS/image-asset.gif Renal/GU - Adrenal Metastasis Patient presented with right flank pain and reported pain was similar to kidney stones. Large solid mass is observed and received a final diagnosis of adrenal metastasis after further imaging. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659634305936-8N6YFKX1WYJIZC65EOT2/image-asset.gif Renal/GU - Severe Hydronephrosis vs Cyst? This is a long axis image of severe hydronephrosis that mimics a cystic kidney. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1658943575410-LUHVWY1H1S08VJ5W55SU/image-asset.gif Renal/GU - Perinephric Abscess Patient was admitted to ICU for DKA + pyelonephritis + E. Coli bacteremia. She was treated in the ICU and downgraded to the medicine floors, after tx for septic shock, but had persistent leukocytosis and intermittent LUQ px. Repeat CT showed 2.2 x 3.5 x 3.9 cm perinephric abscess, with the following images taken after identification on CT. 8cc of purulent drainage was subsequently drained via IR. Shane Solger, MD King's County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644435802092-73H067SEOB6CS7UB3CE5/image-asset.gif Renal/GU - Ureterocele 34-year-old female with a history of type 1 diabetes and recurrent urinary tract infections presenting to the emergency department with complaints of left flank pain and dysuria for two days. CT scan showed a 5.4 x 5.8mm obstructive calculus in the left lower ureter and moderate left hydronephrosis. POCUS additionally noted an anechoic, cystic structure projecting into the bladder, consistent with a ureterocele. Shown here is the transverse bladder scan image. Ibrahim Baida, MS4, @ibbaida Ian Keck, PGY-3 Dax Spencer, PGY-1 Central Michigan University College of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637766027872-8HE30BRVJ29S8M2SMXYB/image-asset.gif Renal/GU - Urinoma Longitudinal view of the kidney reveals an anechoic space adjacent to the kidney, likely due to a urinoma secondary to a calyx rupture. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637763954654-TLE5VRTGMPR5A6JRHDME/image-asset.gif Renal/GU - Bladder Hematoma Sagittal view of the bladder shows a post-procedural hematoma within the bladder wall obstructing one of the ureteric openings. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637763203826-YL2WYLER62W9NXGDT6KO/image-asset.gif Renal/GU - Renal Abscess Longitudinal view of the kidney representative of a renal abscess. Note the heterogenous cystic structure within the renal cortex. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637590332409-1FG5ZOH2UHL6QW2319D9/image-asset.gif Renal/GU - UVJ Stone Patient with flank pain was found to have a 3mm unilateral obstructing ureteric stone without hydronephrosis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1627327177297-7SJ6W6GWJPWQP5JVHBI6/image-asset.gif Renal/GU - Renal Cell Carcinoma Renal parenchyma showed a dysmorphic appearance with the presence of mild ascites in this patient with flank pain and hematuria. Patient was later diagnosed with renal cell carcinoma. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625686024677-NQHO3TNWGKQW9ZM1BIF0/image-asset.gif Renal/GU - Ureteral Erosion A patient with a history of ureteral stent placement presented with flank pain. POCUS revealed no hydronephrosis but shows signs of free retroperitoneal fluid likely due to erosion of the ureter by the stent. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625686401983-RL832TDCXCLMN0O88SVG/image-asset.gif Renal/GU - Testicular Microlithiasis Testicular ultrasound revealed microcalcifications diffusely within the testes presenting with testicular pain. These findings can be associated with germ cell tumors. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620334068751-MD57GRN1ME38057VB6I7/image-asset.gif Renal/GU - Medullary Pyramids A patient was being evaluated for flank pain. This clip shows findings of normal but prominent medullary pyramids as indicated by how they taper down toward the renal pelvis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614980636147-Y600GBK4AXGSQX7BGRBX/image-asset.gif Renal/GU - Horseshoe Kidney POCUS was used for evaluation of right flank pain with suspected hydronephrosis. A transabdominal view revealed obstructive uropathy due to a horseshoe kidney. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611515271216-SI0EKQJU7Y38HTEH3DPY/image-asset.gif Renal/GU - Ureteral Stone during Pregnancy A pregnant female of 8 week gestation presented to the ED with sudden severe right adnexal pain with stable vitals. Ultrasound revealed a viable IUP and a stone within the right distal ureter. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611511452429-NQYPN75DB53O0AJCYNH4/image-asset.gif Renal/GU - Pelvic Kidney A G1P0 female presented to the ED with vaginal bleeding, abdominal pain, and stable vital signs. Examination reveals a mass palpable supero-lateral to the uterus on the right. Ultrasound revealed a pelvic kidney. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1610645890289-HHS4H8279E78NETRMF79/image-asset.gif Renal/GU - Urinoma A patient presented with right flank pain. Ultrasound of the kidney revealed hydronephrosis with surrounding urinoma due to a suspected minor calyx rupture. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1608641413761-JUUY005HMEUUNR95IG1J/image-asset.gif Renal/GU - Misplaced Foley An elderly male presented with complaints of suprapubic pain. He recently had his foley catheter changed, which is draining but with significant pain. Sagittal view of the pelvis revealed the foley balloon inflated within the prostatic urethra. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1608640586550-XA4O3K4PP3UROLNI6NWD/image-asset.gif Renal/GU - Urothelial Thickening A young female presented to the ED with flank pain and a fever. Ultrasound revealed the urothelial lining of the renal pelvis was >2mm suggestive of a recent underlying obstructive process. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609786832917-4T4LA0DS63EODOTTGQPS/image-asset.gif Renal/GU - Bladder Mass An elderly male with a history of atrial fibrillation, hypertension, and COPD presented for evaluation of lower abdominal pain. He denied associated fever, chills, nausea, vomiting, dysuria, increased urinary frequency, hematuria, or incontinence. Also denied history of smoking or exposure to aniline dyes. POCUS was notable for the presence of a hyperechoic mass along the posterior wall of his urinary bladder. This prompted additional image acquisition; CT confirmed the presence of a 2.8 x 1.6 x 3.6 cm bladder mass warranting additional work-up. This serves as an example of how POCUS can help localize intra-abdominal areas of interest, particularly in the setting of a vague HPI. Thomas G. Weiss, MS4; Matthew French, PGY3 Central Michigan University College of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1608043655579-POZW81F5188WV8IFMGJ5/image-asset.gif Renal/GU - Ureteropelvic Junction Stone A young patient presented to the ED with abdominal and back pain. POCUS revealed a hyperechoic stone with acoustic shadowing within the right ureteropelvic junction. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607176675214-N26R6HA3WC9XOXSVDLG7/image-asset.gif Renal/GU - Xanthogranulomatous Pyelonephritis A female presented to the ED with right flank pain, fever, leukocytosis, soft vitals, and dirty urine. Urine culture grew Proteus mirabilis. Bedside ultrasound revealed a bear claw sign with perinephric abscess indicative of xanthogranulomatous pyelonephritis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607174590807-J788OZ96DB2PK8CM4MC2/image-asset.gif Renal/GU - Right Distal Ureterovesicular Junction Stone Transabdominal ultrasound showing right-sided twinkle artifact with strong left-sided urine jet indicative of right-sided UVJ stone obstruction. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598987676187-LSDPKHHPC1DT8PP9LC81/image-asset.gif Renal/GU - Incidental Polycystic Kidney Disease A 12 year old male presented after a MVC. A FAST exam was performed demonstrating incidental finding of Polycystic Kidney Disease (PCKD). Paul Khalil, MD @Khalil3Paul Assistant PEM POCUS director at University of Louisville/Norton Children’s https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594924497912-20KL1R6C1L60SXSYEF5O/ezgif.com-optimize.gif8.gif Renal/GU - Medullary Nephrocalcinosis with Moderate Hydronephrosis A female patient presented with right flank pain. A longitudinal view of the right kidney indicates medullary nephrocalcinosis with posterior shadowing and moderate hydronephrosis. Note the posterior shadowing partially masks the hydronephrosis. Further ultrasound found a distal ureteral stone. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594858588514-XJHJKNS72X2GY2W0AI7N/ezgif.com-optimize.gif Renal/GU - Distal Ureteral Stone A female patient presented with right flank pain. A longitudinal view of the lower ureter reveals a distal ureteral stone. Further ultrasound of the right kidney depicted medullary nephrocalcinosis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1591676037956-QMH860SPWJ069I5TAOAY/image-asset.gif Renal/GU - Ureteral Stones at Ureterovesical Junction Multiple ureteral stones visualized at UVJ with notable ureteral peristalsis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588256167160-5VBS248HIKSQCHS5EWRV/image-asset.gif Renal/GU - Bear Paw Sign A 43-year-old female presented to the ED reporting fever and left-sided flank and low back pain. HPI was notable for recurrent urinary tract infections. POCUS performed on the Left Upper Quadrant revealed severe hydronephrosis, with hypdronephrotic collections in the region of the calyces resembling the outline of a bear’s paw (referred to as “bear paw sign”). Subsequent abdominal CT confirmed severe hydronephrosis secondary to stenosis of the ureteroplevic junction (UPJ). Josiane Almeida https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588264862706-M7EDNW1BYSV9UKI0QV7N/image-asset.gif Renal/GU - Simple Renal Cyst A 84-year-old female presented to the ED in decompensated heart failure. During the POCUS of her RUQ we incidentally identified this simple renal cyst; also note a single calculi within her gallbladder. Josiane Almeida, Emergency Physician Department of Marilia Clinic Hospital, Sao Paulo- Brazil https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579193787585-M4NU747MDTQVLMHWU2XF/image-asset.gif Renal/GU - Diverticuli of Urinary Bladder A middle aged male presented with lower abdominal pain and difficulty urinating. He also reported incomplete bladder emptying. POCUS demonstrated multiple bladder diverticuli that were subsequently confirmed on CT pelvis. Acquired bladder diverticula are often secondary to bladder outlet obstruction that may be related to an enlarged prostate, urethral stricture, or neurologic disease. Lydia Mansour, DO, PGY1 & Sohaib Mandoorah, MD, PGY3 Central Michigan University Emergency Medicine Residents https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606868736108-B7XD5MO7M7JUFVMJIQD2/image-asset.gif Renal/GU - Calyceal Rupture add desp Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579125307628-7V35MTJE7LSKMA5T9OYT/image-asset.gif Renal/GU - Hydronephrosis POCUS evidence of severe right renal hydronephrosis, as identified in a patient who had an ipsilateral 2.5cm mid-ureteral calculus. Aaron Inouye, PA-C, North Canyon Medical Center @PAintheED https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1573692513175-N4JA35ZYIS9Z47BY11SN/ezgif.com-optimize+%2816%29.gif Renal/GU - Septated Hydrocele A 30 year old sexually active male with no previous medical history presented to the emergency department with testicular pain. POC US demonstrates a septated hydrocele. Mario Corro, MD, PGY-3 Staten Island University Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1573682935819-ZZQ7RS3CUSP6HHXTUESX/ezgif.com-optimize+%2814%29.gif Renal/GU - Ureterocele A 27 year old female with no significant past medical history, presented to the emergency department for dysuria. POCUS demonstrated a ureterocele seen projecting into the bladder. Mario Corro, MD, PGY-3 Staten Island University Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1573682438985-0GZ5RVIUVQUWQXZZ9QA2/ezgif.com-optimize+%2813%29.gif Renal/GU - Anterior Bladder Diverticulum A 60 year old male presented to the emergency department for evaluation of hematuria. POCUS demonstrated a diverticulum extending from the anterior bladder surface. Mario Corro, MD, PGY-3, Staten Island University Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1568306470157-WGTCSE4TACMWNINW8XK2/ezgif.com-optimize+%282%29.gif Renal/GU - Epididymitis with Complex Hydrocele This image demonstrates fluid filling the scrotal sac with multiple thin septations consistent with a complex hydrocele. In the setting of epididymitis, a pyocele should be considered. Image courtesy of Aventura Ultrasound See Original Post Via their Twiiter: @AventuraEUS https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513457507178-SFIVJPQLRQEGAYB77BJA/ezgif.com-optimize.gif Renal/GU - Normal Kidney Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1521125735597-H9TCEW0PJRA8IZIQDREU/ezgif.com-optimize+%283%29.gif Renal/GU - Traumatic Kidney Hematoma 19M w/ hx “fell down stairs 1 week ago,” won’t provide additional details. Admitted to an outside hospital for renal laceration and subcapsular hematoma, here in ED today wondering if hematoma still present, asymptomatic; normal vitals. Greg Powell, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1518451352347-K74MYYGSDQ9UVEZHEHKS/ezgif.com-optimize+%285%29.gif Renal/GU - Testicular Rupture 27 y/o M presented wit scrotal pain upon awakening after a night of heavy drinking. He could not recall any trauma. Physical exam revealed a tender, swollen, and ecchymotic scrotum. POCUS demonstrates hematocele, as well as (1) disruption of the tunica albuginea, (2) contour abnormality of the testis, and (3) heterogeneous echotexture of testicular parenchyma. These three findings collectively are highly sensitive and specific for testicular rupture1-3, and warrant urgent surgical exploration. Elizabeth Hanson, MD - EM resident, Kings County/SUNY Downstate 1. Deurdulian C, Mittelstaedt CA, Chong WK, Fielding JR. US of acute scrotal trauma: optimal technique, imaging findings, and management. RadioGraphics2007; 27: 357–369. 2. BuckleyJC, McAninch JW. Use of ultrasonography for the diagnosis of testicular injuries in blunt scrotal trauma. J Urol2006; 175: 175–178. 3. Micalle FM, Ahmad I, Ramesh N, Hurley M, McInerney D. Ultrasound features of blunt testicular injury. Injury2001; 32: 23–26. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1516660671034-U5GQXTFOK26RBGMDMV7O/ezgif.com-optimize.gif Renal/GU - Bladder Diverticulum 78 yo M h/o BPH s/p TURP 1yr ago presents c/o difficulty voiding x2 wks. US of bladder revealed 2 large fluid filled (anechoic) structures w/ a communicating tract and bidirectional flow on color Doppler. The superficial structure is the urinary bladder while the deep structure is a large bladder diverticulum. Pt didn't have any previously documented hx of a bladder diverticulum. A bladder diverticulum is a rare congenital or acquired defect consisting of a protrusion of the mucosa through the bladder musculature. The most common acquired cause is bladder outlet obstruction 2/2 to BPH. Pts w/ a new diagnosis in the ED should be referred for urology follow up. These pts are at high risk of UTIs and bladder calculi due to urinary stasis from incomplete emptying of the diverticulum. This can even occur in pts w/ a Foley, as the catheter may not drain the diverticulum. In fact, having a chronic indwelling catheter is a rare cause of bladder diverticula. Pts w/ hematuria, lower urinary tract symptoms, recurrent UTIs, or bladder calculi may require diverticulectomy. Drs. Justin Berkowitz, Adrian Aurrecoechea, and Catherine Bon https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507588439475-DDG56SZ2OF75JQBAM4XH/Penile+Calculus.gif Renal/GU - Penile Urethral Calculus WCUME 2017 Submission and WINNER for "Creative Caption" Category "Stone in the Sword" The patient presented with penile pain and blood in urine. POCUS demonstrates a calculus obstructing the distal urethra. Inna Shniter, MD - UCI Ultrasound Fellow https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497406426902-Z3I17VIQDTQ6YLCEIMQP/ezgif.com-gif-maker+%2813%29.gif Renal/GU - Perinephric Hematoma This is a longitudinal view of the right kidney in a patient who presented with sudden, severe right flank pain. There was no history of trauma. No gross hematuria. The patient’s pain was difficult to control with analgesics and bedside ultrasound revealed apparent spontaneous perinephric hematoma. Therese Mead, DO Emergency Physician https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507297318677-EK10FPUBQP1SE6VIBWN4/foley+final.gif Renal/GU - Difficult Foley: Bladder Diverticulum WCUME 2017 Submission for "Novel Indication" A urinary catheter is not draining appropriately and bedside ultrasound reveals inflated balloon caught within a bladder diverticulum. Under dynamic ultrasound guidance, the balloon is deflated, the catheter withdrawn into the bladder lumen, and then reinflated in the appropriate position. Sam Langberg, MD - Ochsner Medical Center, New Orleans, LA https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497406505334-WVHG3P9RTFHSCB5CIGQR/ezgif.com-gif-maker+%2823%29.gif Renal/GU - Polycystic Kidney Disease This middle-aged adult female presented to the emergency department with abdominal pain. The patient reported history of polycystic kidney disease. Bedside renal ultrasound revealed multiple renal cysts in both the cortex and medullary areas of the kidney, consistent with her history. Stones and hydronephrosis would be difficult to detect in the setting of polycystic kidney disease. Ahmad Jaber, MBBS PGY3 Resident Physician, Central Michigan University Emergency Medicine Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497406564799-WXAWAJHZ0D175WHYBL3Q/ezgif.com-gif-maker+%289%29.gif Renal/GU - Ureterovesical Junction Nephrolithiasis This is a 58 year old man that presented with first episode of severe LLQ pain and vomiting. The differentials were diverticulitis vs nephro/urolithiasis. POCUS was performed obtaining images of left and right kidneys, bladder and aorta. The image shows a 7mm stone seen with shadowing at the L UVJ. Maria Perez; Emergency Registrar; St Vincent’s Hospital; Melbourne - Australia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509273523668-DQF16KYMDW70H8XGJMSE/ezgif.com-optimize+%286%29.gif Renal/GU - The Twinkle Artifact Ultrasonographic color doppler twinkling artifact is a phenomenon that may aid in the detection of nephrolithiasis. Twinkling artifacts can be seen on color doppler ultrasounds when applied to stationary, highly echogenic objects, generating a false sense of movement on color doppler. The reason this occurs is unclear. Seen here is a left ureterovesicular junction stone with a positive twinkle artifact. Maria Perez; Emergency Registrar; St Vincent’s Hospital; Melbourne - Australia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522623393374-5JZLE6Y95IHORMR1UPJB/jarret-kidney-color.jpg Renal/GU - Assessing Hydronephrosis with Color Flow Normal kidney - No hydro. One of the common pitfalls in identifying hydronephrosis is not using color flow. You must use color flow doppler to ensure that what you're looking at is actually hydronephrosis, not simply vasculature. Dr. Bryan Jarret - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1518479648885-BUC2SM4TGDVXWP632W51/mild+hydro+still.jpg Renal/GU - Mild Hydronephrosis Mild - grade two hydronephrosis with dilation of the renal pelvis and dilation of the some calyces. Grade one would not include dilated calyces. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497411010470-NLX2IRP1L1TZPWHFO715/mild+hydro+comp.gif Renal/GU - Mild Hydronephrosis 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513457363149-2DCO14INH2OJ9F51FUL7/ezgif.com-gif-maker.gif Renal/GU - Moderate Hydronephrosis The degree of hydronephrosis is determined by a grading system. Grade 0 (none) means there's no dilation of the renal pelvis. Grade 1 (mild) means there's mild dilation of the renal pelvis without any dilation of the calyces. Grade 2 means there's moderate dilation of the renal pelvis that extends to a few calyces. Grade 3 (moderate) means the renal pelvis dilation extends to all the calyces. Grade 4 (severe) means there's extension of dilation to all the calyces with the addition of thinning of the renal parenchyma. In this clip, the renal pelvis calyces are dilated but there is no thinning of the renal parenchyma making this mild to moderate, grade 2. Sukh Singh, MD Caption by Matthew Riscinti, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515005466784-PMGIC6UJH99PNKZ1GS39/ezgif.com-optimize+%282%29.gif Renal/GU - Hydroureter with Moderate Hydronephrosis This young lady presented with clinical features of pyelonephritis - fever, rigors and right flank pain. Renal US shows moderate hydronephrosis and hydroureter. CT showed a 5.7mm right mid ureteric stone. Nephrostomy tube was placed to decompress obstructive uropathy. Ultrasound is insensitive for pyelonephritis - most patients have normal scans. POCUS can be used to check for hydronephrosis, renal abscess, pyonephrosis or emphysematous pyelonephritis as these findings will alter management. Images recorded by Dr. Khaled Taha Submitted by Dr Cian McDermott Mater University Hospital, Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522335613356-TYG7G528BE85JFWHUFCV/ezgif.com-optimize+%288%29.gif Renal/GU - Moderate Hydronephrosis This young female presented with colicky left flank pain worsening over the previous 24 hours. POCUS showed moderate hydronephrosis with rounding of the calyces of the left kidney collecting system. The stone is seen at the ureteropelvic junction (UPJ) as a hyperechoic structure with posterior acoustic shadowing measuring 7mm on CT. At ureteroscopy, the stone was retrieved, fragmented and a double J stent was placed Dr Cian McDermott, Mater University Hospital, Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1502563372633-O9GKCR1GR3X11KMYRZDP/ezgif.com-optimize+%281%29.gif Renal/GU - Moderate Hydronephrosis Moderate (grade three) hydronephrosis can be appreciated here with dilation of both the renal pelvis and calcyces. The renal cortex is also thinned. There is not gross atrophy. Dr. Justin Bowra et al. (Dr. Yogi) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515209805730-AS9X4J2Y1M7G50RUML1V/shan+pam+hydro2.gif Renal/GU - Moderate Hydronephrosis 66 yo M with hx of congenital single kidney and prostate cancer presents with suprapubic discomfort x 1 week. Found to be in urinary retention. POCUS allows grading of hydronephrosis based off of the severity of the dilation of the renal pelvis and calyces. Here we see dilated pelvis, ballooning calyces, and cortical thinning. This represents Grade 3, moderate hydronephrosis. Grade 4, severe, would demonstrate further atrophy and loss of borders, occurs with severe hydronephrosis. Rushabh Shah, MD, MBA and Maria-Pamela Janairo, MD - Kings County/SUNY Downstate Emergency Medicine   https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1518776647443-C6QAOCD2KKTF427BOODW/alerhand+severe+hydro.gif Renal/GU - Severe Hydronephrosis with Massive Hydroureter Patient with urinary obstruction with severe hydronephrosis and absolutely massive hydroureter (CT confirmed). Dr. Stephen Alerhand - US Fellow - Mt Sinai Hospital, NYC https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1502561663514-6PQZEX9V2BDRH194N61V/ezgif.com-optimize.gif Renal/GU - Severe Hydronephrosis In this patient with severe hydronephrosis, there is gross dilation of both the renal pelvis and calyces, which are ballooned. The cortex of the kidney has atrophied and is very thin. This is severe, or grade 4. Dr. Justin Bowra et al. (Dr. Browne and Dr. Knights) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497409903526-6ZN7PRQ90D9GQ2ATS7EK/severe+hydro+comp.gif Renal/GU - Severe Hydronephrosis in Prune Belly Syndrome 10 y/o with Prune Belly Syndrome 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1502561881329-4QJ3YAOP3VEMWSPWC7OW/ezgif.com-gif-maker+%281%29.gif Renal/GU - Severe Hydronephrosis 14.9cm long axis In this patient with severe hydronephrosis, there is gross dilation of both the renal pelvis and calyces, which are ballooned. The cortex of the kidney has atrophied and is very thin. Dr. Justin Bowra et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1502560902534-GPNS0C6K4ZTGZPIZU198/ezgif.com-gif-maker.gif Renal/GU - Left Renal Cyst This simple renal cyst can be identified as an anechoic structure with well-defined, thin walls. Sometimes septations can be seen. Large cysts might even demonstrate posterior acoustic shadowing. Dr. Justin Bowra et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1502560651361-H5LHTKEFCPJJSNO0UUP4/ezgif.com-optimize.gif Renal/GU - Bladder Contracted with Indwelling Catheter An echogenic foley catheter with the balloon inflated can be seen floating inside the anechoic urine within the bladder. Dr. Justin Bowra et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1502562987568-0Y5ODKQFEIGST6INJ368/ezgif.com-optimize+%283%29.gif Renal/GU - Ureteric Jet When an obstructing stone is suspected, measurement of the ureteric jets can be performed to see if the ureters are draining into the bladder. In this study, there is no left ureteric jet demonstrating obstruction of the right ureter, and likely an obstructing stone. Renal US is likely to demonstrate hydronephrosis of the right kidney. Dr. Justin Bowra et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1502562400572-JH521X8ZGHDG1KKFGGOQ/ezgif.com-optimize+%282%29.gif Renal/GU - Ureterovesical Junction Stone Twinkle Artifact Twinkling artifacts can be seen on color doppler ultrasounds when applied to stationary, highly echogenic objects, generating a false sense of movement on color doppler. The reason this occurs is unclear. However, this is useful for kidney stones especially when they are in other echogenic environments such as the ureterovesicular junction. This scan demonstrates the twinkle artifact at the UVJ, thus a kidney stone that may have been missed otherwise. Dr. Justin Bowra et al. (Dr. Sutijono) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513455935287-J49M0JCAED2XSKCH3FUS/ezgif.com-optimize+%283%29.gif Renal/GU - Hydroureter with Stone A dilated ureter is visualized posterior to the uterus in this transabdominal POCUS, indicating obstruction. The stone can be directly visualized as a hyperechoic structure in the ureter with shadowing. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513456702001-83ULDCTCWKJVVJ2DIG9B/ezgif.com-optimize+%285%29.gif Renal/GU - Large Prostate In this transverse, transabdominal ultrasound one can see a full bladder and posterior to that a uniformly enlarged prostate suggesting urinary retention secondary to BPH. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513458419789-EQRSMXZ0VEO8UQ6OBA5J/ezgif.com-optimize+%283%29.gif Renal/GU - Renal Cysts Renal cysts can be classified using the Bosniak Classification System based on CT imaging. A category I benign cyst is thin-walled without septations, calcifications, solidifications, nor contrast enhancement. A category II benign cyst is also thin-walled but may contain a few thin septa or calcifications. A category IIF cyst has a small risk of malignancy. It may have a slightly thicker wall, septa or calcifications, but no contrast enhancement. A category III cyst has a significant risk of malignancy and has irregular and thick septa which exhibit contrast enhancement. A category IV cyst (highest risk) has category 3 characteristics with the addition of contrast enhancing soft tissue components. This clip shows septation of one of the cysts suggesting that it is AT LEAST a category 2 cyst. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497405665976-LPH0N532YZFYOO1FUOMF/im_color_16_ezgif-1-f87ca1c0ed.gif Renal/GU - Fournier Gangrene A patient presented for worsening, severe scrotal pain. Point-of-care ultrasound demonstrated a normal appearing testicle with an associated hydrocele. Significant ring down artifact is visualized posterior producing a “dirty shadow”. The patient was taken to the operating room where the ring down artifact was confirmed as significant subcutaneous air associated with a necrotizing infection. By: Michael Schick DO, Emergency Physician   https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507836681868-9ORCPWU8XOBLIONP1F45/pyocele+sexton.gif Renal/GU - Pyocele 83 y/o M with R testicular swelling, tenderness, concern for epididymitis vs orchitis. POCUS with septated fluid collection concerning for pyocele. Pycoeles are a urologic emergency that can lead to Fournier's and often require orchiectomy. Dr. Tess Sexton - Kings County/SUNY Downstate EM https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1525196854712-55265FCWUJIPONNZ99VJ/ezgif.com-optimize%28left_hydro%29.gif Renal/GU - Mild Hydronephrosis Mild - grade two hydronephrosis with dilation of the renal pelvis and dilation of the calyces. Grade one would not include dilated calyces. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1525197088275-IK7XG1GRV5P0SM1X53YA/ezgif.com-optimize+%2825%29.gif Renal/GU - Staghorn Calculi 51yoM with history of staghorn calculi presenting with hematuria and left lower quadrant pain x 3 days. Ultrasound of left kidney in sagittal plane using a phased array 5-1MHz probe demonstrating a large hyperechoic structure in the renal pelvis with associated posterior acoustic shadowing consistent with staghorn calculi. Ultrasound serves as a low-cost, readily available method without radiation which can aid in the detection of renal or ureteral calculi. (Nicolau 2015) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527398321519-56J5B9T1G1GZGP8JGDGF/ezgif.com-optimize+%2841%29.gif Renal/GU - Severe Hydronephrosis - Congenital 16 yo F who is known to have non-neurogenic neurogenic bladder, HTN. Presented to ED with severe bilateral flank pain for 2 weeks, worsening, dull in nature, associated with decreased urination, nausea, vomiting multiple times of food contents. Exam showed severe diffuse abdominal tenderness with bilateral CVA tenderness with light touch. POCUS showed bilateral severe hydronephrosis (L>R) without bladder enlargement. Labs showed elevated creatinine from 1 into 3. Patient then transferred to outside hospital for Pediatric Urology. Dr. Maan Al Dubayan - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527453591039-J4DVDUEU27G54PZHJI2C/severe+hydro+Greenstein.gif Renal/GU - Severe Hydronephrosis An 88 year old female with history of renal stones presented with flank pain and a nonfunctioning nephrostomy tube. Bedside US showed severe hydronephrosis. This is demonstrated by dilation of renal pelvis and ballooning of renal calyces. One calyx measured approximately 15cm. It was later confirmed via CT that the nephrostomy tube had been dislodged and coiled in the abdominal muscles. Dr. Steven Greenstein, Dr. Maan Al Dubayan, Dr. Andrew Aherne - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527453915489-C2ZLTGDCMWDGGHKDOU1D/severe+hydro+no+jets+greenstein.gif Renal/GU - Decreased Right Ureteral Jet An 88 year old female with history of renal stones presented with flank pain and a nonfunctioning nephrostomy tube. Bedside US showed severe hydronephrosis (see other image). Using color Doppler over the bladder, the ureteral jets were evaluated. The diagnosis of obstruction was made, due to the absence of the right jet. Dr. Steven Greenstein, Dr. Maan Al Dubayan, Dr. Andrew Aherne - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1530455943676-542CFJQR8V07F8LRUSQ6/polycystic+kidney.gif Renal/GU - Polycystic Kidney Hydronephrosis, right? Wrong! These are polycystic kidneys! Differentiate the two by looking for communication with the collecting system. Dr. Michael Trauer https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534356904018-OHJB0KMW0J7Z8QQHJ7B5/kidney+doppler.gif Renal/GU - Kidney Doppler This clip shows a kidney with color doppler overlay. Using color doppler is helpful in distinguishing hydronephrosis from prominent renal vasculature which can look similar in 2D mode. In this case, the color flow suggests that what may appear to be a dilated renal pelvis is likely just plump blood vessels. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534357000871-0EEUPN9D6CSDZLMYF3LO/kidney+transverse+.gif Renal/GU - Kidney Transverse This is a clip of the right upper quadrant structures in transverse view. The kidney has a hyperechoic center made up of the renal pelvis and calyces, surrounded by a hypoechoic cortex similar in echogenicity to the liver (seen to the left of the screen). Within the liver we see prominent anechoic vasculature. A dark rib shadow moves across the field as the sonographer fans. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534357078547-F108B1PECP2LUTBI68L8/LUQ+Kidney.gif Renal/GU - LUQ Kidney Long Axis This clip fans through the left kidney in long axis. The hyperechoic central area is the renal pelvis and calyces, the darker hypoechoic area surrounding it is the renal cortex. The renal pyramids are visible as anechoic triangles within the medulla. Deep to the kidney we see the hyperechoic spine;on the left of the screen the spleen comes in and out of view. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534357163130-5D4HVDI3AAM2U6J1C6XB/RUQ+kidney.gif Renal/GU - RUQ Kidney Long Axis This clip fans through the right kidney in long axis. The hyperechoic central area is the renal pelvis and calyces, the darker hypoechoic area surrounding it is the renal cortex. The darker/anechoic spots between the cortex and the medulla are renal pyramids. Deep to the kidney we see the hyperechoic spine. On the left of the screen and superior to the kidney is the liver which has a similar echogenicity to the renal cortex. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534357217442-YC99RMJS2J3EW812AVWP/UVJ+Jets.gif Renal/GU - UVJ Jets This is a clip of the bladder in transverse view with visible ureteral jets. We can use color doppler to help visualize the jets of urine flowing out of the ureterovesical junctions into the bladder. In this case we see the red UVJ jets bilaterally from both ureters, ruling out obstruction proximal to the UVJ. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1554693025451-L3RL8XE14BWU532CSBE1/horseshoe+kidney.gif Renal/GU - Horseshoe Kidney Incidentally found horseshoe kidneys in pelvis joined at the isthmus. Dr. Coneybeare https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607603310688-PFPWOI5GSZKB9RNN46UI/image-asset.gif Renal/GU - Bladder Diverticulum An elderly male presented to the ED following a MVA. Imaging revealed a pelvic fracture. During a FAST exam, the transverse pelvic view revealed a bladder diverticulum. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620834959607-HVY4LVCAD3GDQK144EZU/image-asset.gif Renal/GU - Moderate Hydronephrosis 30s M with no past medical history presented with acute onset right sided flank pain. POCUS demonstrated moderate hydronephrosis of the right kidney with evidence of hydroureter as well. Moderate hydronephrosis is seen here with distension of the renal pelvis as well as distension of most of the renal calyces, with intact renal cortical thickness. This patient had his symptoms controlled and was able to be discharged. Dr. Mark Serpico, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1634789485992-RTSKMROOYAL07B536N2F/Severe+Hydro.gif Renal/GU - Severe Hydronephrosis 30s M PMH HIV, latent TB p/w acute onset flank pain with dysuria. He was found to be febrile and tachycardic. Initial workup was consistent with sepsis due to pyelonephritis. Renal POCUS is shown here, demonstrating severe hydronephrosis, with distortion of the calyceal collecting system as well as thinning of the renal cortex. CT imaging of the abdomen/pelvis demonstrated ureteropelvic junction stenosis causing significant hydronephrosis. Urology was consulted and the patient was admitted for treatment of pyelonephritis as well as further workup of the renal abnormalities. Dr. Nimish Bhatt, US Fellow Denver Health Emergency Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567931550278-ZAIHWANXIB23FZW1OI5U/LUQ-kid-zoom.gif Renal/GU - LUQ Kidney - Colorized Left Kidney Blue: Cortex, Pink: Medulla, Yellow: Spleen, Green: Spine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1673315742950-I2RDDQWC37958NGUMNGJ/image-asset.gif Renal/GU - Subcapsular Renal Hematoma This image demonstrates a subcapsular hematoma of the left kidney (left image) with intraperitoneal hemorrhage (right image). Image courtesy of Cody McIlvain, MD. Resident, Emergency Medicine; Denver Health Residency in Emergency Medicine, Denver, Colorado. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1674668146848-JW1KSWPORU3G31U4H1OS/Pheo+Gif.gif Renal/GU - Pheochromocytoma This image demonstrates an adrenal mass on the right kidney which was a known pheochromocytoma. Image courtesy of Cody McIlvain, MD. Resident, Emergency Medicine; Denver Health Residency in Emergency Medicine, Denver, Colorado. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1677374337045-JG5XA7A8R1CJ2EGV0X0M/MT+Bladder+Diverticulum.gif Renal/GU - Bladder Diverticulum 60s M with past medical history of BPH with chronic indwelling foley catheter was referred to the ED after his foley catheter was noted to be not draining properly after replacement in urology clinic. POCUS demonstrated the foley balloon and distal catheter in a large bladder diverticulum, with resulting urinary retention. Under real time guidance, the balloon was deflated, retracted, and re-inflated in the bladder, and the bladder diverticulum and bladder both decompressed appropriately. Molly Thiessen MD, Attending Physician, Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1677374657896-PHIKF0UG4PTOBVR1PGAS/MH+Bladder+Stone.gif Renal/GU - Bladder Stone 70s M with past medical history of BPH and multiple recent UTIs presented as a referral to the ED after an outpatient CT KUB showed a large bladder stone. POCUS was performed and demonstrates a >3cm bladder stone present which obstructs urinary outflow. The patient was admitted and taken for surgery the next day. Phillip Breslow MD, Resident, Denver Health Residency in Emergency Medicine Mike Heffler MD, Ultrasound Fellow, Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1700074233913-9GWYFK0DBNZ5PLN0OAAH/Ureteral+jets+-+Milgrim_Bolotnikov.Fin.gif Renal/GU - "Light Saber Sign” Ureteral Jets A 48-year old male presented to the ED with lower abdominal pain and flank pain presented to the ED. A renal and bladder point-of-care ultrasound was done to evaluate for hydronephrosis which revealed distinct bilateral ureteral jets, which we dubbed the “light saber sign.” Dr. Jannie Bolotnikov, PGY-1, Denver Health Emergency Medicine Residency Dr. Fred Milgrim, Ultrasound Fellow, Denver Health Emergency Medicine https://www.thepocusatlas.com/ocular daily 0.75 2025-01-27 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1738005363747-419OLXGR994KHJ2FZDGX/image-asset.gif Orbital - Retinal Edema (2/2 - Clip) 17 y/o female with sudden onset bilateral blurry vision after prolonged indoor cat exposure. Fundoscopy showed retinal pigment epithelium loss consistent with bilateral neuroretinitis from cat scratch disease (Bartonella henselae). The hyperechoic retina, normally flush with the posterior aspect of the globe, is seen separated by a hypoechoic band of edema. Retinal edema from cat scratch disease is rare (Gen Opth 19th ed. 2017:378-422), but can be diagnosed by POCUS. Contributed by: John Hipskind, MD, Ultrasound Director, Kaweah Health EM Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1738005363747-419OLXGR994KHJ2FZDGX/image-asset.gif Orbital - Retinal Edema (2/2 - Clip) 17 y/o female with sudden onset bilateral blurry vision after prolonged indoor cat exposure. Fundoscopy showed retinal pigment epithelium loss consistent with bilateral neuroretinitis from cat scratch disease (Bartonella henselae). The hyperechoic retina, normally flush with the posterior aspect of the globe, is seen separated by a hypoechoic band of edema. Retinal edema from cat scratch disease is rare (Gen Opth 19th ed. 2017:378-422), but can be diagnosed by POCUS. Contributed by: John Hipskind, MD, Ultrasound Director, Kaweah Health EM Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1738005195408-QMOAFXFMO8TI3KB1GKNU/image-asset.png Orbital - Retinal Edema (1/2 - Still) 17 y/o female with sudden onset bilateral blurry vision after prolonged indoor cat exposure. Fundoscopy showed retinal pigment epithelium loss consistent with bilateral neuroretinitis from cat scratch disease (Bartonella henselae). The hyperechoic retina, normally flush with the posterior aspect of the globe, is seen separated by a hypoechoic band of edema. Retinal edema from cat scratch disease is rare (Gen Opth 19th ed. 2017:378-422), but can be diagnosed by POCUS. Contributed by: John Hipskind, MD, Ultrasound Director, Kaweah Health EM Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1737044088619-9XVYYH60UMH782V3EJN5/image-asset.gif Orbital - Diagnosis of CRAO on POCUS This point-of-care ocular ultrasound was obtained on an elderly female presenting with complete unilateral vision loss. This image demonstrates a "spot sign", which is a hyperechoic density seen at the distal aspect of the optic nerve, representing an embolus within the central retinal artery. Expedient diagnosis and treatment of central retinal artery occlusion has the potential to save vision to the affected eye. Anthony Capraro, Kevin Kucharski, Tyler Madison https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1723582476269-1KCFVF5AM1JSVT3WCAJC/image-asset.gif Orbital - Intraoccular Lens Subluxation A 50 year old male with a prior history of bilateral intraoccular lens (IOL) transplants presented to our ED with sudden onset foggy vision in his right eye while getting out of the shower. He was unable to participate in visual acuity due to the extent of his blurred. POCUS demonstrated “iridodonesis” and a provisional diagnosis of IOL subluxation/dislocation was made. Ophthalmology was consulted and confirmed the diagnosis. Dr. Piaseczny, PGY4 Emergency Medicine, Queen's University, Kingston, Ontario, Canada https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1643331402605-VDMDC4OD73NVMOKA2DB5/image-asset.gif Orbital - Retinal Detachment - Test This is a test Mike Macias (Twitter handle) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735240843512-FEW2RUXJUXNFUTLSE1CM/image-asset.gif Orbital - Prosthetic Ocular Lens Subluxation This patient presented with decreased vision on a background of advanced macular degeneration. VA in the eye had decreased from 20/150 to 20/400 on presentation. Interestingly the patient stated "I think my ocular lens has displaced." Contributed by: Colin Bell, FRCPC, DPSPC https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727557815605-NSCS5UEAQJRGOYQEKTDJ/image-asset.gif Orbital - Phthisis Bulbi secondary to end stage eye disease 93 year old male with established end stage eye disease found incidentally to have prominent Phthisis Bulbi made evident by a heterogeneous hyper-echoic structures (calcifications) within the posterior chamber of the left eye. Contributed by: Davis, Lindsay; Schlangen, Alex; Welch, Matthew https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1721952605596-LONENGJEPKUQ0ROMF4VQ/image-asset.gif Orbital - Papilledema From Optic Pathway Glioma A 24-year old male presented to the ED with a six-month history of progressive total right vision loss. A bedside ocular ultrasound examination was performed that revealed an elevated optic disc with enlarged ONSD measuring 9.7mm, consistent with papilledema. An MRI of the head confirmed an enlarged intraconal portion of the right optic nerve, consistent with glioma. Marko Lubardic, MS4; Tom Taugher, DO, PGY3; Michael Bernard, DO, PGY1; Central Michigan University Emergency Medicine Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1734651007069-SVFXSS6JB16A5DYC4XKZ/image-asset.gif Orbital - Old Globe Rupture Irregularly shaped eye with internal dense structure concerning for intraocular hematoma. This patient had a history of previous rupture of the globe. A CT Head without IV contrast described the left eye as follows: Small left globe with high density concerning for intraocular hemorrhage. Direct examination is recommended. Halimah Hamidu-Egiebor Central Michigan University College of Medicine MD-MBA '24, Arthur Sieron Central Michigan University Emergency Medicine Resident, Eric 'Dax' Spencer Central Michigan University Emergency Medicine Resident https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1729304396452-7JZV1IHPEU7XSG18DR6L/image-asset.gif Orbital - Vitreous Detachment This was from a 52 year old male with a recent surgical history of vitreous detachment that became a retinal detachment. He presented to the emergency room for vision changes in same eye after an object fell and hit his head. Ocular ultrasound was performed at the bedside which revealed a new vitreous detachment. Important to note here that it is crucial to fan/tilt through the entire eye, making sure to visualize the optic nerve in order to differentiate between a vitreous and retinal detachment. In this case, notice how the lesion spotted in the chamber does not connect to the optic nerve, which is consistent with a vitreous detachment. Dr. Christopher Paulo, DO, PGY-1 Riverside Regional Medical Center Emergency Medicine Program (Newport News, VA) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1730935856494-EDO4Y5VE76YOSXJSGPN6/CRAO_CP.gif Orbital - Central Retinal Artery Occlusion This is from a 63 year old female who initially presented to the emergency department with vision loss over the last 24 hours. She reported bending over when she experienced complete vision loss from one of her eyes. Point of care ultrasound was performed, locating the optic nerve, but more interestingly a hyperechoic structure within the nerve (spot sign). Overall, this is was suggestive of a central retinal artery occlusion. In this sort of situation, color doppler can also be utilized to assess for arterial versus venous occlusion. Dr. Christopher Paulo, DO, PGY-1 Riverside Regional Medical Center Emergency Medicine Program (Newport News, VA) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1726165413727-E14IYAYVBHPQPW01UCXB/image-asset.gif Orbital - Orbital Endophthalmitis A 43 year old male with 3 days of painful right eye vision loss, fever, and URI symptoms presented to the emergency department. POCUS demonstrates echogenic swirl within the vitreous cavity. The patient was diagnosed with endogenous endophthalmitis caused by Klebsiella Pneumoniae. Contributor: Hyun J. Yi (John), D.Sc, PA-C, MAJ, USA, Emergency Ultrasound Fellow, Madigan Army Medical Center, Joint Base Lewis-McChord, WA https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1725917223031-OOV9VEZIKB3J10SXWB1B/image-asset.png Orbital - Enlarged Optic Nerve A 75 year old male with history of ocular melanoma and blindness of the right eye presented for right sided headache and nausea for the past 2 days. Ocular US was performed demonstrating significant enlargement of the optic nerve sheath. Contributors: Michael Bernard, DO; Thomas Taugher, DO; Marko Lubardic Central Michigan University Residency of Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1665094406220-YT74UPZAOIMFYSX1YYOC/image-asset.gif Orbital - Lens Subluxation Middle aged male with prior bilateral lens replacement presented with atraumatic vision loss. POCUS performed that demonstrates subluxed lens without retinal detachment. Discussed with ophthalmology and pt was discharged with 24 hour follow up with ophthalmology, with eventual plan for operative repair. Michael Maurantonio, PGY3, Denver Health Residency in Emergency Medicine Michael Del Valle, Fellow, Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1674673649200-M2KZO33TGXAQX64A7XSA/image-asset.gif Orbital - Metallic Foreign Body In Orbital Soft Tissue This is a clip from a patient presenting with foreign body sensation. They had a piece of metal hit their eye a week ago. Previously seen for complaint but told no foreign body seen on exam. On ultrasound clip a hyperechoic structure can be seen adjacent to the globe. Note that with dynamic eye movements the foreign body does not move suggesting this is outside of the globe. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659119543674-LH6H1F7R61RHH5C1IL8H/image-asset.gif Orbital - Anterior Lens Dislocation and Retinal Detatchment 46 yo woman pmh multiple right eye surgeries presenting with atraumatic left eye pain, decreased vision, and mydriasis, which was initially concerning for acute angle-closure glaucoma. POCUS revealed anterior lens subluxation given the very shallow anterior chamber. Around 5% of acute angle-closure glaucoma is induced by lens subluxation. Retinal detachment, the hyperechoic line in the far field, can also be seen on POCUS. Ophthalmology successfully treated her with lensectomy and secondary intraocular lens implantation. Robert Adrian @RobertAdrianMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625848084915-Q5SIORE8GNFGQ91W5ERL/image-asset.gif Orbital - Ruptured Globe This patient sustained blunt trauma to the eye from a fireworks injury. CT scan performed prior to POCUS showed intra-orbital hematoma and complete absence of any globe tissue. The patient was taken to the OR for primary enucleation, washout, and closure. Earl “Quinn” Cummings, MD @resus_bae Assistant Professor; MUSC Emergency Medicine/Ultrasound; MUSC Pediatric Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623697240672-CHE5LMW1AXJAL3TYAINX/image-asset.gif Orbital - Retinal Detachment Retinal Detachment. Francisco Norman https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1619460539761-CD2T4KMNV5N9QDENVOHJ/image-asset.gif Orbital - Vitreous Hemorrhage An 81 yo female on ASA presented with 6 hour hx of blurred vision in her right eye. Ocular POCUS demonstrated a hyperechoic clot, seen here as 'swirling' movement, with debris settling near the bottom of the globe when eye is not in motion (end of clip). In early presentation of vitreous hemorrhage when blood is still liquified, increasing the ultrasound gain can greatly assist with identification of pathology. Mandy Peach, MD @mandy_peach Saint John Regional Hospital. NB, Canada https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1619456816450-A2VG40SXMCGI4VN641S4/image-asset.gif Orbital - Normal ONSD A 35 yo female presented to a rural ED with worsening headache accompanied by nausea/vomiting after failed treatment for sinusitis. The department did not have immediate access to CT scanning, therefore Optic Nerve Sheath Diameter (ONSD) was used to assess for associated increased intracranial pressure. The optic nerve sheath is contiguous with the subarachnoid space, making ONSD an indirect measure of intracranial pressure. Visualize the hypoechoic optic nerve posterior to the globe and measure 3mm back from the globe (calipers A) to determine site of measurement . Then measure to the edges of the sheath (calipers B) horizontally. Value >5mm is concerning for increased ICP. This ONSD is normal. Mandy Peach, MD @mandy_peach Saint John Regional Hospital. NB, Canada https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1619466450620-SORM3EBMKHQ61NGJTU3F/image-asset.gif Orbital - Vitreous Hemorrhage due to Proliferative Diabetic Retinopathy A 70-year-old man presented with loss of vision to his right eye (hand motion and light perception). He takes warfarin and has diabetes. Monocular vision loss triggered a POCUS that revealed a hazy echogenic substance (consistent with blood) seen best when patient activates extra-ocular muscle movements. Also note the associated bright linear structure within one portion of the bleed, the hyaloid membrane. This patient was subsequently assessed by the Eye Hospital and diagnosed with vitreous hemorrhage due to proliferative diabetic retinopathy. Peter Cheng https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616116010452-4OI6MM2EOTIOIIPZ5EC1/image-asset.gif Orbital - Retrobulbar Hematoma Patient experienced ocular trauma 3 days prior to this exam, having been struck with a baseball to the eye. Notice the hypoechoic area within the retrobulbar space, consistent with a retrobulbar hematoma. Tomasz Przednowek & Jereme Long @jplongest https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616083049107-XXPGAOEHK96R0K4RLK25/image-asset.gif Orbital - Vitreous Hemorrhage A 71-year-old male with a history of hypertension and diabetes presented to the ED reporting gradual vision loss in his right eye over a 3-day period. Physical exam was notable for a 3 mm and nonreactive pupil with ipsilateral visual acuity reduced to patient only being able to detect movement. POCUS revealed swirling echodensity within the right eye, most appreciable with extraocular muscle movements. Ophthalmology subsequently confirmed our suspected diagnosis of vitreous hemorrhage. Richard Cunningham, MD @HappyDays_EM Maricopa Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1602185010345-DJAULLXXRJFBWBXSSBQ7/image-asset.gif Orbital - Endogenous Endophthalmitis A middle aged female with ESRD and longstanding percutaneous HD catheter with recent MSSA bacteremia was admitted with septic shock. She subsequently developed subacute bilateral visual loss (OS > OD). Clinical suspicion of endogenous endophthalmitis was initially supported by POCUS notable for heterogenous intraoccular material within vitreous. She was immediately started in intravitreal antibiotics in addition to previously initiated systemic antibiotics. Diagnosis of endogenous endophthalmitis was subsequently confirmed by vitrectomy. Tessa W. Damm, DO Intensivist, Critical Care Medicine & Neurocritical Care. Wisconsin, USA. @DrDamm https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1633291310834-QBT96UZCCD7ISO7X6LVH/AA+Retinal+Detachment.gif Orbital - Spontaneous Retinal Detachment 30s M with no known medical history or ocular history presented with 2 days of progressive monocular visual field deficits and floaters without antecedent trauma or other injury. Visual acuity was limited to finger counting at 3 feet in the affected eye. POCUS of the affected eye is shown here, demonstrating a macula-off retinal detachment. The patient was seen by ophthalmology and had urgent surgery the next morning. Dr. Amy Allen, PGY1 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1595001149200-DM3WEC5DMRTR41LJAT59/image-asset.gif Orbital - Asteroid hyalosis (an ultrasonographic mimic of vitreous hemorrhage) An 59-year-old male with PMH of ESRD presented with 10-day hx floaters in his right eye. Sonographic findings are shown, notable for multiple, mobile, hyperechoic densities that swirled rapidly with eye movement. The appearance is similar to that of vitreous hemorrhage. The patient was subsequently evaluated by ophthalmology who confirmed a diagnosis of asteroid hyalosis; a rare, benign condition of calcium phospholipid deposition within the vitreous fluid. The sonographic findings are so similar to vitreous hemorrhage that the two are commonly mistaken for each other. The clinical differentiation is that asteroid hyalosis is most often asymptomatic, and almost always without visual deficits (possibly benign floaters). These patients also rarely require vitrectomy. In addition to clinical presentation, asteroid hyalosis can be differentiated from vitreous hemorrhage by subtle sonographic features. In asteroid hyalosis, the hyperechoic calcium phospholipid particles have a sparkling, "starry sky" appearance compared to the typically duller heterogenous blood seen in vitreous hemorrhage. Vicky Lam, MD, MS; Christianna Sim, MD; Olusola Sanusi, MD Kings County Hospital, SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592916231440-HE1HW390LIXP5I19MU8G/image-asset.gif Orbital - Retrobulbar Hematoma A 65-year-old patient presented with sudden-onset headache with associated right eye pain and diplopia. Physical exam also notable for an unsteady gait, exophthalmus, and impaired EOM including absent upward and medial gaze of right eye. Orbital POCUS revealed a retrobulbar hematoma causing external compression of the optic nerve. Marco Garrone, Emergency Medicine Physician @drmarcogarrone https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592313699863-0TC575I1IPE5YR7X4ISW/image-asset.gif Orbital - ONSD Double Take We used OSND to evaluate a patient with COVID-19 encephalitis and found evidence of increased intracranial pressure (ICP). Note, due to the high frequency probe used, we were able to appreciate fine detail including two hypoechoic boarders at each lateral edge of the optic nerve. It is the most lateral outer edge/ hypoechoic structure that represents the optic nerve sheath. Eric M. Siegal, MD, SFHM, FCCM Aurora Critical Care Service; Milwaukee, WI Adjunct Clinical Professor of Medicine University of Wisconsin School of Medicine and Public Health https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592251887870-HU5LMO6TG6QD486D8N4Q/image-asset.gif Orbital - ONSD normal ICP Patient presented with fall from standing height with resultant traumatic subarachnoid hemorrhage (SAH). POCUS of ONSD is reassuring in that ONSD is <5 mm, suggestive of no associated elevated intracranial pressure. Tessa W. Damm, DO. Intensivist. Milwaukee, WI @DrDamm https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592248888077-4Z15Z4C4HLHCBFRUPCH4/image-asset.gif Orbital - ONSD for ICP A patient presented with spontaneous intracranial hemorrhage (ICH) secondary to arteriovenous malformation (AVM). She reported severe HA for 3 days with progressive somnolence and associated vomiting. Assessment of her ONSD revealed a width just >5 mm, consistent with an elevated intracranial pressure (ICP). Tessa W. Damm, DO. Intensivist. Milwaukee, WI @DrDamm https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1591822736014-70ZZSFTVU8U1NZHEENKW/image-asset.gif Orbital - Papilledema A 27 year-old female presented to the emergency department with a two week history of headache, posterior eye pain, and visual changes. A bedside ultrasound was performed demonstrating a dilated optic nerve sheath and a bulging optic disc protruding into the posterior chamber consistent with papilledema. A CT of the head was unremarkable and an LP was performed with opening pressure of 36 mmH2O consistent with intracranial hypertension. Image courtesy of Dr. Amir Aminlari Ultrasound Fellowship Director, University of California San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1591822235899-BRVUOGL0GSW4UWDIR10I/image-asset.jpeg Orbital - Measuring Optic Nerve Sheath Diameter When evaluating for elevated intracranial pressure using optic nerve sheath diameter, (ONSD), proper measurement should be obtained 3 mm posterior to where the optic nerve engages the retina. Image courtesy of Dr. Tessa Damm (@DrDamm) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533326174819-PUI4PJLYNRTF5Y6LNO0C/lense+replacement.gif Orbital - Lense Replacement 60 year-old woman with longstanding history of severe cataracts presenting 5-months s/p cataract extraction with intraocular lens placement (CEIOL). Ultrasound exam demonstrates a linear echogenic structure posterior to the iris with reverberation artifact in place of normal lenticular structure (native lens) consistent with artificial lens. Image acquired by Robert J. McMickle (Medical Student IV, UCLA) under guidance of Yiju Teresa Liu, M.D., RDMS at Harbor-UCLA Medical Center. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533300778567-DEE244SC2NYZ3GKCIO7T/consensual+light+reflex.gif Orbital - Consensual Light Reflex Seen is the constriction of the Pupillary Sphincter when a light is shone on the contralateral pupil, demonstrating the Consensual Pupillary Reflex. In the setting of severe Orbital trauma and swelling, POCUS may be used to assess this reflex arc. Dysfunction in the arc may be associated with pathology at the Retina, Midbrain, Optic, and/or Oculomotor nerve. Dr. Mohamed Elfatihi and Dr. Surriya Ahmad - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523825119971-I1X8B7UNXWR47JDYGMS2/ezgif.com-optimize+%2817%29.gif Orbital - Posterior Vitreous Hemorrhage Posterior Vitreous Hemorrhage Painless visual field cut with position change. Posterior vitreous hemorrhage with organization and dynamic movement gong over the top of the optic nerve, but not involving it to suggest retinal detachment. Dr. Dustin Morrow https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1519836856725-MK1YTSSKKMSFJXK3IY94/ezgif.com-gif-maker.gif Orbital - Orbital Abscess Orbital cellulitis evolving into abscess in diabetic patient. Multiple pus collections are visible on the medial side. Dr. Marco Garrone https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1511632510030-0UWKPGEK3WIBBJIMLPNN/Sukh+-+ocular+look+around.gif Orbital - Looking Around - Normal Exam Normal ocular ultrasound over closed eyelid as patient moves eye medially and laterally. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1511633933727-6PPX9LL0Z0P2REWILNAH/Sukh+-+Retinal+Detachment.gif Orbital - Retinal Detachment Here a hyperechoic linear density is seen arising from the location of the fundus, indicating retinal detachment. Posterior vitreous detachment and vitreous hemorrhage can look similar to retinal detachment. Given the imminent risk of blindness in these conditions it is essential to identify them as soon as possible. POCUS is an excellent way to do so given the time and skills required to perform a proper fundoscopic exam. Literature has shown sensitivity for this test to be 97-100% and specificity 83-100%. So next time ask yourself... is your fundoscopic exam that good? Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514851671869-E5KTL5ZI6Y7BFVXEM5EJ/segarra+retinal+detach%3Ahemorrhage+2.gif Orbital - Retinal Detachment with Vitreous Hemorrhage 34 y/o M with acute, atraumatic, painless, complete vision loss in the right eye x3 days, with an eye exam showing opacification of the right pupil and no light/dark perception. Ocular POCUS revealed a complete retinal detachment (RD) with a classic funnel shape. The funnel shape is caused by strong attachments of the retina to the optic nerve posteriorly, and to the ora serrata anteriorly. POCUS has been shown to have sensitivity 91-100% and specificity 68-96% for RD. In this image, the hyperechoic area within the funnel suggests an associated vitreous hemorrhage (VH), 30% of which are caused by retinal tears (RT). In fact, in patients with fundus-obscuring VH like our patient, 67% and 39% will have an associated RT or RD, respectively. Dr. Theodore J. Segarra, Dr. Stephanie Garcia, Dr. Nayla Delgado-Torres. SUNY Downstate/Kings County Emergency Medicine. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1499135578545-TKFTCDE182KYJAGQXYWK/ezgif.com-optimize%28Vitreous_Detachment%29.gif Orbital - Vitreous vs. Retinal Detachment A 44 year old man came to ED with a shimmering effect in his left eye and unilateral temporary painless visual disturbance. He had previously been treated for a retinal tear. Ocular PoCUS shows a frond-like linear structure lifting away from the posterior surface of the globe. Posterior vitreous detachment (PVD) was suspected while retinal detachment (RD) was also considered. PVD was confirmed by the specialist team and the patient was treated conservatively. Dr. Cian McDermott, Emergency Physician - University Hospital Geelong, Australia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514851125408-5M9Z2KEY99G7EQPFNS9T/roseman+retinal+detachment.gif Orbital - Retinal Detachment 65 y/o F PMH DM with sudden onset flashes of light and floaters followed by progressively worse blurred vision in her right eye. She has history of cataracts surgery as well as DM retinopathy. POCUS of affected eye shows a prominent hyper-echoic linear density floating freely above the posterior fundus as shown. Retinal Detachment is considered one of few emergencies whereby the retina becomes detached from the choroid. Once separated from the choroid’s blood supply, retinal ischemia ensues which can result in complete blindness in the affected eye. Salvage of such a potentially devastating injury relies on quick and efficient diagnosis with subsequent referral to definitive care. Bedside ultrasound has been shown to be 100% sensitive as a screening tool for RD [AEM 2010 Sep;17(9):913-7]. Have patient close eye and place liberal amount of gel either directly over eye or atop a tegaderm dressing. Use a linear probe and scan eye in axial plane to reveal findings demonstrated above. Dr. Eric Roseman - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515005942868-193FHAXT92CSCTGKH2PO/ezgif.com-optimize+%283%29.gif Orbital - Retinal Detachment Retinal detachment in a patient with 1 day of a right sided visual field cut.Literature has shown sensitivity for this test to be 97-100% and specificity 83-100%. So next time ask yourself... is your fundoscopic exam that good? Dr. William Scheels https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514851351369-ZE2QCZLMLLDA6QHIXXFT/lens+dislocation.gif Orbital - Lens Dislocation Patient with severe maxillofacial trauma of unclear etiology. Ocular POCUS demonstrates a biconvex structure with a hyperechoic rim consistent with traumatic lens dislocation. Dr. Joshua Schechter - SUNY Downstate/Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514670262904-4GM6GI5SJYEORXQNLSMK/Vitreal+Hemorrhage+Riscinti+Conrad.gif Orbital - Vitreous Hemorrhage - Washing Machine Sign 47 y/o M with coronary artery disease on aspirin/clopidogrel with 4 days of decreased vision in his right eye. POCUS demonstrates swirling, amorphous echogenicities known as "the washing machine sign." If the eye remains still the blood will settle with gravity. Fundoscopic evaluation by ophthalmology confirmed the diagnosis of vitreous hemorrhage. Dr. Matthew Riscinti and Dr. Taylor Conrad - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514855984781-2X575JI17RLER5ONIK4I/Central+Retinal+Artery+Occlusion+venous+and+arterial+flow+-+Schechter.gif Orbital - Central Retinal Artery and Venous Flow - Normal Venous and arterial flow can be seen in this color flow doppler image. Dr. Joshua Schechter - SUNY Downstate/Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514856196906-FUG64OLXYMGE9IMGE8NE/Central+Retinal+Artery+Occlusion+venous+flow+-+Schechter.gif Orbital - Central Retinal Artery Occlusion Only venous flow can be appreciated in this color flow image. The central retinal artery has been occluded. Dr. Joshua Schechter - SUNY Downstate/Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514909101645-FKDWQH46F5GS19NQL1ZS/papilledema.jpg Orbital - Assessment Using Ultrasound for Elevated Intracranial Pressure Elevated intracranial pressure can be assessed reliably with POCUS. Find the optic nerve and measure 3mm back from the posterior globe. From here measure the optic nerve from inner wall to inner wall. the normal width is < 5 mm. A systematic review and meta-analysis found POCUS has a sensitivity of 96% and specificity of 93% for increased intracranial pressure. J Ultrasound Med. 2015 Jul;34(7):1285-94. doi: 10.7863/ultra.34.7.1285. Dr. Matthew Riscinti - Kings County/SUNY Downstate Emergency Medicine - Image from the Department of Emergency Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534891382819-PW0G50D3LC0FYSJROQ4P/normal+eye+anaomy.gif Orbital - Normal Eye Anatomy This image of the eye shows the following structures, from superficial to deep: eyelid, cornea (hyperechoic), anterior chamber (anechoic), iris (hyperechoic), lens (hyperechoic), vitreous (very large anechoic area), retina (flush with the posterior wall of the globe, not visible as a distinct structure under normal conditions), optic nerve sheath (hypoechoic structure extending midline perpendicularly from the globe at the bottom of the image). Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537196472092-9MNR0TQ86958N1RQSM6E/vitreous+detachment+.gif Orbital - Vitreous Detachment 40 year old male with 6 months of decreased vision from his left eye. No pmh or history of trauma. VA was obviously decreased relative to the contralateral eye. POCUS rapidly revealed a freely floating hyperechoic membrane consistent with vitreal detachment. To differentiate between a vitreous and retinal detachment you must look to see if the membrane is attached to the hypoechoic optic nerve. The retinal is continuous with the optic nerve therefore stays attached to the optic nerve in a retinal detachment. A vitreous detachment would be completely untethered as seen in this image. You can also see the “washing machine sign” better pictured in other images in this gallery. Matt Riscinti, MD Bryan Flores, MD - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1540916992814-JNB8RWNSE90RW1LBI3U2/sq+air+eyelid+.gif Orbital - Subcutaneous Emphysema - Eyelid Eyelid subcutaneous emphysema detected on US ocular scan Dr. Marco Garrone https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620835200689-ROD09XCPV86YF7ANJC98/image-asset.gif Orbital - Retinal Detachment 52M PMH L cataract surgery presented with painless left eye vision loss preceded by flash. POCUS performed in the ED demonstrated a left sided retinal detachment with macula attached (“mac-on”), with retinal hemorrhage as well. Ophthalmology was consulted, and the patient was taken urgently to the OR for vitrectomy and retinal repair. Dr. Michael Kidon, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1627503443638-0PAZQ25A5CLFARM2BVMZ/image-asset.gif Orbital - Macula Off Retinal Detachment 70s F with PMH DM, HTN presented to the ED with 1 month of atraumatic, painless vision loss. Her visual acuity was limited to light perception only. POCUS was performed and is shown here. This clip of the eye is obtained with the left of the screen being medial/nasal, and the right of the screen being lateral/temporal. An irregular hyperechoic line is shown in the posterior chamber, which is attached to the optic disk, representing a detached retina. The patient’s presentation with profound painless vision loss, and detached lateral aspect of the retina is consistent with a macula off retinal detachment. Given the timeframe and POCUS findings, the patient was scheduled for urgent but nonemergent ophthalmology follow up for operative repair of the detached retina. Dr. Cody Brevik, PGY4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1627503648539-FHHMQAQMNNELJ8EVREM7/image-asset.gif Orbital - Macula Off Retinal Detachment with Vitreous Hemorrhage 50s M with PMH cataract surgery presented with sudden onset flashing and floaters in his eye, followed by painless vision loss. His visual acuity was limited to light perception only. A still POCUS image is shown here, with an irregular hyperechoic line in the posterior chamber which is attached to the optic disc, representing a retinal detachment. Scattered hyperechoic areas are seen in the posterior chamber anterior to the retina, likely representing vitreous hemorrhage. The presentation with profound painless vision loss and retinal detachment on the medial and lateral aspects of the retina suggests involvement of the macula (“macula off” retinal detachment). This patient was evaluated by ophthalmology in the ED and was taken for operative repair. Dr. Michael Kidon, PGY4 Denver Health Residency in Emergency Medicine https://www.thepocusatlas.com/hepatobiliary daily 0.75 2025-05-24 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735414651871-N8LVIHMQLTZGQ8YOQMRX/image-asset.gif Biliary - Drainage Tube Within Loculated Liver Collection Drainage tube within a located liver fluid collection. Contributors: Dimitri Livshits, DO; Jane Belyavskaya, MD; Chris Hanuscin, MD Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735414651871-N8LVIHMQLTZGQ8YOQMRX/image-asset.gif Biliary - Drainage Tube Within Loculated Liver Collection Drainage tube within a located liver fluid collection. Contributors: Dimitri Livshits, DO; Jane Belyavskaya, MD; Chris Hanuscin, MD Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735412235586-JYFYTL2279NPMOGP3I03/image-asset.gif Biliary - Loculated Collection Within Liver Located collection within the liver consistent with likely liver abscess. Contributors: Dimitri Livshits, DO; Jane Belyavskaya, MD; Chris Hanuscin, MD Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1728883282342-87F9ZQFLQ314C6WAFAAC/image-asset.gif Biliary - Thick Walled Gallbladder in Dengue Fever (Short Axis) [2/2] A 28 year old female comes to the ER with fever, myalgia, hypotension, and abdominal pain. This case illustrates one of the ultrasound findings in Dengue Fever in the Leakage Syndrome Stage. We can see a large, thick-walled gallbladder and the presence of pericholecystic fluid. This clip demonstrates the gallbladder in short-axis view. Contributor: Renato Tambelli (@R_Tambelli @JediPocus) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1728882762911-WS6YZE9IZ5WVP4XD8BX1/image-asset.gif Biliary - Thick Walled Gallbladder in Dengue Fever (Long Axis) [1/2] A 28 year old female comes to the ER with fever, myalgia, hypotension, and abdominal pain. This case illustrates one of the ultrasound findings in Dengue Fever in the Leakage Syndrome Stage. We can see a large, thick-walled gallbladder and the presence of pericholecystic fluid. This clip demonstrates the gallbladder in long-axis view. Contributor: Renato Tambelli (@R_Tambelli @JediPocus) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1728168248301-305J8KWJ8AGIP5MBTFP0/image-asset.gif Biliary - Pyogenic Liver Abscess with Pleural Effusion A elderly female with severe sepsis with E. coli bacteremia initially thought to be from urinary source developed worsening hypoxia overnight. Using a Butterfly US, a moderate-sized right pleural effusion with associated ~6cm liver abscess is seen. These images helped mobilize pulmonology and IR to place a chest tube and hepatic drain, which led to resolution of hypoxemia and sepsis. Hepatic drain cultures grew E coli. Although one may appreciate a diaphragmatic defect on the image, the pleural fluid remained sterile. POCUS in this case led to successful identification of the true sepsis source and associated pleural effusion as a complication of pyogenic liver abscess. Contributors: Eric Reid, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1670120227889-60C6YLFTN4L1N85L0OZU/image-asset.gif Biliary - Gallbladder cancer Patient presented with right upper quadrant pain. Clip shown demonstrated what appeared to be sludge however it was non-mobile and color doppler demonstrated internal flow. Further work up revealed gallbladder malignancy. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1667328489906-SCCQM9KQN9EA7U0WRQY3/image-asset.gif Biliary - Dilated cystic duct and spiral valves of Heister Patient originally presented with right upper quadrant to mid epigastric pain with jaundice. An obstructing mass can be seen at the head of the pancreas along with intra-heaptic and extra-hepatic duct dilation. The “candy cane” appearing structure is the dilated cystic duct with spiral valves of Heister visible. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1667324988186-QUO3J9USJ6RXLNQCQN3R/image-asset.gif Biliary - Incidental Hepatic Arterial Calcification An elderly patient presented with abdominal pain and hypotension. On eval of liver a linear intrahepatic hyperechoic area was seem consistent with hepatic artery calcification. Pneumobilia and portal venous gas would be include in differentials however pneumobilia would present with air more centrally while portal venous gas would be more peripherally. Here is an example of pneumobilia. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661615315501-NRGMSHXBWAERW1VWJ4TQ/image-asset.gif Biliary - Gangrenous Cholecystitis Stone trapped in cystic duct resulted in gallbladder distention as well as sloughing of intraluminal membranes. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644521235883-GG3X2ZS9MECQS8JA1W6E/image-asset.gif Biliary - Gallbladder Polyp 51 year old male with a chief complaint of RUQ abdominal pain for 3 days with associated nausea and vomiting. The curvilinear probe was used to evaluate the gallbladder for stones or other pathology. A gallbladder polyp at the neck was discovered (also subsequently confirmed on abdominal CT). Lindsay Davis, DO, MPH, @Lindsadavis18 Lydia Mansour, DO Emily Nagourney, MS4 Central Michigan University https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644521746084-LA5UCAVXYPSNRZIHMME8/image-asset.gif Biliary - RUQ Color Doppler 51 year old male with a chief complaint of RUQ abdominal pain for 3 days with nausea and vomiting. When looking to evaluate the aorta, IVC or gallbladder and you find multiple anechoic structures you can you use color doppler to help determine which structures have pulsatile blood flow, non-pulsatile or no flow in a effort to distinguish these anatomic structures. Lindsay Davis, DO, MPH, PGY1; @Lindsadavis18 Lydia Mansour, DO, PGY3 Emily Nagourney, MS4 Central Michigan University Emergency Medicine Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638994651721-FDQGLM7E0TPMHZU9XYG9/image-asset.gif Biliary - Hepatic Abscess A 50-year-old male presented with right upper quadrant pain, vomiting, and fever. A point-of-care ultrasound demonstrated a large, approximately 20cm heterogenous, well-demarcated mass in the liver. CT scan confirmed the presence of an abscess. IR-guided drainage yielded "anchovy paste" purulent aspirate, which later grew out Entamoeba histolytica. Amebic liver abscesses are the most common form of extra-intestinal amebiasis, but abscesses can also form in the lung and brain. He was treated with metronidazole without complications. Mark Zhang https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638990688932-5XWJ838X8963Z2DNQ938/image-asset.gif Biliary - Cholelithiasis - Impacted Stone It’s fundamental to study the gallbladder in its whole extension. In this image, there is an impacted stone at the neck. Dr. Felipe Urriola P. www.thepocus.com https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638990280262-IQV680Q7H3CQLFJ86FGQ/image-asset.gif Biliary - Cholelithiasis - Multiple Stones The gallbladder is studied in both planes, revealing multiple small stones generating acoustic shadowing. Dr. Felipe Urriola P https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638996892692-QAQEI7I31IQM3J4UCRGI/image-asset.gif Biliary - Distended Gallbladder Elderly male with history HTN, DM presented with jaundice and elevated LFTs, bilirubin, and alkaline phosphatase. POCUS showed distended gallbladder with normal wall thickness, and some areas of increased echogenicity in the gallbladder which may represent debris. Patient was later found to have a proximal pancreatic mass likely compressing bile ducts and causing distention of gallbladder and elevated lab findings. Hannah Gadway MS4 Therese Mead, DO, RDMS, FACEP  Central Michigan University College of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637767184623-X4H0MPOY1TMCAB40DTYI/image-asset.gif Biliary - Intrahepatic Ductal Dilation Transverse scan of the liver shows diffuse dilation of intrahepatic biliary ducts. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637766596958-Z0V3KPEKWS30JNUM6KAQ/image-asset.gif Biliary - Cholelithiasis with Adenomyomatosis Longitudinal view of the gallbladder revealing two unique findings. A hyperechoic structure with posterior acoustic shadowing indicative of a stone is located in the neck. Two smaller hyperechoic structures can be seen attached to the wall of the GB body, likely adenomyomatosis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631718996474-HLCUNNPQ3C52ND71IWIA/image-asset.gif Biliary - Liver Hematoma 66 y/o male with a history of a recent CBD stent placement complicated by a ruptured hepatic artery resulting in a subcapsular liver hematoma that required IR drainage. He now presents to the ED with progressively worsening right upper quadrant abdominal pain. POCUS was instrumental in monitoring for continued bleeding following the initial drainage. In the clip, you can see the large hematoma, measuring 15 x 13 cm, obscuring most of the liver. Patient was admitted for surgical deroofing. Jennifer Kaminsky, MD PGY-2; @jen_kaminskyMD Pamela Santivanez, MD PGY-1 Sean Beckman, Rocky Vista University COM OMS-4 Joshua Greenstein, MD, Director of ED Ultrasound Northwell Health – Staten Island University Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626288061300-H7E3MT017QDBNL039RO9/image-asset.gif Biliary - Emphysematous Cholecystitis RUQ US of a patient revealed air within the gallbladder consistent with emphysematous cholecystitis, which can easily be confused with bowel gas. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626281772366-J70QI9J548Q0WQSL6PW8/image-asset.gif Biliary - Pneumobilia Air can be noted within the biliary tract in this ultrasound of the RUQ. This patient was s/p Whipple procedure. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626282860609-SI1NEEBE8KL65B02FWTM/image-asset.gif Biliary - Portal Venous Gas RUQ ultrasound reveals air within the portal venous system in a patient with ischemic colitis. Something that can be difficult to distinguish from pneumobilia. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620333328035-0N6GOKAA2PLKALL3FIZT/image-asset.gif Biliary - Gallstone in Neck Causing Mirizzi's Syndrome Note the hyperechoic structure with posterior acoustic shadowing indicative of a gallstone. Patient was moved and the stone remained lodged in the neck. Additionally, gallbladder sludge can be seen. The patient was found to have elevated LFTs. MRCP performed demonstrating external compression of biliary tree this large stone in GB neck consistent with Mirizzi’s syndrome. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616442235295-PUFHKYLHE52ET80T6Q2D/image-asset.gif Biliary - Choledocholithiasis A 65-year-old female with no PMH presented to ED with 6 hour hx RUQ abdominal pain. She reported no associated vomiting or fever. POCUS seen here reveals the cystic duct emerging from the GB neck to then reach a severely dilated CBD. A hyperechoic round structure with posterior shadowing lies inside the CBD, consistent with a diagnosis of choledocholithiasis. Dr. Felipe Urriola Emergency Unit. Puerto Aysen Hospital, Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616080221978-J4HVEF4BPZRXNNB0GYK4/image-asset.gif Biliary - Cholelithiasis An elderly female presented to the emergency department reporting abdominal pain. POCUS seen here revealed the presence of a gallstone within her gallbladder with shadowing; and a notable absence of findings consistent with cholecystitis including gallbladder sludge, wall thickening, and/or ductal dilatation. This enabled appropriate triage of this patient to outpatient follow-up rather than considering immediate surgical intervention. Rupinder Sekhon, MD & Peter Biggane, MD Central Michigan University, Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609879711430-7OXUHCMM01KAPLUSTTAO/image-asset.gif Biliary - Adenomyomatosis A middle aged patient presented with epigastric pain and vomiting. Ultrasound identified anechoic cystic thickening of the gallbladder wall associated with comet-tail artifact and twinkling artifact. Findings were consistent with adenomyomatosis, a generally benign condition caused by hyperplastic growth of the gallbladder mucosa often associated with chronic inflammation. Michael Cover, MD @michaelc0ver https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607705454344-0DY6ZZ7PKPC31E7V6QFU/image-asset.gif Biliary - Choledocolithiasis A patient presented to the ED with RUQ pain. Sagittal view of the common bile duct revealed dilation and stones indicative of choledocolithiasis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607172601308-HSCN9QOUPMB54ZQVZETT/image-asset.gif Biliary - Cholecystitis with Gallbladder Rupture Patient presented with right upper quadrant abdominal pain and fever. RUQ ultrasound showed an impacted stone in the gallbladder neck with gallbladder wall perforation. Note the flow through the perforation and the associated pericholecystic abscess. Labelled image can be found on the original post with the link below. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606094680996-99C63TXUMG6GSDZB9TEY/image-asset.gif Biliary - Normal Common Bile Duct Often, a left lateral position delivers a clear image of the common bile duct (CBD) on its entire length, as is the case in this clip. Notice the normal hyperechoic walls and its small diameter. The CBD inner wall diameter should be < 6 mm in healthy adults, although it can be enlarged in post-cholecystectomy patients. Dr. Felipe Urriola P. Emergency Unit, Puerto Aysen Hospital. Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606094307859-GIFEV0DRX4HELJPTA1N2/image-asset.gif Biliary - Normal Portal Triad without Doppler The large, pulsatile inferior vena cava lies at the bottom of the screen. Anterior to it and from left to right we see the large portal vein and small, round hepatic artery. Just above the hepatic artery lies another tubular structure which presents hyperechoic walls and an anechoic lumen; this is the common bile duct. Dr. Felipe Urriola P. Emergency Unit, Puerto Aysen Hospital. Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606094018761-FXWF60HQ0K2OFFD8UUZC/image-asset.gif Biliary - Normal Portal Triad - Doppler Both the adjustment of depth and color-doppler allow for better identification of structures. The large, pulsatile inferior vena cava lies at the bottom of the screen. Color-doppler helps to discern blood vessels from other anatomical structures. Anterior to the IVC and from left to right of the screen, we can see the portal vein and hepatic artery with color-flow. Just above the hepatic artery lies another tubular structure which presents hyperechoic walls and an anechoic lumen; this is the common bile duct. Dr. Felipe Urriola P. Emergency Unit, Puerto Aysen Hospital. Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598030728109-1VS9C7USVM175MHC8GL2/image-asset.gif Biliary - Twinkling Artifact in Choledocholithiasis A patient presented with RUQ abdominal pain. Ultrasound showed cholelithiasis and choledocholithiasis. Left image shows a portion of the common bile duct containing a small hyperechoic shadowing mobile stone. Right image shows the same with color Doppler added demonstrating twinkling artifact. Learning point: Twinkling artifact is most often associated with urinary stones but also can be caused by gallstones (depending on composition), bowel gas, foley balloons, metallic objects, and many others. Twinkling artifact may help identify small stones that do not cause prominent acoustic shadowing. Michael Cover, MD @michaelc0ver https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592330024596-X2ZZ91JJMUHK7S16BU06/image-asset.gif Biliary - Extreme GB distention in setting of cholangiocarcinoma A 40-year-old male presented to the ED with several week hx unintentional weight loss and new onset jaundice. POCUS of his RUQ demonstrated an overtly distended gallbladder with plethoric intra-hepatic circulation causing compression of the right kidney. As expected, he had laboratory evidence of an elevated direct bili and acute kidney injury. Subsequent MRI confirmed the diagnosis of cholangiocarcinoma. Dr. Victor Bang. Emergency Physician at Hospital das Clínicas de Marília. Co-founder of Pocus Jedi. @vmjbang https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588177722359-96L21OYBFY9NZZ6N0DCE/image-asset.gif Biliary - Angry gallbladder A patient presented with altered mental status and anorexia; clinically he had findings consistent with sepsis. POCUS revealed one angry gallbladder! You can appreciate gallbladder wall thickening (measuring 6mm), trace pericholecystic fluid, and shadowing from gallbladder sludge. Garrett Ghent, Resuscitationst and diagnostician; Norfolk, VA @garrettghentMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584989960678-PI0A7QE7UIYL0POKJDOO/image-asset.gif Biliary - Biliary Colic A 33-year-old female presented to the ED reporting acute onset abdominal pain immediately after eating a meal. She was well-appearing and afebrile; physical exam notable for reproducible tenderness to palpation of her upper abdomen. POCUS long axis view obtained to right of epigastrium notable for hyperechoic material within the lumen of the gallbladder (anechoic) producing posterior shadowing. This confirmed our clinical suspicion of biliary colic, and the patient was able to be discharged with scheduled outpatient elective surgery. Victor Bang, Medical Student Brazil @vmjbang https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572732158433-SLCWCIB32HA20EQMKRSZ/ezgif.com-optimize+%2812%29.gif Biliary - Gallstone Stuck in GB Neck with Shadowing This image demonstrates a large gallstone lodged in the neck of a distended gallbladder with posterior shadowing. There is no evidence of gallbladder wall thickening seen here. Jonny Wilkinson, Consultant in ICU and Anesthesia https://criticalcarenorthampton.com https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1554692828841-W91Z4L7LUEXANQ3E55UB/pneumobilia.gif Biliary - Pneumobilia 82-year-old male with history of recurrent cholangitis presenting to the ED with abdominal pain. US imaging of the RUQ reveals presence of pneumobilia. Click here to read the full caption. Andrew Morris, M.D. Gaurav Patel, M.D. Vu Huy Tran, M.D. - Aventura Hospital & Medical Center, Emergency Medicine Program https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522031812864-X50C93J7PSLFRWCGVR2P/Adenomyomatosis+lindsay+davis.gif Biliary - Adenomyomatosis Adenomyomatosis is a generally benign condition characterized by diffuse thickening of the gallbladder wall and intramural diverticula. On ultrasound it creates comet tail artifacts (reverberation artifacts that appear as tiny echogenic beams) originating from distinct locations on the gallbladder wall. This is often seen in asymptomatic patients; however it can be associated with chronic inflammation from gallstones and pancreatitis. Dr. Lindsay Davis - NYU/Bellevue Department of Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501699786061-K06INXJGQ9IPQB3MRVKG/ezgif.com-gif-maker.gif Biliary - Cholelithiasis, Not Impacted Two large, hyperechoic stones can be appreciated in this gallbladder. These are likely two stones because of the degree of echogenicity and posterior shadowing. If you have one or two objects in the gallbladder and you're not sure if they're stones, it can be useful to have the patient lay on their side. If the objects moves when the patient moves, they are stones. If not, they are likely polyps or other masses growing from the gallbladder wall. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Darmas) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501723211698-YLUPCF40MJG7180WCVA1/ezgif.com-optimize+%281%29.gif Biliary - Cholelithiasis with Many Stones This non-inflamed gallbladder contains many stones. The stones are hyperechoic with posterior shadowing. The gallbladder wall is not thickened, there is no pericholecystic fluid, and no sonographic Murphy's sign, thus cholecystitis is unlikely. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Ken Lee) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501104245208-RE2Z85UF73V9VCR62WAR/ezgif.com-optimize%28stones_neck%29.gif Biliary - Cholelithiasis - Neck Stones This patient w/o cholecystitis clearly demonstrates cholelithiasis. A 2002 study showed that ER doctors can diagnose gallstones with a sensitivity of 88% and specificity 96% with POCUS. Gallstones can be identified by hypoechoic "shadowing" behind hyperechoic stones. If there isn't shadowing, hyperechoic structures could represent polyps or sludge. In this image the stones are resting mainly in the neck of the gallbladder. Kendall JL, Shimp RJ. Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians. J Emerg. Med. 2001; 21(1):7-13 Submitted by Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501698956853-B7BBNV9VFDG8AZPM4E99/ezgif.com-optimize.gif Biliary - Cholecystitis with Obstructing Stone This clearly demonstrates a stone in the gallbladder neck as a hyperechoic structure with posterior shadowing. The neck is not always clearly visualized on first glance so it is important to scan through the gallbladder in two planes to exclude stones in the neck. Other signs of acute cholecystitis include pericholecystic fluid, gallbladder wall thickening (>3mm) common bile duct dilatation, and positive sonographic Murphy's sign. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Mo) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501699211694-E472ZSB51OIGA7IE4NYO/ezgif.com-resize.gif Biliary - Cholecystitis This still image shows two clear signs of acute cholecystitis. The gallbladder wall is thickened and there is pericholecystic fluid. Of note, when measuring the gallbladder wall it's better to measure the anterior wall as the posterior wall can appear enlarged due to artifact. The cut off for wall thickening is 3mm. The anterior wall is thickened in this case but is not labeled. Other signs to look for are stones, sludge, common bile duct dilatation, and overall gallbladder enlargement. Of note, a positive sonographic Murphy's carries a sensitivity of 63%, specificity of 93.6% and positive predictive value of 72.5%. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Sharon) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513453220973-TQPDLKVMGFNM0OXL0L99/ezgif.com-optimize.gif Biliary - Cholecystitis - Emphysematous Emphysematous cholecystitis is the result of gas formation within the wall or lumen of the gallbladder as a result of infection by a gas forming organism. It is a surgical emergency. The air in the gallbladder appears highly echogenic with mild posterior shadowing, as air next to tissue is highly reflective. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501697664740-52NZKYOCR228H1OTO5WK/ezgif.com-optimize.gif Biliary - Choledocholithiasis - Dilated Common Bile Duct with Stone A normal common bile duct should be < 4mm plus 1mm per decade after 40 years of age. A stone can clearly be seen in the area of color flow doppler. The bile duct is obviously dilated here (although not measured). When searching for the CBD, it can be useful to turn color flow doppler on to ensure you're visualizing a biliary structure and not vessels. This technique was employed here. POCUS is highly sensitive for acute cholecystitis but as many people already know, it can be hard to find the CBD, which is reflected in the lower sensitivity and specificity for this indication in many studies. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Dop Ahilan) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501698276227-SBL8FYU9PV1ZUJRZ5TMG/ezgif.com-gif-maker+%281%29.gif Biliary - Common Bile Duct (Normal) When searching for the common bile duct (CBD), color doppler can be useful to differentiate vascular structures from non-vascular structures. In this case the CBD is being measured anteriorly and does not have any pulsations on color doppler. The portal vein and artery can be seen and with the CBD, make the portal triad. A normal CBD should be less than 4mm plus 1mm per decade after 40 years old. It should be measured inner wall to inner wall. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Chiang) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501698061912-0E1EGUMDWYWZESBF8BLB/ezgif.com-gif-maker.gif Biliary - Common Bile Duct (Normal Labeled) A normal common bile duct should be <4mm plus 1mm per decade after 40 years of age. It should be measured from inner wall to inner wall. You should attempt to find the portal triad: the CBD, the portal vein, and the hepatic artery. You may need color flow to find all three. Here the CBD and portal vein are labeled (no labeled hepatic artery). To get better images, especially if you're dealing with a lot of rib shadow, it can be helpful to have your patient take a deep breath and/or roll onto their left side. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513452494752-8IH0JWSOKT519ZJRXZX3/ezgif.com-gif-maker.gif Biliary - Dilated Common Bile Duct The CBD measures at 1.89cm indicating it is grossly dilated, as a normal common bile duct should be <4mm plus 1mm per decade after 40 years of age. It should be measured from inner wall to inner wall. The color doppler is used to ensure that the dilated structure is indeed a bile duct rather than a vascular abnormality. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501697190288-YZR8OCZAXQ0DMNB9VGWJ/ezgif.com-gif-maker.gif Biliary - Dilated Common Bile Duct This patient has a dilated common bile duct and obstructive pattern LFTs, highly suggestive of choledocholithiasis or other biliary obstruction. No stone is visualized on this study. A normal common bile duct should be <4mm plus 1mm per decade after 40 years of age. Here it is 9.78 mm. POCUS is highly sensitive for acute cholecystitis but as many people already know, it can be hard to find the CBD, which is reflected in the lower sensitivity and specificity for this indication in many studies. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Ken Lee) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501723451109-VN4FW7XKZ64M6BW3ZBK2/ezgif.com-gif-maker+%281%29.gif Biliary - Gallbladder Wall Measurement This normal gallbladder image shows how to measure the anterior wall of the gallbladder. A normal gallbladder wall should be less than 3mm. The posterior wall should not be measured as it can appear enlarged due to artifact. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501104477405-YBJ0ABJ3LTSQJINIBVUG/ezgif.com-gif-maker+%2810%29+%281%29.gif Biliary - Gallbladder with Biliary Sludge The image above is from a patient presenting to the emergency department with recurrent abdominal pain. The image demonstrates a large amount of biliary sludge within a normal sized gallbladder. Biliary colic from intermittent obstruction was suspected. While the gallbladder wall is noted to be mildly thick here, cholecystitis was ruled out based on other clinical factors. Marco Garrone, MD - Torino, Italy https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501722106918-V7UTF0V09W3MRAV76L2Q/ezgif.com-resize.gif Biliary - Gallbladder Sludge Echogenic material can be seen within this gallbladder but there are no stones. It is not bright white (it is not highly echogenic) and furthermore there isn't any shadowing. When there is no shadowing consider polyps or in this case biliary sludge. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Sharon) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1591678323858-WEUZOQ0P0V11A551B29C/image-asset.gif Biliary - Ruptured Viscus from Trauma Pt stuck by car while riding bike. Perihepatic view on FAST exam revealed a perforated viscus (gastric rupture). Note the free air within the fluid. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501723661079-VBDLNVOPQF7XAWJ774KK/ezgif.com-optimize+%282%29.gif Biliary - Gallbladder Wall Echo Shadow (WES Sign) Gallstones can be seen on the right side of the image with a hyperechoic front edge and posterior shadowing. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515006613253-TMAQ1Y4LWSJ2NA8RJIPY/ezgif.com-optimize+%285%29.gif Biliary - Wall Echo Shadow Pt with epigastric pain, elevated LFTs and lipase. U/S shows the whole gallbladder shadowed by a large calcified stone or "wall echo shadow-WES." The novice may not be able to find the GB and can mistake WES for bowel (but bowel does not shadow like this). Dr. Gordon Johnson https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1517504364899-4R6N5L28NI7LYV7D3TVO/ezgif.com-optimize.gif Biliary - Portal Triad Gallbladder with non-obstructing stone. Fanning down one sees the portal triad with bile duct (black) 7 mm, hepatic artery (pulsitile) and portal vein (red). Dr. Gordon Johnson https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501721733512-XYZ9NLNUPJ6A9HWP04CT/ezgif.com-optimize.gif Biliary - Pericholecystic Fluid Free fluid can be appreciated around this gallbladder. This is called pericholecystic fluid. However there are no stones, nor gallbladder wall thickening, and the sonographic Murphy's is negative. This free fluid is unlikely to be caused by cholecystitis. In this case, the free fluid came from a different source. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514854025282-NWWP0W41CPVAMCBYLXGF/shan+carmelli+edematous+gb.gif Biliary - Pericholecystic Fluid - Long 26 y/o F PMH HIV presents with non-bloody, non-bilious vomiting for one day associated with upper abdominal pain. POCUS revealed gallbladder wall thickening and pericholecystic fluid, but no gallstones or sonographic Murphy’s sign. The patient received symptomatic treatment and a surgical evaluation. The patient ultimately improved and was determined to not have cholecystitis. The patient was discharged home after her symptoms resolved and she was able to tolerate PO. Dr. Guru Shan, Dr. Guy Carmelli, Dr. Scott Kendal - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514854025504-NRUPABJ3XS7X8BCO4B03/shan+carmelli+GB+2.gif Biliary - Pericholecystic Fluid - Transverse 26 y/o F PMH HIV presents with non-bloody, non-bilious vomiting for one day associated with upper abdominal pain. POCUS revealed gallbladder wall thickening and pericholecystic fluid, but no gallstones or sonographic Murphy’s sign. The patient received symptomatic treatment and a surgical evaluation. The patient ultimately improved and was determined to not have cholecystitis. The patient was discharged home after her symptoms resolved and she was able to tolerate PO.   Dr. Guru Shan, Dr. Guy Carmelli, Dr. Scott Kendal - Kings County Emergency Medicine   https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501699439698-IVB4WN34UYW89P4FM4W7/ezgif.com-resize+%281%29.gif Biliary - Free Fluid around Normal Gallbladder There is a lot of pericholecystic fluid surrounding this gallbladder but no other signs of inflammation. The gallbladder wall is normal, there are no stones, and there is no sonographic Murphy's sign. The free fluid is likely from another source, not acute cholecystitis. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533301955683-Z1G1MEUMP74Z40FS43UG/WES+sign.gif Biliary - Wall Echo Shadow 38 y/o F presented with abdominal pain, nausea & vomiting. POCUS shows the WES (Wall-Echo-Shadow) sign. This shows a curvelinear hyperechoic line representing the gallbladder wall, followed by a thin hypoechoic line representing a small amount of bile, then a curvelinear hyperechoic line, followed by acoustic shadowing. This sign is seen when the gallbladder has either a large gallstone or multiple small gallstones in a contracted gallbladder taking up the extent of the lumen. Sometimes this sign is misinterpreted as an air filled loop of adjacent bowel. Jaramillo, Juliana MD; Shah, Rushabh MD; Maurelus, Kelly MD - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533301970625-EQ6QDGE50LUAEJUTDF1W/WES+sign+2.gif Biliary - Wall Echo Shadow 38 y/o F presented with abdominal pain, nausea & vomiting. POCUS shows the WES (Wall-Echo-Shadow) sign. This shows a curvelinear hyperechoic line representing the gallbladder wall, followed by a thin hypoechoic line representing a small amount of bile, then a curvelinear hyperechoic line, followed by acoustic shadowing. This sign is seen when the gallbladder has either a large gallstone or multiple small gallstones in a contracted gallbladder taking up the extent of the lumen. Sometimes this sign is misinterpreted as an air filled loop of adjacent bowel. Jaramillo, Juliana MD; Shah, Rushabh MD; Maurelus, Kelly MD - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534358625547-1NCYWQ27D2B0OW39Y7JV/contrcted+GB.gif Biliary - Contracted Gallbladder In this clip, the gallbladder (center right of the screen) appears collapsed and the wall looks thickened. This is the normal appearance of a postprandial gallbladder which is contracted because it has just released its bile content into the duodenum for digestion of a meal. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534358695076-T0JZVDKD0JGIC1VIY7YD/GB.gif Biliary - Gallbladder Long Axis In this clip we see the liver on the left of the screen, and in the center right a large anechoic ovoid structure which is the gallbladder. The gallbladder in long axis together with the portal triad in cross-section form the “exclamation point sign”. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534358770117-FJW54FJ1SKTJLEXZ928T/GB+CBD.gif Biliary - Gallbladder and CBD In this clip we see the liver on the left, and the IVC inferior to the liver with a hepatic vein draining into it. The ovoid anechoic gallbladder is in long axis in the center of the screen. To the left of the gallbladder we see the portal vein in cross-section. Running just superior to the portal vein, in long axis, is the narrow common bile duct. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534358857846-QKDMSPUBE58GDC75BA1B/GB+RHA.gif Biliary - Gallbladder and Right Hepatic Artery Here we see a normal anatomic variant: the right hepatic artery (small perfectly round vessel in cross section) runs superior to the CBD (seen in long axis towards the end of the clip). Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534358977311-YUHVXKF1S6EJPQC0G735/Olive+Sandwich+.gif Biliary - Olive Sandwich The “olive sandwich” sign: the small round hepatic artery (in cross section) sandwiched between long axis views of the CBD superiorly and portal vein inferiorly. The IVC is seen in long axis deep to the portal vein. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644870515275-EA5V2JH53QJEYCVAAO07/image-asset.gif Biliary - Pancreatic Pseudocyst 40s F PMH severe ETOH use disorder and ETOH pancreatitis as well as recent COVID diagnosis presented with continued dyspnea and sore throat as well as abdominal bloating with a 15-20lb weight loss in 2 months. POCUS of the upper abdomen is shown here, demonstrating a large pseudocyst, which was confirmed on CT. The patient was admitted for her symptoms and was seen by GI but ultimately was planned for outpatient drainage rather than urgent/emergent. Dr. Nimish Bhatt, Ultrasound Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644871230313-Z8EFCHLRWJY7L722N0UM/image-asset.gif Biliary - Impacted Gallbladder Neck Stone 20s F presented with recurrent postprandial RUQ pain. POCUS demonstrated multiple hyperechoic stones in the gallbladder including one in the gallbladder neck. No pericholecystic fluid or wall thickening were noted, and the common bile duct was normal caliber. Formal RUQ US confirmed these findings, and the patient was taken to the OR by the surgery team for cholecystectomy. Dr. Nhu-Nguyen Le, Ultrasound Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567929659523-UJ14DRZZOAV38XY9J3AD/contracted-GB-2.gif Biliary - Contracted Gallbladder - Colorized Contracted Gallbladder Green- Gallbladder Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567929662896-OVT3GRVKEE6G5FYO7RDA/gallbladder-and-cbd.gif Biliary - Gallbladder and Commmon Bile Duct - Colorized Gallbladder and Common Bile Duct Green: Gallbladder, Blue: IVC, Orange: Portal vein, Pink: Common bile duct, Yellow: Lumen of hepatic vein Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567929661926-DFZIJ5EL5W6V052XTECC/normal-GB.gif Biliary - Normal Gallbladder - Colorized Normal Gallbladder Yellow: Lumen of gallbladder, Red: Portal vein, Green: Common bile duct Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567929662226-VDSRVFT4MXAAGHOR0HUO/Olive-sandwich.gif Biliary - Olive Sandwich Sign - Colorized Olive Sandwich Sign Red (small): “Olive” or hepatic artery, Green: Common bile duct, Blue: Portal vein, Red (large): IVC Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://static1.squarespace.com/static/58118909e3df282037abfad7/595b0293c534a55db92e450a/683133e3e57bf740e9296df7/1748055011078/ Biliary https://www.thepocusatlas.com/obgyn daily 0.75 2025-01-29 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1734650512204-U4EJ3EQ80VSV94Z7KZGY/image-asset.gif OB/Gyn - Dichorionic Diamniotic Twin Intrauterine Pregnancy A 27-year-old female presented for evaluation of cough, congestion, decreased appetite, muscle aches, and fatigue. Patient was unsure of the date of her last menstrual period. This image is a transabdominal ultrasound of the uterus demonstrating a dichorionic diamniotic twin intrauterine pregnancy. The pregnancy was dated at approximately 8 weeks and 2 days, with fetal heart rates of 167 bpm and 174 bpm. Arthur Sieron BMBS, PGY-1 Emergency Medicine, Central Michigan University; Eric Spencer DO, PGY-3 Emergency Medicine, Central Michigan University; Halimah Hamidu, MS4 Central Michigan University College of Medicine. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1734650512204-U4EJ3EQ80VSV94Z7KZGY/image-asset.gif OB/Gyn - Dichorionic Diamniotic Twin Intrauterine Pregnancy A 27-year-old female presented for evaluation of cough, congestion, decreased appetite, muscle aches, and fatigue. Patient was unsure of the date of her last menstrual period. This image is a transabdominal ultrasound of the uterus demonstrating a dichorionic diamniotic twin intrauterine pregnancy. The pregnancy was dated at approximately 8 weeks and 2 days, with fetal heart rates of 167 bpm and 174 bpm. Arthur Sieron BMBS, PGY-1 Emergency Medicine, Central Michigan University; Eric Spencer DO, PGY-3 Emergency Medicine, Central Michigan University; Halimah Hamidu, MS4 Central Michigan University College of Medicine. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727649667538-2L99BWAE3QTU1X5EFVZ2/image-asset.gif OB/Gyn - Biparietal diameter (BPD) measurement in a 26-week pregnancy. BPD should be measured in the axial plane, perpendicular to the falx cerebri, and from the outer edge of the near calvarial wall to the inner edge of the far calvarial wall. Contributors: Stephen Holihan (MD); Dillon Nerland (MD); Madison Waddell (MS4) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736699702388-UBNZKGBPTLMKBMEIM217/image-asset.gif OB/Gyn - Partial Molar Pregnancy Long Patient was having significant nausea and vomiting and went to her local ER. While there her beta HCG was much higher than expected at her gestational age. Ultrasound shows a large amount of heterogeneous material with possible gestational sac. Confirmed after D&C. Michael Bernard, DO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736699546760-N1X7LEG0FIOWL5O0Q0NT/image-asset.gif OB/Gyn - Partial Molar Pregnancy Transverse Patient was having significant nausea and vomiting and went to her local ER. While there her beta HCG was much higher than expected at her gestational age. Ultrasound shows a large amount of heterogeneous material with possible gestational sac. Confirmed after D&C. Michael Bernard, DO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1726535499810-MW6Y73E7VHAFIF3RC4ZR/image-asset.gif OB/Gyn - Caesarean Section Scar Ectopic Pregnancy 32 year old female at 8-9 weeks gestation by LMP referred to the ED for pregnancy of unknown location. She reported 1-2 weeks of mild pelvic cramping and vaginal spotting. Bedside trans-abdominal imaging demonstrated a round, heterogenous structure without a clear yolk sack or fetal pole, but with several hallmarks of caesarean scar ectopic pregnancy: position in the anterior uterine wall; in the lower (closer to the cervix) half of the uterus; bulging into the neighboring bladder; with thin interposed myometrium. After confirmatory formal ultrasound, she was admitted for methotrexate termination, which proved successful. Contributors: Nicholas Maurer, MD, MPH (PGY-1); Megan Chenworth (PGY-3) Emergency Medicine, Northwestern McGaw Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1726530953707-YJPDWR9Y6Z7L8W2DMURJ/image-asset.gif OB/Gyn - US Confirmation of Appropriate IUD Location Transvaginal ultrasound showing the IUD correctly placed in both sagittal and transverse plane. Contributor: Dr. Nicolay B. Werner Akershus University Hospital, Norway https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1720554061163-UTEU446DV5FSBC5Z61LQ/image-asset.gif OB/Gyn - Fetal Pole with Cardiac Activity This is a transverse uterus view in early pregnancy demonstrating a a fetal pole with visualized cardiac activity. Mike Macias, MD, Emergency Physician, @emedcurious https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1706572667207-G54FANOWVKTIKO92CZU8/image-asset.gif OB/Gyn - Uterus with Leiomyomas (fibroids) Heterogeneous uterus with multiple well defined hypoechoic masses consistent with leiomyomas (fibroids). Dimitri Livshits DO, Ultrasound Fellow, Kings County/SUNY Downstate; Jane Belyavskaya MD, Ultrasound Fellow, Kings County/SUNY Downstate; Chris Hanuscin MD, Ultrasound Division Director, Kings County/SUNY Downstate; https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616444334439-QLT4PHY00W7AIHUQ0JOO/image-asset.gif OB/Gyn - TIE Fighter Sign A 64-year-old woman with hepatic cirrhosis presented to the emergency room with abdominal pain. The abdominal POCUS exam, in this transverse suprapubic view, revealed a large amount of ascites and a floating uterus, an image known as "TIE Fighter Sign" in reference to the famous Star Wars galactic empire ship. Renato Tambelli @R_Tambelli // @JediPocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1706570866137-EE4Q4LKJK92SV4GY7C0B/image-asset.gif OB/Gyn - Ectopic Pregnancy 30s female currently 7 week pregnant with lower abdominal pain and tenderness to palpation to lower abdomen. POCUS showed a gestation sac containing a yolk sac and fetal pole outside of uterus. Also noted is a thickened endometrial stripe (to the right of the gestational sac). No free fluid was noted in the RUQ. The patient was taken to the OR for definitive management of ectopic pregnancy. Dimitri Livshits DO, Ultrasound Fellow, Kings County/SUNY Downstate; Jane Belyavskaya MD, Ultrasound Fellow, Kings County/SUNY Downstate; Farnam Kazi MD, Ultrasound Faculty, Kings County/SUNY Downstate; https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697910693863-4GZSROBLRAI0ZQ9ZNNCT/image-asset.gif OB/Gyn - Molar Pregnancy This is a saggital view of the uterus belonging to a patient who returned to the emergency department after persistent vomiting. An initial urine pregnancy test performed yielded a negative result however this patient’s ultrasound scan ultimately revealed a molar pregnancy. As Dr. Jones explains, this patient false-negative urine pregnancy test is explained by a phenomenon known as the High Dose Hook Effect. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1679283181129-9FZYHC8UIS0DXZUH797J/image-asset.gif OB/Gyn - Tubal Ectopic Pregnancy Notice to the left of the screen the presence of an adnexal mass separate to the ovaries which in this case indicates a right tubal ectopic pregnancy. Also noted here within the endometrium is an outer echogenic layer, middle hypoechoic layer and an inner hyperechoic stripe, which makes up the classic trilaminar pattern that is usually observable during the proliferative phase of menstruation. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678908493199-H3T8KM6FYAOIFPEG8E5H/image-asset.gif OB/Gyn - IUD in Transverse Plane Patient came to the ED due to flank pain. Renal ultrasound was performed by me with the US team. Upon looking for the bladder, I saw my first IUD via US which appeared hyperechoic. ParaGard has been shown to be more than 99% effective. Mehtab Galeh, MD, @GalehMehtab https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678907880298-IBN5SLPVM21R4DMR3Y9T/image-asset.gif OB/Gyn - IUD in Sagittal Plane Patient came to the ED due to flank pain. Renal ultrasound was performed by me with the US team. Upon looking for the bladder, I saw my first IUD via US which appeared hyperechoic. ParaGard has been shown to be more than 99% effective. Mehtab Galeh, MD, @GalehMehtab https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631718104909-9RJBRGUUW4SX7LE6UP9V/image-asset.gif OB/Gyn - Ovarian Hyperstimulation Syndrome (OHSS) 20 y/o female s/p egg retrieval for egg donation 3 days prior presents for diffuse abdominal pain and bloating. In the clip (bladder sagittal view), you can see massive enlargement of the ovary and its multiple follicles. FAST revealed free fluid throughout the abdomen likely secondary to leakage of fluid from these follicles, a process referred to as ovarian hyperstimulation syndrome (OHSS). The patient was admitted to GYN for possible drainage. Jennifer Kaminsky, MD PGY-2; @jen_kaminskyMD Pamela Santivanez, MD PGY-1 Sean Beckman, Rocky Vista University COM OMS-4 Joshua Greenstein, MD, Director of ED Ultrasound Northwell Health - Staten Island University Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631649780694-G8W3TC47X0DD547IWDAT/image-asset.gif OB/Gyn - Fetal Pole with Cardiac Motion - Sagittal Sagittal view of uterus demonstrating fetal pole. A subtle flicker within the fetal pole can be seen consistent with cardiac motion. Michael Macias https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625683233227-NNXRW9S06QPHU8POUBUS/image-asset.gif OB/Gyn - Yolk Sac A transabdominal scan with a curvilinear probe failed to show an intrauterine yolk sac however, when using a linear probe a yolk sac became visible. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616092711119-THV3BAZ5F9HSYKWVWT8G/image-asset.gif OB/Gyn - Pelvic Cystic Mass A middle-aged female with a history of colon cancer presented to the ED with constipation and abdominal pain. A recent colonoscopy had revealed rectosigmoid adenocarcinoma. Her physical exam was notable for a distended abdomen that was tender to palpation. POCUS revealed the presence of a large, complex, cystic structure within the pelvis. Subsequent CT confirmed a loculated fluid collection within the pelvis compressing the rectum and sigmoid colon; this mechanical obstruction was likely contributing to patient’s constipation. Differential diagnosis included loculated ascites versus cystic tumor. Kyla Walworth, MS-4 & Matthew McDowell, PGY-1 Central Michigan University College of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614118447916-J6JW0R4ZKM5EXJ3P1U3Q/image-asset.gif OB/Gyn - IUD Foreign Body Transvaginal US showing a gestational sac of about 6 weeks by dates with a fragment of an old IUD embedded in the endometrium shown as the hyperechoic line with posterior acoustic shadow. Patient had an IUD removal 10 months prior. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609959738037-49YAZDNSYA07CI8PAFG8/image-asset.gif OB/Gyn - Ovarian Torsion A 38-year-old female with PMH ulcerative colitis presented with several hour history of RLQ abdominal pain. Pain was described as sharp and constant; it woke her from her sleep. Vitals were WNL. Physical exam was notable for right adnexal tenderness and RLQ abdominal tenderness to palpation. Pelvic ultrasound revealed an enlarged right ovary with peripheralized follicles, heterogenous ovarian stroma, and peri-ovarian free fluid; findings concerning for ovarian torsion. It is important to remember that while ovarian torsion remains a clinical diagnosis, US grey scale findings are some of the most reliable radiographic adjunct predictors of the diagnosis as Doppler imaging often remains normal. Reference: Grunau GL, Harris A, Buckley J, Todd NJ. Diagnosis of Ovarian Torsion: Is It Time to Forget About Doppler? Journal of Obstetrics and Gynaecology Canada. 2018;40(7):871-875. Devin Peuser, @DevinPeuser Brooklyn, NY https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1608044682784-MFDV90I1YRP07OVJLVUO/image-asset.gif OB/Gyn - Uterine Perforation A patient presented to the ED 4 days s/p pregnancy termination via D&C with a fever and profound hypotension. POCUS revealed pelvic free fluid with rising gas bubbles indicative of a uterine perforation. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631649947186-YF6RJACEZEEZ93U88O6V/image-asset.gif OB/Gyn - Fetal Pole with Cardiac Motion - Transverse Transverse view of uterus demonstrating fetal pole. A subtle flicker within the fetal pole can be seen consistent with cardiac motion. Michael Macias https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607200672734-Y4TG74ED7Z7PBJ73XWZ0/image-asset.gif OB/Gyn - Left Ovarian Cyst A young female presented to the ED with sudden pelvic pain. She has no PMH and a negative hCG. Bedside sagittal transabdominal ultrasound revealed a large right ovarian cyst mimicking the urinary bladder. Notice the bladder decompressed with a foley balloon. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592420185336-Y4LY95YYIK1FRK9FQBIA/image-asset.gif OB/Gyn - Yolk Sac This trans abdominal ultrasound reveals a yolk sac. John Joseph, MD. University of Michigan https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592324702240-MN44AMNCSTRS5VTR0HB0/image-asset.gif OB/Gyn - Intrauterine Pregnancy 21 year old female presented to the ED reporting lower abdominal discomfort. HPI notable for absent trauma, dysuria, hematuria, constipation, and fever. Last menstrual period was 3 months prior to presentation. POCUS was faster than urine pregnancy test to clinch the diagnosis! Dr. Victor Bang. Emergency Physician at Hospital das Clínicas de Marília. Co-founder of Pocus Jedi. @vmjbang https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537196872438-T4G8JJSAKC7RLO9HDKRV/ruptured+ectopic+%2B+FAST.gif OB/Gyn - Ruptured Ectopic With Positive Fast 30 y/o F presented to ED for abdominal pain stating she had a recent miscarriage. Now she is having vaginal bleeding for the last 2 weeks. Borderline hypotensive and in severe distress due to pain. Abdomen diffusely tender with guarding. POCUS demonstrated +FAST with blood in the hepatorenal space. Remember to fan all the way to liver tip in FAST scan to fully evaluate for free fluid, it can be subtle and not simply in morrison’s pouch. The patient was rushed to OR by OBGYN for ex-lap based on this scan and was found to have ruptured tubal ectopic pregnancy. Dr. Stacey Frisch - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534360950744-L41TETJW72TYO7EO1O6U/right+adnexa+%2B+cyst+.gif OB/Gyn - Transabdominal Right Adnexa with Ovarian Cyst In this transabdominal view of the uterus and adnexa we see a thin walled, ovoid anechoic structure on the left side of the screen. This is a simple cyst on the right ovary. As the probe fans, the uterine fundus comes in and out of view medial to the ovary . https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534360939261-X1YWSS0Q9K2VVYS6AY4A/uterus+transverse.gif OB/Gyn - Transabdominal Uterus Transverse This is a clip of the uterus in transverse view using the transabdominal approach. The large anechoic structure in the center is the bladder in transverse view, and immediately deep to the bladder is the round uterine fundus. As the probe fans through the uterus we see some dark shadowing within it, likely due to artifact created by an IUD. The fallopian tubes are also faintly visible bilaterally branching off the uterus. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527396886344-I4C0FO1ZJFKKBNAPY3X1/Flores+Smith+Molar+Pregnancy.gif OB/Gyn - Molar Pregnancy 23 y/o F, gestational age 10 weeks by LMP referred to ER for suspicion of molar pregnancy. TV US shows hydropic vesicles within uterus, represented by anechoic regions scattered throughout a hyperechoic mass in uterine cavity. This is classically described as a “bunch of grapes” or “snowstorm pattern”. Patients diagnosed with molar pregnancy can present with vaginal bleeding or symptoms similar to hyperemesis gravidarum, making ER POCUS a useful evaluation tool that can expedite disposition. Dr. Bryan Flores, Dr. Teresa Smith - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1525198061151-14VYW6JL75NZVRWGOD5E/ezgif.com-optimize+%2828%29.gif OB/Gyn - Hematocolpos 13yoF with worsening abdominal pain and back pain x3 months, found to have large bilobed pelvic mass consistent with hematocolpos/hematometra due to imperforate hymen. Transabdominal ultrasound using a 5-1MHz phased array probe in the transverse plane 2cm above pubic symphysis. A large hypoechoic structure within the uterus is seen displacing the bladder superoanteriorly with posterior acoustic enhancement. US can demonstrate retained old blood as a hypoechoic cystic structure and monitor resolution after hymenectomy. (Hassani 1978) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515084075445-NSY3UQI5A1WW5QF05IJ5/Cornual+Ectopic+Frisch.gif OB/Gyn - Ectopic - Ruptured Cornual Ectopic Pregnancy 29 y/o female with intermittent lower abdominal and vaginal pain and nausea x3 days. LMP 3.5 weeks prior. Transabdominal ultrasound demonstrates pregnancy in cornu of the uterus. Symptoms progressed over 24 hours and patient became hypotensive and was taken to OR for exploratory laparotomy and found to have ruptured cornual ectopic with hemoperitoneum. Stacey Frisch, MD Juliana Jaramillo, MD Stephan Rinnert, MD - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507814918259-B0PL5W0FDO2ON98RMGOJ/bicoronate+uterus+alsup.gif OB/Gyn - Bicornuate Uterus with IUP WCUME 2017 Submission for "Best POCUS" 23 y/o female, pelvic pain, no vb or discharge, g1p0 found to be pregnant at this ER visit. Approximately 4 weeks by dates. Found to be pregnant and found to have a bicornuate uterus with IUP on the right side. Carl Alsup, MD - Sierra Nevada Memorial Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523309830807-MYGD8PS72R095J9VOWOB/cornual+ectopic+longitudinal+azad+kendal.gif OB/Gyn - Ectopic - Ruptured Cornual Ectopic Pregnancy - Longitudinal 24 y/o F presents after a brief syncopal episode. Endorses heavy vaginal bleeding for 2 weeks. On exam, tachycardic and tender to palpation in lower abdomen. Urine HCG was positive. Transabdominal longitudinal sonogram view of the pelvis showed a large hypoechoic collection suggestive of free pelvic fluid in the proximity of a solid hyperechoic mass in the left adnexal. Just inferior to the mass is the uterus a small amount of hypoechoic fluid in the endometrium but no clear intrauterine pregnancy. GYN was consulted immediately and the ultimate operative note for this patient described a ruptured cornual ectopic pregnancy. A cornual pregnancy or interstitial pregnancy is a type of ectopic pregnancy located outside of the uterine cavity in the distal fallopian tube as it penetrates into the muscular wall of the uterus. This type of ectopic pregnancy has the potential to grow to larger sizes than standard tubal ectopic pregnancies and carries a higher mortality risk. Dr. Tareq Azad and Dr. Scott Kendall - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523309830807-MYGD8PS72R095J9VOWOB/cornual+ectopic+longitudinal+azad+kendal.gif OB/Gyn - Ectopic - Ruptured Cornual Ectopic Pregnancy - Transverse 24 y/o F presents after a brief syncopal episode. Endorses heavy vaginal bleeding for 2 weeks. On exam, tachycardic and tender to palpation in lower abdomen. Urine HCG was positive. Transabdominal tranverse sonogram view of the pelvis showed again a hyperechoic mass in the left adnexal abbuting an empty uterus, ovaries in view, and a significant amount of free fluid beneath these structures. GYN was consulted immediately and the ultimate operative note for this patient described a ruptured cornual ectopic pregnancy. A cornual pregnancy or interstitial pregnancy is a type of ectopic pregnancy located outside of the uterine cavity in the distal fallopian tube as it penetrates into the muscular wall of the uterus. This type of ectopic pregnancy has the potential to grow to larger sizes than standard tubal ectopic pregnancies and carries a higher mortality risk. Dr. Tareq Azad and Dr. Scott Kendall - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515084213518-JJXIU8AENPN3ZLQGI1V4/Anembryonic+Pregnancy+Frisch+1.gif OB/Gyn - Anembryonic Pregnancy Anembryonic pregnancy 27 y/o G8P2 (5 prior D&Cs) presenting at 14 weeks pregnant by LMP for left lower quadrant pain radiating to her back "feels like mini-contractions) for 2 hours and vaginal bleeding. POCUS demonstrates intrauterine gestational sac with a mean sac diameter 3.1cm (correlating to 8 weeks) without yolk sac or fetal pole, consistent with an anembryonic pregnancy. The patient left AMA and returned 2 days later with sharp, 10/10, intermittent, contraction-like pain in the lower abd radiating to the back and heavy vaginal bleeding. Physical exam at that time demonstrated cervical dilation to 2cm with tissue in the os and pooling of blood within the vaginal vault. The patient underwent a dilation and curettage in the operating room. Stacey Frisch, MD, Sage Wiener, MD - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515084381808-13OI644ITSN8T8ALRXOS/ectopic+frisch+3.gif OB/Gyn - Ectopic - Tubal Ectopic Pregnancy 31 y/o G1P0 presenting at unknown gestational age for pelvic pain and vaginal bleeding. Described increasing vaginal bleeding for 7 days and intermittent sharp lower abdominal and pelvic pain, mostly left sided, 6/10 in severity. Pelvic exam was significant for cervical motion tenderness and left adnexal tenderness. Pelvic ultrasound shows left adnexal complex heterogeneous structure and associated free fluid in the pelvis. Patient underwent diagnostic laparoscopy with left salpingectomy for left tubal ectopic pregnancy. Stacey Frisch, MD Aleksandr Gleyzer, MD - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1521666984447-81Z8H2TJMJ0OP57VKYY4/hemorrhagic+cyst+changati.gif OB/Gyn - Hemorrhagic Ovarian Cyst 18yo F with 1 month history of abdominal pain presents with acute worsening of abdominal pain for 2 days. Exam revealed diffuse disproportionate pain to palpation of abdomen and right adnexal tenderness. POCUS demonstrates a hemorrhagic ovarian cyst defined by a cystic structure adjacent to the uterus with a well-defined wall and lacy/fishnet pattern within the structure. A hyper-acoustic shadowing can be seen distally along with free fluid surrounding the HOC. HOC can also be mistaken for a neoplastic ovarian mass. A distinguishing feature would be changes in fluid collection and changes in size of diameter of the cyst. Dr. Praneetha Chaganti, Dr. Andrew Aherne Kings County/SUNY Downstate Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514854798595-1RX5NB8PJ0DTLQWZ8PX7/shan+bon+ruptured+ovarian+cyst+3.gif OB/Gyn - Ruptured Ovarian Cyst - Hematoma 28 year-old female was BIBEMS after a witnessed syncopal episode at home. The patient endorsed abdominal pain that started during intercourse that morning and had been getting worse. On arrival, the patient appeared pale and diaphoretic. The patient’s FAST exam was performed immediately and showed free fluid in the RUQ and LUQ. The suprapubic view showed a large pelvic hematoma. The patient was evaluated by the GYN service and was taken emergently to the OR where she was found to have a ruptured cyst. Don't forget, the FAST can be used for more than trauma. Dr. Guru Shan and Dr. Catherine Bon - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514854822073-SWDWA5VV4FFSY38A9EBO/shan+bon+ruptured+ovarian+cyst+4.gif OB/Gyn - Positive FAST in LUQ - Ruptured Ovarian Cyst 28 year-old female was BIBEMS after a witnessed syncopal episode at home. The patient endorsed abdominal pain that started during intercourse that morning and had been getting worse. On arrival, the patient appeared pale and diaphoretic. The patient’s FAST exam was performed immediately and showed free fluid in the RUQ and LUQ. The suprapubic view showed a large pelvic hematoma. The patient was evaluated by the GYN service and was taken emergently to the OR where she was found to have a ruptured cyst. Don't forget, the FAST can be used for more than trauma. Dr. Guru Shan and Dr. Catherine Bon - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514854852142-PRL5MPPJ21UR5DI2KUL3/shan+bon+ruptured+ovarian+cyst+5.gif OB/Gyn - Positive FAST in RUQ - Ruptured Ovarian Cyst 28 year-old female was BIBEMS after a witnessed syncopal episode at home. The patient endorsed abdominal pain that started during intercourse that morning and had been getting worse. On arrival, the patient appeared pale and diaphoretic. The patient’s FAST exam was performed immediately and showed free fluid in the RUQ and LUQ. The suprapubic view showed a large pelvic hematoma. The patient was evaluated by the GYN service and was taken emergently to the OR where she was found to have a ruptured cyst. Don't forget, the FAST can be used for more than trauma. Dr. Guru Shan and Dr. Catherine Bon - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513454529373-4K52PLEHY3NO79RY40Q1/ezgif.com-optimize+%282%29.gif OB/Gyn - Hemorrhagic Cyst and Subchorionic Hemorrhage IUP with hemorrhagic cyst and subchorionic hemorrhage. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1499136278981-5QN5VR5EXUD6C1JOHPRF/ezgif.com-optimize%28uterine_rupture%29.gif OB/Gyn - Uterine Rupture (Positive FAST) 21 year old female that was having prolonged labour and pain, presented in shock and delivered a non-viable fetus with minimal amount of blood loss from vagina. Continued to be hypotensive and became altered requiring intubation and crash central line. RUSH (including FAST) exam performed to determined etiology of undifferentiated shock. FAST revealed free fluid in abdomen and pt was taken to the OR with GYN and Trauma Surgery. Found to have uterine rupture in OR. Dr. Sathya Subramaniam, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533302313067-G40N2W8RO5Y40TMJHTPF/twins.gif OB/Gyn - Twin IUP Young female patient at 19 weeks gestation presented s/p syncopal event. POCUS performed and patient had a negative FAST. This image is a transabdominal ultrasound of an intrauterine twin gestation. A placenta can be visualized as the echogenic material superior to the fetuses and the hyperechoic umbilical cord can be visualized in the center of the gestational sac. A normal fetal heart rate (FHR) ranges from 120-170 and is expected as early as 6 week gestational age. This scan shows FHRs of 150 and 158. Fetal movement can also be appreciated on this scan, which is expected at 9-10 weeks gestational age. Dr. Eli Madden, Dr. Julianna Jaramillo - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513456378870-2KV8BB9OYCRC4ZFUKLEJ/ezgif.com-optimize+%284%29.gif OB/Gyn - Twins This is a normal transabdominal POCUS of twins separated by a membrane. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513458146482-JWGH2927396OZ582MDPH/ezgif.com-optimize+%282%29.gif OB/Gyn - Ovarian Cyst Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513457847711-YZPG9CYPS1W2X7SY7L9U/ezgif.com-optimize+%281%29.gif OB/Gyn - Normal Ovaries Nulliparous patient. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501105850881-5ZUZU57S2C6BPMWR2AFY/ezgif.com-optimize%28ovarian_teratoma%29.gif OB/Gyn - Ovarian Teratoma This is a transverse view of the RLQ in a young female who presented with dysuria and a history of constipation. On physical exam, a visible mass was noted to the right of her umbilicus. Urinalysis and urine pregnancy test were negative. Bedside transabdominal ultrasound revealed a septated mass containing heterogeneous material with scattered hyperechoic foci most consistent with an ovarian teratoma. Allison Perkins MD, PGY-1, Jared Toupin MD, PGY-2 Carnegie Mellon University Emergency Medicine Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631650183066-T5WCFB25JTQLCH0I10BA/image-asset.png OB/Gyn - Crown Rump Length Measurement This image demonstrates caliper measurement of the crown rump length in an early pregnancy. Note that when using the proper setting and measurement function, most cart based ultrasound machines will automatically calculate the gestational age based off measurement obtained. Michael Macias https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534360908899-SIWRDCRDVBNT411MZUO3/transabdominal+left+adnexa.gif OB/Gyn - Transabdominal Left Adnexa In this transabdominal view of the uterus in transverse, we see the left fallopian tube branching off the uterus leading to the left ovary in which multiple small hypoechoic follicles are visible, giving the ovary its typical “chocolate chip cookie” appearance. At the end of the clip, one of the left iliac vessels is seen in long axis just deep and lateral to the ovary. The bright hyperechoic lines with dark shadowing in the surrounding fields are bowel gas. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534360932163-15L2B986QA2P0HRVNVDI/uterus+long+.gif OB/Gyn - Transabdominal Uterus Long Axis This is a transabdominal image of the uterus in long (sagittal) axis. On the far right of the screen we see the anechoic urine filled bladder. Immediately to the left of the bladder is the anteverted uterus which can be followed down and to the right as it curves and transitions into cervix and vagina. The thin, hyperechoic line in the center of the uterus is the endometrial stripe. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537197778436-3PA049BD673RUSJDH436/spontaneous+abortion.gif OB/Gyn - Spontaneous Abortion 28yo F G5P4 presenting at 8 weeks pregnant by LMP for pelvic pain and vaginal bleeding for 2 days. POCUS demonstrates an anechoic gestational sac without a visible yolk sac of fetal pole, progressing past the cervix. The patient had a spontaneous abortion in the ER, passing products of conception shortly after the POCUS. Esther Kwak, MD, Ian Desouza, MD- Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537197787357-99KZ3AJC27OYRALM7WV0/spontaneous+abortion+sagittal+.gif OB/Gyn - Spontaneous Abortion Sagittal 28yo F G5P4 presenting at 8 weeks pregnant by LMP for pelvic pain and vaginal bleeding for 2 days. POCUS demonstrates an anechoic gestational sac without a visible yolk sac of fetal pole, progressing past the cervix. The patient had a spontaneous abortion in the ER, passing products of conception shortly after the POCUS. Esther Kwak, MD, Ian Desouza, MD- Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631650027682-58X75A12FTQGHJ65GRN3/image-asset.gif OB/Gyn - Early IUP with Fetal Motion and Cardiac Activity This is a sagittal view demonstrating a late first trimester pregnancy with fetal movement and cardiac motion. Michael Macias https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544582800125-AF0A3TVGYIKX099NDPUT/Gestational%2BSac%2Bon%2BTransverse%2BAbdominal%2BUSG.png OB/Gyn - Early Pregnancy: Gestational Sac Seen at 4-6 weeks: - Not diagnostic for IUP - Ectopic may have pseudogestational sac, though this is rare - It might be early pregnancy but they will need close follow up https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544582921975-GYA90K1VG0X01PJH9VNW/yolk%2Bsac.png OB/Gyn - Early Pregnancy: Yolk Sac Seen at 5-7 weeks: - First evidence of IUP - Appears as ring like structure within the gestational sac https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631650342625-ZDA6WG4OOKHDERL9UW9D/image-asset.png OB/Gyn - Measuring Fetal Heart Rate with M-mode In this image M-mode (motion mode) is used to calculate the fetal heart rate. Notice in this image, the calipers span two cardiac cycles. Depending on machine settings, the number of cardiac cycles to measure to obtain fetal heart rate varies. Michael Macias https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544582659634-B1NZJDA4TXX31HJRJ3GP/download.png OB/Gyn - Early Pregnancy: Fetal Pole Seen at 6-8 weeks: - Tissue with similar echogenicity as uterus seen within the gestational sac - If you see a fetal pole, you should see fetal cardiac activity - Early on, the yolk sac and fetal pole may be present simultaneously https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509445530220-6O066A1PTG4AIKGLGA5K/Rutz+-+ectopic.gif OB/Gyn - Ectopic Pregnancy Always make sure the "IUP" is actually in the uterus by observing the uterus superior to the bladder in the sagittal view. This young lady could have been diagnosed easily with IUP and her abdomen pain dismissed as pain with pregnancy instead of a 10 week ectopic. Matt Rutz, MD @IUEM_Ultrasound Indiana University School of Medicine Department of Emergency Medicine Division of Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507755132703-DP9I4I9V5C816QC6Y0E8/ruptured+ectopic.gif OB/Gyn - Positive FAST - Ruptured Ectopic 40 y/o F with abdominal pain, syncopal, +HCG. POCUS reveals free fluid in RUQ at inferior pole of the kidney and caudal tip of liver. Patient taken immediately to the OR and 800mL of blood evacuated. A left fallopian ectopic pregnancy was found. Always look for free fluid at the inferior pole of the kidney. POCUS saves lives. Dr. Cian McDermott - Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1629074313119-6O79REPZPAR190Z3RS2J/image-asset.gif OB/Gyn - Ruptured Ectopic Pregnancy A 20s F presented with syncope in the setting of multiple days of abdominal pain which acutely worsened. She arrived hypotensive, tachycardic, and on FAST exam, had free fluid in the right and left upper quadrants as well as suprapubic window. Serum beta-hCG testing was positive. A detailed examination of the adnexa is shown here, demonstrating a ruptured ectopic pregnancy. This patient received blood via massive transfusion protocol and was taken emergently to the OR, where an exploratory laparotomy demonstrated an ectopic pregnancy and more than 2L of hemoperitoneum. Dr. Will Dewispelaere, PGY2, and Dr. Greg Wiener, PGY4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637179074736-WNPEWJU9YAYW32WE23Q1/image-asset.gif OB/Gyn - Bicornuate Uterus - Pregnant “Bicornuate uterus” is not actually a dichotomous diagnosis - patients exist along a morphologic spectrum, and can actually get pregnant without much difficulty in some cases. Dr. Elias Jaffa, MD, MS, FACEP https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637272526658-0SHDIWNNRMOUVHFULUMO/image-asset.gif OB/Gyn - +FAST Ectopic Pregnancy with IUD 30s F with PMH prior ectopic pregnancy with IUD in place presented with positive home pregnancy test and lower abdominal pain. POCUS demonstrated a visible IUD still in place with free fluid surrounding the uterus. As the patient was hemodynamically stable, she had a consultative TVUS which confirmed these findings. Gynecology took the patient to the OR which confirmed a tubal ectopic pregnancy with a small amount of hemoperitoneum. Dr. Michael MacGillivray, PGY4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567931555994-EEJ1XNARVTT4HH3O6JA8/transabd-uterus-long-trimmed.gif OB/Gyn - Transabdominal Uterus Sagittal View - Colorized Transabdominal Uterus (sagittal view) Pink: Uterus, Purple: Cervix, Teal: Bladder Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567931544064-WK4F0T4AZMYQJWRQBQ8M/transabd-uterus-tv.gif OB/Gyn - Transabdominal Uterus Transverse View - Colorized Transabdominal Uterus (transverse) Teal: Bladder, Pink: Uterus Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659122713757-60HCT4NRKJBA8SHGN1A0/image-asset.gif OB/Gyn - Dilated Cervix with intact membranes protruding out 17 YOF, G1P0 and 18 weeks pregnant, who presents to the ER with the complaint of "feeling like something was coming out" of her vagina since this morning. Mild lower back pain. Denies pelvic pain, vaginal bleeding, or leaking fluid. US shows dilated cervix with intact membranes protruding out. Vicky Lam @vickylalaloo https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1677374764374-OVE0VLOAQ3L4O8EJOK2L/netto+mccabe+bartholin+cystabscess.gif OB/Gyn - Bartholin's Abscess 20s F with past medical history of multiple bartholin gland abscesses requiring drainage presented with genital pain and swelling. I&D of the abscess was attempted which was initially unsuccessful, so POCUS was performed to confirm the location of the abscess. Gynecology was then consulted for drainage and was able to successfully drain the abscess. Alexandrea Netto PA, Denver Health and Hospital Authority Katie McCabe MD, Attending Physician, Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1686106521455-Z5UNN7W917VTJ1SSBFZ3/image-asset.gif OB/Gyn - Twin Gestation 30s F G1P0 at ~11-12 weeks by LMP presented to the ED with vaginal spotting and abdominal cramping. POCUS was performed and demonstrated a twin gestation with two viable fetuses, each measuring about 11 weeks by CRL. Tyler LaCoste, PA Dr. Anna Engeln Denver Health Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727649597767-OKM8PC2K54SQXF46Z4BJ/ezgif.com-overlay.gif OB/Gyn https://www.thepocusatlas.com/softtissue-msk daily 0.75 2025-06-07 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1749321780537-9QSN2ZGEPZ0M1I53E2GB/image-asset.gif Musculoskeletal - Flexor Tenosynovitis Waterbath Ultrasound - Short axis 50 yo M presented to the ED after accidentally injuring his middle finger while welding, with reported fevers, finger swelling and all 4 Kanavel signs. Waterbath ultrasound shows fluid along the flexor tendon sheath extending distally. Hand consulted, patient taken to operative room for septic FTS. Erick Otiniano, MD MPH | DHREM PGY1 Fred Milgrim, MD | Director of Residency Ultrasound Education, Denver Health https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1749321780537-9QSN2ZGEPZ0M1I53E2GB/image-asset.gif Musculoskeletal - Flexor Tenosynovitis Waterbath Ultrasound - Short axis 50 yo M presented to the ED after accidentally injuring his middle finger while welding, with reported fevers, finger swelling and all 4 Kanavel signs. Waterbath ultrasound shows fluid along the flexor tendon sheath extending distally. Hand consulted, patient taken to operative room for septic FTS. Erick Otiniano, MD MPH | DHREM PGY1 Fred Milgrim, MD | Director of Residency Ultrasound Education, Denver Health https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1749321740964-ZUH6GD02MZ49QIJA6VIV/image-asset.gif Musculoskeletal - Flexor Tenosynovitis Waterbath Ultrasound - Long axis 50 yo M presented to the ED after accidentally injuring his middle finger while welding, with reported fevers, finger swelling and all 4 Kanavel signs. Waterbath ultrasound shows fluid along the flexor tendon sheath extending distally. Hand consulted, patient taken to operative room for septic FTS. Erick Otiniano, MD MPH | DHREM PGY1 Fred Milgrim, MD | Director of Residency Ultrasound Education, Denver Health https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1749321553792-P7B2WTGYTG09WAF2NDKI/image-asset.gif Musculoskeletal - Flexor Tenosynovitis Waterbath Ultrasound - Color Doppler 50 yo M presented to the ED after accidentally injuring his middle finger while welding, with reported fevers, finger swelling and all 4 Kanavel signs. Waterbath ultrasound shows fluid along the flexor tendon sheath extending distally. Hand consulted, patient taken to operative room for septic FTS. Erick Otiniano, MD MPH | DHREM PGY1 Fred Milgrim, MD | Director of Residency Ultrasound Education, Denver Health https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1737044641343-OIUFV8OYPHPPQXQXD55C/image-asset.gif Musculoskeletal - Baker's cyst causing leg pain Patient in their 50s presented for leg pain that has gradually worsened over the past few days. Bedside lower extremity ultrasound was completed to evaluate for blood clot. It demonstrated a Baker's cyst, the hypo echoic area above the popliteal vasculature. Mehtab Galeh, MD Emergency Medicine Resident PGY3 Central Michigan University; Bayley Espinoza, MD Emergency Medicine Resident PGY1 Central Michigan University https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736376893430-QI8O386E1YGJE8BGPW06/image-asset.gif Musculoskeletal - Partial bicep tendon tear Short Patient presented with pain localized to the right humeral neck after lifting a heavy object and feeling a "pop" sensation. Negative "Popeye" sign and preserved strength in elbow flexion. Effusion was noted in the bicipital groove on both transverse and longitudinal views. In addition, on longitudinal view the ends of the biceps tendon were noted to remain in tension. Charles Jang, EM PGY-3 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736376750929-CU9GV29R88AL9AVECU6E/image-asset.gif Musculoskeletal - Partial biceps tendon tear - longitudinal Patient presented with pain localized to the right humeral neck after lifting a heavy object and feeling a "pop" sensation. Negative "Popeye" sign and preserved strength in elbow flexion. Effusion was noted in the bicipital groove on both transverse and longitudinal views. In addition, on longitudinal view the ends of the biceps tendon were noted to remain in tension. Charles Jang, EM PGY-3 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736374517785-UU5HMK4N8KBEEMO5OQ5K/image-asset.gif Musculoskeletal - Humeral Head fracture Patient fell onto his left shoulder with point tenderness at the proximal humeral neck. Point-of-care ultrasound showed cortical break on a transverse view of the humeral head. Hyperechoic fluid was visualized in the glenohumeral joint, likely clotted blood. A comminuted humeral head/neck fracture was confirmed on XR. Charles Jang, EM PGY-3 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736374428294-YQCMI0R4EMLOGI68C4P5/image-asset.gif Musculoskeletal - Humeral head fracture with traumatic effusion Patient fell onto his left shoulder with point tenderness at the proximal humeral neck. Point-of-care ultrasound showed cortical break on a transverse view of the humeral head. Hyperechoic fluid was visualized in the glenohumeral joint, likely clotted blood. A comminuted humeral head/neck fracture was confirmed on XR. Charles Jang, EM PGY-3 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1728167011736-I4J044VIL8N3Q14V5OK5/image-asset.gif Musculoskeletal - Normal Knee US in TKA Patient 55 yo F s/p RT TKA w/ revision presents after a fall. POCUS was w/o tendinous/bony abnormality. RT knee x-ray was w/o definite acute fracture. The American College of Radiology (ACR) promotes US evaluation of “pain after...(TKA with) suspect(ed) periprosthetic soft-tissue abnormality unrelated to infection” after radiographic evaluation as “usually appropriate”. Although ACEP US Guidelines boast 96.8% sensitivity and 99.7% specificity for diagnosing fractures, POCUS evaluation of traumatic arthroplasty complications does not exist. This creates an area of interest within POCUS. Contributors: Lauren Lowes, DO; Justin Morin, DO; Garrett Richardson, MS4; Nava Kendall, MD Central Michigan University Residency of Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1660945318727-ZAZ9PZJD7JSONDAKVZBE/image-asset.gif Musculoskeletal - Posterior Elbow Joint Injection 92 y/o M presented with moderate to severe osteoarthritis on elbow x-ray who was treated with ultrasound-guided corticosteroid joint injection. Video shows transverse view of the posterior elbow as corticosteroid is injected with a posterolateral approach deep to the posterior elbow fat pad located in the olecranon fossa. This area is continuous with the elbow joint capsule. Posterolateral approach is advantageous due to decreased risk of disrupting neurovascular structures or the articular cartilage from other approaches to the joint space. Posterior approach is also advantageous compared to lateral approach in moderate to severe arthritis due to limited access to the radiocapitellar joint space. Eben Alexander, DO Devesh Patel, MD Eastern Virginia Medical School https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661270078166-UMIRX7ZWO86L28I7C7B5/image-asset.gif Musculoskeletal - Transverse view scanning Proximal to Distal at the Posteromedial Ankle 40 y/o F presented with 9 month history insidious onset L medial ankle pain and was found to have tibialis posterior tendon partial tear. Video shows transverse view scanning proximal to distal at the posteromedial ankle (left is posterior). There is thickening of the posterior tibialis tendon with an anechoic tendon sheath effusion. At the level of the medial malleolus there are two moderate interstitial tears extending distally. Flexor digitorum and hallicus longus appear unaffected. Eben Alexander, DO Devesh Patel, MD Eastern Virginia Medical School https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1660945001007-MZR0I3HL8P2LGZQ9369K/image-asset.gif Musculoskeletal - Metacarpal Head Fracture 34 y/o M presented with fall while skiing injuring closed fist against ice and was found to have a displaced/impact fracture of his third metacarpal head. Video shows sagittal view scanning in the ulnar to radial direction at the third metacarpophalangeal joint (right is proximal). There is diffuse disruption of the cortex of the radial aspect of the metacarpal head and displaced/impaction fracture of the metacarpal head. Usually this surface should appear smooth. Articular cartilage can be seen as anechoic at the interface between the two bones. This defect was not visualized on initial or 2 week post x-ray, so ultrasound was able to guide the clinical team to appropriately splint and manage as a fracture. Eben Alexander, DO Devesh Patel, MD Eastern Virginia Medical School https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1660332805617-21C7P4IHRO9A6EOMRE8K/image-asset.gif Musculoskeletal - Corticosteroid Joint injection in Suprapatellar Recess 60 y/o F with knee arthritis getting corticosteroid joint injection in left suprapatellar recess. Ultrasound probe in transverse axis just superior to the patella. Needle approach lateral to medial. Infiltrate seen injected into anechoic suprapatellar recess. The suprapatellar recess is continuous with the tibiofemoral joint. Deep to suprapellar recess in this video is the prefemoral fat pad. Just superior to the suprapatellar recess in this image is the quadriceps tendon in short axis appearing as a fibrillar structure. Contributors: Eben Alexander, DO Devesh Patel, MD Eastern Virginia Medical School https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1660843427784-HNLTZ5VDDAFW689UBZUY/image-asset.gif Musculoskeletal - Biceps Tendinosis 60 y/o F w/R elbow pain for 8 months found to have distal biceps tendinosis. L=proximal; R=distal. Medial long-axis view of distal biceps tendon. Radial artery seen pulsating directly superficial to biceps tendon. Distal biceps tendon diffusely thickened with decreased echogenicity at its attachment site. Contributor: Eben Alexander, DO Devesh Patel, MD Eastern Virginia Medical School https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1724778824202-59Z3N0HWDE5YTZI2KXDE/image-asset.gif Musculoskeletal - Distal Quadriceps Muscle Rupture 70 y/o male fell onto his right knee presented with visible deformity of the distal quadriceps muscle. Physical exam demonstrated weakness to active extension of the right knee. POCUS with a linear transducer demonstrated complete loss of tendon architecture of the right knee, including a hypoechoic defect between the tendon fibers. When compared to normal knee radiographs, the patient has significant displacement of the patella distally. Radiologists interpreted this as possible quadriceps tendon rupture. During operative repair, a complete rupture of the quadriceps was discovered and repaired. Justin Morin, DO PGY-1 @justinjmorin; Alex Schlangen, DO PGY-1; Lauren Lowes, DO PGY-3; EM Residents at Central Michigan University https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1660944588408-U2I18Z7GIJV1V9RTG3SZ/image-asset.gif Musculoskeletal - Common Flexor Tendon Tear At Elbow 59 y/o M presented with 1 year history of insidious onset R medial elbow pain especially worse with playing golf and was found to have a high grade tear of the common flexor tendon. Video shows coronal view scanning posterior to anterior at the medial epicondyle (right is proximal). There is decreased echogenicity throughout the entire length of the tendon, but normal fibrillar tendon appreciated at deep aspect of tendon. There is an enthesophyte noted at the insertion site. Eben Alexander, DO Devesh Patel, MD Eastern Virginia Medical School https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1660943925025-FRMI9FF9OUATHQLC7Z1A/image-asset.gif Musculoskeletal - Biceps Tendon Sheath Effusion 55 y/o F presented 2 months after a FOOSH with adhesive capsulitis and a biceps tendon sheath effusion. Ultrasound scanning transverse axis proximal to distal along humeral shaft (left screen is lateral). Anechoic space around hyperechoic biceps tendon (center of screen) represents fluid that is continuous with the glenohumeral joint space. Inflammation from the adhesive capsulitis is drawing in fluid into the joint that is extending into biceps tendon sheath. Contributor: Eben Alexander, DO Devesh Patel, MD Eastern Virginia Medical School https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1720554310229-8ZTZYVFTESTPB3ZJ65WJ/image-asset.gif Musculoskeletal - Comminuted Proximal Phalanx Fracture of Great Toe Comminuted, dorsally angulated fracture of the proximal phalanx of the left great toe. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697913100734-RBJUQHRZQBC9149OD6E3/image-asset.gif Musculoskeletal - Fusobacterium Septic Joint This patient presented to the emergency department for several days of ankle pain. Ultrasound of the joint revealed anechoic fluid within the joint, which normally suggests a non-exudative cause. However, this patient’s joint was eventually tapped which revealed thick purulent fluid that grew Fusobacterium, and a rare cause of septic joint. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697819516629-CJNC1NZYWZU2YOWW84TW/image-asset.gif Musculoskeletal - Soleus Hematoma This is a patient who presented to the emergency department with left calf pain, swelling, previous history of DVT and currently on Xarelto. A patient with such a presentation would cause concern for ruling out a new DVT however a subsequent DVT scan proved to be negative. The key approach for this patient was to evaluated the area of maximal tenderness with ultrasound, which in this case, revealed a hematoma within their soleus muscle! Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1702923988610-84CHLG5XD9SAU4FB5MFT/image-asset.gif Musculoskeletal - Biceps long head tendon rupture, transverse view The patient presented with sudden onset right shoulder pain. On physical examination, there was tenderness to palpation anteriorly over the humeral head. POCUS demonstrated a heterogeneous structure within the bicipital groove representing a tendon stump surrounded by a developing anechoic haematoma. This study is in keeping with a complete rupture of the biceps long head tendon. This case illustrates the utility of POCUS as a diagnostic tool for the rapid identification of MSK injuries in the ED. Contributors: Andrew Namespetra(@AndrewNamespet1), MB BCh BAO MSc; Nava Kendall, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1674353694158-9NH2KH7QED1I45N8W7HF/image-asset.gif Musculoskeletal - Tenosynovitis Of The Extensor Hallucis Longus Tendon Patient initially suffered a puncture wound 8 days ago to the top of the foot. He presented a week later with pain in the toe, especially with flexion. US imaging showed extensive fluid surrounding the extensor hallucis longus tendon consistent with infectious tenosynovitis. The patient was taken to OR for debridement with good outcome. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1670210276454-4GDQQJPO5KX79ZMKH0BN/image-asset.gif Musculoskeletal - Retrocalcaneal Bursitis Hockey player with progressive posterior ankle/heel pain. Felt sudden worsening while skating. Clip shown reveals retrocalcaneal bursitis along with insertional Achilles tendinopathy. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1599260703664-0IHNPMY5BDHC7NVH941G/image-asset.gif Musculoskeletal - Mildly Displaced Clavicle Fracture A 15 year old wrestler landed on his right shoulder. POCUS was performed over point of maximal pain demonstrating cortical displacement consistent with a clavicle fracture. Paul Khalil, MD @Khalil3Paul Assistant PEM POCUS Director at University of Louisville/Norton Children’s https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1667688640859-I60EG5Z9PZKR8GB8L6LZ/image-asset.gif Musculoskeletal - Monosodium urate crystals Patient presented with great toe pain. POCUS performed and detected effusion in first metatarsophalangeal joint. Eventually determined to be monosodium urate crystals as seen in gout. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1645129526273-T96G4ZKJTDN5DMDEQZHG/image-asset.gif Musculoskeletal - Complex Left Ankle Effusion This is an image of a left ankle demonstrating a complex effusion in a patient presenting with ankle pain and swelling. Arthrocentesis was performed confirming septic arthritis. Michael Macias https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1640046578746-RJ1RKLYVEGSVSHFMOAOO/image-asset.gif Musculoskeletal - Intra-Articular Air This is an ultrasound clip from a patient who presented to the ED after sustaining a laceration near the knee. There was concern for violation of the knee joint so ultrasound was used to evaluate. The probe is held in an sagittal orientation, just proximal to the patella, overlying the quadriceps tendon. A hyperechoic line with shadowing (similar in appearance to an A-line seen on lung US) can be seen deep to the quadriceps tendon confirming intra-articular air and therefore violation of the knee joint from the laceration. A small joint effusion can also be appreciated. Clip courtesy of Dr. Daniel Mantuani and Highland Ultrasound Twitter: @HGHED https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638994217173-M8I5IM7M19N4G0YA9N04/image-asset.gif Musculoskeletal - Inferior Shoulder Dislocation A 30-year-old male presented to the emergency department with an inferior shoulder dislocation (luxatio erecta). Studies have shown that ultrasound has a very high sensitivity and specificity nearing 100% each (Secko 2020) in identification of the same. On ultrasound, the humeral head is shown dislocated anterior to the glenoid fossa, similar to typical anterior shoulder dislocations. This patient's shoulder was reduced with simple traction/countertraction under procedural sedation without any complications. Mark Zhang Secko MA, Reardon L, Gottlieb M, et al. Musculoskeletal ultrasonography to diagnose dislocated shoulders: a prospective cohort. Annals of Emergency Medicine. 2020;76(2):119-128. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637761706878-HNLM6UYQQIC0NVQMX13R/image-asset.gif Musculoskeletal - Septic AC Joint Patient presenting with shoulder pain and AC joint tenderness. Febrile to 102. POCUS revealed an AC joint effusion. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631722461688-8L60GMM9A3CV0RJUZU60/image-asset.gif Musculoskeletal - Shoulder Subluxation An 18-year-old male with acute left shoulder pain after a physical altercation in which his left arm was pulled. Video clip reveals the left humeral head sliding in and out of the glenoid fossa with internal and external rotation, confirming the diagnosis of shoulder subluxation. Read more about the case and shoulder POCUS on: https://www.aliem.com/ultrasound-for-win-acute-shoulder-injury-us4tw/ Mark Rivera-Morales, MD, PGY-3 Fernando Rivera, MD, PGY-3 Javier Rosario, MD, FACEP @javimedsimus UCF/HCA Emergency Medicine Residency Program of Greater Orlando. Osceola Regional Medical Center @UCFEMOrlando https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625847084706-D10KSGLZQWUVHMVEQQCH/image-asset.gif Musculoskeletal - Clavicle fracture with hematoma 60 year old female with a subacute left clavicular fracture (occurred 2 weeks ago) presented with worsening pain at fracture site of onset while working with occupational therapy. Seen here is the left clavicle (hyperechoic structure) with noted fracture and mild heterogeneous (concern for bloody accumulation) edema around fracture site as observed in long axis view. Kwasi Ampomah, DO, Eben Alexander IV, DO, Tariq Niazi, MD EVMS PM&R https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623684542724-TVAMXU3APIE0T464LM9Z/image-asset.gif Musculoskeletal - Sciatic Nerve Hematoma Patient sustained a gun shot wound through left mid thigh. Image is long axis view of sciatic nerve mid thigh. Nerve is running distal to proximal from left to right at approximately 3cm depth. There is a hypoechoic fluid collection seen superficial to the nerve. The epineurium is intact and we can see smaller nerve fibers contained in it. Patient had 0/5 plantar/dorsiflexion of ankle on admission, consistent with a sciatic nerve injury. The ultrasound exam on the sciatic nerve did not show any gross abnormality other than this fluid collection around the nerve. Within 7 days (4 days after this image) he regained strength in plantar/dorsiflexion in the ankle. Mike Guju, MD @MichaelMGujuMD Resident PM&R EVMS https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1619465519791-JB4XJMDLOI3ZDJ014XU0/image-asset.gif Musculoskeletal - Rib Fracture A middle aged man presented 1 week after sustaining a fall with direct injury to his left chest. He reported pain with inspiration and coughing; he localized pain to one specific area of his chest wall. Seen here is the image obtained when the linear probe was placed in the longitudinal plane to his area of point-tenderness. Notice the disruption of the hyperechoic cortex of the rib. Findings were confirmed in the transverse plan. The patient went on to have an anterior serratus nerve block for pain control related to his rib fracture. Mandy Peach, MD @mandy_peach Saint John Regional Hospital. NB, Canada https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616443063620-CDLDCSSJ70OPCRPYK0A8/image-asset.gif Musculoskeletal - Distal Biceps Tendon Rupture A 30-year-old male presented with acute-onset left anterior elbow pain after feeling a “pop” while weight-lifting. On exam, there was an obvious reverse popeye sign, swelling and mild ecchymosis. There was slight weakness in flexion and supination. Hook test was positive. A Butterfly IQ was used on an MSK soft tissue setting to assess the tendon in long and short axis via an anterior approach. Discontinuity of the tendon and surrounding anechoic fluid representing hematoma were noted. Orthopaedic surgery was consulted and reviewed ultrasound images. As a result, the patient had an urgent MRI and underwent expedited surgical repair. Melanie Leclerc, MD CCFP(EM). @MelanieLecler19 David Lewis MB,BS FRCS FCEM CFEU PGDipSEM Saint John Regional Hospital, New Brunswick, Canada https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616093328575-6W3O2OC7QUW0M7480BBT/image-asset.gif Musculoskeletal - Shoulder Relocation A 9-year-old female presented with left shoulder pain. She has a history of multiple dislocations and, as seen here on POCUS, is able to reduce the dislocation herself. Julie Klensch, PEM Fellow & Paul Khalil, MD University of Louisville/Norton Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616084631649-RF9L444T9FRHBCNNQT6K/image-asset.gif Musculoskeletal - ACL/LCL Injury A 32-year-old male pedestrian struck by a jeep traveling at 30 mph was evaluated with POCUS for left knee injury. He sustained a left-sided rupture of ACL, LCL, and an avulsion fracture of his IT band. Pictured here is his left lateral knee US performed 10-days after the acute injury. You can appreciate the popliteus notch in the lateral femur, typically both the origin of the popliteus muscle and the plane the LCL traverses to the fibula; here only notable for diffuse edema. Eben Alexander https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616083709689-T22VDG6XPQKIDUAGMFYR/image-asset.gif Musculoskeletal - Ligamentous Knee Injury A 34-year-old male trauma patient was evaluated with POCUS for left knee swelling. He was appreciated to have multi-ligamentous injury of the left knee, with imaging notable for hypoechoic fluid within the suprapatellar plica (bursa) and evolving septation of the fluid. Kwasi Ampomah https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1615255004791-780UDI7ZJDTFFE5QKAQB/image-asset.gif Musculoskeletal - Normal Achilles Tendon View of a normal Achilles tendon as seen in long axis, using a linear transducer. The relatively hyperechoic, linear fibers of the tendon are seen running from the calcaneus (right of screen, or inferior) to the gastrocnemius muscle (off screen to the left, or superior). https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1615255200033-HM8ZL0K2L4AVX8EXD701/image-asset.gif Musculoskeletal - Achilles Tendon Injury A 20s M presented with an ankle injury after landing a skateboard trick and feeling a painful pop in his posterior ankle. He had a positive Thompson test on exam. POCUS of the affected Achilles tendon was performed. This clip shows a long axis view of the Achilles tendon using the linear transducer, with inferior at the right of screen and superior at the left of screen. There is a relatively hypoechoic area (within red arrowheads) within the normally hyperechoic tendon, and the thickness is increased in this area as well, indicating focal injury to the tendon. Orthopedics was consulted, and the patient was placed into a splint in plantar flexion and discharged with outpatient follow up. MRI later confirmed a full thickness Achilles tendon tear and the patient was scheduled for surgery. Jaimie Trenney, PA-C Denver Heath Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1615256530846-6YPW3RPB1PWFGD65JMRU/image-asset.gif Musculoskeletal - Achilles Tendon Injury Short Ais A 20s M presented with an ankle injury after landing a skateboard trick and feeling a painful pop in his posterior ankle. He had a positive Thompson test on exam. POCUS of the affected Achilles tendon was performed. This clip shows a short axis view of the Achilles tendon using the linear transducer. There is a relatively hypoechoic area (*) within the normally hyperechoic tendon, indicating focal injury to the tendon. Orthopedics was consulted, and the patient was placed into a short leg splint in plantar flexion and discharged with outpatient follow up. MRI later confirmed a focal full thickness Achilles tendon tear and the patient was scheduled for surgery. Jaimie Trenney, PA-C Denver Heath Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609961854525-2SCIMYE89Y1KVLJOM724/image-asset.gif Musculoskeletal - Nursemaid's Elbow Nursemaid's pre and post reduction. Nathan Jia, Orthopedic Resident https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607175690368-9NHZTVC7HBH2X0N4VIO9/image-asset.gif Musculoskeletal - Myositis Ossificans Patient presents to the ED with severe thigh pain following a subacute MMA injury. After proximal DVT was ruled out, POCUS revealed hypoechoic oval masses in the vastus intermedius and peripheral calcifications with shadowing adjacent to the femur. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1603201414354-M763CKLJBGA2BFY30QZU/image-asset.gif Musculoskeletal - Water Bath POCUS Pictured here is a water bath scan using a high frequency linear transducer; specifically this image visualizes the distal right great toe of a healthy young adult. Water bath scanning is a technique that augments the clarity and distinctness of structures that are otherwise challenging to visualize with POCUS including distal digital examinations. In addition to yielding higher quality images, the use of a water bath circumvents the need for direct contact with the area of interest, often resulting in less patient discomfort. Moudi Hubeishy, MD. Rural Medicine PGY1. California, USA @Hubeishy_MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601048210657-RVGMTUGC6WGSOR5CTBJ9/image-asset.gif Musculoskeletal - Ruptured Achilles Tendon 16-year-old male presented with acute onset sharp pain to his LE and inability to bare weight after having landed oddly while playing basketball. POCUS revealed a near-complete disruption of his Achilles Tendon. Paul Khalil, MD. Assistant PEM POCUS director at University of Louisville/Norton Children’s @Khalil3Paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1596743374931-V17CS1SX7GPP0NZIXBBI/image-asset.gif Musculoskeletal - US-Guided MTP Arthrocentesis Patient with no history of crystallopathy presented with first metatarsophalangeal pain and swelling. Longitudinal view of the MTP joint revealed an anechoic effusion containing echogenic debris. Dynamic US guided aspiration was performed using an in-plane approach. Synovial fluid analysis showed monosodium urate crystals. Gram stain and fluid culture were negative. Learning point: Consider US guidance for arthrocentesis to increase success rate and maximize fluid yield especially in the case of a small effusion. Michael Cover, MD @michaelc0ver https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594851497707-FFDJT52U2BEFTV7ESTG8/ezgif.com-optimize.gif7.gif Musculoskeletal - Intramuscular Abscess after IVDU injection Male with LUE swelling after attempted IV drug use. Ultrasound of bicep reveals intramuscular abscess created from missed injection. Abscess was drained, and pt was admitted and given IV Abx. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594767703341-5HJF9T2VOUUETGAKJI47/deltoid+myonecrosis+.gif Musculoskeletal - Myonecrosis of Deltoid A patient with past medical history of diabetes presented with atraumatic right shoulder pain. Physical exam revealed decreased range of motion without obvious superficial abnormality. The patient was noted to be febrile and tachycardic. A curvilinear ultrasound reveals extensive air (scattered punctate hyperechoic areas) throughout the deltoid muscle indicative of infectious myonecrosis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592496082578-BJ7CFNYN8ROD3EOTMD3L/image-asset.gif Musculoskeletal - Pyomyositis A 35 year-old-male presented with neck pain and a history of recurrent neck abscesses. Prior treatment had included I&D. Soft-tissue POCUS was notable for appearance of muscle inflammation without focal fluid collection; subsequent operative findings confirmed pyomyositis of the right neck including sternocleidomastoid muscle. Brian Toston, Internist. Aventura, FL https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579518146412-VOEGNXYRK2UENS28QYXS/image-asset.gif Musculoskeletal - Rib Fracture A rib fracture is seen here as disruption in the hyperechoic line or bony cortex. Also note the associated hypoechoic hematoma formation. Aaron Inouye, PA-C, North Canyon Medical Center @PAintheED https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1554692225649-HVO3U79SNX8NVQ5GHB8P/finger+abscess+.gif Musculoskeletal - DIPJ Abscess A waterbath-augmented soft-tissue ultrasound of the LEFT index finger was used to diagnose an abscess at the level of the DIPJ Note a hypoechoic collection in the soft tissues sitting on top of the flexor tendon sheath Learning point : Immerse the hand in a waterbath to increase image quality for distal extremities - the water allows improved sound wave transmission Dr Cian McDermott, Mater University Hospital, Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1570903577087-KACI5EC76VV71JIKCGU5/Screen+Shot+2019-10-12+at+11.05.37+AM.png Musculoskeletal - Fracture Reduction Monitoring 72 y/o female presents with right upper arm pain after a mechanical fall from standing. A longitudinal coronal image was obtained at the right proximal humerus. Imaging showed displacement of bone fragments with hyperechoic lines 1.17cm apart. Pictures were obtained intermittently throughout reduction until displacement was reduced to 0.06cm. This case demonstrates the utility of ultrasound in fracture reduction. Traditionally, care teams perform repeat X-rays until the fracture is reduced. In comparison, ultrasound can be quicker and reduce exposure to ionizing radiation. Crozer Chester EM Arthur Strzepka (MS4), Damarcus Ingram (MS4), Dr. Max Cooper https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1570497257699-7VROBE54KOBOF1UHXWKW/ezgif.com-optimize+%286%29.gif Musculoskeletal - Rectus Abdominis Hematoma A 41 year old male presented to the ED with a painful right sided abdominal mass. On examination the area of swelling was tender to palpation and initially suspected to be a hernia. Patient had engaged in strenuous exercise the day before. Using the abdominal probe, a bedside ultrasound demonstrated a hypoechoic 4.9 x 4.7 cm hematoma within the right lower rectus muscle with active extravasation. This patient underwent successful interventional radiology embolization and had unremarkable hospital course. POCUS for abdominal masses can quickly narrow the differential for such patients, which can expedite decision making particularly in those who are hemodynamically unstable and on anti-coagulation. Max Cooper, MD Ultrasound Fellowship Director Crozer-Chester Medical Center Kevin Conor Welch, DO Ultrasound Fellow Crozer-Chester Medical Center Elena Grill, MD EM Resident Physician Crozer-Chester Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1530455486627-ITCXS930IGSI3BQ6XQF9/baker%27s+cyst.gif Musculoskeletal - Baker's Cyst A longitudinal view of a ruptured Baker's cyst. When performing a DVT scan, always look out for incidental findings that may explain the patient's presentation! Dr. Michael Trauer https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1525279154098-LMHZFI8AWTU2OZFTU7HU/ezgif.com-optimize+%2830%29.gif Musculoskeletal - Posterior Fat Pad Posterior fat pad aka Sail sign, is one of the common findings that we look for after a traumatic elbow injury that can indicate an underlying fracture. It represents hemarthrosis pushing the fat pad superiorly causing the triceps tendon to tilt. Plain films has been used as the initial modality of choice to look for sail sign but POCUS has been shown to be highly sensitive (97%) and specific (88%). It can be seen as anechoic fluid between the olecranon, humerus and fat pad. Source: Avci et. al. (PMID: 27645809). Also note the broken crystal on this image causing a dark artifact anteriorly. Dr. Maan Al Dubayan, Steven Greenstein, and Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515004704568-9IKRBPCIS7P2BEGI8RFV/ezgif.com-optimize.gif Musculoskeletal - Achilles Rupture (Long Axis) Full thickness tear of right achilles tendon after a skateboarding accident. (Long Axis) Dr. Mike Butterfield https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515004329351-BSA48P3DPK552PPMRUSQ/ezgif.com-optimize+%283%29.gif Musculoskeletal - Achilles Tendon Rupture (Short Axis) Full thickness achilles tendon rupture of the right leg after a skateboard accident. (Short Axis) Dr. Mike Butterfield https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507294901867-0TIHI8Q6H8WHUARRRS9G/arthrocentesis+riscinti.gif Musculoskeletal - Arthrocentesis and Joint Injection 55 y/o with history of gout and osteoarthritis with an effusion. Join tapped and triamcinalone injected at the end. Going to tap a joint and unsure of the best spot? Grab POCUS to find the biggest fluid pocket. Many prefer the in-place US guidance technique for big targets such as a joint and watching the needle enter the whole way. Matthew Riscinti, MD - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522274487419-39QK35KAPO7XK2YB3R9Z/ezgif.com-optimize+%283%29.gif Musculoskeletal - Elbow Effusion (Traumatic) Aspiration of traumatic elbow effusions may be considered in the management of radial head fracture. Slide a linear transducer along the forearm towards the elbow until the radial head, effusion and capitellum are seen. Using an out of plane approach, insert a needle into the effusion. The syringe will fill itself under intrinsic pressure. Relief is often instantaneous and prolonged and the range of motion of the elbow will increase dramatically Dr Cian McDermott, Emergency Physician, Mater University Hospital, Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507295488833-0I8Z5E7M1RMDZYK54PSY/riscinti+fts.gif Musculoskeletal - Flexortenosynovitis (FTS) 21 y/o F with 1 day of pointer finger pain. 4/4 Kanavel's signs - pain with passive extension, percussion tenderness, sausage digit, flexion posture of finger. Consultant is "unimpressed" and wants the patient on observation. Waterbath POCUS performed and demonstrates a fluid collection between the tendon and the bone (digit on left). Normal digit is on right. POCUS changed management and the patient went to the OR with confirmed FTS. Matthew Riscinti, MD - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507308931616-DNABND3FT69IHDLLFBPE/r.o.+fts.gif Musculoskeletal - Flexor Tendons of Hand (normal) Patient with atraumatic pain and swelling of R proximal phalanx. Flexor tenosynovitis was considered but view revealed normal flexor tendons without surrounding hypoechoic fluid or inflammation of the tendon. Keep in mind this is not a sufficient rule out test. In this image, the tendon can be seen flexing and extending with the proximal and distal phalanges articulating on each other. Drs. Hannah Moreira and John F Kilpatrick - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523826538438-U9BCD0Z8ZXCZJK37G088/ezgif.com-optimize+%2820%29.gif Musculoskeletal - Ganglion Cyst Patient struck his wrist several days ago and noted a deformity. There is a clear cystic structure with no doppler flow diving between the bones and involving the synovium representing a ganglion cyst. Dr. Dustin Morrow https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523824715553-9E8M267URI5XORKCRK4M/ezgif.com-optimize+%2816%29.gif Musculoskeletal - Hand Abscess (Periosteal) Periosteal Hand Abscess Pt is an IVDA with a recent lanced boil, total hand swelling and pain with movement. Water bath demonstrates a large collection periosteally which underwent washout and drainage in the OR for concern of early osteomyelitis. Dr. Dustin Morrow https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1511631139422-FJQDBOQEQ1G5EUOZ7HMD/Sukh+-+Hip+Effusion.gif Musculoskeletal - Hip Effusion POCUS of the R hip shows an anechoic region adjacent to the femoral head and within the joint capsule consistent with an effusion. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522101484931-XGZFRL7J7KCARSS3REX8/Sukh+metacarpal+fracture.gif Musculoskeletal - Metacarpal Fracture Fractures can easily be diagnosed with POCUS especially in resource limited settings. Just remember... this could be painful so use A LOT of gel and try not to press hard or at all. Gently move the probe along the axis of the bones where you suspect a fracture. The deepest and most hyperechoic horizontal line is the cortex and discontinuity in the lines represent fracture. Angulation and displacement can be measured. Two planes should be measured. Sukh Singh, MD, Caption: Matthew Riscinti, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1530459199814-DO9T33C1EBBV3FKB436A/patellar+tendon+rupture+longitudinal+.gif Musculoskeletal - Patellar Tendon Rupture Longitudinal 34 y/o M presented with swelling and pain inferior to his knee following hearing a pop when he jumped playing basketball. Pt unable to extend leg and x-ray demonstrated a high riding patella. Longitudinal ultrasound showed a hyperechoic tendon that is not continuous between the patella and tibia, with an anechoic area of hemorrhage consistent with patellar tendon rupture. Patellar tendon rupture can be diagnosed with H&P and POCUS can be used to confirm this diagnosis. In one study, diagnosis of tendon rupture by physical exam had a sensitivity of 100% and specificity of 76%, while diagnosis by POCUS had a sensitivity of 100% and specificity of 95%. Ultrasound is especially useful in patients who cannot cooperate with a physical exam, and serial ultrasound can also be used to monitor healing of a tendon rupture. Caroline Rago - MS4, Dr’s Bryan Jarrett and Joshua Schechter - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1530459214207-IR55Y4VZTRJ6TEQS2GI4/patellar+tendon+rupture+transverse.gif Musculoskeletal - Patellar Tendon Rupture Transverse 34 y/o M presented with swelling and pain inferior to his knee following hearing a pop when he jumped playing basketball. Pt unable to extend leg and x-ray demonstrated a high riding patella. Longitudinal ultrasound showed a hyperechoic tendon that is not continuous between the patella and tibia, with an anechoic area of hemorrhage consistent with patellar tendon rupture. Patellar tendon rupture can be diagnosed with H&P and POCUS can be used to confirm this diagnosis. In one study, diagnosis of tendon rupture by physical exam had a sensitivity of 100% and specificity of 76%, while diagnosis by POCUS had a sensitivity of 100% and specificity of 95%. Ultrasound is especially useful in patients who cannot cooperate with a physical exam, and serial ultrasound can also be used to monitor healing of a tendon rupture. Caroline Rago - MS4, Dr’s Bryan Jarrett and Joshua Schechter - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1525197468254-E2CJ2KZ6WY5M0IGJLUNQ/ezgif.com-optimize+%2826%29.gif Musculoskeletal - Right Patellar Tendon Rupture 56yo M with right knee swelling after getting foot stuck under a pallet and falling backwards, found to have patella alta and right patellar tendon rupture. Longitudinal image using linear 13-6MHz probe along proximal (left) and distal (right) patellar tendon with hypoechoic fluid at site of tendon rupture. Dynamic ultrasound is useful in diagnosing tendon ruptures as the site and extent of rupture can be easily visualized, which facilitates triage to surgery, if indicated. Dr. Jasmin Harounian https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515164933647-BULKS0OC567OKB6Y3VWP/morerira+azad+kelson+patella+tendon+rupture.gif Musculoskeletal - Patellar Tendon Rupture 50 y/o M presents with acute left anterior knee pain after fall. On exam, patient noted to have high riding patella. Longitudinal sonogram of the infrapatellar region showed marked discontinuity of the normally hyperechoic linear patterned tendon. The discontinuity is replaced with an anechoic collection indicative of hemorrhage. Comparison to normal knee can be seen on the next post. Of note, anisotropy may be encountered when utilizing ultrasound, leading to artifact. Depending on the angle of the insonating beam, a normally hyperechoic structure may be falsely viewed as hypoechoic due to poor return of echo. Ensure US probe remains perpendicular to the tendon to minimize this artifact. Dr. Hannah Moreira, Dr. Tareq Azad, Dr. Kyle Kelson - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507387001677-VLLXJ6QPR47KG8L8CZ2J/plantar+fascitis+JFK.jpg Musculoskeletal - Plantar Fasciitis 84 y/o F who couldn’t bear weight on her left foot. Pt usually ambulatory with no known trauma. L side thickened plantar fascia on symptomatic side (>4.5mm) and a hypoechoic fascia compared to a normal R side. Dr. John F Kilpatrick - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515082617487-TJTMXAV4VK0R7QYCZQ7V/nathan+valesky+segarra+qtendon+2.gif Musculoskeletal - Quad Tendon Rupture (Bilateral) 40 year old M presented with bilateral knee pain and inability to extend knees after injuring knee while carrying heavy plywood boards. POCUS confirmed the diagnosis of bilateral quadriceps tendon rupture. On ultrasound you can see the retracted tendon independent of the patella as the knee is being actively ranged. Also visible is a surrounding traumatic hematoma. One should look for discontinuity in the tendon in longitudinal view to diagnose any sort of tendon rupture. Often, there is an adjacent fluid collection reflecting hematoma. Be careful not to interpret the anisotropy of the ultrasound as discontinuity. Anisotropy is that the US looks different in cross section vs longitudinal views, any variation in the direction of the tendons and the positioning of the probe can lead to a false positive. Dr. Nathan Frank, Dr. Benjamin Weissman, Dr. Walter Valesky - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1511197354343-0A14DI9MRH0KS8PRJWWS/alerhand+rib+fracture.gif Musculoskeletal - Rib Fracture 40 y/o M with polysubstance abuse, left-sided rib pain after a traumatic blow. Chest xray was equivocal. The patient was asked to "point to where it hurt", and the linear transducer revealed a displaced rib fracture. He complained of significant pain even after the resident gave two Percocet and was unwilling to leave the ED. An intercostal nerve block, and that relieved the patient's pain and he went home. Dr. Stephen Alerhand, Mt Sinai Hospital NYC https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501105346718-H52684JFBEUSGFJ8JENG/ezgif.com-optimize%28shoulder_reduction%29.gif Musculoskeletal - In-Vivo Shoulder Reduction This is a posterior approach looking at the left shoulder showing an anterior dislocation. The dislocation was found before X-ray was shot. While the resident was performing the Cunningham technique to reduce the shoulder, the attending was able to, in real time, watch it go back in place. In between the humeral head and the glenoid rim is a large hematoma where I would aim my needle if I were to do an intra-articular block. It is a helpful technique in those recurrent dislocators. Saves the initial X-ray, but probably should get the post-reduction film at this point. Matt Rutz, MD - Indiana University Department of Emergency Medicine, Ultrasound Division https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1577822210410-9FJMIW0A4NC8I4FJRTDU/image-asset.gif Musculoskeletal - Sternal fracture 8 year old male presented following blunt thoracic trauma from having fallen out of a bouncy house. Clinically he had reproducible bony tenderness to palpation of the anterior chest wall. POCUS revealed normal lung slide in the setting of a sternal fracture. The fracture is pictured on the left side of the image as a defect in the cortex with adjacent swelling/hematoma formation; also notice a buckle fracture to the sternal growth plate at the right of the screen. Dr. Paul Khalil, Emergency Medicine Physician @denverem https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1520202421339-FGKZ2WILTAA5LRXHWL64/ezgif.com-optimize+%281%29.gif Musculoskeletal - Shoulder Dislocation 50M w/ R shoulder dislocation (arrow over humeral head), also likely has blood and possible air in joint space from injection of anesthetic. Greg Powell, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515003980300-C93BULQT9T0X1CFJJYQV/ezgif.com-optimize+%282%29.gif Musculoskeletal - Subscapularis Tendinopathy 50 year-old woman with anterior left shoulder pain; severe subscapularis tendinopathy with calcification and several small tears. Dr. Mike Butterfield https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523824120485-I8PQGYWNIPHFCZ0G4ICV/ezgif.com-optimize+%2815%29.gif Musculoskeletal - Suprapatellar Bursitis Suprapatellar bursitis from repetitive trauma of playing on the floor with grandchildren. Presented with over a week of knee pain and swelling. Superficial involvement and septae are possible for abscess, however it is contained within the bursal space above the patella. Arthrocentesis revealed no infection, and conservative therapy yielded improvement. Dr. Dustin Morrow https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1510784139327-C88UDZ5JDYOLT42K7X22/thumb+fracture+alerhand.gif Musculoskeletal - Thumb Fracture 30 year-old male ED resident who injured his thumb at some point while playing football versus the attendings in the annual flag football game. He figured the thumb had merely been sprained, and he kept playing in the game (and scoring touchdowns) while the residents dominated. Two days later the swelling/ecchymoses seemed to worsen, he used the linear transducer in a water bath to diagnose a fracture of the base of the 1st metacarpal. An x-ray confirmed the diagnosis, and he underwent percutaneous pinning in the operation room the following week. Dr. Stephen Alerhand, Mt Sinai Hospital, NYC https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534803660864-B4746GEO5K6FUOK7AU0M/Achilles+tendon+short+.gif Musculoskeletal - Achilles Tendon Short Axis This clip begins with the soft tissue of the heel and calcaneus visible in short axis. As the probe moves proximally, the achilles tendon appears in transverse view as an oval with an echogenic punctate appearance beneath a bright layer of skin at the top of the screen. As we move proximally the achilles tendon tapers and the gastrocnemius/soleus muscle complex becomes more prominent. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534803669583-RH8WSA1N8BYYWLVBKIPD/shoulder.gif Musculoskeletal - Normal Shoulder This clip of the shoulder is obtained by placing the probe in transverse plane on the posterior shoulder, and demonstrates the humeral head (left of screen) rotating in the glenoid. The scapular spine is to the right of the glenoid. The infraspinatus muscle is seen overlying the humeral head superficial to the infraspinatus is the deltoid muscle. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534803679036-RB0W0JHC1TUWFHKY2Z8J/Patellar+Tendon+.gif Musculoskeletal - Patellar Tendon In this clip we see the linear, fibrillar, echogenic patellar tendon in long axis tracking along the top of the screen. It starts with the insertion point at the distal patella (left side of the screen). As the probe moves distally, we see where it attaches to the proximal tibia on the right of the screen. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534803685571-5I7ML0HLRX1PI2LMURUL/quad+tendon+.gif Musculoskeletal - Quadriceps Tendon This clip shows the quadriceps tendon in longitudinal axis. It is hyperechoic, linear and fibrillar in texture. The distal tendon inserts onto the proximal patella, seen on the right side of the screen at the beginning of the clip. As the probe is moved proximally, the quadriceps muscles are seen deep to the tendon. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534804139649-PQKYYHSQX1WNE75RC9F4/Achilles+Tendon+.gif Musculoskeletal - Achilles Tendon In this clip we see the linear, fibrillar, echogenic achilles tendon in long axis along the top of the screen. The clip begins distally at the tendon’s insertion onto the calcaneus (the curved hyperechoic structure on the right of the screen). As the probe is moved proximally, the gastrocnemius and soleus muscles become visible in long axis deep to the tendon. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544999799051-Z8FKPAOHHZ3UD30TVN9T/mcl+bursitis+.gif Musculoskeletal - MCL Bursitis 29 year-old elite level soccer player with medial knee pain. He describes this being 'the worst episode ever', as he was having recurrent episodes of such pain. Valgus and flexion deformity due to prior surgery 15 years ago at the affected knee. Sharp, non-radiating pain 9/10 on NPRS, wakes him up at night. Palpation of medial knee and valgus stress test positive. Concomitant recent trauma. Unable to train/compete. USG of his knee revealed both MCL insertional edema (grade 1 injury) and MCL bursitis. Guided aspiration (3cc) and corticosteroid injection to MCL bursae revealed excellent outcomes. He returned to play 3 days later. Pitfall: It was not an MCL injury. Key point : Intervention was necessary and US-guidance allowed correct needle positioning without complication. Dr. Omer Batin Gozubuyuk, Sports Medicine Specialist, Istanbul University, Istanbul, Turkey. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1615580479469-XUCD2WEOIZS41WMCJ49Q/image-asset.gif Musculoskeletal - Flexor Tendonitis A 50s M presented with atraumatic finger pain/swelling x2 weeks. On exam, he had focal swelling localized the volar aspect of the ring finger over the proximal phalanx, without fusiform edema/erythema or any limitation of ROM. POCUS showed a small fluid collection adjacent to the flexor tendon. The flexor tendon is shown in long axis, with linear fibers seen just superficial to the bone cortex, and then is seen in short axis. The hypoechoic area superficial to the tendon represents the fluid collection. As the patient had intact ROM and no signs of infection, he was splinted and will follow up for a recheck of tendonitis. Kristy Karkula, PA and Dr. Ruth Foss Denver Health Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1617046333211-R501PS9HW8LTB90RSAAG/image-asset.gif Musculoskeletal - Subscapularis Tendon Tear A middle aged male presented to the ED with shoulder pain after skiing crash. POCUS of the shoulder was performed, showing a subscapularis tendon tear. Here, the proximal humerus is shown in short axis, with the linear probe placed in transverse orientation at the anterior aspect of the shoulder. The biceps tendon is seen in the biceps groove, between the greater tuberosity (lateral or right of screen) and lesser tuberosity (medial or left of screen). The patient is asked to externally rotate the arm, which brings the subscapularis tendon into view, and a hypoechoic, thickened area is seen, indicating a tendon tear. Dr. Matthew Riscinti Denver Health Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620693091267-HJ8PUOZYTWEJ9E40ZO7E/image-asset.gif Musculoskeletal - Nearly Complete Achilles Tear Healthy male in late-20s trying to do a backflip off a diving board. Still was able to plantarflex (very weak and with significant pain). Submitted by Dr. Elias Jaffa https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637272045142-9B12L11BDR207RFQXPJ4/image-asset.gif Musculoskeletal - Arthrocentesis of Knee Effusion 40s F with prior history of contralateral trimalleolar ankle fracture s/p multiple surgeries presents 1 month of knee swelling and pain after starting levofloxacin. The symptomatic knee appeared swollen without warmth or erythema, ROM was preserved, and the patient was ambulatory. Point of care US demonstrated an effusion around the knee, so diagnostic and therapeutic arthrocentesis was performed as shown here. The linear probe was used in a transverse orientation just superior to the patella to view the suprapatellar bursa just deep to the quadriceps tendon. Using sterile technique, a needle was advanced under real-time, in-plane US guidance to enter the bursa and aspirate synovial fluid. Ultimately the patient did not have septic arthritis and was discharged with a compressive knee wrap with a plan for orthopedic surgery follow up. Dr. Caleb Knight, PGY-2 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567932283579-2GZ42FDLVBUG89FN9OBC/patella-tendon.gif Musculoskeletal - Patellar Tendon - Colorized Patellar Tendon Red: Patellar tendon Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567932275265-LJOHVVJ6YNUYDBF3AUPG/normal-shoulder.gif Musculoskeletal - Shoulder - Colorized Shoulder Green: Humeral head, Blue: Infraspinatus, Red: Rotator Cuff Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1645519295560-W42P0S7VNVYP717AHYR6/image-asset.gif Musculoskeletal - Anterior Shoulder Dislocation 20s M with history of recurrent shoulder dislocations presented with pain and a deformity after being transferred from an urgent care after multiple failed attempts at closed reduction. POCUS confirmed dislocation at the bedside. The clip shown here is a posterior view of glenohumeral joint, illustrating the anterior displacement of the humeral head (H) in relation to the glenoid rim (G). A humeral head which is more than 1 to 1.5 cm anterior to the glenoid rim should be concerning for anterior dislocation (PMID 32111508). In this case, it is easy to see that the humeral head is almost 2cm anterior to the glenoid rim. After placement of an US guided interscalene nerve block, this patient was able to be reduced without difficulty. Dr. Anthony Rodriguez, PGY1 Denver Health Residency in Emergency Medicine Dr. Nimish Bhatt, Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1657915674052-CMGVJPN5LGH8WR5XYNTA/MT+felon.gif Musculoskeletal - Fingertip Felon 40s M who works as a carpenter presented with finger pain and swelling 10 days after he injured his finger when a heavy object fell on it. He sought medical care on the day of the injury and had radiographs which were negative for fracture, and there was no visible wound initially. On this visit, he was noted to have focal erythema and edema to his distal phalanx. POCUS was performed to evaluate for abscess and flexor tenosynovitis. To improve visualization, a water bath was used. The finger tip is shown here, with a small circumscribed area of hypoechoic fluid at the distal phalanx, indicative of a felon. Incision and drainage was performed and the patient was discharged on oral antibiotics and with plan for PCP follow up. Nayun Lee, MS3 Dr. Molly Thiessen Denver Health Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659982186219-CH770N3B989Z0JN0P46F/image-asset.gif Musculoskeletal - Flexor Tenosynovitis 30s M with PMH IVDU presented with worsening swelling over his middle finger and hand. His clinical exam was concerning for flexor tenosynovitis, so a water bath POCUS was performed to evaluate his flexor tendon sheath. The study is shown here, where the middle finger is shown first in short axis and then in long axis. The flexor tendon is seen as the relatively hyperechoic structure just superficial to the bony cortex, and has a fibrillar appearance when seen in long axis. This clip demonstrates anechoic fluid within the sheath surrounding the flexor tendon, which in this clinical context is diagnostic of flexor tenosynovitis, a surgical emergency. This patient was given IV antibiotics and was taken to the operating room for I&D and washout of his hand. Dr. Brigit Noon, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1677374099147-CFQY0BK79OF1JW2A97PA/ANetto-Lois+achilles.gif Musculoskeletal - Achilles Tendon Rupture 20s M presented with calf/heel pain after skateboarding, found to have a positive Thompson test. POCUS confirmed a full thickness tear of the achilles tendon. The patient was splinted and referred to orthopedic surgery for repair. Alexandrea Netto PA, Denver Health and Hospital Authority Lois Isaksen MD, Attending Physician, Denver Health Residency in Emergency Medicine https://static1.squarespace.com/static/58118909e3df282037abfad7/595b01d4d482e9cbb5ed3bd2/677ef84c7dda2f04ad3e94e6/1749321730371/ Musculoskeletal https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1747858078727-ZL2P5HI4G7L12TH3LVIZ/image-asset.gif Musculoskeletal - Psoas Abscess HIV+ male presents with flank pain and weight loss. Abdominal US demonstrates a psoas abscess inferior to the right kidney. Contributor: Niël van Hoving https://www.thepocusatlas.com/trauma daily 0.75 2024-11-10 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1726520340788-QTT5EJFTHN7TB09RST6G/image-asset.gif Trauma - Pleural and Peritoneal Fluid in EFAST Exam Patient presented to the emergency department with atraumatic acute onset of shortness of breath. An EFAST was performed to evaluate for pneumothorax and assess for free fluid in the abdomen, thorax, and pericardium. A significant right pleural effusion was present. Additionally, US of RUQ demonstrated a liver which appeared small in size with prominent ascites. This demonstrates the utility of POCUS to identify free fluid in a quick and efficient manner as compared to other common studies such as a CT scan, even in non-traumatic patients. Contributors: Lauren Lowes, DO; Krishna Patel, DO; Julia Tu, MS-4 Central Michigan University Residency of Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1726520340788-QTT5EJFTHN7TB09RST6G/image-asset.gif Trauma - Pleural and Peritoneal Fluid in EFAST Exam Patient presented to the emergency department with atraumatic acute onset of shortness of breath. An EFAST was performed to evaluate for pneumothorax and assess for free fluid in the abdomen, thorax, and pericardium. A significant right pleural effusion was present. Additionally, US of RUQ demonstrated a liver which appeared small in size with prominent ascites. This demonstrates the utility of POCUS to identify free fluid in a quick and efficient manner as compared to other common studies such as a CT scan, even in non-traumatic patients. Contributors: Lauren Lowes, DO; Krishna Patel, DO; Julia Tu, MS-4 Central Michigan University Residency of Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697821907301-XZKP1RMW250ZGOEKISFQ/image-asset.gif Trauma - Hemoperotineum Or Not? This is RUQ view from a patient who presented to the emergency department after falling from a roof and with low blood pressures. Although there appears to be perihepatic fluid, an interesting learning point form this case is whether or not we can discern if fluid observed is truly in the retroperotineal space or in the peritoneal cavity. Because the fluid is in direct contact with perinephric fat, this is actually in the retroperitoneal space and not in the peritoneal cavity. This may be difficult to distinguish in patients with very little perinephric fat. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1674272157059-GCWGDG8NVDG7Z7JI8NSJ/image-asset.gif Trauma - Subcapsular Splenic Hematoma This is a clip of the LUQ performed during FAST exam following blunt trauma. It demonstrates loculated fluid around the spleen concerning for blood. CT imaging followed demonstrating a large subcapsular splenic hematoma. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1670208663192-9JBP7E0BCZT23OKF8Y71/image-asset.gif Trauma - Hemoperitoneum This clip was obtained in a patient presenting after a fall from roof. This hepatic window demonstrates an echogenic clot surrounded by a thin sliver of anechoic free fluid. This patient had massive acute hemoperitoneum. Remember that not all acute hemorrhage is anechoic! Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1627328355363-Q119JK9IT6NGFI6R0BZT/image-asset.gif Trauma - Splenic Rupture Positive eFAST exam in a blunt trauma patient reveals abnormal splenic architecture and perisplenic fluid. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625848837127-4UDWGCUU7VAX4V8IFJ8B/image-asset.gif Trauma - Splenic hematoma with active extravasation 72 year-old male on Eliquis presented to the ED hypotensive after a fall. He was found to have left-sided rib fractures and ecchymosis. FAST was negative for intra-abdominal free fluid, pulmonary effusion, and pneumothorax but did show a splenic hematoma with a fluid jet and swirl (seen here). IR read the CTA as no active extravasation. After describing the ultrasound images the pt was taken to IR and had splenic artery angiography which confirmed extravasation, and was subsequently embolized with resultant hemodynamic stabilization. Dr Alec Glucksman PGY-III @alecglucksman, Dr Anna Van Tuyl, Dr Norman Ng, Dr Joshua Greenstein Northwell Health - Staten Island University Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625681136980-U9OQWQE9568VYK3GS217/image-asset.gif Trauma - RUQ Free Fluid A patient presented with LUQ trauma but the perisplenic window was negative for free fluid. Morison’s pouch was positive for free fluid emphasizing the importance of scanning all regions for free fluid in trauma. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620332285239-J024867PXNTK8WMNKRQA/image-asset.gif Trauma - Hepatic Laceration Seen in the superficial region of the liver is an easy to miss hepatic laceration. Ultrasound has a low specificity for detecting solid organ lacerations. Diagnosis was confirmed via CT. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1617895200377-V0I0OWXPC9ZS43NKGORV/image-asset.gif Trauma - Positive FAST Seen here is a subtle positive RUQ FAST scan in a trauma patient — a pertinent reminder to never stop simply after evaluating Morison's Pouch. Always also trace anteriorly to the lowest part of the liver. Hjalti Már Björnsson @hjaltimb https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614449530598-WA8AJXZNHCIIN6IY5MRV/image-asset.gif Trauma - Gunshot Wound Foreign Body Subcostal window in a patient with a gunshot wound revealed a hyperechoic structure with strong comet tail reverberation artifact. These findings are consistent with a metallic foreign body, such as a retained bullet in this patient. Visit the original post for a labelled image. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613854564842-W0QYVTI7M5ZDVPS7RA0G/positive-luq-lvad-watermarked.gif Trauma - Subtle Positive FAST - LUQ Positive FAST exam demonstrating free fluid in the left upper quadrant. Spontaneous hemoperitoneum in an anticoagulated patient with a left ventricular assist device (LVAD). Dr. Elias Jaffa, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613846780357-RB3DLXKDCZCXL76XUEF2/image-asset.gif Trauma - Free Fluid in LUQ This image demonstrates free fluid in the LUQ. Notice the anechoic fluid seen both superior and inferior to the spleen as the probe is fanned. There is significant rib shadow appreciated obscuring parts of the image which makes the free fluid difficult to appreciate if not evaluated closely. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613846337532-MB78MON7PZMNU630T96G/image-asset.gif Trauma - Positive LUQ View This image demonstrates free fluid present in the left upper quadrant following blunt trauma to the abdomen. Notice the anechoic area present along the the pericolic gutter as well as between the spleen and the diaphragm consistent with free fluid. Michael Macias, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1610646305950-3P6GWNXDQMLGXOYJ5RZQ/image-asset.gif Trauma - Adrenal Hematoma An adult male presented to the ED following a MVC with a fractured femur, right sided flank pain, and transient hypotension. FAST exam revealed an isoechoic, oval structure just cephalad to the right kidney indicative of an adrenal hemorrhage/hematoma. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609189315156-FE1HG9XKDCVM4RXR1WAO/image-asset.gif Trauma - Retroperitoneal Hematoma A young male presented to the ED following a 20 foot fall. He presented with LUQ pain, left flank pain, and soft vitals. FAST exam showed no fluid in Morison’s pouch or in the pelvis but revealed a large, left-sided, retroperitoneal hematoma noted by the distortion of the left kidney. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601045812319-WOH9YHMX8MB4KPOK2ZB7/image-asset.gif Trauma - Free Fluid in Morrison's Pouch This 30-year-old male was brought to our ED after a fall from scaffolding with evidence of trauma to his right thoracoabdominal region. E-FAST performed in the RUQ revealed both the presence of free fluid within Morrison's pouch and an ipsilateral hemothorax. Appreciate the presence of “spine sign” as an additional ultrasonographic indicator of free fluid within the pleural space. Renato Tambelli, Emergency Physician Hospital das Clínicas de Marília, Brazil. @R_Tambelli // @JediPocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507764829491-PDTO9VHHH83GTZFGJCN5/bowra+neg+fast+ruq.gif Trauma - Normal FAST - RUQ No free fluid in Morison's pouch. Dr. Justin Bowra https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507764821960-DCBRFWPTSR5S0QQ2OQME/bowra+pos+RUQ+fast.gif Trauma - Positive FAST - RUQ - Morison's Pouch Blunt trauma patient with POSITIVE FAST scan. The liver can been seen floating in free fluid with the kidney posteriorly. The fluid is in Morison's pouch. Be sure to visualize the tip of the liver to complete the evaluation. Dr. Justin Bowra https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527401052157-7XVPIR1DUPGBRWOK5U1T/bon+%2B+fast+1.gif Trauma - Positive FAST - RUQ 30 y/o pedestrian struck by car, hemodynamically unstable, tachycardic. FAST performed after primary survey revealed free fluid in all four abdominal views of the FAST exam Free fluid in Morison’s pouch of the RUQ view. This is the most sensitive view to detect free fluid in trauma. Dr. Catharine Bon - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507764818485-VC2AYDRMTABDP1P7109Z/positive+RUQ+fast+bowra.gif Trauma - Positive FAST - RUQ Blunt trauma patient with POSITIVE FAST scan. The liver can been seen floating in fluid with adjacent bowel. Dr. Justin Bowra https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507764829676-NUGHFB858VEPHHW5EY9S/bowra+neg+fast+luq.gif Trauma - Normal FAST - LUQ No free fluid is seen between the spleen and the diaphragm. Dr. Justin Bowra https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507764825991-7JZ3YA2LEXELD6O86IM4/bowra+pos+fast+LUQ.gif Trauma - Positive FAST - LUQ Blunt trauma patient with POSITIVE FAST scan. Free fluid can be seen between the spleen and the diaphragm in this LUQ view. Dr. Justin Bowra https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507764828853-QISFYNVGK8L7X95TCDA1/bowra+neg+fast+trans+bladder.gif Trauma - Normal FAST - Pelvis - Transverse No free fluid is seen around or behind the bladder in this negative FAST. Dr. Justin Bowra https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507764819541-30PXEQ2ZB7PG4T8QAWTG/bowra+positive+fast+pevlic+free+fluid+trans.gif Trauma - Positive FAST Pelvis - Transverse Blunt trauma patient with POSITIVE FAST scan. The uterus can been seen floating in free fluid. Dr. Justin Bowra https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507764822945-I5AIOFVSXHQ8P5FW445E/bowra+pos+fast+trans+bladder.gif Trauma - Positive FAST - Pelvis Transverse Blunt trauma patient with POSITIVE FAST scan. Free fluid can be seen posterior and lateral to the bladder in this sagittal view. Dr. Justin Bowra https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507764831018-4EZU465PLMIOVYHKHJ0A/bowra+fast+neg+bladder+sag.gif Trauma - Normal FAST - Pelvis - Sagittal No free fluid is seen behind the bladder in this sagital view. Dr. Justin Bowra https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527401061210-DX7EMEH7LWOIG33Z3VSP/bon+%2B+fast+3.gif Trauma - Positive FAST - Pelvis 30 y/o pedestrian struck by car, hemodynamically unstable, tachycardic. FAST performed after primary survey revealed free fluid in all four abdominal views of the FAST exam. Free fluid seen superior and posterior to the bladder in this sagittal view. Dr. Catharine Bon - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1591988872902-DL2Y7IFYFL8C2HQKBNYZ/image-asset.gif Trauma - Ruptured Viscus From Blunt Trauma Pt struck by car while riding bike. Perihepatic view on FAST exam revealed a perforated viscus (gastric rupture). Note the free air within the fluid. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588262822841-8H41CQEHEQ9M9QP2K54E/image-asset.gif Trauma - Free Fluid within Abdomen A 35-year-old woman presented to the ED after experiencing blunt abdominal trauma. She was hemodynamically unable. E-FAST Exam performed at bedside was notable for free intra-abdominal fluid (viewed here from suprapubic region). This rapid diagnosis enabled prompt disposition to the operating room. Josiane Almeida, Emergency Physician; Sao Paulo- Brazil https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594936904680-XEVU08111GJCBBSZ6952/ezgif.com-optimize.gif10.gif Trauma - Ruptured Hepatic Hydatid Cyst 52-yo female presents to ED hypotensive with diffuse urticaria after blunt trauma to abdomen from a fall. FAST exam revealed a small amount of free fluid in RUQ and an abdominal mass. Diagnosis later confirmed to be a ruptured hepatic hydatid cyst. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507764825528-VZD9IDF6SLU94QU2581K/bowra+pos+fast+sag+bladder.gif Trauma - Positive FAST - Pelvis - Sagittal Blunt trauma patient with POSITIVE FAST scan. Free fluid can be seen posterior to the dome of bladder in this sagittal view. Dr. Justin Bowra https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509275752700-QCM0W55SU83JZ9FAXTYJ/ezgif.com-gif-maker.gif Trauma - Traumatic Pneumoperitoneum (1/2) 8 year old boy after pushbike handles went into abdomen. Erect CXR suggested small pneumoperitoneum. Initial POCUS in supine position showed normal RUQ, however this clip in left lateral position shows a small 'bubble' of air between liver and abdominal wall. Dr. Justin Bowra https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509276101981-5GE6NPEQMZA1DUHLCALV/ezgif.com-optimize+%287%29.gif Trauma - Traumatic Pneumoperitoneum (2/2) 8 year old boy after pushbike handles went into abdomen. Erect CXR suggested small pneumoperitoneum. This image shows a lung curtain across the liver. Dr. Justin Bowra   https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534805008477-07VMY00UTHMKXZ65F37T/subxiphoid+.gif Trauma - Subxiphoid The most superficial structure we see is the liver. Immediately deep to that we see the heart separated from the liver by the diaphragm. Closest to the liver is the right atrium, tricuspid valve, and right ventricle. Deeper to that, we see the left atrium, mitral valve, and left ventricle. There is no anechoic fluid between the bright hyperechoic pericardium and the myocardium, indicating absence of pericardial effusion. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534805015669-80P2UZIAR2KEGBPAQRUY/lung+slide.gif Trauma - Lung Slide This is a clip demonstrating lung sliding. The most superficial hyperechoic layers are the soft tissue and muscular layers of the chest wall. Immediately deep to that is a bright, thin hyperechoic line which appears to be in motion - this is the pleural line. The parietal pleura rubbing against the visceral pleura as the patient breathes creates this shimmery appearance of lung sliding, also often described as “ants marching”. Lung sliding indicates that there is no pneumothorax. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1617672010530-3BAG2S393BLNDWCMC79K/image-asset.gif Trauma - Free Peritoneal Fluid with Falciform Ligament 50s F found to be in cardiac arrest by EMS in the setting of 3 days hematemesis, achieved ROSC, and this image was seen on POCUS performed by EMS while packaging for transport. This subxiphoid view demonstrates the presence of organized cardiac activity with no large pericardial effusion, but free peritoneal fluid is seen adjacent to the liver, superficial to the diaphragm in this image, and the falciform ligament is also briefly seen. Zachary Hutchins South Metro Fire Rescue, Centennial, CO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1618249161161-QQ4Q1YB6TGJY4DNUO2R7/image-asset.gif Trauma - Free Peritoneal Fluid from Splenic Injury 20s M presented with abdominal and back pain several hours after a fall off a ladder, and on FAST exam, had a large amount of free fluid seen in the pelvis/lower abdomen and in the RUQ. He was slightly tachycardic but normotensive, so underwent CT of the abdomen/pelvis, which demonstrated a significant spleen injury which was managed by IR embolization. Dr. Greg Wiener, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1618249348272-UF298COQGGRYD71107VN/image-asset.gif Trauma - +FAST in Morrison's Pouch from Splenic Injury 20s M presented with abdominal and back pain several hours after a fall off a ladder, and on FAST exam, had free fluid seen here in Morrison’s pouch, as well as a large amount of free fluid seen in the pelvis/lower abdomen. He was slightly tachycardic but normotensive, so underwent CT of the abdomen/pelvis, which demonstrated a significant spleen injury which was managed by IR embolization. Dr. Greg Wiener, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1618249548746-KYC1PLNBO5FWPF214G1V/image-asset.gif Trauma - +FAST Exam from Splenic Injury 20s M presented with abdominal and back pain several hours after a fall off a ladder, and on FAST exam, had a large amount of free fluid seen in the pelvis/lower abdomen and in the RUQ. He was slightly tachycardic but normotensive, so underwent CT of the abdomen/pelvis, which demonstrated a significant spleen injury which was managed by IR embolization. Dr. Greg Wiener, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630519828843-SM348B9O3JJFJ5V6L7VD/image-asset.gif Trauma - RUQ +FAST A teenage male patient presented to the ED after a helmeted mountain bike crash, and due to mechanism, underwent a bedside FAST exam, which was positive in the RUQ as well as suprapubic views. CT demonstrated a grade 4 spleen laceration as well as multiple buckle rib fractures, and he was admitted for observation. Dr. Gabe Siegel, PGY-2 and Dr. Michael Kidon, PGY-4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630520156317-SD1K5KXUGEMWH156L86G/image-asset.gif Trauma - Subtle RUQ +FAST 30s F presented with worsening abdominal pain in the setting of a known ectopic pregnancy. FAST exam was very subtly positive in the RUQ, with more free fluid seen in the pelvic/suprapubic view. This clip shows the RUQ view, and a trace amount of free fluid is seen at the liver tip, highlighting the importance of complete visualization of this area when viewing the RUQ. This patient remained hemodynamically stable, and so was managed expectantly rather than with surgical exploration. Dr. Lindsay Howe, PGY-3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630520457830-P3YBGYCWEECYA8FCUKPW/image-asset.gif Trauma - Pelvic +FAST from Spleen Lac 20s F presented with presyncopal episode after standing electric scooter crash. She had been evaluated at an urgent care where she had dental injuries identified, but was initially hemodynamically stable. She arrived to the ED tachycardic and hypotensive, and FAST exam was positive in the pelvic view as shown here in transverse and sagittal orientations. She was resuscitated with massive transfusion protocol and responded well. CT scanning showed a grade 2 splenic laceration. The patient was admitted for further observation and serial CBC checks. Dr. Larry Benjey, PGY-3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630520939084-CF0CAF110PYI4ZE705X4/GS+MK+%2BFAST+Suprapubic.gif Trauma - Pelvic +FAST from Splenic Injury A teenage male patient presented to the ED after a helmeted mountain bike crash, and due to mechanism, underwent a bedside FAST exam, which was positive in the RUQ as well as suprapubic views. CT demonstrated a grade 4 spleen laceration as well as multiple buckle rib fractures, and he was admitted for observation. Dr. Gabe Siegel, PGY-2 and Dr. Michael Kidon, PGY-4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1633291621828-5ZJ06HPK8LUIBYB1XR5L/image-asset.gif Trauma - Suprapubic +FAST from GSW 20s M presented as a walk in after sustaining a GSW to the hip. He was initially hemodynamically unstable, however responded well to transfusion of blood products and vitals normalized. FAST exam of the suprapubic/pelvic area is shown here, with heterogenous free fluid seen best in the sagittal view. FAST was also positive in the RUQ and LUQ. Plain films demonstrated a retained missile in the abdomen. As he was hemodynamically stable, CT of the abdomen and pelvis was obtained, showing hemoperitoneum and free air concerning for bowel and vascular injury. The patient was taken emergently to the OR, where exploratory laparotomy demonstrated a pelvic hematoma and hemoperitoneum from an iliac vein injury, as well as multiple areas of small bowel injury. His injuries were repaired, he recovered well, and was discharged within days of his injury. Dr. Ian Eisenhauer, PGY1 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1633292502115-ZL3YLOEZOKVRO6MNPAZ3/image-asset.gif Trauma - Subtle +RUQ FAST from GSW 20s M presented as a walk in after sustaining a GSW to the hip. He was initially hemodynamically unstable, however responded well to transfusion of blood products and vitals normalized. FAST exam of the RUQ is shown here, with a trace amount of free fluid seen along the liver tip. FAST was also positive in the LUQ and pelvic views. Plain films demonstrated a retained missile in the abdomen. As he was hemodynamically stable, CT of the abdomen and pelvis was obtained, showing hemoperitoneum and free air concerning for bowel and vascular injury. The patient was taken emergently to the OR, where exploratory laparotomy demonstrated a pelvic hematoma and hemoperitoneum from an iliac vein injury, as well as multiple areas of small bowel injury. His injuries were repaired, he recovered well, and was discharged within days of his injury. Dr. Ian Eisenhauer, PGY1 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1667694636787-H5K0M94XBWGV4ZBE2G9U/image-asset.gif Trauma - Foreign body: wood piece Alligator forceps being used to removed a retained wood piece within a fingertip Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1667695030653-JZRS1YI13EP232LX5FUN/image-asset.gif Trauma - Foreign body: glass Pictured here is a retained glass piece as result of a closed fist injury with a window Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1667695558144-Z81DYBN1AKGF9N0PGKUL/image-asset.gif Trauma - Foreign body: bamboo This patient was seen at a prior facility with pain in arm. X-rays were negative and was sent home with antibiotics. Pain continued to worsen and after ultrasound was employed, a piece of bamboo was discovered. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1731209968160-AXNUQB06OXH41Z7L670Y/image-asset.gif Trauma - Normal Lung Sliding - FAST 11 year old female presented to the emergency department with a puncture wound to her left chest wall. FAST exam did not reveal any intra-abdominal free fluid, and there was lung sliding bilaterally, suggesting no pneumothorax. The patient had her wound explored, repaired, and was discharged home. Contributor: Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1731210514106-2L5ZBN23TP4ZSYODDQ7Y/image-asset.gif Trauma - Normal LUQ FAST View Normal LUQ FAST view Contributor: Kathryn Pade, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1731211015756-211N6V5MML65XG3OX5ZN/image-asset.gif Trauma - Normal subxiphoid evaluation Normal subxiphoid view on Efast of a 21-month-old patient. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1731214503099-LKV2PKGY8ER42ORHSEC7/image-asset.gif Trauma - Normal Lung Sliding Normal lung sliding on Efast in a 21-month-old patient. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1731215139454-7Z0G89E7U9NY97G7WV1B/image-asset.gif Trauma - Normal RUQ Evaluation Normal RUQ on Efast of a 21-month-old male. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1731216267841-FBLC5ZO9DWFS3BOMZ4RF/image-asset.gif Trauma - Normal LUQ Evaluation Normal LUQ on Efast of a 21-month-old. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://www.thepocusatlas.com/intracranial-stills daily 0.75 2018-04-01 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522614170361-FHKPGK1HL1NO9E504JHR/sathya-cranial-landmarks1+.jpg Intracranial stills - Cranial - Coronal Anterior Labeled Dr. Sathya Subramanian - Pediatric Emergency Ultrasound Fellow at the Children's Hospital of Philadelphia   https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522614170389-19D1R64RONHWQYWNSBMB/sathya-cranial-landmarks2.jpg Intracranial stills - Cranial - Coronal Midline Dr. Sathya Subramanian - Pediatric Emergency Ultrasound Fellow at the Children's Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522614172266-925BBQZH0BWEV8NFSK8Q/sathya-cranial-landmarks3.jpg Intracranial stills - Cranial - Coronal Posterior Dr. Sathya Subramanian - Pediatric Emergency Ultrasound Fellow at the Children's Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522614172335-52N5SSHQUFMN9IRZXAD3/sathya-cranial-landmarks4.jpg Intracranial stills - Cranial - Sagittal Right Dr. Sathya Subramanian - Pediatric Emergency Ultrasound Fellow at the Children's Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522614172911-TSVE1PNB8KBAM53RM8BH/sathya-cranial-landmarks5.jpg Intracranial stills - Cranial - Sagittal Left Dr. Sathya Subramanian - Pediatric Emergency Ultrasound Fellow at the Children's Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522614172959-CMKHJFE4UTPANZ8WOISS/sathya-cranial-landmarks6.jpg Intracranial stills - Cranial - Sagittal Midline https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522614173533-MOC2ESWTNAHZKIL8723H/sathya-cranial-landmarks7.jpg Intracranial stills - Case - Hydrocephalus - Labeled An example of extra axial fluid collection visualized with asymmetric ventricles. Dr. Sathya Subramanian - Pediatric Emergency Ultrasound Fellow at the Children's Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522614173572-X6VNAV98BOUCFYBQS7ZC/sathya-cranial-landmarks8.jpg Intracranial stills - Case - Hydrocephalus - Asymmetrical Ventricles - Labeled Dr. Sathya Subramanian - Pediatric Emergency Ultrasound Fellow at the Children's Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522614174168-ICDVR5IFBPAZIZ5MNQA5/sathya-cranial-landmarks9.jpg Intracranial stills - Case - Hydrocephalus - Extra Axial Fluid - Labeled Dr. Sathya Subramanian - Pediatric Emergency Ultrasound Fellow at the Children's Hospital of Philadelphia https://www.thepocusatlas.com/friends daily 0.75 2023-10-31 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1629723050564-5ZGGRRXC6CID6Q70YON3/image-asset.png Friends - Denver Emergency Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1629723050564-5ZGGRRXC6CID6Q70YON3/image-asset.png Friends - Denver Emergency Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572990143522-9YC5MJATGKTWNLCGT9TU/sonoclipshare.png Friends https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572990261212-PTXX2WN2W8T7CWW9TGK6/sonogif.png Friends https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1568231330223-RUP3N3UY4S7TN6F59CCR/B%26Bblack-12.png Friends https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1698781872362-LTCJD9JT005WH32PZ7MY/5minsono.jpg Friends https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968268719-5U7HWIKEIN3NKFD06QPI/broomedocs.jpg Friends https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968788678-HUD5E7ENFUQ5MSVN7Y9P/emgus.jpeg Friends https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968304446-RHTOZCQ4ZZ9GTAENE8ZX/neum.png Friends https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968350842-WEIKU906YX3CW2YVJ7JN/ultrasoundpodcast.png Friends https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968389698-615IM80CFJ3RX4SV4NAM/ddxof.png Friends https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968273153-KO1W9CDMRH3RRODEISW0/GEL+icon.jpeg Friends https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527819174234-8AOY6XQ4RC74K0S2Y45A/UCSD+Website+Logo+Design-45.png Friends https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1563378934041-G4PQ8BIAUBIST583Z4NT/EGLS+Logo.png Friends https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592942995045-ZJN2OXNHPPHMY94PH8Q6/image-asset.png Friends - Visible Voices https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1612639768052-R3TKV3IWEJTS69MJOFPW/image-asset.png Friends - Wiki EM https://www.thepocusatlas.com/the-evidence-atlas-3 daily 0.75 2024-12-16 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729562521-6RF6HYRNUR2QZNM01SKJ/Screen+Shot+2018-05-30+at+6.13.08+PM.png The Evidence Atlas - End Point Septal Separation This was a prospective observational study (n=80) comparing emergency medicine (EM) physician performed mitral valve EPSS to formal TTE LVEF estimation. A convenience sample of unselected hospitalized patients undergoing comprehensive TTE for any indication was used. While EPSS > 7 mm was noted to be 100% sensitive for predicting severe systolic dysfunction (EF < 30%), a second cutoff of 8 mm was used for assessing any systolic dysfunction. The sensitivity and specificity of an EPSS > 8 mm for any systolic dysfunction were 83.3% (95% CI, 62.6-95.2) and 50.0% (95% CI, 29.2-70.9), respectively. The corresponding positive LR was 1.67, and the negative LR was 0.33. PMID: 24630604 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523668475511-BFOAYJ6M78BHSKFKXTL4/Screen+Shot+2018-04-12+at+3.58.01+PM.png The Evidence Atlas This was a small systematic review evaluating evaluating the utility of emergency department (ED) performed ocular ultrasound. A total of 3 studies were included in the final analysis and overall the data was low risk for bias. One limitation to note is that among the 3 studies included, there was not a clear definition for a positive test result. In one of the included studies, no positive test definition was provided. PMID: 24680547 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729562521-6RF6HYRNUR2QZNM01SKJ/Screen+Shot+2018-05-30+at+6.13.08+PM.png The Evidence Atlas - End Point Septal Separation This was a prospective observational study (n=80) comparing emergency medicine (EM) physician performed mitral valve EPSS to formal TTE LVEF estimation. A convenience sample of unselected hospitalized patients undergoing comprehensive TTE for any indication was used. While EPSS > 7 mm was noted to be 100% sensitive for predicting severe systolic dysfunction (EF < 30%), a second cutoff of 8 mm was used for assessing any systolic dysfunction. The sensitivity and specificity of an EPSS > 8 mm for any systolic dysfunction were 83.3% (95% CI, 62.6-95.2) and 50.0% (95% CI, 29.2-70.9), respectively. The corresponding positive LR was 1.67, and the negative LR was 0.33. PMID: 24630604 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729495981-5Z9PC3WVLD1QFCNGJKAC/Screen+Shot+2018-05-30+at+6.12.18+PM.png The Evidence Atlas - Abdominal Aortic Aneurysm This was a systematic review evaluating the operating characteristics of emergency department (ED) performed ultrasonography for abdominal aortic aneurysm (AAA). A total of 7 studies (n = 655) were included in the analysis, all of which were prospective studies which enrolled adult patients with symptoms/signs suggestive of AAA. AAA was defined as > 3 cm dilation of the aorta. The reference standard was varied among studies including CT, MRI, aortography, radiology performed ultrasound, exploratory laparotomy, or autopsy results. The operator training and experience, as well as the number of participating emergency physicians in each study, was also quite variable. While the pooled data is displayed in the included table, the individual sensitivity and specificity range for AAA detection among the 7 studies were as follows: sensitivity 97.5-100%, specificity 94.1-100%, LR+ 10.8 - infinite, and LR- 0.00-0.025. PMID: 23406071 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729524750-RUDIQ9K3JHWC6YP25LFN/Screen+Shot+2018-05-30+at+6.13.17+PM.png The Evidence Atlas - Acute Heart Failure This was a large systematic review and meta-analysis (57 studies, n = 17,893) of the operating characteristics for diagnostic elements available to the emergency physician for diagnosing acute heart failure (AHF) including the history and physical, ECG, chest radiography, BNP/NT-proBNP (NPs), bedside echocardiography, lung ultrasound, and bioimpedance. They concluded that bedside lung US and echocardiography appear to the most useful tests for affirming the presence of AHF while NPs are valuable in excluding the diagnosis. Reduced ejection fraction was determined to have the highest +LR compared to other elements of the exam. However, the studied included in the final pooling appear to have only used "visual estimation" of reduced EF. With regards to lung US, a positive finding was defined in every study by the presence of at least three B lines in two bilateral lung zones. PMID: 26910112 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729641817-ZVNU81BZZP3GA8Y7F4O2/Screen+Shot+2018-05-30+at+6.12.54+PM.png The Evidence Atlas - Cardiac Arrest Survival This was a prospective observational study at 20 hospitals in the US and Canada evaluating patients presenting with out-of-hospital arrest or in-ED arrest. Patients with pulseless electrical activity or asystole were included. An ultrasound was performed at the beginning and end of ACLS. Clinicians were not blinded to the ultrasound results. Patients with short resuscitation time ( < 5 minutes) were excluded to avoid including patients with resuscitation efforts stopped because of a negative ultrasound. Their findings demonstrated that patients in asystole without cardiac activity are unlikely to benefit from prolonged resuscitation as survival rate is dismal. Note that Positive Predictive Value was used in provided table as this is easier to interpret with respect to their data. Positive predictive value is the probability that subjects with a positive screening test truly have the disease. With respect to the study data, positive predictive value represents the probability that a patient WILL NOT survive if they have no cardiac activity on bedside echo and are in asystole (or PEA). PMID: 27693280 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729668578-I3FV9GV6DITDFUK0NJM8/Screen+Shot+2018-05-30+at+6.13.30+PM.png The Evidence Atlas - Right Ventricular Dysfunction in PE This was a prospective observational study (n=116) of consecutive normotensive patients with confirmed pulmonary embolism, assessing the diagnostic accuracy of biomarkers, CT, and goal-directed echocardiography for right ventricular dysfunction. Emergency physicians, blinded to clot burden and biomarkers, performed qualitative goal-directed echocardiography for right ventricular (RV) dysfunction*: RV enlargement (RV diameter greater than or equal to that of the left ventricle), severe RV systolic dysfunction (RV free wall hypokinesis or TAPSE < 1.0 cm), and/or interventricular septum flattening or bowing into the left ventricle. If any one of these were present, right ventricular dysfunction was diagnosed. Goal-directed echocardiography results were compared to comprehensive echocardiography as the gold-standard. PMID: 26973178 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729728906-5YW06YTDS0505O1S0J3A/Screen+Shot+2018-05-30+at+6.13.40+PM.png The Evidence Atlas - Pulmonary Edema in Heart Failure This was a systematic review including 7 prospective case control or cohort studies (n=1075) evaluating the sensitivity and specificity of B-lines in diagnosing acute cardiogenic pulmonary edema (ACPE). The included studies recruited patients presenting to the hospital with acute dyspnea, or where there was a clinical suspicion of congestive heart failure. The setting was either the emergency department (ED) , ICU, or inpatient wards. Ultrasound examinations were performed by any non-radiologist physician. *Various lung ultrasound protocols were used, including the Volpicelli method, the Lichtenstein protocol, and the Comet Score. All involved using B-lines to make the diagnosis of ACPE. The varied protocols used for diagnosis may explain the increased sensitivity noted in this study compared to other meta-analysis. Gold standard was heterogeneous amongst studies with 'final diagnosis from clinical follow-up' being an acceptable reference standard. PMID: 25176151 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729779649-UV3DCKB5P9JFG7EN3G1F/Screen+Shot+2018-05-30+at+6.13.50+PM.png The Evidence Atlas - Pneumothorax This was a systematic review of 8 prospective studies (n=1048) of adult patients. Included manuscripts evaluated for traumatic or iatrogenic pneumothorax. No studies that screened for spontaneous pneumothorax were included. Examiners were surgeons, radiologists, or emergency providers. Reference standard was pneumothorax found on CT or a rush of air upon tube thoracostomy. All studies but one used the ultrasonographic signs of lung sliding and comet tail to rule out pneumothorax. Although the exact technique used to perform the ultrasound examination is not reported with enough detail in some studies, most agree on requiring the examination of more than one intercostal space in both the midclavicular line and laterally and inferiorly at the anterior or midaxillary lines. Lastly, this data does not evaluate whether the pneumothoraces identified were clinically significant. PMID: 21868468 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729801669-6SW0SPR209YWF751SBFT/Screen+Shot+2018-05-30+at+6.13.56+PM.png The Evidence Atlas - Pleural Effusion This was a meta-analysis including 12 retrospective and prospective studies (n=1554) of adults and pediatric patients. Ultrasound was used to diagnose pleural effusion, with the reference standard either CT, surgery, or a more formal “high quality ultrasound in conjunction with expert end diagnosis.” Ultrasound examinations were performed by a variety of operators including emergency physicians, intensivists, radiologists, and nurses. Exact criteria for diagnosis of a pleural effusion by ultrasound was not defined. PMID: 26862542 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729823511-9QQXFU94KWV1ZLAA75DN/Screen+Shot+2018-05-30+at+6.14.03+PM.png The Evidence Atlas - Pneumonia (Adults and Peds) The was a systematic review including 20 prospective adult and pediatric studies (n=2513) with varied settings including the emergency department, inpatient wards, or ICU. A positive finding on ultrasound was identified as an alveolar and interstitial pattern or consolidation, although this is not further expanded upon. Gold standard was either CT, chest radiography, or “clinical diagnosis” depending on the study. One large caveat of this study is that it has a very large degree of heterogeneity, with ultrasound examinations performed by emergency physicians, intensivists, and radiologists of varying levels of expertise, on patients ranging from ambulatory to critically ill. PMID: 28244009 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1529249136939-5SEGRKH4OZOD2QIA72ZC/Screen+Shot+2018-06-17+at+8.24.12+AM.png The Evidence Atlas - Pneumonia (Adults only) This was a systematic review including 17 prospective studies (n=5108) evaluating the operating characteristics of lung ultrasound for pneumonia in adult patients seen in the emergency department with a clinical suspicion for this diagnosis. Reference standard was either chest radiograph, chest CT, or final clinical diagnosis. Included studies varied with regards to which and how many lung fields were evaluated. The operators performing ultrasound examinations were exclusively emergency physicians or radiologists.*Subpleural consolidation and/or focal B-lines were the diagnostic criteria in the majority of manuscripts included, however in 4 studies, no clear positive findings were specified. PMID: 29189351 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729867259-X1ZHWHQXSRHHIHK3S318/Screen+Shot+2018-05-30+at+6.14.22+PM.png The Evidence Atlas - Cholecystitis This was a systematic review including 4 prospective studies evaluating the operating characteristics of bedside ultrasound for acute cholecystitis (AC) in adult patients seen in the emergency department with a clinical suspicion for AC or right upper quadrant pain. Sample size of the studies varied from 30 to 193 subjects. Reference standard was surgical pathology. The experience of the sonographers varied between the studies and in one study no documentation of sonographer experience was noted. There was significant heterogeneity across the included studies precluding the authors ability to pool the results hence a range is noted in the operating characteristics table. PMID: 27862628 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729894049-WS0DU6ZGFVJDBTRBBV69/Screen+Shot+2018-05-30+at+6.14.30+PM.png The Evidence Atlas - Cholelithiasis This was a meta-analysis including 8 studies (n=710) evaluating the operating characteristics of emergency ultrasound (EUS) for identifying cholelithiasis in adult patients presenting to the emergency department with symptoms suggestive of biliary colic (RUQ pain, epigastric pain, or right flank pain). Reference standards included radiology performed ultrasound, CT, MRI, and/or surgical pathology. There was quite a variation in the technical ability between operators which may distort the pooled sensitivity and specificity. PMID: 21401784 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729912055-VIUS5TPMD6N64Q1WJO0F/Screen+Shot+2018-05-30+at+6.14.38+PM.png The Evidence Atlas - Nephrolithiasis This was a meta-analysis including 5 studies (n=1773) evaluating the accuracy of POCUS to diagnose nephrolithiasis in adult patients presenting to the emergency department with symptoms suggestive of renal colic (flank pain, dysuria, abdominal pain radiating to groin). Reference standards included CT, direct stone visualization, or surgical findings. Specificity improved significantly (~94.4%) for moderate to severe hydronephrosis (i.e. exclusion of mild hydronephrosis). This systematic review has some flaws (most importantly not having a single uniform gold standard) but appears to be the best available evidence. PMID: 29427476 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729961184-DYZ9K5DA0E16KADB3SXB/Screen+Shot+2018-05-30+at+6.14.49+PM.png The Evidence Atlas - Small Bowel Obstruction This was a meta-analysis including 11 studies (n=1178) to evaluate the test characteristics of US in diagnosis of small bowel obstruction (SBO). There was mild to moderate heterogeneity in diagnostic criteria, study location, sonographer experience, and reference standard. Specifically, most studies used 2.5 cm as the cutoff to diagnose SBO while one study used the cutoff of 3.0 cm, and several other studies only noted the presence of “dilated bowel loops” as a diagnostic criteria. Of the 11 studies included, only 3 were emergency department studies. Reference standards included surgery, clinical diagnosis, CT, or other advanced imaging. While there were multiple components to the index test and varied reference standard, this does appear to be the best and biggest review on this topic. These operating characteristics suggest ultrasound to be a valuable tool in the diagnosis of SBO, however further studies are needed specifically with regards to the emergency department setting. *Other diagnostic criteria included visualizing collapsed distal loops of bowel with decreased peristalsis PMID: 28797559 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527730004453-2RBA1WLC8GBPD3Z4S9DI/Screen+Shot+2018-05-30+at+6.14.56+PM.png The Evidence Atlas - Pediatric Appendicitis This systematic review and meta-analysis of 4 studies (n=461) evaluated the accuracy of emergency department POCUS performed by EM or PEM physicians for diagnosis of acute appendicitis in children. The main limitation of the study was the high prevalence of equivocal results. However, authors did a sensitivity analysis with and without equivocal cases and results were similar. A mathematical model was used to compare POCUS to CT scan and MRI. The authors concluded that a positive POCUS exam is diagnostic, obviating the need for CT, however if POCUS is equivocal or negative, further imaging with CT or MRI is necessary. PMID: 28214369 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527730030329-JP5FS1QZP43BUFMMFYAR/Screen+Shot+2018-05-30+at+6.15.03+PM.png The Evidence Atlas - Ectopic Pregnancy This was a meta-analysis including 10 studies (n=2057) examining the operating characteristics of bedside emergency provider (EP) performed ultrasound to rule out ectopic pregnancy. All studies used the visualization of an IUP (intrauterine pregnancy) on ultrasound as the rule out criteria. The ultrasound examinations performed by EPs included transabdominal, transvaginal or both. Reference standards included formal radiology US, gynecology US, over-read of EP performed US by radiology, or clinical record review. They did not report specificity and positive LR's because of significant heterogeneity in these results when data was pooled. This study supports the utility of EP performed ultrasound as a strong rule out test for ectopic pregnancy. PMID: 20828874 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527730047936-QV1EYLQURR2XZ7VTCJ0P/Screen+Shot+2018-05-30+at+6.15.12+PM.png The Evidence Atlas - Surgical Intervention in Ruptured Ectopic This was a prospective observational study (n=242) of patients presenting to the emergency department with suspected ectopic pregnancy, evaluating if free fluid in the peritoneal cavity identified by bedside ultrasound was predictive of the need for operative intervention. The included patients were suspected to have an ectopic pregnancy based on positive pregnancy test results, in their first trimester, with either abdominal pain or vaginal bleeding. All examinations were performed by emergency providers (EPs) using a transabdominal approach, to determine if free fluid was present in the hepatorenal space (Morison’s Pouch) and/or pelvis. Reference standard was chart review by one of four study investigators who were blinded to the EP performed US results. There was one patient who had free fluid in Morison’s Pouch but had a confirmed IUP (suspected to be a ruptured corpus luteum cyst) and no ruptured ectopic pregnancy. This study supports that free fluid present in Morison’s pouch in patients with suspected ectopic pregnancy strongly predicts the need for operative intervention. PMID: 17554008 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527730134352-CCJU9US8XFC98M269BX2/Screen+Shot+2018-05-30+at+6.15.22+PM.png The Evidence Atlas - DVT This was a meta-analysis including 16 studies (n=2379) evaluating the operating characteristics of emergency physician (EP) performed ultrasound for the diagnosis of DVT. The providers used color-flow duplex ultrasound in two studies, proximal venous ultrasound in 13 studies (not looking at the calf), and whole-leg venous ultrasound in one study. Reference standard was radiology department ultrasound, vascular lab, or angiography. Considering only high quality studies which met QUADAS-2 Criteria (11 out of 16 initially selected studies), the sensitivity and specificity improved to 97.6% and 96.8% respectively. PMID: 23138420 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527730152469-FJ8WJKJMLF5DT7FEOA9Q/Screen+Shot+2018-05-30+at+6.15.30+PM.png The Evidence Atlas - Abscess This was a systematic review including 6 prospective observational studies (n=800) comparing physical exam and POCUS to diagnose abscess in both children and adults in the emergency department (ED). Inclusion criteria for all but one study was the presence of a skin & soft tissue infection (SSTI) while once study specifically included patients where abscess was suspected with plan to incise and drain. The reference standard for abscess was pus drainage on initial I&D or at follow up. In many studies, facial and genital/rectal area SSTIs were excluded therefore these results should be interpreted with caution in evaluation of SSTIs in these areas. PMID: 27770490 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527730189158-KGGBTGQT9PLR9B0FS7ZO/Screen+Shot+2018-05-30+at+6.15.51+PM.png The Evidence Atlas - FAST Exam This was a meta-analysis including 22 studies (n=12089) in adult patients presenting with blunt trauma, evaluating the accuracy of the FAST examination for the detection of intra-abdominal injury. All included studies had at least 1 reference standard including abdominal computed tomography, diagnostic peritoneal lavage, laparotomy, autopsy, and/or clinical course. 5 of the studies excluded patients with hemodynamic instability. When these studies were looked at alone, the positive LR increased to 82. PMID: 22496266 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1571338567692-NO0WO4EDB0B16QSXHD3H/Screen+Shot+2019-10-17+at+11.55.45+AM.png The Evidence Atlas - Pediatric FAST Exam This was a systematic review and meta-analysis including 8 studies (n = 2135) to evaluate the utility of FAST examination in the diagnosis of intra-abdominal injury (IAI) in pediatric blunt abdominal trauma patients. All included studies used 3 different reference standards, which introduced bias by not equally categorize a patient as disease positive or negative. Inclusion criteria for age across these 8 studies ranged from an upper limit of 13 to 18 years old. Index test was presence of any amount of free fluid in hepatorenal, splenorenal, or suprapubic windows during FAST. Reference standards were laparotomy, CT, or observation. Sensitivity was highly variable across 8 studies (20-80%) and found to have a pooled sensitivity of 35%. Specificity remained very high, 96%. Overall, this systemic review found that a negative index test alone cannot rule out the need for further imaging in pediatric intra-abdominal trauma. PMID: 30870341 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527730214405-G3FEOI3Z8S6232DA8DKO/Screen+Shot+2018-05-30+at+6.15.43+PM.png The Evidence Atlas - Death Despite ED Thoracotomy This was a prospective study (n=187) at a Level I trauma center evaluating the utility of resuscitative thoracotomy (RT) in acute trauma patients. A bedside FAST exam was performed before or concurrent with RT. The bedside FAST exam evaluated for cardiac motion and/or pericardial effusion. A sensitivity analysis utilizing the primary outcome measures of survival to discharge or organ donation was performed. Only the outcome of survival to discharge is provided in the accompanying table. Note that Positive Predictive Value was used in provided table as this is easier to interpret with respect to their data. Positive predictive value is the probability that subjects with a positive screening test truly have the disease. With respect to the study data, positive predictive value represents the probability that a patient WILL NOT survive following RT if they have no cardiac activity on bedside echo. PMID: 26258320 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527745594499-COAP28LC4RC7ABEMNR7C/Screen+Shot+2018-05-30+at+10.46.09+PM.png The Evidence Atlas - Central Line Confirmation This was a prospective study (n=78) in critically ill patients in the emergency department (ED) and intensive care unit (ICU) at a single academic center, evaluating the use of POCUS to identify correct placement of supra-diaphragmatic central venous catheter (CVC) placement. All CVC placements and POCUS exams were performed by resident trainees. Correct positioning of the CVC was considered if turbulent flow was visualized in the right atrium on sub-xiphoid, parasternal, or apical cardiac ultrasound after injecting 5 cc of sterile, non-agitated, normal saline through the CVC. Reference standard was confirmatory chest radiography. PMID: 28123616 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1530841122753-0FD45GCQ172RLD5N3AGH/Screen+Shot+2018-07-05+at+6.37.45+PM.png The Evidence Atlas - Shoulder Dislocation This was a prospective observational study (n= 73) evaluating the diagnostic accuracy of ultrasound for both identification of shoulder dislocation and confirmation of successful reduction. Patients with suspected shoulder dislocation were enrolled, with 69/73 having dislocation confirmed by shoulder radiographs. Patients with multi trauma or decreased level of consciousness were excluded. Both the anterior and lateral approach were used to evaluate for dislocation. Examinations were performed by either an experienced ultrasound trained emergency physician or a senior emergency medicine resident. An ultrasound exam was performed prior to initial shoulder radiographs and after reduction attempt. Ultrasound was found to be 100% accurate with respect to both shoulder dislocation identification and reduction confirmation. *This is a limited study as the sample size is relatively small and this ultrasound examination is dependent on operator experience therefore these results should be interpreted with caution. PMID: 23489654 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1571338726976-UPK02Y29DQWFZ5ZLZWZ1/Screen+Shot+2019-10-17+at+11.55.09+AM.png The Evidence Atlas - Retinal Detachment This was a prospective, multi-center study conducted at 2 academic emergency departments (ED) and 2 county hospital EDs (n = 225) to evaluate the accuracy of POCUS for diagnosing retinal detachment (RD), vitreous hemorrhage (VH), and vitreous detachment (VD). Each hospital recruited patients presenting to the ED with symptoms of blurry vision, flashers/floaters, and vision loss, whom required emergent ophthalmologic consultation; patients with ocular trauma or suspected globe rupture were excluded. Reference standard was attending ophthalmologists’ final diagnosis masked to POCUS results. Exams were performed by seventy-five unique providers including seventy emergency physicians of varying training level and 5 physician assistants. Study findings demonstrate that the utility of ED POCUS in the diagnosis for RD and VH were quite sensitivity and specific. The utility of POCUS in the diagnosis of VD was less sensitive (42.5%) but remained specific (96%). Overall, ocular POCUS by ED providers is a very good test to both rule-in and rule-out the emergent diagnosis of RD. The use of ocular POCUS is not as good of a test to rule-in or rule-out less emergent diagnoses of VD and VH but provides useful adjunct information to support evidence for those diagnoses. PMID: 30977855 - Reviewed by Dr. Jaclyn Walker https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1571338919912-PVBBI3YFHNI0H2VXLONB/Screen+Shot+2019-10-17+at+11.55.28+AM.png The Evidence Atlas - Vitreous Hemorrhage This was a prospective, multi-center study conducted at 2 academic emergency departments (ED) and 2 county hospital EDs (n = 225) to evaluate the accuracy of POCUS for diagnosing retinal detachment (RD), vitreous hemorrhage (VH), and vitreous detachment (VD). Each hospital recruited patients presenting to the ED with symptoms of blurry vision, flashers/floaters, and vision loss, whom required emergent ophthalmologic consultation; patients with ocular trauma or suspected globe rupture were excluded. Reference standard was attending ophthalmologists’ final diagnosis masked to POCUS results. Exams were performed by seventy-five unique providers including seventy emergency physicians of varying training level and 5 physician assistants. Study findings demonstrate that the utility of ED POCUS in the diagnosis for RD and VH were quite sensitivity and specific. The utility of POCUS in the diagnosis of VD was less sensitive (42.5%) but remained specific (96%). Overall, ocular POCUS by ED providers is a very good test to both rule-in and rule-out the emergent diagnosis of RD. The use of ocular POCUS is not as good of a test to rule-in or rule-out less emergent diagnoses of VD and VH but provides useful adjunct information to support evidence for those diagnoses. PMID: 30977855 - Reviewed by Dr. Jaclyn Walker https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1571339023496-4K7WU4OX99GXXK6TYCRE/Screen+Shot+2019-10-17+at+11.55.20+AM.png The Evidence Atlas - Vitreous Detachment This was a prospective, multi-center study conducted at 2 academic emergency departments (ED) and 2 county hospital EDs (n = 225) to evaluate the accuracy of POCUS for diagnosing retinal detachment (RD), vitreous hemorrhage (VH), and vitreous detachment (VD). Each hospital recruited patients presenting to the ED with symptoms of blurry vision, flashers/floaters, and vision loss, whom required emergent ophthalmologic consultation; patients with ocular trauma or suspected globe rupture were excluded. Reference standard was attending ophthalmologists’ final diagnosis masked to POCUS results. Exams were performed by seventy-five unique providers including seventy emergency physicians of varying training level and 5 physician assistants. Study findings demonstrate that the utility of ED POCUS in the diagnosis for RD and VH were quite sensitivity and specific. The utility of POCUS in the diagnosis of VD was less sensitive (42.5%) but remained specific (96%). Overall, ocular POCUS by ED providers is a very good test to both rule-in and rule-out the emergent diagnosis of RD. The use of ocular POCUS is not as good of a test to rule-in or rule-out less emergent diagnoses of VD and VH but provides useful adjunct information to support evidence for those diagnoses. PMID: 30977855 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527729616772-PQKAQ8DHEMS3WXBZYICT/Screen+Shot+2018-05-30+at+6.12.29+PM.png The Evidence Atlas - Increased Intracranial Pressure This was a systematic review, which including 12 studies (n = 478) using ultrasound measurement of optic nerve diameter (cut point of 5 mm for adult studies, 4.5 mm for age 1–17 years, and 4 mm for age <1 year) to evaluate for increased intracranial pressure (ICP). There was moderate to high heterogeneity among these studies given multiple patient populations. This resulted in wide confidence intervals: sensitivity of 95.6% (95% CI, 87.7%–98.5%), specificity of 92.3% (95% CI, 77.9%–98.4%), positive likelihood ratio of 12.5 (95% CI, 4.2–37.5), and a negative likelihood ratio of 0.05 (95% CI 0.016–0.14). It is also important to mention that the gold standard in this review was CT, which is not as accurate as invasive ICP monitoring. Overall their conclusions were that ocular sonography had a very low LR- (0.05) making it a good test for ruling out raised ICP in a low-risk group, and a high LR+ (12.4) making it a good test for ruling in raised ICP in a high-risk group. PMID: 26112632 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592518803139-BRS5EXLWNO8L4JL8T2EY/Bronchiolitiis+evidence+atlas+chart.png The Evidence Atlas - Bronchiolitis in Pediatric Patients This was a prospective observational study comparing the operating characteristics of emergency department (ED) performed LUS versus CXR for diagnosis of children with bronchiolitis. A total of 52 patients were enrolled in the study. All LUS were performed by one blinded experienced sonographer. Abnormal LUS findings in the study included: subpleural consolidations, b-lines (confluent b-lines or areas of multiple b-lines), and pleural abnormalities. In 44/52 infants with bronchiolitis, subpleural consolidations were present, compared to 0/52 infants without bronchiolitis. Notably, the sensitivity increased from 84% to 90% when all LUS abnormalities are considered (b-lines and pleural irregularities in addition to subpleural consolidation). The presence of multiple areas of lung consolidation and confluent b-lines (white lung) were most predictive of the bronchiolitis severity. CXR was considered positive in 38/52 patients when lung consolidation, peribronchial thickening, or hyperexpansion was identified. Nine patients with a negative CXR but abnormal LUS findings had a clinical course that was consistent with bronchiolitis. An advantage of LUS in this study was decreased time to diagnosis. LUS was interpreted during the study, while CXR took an average of 4 hours and 45 minutes to interpret after imaging was obtained. Limitations of this study include the small sample size and a single operator for all ultrasounds performed. Bronchiolitis is typically a clinical diagnosis and as such was defined by history and clinical examination in this study. The current study compared LUS to CXR, but there is no gold standard for diagnosing bronchiolitis.. These limitations make the specificity of 100% questionable and indicate the need for larger studies. PMID: 21468639 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592518822017-L4KM2METDX8Y4OEEITQA/h1n1+evidence+atlas+chart.png The Evidence Atlas - Diagnosis of Pneumonia in Adults with Suspected H1N1 Influenza This was a prospective observational study comparing the operating characteristics of emergency department (ED) performed LUS versus CXR for the diagnosis of pneumonia in patients with suspected H1N1 influenza. The operating characteristics described in the table include patients with any pneumonia: primary bacterial pneumonia, viral (H1N1) pneumonia, or a secondary bacterial pneumonia in H1N1 infected patients. Patients were included in the experimental arm if they had signs or symptoms of influenza-like illness (ILI) with suspicion of lung involvement (pneumonia), either bacterial or viral. A total of 87 patients were enrolled in the study, 41 with ILI with suspected pneumonia and 46 with ILI without suspected pneumonia (control group). The gold standard final diagnosis of pneumonia was based on the chart review of the hospital course including the history, physical exam, lab results, and radiographic findings. The reviewers were blinded to the LUS results. Three outcomes were reported: viral pneumonia with laboratory confirmation of the H1N1, primary bacterial pneumonia, or secondary bacterial pneumonia with confirmed H1N1. The LUS studies were performed by three different emergency physicians with greater than 10 years of ultrasound experience. This study evaluated each hemithorax in five areas: two anterior, two lateral, and one posterior. The presence of any of the following signs on LUS indicated an abnormal exam*: >3 B-lines per intercostal space Thickness of pleural line > 2mm or coarse appearance Consolidation or hepatization Pleural effusion Lung ultrasound showed a sensitivity of 94.1% and specificity of 84.8%. An abnormal ultrasound was present in 32 of 34 patients with the ultimate diagnosis of pneumonia (including viral and bacterial). In patients with initially negative CXRs, 15/16 demonstrated an US pattern reflecting interstitial syndrome, all of whom ultimately had the diagnosis of pneumonia. In patients with initial abnormal CXRs, 17/18 had positive chest ultrasounds. The control arm did have 5/33 false positives which the author speculates may have been attributed to subclinical viral infections without clinical relevance or previous interstitial syndromes reflecting priorillness. The one false negative case was a patient with bacterial pneumonia with a deep, perihilar opacity. The main limitation of this study is the small sample size and that the LUS studies were performed by expert sonographers. Beyond this though, we recognize that this study identified operating characteristics of LUS for all pneumonia and did not specifically analyze the sensitivity and specificity of lung ultrasound for viral pneumonia alone. It also excluded patients with comorbidities making this a very limited patient population which likely greatly affected the specificity of POCUS for pneumonia in this setting. Furthermore, expert adjudication was used to determine final diagnosis which is an imperfect gold standard. In the end, H1N1 has many similar characteristics to the COVID pandemic and this study is highly suggestive that lung ultrasound, particularly in patients with negative CXRs, can assist in diagnosis. PMID: 22340202 https://www.thepocusatlas.com/link-gallery-evidence-atlas daily 0.75 2018-05-22 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527003077551-2ZU72JSM35GX7OC266MP/aorta+link.png Link Gallery: Evidence Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527003077551-2ZU72JSM35GX7OC266MP/aorta+link.png Link Gallery: Evidence Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527003106610-NP5SKIW28FBBMVHSYYIH/bowel+link.png Link Gallery: Evidence Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527003131741-10GHY123XDBK5AXAUSQI/Dvt+Link.png Link Gallery: Evidence Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527003172847-BMM9IU81KQYTAPQ9PQR3/echo+link.png Link Gallery: Evidence Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527003225959-F3S5QOH1NSGLYP88KZCT/hepatobiliary+link.png Link Gallery: Evidence Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527003197725-AJLZR5YAWPIK4W93CMC2/ob%3Agyn+link.png Link Gallery: Evidence Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527003272720-0CVAP6W83ZL4OGQZJ7TW/orbit+link.png Link Gallery: Evidence Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527003303458-4Q9G5ELIJDVR1T3NIE26/procedures+link.png Link Gallery: Evidence Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527003348820-08Q80GGKAZFJ6H5HOQXN/Pulm+Link.png Link Gallery: Evidence Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527003414055-5KD4QUEQFPESPG9PZGQF/Renal+link.png Link Gallery: Evidence Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527003461477-MKZYPPE7FHLTU4FEU96U/soft+tissue+link.png Link Gallery: Evidence Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527003506913-VOZUZZDYSHO6HBJJP6I4/trauma+link.png Link Gallery: Evidence Atlas https://www.thepocusatlas.com/colorized-appendicitis daily 0.75 2018-08-02 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168901636-1YO93U6KXSWMPWU4LZ9Z/sathya-appendix-landmarks-colorized-labeled.gif Colorized Appendicitis - Labeled Colorized Appendix with Landmarks Normal appendix with landmarks highlighted. P=Psoas, Ap=Appendix, Ia=Iliac Artery, Iv=Iliac Vein Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168901636-1YO93U6KXSWMPWU4LZ9Z/sathya-appendix-landmarks-colorized-labeled.gif Colorized Appendicitis - Labeled Colorized Appendix with Landmarks Normal appendix with landmarks highlighted. P=Psoas, Ap=Appendix, Ia=Iliac Artery, Iv=Iliac Vein Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168901673-SM6SJKJ068VFRBO4FCW1/sathya-appendix-landmarks-colorized.gif Colorized Appendicitis - Colorized Appendix Landmarks Normal appendix with landmarks highlighted. Green = Psoas Yellow = Appendix Red = Iliac Artery Blue = Iliac Vein Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168904770-Q65PM1BRQ4KUGVYXRMMJ/sathya-appendix-landmarks.gif Colorized Appendicitis - 2D Appendix Landmarks Normal appendix with landmarks including the psoas, ilac artery/vein, and the appendix. Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168923765-GL60ZV37DD8Q91QEJYTO/sathya-blind-end-vessels-color-label.gif Colorized Appendicitis - Labeled and Colorized Appendix and Landmarks (Longitudinal) Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168923652-2K6A23VVAPUPZKGCLOQH/sathya-blind-end-vessels-colorized.gif Colorized Appendicitis - Colorized Appendix with Landmarks (Longitudinal) Yellow = Appendix Red = Iliac Artery Blue = Iliac Vein Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168927436-9NP4WDOVYXYBWTBOZEMS/sathya-blind-end-vessels.gif Colorized Appendicitis - 2D Appendix with Landmarks (Longitudinal) Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168933429-QYH2WVTMBNYS4U50FG1G/Sathya-normal-appendix-1-blind-end-colorized-labeled.gif Colorized Appendicitis - Labeled and Colorized Appendix and Psoas Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168936705-9SDBP9BEF9PBP7TG4W6G/Sathya-normal-appendix-1-blind-end-colorized.gif Colorized Appendicitis - Colorized Appendix and Psoas Red = Appendic Blue = Psoas Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168938202-URFOUCC7QFKEZORMTIGF/Sathya-normal-appendix-1-blind-end.gif Colorized Appendicitis https://www.thepocusatlas.com/procedures daily 0.75 2018-12-12 https://static1.squarespace.com/static/58118909e3df282037abfad7/t/5c107cba4d7a9cec045951e9/1544584203685/ Procedures https://static1.squarespace.com/static/58118909e3df282037abfad7/5c107bfa4ae23730c6cd2c00/5c107c0b758d46e15e665408/1544584203685/ Procedures https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544584219933-8SND1ZUE5FPLAG4I0183/Riscinti%2BGordon%2BCVC%2BConfirmation.gif Procedures - Central Line Placement Confirmation A central venous catheter was placed in the right internal jugular under ultrasound guidance and sub-xiphoid view was obtained. Saline was rapidly flushed through the brown port and turbulent saline can be seen traveling through the right side of the heart. - Dr. Matthew Riscinti and Dr. Isaac Gordon - Kings County Emergency Medicine https://www.thepocusatlas.com/dvt daily 0.75 2024-12-24 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735037008481-L0XA89FRI9NK86B9MKNT/image-asset.gif Vascular - Popliteal DVT noncompressible Clip showing non-compressible popliteal vein consistent with DVT Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735037008481-L0XA89FRI9NK86B9MKNT/image-asset.gif Vascular - Popliteal DVT noncompressible Clip showing non-compressible popliteal vein consistent with DVT Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727555432243-Z6GTNMHOES03Z61936LZ/Free+Floating+DVT+-+Anthony+Elias.gif Vascular - Free Floating DVT 71 year old male presented to the ED complaining of left leg pain. POCUS revealed free floating DVT in common femoral vein extending down to the popliteal vein. Free floating DVTs, especially those greater than 5cm, can increase a patient’s risk of developing a pulmonary embolism. Common femoral vein in transverse (left) and sagittal (right) views demonstrate a hyperechoic thrombus that is noncompressible with surrounding anechoic fluid suggesting free floating thrombus with circumferential blood flow. Cite: Chernukha L, et al. Danger of floating venous thrombosis: myth or reality? Phlebology. 2023 Jun;38(5):322-333. doi: 10.1177/02683555231169507. Epub 2023 Apr 20. PMID: 37078365.'] Anthony Elias, DO; Brian Tang, DO; Mike Olshansky OMS-IV, Josh Greenstein, MD; Simone Rudnin, DO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1734375629985-PHEBLFE1CPBS4KOJN62T/image-asset.gif Vascular - Femoral Artery Stent Femoral artery stent can be appreciated in this short axis view as a bright, hyperechoic structure within the femoral artery borders. Contributed by: Brittany Garza, DO; Saleem Nasseh, MD; Sadie Ellerson, MS4 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1734375150905-4XHJI2D215ZOYOV9PP0K/image-asset.gif Vascular - Occlusive DVT of the Left Popliteal Vein This clip demonstrates a non-compressible left popliteal vein consistent with deep venous thrombosis. Contributed by: Brittany Garza, DO; Saleem Nasseh, MD; Sadie Ellerson, MS4 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1729305874817-QQYGI0T6SEAFDBOZ3KD7/image-asset.gif Vascular - Popliteal DVT This is of a 52 year old male who presented to the emergency department complaining of leg pain and erythema while at work. He was evaluated prior to his arrival to the emergency department and was noted to have an elevated d-dimer level. Point of care ultrasound was performed starting from the great saphenous vein and common femoral vein, descending along his femoral vein. Initial compression did not reveal any thrombus until arriving at his popliteal vein which revealed a non-compressible vein due to a large thrombus. Dr. Christopher Paulo, DO, PGY-1 Riverside Regional Medical Center Emergency Medicine Program (Newport News, VA) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659220535824-3QEMSB050SDKT9BQA37E/image-asset.gif Vascular - PICC Line in Subclavian Vein 55 y/o man with septic shock and multiorgan failure due to SBP and liver failure. Picc line visualized within the R subclavian vein. longitudinal view. Alex Steinberg https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1679281535002-YGPXCMA39JTWXS41AKIA/image-asset.gif Vascular - Dual Radial Artery Very interesting find while performing a wrist ultrasound where we see the presence of two radial arteries Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644438057566-506CY29G7E2S3ZQXSXDN/image-asset.gif Vascular - DVT Elderly patient with a history of dyspnea and desaturation. POCUS of the common femoral vein in its transverse axes with color Doppler and longitudinal axes, showing partially mobile hyperechoic content in its interior associated with the absence of venous compressibility. Paula Martins, @paula_smrtns Medical Student at The Faculdade de Medicina de Marília https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626288896671-HXRWMPFW1JKWXILXQX1H/image-asset.gif Vascular - Great Saphenous Thrombosis POCUS of a patient with unilateral leg swelling and redness revealed thrombosis of the great saphenous vein seen as an isoechoic structure within the lumen. No DVT was noted in this patient. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625681655376-YPYNB5CRAL5DZ7PH0H9S/image-asset.gif Vascular - IVC Thrombus This patient presented with bilateral LE swelling and negative DVT scans. Doppler waveform showed results concerning for proximal obstruction. Transverse abdominal scan shows a thrombus within the inferior vena cava. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625680253715-4SI0YEGT18HVBXF9PG2P/image-asset.gif Vascular - Spontaneous Echo Contrast This clip shows spontaneous echo contrast (SEC) in the IJV. This finding is indicative of blood stasis and may be a precursor to thrombus formation. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620331118832-FW90ULSPN52C9Q47WM2L/image-asset.gif Vascular - Venous Valves Seen here is healthy appearing venous system with effectively functioning valves. Important distinction between the arterial and venous systems. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620333678505-DAAHJ4KDBCVJA2HJH8TK/image-asset.gif Vascular - DVT POCUS revealed an acute DVT becoming easily mobile when the patient coughs. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1619455955418-94S5I2LXY8I4R9QMIOQA/image-asset.gif Vascular - Common Femoral DVT A 65 yo male presented with 2 week hx of proximal left LE pain. Pt denied trauma or risk factors for VTE. Also did not have visible abnormalities on clinical exam. Seen here is POCUS of his common femoral vein; note the hyperechoic thrombus and absent blood flow (when compared to adjacent femoral artery). This vein was also non compressible. This case highlights that even with low pre-test probability, POCUS can help drive ones differential diagnosis! Mandy Peach, MD @mandy_peach Saint John Regional Hospital. NB, Canada https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616444926827-W22JF17PPRY457HAE3GA/image-asset.gif Vascular - Floating Venous Thrombus A 60-year-old woman seen in the emergency department with pain and edema in her right lower limb. Bedside vascular US with a linear probe in the femoral territory showed a large floating venous thrombus . This condition has great potential for pulmonary embolization. Renato Tambelli @JediPocus // @R_Tambelli https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1615664462687-FFHVZQRA9CFYZAM2B8M1/image-asset.gif Vascular - Superficial Thrombophlebitis A patient presented reporting a tender, erythematous, and edematous portion of his left forearm; notably at the site of an IV that had been in place at the time of a recent surgery. POCUS as seen here revealed a hyperechoic area within a vessel concerning for thrombus, consistent with the diagnosis of superficial thrombophlebitis. Point of care ultrasound can be useful in differentiating thrombophlebitis from other differential diagnoses including muscle strain or sprain. Rupinder Sekhon, MD Central Michigan University, Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614981532344-SX73IN7J3N4R62O2A7ZU/image-asset.gif Vascular - Pseudoaneurysm POCUS of a suspected abscess revealed a pseudoaneurysm of the femoral artery. Note the “Pepsi sign” on color doppler made by the turbulence of the blood entering the pseudoaneurym. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609880270560-7KA7PWUNPHB8UNPNR86P/image-asset.gif Vascular - Carotid Dissection A middle aged patient presented with severe chest pain without associated neurologic deficits. CTA revealed a Type A aortic dissection with equivocal carotid extension. Subsequent POCUS seen here confirmed presence of a mobile echogenic intimal flap consistent with carotid artery dissection. Michael Cover, MD @michaelc0ver https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607706296041-FXCHK95RESNDUT8QH5LA/image-asset.gif Vascular - AV Fistula A male presented with thigh pain and swelling with a history of an untreated stab wound 2 months prior. A sagittal view over the femoral artery revealed bidirectional flow indicative of an AV fistula. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605901901006-XBTNVZYMZXWHL1M9JHB3/image-asset.gif Vascular - Right Femoral DVT 69-year-old male patient with no relevant chronic medical history presents to the ER complaining of two-day right inguinal pain and swollen lower extremity. Directed interrogation revealed one-month subacute dyspnea upon physical effort. Femoral POCUS showed this image. The contractile femoral artery lies superficially and to the left of the screen. The common femoral vein is not fully compressible in this study, and an echogenic thrombus can clearly be identified in its interior. Subsequently, angio CT confirmed a massive bilateral PE, although the patient remained stable and did not require invasive interventions. Dr. Felipe Urriola P. Emergency Unit, Puerto Aysen Hospital. Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604502808067-BI5A8FD3BXF79TZT8WNI/image-asset.gif Vascular - Normal IVC to RA - Longitudinal view The IVC drains into the RA. A normal IVC frequently demonstrates transmitted pulsations from the RA. This clip is taken over the subxiphoid region, longitudinally to the body’s axis, and with the probe marker oriented to the patient’s head and RA. The hepatic vein can also be seen draining into the IVC. Dr. Felipe Urriola P., Emergency Unit, Puerto Aysen Hospital, Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601047200640-6EBKO2HR9MT5KMI1J0R9/image-asset.gif Vascular - Subclavian Vein This POCUS revealss a supraclavicular long axis view of the subclavian vein. It is an ideal view for US-guided central venous access. Renato Tambelli, mergency Physician Hospital das Clínicas de Marília, Brazil. @R_Tambelli // @JediPocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1600980612452-X6FDK0SX073IHM96EY0U/image-asset.gif Vascular - Internal Jugular Thrombus This POCUS was obtained using a linear probe and reveals a short axis view of an internal jugular vein containing a large thrombus. This highlights the importance of evaluating vascular structures with ultrasound prior to placing central lines. Renato Tambelli, Emergency Physician Hospital das Clínicas de Marília, Brazil @R_Tambelli // @JediPocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1591372723093-TIMPF99C2SKPQYCGXF9S/image-asset.gif Vascular - Left femoral DVT A 45-year-old female presented to the ED with chest pain, dyspnea, and evidence of shock. Our FOCUS cardiac exam was notable for acute pulmonary hypertension. Subsequently using our multi-organ approach we identified evidence of a DVT (linear probe on the proximal left leg reveals hyperechoic material within the non-compressible femoral vein). Diagnosis of pulmonary thromboembolism secondary to VTE causing obstructive shock was immediately confirmed at the bedside. Images from: Emergency Department of Marilia Clinic Hospital, Sao Paulo, Brazil. POCUSJEDI Team. @JediPocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1502378040339-6IZ8FE110LCU40MNBF35/ezgif.com-optimize.gif Vascular - DVT of Left Common Femoral Vein Patient with profound rapid onset lower extremity pain and swelling. POCUS can be used to rapidly assess for DVT with as high as 95% sensitivity and 96% specificity amongst ED providers. In this image the artery can be seen as the pulsating thick walled vessel with strong pulsations under color doppler. The vein is the large vessel with echogenic material with flow only around the edge of the clot. Inability to compress the vessel would confirm the diagnosis of DVT (not pictured). Dr. Justin Bowra et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1511633080600-YPADIKOVIHFECM3ILFGJ/Sukh+-+pop+dvt.gif Vascular - DVT - Popliteal When pressure is applied to the ultrasound probe over blood vessels, veins usually collapse before arteries because of their much thinner walls. In this clip, enough pressure was applied to the ultrasound probe to partially collapse the popliteal artery, which is the pulsatile vessel visualized. Despite such high pressure, the popliteal vein remains fully patent, indicating a deep vein thrombosis within its walls. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1502378869283-T8RBI0NR6GWZH6ZTNCNR/ezgif.com-optimize.gif Vascular - DVT Left Common Femoral Vein Patient with pain and swelling of the entire left lower extremity. Three point POCUS carries a sensitivity of 95% and specificity of 96% for detecting DVT when performed by emergency physicians. Mild external rotation of the hip can help open up the inguinal crease to find the femoral vein. The POCUS should be performed 1-2cm distal to the bifurcation of the common femoral for a complete study. Dr. Justin Bowra et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1517503995845-3BZXPV12ODE2V0F9PZ3L/ezgif.com-optimize-4.gif Vascular - Axillary Vein (Normal Compressible) Axillary vein thrombus ruled OUT in a patient with arm swelling. Doppler used to highlight vein and artery. Dr. Gordon Johnson https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1502563784348-TB8ZV3J3K4OX7DZZXUVU/ezgif.com-gif-maker.gif Vascular - Cephalic Vein Thrombophlebitis Patient with pain and swelling to area above the antecubital fossa where an IV had been the week before, a palpable cord was appreciated proximal to the former IV site. POCUS demonstrated a clot, likely septic thrombophlebitis secondary to IV site infection. This is a similar techinque as what is done for DVT by finding the vessel, looking for a clot, and seeing if the vessel can be compressed. Dr. Bowra et al. (Dr. Chiang) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585232895119-842TARFMDXP0UDLVCNUK/image-asset.gif Vascular - Swirling Blood in the Internal Jugular Vein after Aortic Dissection Patient presented with near syncope and unilateral neck pain. Ipsilateral neck ultrasound revealed swirling blood within the IJ; subsequent evaluations identified etiology to be a thoracic aortic dissection contributing to pericardial effusion and cardiac tamponade! Peter Weimersheimer, MD. Director EM POCUS at ULA @VTEMSONO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592331006361-BSHBYMQVIC5UU0PUTRVS/image-asset.gif Vascular - VTE in PE A 27-year-old women presented to ED with acute onset of dyspnea and chest pain. She was hypoxic with an O2 saturation of 91% on room air and tachycardic. POCUS lung ultrasound revealed an A-line pattern bilaterally and was notably absent for pleural effusions. Venous scan of the proximal right femoral region revealed a non-compressible femoral vein with hypoechoic material within the lumen. High resolution chest CT confirmed diagnosis of PE. Dr. Victor Bang. Emergency Physician at Hospital das Clínicas de Marília. Co-founder of Pocus Jedi. @vmjbang https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1568924367591-3N883WRHIA68BRB3LPYN/radial+artery+occlusion.gif Vascular - Post Arterial Catheterization Complication A middle aged male with history of hypercoagulability and recent cardiac catheterization utilizing radial artery access, presented with right arm pain, numbness and tingling. POCUS revealed a complete occlusion of the distal right radial artery. The patient was started on anticoagulation therapy initially, with plan for potential thrombectomy with interventional radiology Kathrin Parisi, MS-IV; Courtney Hollingsworth, MD; Therese Mead, DO, RDMS, FACEP; Matt French, DO - Central Michigan University https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1511631840053-5KVWQ2BWD93FK1WDI2PN/Sukh+-+common+fem+dvt.gif Vascular - DVT - Common Femoral When applying pressure to the ultrasound probe, veins collapse first while arteries remain patent and pulsatile. In this clip one can see that proximally, the large pulsatile vessel (which represents the common femoral artery) sits adjacent to a mostly compressible common femoral vein. As the probe moves distally and both the artery and vein split into deep and superficial branches, the superficial femoral vein is not entirely compressible along its medial aspect, representing a thrombus. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1511634345375-AFTCBO6NZL0GCKTBK450/Sukh+-+sfv+dvt.gif Vascular - DVT - Superficial Femoral Vein The superficial femoral artery (pulsatile, to the left) and superficial femoral vein are visualized. As pressure is applied to the probe, the artery becomes oblong but the vein does not collapse as it should, indicated a deep vein thrombosis within its walls. Veins should collapse before arteries under pressure as they have much thinner walls. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1517503738762-YP03CQZLB96VFEU0VKI0/ezgif.com-optimize-6.gif Vascular - Great Saphenous Vein The greater saphenous vein, as it takes off from the femoral vein. Make sure to scan up this high and start compressions here to rule out DVT in the lower extremity. Dr. Gordon Johnson https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501628652462-MLN5DTMSSKB0L4HGWLFW/kilpatrick+Lemierre.gif Vascular - Lemierre Syndrome 25yo w/ no PMH had left molar extracted 10days prior, presents with four days of subjective fever, malaise, and increasing pain to L neck, tachypneic and hypoxic and was intubated w/ central line placed. POCUS scans through the jugular vein to reveal a clot. CT angiogram showed left internal jugular vein thrombosis, low attenuation L temporal lobe concerning for parenchymal abscess. Dr. John F. Kilpatrick - Kings County/SUNY Downstate Emergency Medicine   https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507297679606-G7LAFL0GD1CGVWR3PGI7/Radial+Artery+Pseudoaneurysm.gif Vascular - Pseudoaneurysm - Radial Artery WCUME 2017 Submission and WINNER of "Best POCUS" Category Radial artery pseudoaneurysm 5 days following transradial coronary angiography. Thrill. Instant diagnosis with POCUS. Stephen Alerhand, MD - Mount Sinai Hospital   https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509067318783-WBD0M6AE6NUGJS2X5YSX/Horowitz+-+Thar+she+blows.gif Vascular - Pseudoaneurysm - "Thar She Blows" WCUME 2017 Submission for "Best POCUS" Thought this was an abscess and almost cut into it. POCUS saved me. Russell Horowitz, MD - Northwestern https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1530456881986-B3IAU45LCHQCYOSUA525/colorextravasation.gif Vascular - Color Extravasation Active extravasation 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. Elias Jaffa https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522102842297-RK5IN854F92PRM44T33Y/kaufman+radial+artery+tpa.gif Vascular - Radial Artery Thrombus (Pre/Post TPA) The images above are from a middle-aged woman who presented to the emergency room as a stroke code. She complained of paresthesias in her right arm and had decreased sensation to light touch. It was noted that this arm was colder than the left, so after she returned from head CT, POCUS was performed of her brachial artery. There is a non-compressible hyperechoic structure inside the brachialartery, consistent with the clinical picture of an arterial embolus. Given the urgency of stroke treatment, these images were obtained after the stroke team had administered tenecteplase. Vascular surgery consult was made aware of the findings and repeat images taken an hour after presentation and administration of tenecteplase were obtained at bedside with the vascular surgery consult. These images show near resolution of the embolus. Dr. Ben Kaufman https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534890228001-JWE7OD4MO2ZHE46H4GLB/carotid+bulb.gif Vascular - Carotid Bulb Long Axis The pulsatile carotid artery in long axis at the level of the carotid bulb (widened segment in center of the screen). The intima is visible as a distinct layer of the carotid wall. The bifurcation of the internal and external carotid is not visible here. A portion of the internal jugular vein is seen superficial to the carotid. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534890320753-8LTNBIL6OUGE5W8CA7LJ/carotid+IJ.gif Vascular - Carotid and IJ - Doppler This clip shows the common carotid artery (red) and internal jugular vein (blue) in cross-section side by side using color doppler overlay. The sternocleidomastoid muscle is seen in cross-section at the top of the screen. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534890392207-1PUITEDZU6T3WG2YLQZP/carotid+long.gif Vascular - Carotid Long - Doppler The common carotid artery in long axis with color doppler overlay. On the far left of the screen the wide carotid bulb is visible. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534890449786-KBTUKU0FZK0CKI0I4RBK/IJ+vs+carotid.gif Vascular - Carotid vs IJ - Doppler In this clip the probe sweeps between the internal jugular vein (red, demonstrating respiratory variation) and the common carotid (blue, pulsatile) in long axis with color doppler overlay. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584977510272-01BEUXYOOWXZ1QXKG304/image-asset.gif Vascular - Suspected Carotid Dissection Patient presented with near-syncope and unilateral neck pain. Ipsilateral neck ultrasound revealed swirling blood within the IJ; further evaluation revealed etiology to be a thoracic aortic dissection contributing to pericardial effusion and cardiac tamponade. Peter Weimersheimer, MD. Director EM POCUS at ULA @VTEMSONO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534890590711-6N41E8Q81929DDZVGROG/IVC+hepatic.gif Vascular - IVC and Hepatic Vein In this longitudinal subxiphoid view, we see the liver in the center and beating heart to the left of the screen. The IVC in long axis empties into the right atrium. A hepatic vein is seen draining into the IVC just prior to its confluence with the heart. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534890699588-U1YAQQBMRR9CHH33H5X5/popliteal+compression+est.gif Vascular - Popliteal Compression Test This clip demonstrates compression of the popliteal vein moving distally from the popliteal fossa down the calf as is often done to assess for DVT. The non-compressible vessel deep and medial to the popliteal vein is the popliteal artery. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1534890798670-45USUOTK8OSPZ3GPLVE0/popliteal+vasculature.gif Vascular - Popliteal Vasculature - Doppler In this clip the color doppler helps to differentiate the popliteal artery (deep, red, pulsatile) from the popliteal vein (no color, superficial). Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607177523912-U6SE33NNBSDJ6BZ6WMZA/image-asset.gif Vascular - Lemierre Syndrome A young male presented to the ED with high fever and right lateral neck pain with swelling and associated chest pain. He has a recent history of a sore throat. Transverse view of the neck reveals IJ thrombus with enlarged surround lymph nodes. Chest CT revealed a septic pulmonary emboli. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1554692425491-73EL4MZU84AQ4C2TEF2U/CVC+kinked+in+IJV.gif Vascular - CVC kinking in IJV After a troubled implant (Seldinger wire got somehow stuck) there was normal IV dripping and normal blood reflux after positioning IV bottle below the patient. However, no flush in AD was visible. We scanned to find a 180° degrees kinking in IJV just below insertion site . Dr. Garrone https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567930261152-69Q2INLJDU029ARQDEM7/popliteal-vasc-doppler.gif Vascular - Popliteal Vasculature - Colorized Popliteal vessels Green: Popliteal artery, Yellow: Popliteal vein Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567930258400-L55SNO46KDA67WUE8D2W/carotid.IJ.gif Vascular - Carotid and Internal Jugular Doppler - Colorized Carotid Artery and Internal Jugular Doppler Green: Sternocleidomastoid, Blue outline: Common carotid artery, Red outline: Internal jugular vein Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567930265171-D6XOWKWTM0ZL469G5V6K/carotid-bulb-long.gif Vascular - Carotid Bulb Long Axis - Colorized Carotid Bulb (long axis) Red: Common carotid artery, Blue: Lumen of internal jugular vein Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567930276981-9YY0WLRZQUQ9FEM9OTLZ/carotid-long-doppler.gif Vascular - Common Carotid Long Axis - Colorized Long Axis of Common Carotid Artery Red: Common carotid artery, Green: Carotid bulb Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567930273088-56QIB8MVTY51XTS84OEP/IJ-vs-carotid-doppler.gif Vascular - Internal Jugular and Common Carotid Doppler (long axis) - Colorized Long Axis Doppler of Common Carotid Artery and Internal Jugular Vein Yellow outline: Internal jugular vein, Green outline: Common carotid artery Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727653939039-S52RV2DZJWBH9EHEYNJ1/image-asset.gif Vascular - Upper Extremity DVT in a 32 y/o female [2/2] 32 year old female presenting to the ED with dorsal L hand pain and localized swelling and tenderness in an area with recent IV line placement. Daniella Santiago MD Miguel Agrait MD Division of Emergency Ultrasound, St. Luke's Medical Center/PHSU Ponce, PR https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727653790147-DEKFGY86PGAEBWTJPUWX/image-asset.gif Vascular - Upper Extremity DVT in a 32 y/o female [1/2] 32 year old female presenting to the ED with dorsal L hand pain and localized swelling and tenderness in an area with recent IV line placement. Daniella Santiago MD Miguel Agrait MD Division of Emergency Ultrasound, St. Luke's Medical Center/PHSU Ponce, PR https://www.thepocusatlas.com/colorized-atlas daily 0.75 2023-10-18 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567927419294-MZKW5LWA8HOQF933QT2M/good-PLAX_simple.gif Colorized Atlas - Parasternal Long Axis - Colorized - Simple Parasternal Long Axis Blue : Left atrium and ventricle, Yellow: Mitral valve, Green: Right ventricle Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567927419294-MZKW5LWA8HOQF933QT2M/good-PLAX_simple.gif Colorized Atlas - Parasternal Long Axis - Colorized - Simple Parasternal Long Axis Blue : Left atrium and ventricle, Yellow: Mitral valve, Green: Right ventricle Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567928845136-YWIL4NGIVK78N61MJLGX/good-PLAX2_cropfinal.gif Colorized Atlas - Parasternal Long Axis - Colorized - Complex Parasternal Long Axis (detailed) Blue: Left ventricle, Green: Right ventricle, Orange: Aortic outflow Pink: Aortic valve; Yellow: Mitral valve; Red: Pericardium; Light orange: Left atrium Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567928714189-RS38B7QKUK6RPIS8727F/good-PSAX.gif Colorized Atlas - Parasternal Short Axis - Colorized Parasternal short axis Red: Left ventricle, Blue: Mitral valve, Green: Right ventricle Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567928486979-Z07O88AXBF5Y8PVSU2L7/a4ch-trimmed_simple.gif Colorized Atlas - Apical 4 - Colorized Simple Apical 4 Red: Right atrium and ventricle, Blue: Left atrium and ventricle, Pink: aortic valve Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1583609036457-L7LXEIT6TIU6CI7UVL4Q/a4ch-trimmed_cropaortic.gif Colorized Atlas - Apical 4 - Colorized - Complex Apical 4 View Red: Right Ventricle, Green: Right Atrium, Blue: Left Ventricle, Yellow: Left atrium. Pink: Mitral valve. Teal: Tricuspid Valve. Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567928828934-JGP4G77LMRPEEPAKNJ5G/goodsubxiphoid_simple.gif Colorized Atlas - Subxiphoid - Colorized 1 Subxiphoid view Red: Lumen of left atrium and ventricle, Blue: Lumen of right atrium and ventricle Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567928861700-N9T152WFWAB3LR8D5ZLE/goodsubxiphoid.gif Colorized Atlas - Subxiphoid - Colorized 2 Subxiphoid Red: Liver. Orange: Diaphragm. Blue: Right Atrium, Teal: Right Ventricle, Green: Left Atrium,Purple: Left Ventricle Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1567930278544-QJETKM44K5B9VDRU9XA4/IVC_hepaticv.gif Colorized Atlas - Inferior Vena Cava and Hepatic Vein - Colorized Inferior Vena Cava and Hepatic Vein Red: Heart, Yelow: Hepatic vein, Blue: Inferior vena cava Images: Dr. Lindsay Davis, Dr. Hannah Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti https://www.thepocusatlas.com/new-blog-1 daily 0.75 2019-09-18 https://www.thepocusatlas.com/custom-grid-1 daily 0.75 2020-12-01 https://static1.squarespace.com/static/58118909e3df282037abfad7/t/5fc5a0b7e18c5c478ebd2150/1569451823366/ Normal Anatomy - Seagull Sign https://static1.squarespace.com/static/58118909e3df282037abfad7/5d8bed346412ab652b4104a2/5d8beeb10675282db8910b1f/1569451823366/ Normal Anatomy - Seagull Sign https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601053065027-P7LJAE4FZKJBQJXAVRJH/Aorta-seagull.gif Normal Anatomy - Seagull Sign https://www.thepocusatlas.com/new-project daily 0.75 2020-12-06 https://static1.squarespace.com/static/58118909e3df282037abfad7/t/5fcc4bda2fa8bc6bcddd8e6a/1607224254766/ New Project https://static1.squarespace.com/static/58118909e3df282037abfad7/5d9d1ff30bfcde330330efb0/5fcc4bbe2bc7884852a941af/1607224254766/ New Project https://www.thepocusatlas.com/ob-dating-atlas daily 0.75 2020-11-13 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1589923173841-5PQGY01OI79391DW2VQI/Week+6_Gestational+Sac+A.gif OB Dating Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1589923173841-5PQGY01OI79391DW2VQI/Week+6_Gestational+Sac+A.gif OB Dating Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1589926807344-M0603CJB8DO2MO7ZDMT9/Week+4_Gestational+Sac+A.gif OB Dating Atlas - Week 4 - Mean Sac Diameter (MSD) A 28-year-old G0 with an unknown last menstrual period (LMP) presents for a missed period and a positive urine pregnancy (UPT) test two days ago. On abdominal ultrasound, the mean sac diameter is .92 cm consistent with a 4w6d intrauterine pregnancy (IUP). General Rules: MSD is the earliest measurement that can assess GA. MSD can be used until the embryo is present (5w0d-8w0d), then use the CRL. Mean of 3 orthogonal measurements (length, width, and height) of fluid-filled space in sac. Gestational Age (days) = MSD (mm) + 25 This equation can be used when using a portable or handheld device that does not calculate the gestational age automatically. Accuracy3: ± 5-7 days Pearls: A gestational sac alone cannot confirm a pregnancy. In the presence of an ectopic pregnancy, a pseudogestational sac may be present. An MSD > 12.0 cm with no yolk sac visualized should raise concerns for a missed abortion or blighted ovum and should be further investigated. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1589927846651-2SY5DXIB8Q2LHUUMVPD4/image-asset.png OB Dating Atlas - Week 7 - Mean Sac Diameter (MSD) A 21-year-old G3P3 with an unknown LMP presents for a missed period and a positive UPT. On abdominal ultrasound, a yolk sac is present. Three measurements of the gestational sac are 2.1 cm, 2.7 cm, and 2.5 cm, giving a mean sac diameter of 2.4 cm, consistent with a 7w0d IUP. General Rules: MSD is the earliest measurement that can assess GA. MSD can be used until the embryo is present (5w0d-8w0d), then use the CRL. Mean of 3 orthogonal measurements (length, width, and height) of fluid-filled space in sac. Gestational Age (days) = MSD (mm) + 25 This equation can be used when using a portable or handheld device that does not calculate the gestational age automatically. Accuracy3: ± 5-7 days https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1589925020664-IMP1TZ1VBDSK2ITWO4J0/image-asset.gif OB Dating Atlas - Week 10 - Crown Rump Length (CRL) A 24-year-old G0 with an unknown LMP presents for a missed period and confirmation of pregnancy. She had a positive UPT 5 days ago. On abdominal ultrasound, an embryo is visualized. The crown-rump length measures 3.84 cm consistent with a 10w5d IUP. General Rules: Most accurate single measurement once the embryo is present (6w0d-13w6d) [1] Mean of 3 linear measurements from the outer margin of the cranium/cephalic pole to caudal rump in the true midsagittal plane. Gestational Age (weeks) = CRL (cm) + 6.5 This equation can be used when using a portable or handheld device that does not auto calculate the gestational age. Accuracy3: ± 5 - 7 days https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1589925555979-AW5CY4GV5PMFWDEXWKD0/image-asset.gif OB Dating Atlas - Week 15 - Biparietal Diameter (BPD) A 26-year-old G4P3 with an unknown LMP and no prior prenatal care presents with vaginal spotting. She had a positive home UPT 3 weeks. On abdominal ultrasound, the biparietal diameter measures 2.79 cm consistent with a 15w0d IUP. General Rules: Used to estimate gestational age starting at 14w0d Both measurements should be taken in the transverse plane at the level of the of thalami and cavum septum pellucidum with no cerebellum in view BPD: measure from the outer edge of parietal bone to inner edge on the opposite side Accuracy3: ± 7 - 12 d https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1589925788461-IVJIFT2EFIYG4MPO5HRA/Week+16_Femur+Length.gif OB Dating Atlas - Week 17 - Femur Length A 34-year-old G6P5 with an LMP of “a few months ago” presents for vaginal spotting. She had a positive UPT 5 days ago. FL measures 2.42cm, consistent with a 17w2d IUP. General Rules: Measure diaphyseal length only (excluding epiphysis) with the length of the bone perpendicular to the ultrasound beam A simple measure to get in a critically ill medical or surgical patient to determine if the fetus is viable outside of the uterus [4] Accuracy3: ± 7 - 17 d https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1589925184857-XWNHDZSPPEDA349DQJWA/Week+22_Biparietal+Diameter.gif OB Dating Atlas - Week 22 - Biparietal Diameter (BPD) An 18-year-old G1P0 with an LMP of “a few months ago” and no prior prenatal care presents to initiate care. She had a positive home UPT two months ago. On abdominal ultrasound, there is positive cardiac activity and positive fetal movement. The biparietal diameter measures 5.4 cm consistent with a 22w0d IUP. General Rules: Used to estimate gestational age starting at 14w0d Both measurements should be taken in the transverse plane at the level of the of thalami and cavum septum pellucidum with no cerebellum in view BPD: measure from the outer edge (closest to the probe) of parietal bone to inner edge on the opposite side (farthest away from u/s probe) Accuracy3: ± 7 - 12 d https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1589926030243-AHS7DI3FY06YIOZ97BYS/Week+25_Abdominal+Circumference.gif OB Dating Atlas - Week 25 - Abdominal Circumference (AC) A 19-year-old G0 with an unknown LMP presents for a missed period and light vaginal bleeding. UPT is positive and on abdominal ultrasound, abdominal circumference measures 21.4 cm confirming a 25w6d IUP. General Rules: Measure the in the transverse section around the skin line making sure to be in the same plane as the stomach, umbilical vein, and portal sinus It is important to take multiple measurements here, as measurements can be altered due to fetal breathing motion. Accuracy [3]: ± 7-17 days https://www.thepocusatlas.com/new-gallery daily 0.75 2020-03-28 https://static1.squarespace.com/static/58118909e3df282037abfad7/t/5e7facca971cba01a86c4421/1584910242713/ COVID 19 Lung US Disease Progression https://static1.squarespace.com/static/58118909e3df282037abfad7/5e77cf9b7531ce4dfe529315/5e77cfa2e08d1b666d128ecc/1584910242713/ COVID 19 Lung US Disease Progression https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584912023813-2HJSCJP8CYARBIFWY2TV/image-asset.gif COVID 19 Lung US Disease Progression - Day 1 Day 1 after #COVID diagnosis. Sore throat, headache (strong!), dry cough but not shortness of breath. No lung US abnormalities. Will keep a #POCUS track of my lungs. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584912059748-B3CL2NYKBQ14AI6RGZYE/Day+2.gif COVID 19 Lung US Disease Progression - Day 2 Day 2 after #COVID diagnosis. Less sore throat, cough & headache (thank God!), still no shortness of breath or pleuritic chest pain. #POCUS update: small bilateral pleural effusion, thickened pleural line & basal b-lines (plaps). @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585002168742-REUN95U5LT82ZRNZWDMC/Day+3.gif COVID 19 Lung US Disease Progression - Day 3 Day 3 after #COVID diagnosis. No sore throat/headache. Yesterday was cough day, still no shortness of breath/chest pain. Diarrhea started, lucky cough got better. #POCUS update: similar effusion, seems less thickened pleural line + no b-lines (PLAPS). @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585002209612-J25S0LJWM7RROYISLBM4/Day+4.gif COVID 19 Lung US Disease Progression - Day 4 Day 4 after #COVID diagnosis. More cough & tiredness (very badly), still no dyspnea/chest pain. #POCUS update: Right side on resolution, Left side a more thickened pleural line + 2 subpleural consolidations. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584912064294-TH6HZ4UN7PXSPY6C6BH5/Day+5.gif COVID 19 Lung US Disease Progression - Day 5 Day 5 after #COVID diagnosis. Less cough & tired, still no dyspnea/chest pain. #POCUS update: Effusion resolved, as subpleural consolidations spread bilaterally on both posterior lower lobes. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584912067116-APQOD1VEUDCA8R4GLKD4/Day+6.gif COVID 19 Lung US Disease Progression - Day 6 Day 6 after #COVID diagnosis. Less cough, bit tired, still no dyspnea. No fever. Oxygen saturation 98%. #POCUS update: thick pleural line, b-lines and subpleural consolidations tend to resolve. Significant lung improve from yesterday. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584912069698-RQZUXW5LUBLEVXIBVHMN/Day+7.gif COVID 19 Lung US Disease Progression - Day 7 Day 7 after #COVID diagnosis. Cough & weakness got worse (again), still no dyspnea. No fever. SpO2 96%. #POCUS update: similar to yesterday - thick pleural line, b-lines & consolidations tend to resolve. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584912070963-RYTB44UTT9IA20ZZQLBE/Day+8.gif COVID 19 Lung US Disease Progression - Day 8 Day 8 after #COVID diagnosis. Less Cough & similar weakness, still no dyspnea or red flag symptoms. No fever. SpO2 96%. #POCUS update: Right resolved. Left lower lobe much better. Left lateral appeared new focal B-lines. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584912072537-W7MUA3ZZE61HZ3J61VA9/Day+9.gif COVID 19 Lung US Disease Progression - Day 9 Day 9 after #COVID diagnosis. Feeling slightly better. More cough. No dyspnea or red flag symptoms. No fever. SpO2 97%. #POCUS update: similar to yesterday. Left lower & lateral with thick pleural line & focal B-lines. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584912074478-Q7MTE8DKUA4P94D2C481/Day+10.gif COVID 19 Lung US Disease Progression - Day 10 Day 10 after #COVID diagnosis. Less tired, but more cough, ageusia & anosmia. No dyspnea or red flag symptoms. No fever. SpO2 97%. #POCUS update: Right, Left lower & lateral with thick pleural line & focal B-lines. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584912075983-IK93HTF1ADX1GE0KVYHP/Day+11.gif COVID 19 Lung US Disease Progression - Day 11 Day 11 after #COVID diagnosis. Less tired & cough, unable to endure small efforts. No dyspnea or red flag symptoms. No fever. SpO2 98%. #POCUS update: Bilateral subpleural consolidations, thick pleura & focal B-lines. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584912077837-3MM8ZQQAP4ZNLJXSUJ9B/Day+12.gif COVID 19 Lung US Disease Progression - Day 12 Day 12 after #COVID diagnosis. Better, main symptoms cough, nausea & diarrhea. No dyspnea or red flag symptoms. No fever. SpO2 98%. #POCUS update: Subpleural consolidations resolving, thick pleura & B-lines, small effusion. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584912078567-U7WUMT67NS5FCHI77FEM/Day+13.gif COVID 19 Lung US Disease Progression - Day 13 Day 13 after #COVID diagnosis. Lesser cough, weakness, nausea & diarrhea. No dyspnea or red flag symptoms. No fever. SpO2 97%. #POCUS update: 2 subpleural consolidations (resolving), thick pleura & bilateral scattered B-lines. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584912080188-JY7O72YVULEPWMWG2TCK/Day+14.gif COVID 19 Lung US Disease Progression - Day 14 Day 14 after #COVID diagnosis. Less symptoms - cough, weakness, nausea, light headache. Regaining appetite/smell. No fever/dyspnea. SpO2 98%. #POCUS update: Improving - thick pleura & Bilateral scattered B-lines, no effusion. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585002231728-IC3BH68PG75L7YQY6T6N/Day+15.gif COVID 19 Lung US Disease Progression - Day 15 Day 15 after #COVID diagnosis. Similar cough, less weakness. Diarrhea due azithromycin. No fever or shortness of breath. SpO2 97%. #POCUS update: Similar to yesterday, thick pleura & bilateral scattered B-lines. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585162446907-L7FJBV5LBYGWSENNFBQH/Day+16.gif COVID 19 Lung US Disease Progression - Day 16 Day 16 after #COVID diagnosis. Similar dry cough, but with good energy & high spirit. No fever or dyspnea. SpO2 97%. #POCUS update: Improved, less thickened pleura & less bilateral B-lines. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585162449766-TX2A22X621WT751DY4OC/Day+17.gif COVID 19 Lung US Disease Progression - Day 17 Day 17 after #COVID diagnosis. Less cough, nausea & more appetite, energy. No fever or dyspnea. SpO2 97%. #POCUS update: right side resolved, left lateral & lower less thickened pleura & B-lines. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585425364868-QZ9MIN5KEB90Z1YMUG4L/Day+18.gif COVID 19 Lung US Disease Progression - Day 18 Day 18 after #COVID diagnosis. Similar cough. No fever or dyspnea. SpO2 97%. #POCUS update: slight worsening. Bilateral thickened pleura & B-lines, subpleural consolidation reappeared. On HCQ (D14). Waiting to re-test on friday. @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585425364721-GHHMEPB7DQRZ09YZ864N/Day+19.gif COVID 19 Lung US Disease Progression - Day 19 Day 19 after #COVID diagnosis. More cough & weakness. No fever or dyspnea. SpO2 97%. #POCUS update: Subpleural consolidation got bigger on left lower lobe. Yesterday started levofloxacin (bacterial super infection?). @yaletung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585425365966-ASLAEE8QPNE0UXH2EFGD/ezgif.com-optimize+%2852%29.gif COVID 19 Lung US Disease Progression - Day 20 Day 20 after #COVID diagnosis. Almost recovered. SpO2 96%. #POCUS update: Significant improvement, remains thick pleura & B-lines. Yesterday tested NEGATIVE. I will try update a lung scan every week. FINALLY, I am returning to the TRENCHES. @yaletung https://www.thepocusatlas.com/covid19-links daily 0.75 2020-03-24 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584902390317-KDO3YSPBBLY1Q1JZKRW4/original+%281%29.png COVID-19 Links - PODCAST POCUS in COVID-19 via Ultrasound GEL. Michael Pratt sits down with Mike Mallin to discuss the most recent evidence regarding POCUS use in COVID-19 patients. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584902390317-KDO3YSPBBLY1Q1JZKRW4/original+%281%29.png COVID-19 Links - PODCAST POCUS in COVID-19 via Ultrasound GEL. Michael Pratt sits down with Mike Mallin to discuss the most recent evidence regarding POCUS use in COVID-19 patients. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584903080708-KRS75BMN9ZVN3SR3I63F/CoreUltrasound_new_Subtitle.jpg COVID-19 Links - VIDEOCAST POCUS Use in Patients with Suspected COVID-19 via Core Ultrasound. Mike Mallin and Jacob Avila talk with Michael Prats and Mike Stone on how ultrasound can be used to help manage your patients with suspected COVID. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584921289133-T2ZNOKTDI3CGEL9BHF2R/zedu-logo-03.png COVID-19 Links - RESOURCE LIST A comprehensive list of all things related to COVID-19 POCUS from Zedu! https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584921307576-ZJNIAZPE8JJXZJS7BJE0/Screen+Shot+2020-03-22+at+12.01.24+PM.png COVID-19 Links - LEARN + RESOURCE LIST Comprehensive resource page on use of bedside ultrasound in suspected COVID-19 patients tailored towards Butterfly iQ use. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585004652857-GLALIIBWPF0T6357ACPX/GwnZAPYE_400x400.jpg COVID-19 Links - RESOURCE LIST One-stop shop for current #POCUSforCOVID #FOAMUS resources! https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585031984451-ZHTTUA0JLXIBLL8752EM/IMG_4512.png COVID-19 Links - LEARN The Ultrasound Leadership Academy is offering a free point of care lung ultrasound learning module! https://www.thepocusatlas.com/team daily 0.75 2025-09-26 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1651641817998-DZTX8DHOUNJI4GS6GN4L/Mike+Macias.png Team - Michael Macias MD Founder, Designer Amateur shutterbug, mediocre cook & ultrasound junkie living in sunny San Diego, California. I am a graduate of The Ultrasound Leadership Academy and the UCSD Ultrasound Fellowship Program. Currently the Ultrasound Director and Co-Fellowship Director for the Southwest Healthcare Medical Education Consortium. I am also the creator of EMcurious, The NUEM blog, and UCSD Ultrasound, with a strong interest in digital education. Contact me at emedcurious@gmail.com Twitter: @emedcurious https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1651641817998-DZTX8DHOUNJI4GS6GN4L/Mike+Macias.png Team - Michael Macias MD Founder, Designer Amateur shutterbug, mediocre cook & ultrasound junkie living in sunny San Diego, California. I am a graduate of The Ultrasound Leadership Academy and the UCSD Ultrasound Fellowship Program. Currently the Ultrasound Director and Co-Fellowship Director for the Southwest Healthcare Medical Education Consortium. I am also the creator of EMcurious, The NUEM blog, and UCSD Ultrasound, with a strong interest in digital education. Contact me at emedcurious@gmail.com Twitter: @emedcurious https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1758911570686-04Q6V8D2GQSXRD9603OK/image-asset.jpeg Team - Matthew Riscinti MD Co-founder, Editor System-Wide Ultrasound Director, ED Ultrasound Director and Ultrasound Fellowship Director at Denver Health in Denver, Colorado. He has special interests in Deep Learning augmentation of Ultrasound Education, Teleguidance, and technologic innovations in Ultrasound Education. He shared the ACEP Innovation in Ultrasound Education Award in 2018 with Dr. Macias. Contact: mriscinti.com Twitter: @mriscinti https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592844508349-ORRA9UJQMNS4AEA7YU7Z/Tessa.png Team - Tessa Damm DO Image Atlas Senior Editor Tessa Damm, DO is a practicing intensivist trained and board certified in Internal Medicine, Critical Care Medicine, and Neurocritical Care. She practices multidisciplinary critical care in Milwaukee, WI where she uses bedside ultrasound in daily clinical practice and teaching. She serves as the Associate Regional Medical Director for Critical Care for Wisconsin SSM Health and as a Clinical Adjunct Assistant Professor at the University of Wisconsin School of Medicine & Public Health as well as teaching critical care fellows from the Medical College of Wisconsin. Twitter: @DrDamm https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1593286322433-YH98O9VC3RLV4G8P95CF/The+POCUS+ATLAS-77.png Team - Timothy Scheel DO Communications and Social Media Strategist Emergency Medicine Physician in Northern Colorado. Trained in Southwest Michigan at Spectrum Health Lakeland and is a graduate Fellow of Emergency Ultrasound at Denver Health. Adjunct Faculty at Denver Health Emergency Medicine Residency. Spends off days in the mountains of sunny Colorado, shredding pow and running trails with his wife and their dog, Aspen. Check us out on social media @thepocusatlas! Contact: scheel.emdo@gmail.com Twitter: @tscheelEMUS https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592844506438-9RBSWEDDC85PTZX23E2B/Mike+Amador.png Team - Michael Amador Colorized Atlas Editor Fourth year medical student at Albany Medical College applying to emergency medicine residencies this upcoming cycle. Very interested in clinical education and ultrasound . I am thankful for the opportunity to help educate students and providers on some of the basics of ultrasound anatomy through this platform. I spend most of my free time playing guitar/bass/drums and taking my 5 year old Golden retriever/Bassett hound buddy for long walks. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592844503573-HN74ONMYK25I4N95ONQD/Sara.png Team - Sarah Angarita-Jones MD MPH OB Section Editor Emergency Medicine PGY4 at SUNY Downstate/Kings County Hospital in Brooklyn, NY, with a special interest in Medical Education and Diversity and Inclusion in Medicine. Headed to Miami, Florida as an Attending Physician in the Jackson Health System next year. When I'm not in the ER, I enjoy hiking with my husband Jaime and building lego rockets with my son, Favian. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594228929538-RZKLM0W1M2AUUKCVDZX6/image-asset.png Team - Kiara Blough MD OB Dating Atlas/OB Section Editor Kiara is an OB/GYN resident physician at New York Presbyterian - Brooklyn Methodist Hospital. Outside of her clinical roles, she is a health policy nerd, a patient advocate, and is committed to combatting disparities in our health care system. As a Coloradan at heart, outside of work, she recharges in the mountains by rock climbing, mountain biking, and snowboarding. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1758911695114-9Z4IP8E09JZFSVLFWRXU/image-asset.jpeg Team - Dr. Joseph Brown, MD Nerve Block Atlas Editor https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1758911740397-Z17F70NZGC0YVSQKGCE8/image-asset.jpeg Team - Dr. Jamie Pospishil Nerve Block Atlas Editor https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1612637858209-XHTQZ0W4AJ07Q5P05WMN/image-asset.png Team - Michael Heffler MD Nerve Block Chief Editor, Image Atlas Editor Currently, practicing Emergency Medicine at UCHealth Highlands Ranch Hospital and serves as a Faculty Instructor at the University of Colorado Department of Emergency Medicine. Graduate of Denver Health Ultrasound Fellowship and Denver Health Emergency Medicine Residency where he served as Chief Resident. Outside of the ED, he can be found exploring Colorado by bike, by snowboard, by microbrewery, or on foot. Contact: michael.heffler@denverem.org Twitter: @MikeHefflerMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606072257708-CQ8Z6GM1C9C75Q7C5W79/Team+Pictures-06.png Team - Michael Cox, DO Digital Education Intern Current emergency medicine resident at Prisma Health - Uof SC Columbia with a passion for ultrasound. During medical school, I developed a strong interest in ultrasound curriculum development and medical student education. Contact information: michaeldcox2022@gmail.com https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1593286310114-V3ZYHUELTBZF9NAJJEAZ/The+POCUS+ATLAS-76.png Team - Lindsay Davis MD Colorized Anatomy Atlas Editor Director of Emergency Ultrasound Fellowship, NYU Langone/Bellevue Medical Center Interests include innovative curriculum development and interactive US learning modalities. Outside of the ED, I can be found soaking up NYC's amazing theatre scene (or could be, pre-covid!), and exploring the city via bike. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592844508666-A93TSTPUNUY4ZFD88I1J/Tom%2BFadial-17.png Team - Tom Fadial MD Evidence Atlas App Developer, Editor Assistant Professor and Educational Technology and Innovation Officer at McGovern Med at UTHealth. I’m passionate about creating free, innovative and well-designed medical education tools like ddxof.com. See all of my work at fadial.com. Twitter: @thame https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1595825165333-LISRSD5W5GFAVA2AFFQA/image-asset.png Team - Hannah St. Francis MD, Color Atlas Editor Emergency medicine resident at NYU/Bellevue in New York City. Hannah spends her spare time escaping the city for outdoor adventures, experimenting in the kitchen, and perfecting her veterinary POCUS skills at home on her greyhound, Luna. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1593718357350-IEJ7TCZLCNH94LM5C78W/Blank+-75.png Team - Garrett Ghent MD Lead Editor for the Evidence Atlas Advanced Resuscitation and Ultrasound Fellow at Stony Brook University Hospital, Long Island, New York. Interests in emergency critical care and bedside ultrasound. I grow most of my own food. Twitter: @garrettghentMD Email: garrett.ghent@gmail.com https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664657851002-O3SCA8JTPMCYKJSMCEQ1/Brian+.png Team - Brian Hizon MD Atlas Hierarchy Designer PGY-1 at Cook County EM in Chicago, IL with a love for POCUS, social EM, and high resolution gifs. You can find me hanging out at the local coffee shop or climbing gym. Twitter: @HizonBrian https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606072261627-YPR0IXFFD44CZD8694M1/Team+Pictures-07.png Team - Elias Jaffa MD Image Review Senior Editor, UI Consultant Elias Jaffa, MD, MS is an emergency physician currently practicing in the rural southeastern US. During his emergency ultrasound fellowship at Duke University Hospital, he found his way back to his first love—technology. Since then, he has worked on a number of POCUS-focused software and hardware solutions, including an open-source platform for facilitating telePOCUS. Learn more about his work at https://jaffamd.com and https://github.com/jaffamd . https://static1.squarespace.com/static/58118909e3df282037abfad7/5ef0e037748a1424302f175a/5ef0e0c465e27324a65b2d8c/1592844484796/ Team https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1593286317689-W8L0NGKCJW7W05Q9I2TD/The+POCUS+ATLAS-78.png Team - Sathyaseelan Subramaniam MD FAAP Pediatrics Editor Emergency Ultrasound Director Summerlin Hospital Medical Center Las Vegas, Nevada https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611864019265-ISCQJKDGX3KT8DY0I4ZF/image-asset.png Team - Robert Jones DO FACEP, Ultra-Contributor Director, Emergency Ultrasound MetroHealth Medical Center Professor, Case Western Reserve Medical School, Cleveland, OH Past President, ACEP Ultrasound Section Dr. Robert Jones has been performing point-of-care ultrasounds since 1991 and has developed and led emergency ultrasound programs at several emergency medicine residency programs. Dr. Jones has served as president of ACEP’s ultrasound section and has authored handbooks, textbook chapters, policy statements and research articles on point-of-care ultrasound. Dr. Jones is the author of the on-line materials at EMSONO.COM as well as the SONOBRIDGE ultrasound curriculum and has incorporated thousands of cases obtained over the past 27 years into the modules. Twitter: @RJonesSonoEM https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592844501599-WBWONOUCO2W3O2WDJQA4/jfk2.png Team - John F Kilpatrick MD Consultant Website: Kings County US https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592844501530-P9U1O29PS6KR23QEMXLX/Resa.png Team - Resa E. Lewiss MD Consultant Twitter @RELewiss https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592844503303-E5BAMWH9OMO46L5HQLW4/Rachel+.png Team - Rachel Liu MD Consultant, Gamification Specialist Twitter: @RubbleEM https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592844505381-8IPS8L4MAVBG9WQLAXWT/lisa.png Team - Lisa Feit MS4 Former Co-chief of Operations Fourth year, Emergency Medicine bound medical student at SUNY Downstate in Brooklyn, NY. Working on this project has given me a lot of insight into the uses and importance of ultrasound in the ED. I like spending my spare time defying gravity flying the trapeze or at gymnastics. Feel free to contact me at lisa.feit@downstate.edu https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592844505287-SRGY6UNECT8LVEDFKNCC/Carissa+Solari+.png Team - Carissa Solari Former Chief of Operations & Social Media Specialist Resident in Emergency Medicine at the University of New Mexico and graduate from SUNY Downstate Medical School in Brooklyn, NY. I have come to respect the enormous utility of US in the ED and hope to learn a great deal while working on this project over the upcoming years. Outside of academics I spend my free time rock climbing or traveling (to a rock climbing destination.) Feel free to contact me at carissa.solari@downstate.edu https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1633980717189-K2PUSZTRXH1HNU85T79C/image-asset.png Team - Kathryn H Pade MD POCUS Atlas Jr Editor Kathryn H Pade, MD Pediatric Emergency Medicine Attending at Rady Children's Hospital San Diego. Also serves as the Pediatric Emergency Medicine Fellowship Director and Pediatric Emergency Medicine Ultrasound Associate Fellowship Director. Outside of the ED, she spends time at the beach, hiking and baking. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1643398341365-SDPYJQOCXSJMHCCTODFL/image-asset.png Team - Nhu Nguyen Le, MD Image Review Editor Current Associate Fellowship Director of Riverside Community Hospital Ultrasound Fellowship. Graduate of Denver Health Ultrasound Fellowship and LAC+USC Emergency Medicine Residency with a special interest in medical education. Outside of work, I enjoy running, biking, diving, and spending time with family and friends. Contact: nhunguyenle1@gmail.com Twitter: @NhuNguyenLe https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659457269160-OZE0GJH73780Y1ARPT7Z/russ-11.png Team - Russ Horowitz MD POCUS Atlas Jr Editor My role is the Director of Emergency and Critical Care Ultrasound at Robert H Lurie Children’s Hospital of Chicago. I am also the Topic Expert for Medical Ultrasound for the Feinberg School of Medicine (I lead the med student ultrasound curriculum). My hobbies are snowboarding, mixology and bourbon sampling. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659479275566-2CB0610W5JZYKCDSO51S/About+Us+Pictures-61.png Team - Julia Brant MD POCUS Atlas Jr Editor She completed her ultrasound fellowship in 2019 at Denver Health and is currently finishing PEM fellowship at University of Colorado. She is part of the ultrasound team at the Children’s Hospital Colorado and involved in multiple projects on POCUS curriculum development and nerve block task trainers. Twitter @pedipocus Outside of work, she enjoys hanging with her 2 kiddos and drinks an excessive amount of coffee. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659541437132-VR31U3ROA2YFC5XLV1H1/Team+Pictures-12.png Team - Maher M. Abulfaraj MD POCUS Atlas Jr Editor Pediatric emergency medicine physician and director of emergency ultrasound at Arkansas Children’s Hospital/University of Arkansas for Medical Sciences. Outside of work and parenting, I am a coffee addict and enjoy relaxing while in nature. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659541531448-3MJ26NSFJ2XTT100LKGZ/Team+Pictures-13.png Team - Paul Khalil MD POCUS Atlas Jr Editor Paul is the PEM POCUS Director at Nicklaus/Miami Children’s Hospital. Outside of the ED, he likes to hang out with his wife and two daughters, SCUBA dive, and travel. Twitter @Khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659807931330-V2L81184VDFFYHJK70LN/About+Us+Pictures-62.png Team - Dr. Vanitha Jagannath POCUS Atlas Jr Editor Pediatrician and neonatologist from India, Cochrane systematic review author and POCUS enthusiast with a focus on adopting POCUS across the practice spectrum from primary care to ED https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1660063130205-EWIJL88AA1SDS3MRPTK1/Team+Pictures-14.png Team - Carlo Zamora DO Digital Education Intern Emergency Medicine resident training at Riverside Regional Medical Center in Newport News, VA. I developed a passion for ultrasound education during my first two years of medical school and served as an ultrasound tutor as well as organized educational events. It is a joy to help anyone grow in their confidence with ultrasound and I am excited to continue my love for teaching as a resident. When I have a day off, you can either catch me at the gym, looking at watches, jamming on my guitar to another John Mayer song, watering my indoor plants, seeing when Aimé Leon Dore is dropping another collection or catching up with my growing stack of books to finish reading. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1698517021436-UQ8O8NRP44LQ4TRNAWXT/image-asset.png Team - Erick Otiniano MD MPH POCUS Atlas Image Editor Emergency Medicine Resident at Denver Health. Erick is interested in using ultrasound and AI to improve patient care and doctor-patient relationships. He also enjoys espresso, long runs, and taking pictures of his Goldendoodle, Obi. Contact: erick.otiniano@gmail.com Connect with me on LinkedIn X: @ErickMOtiniano https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1723048220788-E04KZ1VWZDPPGPGHHBGP/image-asset.png Team - Natasha Holden POCUS Atlas Jr Editor I am third-year medical student at Western University of Health Sciences, and has a keen passion for pediatrics and radiology. My background includes an MSc in Global Health and Development, and a consequent certificate in global health radiology with a particular emphasis on pediatric radiology and ultrasound in low-resource settings. Outside of school, I like to play soccer and explore new places with my dog. Feel free to contact me at natasha.holden@westernu.edu . https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1753934128271-25MDM6D1IGEPJR1KZGY4/image-asset.png Team - Rachel Meach POCUS Atlas Editor Emergency medicine resident at Baylor University Medical Center (BUMC) in Dallas, TX. I fell in love with ultrasound in the ED while working with an ultrasound fellowship trained attending while I was a scribe in college. I realized I had a passion for ultrasound education during my first two years of medical school and served as the president of ultrasound club to create organized educational events and develop curriculum. I enjoy helping learners grow their confidence with ultrasound and am excited to continue practicing throughout residency! https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1723324688776-2B7ROH411HS2XJHG79KP/image-asset.png Team - Nisar Sheren POCUS Atlas Editor Third year medical student at Western University of Health Sciences. My clinical experiences as an ER-Tech have built the foundation for my passion towards Emergency Medicine and its application of Ultrasound. As a former EMIG president, I collaborated with ED physicians and POCUS enthusiasts to deliver educational workshops and am eager to continue advancing my passion for teaching and education. Outside of medical school I enjoy playing basketball, cooking (especially my kabobs), being outdoors, and of course spending time with friends and family. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1726861809936-HBJ04LAW9RIAQ7SN492G/image-asset.png Team - Kenny Le POCUS Atlas Editor I am a fourth-year medical student at Western University of Health Sciences. My fascination for science was sparked as a child by shows like Bill Nye the Science Guy and Cosmos, leading me to pursue physics and later medicine. As a life-long learner, I am enthusiastic about sharing my knowledge, and have continued that with The POCUS Atlas. Beyond medicine, I enjoy cooking, snowboarding, and improv theater. Feel free to contact me at Kenny.le@westernu.edu. https://www.thepocusatlas.com/nerve-blocks-gallery daily 0.75 2025-01-29 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727480896401-BLPL7KGQ8QYL3IE3P067/image-asset.gif Nerve Block Gallery - Left Popliteal Sciatic Nerve Block 20 year old female with a history of IV drug use presents with a sizable calf abscess. She is admitted to the hospital for sepsis criteria and abscess drainage. She prefers no analgesia, therefore a popliteal sciatic nerve block is performed (demonstrated by injection of anesthetic adjacent to sciatic nerve) with resolution of her pain and successful incision and drainage. Contributors: John Bowling, DO (@BModeBowling); Bob Stenberg, MD (@POCUSaurusRex) Cleveland Clinic Akron General https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727480896401-BLPL7KGQ8QYL3IE3P067/image-asset.gif Nerve Block Gallery - Left Popliteal Sciatic Nerve Block 20 year old female with a history of IV drug use presents with a sizable calf abscess. She is admitted to the hospital for sepsis criteria and abscess drainage. She prefers no analgesia, therefore a popliteal sciatic nerve block is performed (demonstrated by injection of anesthetic adjacent to sciatic nerve) with resolution of her pain and successful incision and drainage. Contributors: John Bowling, DO (@BModeBowling); Bob Stenberg, MD (@POCUSaurusRex) Cleveland Clinic Akron General https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1737046951114-IKVEYCHMYW912RMAKDDO/image-asset.gif Nerve Block Gallery - PENG Block A PENG block was performed using the linear probe. The hyperechoic psoas tendon can be seen lifting off the ileum with the injection of anesthetic. Ariella Cohen M.D., Eric Quinn M.D. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1736005915962-9PRSH8V7BXU2MQN8R2E0/image-asset.gif Nerve Block Gallery - Ulnar Nerve Block for Boxer's Fracture 37 yo female presented with hand pain and deformity after punching a wall. XR and clinical exam showed displaced and rotated 5th MC fracture which required reduction prior to splinting. Ulnar nerve block was performed with needle in plane under US guidance. Nerve is located ulnar to the ulnar artery in the mid forearm and needle path is from lateral to medial. Following the block, reduction performed without any pain and patient was discharged with hand surgery follow up on outpatient basis with near anatomic positioning following reduction and splinting. Miguel F. Agrait MD CAQ-SM, Tatiana Vargas PGY-3 Centro Médico Episcopal San Lucas, Ponce PR https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264196375-MA6VXHUUURPJUBJFNQ5T/Median+Area.jpg Nerve Block Gallery - Median Nerve Palmar Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606263511428-EWDEVCZ9EV1VZYPGMZZ7/Radial+Probe.jpg Nerve Block Gallery - Median Nerve Probe Location https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606263519755-NADPQ0LQWH4IR9ZKENFE/Ulnar+Probe.jpg Nerve Block Gallery - Ulnar Nerve Probe Location https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264169334-AGT9WL087EHIJG089RXA/Fascia+Iliaca+Area.jpg Nerve Block Gallery - Fascia Iliaca Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606263687322-5AV6S71YJCFK89AGEPFS/Fascia+Iliaca+Probe.jpg Nerve Block Gallery - Fascia Iliaca Nerve Probe Placement https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606263496014-G9ZSHMWOSMMDUZ7X3FQM/Erector+Spinae+Probe.jpg Nerve Block Gallery - Erector Spinae Probe Location https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606263505585-Z7KIJIWYSDMPTETHA33A/Infraclavicular+Probe.jpg Nerve Block Gallery - Infraclavicular Probe Placement https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1615756229876-PPR0LJD1RB0N623ZEYYN/Untitled-1-01.png Nerve Block Gallery - Interscalene Sonoanatomy https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697588773180-KSIU1BPS0VOPRV0PT4KJ/Interscalene%2BProbe.jpg Nerve Block Gallery - Interscalene Probe Placement https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606263507823-N8DAXNXMHUI1OK57G5EB/Popliteal+Sciatic+Probe.jpg Nerve Block Gallery - Popliteal Nerve Probe Location https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606263509851-6TUV8IGB8JZPDK2UJOLH/Posterior+Tibial+Probe.jpg Nerve Block Gallery - Posterior Tibial Probe Location https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606263512713-LP73J0ZC7YCJ5DH0F56A/Serratus+Anterior+Probe+2.jpg Nerve Block Gallery - Serratus Anterior Probe Location https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606263513109-V37G96PDX39QR8SDZNM2/Serratus+Anterior+Probe.jpg Nerve Block Gallery - Serratus Anterior Probe Location https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606263514453-ICKPKQQP54104X750L26/Superficial+Cervical+Plexus+Probe.jpg Nerve Block Gallery - Superficial Cervical Probe Location https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606263519613-PVLVJWG1Z77IUFMXQP7A/Supraclavicular+Probe.jpg Nerve Block Gallery - Supraclavicular Probe Location https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264163215-G4LOAHZO4YCD3LJAYKEF/Common+Peroneal+Area.jpg Nerve Block Gallery - Common Peroneal Nerve Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264202207-7XKM40SPSLE8JHSW3ZBX/Popliteal+Sciatic+Area+Posterior.jpg Nerve Block Gallery - Popliteal Sciatic Nerve Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264204769-ZEQF75UN9O3R44ZYJL2U/Posterior+Tibial+Area.jpg Nerve Block Gallery - Posterior Tibial Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1641324780273-CEPZ8X9Z2OAPBFH770G7/Radial+Area.jpg Nerve Block Gallery - Radial Nerve Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264215036-YZ1EQPXFQ1885ITZS0QY/Saphenous+Area+Anterior.jpg Nerve Block Gallery - Saphenous Nerve Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264219834-SILYS8MD1SZ0BKT0G5QM/Saphenous+Area+Posterior.jpg Nerve Block Gallery - Saphenous Nerve Posterior Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264221761-B4T4EEB87J0DZP0BQFIB/SCP+Area.jpg Nerve Block Gallery - Superficial Cervical Plexus Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264225431-WI9Q70VEMW4YAYMX1P4O/Serratus+Anterior+Area+Anterior.jpg Nerve Block Gallery - Serratus Anterior Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264226837-591GT1QF20EJWLALP07D/Serratus+Anterior+Area+Posterior.jpg Nerve Block Gallery - Serratus Anterior Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264250805-XSZNT9LWH2YEUXIK2QOS/Ulnar+Area+Palmar.jpg Nerve Block Gallery - Ulnar Nerve Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264244324-UQPG0VTB2MXHTRIT6X6M/Ulnar+Area+Dorsal.jpg Nerve Block Gallery - Ulnar Nerve Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606265503783-O0EVO7ZQFEGTG1ES9T5L/Interscalene+Area+Anterior.jpg Nerve Block Gallery - Interscalene Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606265506966-EELHMXM4RGPKYGINNNR3/Interscalene+Area+Posterior.jpg Nerve Block Gallery - Interscalene Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606265620974-FLWDESIMV7Y71Q624401/Supraclavicular+Area+Anterior.jpg Nerve Block Gallery - Supraclavicular Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606265625617-R91A8MJ76FSQHYUFCLK3/Supraclavicular+Area+Posterior.jpg Nerve Block Gallery - Supraclavicular Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606265309933-XQGIGSO239L020AGNBZ9/Axillary+BP+Area+Anterior.jpg Nerve Block Gallery - Axillary Nerve Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606265315790-JOB8VMGWYTXDONUE8EFR/Axillary+BP+Area+Posterior.jpg Nerve Block Gallery - Axillary Nerve Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264169528-4LZAV3I55S6D13ACI0E3/Infraclavicular+Area+Anterior.jpg Nerve Block Gallery - Infraclavicular Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606264158195-900OWZ76BP74KFX44AAK/Axillary+BP+Area+Posterior.jpg Nerve Block Gallery - Infraclavicular Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606265847438-Y7MCWRV00YKRSC488JMT/Popliteal+Sciatic+Area+Anterior.jpg Nerve Block Gallery - Popliteal Sciatica Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1651110446178-1FWYA2NBN632GG7GTB7D/image-asset.gif Nerve Block Gallery - Suprainguinal Nerve Block An 89 year old male presented after a mechanical fall onto his right hip. X-rays demonstrated a comminuted right intertrochanteric fracture. An ultrasound-guided fascia iliaca block can be performed using the suprainguinal approach when placing the probe perpendicular to the inguinal ligament. The internal oblique (cephalad, blue) and the sartorius (caudad, red) muscles are encompassed by the fascia lata (green) superiorly and the fascia iliaca (yellow) inferiorly. These two come together to form a “bow tie” as shown above, anesthetic is deposited below the fascia iliaca. Studies have shown improved analgesia with the suprainguinal, as it is believed to have a higher likelihood of blocking the lateral femoral cutaneous nerve and the obturator nerve. Sanna Ho-Gotshall, DO, Ultrasound Fellow Casey Wilson, MD, Ultrasound Director, Emergency Medicine Program Director https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1602103765610-770GQ38T83QUQDQ8BYIR/image-asset.gif Nerve Block Gallery - Ulnar Nerve Block Ulnar nerve block done in plane. Provides excellent anesthetic for isolated hand injuries. In this case, allowed for faster time to repair and avoided use of ketamine sedation. Inject in place and use small amounts of lidocaine to make sure you are in the correct space before bathing the nerve with the entire amount of anesthetic. Julia Brant, Pediatric Emergency Medicine Fellow @pedipocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507758336200-4A394U210XO7Z6309QJD/median+nerve+block.gif Nerve Block Gallery - Median Nerve Block 15 y/o M "fell into a mirror," landing on his hand and suffering multiple, complicated lacerations at the base of his second digit with the tendon showing. Instead of injecting local anesthesia throughout, a simple median nerve block was done under POCUS guidance. In plane technique. One stick. One happy patient. Matthew Riscinti, MD - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579126308247-APSFIQMTVC7YLNNIHD1M/image-asset.gif Nerve Block Gallery - Radial Nerve Block Notice here in a still-shot of a radial nerve block, you can visually appreciate the infiltration of local anesthetic as evidenced by the hypoechoic area surrounding the radial nerve. Aaron Inouye, PA-C North Canyon Medical Center @PAintheED https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1573161730082-NMG81LPMUQWPX6Z3HV6T/interscalene+denver+em+-+forrest+.gif Nerve Block Gallery - Interscalene Block - High Speed 80 y/o intoxicated female found down with L shoulder dislocation. In order to avoid opiates/sedatives, inter-scalene block was done to facilitate reduction. http://highlandultrasound.com/interscalene-block - for more on technique Dr. Forrest Andersen - Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1573158441252-HV95XZCYF29JDUQZTY1N/interscalene+denver+em+-+forrest+.gif Nerve Block Gallery - Interscalene Block 80 y/o intoxicated female found down with L shoulder dislocation. In order to avoid opiates/sedatives, inter-scalene block was done to facilitate reduction. http://highlandultrasound.com/interscalene-block - for more on technique Dr. Forrest Andersen - Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1535251407429-3CHXLPQ4QH0ZQ5TBBCW8/median+nerve.gif Nerve Block Gallery - Median Nerve The median nerve is the most echogenic of the upper extremity nerves. It is also the only forearm nerve that that does not run alongside vessels, making it an easy and safe target for a nerve block. It is seen here as a hyperechoic, honeycomb appearing oval in the center of the screen. The probe is positioned in transverse orientation on the volar aspect of the forearm. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1535251429209-KORLS6GR6CZIXJZISX8H/radial+nerve.gif Nerve Block Gallery - Radial Nerve The radial nerve is the least echogenic of the upper extremity nerves, and can be difficult to visualize. It is located lateral (radial) to the radial artery. It is best seen by following the radial artery in transverse proximally up the arm; eventually a bright hyperechoic oval will be visible traveling away from the artery. (right arm seen here) Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1535251459912-VRQGPB91TSWGBA8QOF5L/ulnar+nerve.gif Nerve Block Gallery - Ulnar Nerve (Copy) The ulnar nerve is located medial (ulnar) to the ulnar artery. It is best seen by following the ulnar artery in transverse proximally up the arm; eventually a bright hyperechoic triangle will be visible traveling away from the artery. (left arm seen here) Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1535251472951-8GWOXELHX6BDV1M633IO/ulnar+nerve+and+artery.gif Nerve Block Gallery - Ulnar Nerve and Artery The ulnar artery with color doppler showing pulsatile flow, and the bright hyperechoic ulnar nerve visible to the left of the screen. Remember, the ulnar nerve is always “ulnar” to the ulnar artery. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1540914178036-2PKAHMG4TJ9OARU9WV0T/median+nerve+injection.gif Nerve Block Gallery - Median Nerve Injection 55 y/o female with recurrent carpal tunnel symptoms not improved with conservative management. Benefits of US guidance include vessel avoidance, and needle placement for surrounding median nerve with steroid solution. Dr. Magner https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598380445949-OYHTGQS42YKLF5QHHZWZ/radialNB.SM%3AKM.annotated.gif Nerve Block Gallery - Radial Nerve Block Radial Nerve Block Performed for wound exploration and laceration repair of a 1.5cm laceration located at the radial aspect of the forearm, proximal 4cm from the radial styloid. The nerve was identified as a heterogenous hyperechoic structure lateral to the radial artery and superficial to the radius. Located superior is the extensor carpi radialis longus and brevis muscle. Hydrodissection was performed in-plane using a 22-gauge needle with 5mL of 1% lidocaine without epinephrine. Submitted by Dr. Spencer Kim and Dr. Maurelus, Kings County Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1597698494840-WAFLB4EEXZP1Z4NRRP7X/shan%2Bbon%2Bruptured%2Bovarian%2Bcyst%2B4.gif Nerve Block Gallery - Radial Nerve Block write up Byline https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598381064373-URQ70VVGEOZKMYT1AKBL/posteriortibialnerveblock.final.gif Nerve Block Gallery - Posterior Tibial Nerve Block Posterior Tibial Nerve Block Foot and heel pain after missing a jump while skiing. XR showed calcaneal fracture. Pain not relieved by IV analgesics, posterior tibial nerve performed proximal to medial malleolus with complete resolution of pain. Nerve seen inferior to artery. Watch as fluid surrounds nerve. Use in-plane approach to avoid vasculature and avoid intraneural injection. Submitted by Dr. Miguel Agrait Gonzalez, University of Puerto Rico https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598381447616-PT6YC8HL3Q2YQZ5937S9/sciaticNB.JD%3AKM.annotated.gif Nerve Block Gallery - Popliteal Sciatic Nerve Block Popliteal Sciatic Nerve Block A 71 year old woman with dementia and mobility constraints presented with a gaping laceration over the posterior gastrocnemius extending inferiorly towards the achilles after a “fall from wheelchair”. Achilles tendon function was preserved and the wound was explored without foreign body. The patient did not tolerate initial attempts at laceration repair after local anesthesia due to pain and anxiety. A decision was made to perform a popliteal sciatic nerve block. The patient was placed in the prone position and 1% lidocaine without epi was drawn up in a syringe with extension tubing connected to a spinal needle under sterile conditions. A linear probe was used to identify the sciatic nerve just below the adductor magnus muscle. Lidocaine was injected 1 cm distal to the sciatic nerve’s bifurcation into the Common Peroneal N. and Tibial N. using the “in-plane” view. 20mL spread above, below and around the sciatic nerve sheath was sufficient to provide near-complete anesthesia and the patient tolerated the entire laceration repair. Submitted by Dr. Jordan Dow and Dr. Kelly Maurelus, Kings County Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1600212225273-3LMIHD7465IM1GCEU372/superficialcervicalplexus.gif Nerve Block Gallery - Superficial Cervical Plexus Block The superficial cervical plexus block pictured above was utilized in an elderly awake patient with dementia for the placement of an IJ CVC. Other indications include I&Ds of submandibular abscesses, lac repair to the ear lobe, and clavicular fractures. The block is best performed in-plane so as to directly visualize the dissection of the plane between the Sternocleidomastoid muscle (visualized superiorly) and the scalene muscles (visualized inferior to the needle insertion), and works by bathing several nerve branches at once. The area of anesthetic overlies the sternocleidomastoid muscle from the clavicle up to the preauricular space and oddly enough, includes the earlobe. Authored by Dr. Nicole Anthony and Dr. Kelly Maurelus, Kings County Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604347060957-GOI6BX4WTJ69QY5L19GG/image-asset.gif Nerve Block Gallery - Femoral Nerve Block Demonstration of an in-plane femoral nerve block, with needle seen entering from lateral to medial, depositing anesthetic in the space just lateral to the femoral nerve (*). This block was performed in a 50s year-old male patient with an intertrochanteric femur fracture, with successful analgesia until surgery was performed the next day. Drs. Kathleen Joseph, PGY-2 and Reid Haflich, PGY-4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604347681739-3S0X9F87W5ZQ3T51VMRJ/image-asset.gif Nerve Block Gallery - Radial Nerve Block at the Elbow Demonstration of an in-plane radial nerve block, with needle shown entering from the radial aspect, depositing anesthetic deep and radial to the radial nerve (*). Dr. Claudia Quenelle, PGY-3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604348788934-8IBH1850LGTTOBG6M778/image-asset.gif Nerve Block Gallery - Interscalene Brachial Plexus Block In-plane interscalene block, with needle entering from screen right (lateral and posterior), showing injection of anesthetic within the interscalene groove, surrounding the brachial plexus (*). The subclavian artery can be seen pulsating screen left (medial) to the brachial plexus. Denver Health Ultrasound Fellowship Archive https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604349275920-BP5RNKOX7FH622FZ1DL5/CommonPeronealNerve2.4.gif Nerve Block Gallery - Common Peroneal Block In-plane common peroneal nerve block at the level of the proximal fibula. The needle is seen first contacting the common peroneal nerve (*), then injecting anesthetic within the nerve perineurium. Denver Health Ultrasound Fellowship Archive https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604349588222-K9P5TOP1A3SRBUK16AJ8/image-asset.gif Nerve Block Gallery - Tibial Nerve Block In-plane tibial nerve block, with needle seen entering from screen right (posterior), with injection of anesthetic superficial to the tibial nerve (*). The posterior tibial artery can be seen pulsating screen left of (anterior to) the nerve. Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604348432397-AT9UCE0QYU7BMH0ILOF9/image-asset.gif Nerve Block Gallery - Common Peroneal Block In-plane common peroneal nerve block, with needle entering from the medial aspect. Sequential injection of anesthetic, eventually injecting superficial to common peroneal nerve (*). The proximal fibula cortex is visible at bottom of screen left. Denver Health Ultrasound Fellowship Archive https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604350213317-8VJG6RFOB3CP4Z2UYRYA/image-asset.gif Nerve Block Gallery - Ulnar Nerve Block 2 In-plane ulnar nerve block, with needle seen entering from screen right (ulnar aspect), with anesthetic sequentially deposited deep, lateral, then superficial to ulnar nerve (*). The ulnar artery can be seen pulsating to the left of (radially to) the ulnar nerve. Denver Health Ultrasound Fellowship Archive https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604350715644-SFYGMP8W6SOPA8CAAQTS/image-asset.gif Nerve Block Gallery - Ulnar Nerve Block 3 In-plane ulnar nerve block with needle entering from screen left (ulnar aspect). Demonstration of successful block with anesthetic located deep to ulnar nerve (*). The ulnar artery can be seen pulsating to screen right of (radial to) the nerve. Denver Health Ultrasound Fellowship Archive https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604351335943-9L17HL2Q5AAYKOJRW1AF/image-asset.gif Nerve Block Gallery - Median Nerve Block 1 In-plane median nerve block at the wrist, with needle seen entering from screen right, with anesthetic deposited adjacent to median nerve (*). Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604351764252-3OY95HYSM79ATMS152B3/image-asset.gif Nerve Block Gallery - Median Nerve Block 2 Out-of-plane median nerve block, with needle seen entering directly above median nerve, with anesthetic deposited superficial to median nerve (*). Denver Health Ultrasound Fellowship Archive https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604352031313-A4ERJINE8UKII2RZA1AY/image-asset.gif Nerve Block Gallery - Median Nerve Block 3 In-plane median nerve block, with needle seen entering from screen right (ulnar aspect), with anesthetic deposited deep to median nerve (*). the radial artery can be seen pulsating superficial to and screen left of (radial to) the nerve. Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604352223969-5A25X9UOMLI3ZC89C1ZB/image-asset.gif Nerve Block Gallery - Median Nerve Block 4 Out-of-plane median nerve block, with needle seen entering just above the nerve, with anesthetic deposited superficial to median nerve (*). Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604352373630-QF393HJFR3WO2ARUQLVM/image-asset.gif Nerve Block Gallery - Median Nerve Block 5 Out-of-plane median nerve block, with needle seen entering directly above the nerve and depositing anesthetic superficial to median nerve (*). The distal radius cortex can be seen at the lower left of the image (deep and radial to the nerve). Denver Health Ultrasound Fellowship Archive https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604352770885-TFUKEX80F3NOEHV51QCM/image-asset.gif Nerve Block Gallery - Ulnar Nerve Block 4 In-plane ulnar nerve block, with needle seen entering from screen right (radial aspect), with anesthetic deposited superficial to ulnar nerve (*). The ulnar artery can be seen pulsating screen right of (radial to) the nerve. Denver Health Ultrasound Fellowship Archive https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604353089601-K6QK6NBYOY75U9RQRXXH/image-asset.gif Nerve Block Gallery - Ulnar Nerve Block 5 In-plane ulnar nerve block with needle seen entering from the ulnar aspect, depositing anesthetic first in soft tissues, followed by injection adjacent to the ulnar nerve (*). The ulnar artery can be seen pulsating screen left (radial to) the nerve. Denver Health Ultrasound Fellowship Archive https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604353320833-HOESXWNBYUSE2E5L25H2/image-asset.gif Nerve Block Gallery - Ulnar Nerve Block 6 In-plane ulnar nerve block, with needle seen entering from screen right (ulnar aspect), with anesthetic deposited superficial/adjacent to ulnar nerve (*). The ulnar artery can be seen pulsating screen left of (radial to) the nerve. Denver Health Ultrasound Fellowship Archive https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604512164201-G6VVJCO6BQJNGBJKMAEC/image-asset.gif Nerve Block Gallery - Interscalene Anatomy Localization and view of the brachial plexus nerve roots (*) in the interscalene groove. The right of screen is anterior/medial and left of screen is lateral/posterior. The carotid artery (A) and internal jugular vein (V) can be seen anterior and medially to the brachial plexus. Dr. Nick Aunchman University of Vermont Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604512535954-87UYN2NTR26NU7M2RA10/image-asset.gif Nerve Block Gallery - Ulnar Nerve Block 7 In-plane ulnar nerve block with needle entering from ulnar aspect, with anesthetic surrounding ulnar nerve. the ulnar artery (A) can be seen pulsating radially to the nerve. Dr. Peter Weimersheimer University of Vermont Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605665047706-0GS9Z718BYIBOQ90G5KV/image-asset.gif Nerve Block Gallery - Fascia Iliaca "74 male presenting with mechanical fall down twelve steps complaining primarily of severe right hip pain. X-ray demonstrating comminuted subcapital femoral neck fracture with significant angulation. In agreement with orthopedic recommendations an ultrasound-guided fascia iliaca nerve block was performed with 40cc of bupivacaine 0.25% with successful analgesia. Transverse views of the right femoral artery and vein are first identified (not shown), then translocated laterally to identify the fascia iliaca plane. Sartorius and iliacus muscles are seen above and below, respectively. An ultrasound-guided longitudinal view was utilized to introduce the needle immediately below the fascia iliaca plane and administer anesthetic." Authored by Dr. Chris Lim, Kings County Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605812961577-ZM5ZO830LPS0WPE1OJB4/image-asset.gif Nerve Block Gallery - Serratus Anterior Plane Block 80s F presented with a mechanical fall, found to have multiple rib fractures and subsequent poor incentive spirometry. An in-plane serratus anterior plane block was performed on the affected side using the linear transducer in a transverse plane orientation at the level of the 4th/5th rib at the mid axillary line. Local anesthetic can be seen spreading in the fascial plane between serratus anterior (deep) and latissimus dorsi (superficial) muscles. The lung pleura can be seen sliding below serratus anterior. The patient reported relief soon after the block. Dr. Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605813338599-5B9OKMN0BRHMCS5H2U8F/image-asset.gif Nerve Block Gallery - Radial Nerve Block at the Elbow 50s M with PMH IVDU presented with a dorsal hand abscess. To facilitate I&D, a radial nerve block was performed at the level of the elbow using the linear transducer and an in-plane approach. Injection of anesthetic seen adjacent to the radial nerve (*). The hyperechoic distal humeral cortex can be seen at the right of the image. Shortly after the block, I&D was able to be performed at bedside. Dr. Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605813611056-3C48RBENZH2B79TOYUIJ/image-asset.gif Nerve Block Gallery - Axillary Brachial Plexus Anatomy Demonstration of the axillary brachial plexus as seen in transverse view with the linear transducer at the level of the proximal humerus. The brachial plexus (*) can be seen medial to the pulsating axillary artery. The musculocutaneous nerve (^) can be seen lateral to the artery/brachial plexus, deep to the biceps muscle and superficial to the coracobrachialis muscle. Drs. Sam Paskin-Flerlage, PGY4 and Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605814141480-19B44LF6ZL3HHOUBUFBE/image-asset.gif Nerve Block Gallery - Infraclavicular Brachial Plexus Anatomy Demonstration of the anatomy of the infraclavicular brachial plexus with the linear transducer in a parasagittal orientation just lateral to the mid-clavicular line. The pulsating subclavian artery can be seen surrounded by the brachial plexus (*). The hyperechoic clavicle is seen in short axis at the right of the image. Sliding pleura can be seen deep to the artery/brachial plexus. Drs. Sam Paskin-Flerlage, PGY4 and Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605814442512-MWTPX4LL517EQAE7EKKW/image-asset.gif Nerve Block Gallery - Interscalene Brachial Plexus Anatomy Demonstration of the anatomy of the brachial plexus in the interscalene groove. The C5-7 nerve roots (*) can be seen between the anterior and middle scalene muscles at the right (lateral/posterior) aspect of the image. The posterior edge of the sternocleidomastoid muscle is seen superficial and left of the image. Drs. Sam Paskin-Flerlage, PGY4 and Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605814800512-V3UTJ0LXBTV9AK2OANK5/image-asset.gif Nerve Block Gallery - Common Peroneal Nerve Anatomy Demonstration of the anatomy of the common peroneal nerve at the level of the proximal fibula. This image was obtained with the linear transducer placed in a transverse orientation on the lateral aspect of the fibular head. The nerve (*) is seen just superficial to the hyperechoic fibular cortex. Drs. Sam Paskin-Flerlage, PGY4 and Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605815130764-U9K80VUZPRTGKMBSD570/image-asset.gif Nerve Block Gallery - Sciatic Nerve Anatomy Anatomy of the sciatic nerve in the popliteal fossa. This image was obtained using the linear transducer in a transverse orientation in the popliteal fossa. The sciatic nerve (*) can be seen superficial to the pulsating popliteal artery, just superficial to the partially compressed popliteal vein. The hyperechoic femoral condylar cortex can be seen at the left of the image. Drs. Sam Paskin-Flerlage, PGY4 and Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605815454397-1XUDG17GGLRNTNTPR2W9/image-asset.gif Nerve Block Gallery - Tibial Nerve Anatomy Anatomy of the tibial nerve as it passes posterior of the medial malleolus. The image was obtained using the linear transducer in a transverse orientation just posterior to the medial malleolus. The nerve (*) is seen posterior to (right of) the pulsating posterior tibial artery. Also seen is the hyperechoic malleolar cortex of the distal tibia at the bottom of the image, as well as the tendons of tibialis posterior and flexor digitorum longus anterior to (left of) the artery and nerve. Drs. Sam Paskin-Flerlage, PGY4 and Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605815952957-DFQAOMVN5P97IFHIP7SM/image-asset.gif Nerve Block Gallery - Serratus Anterior Anatomy Anatomy of the serratus anterior, as obtained using a linear transducer in a transverse orientation at the level of the 4th/5th rib in the mid axillary line. Anterior is at the left of the image. The latissimus dorsi muscle is seen most superficially, with the serratus anterior muscle deep to it, just above the hyperechoic ribs. Sliding pleura can be seen below the ribs. The thoracodorsal artery can be seen pulsating in the fascial plane between latissimus dorsi and serratus anterior. Drs. Sam Paskin-Flerlage, PGY4 and Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605816438963-MCHHR8HBK9NVTL1M9CXH/image-asset.gif Nerve Block Gallery - Superficial Cervical Plexus Anatomy Demonstration of the anatomy of the superficial cervical plexus. The posterior border of the sternocleidomastoid muscle is seen at the center left of screen, and the target fascial plane for a superficial cervical plexus nerve block is highlighted (*). The pulsating carotid artery is seen at the anterior aspect of the image. Drs. Sam Paskin-Flerlage, PGY4 and Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605816717872-6GJM6BMTQW1FWZKR5MDP/image-asset.gif Nerve Block Gallery - Supraclavicular Brachial Plexus Anatomy Anatomy of the supraclavicular brachial plexus. This image was obtained with the linear transducer in a parasagittal orientation just lateral to the neck. Left of image is anterior in this view. The brachial plexus (*) is seen just posterior to the pulsating subclavian artery. The hyperechoic first rib can be seen just below the artery and brachial plexus. Drs. Sam Paskin-Flerlage, PGY4 and Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605817087318-YG9HOPG09QEACK1M5P9V/image-asset.gif Nerve Block Gallery - Thoracic Vertebral Anatomy Anatomy of a thoracic vertebra as seen in transverse view, using the linear transducer. The spinous process (SP) is seen most superficially and in the midline, with the lamina (L) seen connecting the spinous process to the transverse process (TP) laterally. Sliding pleura can also be seen lateral and deep to the transverse process. Drs. Sam Paskin-Flerlage, PGY4 and Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605817449147-ABT2WXL48ZXP1A6SQ6GJ/image-asset.gif Nerve Block Gallery - Serratus Anterior Plane Block 2 60s F presented to the ED three days after a fall at home, complaining of right chest pain, and was found to have multiple rib fractures on CT with a small amount of hemothorax and blood in the horizontal fissure. A serratus anterior plane block was performed using an in-plane approach to inject anesthetic in the fascial plane between the pectoralis minor (PM) and serratus anterior (SA) muscles. Fluid can be seen in the pleural space beneath serratus anterior. 30 minutes after the nerve block, the patient was feeling much improved, her performance on incentive spirometry improved markedly, and she requested discharge. Dr. Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605817923946-KAI2E227MTDXOWA0GKGB/image-asset.gif Nerve Block Gallery - Sub-Serratus Anterior Plane Block 60s F presented to the ED three days after a fall at home, complaining of right chest pain, and was found to have multiple rib fractures on CT with a small amount of hemothorax and blood in the horizontal fissure. A serratus anterior plane block was performed using an in-plane approach to inject anesthetic in the fascial plane between the pectoralis minor and serratus anterior muscles (not shown), followed by this injection into the fascial space between the rib and serratus anterior. Additionally, fluid (likely blood) can be seen here in the pleural space below the rib. 30 minutes after the nerve block, the patient was feeling much improved, her performance on incentive spirometry improved markedly, and she requested discharge. Dr. Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605818234594-SX57AFP7EQJSNI63J8BQ/image-asset.gif Nerve Block Gallery - Erector Spinae Anatomy Scan Dynamic view of the anatomy of the erector spinae block. This view is obtained using the linear transducer in a sagittal orientation. The clip starts in the midline, and a pinpoint hyperechoic thoracic spinous process is briefly seen. As the probe is swept laterally, broad hyperechoic transverse processes are seen, with the erector spinae muscles just superficial to these. Further laterally, the transverse processes disappear and broad hyperechoic ribs come into view, with sliding pleura visible underneath. Notice the lack of visible pleura when transverse processes are in view. The erector spinae block is performed in the plane viewing transverse processes, without ribs/pleura visible. Drs. Sam Paskin-Flerlage, PGY4 and Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607716563053-MYA8FI0JSPG4WNB9VN6E/image-asset.gif Nerve Block Gallery - Neonatal Fascia Iliaca Block A 50 day-old male was transferred from an outside hospital with concern for NAT after skeletal survey showed old rib fractures, and a significantly displaced and angulated femoral midshaft fracture. A ultrasound-guided fascia iliaca block was performed to aid with passive reduction while in a Pavlik harness. Anesthetic spread can be seen along the fascial plane just superior to the femoral nerve (*). The pulsating femoral artery is seen medial (left of screen) to the nerve. The patient had pain relief with the block, and follow up radiographs showed better reduction after being in the harness without manual manipulation. Dr. Michael Heffler, PGY3, Denver Health Residency in Emergency Medicine Dr. Emily Greenwald, 3rd year PEM fellow, Children’s Hospital Colorado Dr. Megan Mickley, PEM Attending Physician, co-director Pediatric Emergency Ultrasound, Children’s Hospital Colorado https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1610755687362-K9AEAI98QLD7LUFA81KK/image-asset.gif Nerve Block Gallery - Superficial Cervical Plexus Block 40s F presented to the ED with left shoulder pain after a fall out of bed 1 day prior to arrival. She was found to have a closed, displaced and comminuted fracture of the distal clavicle, which was managed non-operatively with a sling. A superficial cervical plexus nerve block was performed for analgesia. This clip shows the block being performed with an in-plane technique, with the needle entering posteriorly/laterally (screen right), to instill local anesthetic along the fascial plane (*) just deep to the sternocleidomastoid muscle. The carotid artery can be seen pulsating medially (left of screen). The patient had significant improvement of her pain after the block, and was discharged. Drs. Anna Engeln and Matt Riscinti Denver Health Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579126308247-APSFIQMTVC7YLNNIHD1M/image-asset.gif Nerve Block Gallery - Radial Nerve Block Notice here in a still-shot of a radial nerve block, you can visually appreciate the infiltration of local anesthetic as evidenced by the hypoechoic area surrounding the radial nerve. Aaron Inouye, PA-C North Canyon Medical Center @PAintheED https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1573161730082-NMG81LPMUQWPX6Z3HV6T/interscalene+denver+em+-+forrest+.gif Nerve Block Gallery - Interscalene Block - High Speed 80 y/o intoxicated female found down with L shoulder dislocation. In order to avoid opiates/sedatives, inter-scalene block was done to facilitate reduction. http://highlandultrasound.com/interscalene-block - for more on technique Dr. Forrest Andersen - Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1573158441252-HV95XZCYF29JDUQZTY1N/interscalene+denver+em+-+forrest+.gif Nerve Block Gallery - Interscalene Block 80 y/o intoxicated female found down with L shoulder dislocation. In order to avoid opiates/sedatives, inter-scalene block was done to facilitate reduction. http://highlandultrasound.com/interscalene-block - for more on technique Dr. Forrest Andersen - Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507758336200-4A394U210XO7Z6309QJD/median+nerve+block.gif Nerve Block Gallery - Median Nerve Block 15 y/o M "fell into a mirror," landing on his hand and suffering multiple, complicated lacerations at the base of his second digit with the tendon showing. Instead of injecting local anesthesia throughout, a simple median nerve block was done under POCUS guidance. In plane technique. One stick. One happy patient. Matthew Riscinti, MD - Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1540914178036-2PKAHMG4TJ9OARU9WV0T/median+nerve+injection.gif Nerve Block Gallery - Median Nerve Injection 55 y/o female with recurrent carpal tunnel symptoms not improved with conservative management. Benefits of US guidance include vessel avoidance, and needle placement for surrounding median nerve with steroid solution. Dr. Magner https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1612810928085-W9NOZBSHVYTESEP8W5A7/image-asset.gif Nerve Block Gallery - Radial Nerve Block at the Elbow 2 20s F presented with large complex laceration to the distal forearm after an assault. Ultrasound radial and median nerve blocks were performed at the elbow to facilitate washout and closure. This clip illustrates the radial nerve block, where the needle is entering from the posterolateral aspect of the upper arm, and anesthetic can be seen surrounding the radial nerve (*). Dr. Gabe Siegel Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1612811267006-1YOOIHBMIX44TDEWB8VZ/image-asset.gif Nerve Block Gallery - Median Nerve Block at the Elbow 20s F presented with large complex laceration to the distal forearm after an assault. Ultrasound radial and median nerve blocks were performed at the elbow to facilitate washout and closure. This clip illustrates the median nerve block, where the needle is entering from the lateral/radial aspect of the upper arm, and anesthetic can be seen adjacent to the median nerve (*). Dr. Gabe Siegel Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613328234886-KVEM2RJFCV8W71M2S9L9/image-asset.gif Nerve Block Gallery - Popliteal Sciatic Nerve Block 30s M presented to the ED with a large anterior shin wound after being struck by a car. A popliteal sciatic nerve block was performed for analgesia with good effect, and the patient was able to have his wound irrigated and repaired. In this clip, the sciatic nerve (*) is first seen superficial to the pulsating popliteal artery, and then anesthetic can be seen being injected within the sciatic nerve sheath (Vloka’s sheath). Dr. Sabrina Kaplan, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613965236487-0GHIL3FDXZABPTDC4FWM/image-asset.gif Nerve Block Gallery - Fascia Iliaca Nerve Block An elderly female with multiple medical comorbidities presented to the ED with hip and thigh pain after a fall at home. Imaging demonstrated an intertrochanteric proximal femur fracture, and, after consultation with Orthopedic Surgery and detailed documentation of the patient’s neurovascular exam, a fascia iliaca nerve block was performed. This clip demonstrates the block, where the needle can be seen entering from the left of screen (laterally) along the trajectory outlined by the yellow diagonal, and anesthetic can be seen infusing just deep to the fascia iliaca and superomedially to the iliacus muscle. The pulsating femoral artery is seen medial to the site of injection. After the nerve block, the patient’s pain was improved and she was admitted for surgical fixation the next morning. Dr. Arian Anderson, PGY-4 and Dr. Michael Heffler, PGY-3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614352734963-SOFMPJ0TAXIL3FOK21RD/image-asset.gif Nerve Block Gallery - Fascia Iliaca Block 2 A 60s F presented to the ED with hip/leg pain after a mechanical slip and fall. She had an obvious closed deformity of the proximal femur on exam, and radiographs demonstrated an intertrochanteric femur fracture with subtrochanteric extension. After consultation with orthopedic surgery, a fascia iliaca block was performed to provide analgesia and to facilitate traction radiographs, and she was admitted for surgery. This clip shows the block being performed, with the needle entering from left of screen (laterally), depositing anesthetic just deep to the fascia iliaca, superficial to the iliacus muscle. The femoral artery and vein can be seen to the right (medial) of the area of injection. Dr. Arian Anderson, PGY4, and Dr. Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1615258832307-ESH5ELVBUQP5PA46EBPV/image-asset.gif Nerve Block Gallery - Fascia Iliaca Nerve Block for Femur Fracture A 20s F was brought in by ambulance after she was struck by a vehicle. She had an obvious closed deformity to her thigh. Initial trauma workup was negative for other injuries, she remained awake/alert and hemodynamically stable, and was neurovascularly intact distally. After orthopedic consultation, a fascia iliaca nerve block was performed for analgesia in preparation for distal femur traction pin placement. The needle here enters from left of screen (lateral), injecting anesthetic just deep to the fascia iliaca, and spreading adjacent to the femoral nerve, which is seen to the left of (lateral to) the pulsating femoral artery. The patient had improvement of her pain, traction pinning was performed, and she was admitted for surgery. Dr. Arian Anderson, PGY4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1615259251343-F6ZZP5AUJ4XAZFP48TPH/image-asset.gif Nerve Block Gallery - Fascia Iliaca Nerve Block Anatomy This clip shows the normal anatomy seen during a fascia iliaca nerve block. The image is obtained using a linear transducer in a transverse orientation over the middle to lateral third of the inguinal ligament. The probe marker is to the lateral aspect of the patient. The femoral nerve (N) is seen lateral to the femoral artery (A), and the sartorius muscle (S) is seen superficial to the iliacus muscle (I), with the fascia iliaca in between the two muscles. The target site for injection is just deep to the fascia iliaca, at a point lateral to the femoral nerve (*). Anesthetic should be visualized tracking medially toward the femoral nerve. Dr. Arian Anderson, PGY4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1535251459912-VRQGPB91TSWGBA8QOF5L/ulnar+nerve.gif Nerve Block Gallery - Ulnar Nerve The ulnar nerve is located medial (ulnar) to the ulnar artery. It is best seen by following the ulnar artery in transverse proximally up the arm; eventually a bright hyperechoic triangle will be visible traveling away from the artery. (left arm seen here) Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1535251472951-8GWOXELHX6BDV1M633IO/ulnar+nerve+and+artery.gif Nerve Block Gallery - Ulnar Nerve and Artery The ulnar artery with color doppler showing pulsatile flow, and the bright hyperechoic ulnar nerve visible to the left of the screen. Remember, the ulnar nerve is always “ulnar” to the ulnar artery. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1535251407429-3CHXLPQ4QH0ZQ5TBBCW8/median+nerve.gif Nerve Block Gallery - Median Nerve The median nerve is the most echogenic of the upper extremity nerves. It is also the only forearm nerve that that does not run alongside vessels, making it an easy and safe target for a nerve block. It is seen here as a hyperechoic, honeycomb appearing oval in the center of the screen. The probe is positioned in transverse orientation on the volar aspect of the forearm. Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1535251429209-KORLS6GR6CZIXJZISX8H/radial+nerve.gif Nerve Block Gallery - Radial Nerve The radial nerve is the least echogenic of the upper extremity nerves, and can be difficult to visualize. It is located lateral (radial) to the radial artery. It is best seen by following the radial artery in transverse proximally up the arm; eventually a bright hyperechoic oval will be visible traveling away from the artery. (right arm seen here) Hannah Kopinksi and Dr. Lindsay Davis - NYU Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616882436200-54BZC219LJHNWYWD6HYC/image-asset.gif Nerve Block Gallery - Pediatric Fascia Iliaca Nerve Block A teenage female patient arrived to the ED via EMS after she was truck by a car, sustaining multiple serious injuries, including a midshaft femur fracture which was significantly displaced. She required multiple rounds of IV analgesics, so a fascia iliaca block was performed to augment pain control. Shown here, the needle is seen entering from the lateral aspect through the iliacus muscle, injecting anesthetic just deep to the fascia iliaca. The femoral artery and vein are seen medial to this at the left of the image. The patient had improvement in pain level, and was able to be admitted to the ICU for further care. Dr. Kate Simeon, PGY1, and Dr. Nik Matsler, PGY4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1615339482639-A3M121C677CKXQ81FRWR/Radial+Elbow+Probe.jpeg Nerve Block Gallery - Radial Nerve Probe Location https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1615395081431-T175SSQ9A0UVM5INOTO9/Radial+Probe.jpg Nerve Block Gallery - Radial Nerve Probe Location https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1617338055070-COTT8I9722T5M15SLUGM/image-asset.gif Nerve Block Gallery - Interscalene Nerve Block 20s M with PMH recurrent shoulder dislocation presented with shoulder pain and concern for dislocation. Radiographs confirmed anterior glenohumeral dislocation and showed a Hill-Sachs deformity. An interscalene brachial plexus block was performed for analgesia. The block is shown here, with the needle entering from the lateral aspect or left of screen, injecting anesthetic adjacent to the nerve roots (*) within the interscalene groove. The patient had good pain control with the block, allowing easy bedside reduction without additional parenteral medications or conscious sedation. Repeat radiographs confirmed adequate reduction of the dislocation and the patient was discharged with orthopedic follow up. Dr. Molly Thiessen Denver Health Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1617815270186-5UBIXHYKGZTPV1O99VM9/image-asset.gif Nerve Block Gallery - Serratus Anterior Plane Block for Chest Tube Placement 20s F presented with chest pain after a trigger point injection to the back at a chiropractic appointment, found to have a large pneumothorax. To facilitate analgesia for chest tube placement, a serratus anterior plane block was performed under ultrasound guidance. Seen here, the needle is entering from the posterior aspect, and deposits anesthetic in the plane between serratus anterior and latissimus dorsi. The patient had improved pain and was able to have a tube thoracostomy performed, and she was admitted for further observation. Dr. Mark Serpico, PGY3 and Dr. Molly Thiessen, Ultrasound Fellowship Director Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620833583531-X3LQRQRHAQY6E3SXYK5N/image-asset.gif Nerve Block Gallery - Interscalene Nerve Root Anatomy 30s M presented with shoulder dislocation. To facilitate reduction, an interscalene nerve block was performed. This clip demonstrates the brachial plexus nerve roots (*) as seen just outside of the interscalene groove - the middle scalene muscle is seen just deep to the nerve roots, with the sternocleidomastoid muscle seen superficial to these. The patient had onset of anesthesia after the block and was able to have closed reduction performed in the ED. Dr. Olivia Serigano, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623256555878-5V1VC4DG6J2IF9NE9UNX/image-asset.gif Nerve Block Gallery - Superficial Cervical Plexus Block for Clavicle Fracture 30s M presented with clavicle pain after fall on bike, noted to have obvious deformity to L clavicle, and to be closed and neurovascularly intact. Radiographs confirmed a distal third clavicle fracture, and nonoperative management was recommended by orthopedic surgery. To augment pain control, a superficial cervical plexus block was performed. In these images, the needle is seen entering from the posterior aspect (left of screen), depositing anesthetic in the plane just deep to the sternocleidomastoid muscle (*). The patient had improvement of pain and was discharged with outpatient orthopedic follow up. Dr. Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623560609599-VVVH4FALYI5DQY39T39Q/AE+Popliteal+Sciatic.gif Nerve Block Gallery - Popliteal Sciatic Nerve Block 30s M presented with foot pain after an accidental injury from a lawn mower blade. Found to have a large laceration and open metatarsal fracture. A popliteal sciatic nerve block was performed for pain control overnight while the patient awaited surgery the next morning. The block is shown here, with the needle entering from the lateral aspect (right of screen), injecting anesthetic adjacent to the sciatic nerve (*) in the popliteal fossa. The patient had improved pain control and was admitted for surgery. Megan Foy, MS4, University of Colorado School of Medicine Dr. Adam Esch, PGY4, Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623561709827-0J0TOXPQKTR5T41IUNUJ/image-asset.gif Nerve Block Gallery - Fascia Iliaca Block for Distal Femur Fracture 70s F presented with lower extremity pain after a mechanical trip and fall on the stairs. She arrived with a closed deformity of the distal thigh, and radiographs confirmed a comminuted distal femur fracture. A fascia iliaca block was performed for analgesia and to facilitate traction pinning. The block is shown here, with the needle entering from the lateral aspect (screen right) and depositing anesthetic just deep to the fascia iliaca (*) which lies deep to the sartorius muscle and superficial to the iliacus muscle. The patient had significant relief soon after the block and was able to be admitted for surgery. Dr. Michael Heffler, PGY3, Dr. Spencer Tomberg, Attending Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1624062737903-S0U9K07W5ADNGA3DW9OQ/MH+Interscalene+Anatomy.gif Nerve Block Gallery - Interscalene Anatomy This clip demonstrates the anatomy of the brachial plexus in the interscalene groove. The anterior scalene (AS) and middle scalene (MS) muscles are seen, with the brachial plexus nerve roots (*) seen in the interscalene groove. Color doppler is used to highlight the carotid artery (red) and internal jugular vein (blue) which lie medial/anterior to the brachial plexus. Color doppler is also useful to verify that the brachial plexus nerve roots are not lying deep to other blood vessels. Dr. Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623562179073-ONWZGY61V0HT055NOQBF/DF+FICNB.gif Nerve Block Gallery - Fascia Iliaca Block for Subtrochanteric Femur Fracture 90s F presented with lower extremity pain after mechanical trip and fall at home. Radiographs demonstrated a subtrochanteric femur fracture. The patient had significant pain after arrival and so a fascia iliaca block was performed. The block is shown here, with the needle entering from the lateral aspect (screen left), depositing anesthetic in the fascia iliaca plane, just deep to the sartorius muscle (*). The patient had improvement of her pain rapidly after the block and was admitted for surgery. Dr. Daniel Fuchs, PGY2 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1624062932379-OUS83W2HEN7HBEHA84Q5/image-asset.gif Nerve Block Gallery - Interscalene 30s M with past medical history of recurrent shoulder dislocations who had failed prior surgery presented with anterior shoulder dislocation. An interscalene nerve block was performed for analgesia to facilitate reduction. After confirmation and documentation of intact neurovascular exam, the nerve block was performed as shown. The needle is seen entering from the posterior aspect (left of screen), and is instilling local anesthetic which surrounds the brachial plexus (*). The patient had significantly improved pain after the nerve block but ultimately did require further sedation to overcome muscle spasm in order to facilitate successful reduction. Dr. Michael Heffler, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626365602966-E749SXQ1BLKRBW1GB4QK/image-asset.gif Nerve Block Gallery - Posterior Tibial Nerve Block A 20s y/o patient presented after a laceration to the plantar surface of the foot from glass. After exclusion of retained foreign body by XR and physical exam, the laceration was irrigated and repaired using local infiltration of anesthesia, and the patient was discharged. The patient re-presented to the ED within a few hours with continued pain. The laceration repair was intact, and a posterior tibial nerve block was performed for analgesia. This clip shows the nerve block being performed. The linear probe was placed in a transverse plane, just posterior to the medial malleolus, over the “tarsal tunnel.” The left of this image is anterior, and the right is posterior. The needle (^) can be seen entering from the posterior aspect, infiltrating anesthetic around the tibial nerve (*). The pulsating posterior tibial artery is seen anterior to the nerve. The anatomy of the tarsal tunnel can be recalled by the mnemonic “Tom, Dick, And Very Nervous Harry,” which lists the structures in order of anterior to posterior (tibialis posterior tendon, flexor digitorum longus tendon, posterior tibial artery, posterior tibial vein, tibial nerve, flexor hallucis longus tendon), however the tendons and posterior tibial vein are less well seen in this clip. Dr. James Sutton, PGY-3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626832516307-9S39NNLDYEM48MLYKFOL/image-asset.gif Nerve Block Gallery - Interscalene Brachial Plexus Nerve Block 20s M with history of recurrent shoulder dislocation presented with shoulder pain and suspected dislocation. He was found to be neurovascularly intact, and after confirmation of dislocation with POCUS and XR, an interscalene nerve block was performed to facilitate reduction. The block is shown here, where the needle is seen entering from the posterior/lateral aspect at the left of screen, injecting anesthetic between the middle and anterior scalene muscles, adjacent to the brachial plexus nerve roots (*). The patient had relief of pain within minutes and was able to be reduced at the bedside without complication. Dr. Ian Eisenhauer, PGY-1 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628029366991-T7NFM1A8CHII1YMPWFUO/Superficial+Cervical+Plexus+Probe.jpg Nerve Block Gallery - Superficial Cervical Plexus Probe Placement https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628449405622-4RMSATUXPJW3CCK7M5GU/image-asset.jpeg Nerve Block Gallery - Erector Spinae Anterior Area https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628449435338-89HZKLUYUEU1JMLBJ7FU/image-asset.jpeg Nerve Block Gallery - Erector Spinae Posterior Area https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628451056199-01DR46L9QAK9RF0T9Z7O/image-asset.jpeg Nerve Block Gallery - Ulnar Probe Position at Elbow https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630176796854-MPARQTAE3ZS01LVUK7EH/image-asset.gif Nerve Block Gallery - Supraclavicular Nerve Block Anatomy This is an ultrasound clip demonstrating the anatomy for a supraclavicular nerve block. The probe is placed parallel to and just superior to the clavicle. The subclavian artery can be seen pulsating in the middle of the screen just superior to the hyperechoic cortex of the first rib. The * denotes the large brachial plexus bundle which can be seen just lateral to the artery. Pleural sliding can also be appreciated on both sides of the rib. Michael Macias https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630183925091-RAQ0SPFHREJUM3R26Y18/image-asset.gif Nerve Block Gallery - Infraclavicular Brachial Plexus Block Anatomy This is an ultrasound clip demonstrating the anatomy for an infraclavicular block. The probe is placed in a parasagittal orientation just medial to the coracoid process and inferior to the clavicle. The axillary artery can be seen pulsating in the middle of the screen. The * denotes the three cords of the the brachial plexus at this location (lateral, medial, and posterior). Two muscles layers can be seen at the top of the screen, pec major and the underlying pec minor. Michael Macias https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630521095637-F0QYNCTIFMR55TYSWEYF/image-asset.gif Nerve Block Gallery - Posterior Tibial Nerve Block for Heel Wounds 30s M presented with foot pain after his foot was run over by a car while he was riding a moped. He had lacerations over the plantar aspect of his foot without underlying fracture on XR. To facilitate wound irrigation and dressing, a posterior tibial nerve block was performed. The block is shown here, with the medial malleolus just out of view to the right of the image. The needle approaches in plane from the posterior aspect, and deposits anesthetic adjacent to the posterior tibial nerve (*). The posterior tibial artery is seen pulsating just anterior (right of screen) to the nerve. The patient had anesthesia achieved and his wounds were able to be irrigated and dressed. Dr. Carleigh Benton, PGY-4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630689524357-QZ782LXSR0TAZY7Y13HV/image-asset.jpeg Nerve Block Gallery - Supraclavicular Probe Placement https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630689580172-BIWZE7CNQRKLGQ7PSU3W/image-asset.jpeg Nerve Block Gallery - Infraclavicular Probe Placement https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632504394930-K8VPSYXK9UU5AOIKKXYZ/ezgif.com-gif-maker+%2872%29.gif Nerve Block Gallery - Supraclavicular Nerve Block In plane supraclavicular nerve block used for pain management in a patient with a mid shaft humerus fracture. Spread of anesthetic can be seen around the brachial plexus bundle (*). Michael Macias https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1637775850153-O0Y50PZ954BLPFPMCKIO/image-asset.gif Nerve Block Gallery - Erector Spinae Plane Block 60s M presented after bicycle crash, and was found to have multiple unilateral rib fractures. To aid with pain control, an erector spinae plane block was placed using bupivacaine. The block is shown here, with the needle approaching in plane from the right of the screen (inferior). The first few seconds of the clip show the anatomy from lateral to medial, with the posterior rib with associated pleura seen, before the more medial transverse process is seen, without associated pleura. The target of anesthetic spread is the fascial plane (*) between the transverse process and the overlying erector spinae muscle. The second half of the clip shows administration of anesthetic with spread visible along the target fascial plane. Dr. Matthew Riscinti, Fellowship Director Denver Health Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638075361249-D0UZGL9YEAAQ3URZOG8E/image-asset.gif Nerve Block Gallery - Sub-Serratus Anterior Plane Block for GSW 20s M presented after GSW to the chest, and sustained a hemothorax requiring non-emergent chest tube placement. To augment pain control, a serratus anterior plane block was performed with bupivacaine. The block is shown here, with infiltration of the hypoechoic anesthetic deep to the serratus anterior muscle, just above the rib and intercostal muscles. Anesthetic could alternatively be placed in the fascial plane between serratus anterior and latissimus dorsi, which is the fascial plane seen superficial to the anesthetic in this clip. This patient was able to have a chest tube placed with adequate analgesia and without complication and was admitted for further management of his GSW. Dr. Olivia Serigano, PGY4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638075602043-OOJRQ7U0H3FPEVSF6LWX/image-asset.gif Nerve Block Gallery - Supraclavicular Brachial Plexus Block 40s M presented with shoulder pain after a fall at work, and radiographs confirmed a proximal humerus fracture. As the patient was neurovascularly intact and had a closed fracture, conservative management in a sling was planned by orthopedic surgery. To augment pain control, a supraclavicular brachial plexus block was performed using bupivacaine and dexamethasone. The block is shown here, with color doppler first used to identify the carotid artery and confirm the absence of vascular flow in the region of the brachial plexus. The supraclavicular brachial plexus is seen at the center right of the image, just lateral and adjacent to the pulsating carotid artery with color flow. The first rib is seen just deep to the artery and plexus, providing a physical backstop to avoid inadvertent pneumothorax. An in-plane technique was used to advance the needle and anesthetic was deposited just superficial to the brachial plexus. The patient had improvement of his pain and was able to be discharged with outpatient orthopedic follow up. Dr. Lindsay Howe, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638076047497-GCV53HWW87HYJNUB8ER1/image-asset.gif Nerve Block Gallery - Serratus Anterior Plane Block for PTX 20s M presented with acute onset atraumatic chest pain, and was found to have a large spontaneous pneumothorax on chest radiography. To augment pain control for chest tube placement, a serratus anterior plane block was placed using 20 mL of 0.5% bupivacaine and 20 mL of 1% lidocaine. The block is shown here, where the needle is seen in-plane instilling anesthetic in the plane between latissimus dorsi superficially and serratus anterior deeply. The anechoic pocket of anesthetic is seen to spread between the two muscles and dissipates quickly after injection is paused, indicating successful placement. This patient had adequate pain control and was able to have a pigtail chest tube placed and was admitted to the hospital. Dr. Matthew Riscinti, Fellowship Director Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638419230652-SLEB8HMNQG6DXNHF69HV/image-asset.gif Nerve Block Gallery - Supraclavicular Nerve Block 60s F presented with arm pain after a fall out of a wheelchair, and was found to have a proximal humerus fracture. A supraclavicular brachial plexus block was placed for analgesia. The brachial plexus is seen here, lateral to the pulsating subclavian artery, superficial to the first rib. The block is shown with the needle entering from the lateral aspect, depositing anesthetic adjacent to the brachial plexus just superficial to the first rib, which acts as a physical backstop, helping reduce the risk of inadvertent pneumothorax. Pleural slide is seen deep to the first rib lateral and medial , highlighting the proximity and underscoring the importance of keeping the entire needle in view during the entire nerve block procedure. This patient had improvement in their pain and was able to be discharged home. Dr. Greg Wiener, PGY4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1639070108183-8LXKDKV9WVGBPKHT0UJA/image-asset.gif Nerve Block Gallery - Supraclavicular Brachial Plexus Anatomy Anatomy for a supraclavicular brachial plexus block. Tom Jelic @tomjelic https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1639070462239-HJTQE130OZ2D270KL672/image-asset.gif Nerve Block Gallery - Lateral femoral cutaneous nerve block Lateral femoral cutaneous nerve block. Clip attached is one of the actual block being performed for a male patient with a large vertical laceration along the lateral aspect of the proximal thigh. Tom Jelic @tomjelic https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1639874174630-O1W5VZX9CG6PUSWBVGHD/image-asset.gif Nerve Block Gallery - Fascia Iliaca Compartment Block A 60s M presented with hip pain after a fall while skiing. He had a visible closed leg deformity but was neurovascularly intact. Radiographs confirmed a femoral neck fracture. A fascia iliaca compartment block was performed for analgesia and to facilitate orthopedic evaluation. The first part of this clip shows the anatomy of the fascia iliaca, with the femoral artery (A), femoral vein (V), and femoral nerve (*) superficial and medial to the iliacus muscle (I). The fascia iliaca (^) overlies the iliacus muscle. The later portion of the clip shows a fascia iliaca compartment block performed by inserting a needle from the lateral aspect until the tip is just deep to the fascia iliaca, and instilling a large amount (30-40cc) of anechoic local anesthetic in the fascial plane just superficial to the iliacus muscle (I). The injection of anesthetic in this fascial plane allows the anesthetic to spread over a larger anatomic area, providing anesthesia to the lateral femoral cutaneous nerve and obturator nerve in addition to the femoral nerve. Dr. Larry Benjey, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1639875674436-FLSQCOM3319WMZ8HQV4T/image-asset.gif Nerve Block Gallery - Interscalene Block 20s M with history of shoulder dislocations in the past presented with shoulder pain after boxing. He had a visible deformity to the shoulder, and radiographs confirmed an anterior glenohumeral dislocation. After documentation of a neurovascular exam, an interscalene nerve block was performed to facilitate reduction. The block is shown here, first with identification of the brachial plexus nerve roots (*) between the anterior and middle scalene muscles. The second part of the clip shows injection of anesthetic in the interscalene groove adjacent to the nerve roots. This patient had quick pain relief and closed reduction was achieved easily without sedation. Tanner Muggli, PGY1 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1641324140229-ED59ARK92L2UCIAZYPQS/image-asset.jpeg Nerve Block Gallery - Median Nerve Dorsal Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1641414141832-GLYKJMI9387Z4JFCLOOA/image-asset.gif Nerve Block Gallery - Popliteal Sciatic Block 40s M presented with a laceration to the lateral lower leg after jumping through a window. To facilitate laceration irrigation and repair, a sciatic nerve block was performed at the popliteal fossa. The patient was placed in the contralateral decubitus position, and the linear probe was placed in the popliteal fossa in a transverse orientation to identify the sciatic nerve just proximal to the bifurcation into tibial and common peroneal nerves. This image shows the nerve block, with the needle entering from the lateral aspect, depositing anesthetic within Vloka’s sheath which surrounds the sciatic, tibial, and common peroneal nerves at the bifurcation. The block was performed just at the level of the bifurcation, and the tibial and common peroneal nerves are marked by the red asterisk (*) here. The patient had relief of pain, and the irrigation and laceration repair were able to be performed without any additional local anesthetic. Dr. Rachel Vanderwel, PGY3, and Dr. Michael Heffler, PGY4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1641462592040-9BJOAS0LJJ55YO05N3DP/image-asset.jpeg Nerve Block Gallery - Common Peroneal Probe Location https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1641559835926-JLI0OOKTEBFGP0QTM2U2/image-asset.gif Nerve Block Gallery - Fascia Iliaca Nerve Block for GSW Teenaged male presented with a single GSW to the medial thigh. The trauma evaluation revealed a displaced and shortened transverse femur fracture. To facilitate traction pin placement and provide analgesia, a fascia iliaca block was performed. The block is shown here, with the needle is seen entering from the lateral aspect and depositing local anesthetic just deep to the fascia iliaca (*), lateral to the pulsating femoral artery. The patient had improvement of his pain and was able to be admitted to the surgical floor for operative repair the next morning. Dr. Phillip Breslow, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1641693874475-5QA6ALDRFCB3QZAZ5ZNM/image-asset.gif Nerve Block Gallery - Posterior Tibial Block for Frostbite 60s M presented with foot/toe pain in the setting of recent freeze/thaw frostbite. To aid in analgesia, a posterior tibial nerve block was performed. The block is shown here, with the needle entering from the posterior/medial aspect, depositing local anesthetic adjacent to the tibial nerve (*). The patient had improvement of his pain and was subsequently able to be discharged. Dr. Tyler Prince, PGY1 Denver Health Residency in Emergency Medicine Dr. Nimish Bhatt, Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644265911750-GTNF4UHO6IF9CA9CV98Y/image-asset.gif Nerve Block Gallery - Supraclavicular Nerve Block for Elbow Dislocation 50s F presented to the ED from ortho clinic for recurrent elbow dislocation. She had previously been reduced 7 days prior and found to be re-dislocated in clinic. The patient required procedural sedation for her initial reduction. On this encounter a supraclavicular nerve block was performed using 20 cc of 0.25% bupivacaine with 15 cc injected deep to brachial plexus and 5 cc injected superficial. The block is shown here, with the brachial plexus (*) seen lateral to the subclavian artery (A). She tolerated the block well and had improvement in pain, but did ultimately require procedural sedation to facilitate reduction due to anxiety about moving the arm. Dr. Fred Milgrim, PGY3 Mount Sinai Emergency Medicine Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1645468844947-78XU0V0TXFXE2AF9EXTS/image-asset.gif Nerve Block Gallery - Serratus Anterior Plane Block for Rib Fractures 50s M presented with side pain after a fall, and on imaging was found to have multiple unilateral rib fractures without other injuries. In order to help with pain control, a serratus anterior plane block was performed. The block is shown here, with the needle entering from the posterior/lateral aspect and placing anesthetic in the fascial plane (*) superficial to the serratus anterior muscle and deep to the latissimus dorsi muscle. This patient had improvement in his pain and was able to be discharged. Dr. Riku Moriguchi, PGY3 and Dr. Smitha Bhaumik, PGY4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1645518652967-TMJQKZCXKWVWML43PN8I/image-asset.gif Nerve Block Gallery - Interscalene Nerve Block for Shoulder Dislocation 20s M with history of recurrent shoulder dislocations presented with shoulder pain and deformity after being transferred from an urgent care after multiple unsuccessful attempts at reduction using intra-articular lidocaine alone. He was neurovascularly intact and clinically dislocated, which was confirmed on US. To facilitate reduction, an interscalene brachial plexus block was performed using US guidance. Shown here, the needle enters from the posterior aspect, approaching the brachial plexus (*) and depositing anesthetic adjacent to it. The patient had relief of his pain, and closed reduction was accomplished at the bedside without need for any additional analgesia or sedation. Dr. Cheyenne Smith, PGY3 Denver Health Residency in Emergency Medicine https://static1.squarespace.com/static/58118909e3df282037abfad7/5f3af18380ba5078b533f714/621512559a284c3e32965f65/1738108778939/ Nerve Block Gallery https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1645557914954-LXZ3WWRQDCH6TR3235YR/image-asset.gif Nerve Block Gallery - Erector Spinae Plane Block for Pancreatitis 30s M PMH chronic pancreatitis presented with epigastric pain, failing conservative management and continuing to have breakthrough pain on his home PO opiates. He was scheduled to have a celiac plexus neurolysis later in the month with interventional radiology but presented for uncontrolled pain. He had been given multiple doses of IV opioids in ED without effective pain control. An US guided erector spinae plane block was performed as shown. The needle is seen entering in-plane with a probe placed in the sagittal plane, and advanced until touching the transverse process (*), and injecting anesthetic within the fascial plane between the transverse process and the erector spinae muscles. The patient had effective control of pain and was able to be discharged home. Dr. Nhu-Nguyen Le, Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1645564571309-CJITKSXC78SJRH3CA9UD/image-asset.gif Nerve Block Gallery - Transversus Abdominis Plane Block A transversus abdominis block is shown, with the needle approaching in plane, passing through the external oblique muscle superficially, then the internal oblique muscle in the middle, and depositing anesthetic in the fascial plane below the internal oblique muscle and superficial to the transversus abdominis muscle. This nerve block provides anesthesia of the hemi-abdomen and is useful in providing analgesia for conditions like appendicitis or diverticulitis. Dr. Nhu-Nguyen Le, Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1645564909032-LJHMVB6I1KAHYAUV9NP7/image-asset.gif Nerve Block Gallery - Erector Spinae Plane Block Approach An erector spinae plane block is shown here, with the needle approaching in plane to touch the transverse process (*), and preparing to deposit anesthetic in the fascial plane between the transverse process and overlying erector spinae muscles. This block is generally best performed with the patient sitting facing away from the clinician, the US transducer in a parasagittal orientation just lateral to midline on the painful side, with an in plane approach, inserting the needle from the cranial or caudal aspect. Dr. Nhu-Nguyen Le, Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1645565098210-9I9EJ49AO7KI1OTDSSCC/image-asset.gif Nerve Block Gallery - PECS 1 Block A PECS 1 block is shown here, with the needle entering from the superior and medial aspect, passing through the more superficial pectoralis major muscle and depositing anesthetic in the fascial plane between the more superficial pectoralis major and deeper pectoralis minor muscle. This nerve block provides analgesia to the anterior thoracic wall and is useful for breast or chest wall procedures such as I&D. The pleura is easily seen in this clip, which reinforces the importance of careful needle handling to avoid inadvertent pneumothorax or intrapleural infection. Dr. Nhu-Nguyen Le, Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1647005974384-FRD0EWM9GZ07GU7JZW73/image-asset.gif Nerve Block Gallery - Popliteal Sciatic Nerve Block for Lac Repair 30s F presented with multiple self inflicted lacerations to the leg. To facilitate laceration repair without using a near toxic dose of lidocaine, a popliteal sciatic nerve block was performed. The block is shown here with the needle approaching from the lateral aspect of the popliteal fossa, in plane with the probe, depositing anesthetic next to the popliteal nerve (*). The anesthetic in this clip is outside of Vloka’s sheath, which encompasses the sciatic nerve and its more distal branches, the common peroneal and tibial nerves. Accordingly, onset of anesthesia in this patient was delayed, and so the laceration repair was completed using a combination of local infiltration of anesthetic as well as this nerve block. Dr. Kathleen Joseph, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1648834580896-ZP6PDS14DK6IAXO5O2DB/NB+Median.gif Nerve Block Gallery - Median Nerve Block 30s M presented with a unintentional laceration to the middle finger nailbed while preparing food with a knife. To provide pain control and facilitate nailbed removal and repair, a median nerve block was performed. The block is shown here, first with a survey scan of the distal volar forearm showing the median nerve (*) deep to the flexor digitorum superficialis muscle bellies and superficial to the flexor digitorum profudus muscle bellies. The nerve was anesthetized using an in-plane approach, with the needle depositing anesthetic in the fascial plane adjacent to the median nerve. The patient had improvement in his pain. He ultimately declined nailbed repair but had good pain control and was discharged with outpatient orthopedic follow up. Dr. Nimish Bhatt, Ultrasound Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1648835851112-JKX0FOGLE1QXHCL16BE2/Brevik+Serratus+Anterior.gif Nerve Block Gallery - Serratus Anterior Block 30s M presented with atraumatic acute onset chest pain in the context of inhaled marijuana use, and was found to have a spontaneous pneumothorax. The patient was hemodynamically stable, so a serratus anterior plane block was performed for analgesia and to facilitate pigtail chest tube placement. The block is shown here, with the fascial plane (*) between the serratus anterior muscle (deep) and latissmus dorsi (superficial). This block was performed using an out-of-plane approach, depositing anesthetic in to the fascial plane. This patient had mixed analgesic efficacy and so required additional anesthetic for chest tube placement, and was then admitted for further management. Dr. Cody Brevik, PGY4, Denver Health Residency in Emergency Medicine Dr. Nimish Bhatt, Fellow, Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1648836321992-IAW1NVE6QPPR6UPX6Y7I/NL+erector+spinae.gif Nerve Block Gallery - Erector Spinae Plane Block for Pancreatitis 30s M PMH ETOH pancreatitis presented with epigastric and upper abdominal pain in the setting of running out of his analgesic medications. To aid in pain control, an erector spinae plane block was performed. The block is shown here, with the needle entering from the cranial aspect to the thoracic process (*). Anesthetic was injected and observed to spread in the plane between the transverse process and the overlying erector spinae muscles. The patient had significant improvement in his pain and was able to be discharged with outpatient folllow up. Dr. Nhu-Nguyen Le, Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1649186614220-Z2VU8OTBMK3BQZZ197C9/image-asset.gif Nerve Block Gallery - Serratus Anterior Plane Block for Herpes Zoster 60s M presented with unilateral chest pain and a rash, and was ultimately diagnosed with a flare of herpes zoster. To aid in pain control, a serratus anterior plane block was performed. The block is shown here, with the needle advanced using in-plane guidance to the fascial plane (*) between the deeper intercostal muscles and more superficial serratus anterior muscle, where anesthetic was injected. The patient had improvement in their pain and was able to be discharged. Dr. Henrik Galust, PGY4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1650476681521-1NG0E7227J5EC4O5UZ4F/image-asset.gif Nerve Block Gallery - Interscalene Brachial Plexus Block for Recurrent Shoulder Dislocation 30s M with PMH of many previous shoulder dislocations presented to the ED with pain and reduced ROM of shoulder after lifting his arm slightly. Radiographs confirmed an anterior shoulder dislocation, so an interscalene brachial plexus nerve block was performed to facilitate closed reduction without the need for procedural sedation. The block is shown here, with the needle entering from the posterior/lateral aspect with the tip adjacent to the brachial plexus (*), just posterior to the anterior scalene muscle which is seen at the left of the image. The block was effective, and the shoulder was reduced without need for additional medications. Dr. Fred Milgrim, PGY3 Mount Sinai Emergency Medicine Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1656433753061-PZJ6CVAZVNS26XBNLER3/image-asset.gif Nerve Block Gallery - Fascia Iliaca Block for Intertrochanteric Femur Fracture A teenaged male patient presented with hip pain and inability to ambulate after a fall off of an electric scooter. XRs demonstrated an intertrochanteric femur fracture, and CT ruled out other involvement of the pelvis or femoral head. To provide analgesia, a fascia iliaca block was performed. Shown here, the needle enters from the lateral aspect, lateral to the femoral nerve, artery, and vein which are seen at the top right of the image. Anesthetic is spread along the fascial plane shown (*). This patient had improved pain and was able to be admitted to the floor for surgery the next day. Dr. Lee Johnson, PGY2 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1656434117383-NF6BD9XE08PBWQBR11QS/image-asset.gif Nerve Block Gallery - Fascia Iliaca Compartment Block for Hip Fracture An elderly female presented with hip pain after an unwitnessed fall at her nursing home, and was found to have a shortened, rotated lower extremity, and after a broad workup was found to have a proximal femur fracture. To aid in pain control, a fascia iliaca block was performed under US guidance. The block is shown here, with the needle entering from the lateral aspect and injecting anesthetic in the fascia iliaca fascial plane. As seen by the very superficial femoral cortex, this 90s year old female was quite sarcopenic, so the normal muscular sonoanatomy is limited. The fascial spread seen in this clip helped to confirm appropriate placement of anesthetic. This patient was able to be admitted for surgery and had significant pain relief. Dr. James Sutton, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1656434558362-FKMJOGPZAWY2H8XMJHJD/image-asset.gif Nerve Block Gallery - Interscalene Brachial Plexus Block for Shoulder Dislocation A 20s M with past medical history of prior shoulder dislocations presented with atraumatic shoulder pain and decreased range of motion after he felt a pop while playing sports and reaching across his body. He was found to have an anterior shoulder dislocation without fracture or neurovascular compromise. To facilitate reduction without procedural sedation, an interscalene brachial plexus block was performed. Shown here, the needle enters from the lateral/posterior aspect and the tip is placed adjacent to the brachial plexus, which is seen as 3 hypoechoic circles in a relatively vertical line deep to the sternocleidomastoid muscle. Anesthetic is injected sequentially lateral, deep, medial, and then superficial to the brachial plexus. This patient had relief of pain and his shoulder was able to be reduced at bedside without additional sedation or analgesia. Dr. Larry Benjey, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1656435155527-FGHN24U4R7NTFMJT0JS9/image-asset.gif Nerve Block Gallery - Fascia Iliaca Block for Femoral Neck Fracture A 90s year old female presented with hip pain after a fall off of a couch. Her workup confirmed an isolated femoral neck fracture in addition to acute metabolic encephalopathy and dementia. To provide analgesia while avoiding further sedation medications given her altered mental status, a fascia iliaca block was offered. After an informed consent conversation with the patient’s MDPOA, the block was performed as shown here. The needle is seen entering from the lateral aspect, injecting anesthetic along the fascia iliaca lateral to the femoral neurovascular bundle. This patient had improved pain and was able to be admitted for further management. Dr. Cheyenne Smith, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1656436057937-4I1ELECD854D1EL1GU8D/image-asset.gif Nerve Block Gallery - Median Nerve Block for Carpal Tunnel Syndrome 60s F presented with intractable wrist pain due to known carpal tunnel syndrome. The patient was already established with hand specialist followup and had failed multiple other analgesics including a steroid course. To aid in analgesia, a median nerve block was performed. Shown here, the median nerve (*) is seen in the forearm, in the fascia plane between the flexor digitorum profunda and flexor digitorum superficialis muscle bellies. Anesthetic was injected in this fascial plane, adjacent to the median nerve. The patient had significant pain relief and was able to be discharged with hand specialist follow up. Dr. Nimish Bhatt, Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1658890067068-G14PLPQROLG4RWGESUH0/image-asset.gif Nerve Block Gallery - Popping through the Fascia Iliaca A 60s F presented with hip pain after a recent fall. Radiographs showed a subacute femoral neck fracture. To aid with pain control, a fascia iliaca compartment nerve block was performed. The needle is seen here popping through the fascia iliaca, just superficial to the iliacus muscle, before injecting anesthetic just below the fascia iliaca. This injection was somewhat intramuscular. The expansion of the anesthetic pocket with injection and collapse when injection is paused helps confirm that anesthetic is spreading along the fascial plane rather than pooling in a contained area within muscle. Joseph Ponce, PGY-3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659978812350-2CRRG08P2TUHCMIC1H4U/image-asset.gif Nerve Block Gallery - Erector Spinae Block for Nephrolithiasis 30s M with PMH nephrolithiasis in the past presented with acute onset flank pain. POCUS demonstrated mild hydronephrosis, and his workup was not suggestive of renal insufficiency or UTI, so aggressive symptom control was pursued. He was still experiencing significant pain after two doses of IV morphine, so an erector spinae plane block was offered. After informed consent and setup of supplies, the block was performed and is shown here. The transducer was placed in a sagittal orientation on the mid back at the level of T9, just lateral of midline (toward the affected side) in order to visualize the transverse process. A clip is shown here highlighting the transverse process, and the probe slides laterally to show the more superficial ribs with sliding pleura visible deep to them. The erector spinae muscle can be seen in long axis, just superficial to the transverse process. A 4 inch 20g nerve block needle was advanced using in-plane guidance until the needle tip contacted the transverse process, just deep to the erector spinae muscle. After a negative aspiration for blood, 30 mL of 0.5% bupivacaine with epinephrine plus 1 mL of dexamethasone (4mg in 1 mL) was injected deep to the erector spinae muscle. The patient had improvement of his pain and was able to be discharged with outpatient PCP follow up. Dr. Michael Heffler, Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659979473029-WAAL5NVK0DR46LDY346M/image-asset.gif Nerve Block Gallery - Median Nerve Block for Laceration Repair 30s M presented with a laceration to his thenar eminence. He was neurovascularly intact, and there was no concern for retained foreign body or fracture. To facilitate laceration repair, a median nerve block was performed. Shown here, the median nerve is seen in the fascial plane between the muscle bellies of the flexor digitorum superficialis and flexor digitorum profundus. A 27g needle was advanced using in-plane guidance into the fascial plane, and after a negative aspiration for blood, anesthetic was injected, with spread of anesthetic visualized surrounding the median nerve. The patient had significant improvement in his pain, and the laceration was able to be irrigated and repaired. Dr. Michael Heffler, Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659979777528-4TA4V9BCMMBXTJOD14QQ/BN+pop+sciatic.gif Nerve Block Gallery - Popliteal Sciatic Nerve Block for Foreign Body Removal 30s M presented with a nailgun injury after he unintentionally fired a nailgun into his booted foot. To facilitate removal, a popliteal sciatic nerve block was performed. The block is shown here, where a 20g block needle was advanced using in-plane guidance until the needle tip was visualized adjacent to the sciatic nerve. Anesthetic spread was visualized within Vloka’s sheath, the nerve sheath which encompasses the sciatic nerve as well as its branches (common peroneal and tibial nerves). A total of 20cc of anesthetic was injected. The patient had complete resolution of his pain shortly thereafter, and the nail was able to be removed without difficulty. Dr. Brigit Noon, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697039712586-SA36FJZ2ZHKCRGH9EVJM/image-asset.gif Nerve Block Gallery - Transgluteal Sciatic Target https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697588590637-T9URXQP766DL4IS6J5M2/image-asset.gif Nerve Block Gallery - Transgluteal Sciatic Nerve Block Anatomy https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697588784377-W497L6CO8JO4NABDDU2P/image-asset.gif Nerve Block Gallery - Transgluteal Sciatic Nerve Block Anatomy 2 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697588849911-RA9W6JUZRPZ3PQHG2XGM/image-asset.png Nerve Block Gallery - Transgluteal Sciatic Area of Anesthesia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697588926768-RE19EN8SVEP1ROP2Z09X/image-asset.gif Nerve Block Gallery - Transgluteal Sciatic Nerve Block 1 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697589077272-RF8FSGAXK2E0VOKT932S/image-asset.gif Nerve Block Gallery - Transgluteal Sciatic Nerve Block 2 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697589522107-K0X25OEDI81ONSW0S21T/image-asset.png Nerve Block Gallery - Transgluteal Sciatic Anatomy https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697588849911-RA9W6JUZRPZ3PQHG2XGM/TGSNB+Color+Overlay.png Nerve Block Gallery https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1698184828967-08RHB63SKGCDWMT9B2KH/image-asset.gif Nerve Block Gallery - Fascia Iliaca Nerve Block Hydrodissection A 70s M w ground level fall pw a left femoral neck fracture. The needle can be seen approaching from the right of the screen (laterally) using an in-plane anteromedial approach. The pulsating left femoral artery is seen on the left of the screen (medial). Adequate hydrodissection is shown with 10cc of normal saline in the fascial space prior to depositing the anesthetic, 30cc of 0.2% ropivacaine. 45 minutes after administration, pain was significantly decreased and the patient was admitted for surgery. Dr. Brigit Noon, PGY-4, Denver Health Emergency Medicine Residency Dr. Matthew Riscinti, Ultrasound Fellowship Director, Denver Health Emergency Medicine Erick Otiniano, MS4, University of California Riverside School of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1700096327641-JH1G3IRTEKM0B0AUGXEC/Infraclavicular+Block_+Seballos+Milgrim.gif Nerve Block Gallery - Infraclavicular Brachial Plexus Nerve Block A 71-year-old male presented to the ED one day after a ground level mechanical fall during which he sustained a L shoulder injury. Given his age and initial borderline blood pressures, he received CT images of his chest, abdomen and pelvis which initially revealed a minimally displaced humeral head fracture extending into the greater tuberosity. His workup was ultimately otherwise unremarkable. He was consented for an infraclavicular block for pain control prior to being placed in a cuff and collar sling. The needle can be seen approaching the axillary artery, around which the lateral, posterior and medial cords of the brachial plexus lie anatomically. The needle approach is from cephalad to caudal, with the ultrasound probe placed in the deltopectoral groove. The goal of this block is to deposit anesthetic at the 6 o’clock position relative to the axillary artery. Anesthetic can be seen depositing just superior to the axillary artery, around the 7 o’clock position (screen right). A total of 20 cc of 0.25% bupivicaine with 4 mg of dexamethasone was used. Prior to the block, the patient’s pain score was an 8 out of 10, with significant pain with passive or active range of motion. Shortly after the block, his pain decreased to a 2 and he started ranging his shoulder with minimal discomfort. He was placed in a sling and ultimately stayed in the observation unit for frequent falls and PT/OT evaluation. Dr. Spencer Seballos, PGY-2, Denver Health Emergency Medicine Residency Dr. Fred Milgrim, Ultrasound Fellow, Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1700096659409-9YLIELPH0RIMUHNUDSF8/Saphenous+Block_+Ng+Milgrim.gif Nerve Block Gallery - Adductor Canal (Saphenous) Nerve Block A 58-year-old woman presented to the ED two weeks after being bitten on her right thigh by her dog with a growing abscess over the medial thigh just superior to the knee. In order to facilitate abscess drainage, a combination of femoral nerve and adductor canal (saphenous) nerve blocks were performed. Seen here is the saphenous block. The transducer was placed over the middle third of the thigh on the medial aspect. The needle is seen approaching from lateral to medial with the femoral artery pulsating at the bottom of screen right. The adductor canal contains the saphenous nerve, the femoral artery and femoral vein. It lies just deep to the sartorius muscle, lateral to the vastus medialis and medial to the adductor longus muscle. 10 cc of 1% lidocaine without epinephrine can be seen hydrodissecting the fascial plane just deep to the sartorius muscle. The patient then underwent a pain free abscess drainage. Dr. Wesley Ng, Ultrasound Fellow, Denver Health Family Medicine Dr. Fred Milgrim, Ultrasound Fellow, Denver Health Emergency Medicine Dr. Matthew Riscinti, Ultrasound Fellowship Director, Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1700097403577-7Q65A4XTF09FGP6O459K/ESP+Block_Milgrim.gif Nerve Block Gallery - Erector Spinae Nerve Block A 43-year-old female presented to the ED with four weeks of ongoing R sided costovertebral angle and anterior chest wall discomfort, previously having been treated for pyelonephritis at the onset of her pain. Given her nonspecific symptoms that had been refractory to standard management, a right sided erector spinae block was offered for analgesia. The needle can be seen approaching the T6 transverse process (the approximate site of her pain) from cephalad. The erector spinae muscle is lifted off the transverse process with good spread in the fascial plane demonstrated in the subsequent images. 30 cc of 0.33% bupivacaine with 10 mg of dexamethasone was used. The patient had moderate pain relief. Dr. Fred Milgrim, Ultrasound Fellow, Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1700097670481-BRAB7D0CH1MF3X1K6V1L/Ulnar+Nerve+Block_+Bobzien+Milgrim.gif Nerve Block Gallery - Ulnar Nerve Block A 45-year-old male presented to the ED with an accidental self inflicted laceration to the hypothenar eminence of his R hand sustained from a pocket knife. He received an ulnar nerve block for pain control. The ulnar nerve can be seen separating from the ulnar artery as the probe is fanned up the medial aspect of the forearm. The needle can then be seen approaching the nerve from medial to lateral and approximately 5 cc of 2% lidocaine was deposited just lateral to the nerve. The patient then underwent a pain free laceration repair. Danielle Bobzien, PA, Denver Health Emergency Department Dr. Fred Milgrim, Ultrasound Fellow, Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1702413871875-1YCKUDKAKJHL42D14H10/ESP_Milgrim+Rice.gif Nerve Block Gallery - Erector Spinae Block for a Traumatic Injury A 45-year-old male presented to the ED as a pedestrian struck by a car. He was hit from behind and pinned to a wall briefly. Workup revealed left sided 1st-5th anterior rib fractures, 3rd-7th posterior rib fractures with significant displacement, as well as left C7 and T1 transverse process fractures and a left medial clavicle fracture. An erector spinae block was performed for analgesia. In the first image, the erector spinae muscle layer can be seen sitting atop two levels of transverse processes. The patient was slowly rolled onto the right lateral decubitus. The second clip shows a needle approaching from cephalad and depositing anesthetic into the fascial plane between the erector spinae and transverse process. The patient felt near immediate pain relief at the termination of the procedure. He was subsequently brought to the SICU prior to having a rib plating operation the following day, and received a serratus anterior catheter placed by anesthesia during pre-op. Dr. Makenna Rice, PGY-1, Denver Health Emergency Medicine Residency Dr. Fred Milgrim, Ultrasound Fellow, Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1700098027607-6UJEUCCWBP01VUV280T3/Transgluteal_Simeon+Milgrim.gif Nerve Block Gallery - Transgluteal (Proximal) Sciatic Nerve Block A 36-year-old male presented to the ED with acute onset left sided back pain that started suddenly 6 hours prior to arrival while bending over. The pain radiated down his left leg and he had a positive straight leg raise with a severely antalgic gait. A transgluteal sciatic nerve block was performed. The patient was positioned in the right lateral decubitus position with the left hip and knee flexed. The needle can be seen approaching from lateral to medial, just over the greater trochanter. The needle reaches the fascial plane between the gluteus maximus and quadratus femoris muscles where the sciatic nerve and inferior gluteal artery lie. The plane is seen separating with hydrodissection using 20 cc of 0.5% bupivacaine with 10 mg of dexamethasone. The patient had complete relief after the block and was able to ambulate out of the department with ease. Dr. Kate Simeon, PGY-4, Denver Health Emergency Medicine Residency Dr. Fred Milgrim, Ultrasound Fellow, Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1702754535635-0LYVWVNR7N829MFM8LHM/PENG+Block_Cohen.gif Nerve Block Gallery - PENG Block A PENG block was performed using the linear probe. The hyperechoic psoas tendon can be seen lifting off the ileum with the injection of anesthetic. Ariella Cohen MD Eric Quinn MD Maimonides Medical Center Emergency Medicine https://www.thepocusatlas.com/image-review daily 0.75 2021-06-10 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604774588074-A196KFRDS2CL6U24J3GA/One+minute+image+review-80.png One Minute Image Review https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604775864887-9B1E5UYA7ZSPMOSO7FHM/pericardial%2Bhematoma.gif One Minute Image Review https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604776685829-4VKXSRMT7ZG48KC2KB9I/image-asset.gif One Minute Image Review https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604783470465-RBLQUGS0WT5G53EXRLHK/ezgif.com-optimize+%283%29.gif One Minute Image Review https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604783558853-Y7XW7YXMDZ3Y90MCSMRZ/bowra%2Bpos%2BRUQ%2Bfast.gif One Minute Image Review https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604899651312-2WLJKKXEQ2RWDQ59MF63/Sukh%2B-%2BRetinal%2BDetachment+%282%29.gif One Minute Image Review https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604900186964-FHQBWD77B8UQK56Y9CXX/ezgif.com-optimize+%2867%29.gif One Minute Image Review https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604900692602-GBCY700EY3JC2WRZ1KQ1/ezgif.com-gif-maker%2B%2823%29.gif One Minute Image Review https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604901343877-CB17JYBRILC0F2FONU92/twins.gif One Minute Image Review https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604903120556-FZJNTAA8Q3NHB2570E2R/ezgif.com-optimize%28shoulder_reduction%29.gif One Minute Image Review https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606176875627-CMBGPDD1HLON6GUBQZ6A/ezgif.com-gif-maker.gif One Minute Image Review https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611768212493-8UYVJNMO78JKL7CI8Z78/image-asset+%283%29.gif One Minute Image Review https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616441076753-VVK1DU4GGEEUVNEFQDI3/ezgif.com-gif-maker-5+copy+4.gif One Minute Image Review https://www.thepocusatlas.com/one-minute-image-review daily 0.75 2022-07-25 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1658790341821-V9XBJ9PI06Q70RXH8OB8/image-asset.jpeg Image Review - Anterior Shoulder Dislocation In this video Dr. Nhu Nguyen Le discusses correct probe placement and sonoanatomy for evaluation of shoulder dislocation. Note that ultrasound can be used to make the diagnosis but also to confirm that the shoulder has been appropriately reduced! https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1658790341821-V9XBJ9PI06Q70RXH8OB8/image-asset.jpeg Image Review - Anterior Shoulder Dislocation In this video Dr. Nhu Nguyen Le discusses correct probe placement and sonoanatomy for evaluation of shoulder dislocation. Note that ultrasound can be used to make the diagnosis but also to confirm that the shoulder has been appropriately reduced! https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1657647878516-5ML4UPLO2P4CBSEM6PHI/image-asset.jpeg Image Review - Hip Effusion In this video Dr. Nhu Nguyen Le discusses how to identify a hip effusion in a patient with a suspected septic joint. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1647029002556-WF4POM6LJY4HVZR0JRG6/image-asset.png Image Review - Retinal Detachment In this video Dr. Nhu Nguyen Le discusses an ultrasound image demonstrating a retinal detachment. He also reviews this image in comparison to vitreous detachment which can be a common mimic. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1645824856101-AYGUHAQD4LDYTVI77X2M/image-asset.jpeg Image Review - General Nerve Block Principles In this video Dr. Nhu Nguyen Le discusses several essential nerve block concepts as we view an example of a supraclavicular brachial plexus block! https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1643924848715-L4TCYZ068C7K50DHIMJN/image-asset.jpeg Image Review - Wrist Effusion In this video Dr. Nhu-Nguyen Le discusses how to evaluate for a wrist joint effusion using point of care ultrasound. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1634852287496-YYQU14TKFVQII9J7TTL2/image-asset.png Image Review - Proximal Aorta In this video we review the anatomy of the proximal aorta in both a transverse and longitudinal orientation. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1633370072364-3QS17JEVBBM6LJDD7FK3/image-asset.png Image Review - Normal Subxiphoid View In this video, Dr. Elias Jaffa discusses how to properly obtain the subxiphoid view along with the pertinent visualized sonoanatomy. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631575671257-VP6VBFJHR6DZK5E5WQRP/image-asset.png Image Review - Pleural Effusion In this video, Dr. Elias Jaffa discusses how to utilize ultrasound to evaluate for a pleural effusion. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1629399381942-C38H8SXK8ZHHRBMBM5OV/image-asset.png Image Review - Utilizing A Linear Probe For Early IUP Confirmation In this video, we discuss how to use a linear probe when evaluating for an IUP to improve early pregnancy diagnosis. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1627574285352-0XNGVOVFKSVZAORUGNBT/image-asset.png Image Review - Pneumothorax In this video, Dr. Elias Jaffa dives into ultrasound use in pneumothorax including exam operating characteristics, lung sliding, and the pathognomonic lung point! https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625770588243-0NPX0KX1ZBIWTB69WGXL/image-asset.png Image Review - Cholecystitis In this video, Dr. Elias Jaffa (@jaffa_md) discusses an ultrasound clip demonstrating findings seen in acute cholecystitis. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1624489618561-QDGTU7IRL5BPC16J476K/image-asset.jpeg Image Review - Measuring Fetal Heart Rate In this video we discuss utilizing M-mode to calculate fetal heart rate in early pregnancy. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623341955179-JMNXJ9ASIOZX4534AKWI/image-asset.jpeg Image Review - Small Bowel Obstruction In today's video we discuss ultrasound findings suggestive of small bowel obstruction. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1621531678199-SKZFE7NTOQEFU1NHBP3N/image-asset.jpeg Image Review - Normal Lung Sliding In this week's video we discuss lung sliding which is a normal finding in lung ultrasound that rules out a pneumothorax. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620231858240-F5KA1H0VWVKO7UI27LB3/image-asset.jpeg Image Review - I -lines - AKA Comet Tails In this video we discuss a common artifact seen in lung ultrasound including its ultrasound characteristics and clinical utility. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1619043843888-ZIZ3RLIUM61EEHROZIT1/image-asset.jpeg Image Review - Ultrasound Guidance In Hematoma Block In this video we demonstrate ultrasound findings in a displaced distal radius fracture and provide strategies to perform an ultrasound guided hematoma block. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1618420116935-HRR3O5W3MHV1HSXMVL5Y/image-asset.jpeg Image Review - Vitreous Detachment In this week's video we discuss the characteristics of a vitreous detachment along with important aspects of performing a proper ocular ultrasound to evaluate for retinal pathology. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1617231253109-ANIKDW8ATCJUN2OAZK8Y/image-asset.jpeg Image Review - Right Upper Quadrant View In this video we discuss the normal sono-anatomy of the right upper quadrant view performed during FAST exam along with important pearls when evaluating this view for free fluid! https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616630503526-ZCYPVNHB8YFGTPQAAQAY/image-asset.jpeg Image Review - Fine Ventricular Fibrillation In this video, we discuss a cardiac arrest case demonstrating fine ventricular fibrillation initially thought to be asystole based on rhythm evaluation! https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616010639672-1SIUFY0KIRN166N2QRL4/image-asset.jpeg Image Review - Evaluating for Reduced Ejection Fraction on PSLA In this video Dr. Elias Jaffa discusses specific characteristics of the left ventricle that can be utilized when evaluating left ventricular function on the parasternal long axis view (PSLA). https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614791280652-SJRARFCI6WHSMIB29FDP/image-asset.jpeg Image Review - Don't Confuse a Lymph Node with an Abscess! In this week's video we discuss the characteristics of a lymph node seen on ultrasound as well as the importance of color doppler in distinguishing this structure from a fluid collection. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614193518806-XDJUQ5EZMX8CZEISP1VT/image-asset.jpeg Image Review - Identification of A Felon Using Ultrasound In this video we discuss the imaging findings of a finger tip abscess, aka a felon, as well as proper technique to evaluate distal finger tip infections. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1613671334695-HVA3NKTMMUE9HU34FNK0/image-asset.png Image Review - Aorta Versus The IVC In this video, Dr. Elias Jaffa discusses how to differentiate between the aorta and the IVC on ultrasound. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1612979343624-74P29RREIE0JETR2P8X3/image-asset.jpeg Image Review - Normal Gallbladder in Long Axis In this video we discuss imaging of the gallbladder and identification of the portal triad. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614193954298-XATP84STMGHVZGC530CO/image-asset.jpeg Image Review - Normal Sonoanatomy of the Musculoskeletal Layers In this video we review the normal sonoanatomy of the various tissue layers evaluated during soft tissue and musculoskeletal ultrasound. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611768383689-TQT6J4BAQE188M3SFD4C/image-asset.jpeg Image Review - Ultrasound Guidance for Paracentesis In this video Dr. Elias Jaffa discusses how to utilize ultrasound to facilitate a safe and successful paracentesis. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611164219963-8M9EJCB2GT3PRQL9FAM9/image-asset.jpeg Image Review - Aortic Dissection - Short Axis In this video, we discuss findings of acute aortic dissection. Specifically we identify a dissection flap seen in the abdominal aorta on a short axis view. Voice over and annotations by Dr. Elias Jaffa. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1610558334491-2C1FJSLOQ545ZP3PETSN/image-asset.jpeg Image Review - Definitive IUP - Fetal Pole In this video we discuss evaluation of a definitive IUP with visualization of both a fetal pole and yolk sac. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609963540101-NRYXRCIQ4KVTFUUZUJ2R/image-asset.jpeg Image Review - Cardiac Tamponade - PSLA In this video we discuss findings of a pericardial effusion with evidence of cardiac tamponade in a parasternal long axis view. Specifically we discuss the finding of right ventricular diastolic collapse. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609355696198-ZN1MXALZMEKULZYME8F7/image-asset.jpeg Image Review - The Spine Sign In this video we review the findings of a pleural effusion including the "Spine Sign" and why it occurs. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1608159161436-FZUSXL06APNX8X0IEEY1/image-asset.jpeg Image Review - Dynamic Air Bronchograms in Lobar Pneumonia In this video we discuss two findings that can be seen in a lobar pneumonia including hepatization of the lung and dynamic air bronchograms. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607545109630-PTF3AO757SPTFU5UEJWY/image-asset.jpeg Image Review - Normal Ocular Ultrasound Anatomy In this video we discuss important sonoanatomy of the eye as well as key points regarding proper ocular examination technique. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606950840853-9SX9EXLRWK6PSNF5GYJO/image-asset.jpeg Image Review - Normal Parasternal Short Axis View In this video, Elias Jaffa discusses imaging of the normal parasternal short axis view including probe orientation and sonoanatomy. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606177036454-FR6IJJJV6ZKWTU8OIKX7/image-asset.jpeg Image Review - Gallstones in the Neck of the Gallbladder In this video we discuss obtaining a long axis view of the gallbladder and identifying gallstones in the gallbladder neck. In this image we also discuss the LACK of signs of cholecystitis suggesting a diagnosis of acute biliary colic. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604971232565-U2X6ZX7ZGU2K1S1KVILB/image-asset.jpeg Image Review - Positive RUQ View At Liver Tip In this video we discuss an ultrasound clip demonstrating free fluid in the right upper quadrant. We review relevant sono-anatomy, clinical correlation, and the importance of the caudal liver tip! https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604904462690-1R4M1A5C153CDEFIBMNR/image-asset.jpeg Image Review - Normal Apical 4 Chamber View In this video, we discuss a normal apical 4 chamber view including features that suggest proper imaging as well as the utility of this view in point of care echocardiographic evaluation. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604904236897-GTDE8O26CIPN81O0M1S4/image-asset.jpeg Image Review - Hyperdynamic Left Ventricle In this video we discuss findings in a hyperdynamic left ventricle and its clinical implications. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604904000860-OYAU9BB491VWTCTQ2GMT/image-asset.jpeg Image Review - A Plethoric IVC In this video, we discuss a normal apical 4 chamber view including features that suggest proper imaging as well as the utility of this view in point of care echocardiographic evaluation. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604903720291-8TE7LPEF9NJNM2QC1E8L/image-asset.jpeg Image Review - Soft Tissue Foreign Bodies Ultrasound can be an excellent adjunct for both evaluation and removal of a soft tissue foreign body. In today's video we discuss characteristic sonographic features of foreign bodies. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604903306501-D1SSDVPNJ4UD0OVFHXZ0/image-asset.jpeg Image Review - Patellar Tendon Rupture This is an ultrasound clip demonstrating a complete patellar tendon rupture in a patient presenting to the emergency department with sudden knee pain, swelling and inability to ambulate. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604902706950-V6IKQY79Q58P1CCA97VC/image-asset.jpeg Image Review - The D Sign In this clip we discuss the important ultrasound finding known the D-Sign. When the D sign is present throughout systole and diastole, this indicated RV pressure overload which may be from etiologies including pulmonary embolism or pulmonary hypertension. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604902428911-230GSW2XIIQGW53PM7VV/image-asset.jpeg Image Review - Subcutaneous Emphysema In today's video we discuss the appearance of air in the soft tissue. This finding can be seen as air tracks into the soft tissue from a pneumothorax but also can be associated with gas producing organisms in the setting of infection such as necrotizing fasciitis. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604901977488-1VMUF3688B8HUP9E3ELC/image-asset.jpeg Image Review - POCUS Findings in Sympathetic Crashing Acute Pulmonary Edema SCAPE In this video we discuss ultrasound findings seen in a patient with SCAPE. In general these patients are very sick from acute redistribution of fluid into their lungs and the treatment should focus on NIPPV and high dose nitroglycerine. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604901513307-V6ASC5MS516LU995R0YN/image-asset.jpeg Image Review - Can't Miss Ectopic Pregnancy In this clip we demonstrate an ectopic pregnancy that on first glance could be called an intrauterine pregnancy if not carefully evaluated. When confirming the presence of an intrauterine pregnancy it is very important to first identify the uterus, then evaluate in both sagittal and transverse planes to ensure the pregnancy lies within the uterus. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604900851653-ZXHRMQWAR7Z1XT9ZRWTK/image-asset.jpeg Image Review - Mild Hydronephrosis from an Ureteral Stone In this video, we discuss renal anatomy and signs of mild hydronephrosis. Note that USUALLY ultrasound does not identify the ureteral stone itself but instead looks for indirect signs of a stone. The presence of unilateral hydronephrosis on the side of pain in conjunction with high clinical suspicion for obstructing stone should be taken into account when using this finding for diagnostic purposes. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604900348628-KD0FJHCAMIHRVOD51V0S/image-asset.jpeg Image Review - Ruptured Abdominal Aortic Aneurysm In this video we discuss signs of a ruptured AAA and compare this to findings seen in a non-ruptured AAA. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604899758523-G49ZNLG2NLSYBGR0JS8U/image-asset.jpeg Image Review - Simultaneous Vitreous & Retinal Detachment In this ultrasound clip we identify both a vitreous and retinal detachment. We also briefly discuss the difference between these two entities based on their relationship to the optic nerve. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604899147181-TG0271PXYXWBGI9MYGDY/image-asset.jpeg Image Review - Positive FAST in LUQ View This is an ultrasound clip demonstrating free fluid present in the left upper quadrant. It is important to note that free fluid in the left upper quadrant usually accumulates first between the spleen and the diaphragm so be sure to include this area in your evaluation! https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604898385041-MGQC3IE31OFCCL1QTURN/image-asset.jpeg Image Review - The Swirl Sign Can Identify A Subtle Abscess In this clip we discuss the swirl sign and how it can be used to identify a fluid collection or abscess that may have been otherwise missed. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604782768126-5XHZFMI6X50C3DI7KW9H/image-asset.jpeg Image Review - Aortic Root Dilation in Acute Aortic Dissection In this image we discuss an enlarged aortic root seen on parasternal long axis in the setting of acute aortic dissection. The aortic root is normally < 4cm and any dilation in the setting of acute chest symptoms should raise suspicion for Type A aortic dissection and further imaging and specialist consultation should be considered. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604782273394-DE0UMSIRW9I6BVWSAVFV/image-asset.jpeg Image Review - Mirror Artifact At A Normal Lung Base Mirror artifact is seen when there is a highly reflective surface encountered by an ultrasound beam such as the surface of the diaphragm. It is a useful artifact that RULES OUT a pleural effusion when present at a lung base. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604781393644-3OPK3IU0GAIJHHJ7K8JV/image-asset.jpeg Image Review - Right Ventricular Strain in Pulmonary Embolism In this clip we discuss several signs seen in pulmonary embolism with right ventricular strain including: RV dilation, McConnell’s sign and thrombus (clot)-in-transit. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604781079566-I7TY74EX12M2P5WS6GZR/image-asset.jpeg Image Review - A Comparison of Pleural Findings in COVID 19 Versus Acute CHF In this video we discuss pleural findings in both COVID 19 and CHF and how to distinguish between the two distinct entities using ultrasound. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604776478524-ZPPI4O7OJ61PC3ECE7KB/image-asset.jpeg Image Review - Subpleural Consolidation in COVID 19 Pneumonia In this video we discuss the sonographic characteristics of a sub-pleural consolidation in the setting of a patient who was ultimately diagnosed with COVID-19. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604898179171-WRVO2YM1XGPL3F69R8EZ/image-asset.jpeg Image Review - Normal Parasternal Long Axis View In this video we discuss the normal sono-anatomy of the parasternal long axis view. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604773531935-WV777HCBPKKAIO7HJPY1/image-asset.jpeg Image Review - Left Upper Quadrant View In this video, we discuss the sono-anatomy of a normal left upper quadrant view. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604773531919-JG2P7VY2UAY0R6BA59RI/image-asset.octet-stream Image Review https://www.thepocusatlas.com/hepatobiliary-test daily 0.75 2020-11-15 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605396099238-TC1CXL8GIV5FVZJMSUS8/image-asset.gif Biliary Disease https://www.thepocusatlas.com/hocus-pocus-cases daily 0.75 2021-10-26 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1634844586940-EXA30KDAS0ET6AWQ0P8G/Rutz%2B-%2Bectopic.gif HOCUS POCUS Cases - Case 1 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1634844586940-EXA30KDAS0ET6AWQ0P8G/Rutz%2B-%2Bectopic.gif HOCUS POCUS Cases - Case 1 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1634845875151-IJFRD1JLYT3V7NHWTT1C/ezgif.com-gif-maker+%2879%29.gif HOCUS POCUS Cases - Case 2 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1634857582604-JFSBUN1E05HI7HCPIY7D/ezgif.com-optimize%2B%2812%29.gif HOCUS POCUS Cases https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1634858451281-ZGX1OVBRTTW989A3B381/image-asset.gif HOCUS POCUS Cases - Case 5 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1635017329708-NKNGY81IHZUUFYI8XL7F/ezgif.com-optimize%28target_sign%29.gif HOCUS POCUS Cases https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1635017631140-ACZDB8LAZL21F6DQPM5U/image-asset.jpeg HOCUS POCUS Cases https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1635281768423-XX98MHE4DQGTE40S5CJ0/bowra%2Bpos%2Bfast%2BLUQ.gif HOCUS POCUS Cases https://www.thepocusatlas.com/y-m daily 0.75 2021-12-23 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1640295367702-PNW4W0SUOK9IKQA472FP/image-asset.gif YM https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1640295367702-PNW4W0SUOK9IKQA472FP/image-asset.gif YM https://www.thepocusatlas.com/normal-cardiac-anatomy daily 0.75 2022-09-08 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625940717777-5S50RX08LBAOZPSET7G7/image-asset.gif Normal Cardiac Anatomy - Normal Parasternal Long Axis (PLAX) View Parasternal long axis view with normal ejection fraction Nigist Taddese MBChB. Division of Hospital Medicine, John H Stroger Hospital of Cook County https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625940717777-5S50RX08LBAOZPSET7G7/image-asset.gif Normal Cardiac Anatomy - Normal Parasternal Long Axis (PLAX) View Parasternal long axis view with normal ejection fraction Nigist Taddese MBChB. Division of Hospital Medicine, John H Stroger Hospital of Cook County https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1604501874660-0IU60BXMGI6IPAFZ2YMQ/image-asset.gif Normal Cardiac Anatomy - Normal Parasternal Short Axis View Normal PSAX view at a level of the papillary muscles. In the center of the screen is the muscular walled LV, which forms a perfect circle. The smaller, thin-walled RV is seen superficially and wrapped around the LV. Dr. Felipe Urriola, Puerto Aysen Hospital, Emergency Department, Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1603202538120-87UL3B1IZ4E9YS6VDRMV/image-asset.gif Normal Cardiac Anatomy - Normal PLAX This is a normal parasternal long axis (PLAX) view. The right ventricle (RV) is at the top of the screen. Further down and from left to right: left ventricle (LV), outflow tract, aortic valve, ascending aorta. The actively moving mitral valve separates the LV from the left atrium (LA). At the bottom of the screen, the circular, anechoic image is the descending aorta. Dr. Felipe Urriola. Puerto Aysen Hospital Emergency Department, Chilean Patagonia. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1596723924730-5KCBLDUKY184F115HXUO/image-asset.gif Normal Cardiac Anatomy - Normal Parasternal Long Seen here is a parasternal long axis view of the heart highlighting normal anatomy. You can see the left atrium, aorta, and right ventricular outflow tract, descending thoracic aorta, mitral valve and interventricular septum. Also notice the presence of a small amount of physiologic pericardial fluid. Pericardial fluid in this image is the hypoechoic shadow anterior to the descending thoracic aorta. There is no evidence of pleural effusion, however when present it would appear as a hypoechoic shadow inferior to the descending thoracic aorta. Shahad Al Chalaby, MD. PGY3, Highland Hospital, Alameda Health System Internal Medicine Residency Program @shahad_Chalaby https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594128974353-5WZZBCAYQVZ3V7ICD344/image-asset.gif Normal Cardiac Anatomy - Normal subcostal view Seen here is a normal subcostal view of the heart. Note the hyperechoic strings (chordae tendenae) attaching to the cusps of mitral and tricuspid valves as well as to the ventricular walls via the papillary muscles. There is also notable absence of any hypoechoic pericardial fluid or effusion. Shahad Al Chalaby, MD. PGY2, Internal Medicine Highland Hospital, Alameda Health System Internal Medicine Residency Program. CA, USA @shahad_Chalaby https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533340845625-F7BQZ7TISCDQ4S5YXZ8C/subxi+normal.gif Normal Cardiac Anatomy - Subxiphoid / Subcostal - Normal The most superficial structure we see is the liver. Immediately deep to that we see the heart separated from the liver by the diaphragm. Closest to the liver is the right atrium, tricuspid valve, right ventricle. Deeper to that, we see the left atrium, mitral valve, and left ventricle. Hannah Kopinski - MS4, Dr. Lindsay Davis - NYU/Bellevue Department of Emergency Ultrasound, Dr. Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533303070183-8RPVDSNN45H5L2XH8643/central+line+confirmation.gif Normal Cardiac Anatomy - Central Line Confirmation After placing a central line, POCUS can be used to rapidly and accurately assess correct venous placement as well as exclusion of pneumothorax prior to confirmation via a CXR. Simply attach an agitated flush to the central line, get a good view of the right side of the heart (here we used the subxiphoid view) then flush rapidly. If you see bubbles pass from the right atrium to the right ventricle of the heart, you know you’re good to go. POCUS has a sensitivity of 86.8% and specificity of 100% for identifying correct central venous catheter placement. See our evidence atlas for more information. PMID: 28123616 If you placed this under direct visualization you know you aren’t likely to have caused a pneumothorax… but POCUS can rule that out too! (Look for lung sliding, lung point, B lines, and lung pulse.) Devki Joshi MS4 - SUNY Downstate Medical School, Dr. Matthew Riscinti and Dr. Isaac Gordon - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533340755751-28DSIIEOY3LCLELVB8FQ/parasternal+long+axis+normal.gif Normal Cardiac Anatomy - Parasternal Long Axis - Normal In this view we see the muscular left ventricle and the smaller left atrium separated by the mitral valve near the bottom of the screen. The aortic outflow tract (valve and root) comes off the left ventricle superficial to the left atrium. The most superficial chamber seen in this view is the right ventricle, separated from the left ventricle by the interventricular septum. The heart is surrounded by the bright hyperechoic pericardium. At the very bottom of the screen, the round structure outside the pericardium is the descending thoracic aorta in transverse view. Hannah Kopinski - MS4, Dr. Lindsay Davis - NYU/Bellevue Department of Emergency Ultrasound, Dr. Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533340808137-QW4J27CSDFUL639PG3BJ/parasternal+short+axis+papillary+normal.gif Normal Cardiac Anatomy - Parasternal Short Axis - Normal In this view we are evaluating the heart in cross-section. In the center of the screen is the muscular walled left ventricle, which should form a perfect circle. This is at a level below the mitral valve and we can see the papillary muscles come into view. The smaller, thin walled, crescent shaped right ventricle is seen superficially and to the left of the screen. Hannah Kopinski - MS4, Dr. Lindsay Davis - NYU/Bellevue Department of Emergency Ultrasound, Dr. Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533340807311-EOLBMG24ZZ8FW4CUSBY7/parasternal+short+mitral+normal.gif Normal Cardiac Anatomy - Parasternal Short Axis (Mitral Valve) - Normal In this view we are evaluating the heart in cross-section. In the center of the screen is the muscular walled left ventricle, which should form a perfect circle. At the beginning of the clip, we see the “fish mouth” appearance of the mitral valve as it opens and closes. Then the probe is tilted inferiorly towards the apex and the papillary muscles come into view. The smaller, thin walled, crescent shaped right ventricle is seen superficially and to the left of the screen. Hannah Kopinski - MS4, Dr. Lindsay Davis - NYU/Bellevue Department of Emergency Ultrasound, Dr. Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533340735596-NXETNR654CKDAUXS3RD9/apical+5+normal.gif Normal Cardiac Anatomy - Apical 5 Chamber - Normal In this view we are able to visualize all four chambers of the heart. Clockwise from the top left of the screen we see the right ventricle, left ventricle, left atrium, and right atrium. We can also see the tricuspid valve between the RA and RV and the mitral valve between the LA and LV. The “fifth chamber” is the aortic valve/root which can be appreciated in the center of the image. Hannah Kopinski - MS4, Dr. Lindsay Davis - NYU/Bellevue Department of Emergency Ultrasound, Dr. Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533340761896-F7CB7JOJRV4HKYLFYT5E/apical+4+normal.gif Normal Cardiac Anatomy - Apical Four Chamber - Normal In this view we are able to visualize all four chambers of the heart. Clockwise from the top left of the screen we see the right ventricle, left ventricle, left atrium, and right atrium. We can also see the tricuspid valve between the RA and RV and the mitral valve between the LA and LV. Hannah Kopinski - MS4, Dr. Lindsay Davis - NYU/Bellevue Department of Emergency Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533340837831-96B9SO0G3BZYRAU7H8F6/subxi+normal+2.gif Normal Cardiac Anatomy - Subxiphoid / Subcostal - Normal Anatomy The most superficial structure we see is the liver. Immediately deep to that we see the heart separated from the liver by the diaphragm. Closest to the liver is the right atrium, tricuspid valve, right ventricle. Deeper to that, we see the left atrium, mitral valve, and left ventricle. Hannah Kopinski - MS4, Dr. Lindsay Davis - NYU/Bellevue Department of Emergency Ultrasound, Dr. Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507300178195-H3VUZYZIPGO7XG6JLTD8/Subcostal+Short+Axis.gif Normal Cardiac Anatomy - Subcostal Short Axis WCUME17 Submission for "Novel Indication" Subcostal short axis view of the left ventricle can be useful if PSAX window is poor. A good alternative to estimate LV function. This image shows: LV in short axis at level of MV and the RV in short axis, and the interventricular septum. The liver is overlying. Technique: Start with IVC in long axis at entrance to RA and tilt transducer cephalad. Slide transducer to patient's right, fan transducer out to patient’s left. Dr. Cian McDermott - Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515543912261-MX3UJMRSXF12D9US2UT1/ezgif.com-gif-maker+%281%29.gif Normal Cardiac Anatomy - Normal Apical 2 Chamber View Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515544100377-BDN6UHGVSAYQOGJO3PT8/ezgif.com-optimize+%286%29.gif Normal Cardiac Anatomy - Normal Apical 4 Chamber Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515544218048-AUE30MHR134JXT7ZGF4R/ezgif.com-optimize+%287%29.gif Normal Cardiac Anatomy - Apical 5 Chamber View Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515767679206-BH2GJASY9HR62MV80RJ6/ezgif.com-gif-maker+%281%29.gif Normal Cardiac Anatomy - Normal Subcostal View Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515545459549-ND42DTE1LFWWBU75CEA9/ezgif.com-optimize+%2820%29.gif Normal Cardiac Anatomy - Aortic Valve (Short) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515618754085-8GLR2N3BJNYT4C9SUCSY/ezgif.com-optimize+%2816%29.gif Normal Cardiac Anatomy - Inferior Vena Cava Emptyting into Right Atrium Normal IVC seen in longitudinal view, emptying into the right atrium. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515766527217-ENE3R8HJHFOPERYO15MC/ezgif.com-optimize+%2818%29.gif Normal Cardiac Anatomy - Normal Inferior Vena Cava Normal IVC seen in transverse plane using a subxiphoid approach. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. S Fares) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515767288177-H89BPAD3DFDGV1R1S04A/ezgif.com-optimize+%2826%29.gif Normal Cardiac Anatomy - Mitral Valve Parasternal Long-Axis View Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515767787105-MGQSHB3P1C37KRDVZHNH/ezgif.com-gif-maker+%282%29.gif Normal Cardiac Anatomy - Normal Parasternal Long-Axis View Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515767891946-8YMWL433EEP1M0B2L427/ezgif.com-gif-maker+%283%29.gif Normal Cardiac Anatomy - Normal Aortic Valve (Parasternal Short-Axis View) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515767987129-38FDMKMX49TYL04REUES/ezgif.com-gif-maker+%284%29.gif Normal Cardiac Anatomy - Normal Mitral Valve (Parasternal Short-Axis View) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://www.thepocusatlas.com/pericardial-disease daily 0.75 2025-06-07 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1749318777461-4105WD0NQ94K3NQDCEL5/image-asset.gif Pericardial Disease - SLE Pericardial Effusion in multiple views 20-year-old female patient, not known to have any medical illnesses. Presented to the ED complaining of generalized fatiguability, lightheadedness, exertional dyspnea, chest pain, palpitation, dry cough, and lower limb edema for 4 months, these symptoms has been intermittent and progressively worsening. Chest pain is position, aggravated by exertion and lying flat, relieved by rest and leaning forward. The patient also complains of hand joints pain and swelling, with temporary morning stiffness. The patient was tachycardic with a maintained BP. The patient’s clinical exam is positive for bilateral lung basal crepitation and bilateral lower limb pitting edema. Labs showed critically low Hb of 4.9 g/dL, ANA of 1:320, DAT+, and high agglutinin titer. Echo showed large pericardial effusion and evidence of early systolic collapse of right atrium (RA). The patient was diagnosed with systemic lupus erythematosus (SLE) and autoimmune hemolytic anemia with serositis. Hassan Alshaqaq, MBBS, Emergency Medicine Resident at King Saud University Medical City, Riyadh, Saudi Arabia. Twitter: @HassanAlshaqaq https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1749318777461-4105WD0NQ94K3NQDCEL5/image-asset.gif Pericardial Disease - SLE Pericardial Effusion in multiple views 20-year-old female patient, not known to have any medical illnesses. Presented to the ED complaining of generalized fatiguability, lightheadedness, exertional dyspnea, chest pain, palpitation, dry cough, and lower limb edema for 4 months, these symptoms has been intermittent and progressively worsening. Chest pain is position, aggravated by exertion and lying flat, relieved by rest and leaning forward. The patient also complains of hand joints pain and swelling, with temporary morning stiffness. The patient was tachycardic with a maintained BP. The patient’s clinical exam is positive for bilateral lung basal crepitation and bilateral lower limb pitting edema. Labs showed critically low Hb of 4.9 g/dL, ANA of 1:320, DAT+, and high agglutinin titer. Echo showed large pericardial effusion and evidence of early systolic collapse of right atrium (RA). The patient was diagnosed with systemic lupus erythematosus (SLE) and autoimmune hemolytic anemia with serositis. Hassan Alshaqaq, MBBS, Emergency Medicine Resident at King Saud University Medical City, Riyadh, Saudi Arabia. Twitter: @HassanAlshaqaq https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1729635075314-S0NG28AXV49H8DIHXC1X/image-asset.gif Pericardial Disease - Cardiac Tamponade Found During RUSH Exam Here is an excellent of example of utilizing Rapid Ultrasound for Shock and Hypotension (RUSH). This was from a 77 year old patient who presented initially presented with progressive weakness and a fall while in the bathroom. His initial blood pressure was labile but not hypotensive. Workup revealed leukocytosis in the presence of anuria and was eventually admitted with broad spectrum antibiotics. Shortly after admission, he became increasingly hypotensive and required norepinephrine. RUSH performed initially with the intention of assessing IVC for fluid status however the image above was discovered. There is obvious right ventricular diastolic collapse in the presence of pericardial effusion, consistent with cardiac tamponade. Dr. Austin Shanks, MD, PGY-2 Riverside Regional Medical Center Emergency Medicine Residency (Newport News, VA) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1706572256915-IHC9Q7TA3HI3XRJ3MBL1/image-asset.gif Pericardial Disease - Pericardial and Pleural Effusion In PSSA Patient with both a pericardial and pleural effusion in cardiac short axis view. You can see a large anechoic effusion surrounding the lung (pleural effusion) and a trace anechoic effusion spreading anterior to the descending aorta (pericardial effusion). Pleural effusions are never anterior to the aorta. Dimitri Livshits DO, Ultrasound Fellow, Kings County/SUNY Downstate; Jane Belyavskaya MD, Ultrasound Fellow, Kings County/SUNY Downstate; Chris Hanuscin MD, Ultrasound Division Director, Kings County/SUNY Downstate; https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1706570222652-Z6J3FZ0G4CX2KG8QEL57/image-asset.gif Pericardial Disease - Pericardial Effusion Vs Fat Pad [1/2] Pericardial fat pad is often mistaken for a pericardial effusion, this clip demonstrates both in the same clip. Pericardial fat pad moves in concert with the heart, while an effusion is circumferential, stationary and does not move in concert with the heart. Multiple cardiac views are helpful in making the diagnosis. Dr. Dimitri Livshits Ultrasound Fellow;Dr. Jane Belyavskaya Ultrasound Fellow;Dr. Chris Hanuscin Ultrasound Fellowship Director https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1706570376077-9Q7LONXIFC3PJAQY5WZJ/image-asset.gif Pericardial Disease - Pericardial Effusion Vs Fat Pad [2/2] Pericardial fat pad is often mistaken for a pericardial effusion, this clip demonstrates both in the same clip. Pericardial fat pad moves in concert with the heart, while an effusion is circumferential, stationary and does not move in concert with the heart. Multiple cardiac views are helpful in making the diagnosis. Dr. Dimitri Livshits Ultrasound Fellow;Dr. Jane Belyavskaya Ultrasound Fellow;Dr. Chris Hanuscin Ultrasound Fellowship Director https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697820597548-NF0G2VR1XSPW22W4FS83/image-asset.gif Pericardial Disease - Hemopericardium From a Stab Wound This subxiphoid view of the heart was performed on a patient after a singular stab wound to the chest. From here, we can observe a large collection of blood within the pericardial sac (hemopericardium) with visible cardiac activity still occurring. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598021567291-K04USWN8TYTPCQE7CI92/image-asset.gif Pericardial Disease - Pericardial Tamponade A 39-year-old female with known metastatic lung cancer complicated by multiple pulmonary emboli on apixaban presented with worsening dyspnea and productive cough over one week duration. POCUS identified a large, circumferential pericardial effusion (appreciated in multiple views; subcostal view shown here). Of note, she had echocardiographic findings consistent with tamponade physiology including early right ventricular (RV) diastolic collapse and right atrial systolic collapse. She also has evidence of RV strain demonstrated by flattening of her interventricular septum with ventricular interdependence (the latter findings are likely secondary to underlying chronic thromboembolic disease and pulmonary hypertension). Shahad Al Chalaby, MD. PGY3 Internal Medicine. Highland Hospital. Alameda Health System Residency Program. Oakland, CA, USA. @shahad_Chalaby Adam Mortimer, DO. PGY1 Internal Medicine. Highland Hospital. Alameda Health System Residency Program. Oakland, CA USA. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1596726833749-TQAC3KE5Z9C4OW747YNA/image-asset.gif Pericardial Disease - Cardiac Tamponade A 62-year-old female with a history of metastatic breast cancer presented with acute dyspnea and was found to have pericardial effusion with temponade physiology. Seen here in parasternal long and subsequent short axis views, POCUS demonstrates diastolic RV collapse, systolic RA collapse, and ventricular interdependence. Notice the presence of hypoechoic pericardial effusion both anteriorly and posteriorly consistent with a circumferential effusion; also note the hyperdynamic LV. Shahad Al Chalaby, MD. PGY3. Highland Hospital. Alameda Health System Internal Medicine Residency Program @shahad_Chalaby https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594841146277-2Y0XGZTSJQFFJA57E83Z/ezgif.com-optimize.gif3.gif Pericardial Disease - Ascites, Pericardial Effusion & Left Pleural Effusion Subcostal window of patient with Lupus. An anechoic region is seen within the peritoneum, pericardium, and left lung indicating simultaneous ascites, pericardial effusion, and pleural effusion respectively. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616075126653-C8MY1A30G7C0Z7C0IX4L/image-asset.gif Pericardial Disease - Circumferential Pericardial Effusion with Tamponade Seen here is the subcostal view of a patient with hemodynamic compromise. Note the circumferential area of anechoic fluid, resulting in dynamic right atrial and ventricular collapse as well as global hyperdynamic systolic function. It is important to remember that systolic right atrial collapse may be the earliest echocardiographic sign of tamponade. Diastolic right ventricular collapse indicates decreased cardiac output as a consequence of inappropriate right ventricular filling. Rupinder Sekhon, MD Central Michigan University, Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616438112737-2TDYCSPN673K52PDFQU0/image-asset.gif Pericardial Disease - Cardiac Tamponade secondary to Type A Aortic Dissection A 72-year-old male presented with syncope and was found to be hypotensive. POCUS revealed a large, circumferential pericardial effusion with tamponade physiology. Additional workup including chest CT revealed POCUS findings to be the consequence of a Type A aortic dissection (with blood extending back into the pericardial sac). Dr. John Cook, @J_County Dr. Tim Scheel, @tscheelEMUS https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616097821668-E60DF5UR57A8BH3CEHRP/image-asset.gif Pericardial Disease - Pre- & Post- Pericardiocentesis Subcostal view of a pericardial effusion with cardiac tamponade and its resolution with pericardiocentesis. Renato Melo, Pocus Jedi co-founder, @JediPocus Emergency Physician at H.C. de Marília/SP Brazil https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1619467281684-455EBQAR90TXD14FN80J/image-asset.gif Pericardial Disease - Pericardial Effusion noted during CPR POCUS obtained during a cardiac arrest demonstrates both CPR in progress as well as a large pericardial effusion. This patient had been waiting for CT aortogram to further evaluate severe back pain prior to onset of arrest. The pericardial collection appears hyperechoic indicating clotted blood (most likely secondary to a Type A aortic dissection). An attempt at needle aspiration was unsuccessful and the patient died. Peter Cheng https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620332894602-ZPG24CWVW9YHNBLUBRC2/image-asset.gif Pericardial Disease - Attempted Pericardiocentesis Patient had PEA arrest. View of the heart revealed pericardial effusion. The needle entering the pericardium can been seen in this clip. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620331924720-9DA4180VWGMN1L2VUP45/image-asset.gif Pericardial Disease - Confirmation of Needle Placement For Pericardiocentesis Initial stage of the pericardiocentesis. Agitated saline was injected to confirm needle location prior to withdrawing bloody fluid. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625684275085-AX4I4LL9J78I59MFWXP6/image-asset.gif Pericardial Disease - Pericardial Cyst This subcostal view shows cysts located on the pericardium. A benign and rare finding to be aware of while performing an echo. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631721796649-ZA1GTOU3A73F06QQJFFL/image-asset.gif Pericardial Disease - RV Diastolic Collapse in Cardiac Tamponade A patient with a history coronary artery disease presented to our emergency department complaining of acute weakness. He was febrile, tachycardic and hypotensive. POCUS was performed and demonstrated a circumferential anechoic rim in multiple views, consistent with a pericardial effusion (subcostal four-chamber view is shown above). Right ventricular (RV) diastolic collapse was visualized and consistent with the diagnosis of pericardial tamponade. Loss of central pulses prompted resuscitative efforts and an emergent pericardiocentesis, which resulted in return of spontaneous circulation. Andrew Namespetra, MB BCh BAO. @AndrewNamespet1 PGY-1 EM Resident at Central Michigan University Samantha Wong, DO. PGY-3 EM Resident at Central Michigan University https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631713248907-U0P8EHLB7FPPFMVQT9C7/image-asset.gif Pericardial Disease - Subxiphoid View of Pericardial Effusion Seen here is a subxiphoid view of a circumferential pericardial effusion. Of note, there is no diastolic RV collapse, therefore no echocardiographic tamponade. Moudi Hubeishy @moudihubeishy https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631712704017-4NE36PEQSE6HLKVXXRTS/image-asset.gif Pericardial Disease - Circumferential Pericardial Effusion Seen here is a circumferential pericardial effusion identified in a patient without hemodynamic evidence of tamponade. Moudi Hubeishy @moudihubeishy https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1627053173610-QM07PLB90XSS5WJT6KD0/image-asset.gif Pericardial Disease - Traumatic Tamponade 27-year-old woman presents with gunshot wound to right chest. Patient phonating on arrival but tachycardic in 150s with BP 60/palp. EFAST revealed pericardial effusion with hematoma and near complete RV diastolic collapse, consistent with cardiac tamponade. Decision was made to take patient directly for OR thoracotomy based on EFAST findings. Patient lost pulses for 10 sec intra-operatively prior to receiving pericardial window. ROSC was achieved with removal of pericardial hematoma. LV laceration was identified and repaired. LAD laceration identified for which patient received emergent CABG by CT surgery. Patient was successfully extubated the next day, discharged one week later. EFAST aids in rapid diagnosis and expedites care in hemodynamically unstable trauma patients. POCUS is a useful tool for determining etiology of undifferentiated shock. Quinn Fujii DO, William Hamrick DO, Ulysses Garcia DO, Robert Rigby DO Desert Regional Medical Center, Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1623695931590-IOY6S9OE5O2KXKMJFWH2/image-asset.gif Pericardial Disease - Cardiac Tamponade Seen here is a parasternal long axis view of a patient with cardiac tamponade. Francisco Norman https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626286516799-QH3QETRQ2MB96PJX6VBO/image-asset.gif Pericardial Disease - Hemopericardium POCUS revealed isoechoic fluid within the pericardium indicative of a hemopericardium in a patient suffering from a gunshot wound. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625682637632-0YDLWSMPKVSNS169JE1Z/image-asset.gif Pericardial Disease - Ascitic Fluid on Subcostal View This subcostal view shows a patient with ascites, a small pericardial effusion, and a left sided pleural effusion. When suspecting a pericardial effusion, always ensure which side of the diaphragm the fluid presents. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1627324112088-ISBE7CA5GEBSR6D3M7Z6/image-asset.gif Pericardial Disease - Intrapericardial Hematoma Parasternal short axis view of a Post-CABG intrapericardial hematoma. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626287209098-6CAPYOMF5N0X89OKIPKR/image-asset.gif Pericardial Disease - Hemopericardium POCUS revealed a retained bullet near the left ventricular wall in a patient following a gunshot wound. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614119500699-GJJ07O24O0WFBAE79PWN/image-asset.gif Pericardial Disease - Pericardial Effusion Parasternal short axis view of a pericardial effusion. View the thread at the link below for parasternal long axis and associated EKG findings. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614808578334-HZG3NWLOBLCZBGIL702J/image-asset.gif Pericardial Disease - Uremic Pericarditis PLAX view in a patient who presented to the ED after missing several scheduled dialysis sessions reveals a small pericardial effusion with a pericardial friction rub on exam. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1610645109459-FWOUATEKDRRKDMQ2TDV1/image-asset.gif Pericardial Disease - Hemopericardium A young previously healthy male presented to the ED with a transmediastinal gunshot wound. FAST exam revealed hemopericardium on the subxiphoid window. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609788612615-MPCVTB9BK19H61P41QBJ/image-asset.gif Pericardial Disease - Fibrinous Pericardial Effusion A young male presented with a 5-month history of signs and symptoms of heart failure. Apical four chamber view pictured here revealed a large pericardial effusion, most significant for the presence of fibrinous stranding. Fibrinous pericardial effusions are most commonly related to tuberculosis (worldwide) whereas malignancy and inflammatory/infectious processes are alternate possible etiologies. PCR of pericardial fluid went on to confirm Mycobacterium tuberculosis in this patient. Note: depth of this image was intentionally used to augment the view of the apex and presence of fibrinous strands. Gordon Johnson, @pdxfutebol Portland, Oregon https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609780075075-NNJT1T7MF3XX3AFCCCI7/image-asset.gif Pericardial Disease - Pericardial Effusion vs Tamponade Seen here is a subxiphoid view of a moderate sized, free-flowing pericardial effusion. There is >50% collapsible IVC which makes tamponade less likely in the absence of clinical signs of hemodynamic deterioration (i.e. normal blood pressure, mild tachycardia and pulsus paradoxus <10 mmHg). Plethora of the IVC in pericardial effusion is associated with elevated right heart filling pressures and is more sensitive though less specific for tamponade than right heart chamber collapse or jugular venous distention. Plethora of the IVC also has greater sensitivity than does elevated jugular venous distention on physical examination (97% versus 61%). Reference: Ronald Himelman, Barbara Kircher, Don Rockey, Nelson Schiller. Inferior vena cava plethora with blunted respiratory response: A sensitive echocardiography sign of cardiac tamponade. JACC. 1988; 12:1470-1477. Shahad Al Chalaby, MD (PGY3) @shahad_Chalaby Alameda Health System Internal Medicine Residency Program Oakland, CA https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607704589392-NSQ9M591FDC4Z6U1D0YL/image-asset.gif Pericardial Disease - Constrictive Pericarditis A young patient with a history of SLE presented to the ED with new onset HFpEF. A subcostal view revealed constrictive pericarditis with septal wall bouncing and a mild pericardial effusion. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1606993231208-NMKGJ19PUJQM7IL2KW5N/image-asset.gif Pericardial Disease - Purulent Pericarditis A male in his 20’s presented following failed community acquired pneumonia treatment with fever, chest pain, and soft vitals. Bedside ultrasound revealed purulent pericarditis visible in this subcostal window. CT showed LLL pneumonia with empyema. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1602187194978-JME7T3B9TWSISQOD4CXI/image-asset.gif Pericardial Disease - Cardiac Tamponade with Swinging Heart 31-yo-male presented s/p syncopal episode and ongoing hypotension. Initial evaluation included POCUS that revealed a circumferential pericardial effusion causing RA and RV diastolic collapse as well as a “swinging heart”. Patient was promptly sent for a pericardial window. Tessa W. Damm, DO Intensivist, Critical Care Medicine & Neurocritical Care Wisconsin, USA @DrDamm https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1510783742149-K6F7JUMUZ1RU1KP9PWTN/alerhand+tamponade.gif Pericardial Disease - Cardiac Tamponade 60 y/o M with metastatic lymphoma presented with SOB over 3 days. POCUS revealed a pericardial effusion that, along with his vital signs and clinical picture, altogether suggested pericardial tamponade. Notice the diastolic collapse of the right ventricle (as the mitral valve opens, the right ventricle free wall collapses). Mitral and tricuspid inflow velocities were also used as a surrogate for pulsus paradoxus. Dr. Stephen Alerhand - Mt Sinai Hospital, NYC https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592917193413-2JUHHPNDHDPYQCZ5FF9X/image-asset.gif Pericardial Disease - Acute Pericarditis A young male presented with 2-day history of chest pain. His ECG revealed diffuse ST segment elevation. He had an elevated but serially stable troponin level. POCUS excluded focal wall motion abnormality though was notable for the presence of a small pericardial effusion and a thickened, hyperechoic pericardium; consistent with his diagnosis of acute pericarditis. Renato Melo, Emergency Physician @Renato_Melo_ https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1586982593241-WS3RCMQOM8F4RTUHTHV4/image-asset.gif Pericardial Disease - Cardiac Tamponade in PEA A 83-year-old woman comes to emergency department In cardiac arrest after an episode of severe chest pain. During pulse check we identified PEA (Pulseless Electrical Activity) and performed a CASA Exam. The subcostal view demonstrates a hyperechoic structure in the pericardial space concerning for clot. There is also evidence of cardiac tamponade. Image courtesy of Josiane Almeida https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579294878267-G35L8N4QQNZH3UCYMYBJ/image-asset.gif Pericardial Disease - Pericardial Effusion in Parasternal Short-Axis Here is an example of relatively preserved myocardial function in the setting of a moderate-sized, circumferential pericardial effusion, as seen from the parasternal short-axis view. Edgar Miranda, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1569843457832-A1HX02E1Z7RE8QK5T514/pericardial+hematoma.gif Pericardial Disease - Pericardial Effusion with Hematoma This is a subcostal view of a patient presenting after a motor vehicle collision. The image demonstrates a pericardial effusion containing a large hypoechoic mobile structure concerning for hematoma. Image courtesy of IUEM Ultrasound Original Twitter post can be found here. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1576958119778-MBY3TS5RU3VP5US30LN5/image-asset.gif Pericardial Disease - Pericardial Effusion and Rapid Atrial Fibrillation 50 y/o male presented with 1 week of feeling generally unwell, tired and short of breath. Rapid atrial fibrillation was present in the department. POCUS performed demonstrating large pericardial effusion (note some evidence of diastolic collapse as well as partially complex-appearing pericardial fluid collection). Nishant Cherian Emergency Medicine Registrar https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579514509514-SJI41FI5NNHR0HYQETPV/image-asset.gif Pericardial Disease - Pericardiocentesis Dynamic needle guidance in a parasternal view used to perform an emergent pericardiocentesis in a hemodynamically unstable patient. Ahad Al Saud, Emergency Medicine Physician @Ahad_AlSaud https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533300309324-073V1LJCQLNNH0LPHCCD/exudative+effusion.gif Pericardial Disease - Exudative Effusion A 67y/o M PMH ESRD presented to the ED with recurrent sharp chest pain, cough, and fever that were reported during routine dialysis. He had been recently hospitalized for chest pain one week prior and diagnosed with pericardial effusion. Upon repeat presentation to the ED, the patient’s vital signs and examination were unremarkable. ECG showed diffuse PR depressions and ST elevations. PoCUS (cardiac subcostal view shown) demonstrated a circumferential, anechoic pericardial fluid collection with septations; there was no evidence of tamponade. The patient was started on indomethacin and colchicine and admitted to the CCU. A few days later, cardiothoracic surgery performed a pericardial window, drained 350 ml of serosanguinous fluid, and lysed multiple adhesions. Biopsied tissue revealed a thickened, inflamed pericardium with abscess and granulation tissue formation. Pericardial fluid testing was negative for bacteria, fungi, acid-fast bacilli, and malignancy. Emergency physicians can detect pericardial effusion with a sensitivity of 96% (95% confidence interval [CI] 90.4% to 98.9%), specificity of 98% (95% CI 95.8% to 99.1%).[i] High risk features that warrant hospital admission include temperature > 38°C, subacute course, large effusion (echo-free space > 20 mm), tamponade, and lack of response to aspirin or non-steroidal anti-inflammatory drug therapy; however, the etiology often remains a mystery. [ii] The presence of a loculated effusion on echocardiography may suggest the eventual need for surgical intervention with pericardiectomy or pericardial window.[iii] Dr. Ian Desouza - Kings County Emergency Medicine [i] Mandavia DP, Hoffner RJ, Mahaney K, Henderson SO. Bedside echocardiography by emergency physicians. Ann Emerg Med 2001;38:377-82. [ii] Imazio M, Cecchi E, Demichelis B, et al. Indicators of poor prognosis of acute pericarditis. Circulation 2007;115:2739-44. [iii] Imazio M, Spodick DH, Brucato A, Trinchero R, Adler Y. Controversial issues in the management of pericardial diseases. Circulation 2010;121:916-28. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522721694296-O2PEODDWOC4CWXHB3K4V/riscinti+dissection+tamponade.gif Pericardial Disease - Aortic Dissection with Tamponade - Parasternal Long 50 year old mandarin speaking man complains of vague central chest pain. You pursue a routine cardiac workup which is fairly normal. Upon discharging him, the nurse tells you his systolic in now in the 80's. You perform a RUSH exam - echo demonstrates a widened aortic outflow tract (well exceeding the rule of thirds) suggesting a Type A aortic dissection. You also see a pericardial effusion with right ventricular diastolic collapse. This is "the man jumping on the trampoline" or dimpling of the right ventricular free wall during diastole while it should be filling - clenching the diagnosis of tamponade. You better hope your CT surgeon is in house. Scroll to see the rest of the case for further images. Dr. Matthew Riscinti - Kings County Emergency Medicine, Dr. Benjamin Clearly - NYU Langone Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522722707642-2AIRIXP6AOEC5M3GZSPV/riscinti+dissection+tamponade.gif Pericardial Disease - Aortic Dissection with Tamponade - Apical 50 year old mandarin speaking man complains of vague central chest pain. You pursue a routine cardiac workup which is fairly normal. Upon discharging him, the nurse tells you his systolic in now in the 80's. Your RUSH exam and echo on this apical four demonstrate a pericardial tamponade with both: 1. Right ventricular DIASTOLIC collapse - dimpling of the right ventricular free wall during diastole while it should be filling 2. Right Atrial SYSTOLIC collapse - (but in atrial diastole) while the atrium should be filling Scroll to see the rest of the case for further images. Dr. Matthew Riscinti - Kings County Emergency Medicine, Dr. Benjamin Clearly - NYU Langone Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522981691885-TB6Z6K1RTSUPDAPWSSY5/riscinti+tamponade+parasternal+long+mmodify.jpeg Pericardial Disease - Aortic Dissection with Tamponade - M-mode Your RUSH exam's echo, parasternal long, shows tamponade. M-mode can be used to confirm by placing the M-mode line through the RV and the mitral valve to better visualize the RV diastolic collapse. The top line of the image shows the RV free wall collapsing during diastole when it should be filling. You know this is during diastole because the mitral valve is opening at this time, seen toward the bottom of the M-mode image. This image was created retrospectively using M.Mode.ify by Dr. Ben Smith. Dr. Matthew Riscinti - Kings County Emergency Medicine, Dr. Benjamin Clearly - NYU Langone Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537199459126-CYP40BWMXNTFXGLK5UMR/tamponade+parasternal+short.gif Pericardial Disease - Cardiac Tamponade Parasternal Short 41 yo M with history of stage 4 lung cancer presents with AMS and dyspnea, normotensive and tachycardic to 140s. Parasternal long view showed moderate pericardial effusion with RV collapse. With M mode we are able to see the RV wall collapse (top line) corresponds with the mitral valve opening i.e. it occurs during diastole. Even though the patient was normotensive he was taken to the OR for a pericardial window within the hour given this evidence of echocardiographic tamponade. Nathan Kabariti MS4, Dr. Charles Murchison, Dr. John Riggins, Dr. Donald Doukas - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1518201775178-POYN3T69DCU9UDXRBBKH/surles+kendal+tamponade.gif Pericardial Disease - Malignant Pericardial Effusion 40 y/o F with 2-3 months of weight loss and new diagnosis of mediastinal mass. Sent from clinic for SOB. Patient initially tachycardic, tachypnic. EKG shows electrical alternans. US shows large hypoechoic area with mobile hyperechoic lines in an effusion concerning for fibrinous exudate/growth. There is no sign of end diastolic right ventricular collapse. Findings are consistent with a pericardial effusion with fibrin deposits without evidence of tamponande. For POCUS - the easiest assessment of tamponade is to look at end diastolic right atrial and ventricular collapse. Since the right side of the heart typically is at lower pressures, it will be the first to collapse from the pressure in the pericardium. It is easily measured with m-mode across the wall of the ventricle or atria. Bedside US is an amazing tool and can quickly and effectively show the hemodynamic status in pericardial effusion, so that the correct management can be done. Dr. Carolina Camacho, Taylor Surles, Michael Greisinger, and Scott Kendall - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507299584019-WF11PCAIWDURY9SJ1J19/Chronic+Pericardial+Effusion.gif Pericardial Disease - Chronic Pericardial Effusion WCUME17 submission for "Creative Caption" "When the turtle's head appears you know you're in trouble!" Patient with chronic pericardial effusion and... a heart that looks like a snapping turtle? Dr. Robert Jarman - UK https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507868498140-FXGBDT9O7WPCSV9UGNAN/Hemorrhagic+Cardiac+Tamponade.gif Pericardial Disease - Acute Traumatic Cardiac Tamponade WCUME 2017 Submission for "Best POCUS" Massive hemopericardium with coagulating blood and tamponade in a pediatric trauma patient. The patient went straight to the OR based on this image! Dr. Sarah Medeiros - Sacramento, CA https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515543755104-USLPQ1E3MZ3CE2A6K49O/ezgif.com-optimize+%285%29.gif Pericardial Disease - Cardiac Tamponade - Subxiphoid View This is a subxiphoid view demonstrating a moderate pericardial effusion and diastolic collapse of the right ventricle concerning for cardiac tamponade. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515768436144-4ZFBBEBZKUSK0W8YXRC8/ezgif.com-optimize+%2832%29.gif Pericardial Disease - Cardiac Tamponade in Stabbed Patient Hematoma and relatively hypoechoic blood can be seen around the heart. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515768183208-AAVKN6XWDKZ30HMUGYP3/ezgif.com-optimize+%2830%29.gif Pericardial Disease - Cardiac Tamponade in Apical View Apical view demonstrating rocking heart with diastolic collapse of RV free wall. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Orr) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515768544020-TUJ7299YYVIM4M6O6KE0/ezgif.com-optimize+%2834%29.gif Pericardial Disease - Cardiac Tamponade Subcostal view demonstrating signs of cardiac tamponade including right ventricular collapse during diastole. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Orr) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515768290263-IB6LRP24TWSA1A1SR8FN/ezgif.com-gif-maker+%286%29.gif Pericardial Disease - Cardiac Tamponade (Parasternal Short-Axis View) Parasternal short axis view demonstrating evidence of diastolic RV free wall collapse. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Orr) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513461340076-K2TW9ENOXBQ4LCY2C0QV/ezgif.com-optimize+%283%29.gif Pericardial Disease - Cardiac Tamponade with Doppler Mitral inflow velocity respiratory variation > 25% consistent with cardiac tamponade physiology. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537199435585-FMNWDN8BLOYPVWVK8WUD/tamponade+apical+four.gif Pericardial Disease - Cardiac Tamponade Apical Four 41 yo M with history of stage 4 lung cancer presents with AMS and dyspnea, normotensive and tachycardic to 140s. Parasternal long view showed moderate pericardial effusion with RV collapse. With M mode we are able to see the RV wall collapse (top line) corresponds with the mitral valve opening i.e. it occurs during diastole. Even though the patient was normotensive he was taken to the OR for a pericardial window within the hour given this evidence of echocardiographic tamponade. Nathan Kabariti MS4, Dr. Charles Murchison, Dr. John Riggins, Dr. Donald Doukas - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537199443838-L5SLCT9UVVIGR0D84KOM/tamponade+M-mode.gif Pericardial Disease - Cardiac Tamponade RV Diastolic Collapse M-mode 41 yo M with history of stage 4 lung cancer presents with AMS and dyspnea, normotensive and tachycardic to 140s. Parasternal long view showed moderate pericardial effusion with RV collapse. With M mode we are able to see the RV wall collapse (top line) corresponds with the mitral valve opening i.e. it occurs during diastole. Even though the patient was normotensive he was taken to the OR for a pericardial window within the hour given this evidence of echocardiographic tamponade. Nathan Kabariti MS4, Dr. Charles Murchison, Dr. John Riggins, Dr. Donald Doukas - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537199450965-R95OR2ALW0VYUQ77LN5P/tamponade+parasternal+long.gif Pericardial Disease - Cardiac Tamponade Parasternal Long 41 yo M with history of stage 4 lung cancer presents with AMS and dyspnea, normotensive and tachycardic to 140s. Parasternal long view showed moderate pericardial effusion with RV collapse. With M mode we are able to see the RV wall collapse (top line) corresponds with the mitral valve opening i.e. it occurs during diastole. Even though the patient was normotensive he was taken to the OR for a pericardial window within the hour given this evidence of echocardiographic tamponade. Nathan Kabariti MS4, Dr. Charles Murchison, Dr. John Riggins, Dr. Donald Doukas - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1553995280112-029L1GF9JAJN3MDS0W40/ezgif.com-optimize%2B%2838%29.gif Pericardial Disease - Parasternal Long Type A Aortic Dissection with Tamponade 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. Right ventricular diastolic collapse can be seen. Claire Heslop - Pediatric Emergency Medicine - University of Toronto Hospital for Sick Children https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1748054873166-VDRS91ZW252QIQ27K1R9/image-asset.gif Pericardial Disease - Cardiac Tamponade in Apical 4-Chamber View 52 y/o male, with PMH of T2DM, HTN, Obstructive Sleep Apnea, and Hyperlipidemia presented to the Emergency Department with worsening SOB for 1 month. Bedside Cardiac US demonstrated large pericardial effusion. Patient was sent to the OR for an emergency pericardiocentesis with removal of 1.1 L of fluid. Contributors: Dr. Lauren Lowes, DO; Dr. Shivani Lohit, MD; Maya Eylon MS4 Central Michigan University College of Medicine, Emergency Medicine https://www.thepocusatlas.com/valvulopathy daily 0.75 2024-12-20 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1734719143816-WT8C5J343M47K7YLIFNZ/image-asset.gif Valvulopathy - Mitral Regurgitation Jet Mitral regurgitation, blue jet regurgitating into the atrium Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1734719143816-WT8C5J343M47K7YLIFNZ/image-asset.gif Valvulopathy - Mitral Regurgitation Jet Mitral regurgitation, blue jet regurgitating into the atrium Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631721221856-9WM15CE8LGRGSIWYCY1U/image-asset.gif Valvulopathy - Mitral Valve Vegetation 32-year-old woman presented to ED with clinical signs of subacute stroke - confirmed via Brain CT . In the investigation of etiology of cerebral injury, POCUS identified this large hyperechoic vegetation on the mitral valve (seen here both in PLAX and PSAX views). As a result of these images, a diagnosis of infectious endocarditis causing cerebral septic emboli injury was considered. Renato Tambelli; @JediPocus Emergency Physician (HCFAMEMA /Sao Paulo, Brazil) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616437523726-ZU23SX9LNCRMVAXQ784R/image-asset.gif Valvulopathy - Mitral Regurgitation in Parasternal Long Axis Parasternal long axis view in a patient with severe mitral regurgitation. Rohan Rastogi, MD @RohanRastogiMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1608588604314-PHP9FX3LKS5CW5YCTPZO/image-asset.gif Valvulopathy - Tricuspid Regurgitation A patient with IVC and hepatic congestion on CT also had a holosystolic murmur at the left lower sternal border, worsened with inhalation. POCUS revealed severe tricuspid regurgitation on parasternal short axis view with color doppler. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1608042046731-5YS9DO0DEZB5F59C8DYB/image-asset.gif Valvulopathy - Tricuspid Valve Endocarditis Tricuspid valve endocarditis seen in a patient with IVDU. This subcostal view allows great visualization of the tricuspid valve when using the liver as an acoustic window. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1607707062543-DX5DZUVIQAOSXV440I6C/image-asset.gif Valvulopathy - Mitral Valve Endocarditis A patient presented to the ED with fever, sepsis, Janeway lesions, Osler nodes, and splinter hemorrhages. PLAX view revealed a vegetation on the mitral valve indicative of MV endocarditis. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1596721056016-KXU8EPCM3YDSN3VX4ZM6/image-asset.gif Valvulopathy - Functional MR in Heart Failure A 58-year-old male with ischemic cardiomyopathy and recently implanted AICD presented with subacute dyspnea without signs of volume overload on physical exam. Seen here is POCUS (apical four chamber view) notable for mitral valve regurgitation (MR) as demonstrated by the presence of a regurgitant jet. After excluding acute myocardial ischemia, patient was diagnosed with secondary (functional) MR due to heart failure. Separately, notice the hyperechoic lesion traversing the right atrium. In this patient it represents a segment of his AICD. The differential diagnosis, however, includes atrial thrombus and/or vegetation. Shahad Al Chalaby, MD. PGY3 Internal Medicine Highland Hospital. Alemeda Health System Internal Medicine Residency Program. CA, USA @shahad_Chalaby https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594933559073-SOWVYTJYJM5MPHVMKD5E/ezgif.com-optimize.gif9.gif Valvulopathy - Tricuspid Endocarditis Subcostal view of a patient with a history of IV drug use. Ultimately this patient was diagnosed with a polymicrobial endocarditis of the tricuspid valve with MRSA and Candida Albicans as culprits. Note the hyperechoic lesion swinging between the right atrium and right ventricle. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572731313207-COZHKPT2LB102LAIHJWC/ezgif.com-optimize+%2811%29.gif Valvulopathy - TAVR in Short Axis A 71-year-old male was brought to the ED via EMS for exertional chest pain. The patient was a poor historian and vaguely described a prior cardiac stenting procedure. Bedside echocardiography was performed and demonstrated a hyperechoic ring-shaped structure at the cardiac base when viewed in the parasternal short axis. This structure was determined to be a Transcatheter Aortic Valve Replacement (TAVR). This finding improved the care teams understanding of the patients medical history and altered their evaluation to include pathology of the proximal aorta. Arthur Gross, DO; Max Cooper, MD - Crozer-Chester EM https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584978436743-CQY5J4FMD4T4REJER765/image-asset.gif Valvulopathy - MV Inflow Variation This patient presented with acute blood loss anemia and high output heart failure. Note the significant mitral valve inflow respiratory variation secondary to hypovolemia (not attributed to the trace pericardial effusion). This nicely illustrates potential mitral/tricuspid valve inflow variation in hypovolemic patients. Luka Petrovic, Chief Medical Resident Rutgers New Jersey Medical School @lukapetrovic89 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515003475042-E04VVVDPUF2XNT2VP94E/ezgif.com-optimize+%281%29.gif Valvulopathy - Endocarditis Vegetations on the AV valve (endocarditis). 40y old female coming to the ED with acute ischemia of the left lower limb and fever. IVDA. Dr. Dominik Doeller https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1595954617513-ZML78F2O1YV6XYU1IRL8/thiessen+banks+mitral+endocarditis+a4c.gif Valvulopathy - Endocarditis in an Intravenous Drug User A careful look will show something extra on the mitral valve. Dr. Sarah Banks, Dr. Molly Thiessen - Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638505809978-7JI81TK5IKYC11CVW066/image-asset.gif Valvulopathy - Severe Mitral Regurgitation 60s M with PMH ischemic cardiomyopathy and CHF presented with multiple episodes of syncope. The initial workup was unrevealing so POCUS was performed. These color doppler images demonstrate severe mitral regurgitation as seen as a multicolored retrograde jet from the mitral valve during systole. This patient was admitted for further workup of his syncope and telemetry monitoring given the structural heart disease and concern for underlying dysrhythmia. Dr. Nhu-Nguyen Le, Fellow Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1539527827078-HBV91IH8HQQ2ORP4W7TD/aortic+root.gif Valvulopathy - Aortic Root Dilation with Aortic Regurgitation This images demonstrates a dilated aortic root in a patient with chest pain radiating to the back. Note that the ratio of the RV outflow tract, aortic root, and left atrium are not 1:1:1. Whilst you may not always see an intimal flap, a dilated aortic root and new aortic regurgitation may indicate acute aortic dissection. In this case, this was subsequently confirmed on CT aortogram. Dr. Peter Cheng https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509039121939-RMX8Y9HEGMP8GNH824O7/Hockey+stick+sign-Johnson.gif Valvulopathy - Hockey Stick Sign Mitral stenosis with mitral regurgitation with the classic MV "hockey stick" sign of rheumatic mitral valve disease. Dr. Gordon Johnson MD Internist Portland Oregon & Uganda https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507587643995-UJJY2DA2BX75P3WTS94B/AV-MV+Vegetations.gif Valvulopathy - Aortic & Mitral Valve Vegetations WCUME 2017 Submission for "Best POCUS" 40 year old male who presented with 1 week low grade fever and mild pedal edema and orthopnea. POCUS demonstrates a small vegetation on the anterior leaflet of the mitral valve as well as large vegetations on the aortic valve with obvious poor coaptation of valve leaflets. Dr. Peh Wee Ming - Singapore General Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515542920443-P3ONGAVPVL4FG9ETD984/ezgif.com-optimize.gif Valvulopathy - 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. Jason Tanguay, DO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496100348584-BXSCGL71OP6Z96BBJ58S/ezgif.com-optimize+%285%29.gif Valvulopathy - Mild Tricuspid Regurgitation A narrow, central tricuspid regurgitation jet is seen on this apical 4-chamber view consistent with mild tricuspid regurgitation. Jason Tanguay, DO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496100206379-MS6S41UXWRMQSBLO1QUI/ezgif.com-optimize+%284%29.gif Valvulopathy - Moderate Mitral Regurgitation A 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. Jason Tanguay, DO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515544589455-2OO4HUH2A1Y3R2BW2I1P/ezgif.com-gif-maker+%283%29.gif Valvulopathy - Moderate Aortic Regurgitation Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Giles and Dr. Jacob) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515544902163-45V9HHSS788B6OIFGQLU/ezgif.com-optimize+%2813%29.gif Valvulopathy - Severe Aortic Stenosis Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al.   https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515545052459-33RDR7171KVP7ABV1KU8/ezgif.com-optimize+%2815%29.gif Valvulopathy - Severe Aortic Stenosis Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515545210433-YLBG5VCV5DPNUL3KWYYA/ezgif.com-optimize+%2816%29.gif Valvulopathy - Aortic Valve Prosthesis (Long) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (with Dr. Orr) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515545345813-FOFNSLLDWUQW1XPO7VU0/ezgif.com-optimize+%2818%29.gif Valvulopathy - Aortic Valve Prosthesis (Short) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (with Dr. Orr) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515545626103-DMJ9N8JYQSK59Q7LB14D/ezgif.com-gif-maker+%284%29.gif Valvulopathy - Mild Aortic Valve Regurgitation Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Mo Haywood) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515545755031-TNS9XXSNQXBHO8ZXM6C4/ezgif.com-optimize+%2822%29.gif Valvulopathy - Heart Failure with Moderate Mitral Regurgitation Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. K Kaynama) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515767019629-YXWCB7H5VYOJCMGSAYOH/ezgif.com-optimize+%2824%29.gif Valvulopathy - Mixed Aortic and Mitral Regurgitation Mixed aortic and mitral regurgitation with color doppler. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515767388997-DGBRXU75CF4Z9XH33C74/ezgif.com-optimize+%2828%29.gif Valvulopathy - Mitral Valve Prolapse (Apical Long-Axis View) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Pankaj Arora) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515767555060-Q4XCSW79LKP2JGI1NGSY/ezgif.com-gif-maker.gif Valvulopathy - Prosthetic Mitral Valve (Apical 4 Chamber View) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515768627624-QQ9ALMF4JT2BZ49V0PGN/ezgif.com-gif-maker+%287%29.gif Valvulopathy - Tricuspid Valve Regurgitation Moderate to severe tricuspid regurgitation demonstrated on apical 4 chamber view. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Kaynama) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515768707079-7B86FVPZ5HERSOTTV9M1/ezgif.com-gif-maker+%288%29.gif Valvulopathy - Tricuspid Valve Regurgitation Subcostal View demonstrating mild tricuspid regurgitation Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513460839864-4OMCS2D9Y3O3M8TOYNL6/ezgif.com-optimize+%281%29.gif Valvulopathy - Mitral Regurgitation Moderate mitral regurgitation Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513461001628-ACO1KT52SIW4SIJ2CUE2/ezgif.com-optimize+%282%29.gif Valvulopathy - Pulmonic Vegetation Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537201148072-3XS5UAFFONKNWNJK3KS7/vegetations+.gif Valvulopathy - Mitral Vegetations 62 y/o M no PMH visiting from the Caribbean presents with 3 days of acute onset shortness of breath associated with severe exertional dyspnea, orthopnea and cough productive of whitish sputum without fevers or chest pain. POCUS was performed to evaluate undifferentiated shortness of breath. Subcostal view revealed vegetations on both mitral valve leaflets with severe mitral regurgitation, biatrial enlargement and global hypokinesis. Acute onset of severe heart failure requires emergent surgical intervention including mitral valve repair vs replacement. In our patient, POCUS lead to emergent transfer for CT surgery. Dr’s Karen Benabou, Eden Kim, and Eric Schnitzer - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631801181849-8RMKNMFK86TZ7WRE929W/image-asset.gif Valvulopathy - Tricuspid Valve Vegetation 50-60s F with PMH IVDU presents with chest pain, dyspnea, and fever. This POCUS image shows the parasternal short axis view at the level of the aortic valve, revealing a large vegetation on the tricuspid valve. Color doppler demonstrates tricuspid regurgitation. Daniel Fuchs, PGY3 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609776499746-TUIDH9ZPWHPLUXT8S0D1/image-asset.gif Valvulopathy - Mitral Clip A 54-year-old man with history of dilated cardiomyopathy on maximum tolerated doses of guideline directed medical therapy and implantable cardioverter defibrillator presented with progressively worsening dyspnea with minimal activity. Transthoracic ultrasonography showed evidence of severe functional mitral regurgitation for which he underwent mitral clip placement (seen here). This point of care ultrasound was obtained during a clinic follow up when he reported sustained resolution of symptoms; there was also no appreciable mitral regurgitant jet on color doppler. Shahad Al Chalaby, MD (PGY3) @shahad_Chalaby Alameda Health System Internal Medicine Residency Program Oakland, California https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605885235266-6N7NIDKBFIV65G7OE2IG/image-asset.gif Valvulopathy - Infective Endocarditis A 35-year-old with history of a "heart problem" presented for concern of COVID-19. He was found to be in wide complex tachycardia with hemodynamic instability (MAP 50) with associated findings of crushing chest pain and diaphoresis. RUSH demonstrated severely reduced EF, a tricuspid valve vegetation, and aortic valve vegetation complicated by aortic root abscess. Seen here is a parasternal short axis view (on the left) demonstrating an almost entirely occluded aortic valve and outflow tract. The apical four chamber view (on the right) demonstrates both a tricuspid valve vegetation as well as this patient’s severely reduced LVEF. Gregory Wiener, MD. Denver Health Residency in Emergency Medicine @DenverEMed https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1614119068180-XGS990IQU7GWZMUH7RZF/image-asset.gif Valvulopathy - Left Ventricular Outflow Tract Obstruction Septic patient with hypotension shows LVOT obstruction with systolic anterior motion of the mitral valve on echo. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507587035833-R1CUTQWTVV46CFHNLY75/HCM.gif Valvulopathy - Hypertrophic Obstructive Cardiomyopathy WCUME 2017 Submission for "Creative Caption" - "Uncle SAM" 19 year old male out of hospital cardiac arrest s/p ROSC. POCUS shows hypertrophic interventricular septum with systolic anterior motion of the mitral valve (SAM) causing LVOT obstruction. LVOT gradient was measured at 118 mmHg and AICD was fitted during hospital stay. Treatment for HCM usually recommended if: SAM lesion visualized, IVS >18mmm, LVOT gradient > 30mmHg. Cian McDermott, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1540915378472-U5E2EIUU9Y5OBT8WIG0E/endocarditis+plax.gif Valvulopathy - Endocarditis PLAX Patient with history of IV drug use, admitted for sepsis. Parasternal long axis view shows large mass attached to anterior leaflet of mitral valve. Blood cultures prove bacterial endocarditis. Ria Dancel, MD. University of North Carolina at Chapel Hill https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1540915392098-N5HPEU6LLRC63RVNPN2M/endocarditis+psax.gif Valvulopathy - Endocarditis PSAX Patient with history of IV drug use, admitted for sepsis. Parasternal short axis view shows large mass attached to anterior leaflet of mitral valve. Blood cultures prove bacterial endocarditis. Ria Dancel, MD. University of North Carolina at Chapel Hill https://www.thepocusatlas.com/cardiac-tumors daily 0.75 2024-01-11 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697909309534-9K6UUG64TYQHBDVJUPTX/image-asset.gif Cardiac Tumors - Cardiac Sarcoma This patient presented to the emergency department after a syncopal episode upon exertion. From this subxiphoid view of their heart, we can see isoechoic structures within their right atrium. This patient was ultimately diagnosed with a cardiac sarcoma. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697909309534-9K6UUG64TYQHBDVJUPTX/image-asset.gif Cardiac Tumors - Cardiac Sarcoma This patient presented to the emergency department after a syncopal episode upon exertion. From this subxiphoid view of their heart, we can see isoechoic structures within their right atrium. This patient was ultimately diagnosed with a cardiac sarcoma. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631720547287-8LDLFH0JSA04AH053QV1/image-asset.gif Cardiac Tumors - Cardiac Myxoma 64 yo man with history of hepatic cirrhosis presented to ED with hypotension. During the RUSH exam, we incidentally identified this large hyperechoic mass occupying a large part of the right heart. Cardiac myxomas are the most common primary cardiac tumor in adults, though only 15–20% originate within the right atrium as does this one. The etiology of hypotension in our patient ended up being septic shock secondary to SBP. However, bedside ultrasound sometimes surprises you with stunning and unexpected images! Renato Tambelli, @JediPocus Emergency Physician (HCFAMEMA /Sao Paulo, Brazil) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626286136693-IV4VE7EIYZN4P41HS8ES/image-asset.gif Cardiac Tumors - Right Atrial Myxoma An apical 4 chamber view on a patient with CP, SOB, and palpitations revealed a right sided atrial myxoma. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626285605018-N5OSUOHQNVDYXC201NCD/image-asset.gif Cardiac Tumors - Left Atrial Myxoma Apical 4 chamber view of a patient with dyspnea of exertion revealed a left atrial myxoma. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496100636646-WM78Y8CFKROZKXER97GK/ezgif.com-optimize+%288%29.gif Cardiac Tumors - Atrial Myxoma In 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620700014452-HLEQQ13SX5LRV9Z3HC0G/image-asset.gif Cardiac Tumors - Cavo-Atrial Tumor-Thrombus Complex Extensive tumor-thrombus complex originating from a right adrenal malignancy that invaded the IVC and migrated cephalad until it was prolapsing through the tricuspid valve into the RV. Shockingly, this monstrous goomba was almost invisible on PSL, PSS, and A4C views. Submitted by Dr. Elias Jaffa https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501627964771-6VH18QNLDHYRI3NAZ4NE/schecter+scc+echo.gif Cardiac Tumors - Squamous Cell Metastases to the Heart 59 y/o F PMH metastatic squamous cell carcinoma of lung with metastases to bone, brain, liver, subcutaneous tissue presents with undifferentiated SOB. Patient tachycardic, hypotensive but alert with EKG showing non-sustained ventricular tachycardia. Multiple hypodensities and cystic lesions in the LV, proximal outflow tract in left ventricle, all suggestive of a thrombus vs mass vs vegetations. Eventual presumed diagnosis after formal transthoracic echo is metastases to the heart. Dr. Joshua Schecter, Dr. John F. Kilpatrick - Kings County/SUNY Downstate Emergency Medicine https://www.thepocusatlas.com/right-ventricular-dysfunction daily 0.75 2025-06-07 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1749321363624-P7OZUMUJHFUWJI39U8OY/image-asset.gif Right Ventricular Dysfunction - Right Heart Strain in Pulmonary Hypertension PSL 28 yo M PMH Pulmonary Hypertension (PH) group 1 and 4, RV failure due to PH, invasive pulmonary aspergillosis in MICU for mixed shock (Cardiogenic vs Sepsis). Lethargic with high needs for Heated High Flow Nasal Canula. RV failure is noted with significant RV and RA dilation with bowing of interventricular septum into LVOT as well as McConnell's sign. Patient also has a pericardial effusion, bilateral pleural effusions and ascites. Erick Otiniano, MD MPH | DHREM PGY1 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1749321363624-P7OZUMUJHFUWJI39U8OY/image-asset.gif Right Ventricular Dysfunction - Right Heart Strain in Pulmonary Hypertension PSL 28 yo M PMH Pulmonary Hypertension (PH) group 1 and 4, RV failure due to PH, invasive pulmonary aspergillosis in MICU for mixed shock (Cardiogenic vs Sepsis). Lethargic with high needs for Heated High Flow Nasal Canula. RV failure is noted with significant RV and RA dilation with bowing of interventricular septum into LVOT as well as McConnell's sign. Patient also has a pericardial effusion, bilateral pleural effusions and ascites. Erick Otiniano, MD MPH | DHREM PGY1 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1749321181136-S9H2TXWJ8LM1QGFTCGW9/image-asset.gif Right Ventricular Dysfunction - Right Heart Strain in Pulmonary Hypertension A4C 28 yo M PMH Pulmonary Hypertension (PH) group 1 and 4, RV failure due to PH, invasive pulmonary aspergillosis in MICU for mixed shock (Cardiogenic vs Sepsis). Lethargic with high needs for Heated High Flow Nasal Canula. RV failure is noted with significant RV and RA dilation with bowing of interventricular septum into LVOT as well as McConnell's sign. Patient also has a pericardial effusion, bilateral pleural effusions and ascites. Erick Otiniano, MD MPH | DHREM PGY1 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1737048913787-AGOMV8VCX8753XNA2BIW/image-asset.gif Right Ventricular Dysfunction - RV Strain with RV dilation and D-sign on PSSA A 74-year-old male patient with Chronic Obstructive Pulmonary Disease (COPD) (not on home oxygen) presented to the ED with acute worsening dyspnea with persistent hypoxia despite supplemental oxygen, tachypnea, and increased work of breathing. There was no infectious or environmental exposure to explain the patient’s presentation. The patient’s differential diagnosis included acute pulmonary embolism (PE) and COPD exacerbation/progression. Parasternal long-axis (PSLA) and short-axis (PSSA) views showed RV dilatation with RV strain. The RV strain was demonstrated by flattening of the interventricular septum, creating a D-shaped LV during systole (D-sign). Also, it shows hyperdynamic LV from tachycardia with near obliteration of the LV cavity in systole. CT angiography scan showed no evidence of PE. The patient was admitted and diagnosed with a progression of severe COPD with pulmonary hypertension and right ventricular remodeling. Contributed by: Hassan Alshaqaq, MBBS, Emergency Medicine Resident at King Saud University Medical City, @HassanAlshaqaq https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1737048791103-PE0R34W9ITBY82ARAG0A/image-asset.gif Right Ventricular Dysfunction - RV Strain with RV dilation on PSLA A 70-year-old patient with Chronic Obstructive Pulmonary Disease (COPD) (not on home oxygen) presented to the ED with acute worsening dyspnea with persistent hypoxia despite supplemental oxygen, tachypnea, and increased work of breathing. There was no infectious or environmental exposure to explain the patient’s presentation. The patient’s differential diagnosis included acute pulmonary embolism (PE) and COPD exacerbation/progression. Parasternal long-axis (PSLA) and short-axis (PSSA) views showed RV dilatation with RV strain. The RV strain was demonstrated by flattening of the interventricular septum,. Also, it shows hyperdynamic LV from tachycardia with near obliteration of the LV cavity in systole. CT angiography scan showed no evidence of PE. The patient was admitted and diagnosed with a progression of severe COPD with pulmonary hypertension and right ventricular remodeling. Contributed by: Hassan Alshaqaq, MBBS, Emergency Medicine Resident at King Saud University Medical City, @HassanAlshaqaq https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727210535343-MC55EOY2BG7KCI6BPTIL/image-asset.gif Right Ventricular Dysfunction - RV Failure 100 year old patient presented with dyspnea. CXR showed "atelectasis vs. pneumonia." No leukocytosis or fever seen. She began to have episodes of hypotension. Before giving fluids, an echo was performed...... She had chronic RV failure with an acute exacerbation. Notice severe RV enlargement seen in this PSLA view. John Bowling, DO, Cleveland Clinic Akron General, @BModeBowling https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1737050502282-0LAC2UIWAX6JZLSP8I22/image-asset.gif Right Ventricular Dysfunction - PSLA view demonstrating RV dilation and clot in transit An elderly female presented with 3 days of shortness of breath. PSLA view identified severe RV dilation on bedside ultrasound prior to CT confirming saddle PE. Contributed by: Max Goder-Reiser, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735939424463-9C9UGK106BQSVFZX4Q83/image-asset.gif Right Ventricular Dysfunction - D Sign in Right Heart Strain Parasternal short axis view with interventricular flattening showing a ‘D-sign’ consistent with right heart strain in this patient with an acute pulmonary embolism Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1737045504138-TBMLDRQGPHJBNPVIBKK7/image-asset.gif Right Ventricular Dysfunction - Apical 4 Chamber view demonstrating massive PE with RV dilation, D-sign, and McConnel sign with clot in transit An elderly female presented with 3 days of shortness of breath. Apical 4 chamber view identified clot in transit, severe RV dilation, and McConnell’s sign on bedside ultrasound prior to CT confirming saddle PE Contributed by: Max Goder-Reiser, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735940253911-GXCW39GVM75T6BAKSZNW/image-asset.gif Right Ventricular Dysfunction - Right heart enlargement in PSLA Right ventricular enlargement in parasternal long view. Using the normal 1:1:1 ratio of LV:LVOT:RV you can see that RV in this clip is larger than the LV and LVOT. Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1734819540783-4OPJUHJWJDSOONU5VNG4/image-asset.gif Right Ventricular Dysfunction - McConnell Sign with RV Enlargement Clip showing McConnell Sign and right side heart enlargement consistent with acute RV strain. While this can be seen in acute pulmonary embolism, it can also be seen in other conditions that cause acute RV dysfunction such as MI or pHTN. Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1677001287762-9IFR92XTUJ7PUZU04E5E/ezgif.com-optimize.gif Right Ventricular Dysfunction - McConnell's Sign Due to NSTEMI An elderly patient presented with shortness of breath and generalized weakness found to have an NSTEMI and high degree AV block. Bedside focused cardiac ultrasound with 4 chamber apical view revealed: McConnell’s Sign. Chest CTA neg for PE. Patient underwent cardiac catherization with culprit lesion being mid RCA. Not all McConnell’s sign is related to acute PE. In this case RV infarct secondary to NSTEMI with mid RCA occlusion s/p DES PCI with complete resolution of AV block. Dat Lu MD, Internal Medicine Clerkship Site Director Kaiser Roseville https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632090958663-FYHOZPVI48VA6CNJNAKH/image-asset.gif Right Ventricular Dysfunction - McConnell's Sign on PLAX View RV dilation violating the rule of thirds. McConnell’s sign is also demonstrated in this view with RV apical hyperkinesis and lateral wall hypo/akinesis. Patient was found to have a submassive pulmonary embolism. Moudi Hubeishy @hubeishy_MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631719774865-8RXXRUMYDCC3N3RVZZNB/image-asset.gif Right Ventricular Dysfunction - Clot in Transit An 50-year-old presented with shortness of breath and suffered witnessed PEA arrest subsequent to having obtained this POCUS image (subcostal view) notable for a hyperechoic, mobile structure within the RA). ACLS was administered in addition to TPA and ROSC was achieved. Subsequent formal ultrasound, following thrombolytic administration, revealed absence of thrombus. Ryan Shelby PGY-3 EM Resident; @RyanShelby18 Central Michigan University https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1631717581790-QVGY5HEYNBSJ3LBU988S/image-asset.gif Right Ventricular Dysfunction - Septal Flattening in Saddle Pulmonary Embolism PSSX View. Septal Flattening is being demonstrated (D-sign) at the level of the papillary muscles and chordae tendinae visible in both the left ventricle and right ventricle. The right ventricle is demonstrating significant dilation in the setting of increased pressures secondary to a saddle embolus. Moudi Hubeishy @moudihubeishy https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1610644370748-M46E8U03SQW1T4I7K8X5/image-asset.gif Right Ventricular Dysfunction - McConnell's Sign A female in her mid-30’s presented to the ED with chest pain and shortness of breath. POCUS at the apical window revealed right ventricular free wall akinesis with sparing of the apex, indicative of McConnell’s sign of a pulmonary embolism. A clot can also be seen within the right atrium. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601059647852-XJKMERA2YB53WPQS77AL/image-asset.gif Right Ventricular Dysfunction - Obstructive Shock & RUSH Shown here is an image acquired while performing a RUSH exam on a 40-year-old female who presented in shock. HPI notable for SOB and worsening abdominal distention x5 days; PMH of decompensated etoh cirrhosis. Vitals included BP 80/40; HR 110; RR 30; O2 sat 90% RA. Seen here is the image obtained while performing subcostal sweep from base to apex. It is most notable for a dilated, hypokinetic RV with paradoxical septal motion and an underfilled, hyperdynamic LV. There is also intraperitoneal free fluid appreciated. Subsequent CT chest confirmed presence of large, bilateral pulmonary emboli as etiology of patient’s shock. David Carroll https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598022615747-O8B4ZRJZSJYJYA12KZUZ/image-asset.gif Right Ventricular Dysfunction - RV Strain A 39-year-old female with known metastatic lung cancer complicated by multiple pulmonary emboli on apixaban presented with worsening dyspnea and productive cough over one week duration. POCUS identified a large circumferential pericardial effusion in multiple cardiac views in addition to signs of RV strain as demonstrated by flattening of her interventricular septum and ventricular interdependence (shown here on parasternal short axis view). The findings of RV strain are likely chronic and secondary to chronic thromboembolic disease complicated by pulmonary hypertension. Shahad Al Chalaby, MD. PGY3 Internal Medicine.Highland Hospital. Alameda Health System Residency Program. Oakland, CA, USA. @shahad_Chalaby Adam Mortimer, DO. PGY1 Internal Medicine. Highland Hospital. Alameda Health System Residency Program. Oakland, CA USA. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1596725303851-KHCYE3F3N72U2PTBVXW1/image-asset.gif Right Ventricular Dysfunction - D-Shaped Septum A 56-year-old female with history of metastatic breast cancer presented with acute shortness of breath. Physical examination was notable for hypotension, sinus tachycardia, raised JVP, and mild respiratory distress. There was no evidence of lower extremity edema and chest xray was unremarkable. POCUS showed no B lines on lung views. Cardiac views (seen here) were notable for a hypokinetic and dilated RV with flattening of the interventricular septum creating a D shaped LV during systole. These findings are consistent with high right ventricle and pulmonary artery pressures in the absence of pulmonary artery stenosis. Specifically, a D-shaped LV during diastole reflects RV volume overload; a D-shaped LV during systole reflects RV pressure overload. RV pressure overload can be seen in massive and submassive pulmonary embolism (PE) and this patient was diagnosed with a submassive PE; findings confirmed by CT angiography. In this instance, POCUS enabled prompt diagnosis and early initiation of therapeutic anticoagulation. Shahad Al Chalaby, MD. Highland Hospital. Alameda Health System Internal Medicine Residency Program. California, USA. shahad_Chalaby Katherine Farley, OMS4. Touro University. California, USA. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592915135216-X1R1R2IJTHVGUMKZSYHP/image-asset.gif Right Ventricular Dysfunction - Clot in Transit 38 yo previously-healthy male 8 days s/p ligamentous repair of the knee, presented with dyspnea and chest pain. Physical exam on room air notable for tachypnea (RR 35), hypoxia (O2 sat 89%), and lungs that were clear to auscultation. POCUS revealed intracardiac thrombus with D-sign and McConnell's Sign. Pt received full-dose anticoagulation prior to CTA-PE confirming the suspected diagnosis of PE. He subsequently underwent successful thrombectomy. Stacey Frisch, MD Chief Resident, Emergency Medicine Kings County Hospital/SUNY Downstate @emergenStacey https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1554691074642-A1JFYVFOBDJK4NPQGXSO/d-sign+.gif Right Ventricular Dysfunction - The D-Sign in Acute PE A 70 year old female patient presented with complaints of acute dyspnea. Oxygen saturation was 86% on room-air improved with O2-supplementation. She had poor hemodynamics with SBP ~ 100 mmHg. POCUS showed obvious right heart strain with a D-sign and thrombus intermittently visualized in the right ventricle. Correct therapy (thrombolytics) were given almost straight away after presentation in the ED because POCUS was available. Once stabilized, the patient was taken for a CTA chest which demonstrated a saddle embolism. Dr. Van Roosmalen https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588263775630-HE5UZAUQ1HSA3IJNCDTI/image-asset.gif Right Ventricular Dysfunction - McConnell's Sign An elderly female presented with complete AV heart block. Apical 4-chamber view was performed and was notable for regional RV dysfunction (aka McConnell’s Sign). Though this finding is commonly associated with acute PE, our patient was found to have right coronary artery occlusion as the etiology of all findings. Renato Melo, Emergency Physician at HC de Marília-SP, Brazil. PocusJedi co-founder. @Renato_Melo_ https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579831690417-UZWC6Z0LPMS5E3SQM8PQ/image-asset.jpeg Right Ventricular Dysfunction - Measure TAPSE for RV function in PE This apical 4-chamber view on M-mode was obtained from a patient with acute pulmonary embolism with right ventricular strain. We measured tricuspid annular plane systolic excursion (TAPSE) as a validated parameter of global RV function. Specifically, TAPSE describes apex-to-base shortening and correlates closely with right ventricular ejection fraction. TAPSE is measured on echo by placing a cursor at the tricuspid lateral annulus and measuring the distance to systolic annular RV excursion. Any distance of <17mm is suggestive of RV strain. Our patient’s TAPSE was 11.5mm. Though there are multiple strategies to assess for right heart strain, TAPSE has the highest interrater reliability and best predicts 30-day mortality. DaMarcus Ingram (MS4), Drexel University College of Medicine Arthur Strzepka (MS4, Nova Southeastern University College of Osteopathic Medicine Dr. Max Cooper, Director of Emergency Ultrasound at Crozer Chester Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1582735906938-7XQXYWZ59DKWX671YMFT/image-asset.gif Right Ventricular Dysfunction - RV Thrombus & McConnell's Sign 60 year-old smoker presents with dyspnea and chest pain. Apical 4 chamber view is notable for a thrombus within the RV and associated evidence of RV strain including increased RV size and impaired systolic function with sparing of the apex (known as McConnell’s sign). Renato Tambelli, @R_Tambelli Emergency Physician Hospital das Clínicas de Marília, Sao Paulo/Brazil https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1576790543576-6ZVXQLG135T7V8WB081I/image-asset.gif Right Ventricular Dysfunction - Post Traumatic Arrest Echo with RA/RV Thrombus This image is from a patient presenting after a high speed MVC. The patient had a past medical history of atrial fibrillation and was anti-coagulated. On arrival to ED, the patient was agitated, clammy, and noting shortness of breath. The initial eFAST was negative. The patient was intubated with propofol for CT imaging. 15 min post-intubation the patient became hemodynamically unstable and bradycardic followed by cardiac arrest. An apical four chamber view was obtained during pulse check showing dense clot in RV/RA with minimal cardiac activity. Nishant Cherian Emergency Medicine Registrar https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1578968629114-4XJ1KOY92LQ7EMG5ADP6/image-asset.gif Right Ventricular Dysfunction - Right Ventricular Enlargement in Chronic COPD This clip demonstrates severe right ventricular enlargement seen on a parasternal long axis view. The patient had developed cor pulmonale from longstanding COPD. Pooja Belligund https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1587250943565-V0GD7QZVKQO4R3J6OPZT/image-asset.gif Right Ventricular Dysfunction - Hyperechoic lesion with enlarged RV from PE [SonoClipShare Submission]: PLA demonstrating a small LV, an enlarged RV, and a hyperechoic lesion moving back and forth (later views confirming moving between RA and RV). 1st of 4 views to be submitted on the same case. This was an unfortunate 40ish y/o 6 months s/p CVA 2/2 ruptured aneurysm and IDDM presenting with 4 days of "feeling weak". Found to have a HR of 120 to 130, a BP around 90-100/60-70 and pulse ox of 90 - 92%. POCUS lungs were normal. Started on heparin, CTA confirmed PE and went to IR for catheter-directed tPA lysis with normalization of BP, HR and good clinical outcome. Image courtesy of John Hipskind MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533167012373-PS5U02FHT0R3XXY6K2RZ/roderick+pre+tpa+r+sided+clot.gif Right Ventricular Dysfunction - Right Heart Thrombus pre TPA 88 y/o F presenting with chest pain and syncope. Shortly after arrival patient went into brief period of cardiac arrest with ROSC. POCUS shows massive thrombus floating back and forth across the tricuspid valve with a dilated right ventricle, D-sign, and global right heart hypokinesis. Patient was given TPA bolus. Approximately 1 hour after pushing TPA, repeat POCUS with resolution of thrombus on RV, but patient continued RV hypokinesis. Patient vitals stabilized enough for a CTA which showed left main pulmonary artery extending into both left upper lobe and left lower lobe branches with evidence for right heart strain. Dr. Roderick Alfonso, Maan Al Dubayan, Andrew Sweeny - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533167048298-QMO9AEKPV6EDAVKWJVYO/roderick+post+tpa+r+sided+clot.gif Right Ventricular Dysfunction - Right Heart Thrombus post TPA 88 y/o F presenting with chest pain and syncope. Shortly after arrival patient went into brief period of cardiac arrest with ROSC. POCUS shows massive thrombus floating back and forth across the tricuspid valve with a dilated right ventricle, D-sign, and global right heart hypokinesis. Patient was given TPA bolus. Approximately 1 hour after pushing TPA, repeat POCUS with resolution of thrombus on RV, but patient continued RV hypokinesis. Patient vitals stabilized enough for a CTA which showed left main pulmonary artery extending into both left upper lobe and left lower lobe branches with evidence for right heart strain. Dr. Roderick Alfonso, Maan Al Dubayan, Andrew Sweeny - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1525198488674-KAGVBOFZUMEO0B00O0KE/ezgif.com-optimize+%2829%29.gif Right Ventricular Dysfunction - McConnell's Sign - Pulmonary Embolism Elderly patient with chest pain, sob, and HR in 120’s. During ER stay became hypotensive with systolic in 80’s. POCUS demonstrated RV enlargement and McConnell’s Sign - systolic akinesia of the RV free wall with preserved functioning of the apex. This is concerning for acute PE. Patient became progressively hypotensive and TPA was pushed. Dr. Kelly Maurelus, Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522330918592-HL83X4HQ7HYZOUX9R8C1/ezgif.com-optimize+%288%29.gif Right Ventricular Dysfunction - Right-Sided Heart Failure (A4C) Young woman with a history of Idiopathic Pulmonary Arterial Hypertension w/ resultant R heart failure who came in short of breath. Greg Powell, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522330549198-RMW89L3BDC6MGOMBHAYZ/ezgif.com-optimize+%2810%29.gif Right Ventricular Dysfunction - Right-Sided Heart Failure (PSAX) Young woman with a history of Idiopathic Pulmonary Arterial Hypertension with resultant R heart failure who came in short of breath. Greg Powell, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527400338494-2N6SP0EW9PC3ASH12SII/ezgif.com-optimize+%2849%29.gif Right Ventricular Dysfunction - D-Sign in acute PE - Pre TPA 34 y/o female no PMH with chest pain and rapid onset dyspnea on exertion noticed over 1 day. Patient became increasingly tachycardic and ultimately hypotensive so RUSH exam was performed showing D - Sign. CTA was subsequently performed and found to have saddle emboli. Echo was done pre and post TPA showing partial resolution of the D-sign. Dr. Joshua Schechter - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522331113716-DQ7XRPHPXLCBGCK4YDHN/ezgif.com-optimize+%289%29.gif Right Ventricular Dysfunction - Right-Sided Heart Failure (PLAX) Young woman with a history of Idiopathic Pulmonary Arterial Hypertension with resultant R heart failure who came in short of breath. Greg Powell, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509040621260-42MSVXBS839B1DRP0AOF/Right-sided+Heart+Failure+-+Johnson.gif Right Ventricular Dysfunction - Right-Sided Heart Failure Young male from Latin America with findings of right HF. Focused cardiac ultrasound shows massive RA, moderate pericardial effusion, relatively normal RV and LV. Significant TR ruled out. Findings consistent with Endomyocardial Fibrosis, found in tropical countries. Need cardiac MRI to confirm. Similar to eosinophilic myocardial fibrosis found in temperate climates. Dr. Gordon Johnson MD Internist Portland Oregon & Uganda SonoPortlandia.com https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501612875712-33TDSAPJ8USNZ11HHTRF/dsign+2.gif Right Ventricular Dysfunction - D-Sign with RV Dilation, Effusion, PSSA A 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. Drs. Ronald Rivera, Elizabeth Hanson, Melanie Malloy, Kelly Maurelus, Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501613711642-AU3D9MQVAHR8Q5VOOQKI/dsign+3.gif Right Ventricular Dysfunction - RV Dilation, Effusion, A4C A 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. Drs. Ronald Rivera, Elizabeth Hanson, Melanie Malloy - Emergency Medicine Residents Dr. Kelly Maurelus, Ultrasound Education Director Kings County/SUNY Downstate Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496100051312-3BUI373M319O6TBIYUCS/ezgif.com-optimize+%283%29.gif Right Ventricular Dysfunction - 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, DO Emergency Physician https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1521127220764-X70YB3JACHHU91879OY0/ezgif.com-optimize+%284%29.gif Right Ventricular Dysfunction - RA Thrombus with R Heart Strain Middle age F presented initially to ED after a mechanical fall complaining of hip pain. Patient became tachypnic and altered during ER stay. POCUS done, and RA thrombus was noted with D sign and enlarged R ventricle. R heart thrombus (thrombus in transit) is highly mobile differentiating it from a mural thrombus, which forms in situ. A meta-analysis of 1113 patients from the International Cooperative Pulmonary Embolism Registry showed mortality was 2x as high for pts with right heart thrombus and PE compared to those without right heart thrombus. The difference in mortality was more pronounced in the heparin alone treatment group (vs. lytics or embolectomy). Another study by Rose et al (2002) showed patients with PE and a right heart thrombus had a mortality of 27%. They found these patients did better when treated more aggressively (i.e. thrombolysis or embolectomy). Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest. 2002;121(3):806-14. (PMID: 11888964) Torbicki A, Galié N, Covezzoli A, et al. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003;41(12):2245-51. (PMID: 12821255) Submitted by Bobak Zonnoor, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515544338155-MMTO3N0VZ0TW6J1RZWXA/ezgif.com-optimize+%288%29.gif Right Ventricular Dysfunction - Acute Cor Pulmonale (Parasternal Long-Axis View) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. S Fares) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515544464980-XJ9RAP4NKLW09VFH65Y7/ezgif.com-gif-maker+%282%29.gif Right Ventricular Dysfunction - Cor Pulmonale (Short) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. S Fares) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515616919499-WHFYML6G4U83X9LXLLDU/ezgif.com-optimize.gif Right Ventricular Dysfunction - Cor Pulmonale (Long) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513461538396-8HFQICFNTYBV9H9NK573/ezgif.com-optimize+%284%29.gif Right Ventricular Dysfunction - Right Ventricular Failure with Tricuspid Regurgitation Significant right ventricular dysfunction with moderate tricuspid regurgitation Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527400511260-1TXKULLK2M1EDKP2KDKX/ezgif.com-optimize+%2850%29.gif Right Ventricular Dysfunction - D-Sign in acute PE - Post TPA 34 y/o female no pmh with chest pain and rapid onset dyspnea on exertion noticed over 1 day. Patient became increasingly tachycardic and ultimately hypotensive so RUSH exam was performed showing D - Sign. CTA was subsequently performed and found to have saddle emboli. Echo was done pre and post TPA showing partial resolution of the D-sign. Dr. Joshua Schechter - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1540917855267-I8BU1FL8CKBH8W85XQN1/McConnells+sign+.gif Right Ventricular Dysfunction - McConnell's Sign This is a middle-aged male who developed dyspnea suddenly while ambulating. Several weeks prior, he had a laparoscopic procedure with a prolonged post-operative course spanning several weeks in the hospital. He denied chest pain or fever. He was tachypneic with otherwise normal vital signs. Lung sounds were clear, although he had obviously increased work of breathing and appeared diaphoretic. Bedside echocardiography revealed a dilated right ventricle with a positive McConnell sign. There was also a large, lobulated, and mobile hyperechoeic mass within the right atrium suspicious for thrombus. CTA of the chest showed bilateral pulmonary emboli. BNP and troponin were moderately elevated, consistent with submassive pulmonary embolism. Andrew Goodrich, MS, DO, PGY-3 Chief Resident, Central Michigan University Emergency Medicine Residency Therese Mead, DO, RDMS, FACEP Associate Program Director and Ultrasound Director, Central Michigan University Emergency Medicine Residency https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1554691209003-XMHEXN75V263JUAUZYD3/RA+thrombus+.gif Right Ventricular Dysfunction - Right Atrial Thrombus A 70 year old female patient with complaints of acute dyspnea. Oxygen saturation 86% with room-air improved with O2-suppletion. Poor hemodynamics with systolic presure around 100 mmHg. POCUS shows obvious right heart strain with apical sparing (McConnel's sign) and trombus drifting around in right atrium and even hitting the right ventricle. Correct therapy (trombolytics) was started almost straight away after presentation at the ED because POCUS was available. Dr. Van Roosmalen https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1554690605733-YTP3Q8LT0F9NJGCGP8WQ/actue+cor+pulmonale.gif Right Ventricular Dysfunction - Acute PE with McConnell's Sign 46 year old man, intraoperative cardiac arrest after massive pulmonary embolism. Apical four chamber view obtained after resuscitation showed McConnell's sign. We found other signs of acute cor pulmonale : the 60/60 sign and RV dilatation. Dr. Devigne https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609881002392-F2B12JXY344WHPMHQD2N/image-asset.gif Right Ventricular Dysfunction - Clot in Transit & Femoral DVT A 73 year old male presented with several day history of moderate dyspnea as well as right LE discomfort. POCUS identified both a right intracavitary thrombus as well as right femoral phlebitis. He was treated with heparin for both. Pierre Bernatas, @pb2316 Emergency Physician. Limousin, France. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515006285861-ZWE0341OZKJNO5RT25ZF/ezgif.com-optimize+%284%29.gif Right Ventricular Dysfunction - Right Atrial Thrombus Elderly female with hypotension and shortness of breath and back pain presenting in extremis. Treated with TPA for a RA thrombus and saddle pulmonary embolism. Dr. William Scheels https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1650402527022-EEJZ8UQ8AN630FDEZ9LJ/image-asset.gif Right Ventricular Dysfunction - RV Dysfunction and Pulmonary Hypertension from COPD 50s M with PMH COPD presented with dyspnea and increasing oxygen requirement. POCUS is shown here, demonstrating significant RV dilation, reduced RV function, and bowing of the septum concerning for pulmonary hypertension. Additional workup ultimately ruled out ACS and DVT/PE, and the patient was admitted for COPD exacerbation, and formal TTE confirmed a new diagnosis of pulmonary hypertension. Dr. Cailin Frank, Ultrasound Fellow, Denver Health Ultrasound Fellowship Dr. Anna Engeln, Denver Health Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1663476894065-DGOA56K3UXZBX4YX2QA9/image-asset.gif Right Ventricular Dysfunction - Pulmonary Hypertension from Triscupid Endocarditis 30s F with PMH IVDU and prior endocarditis s/p tricuspid valve repair presented with fever, hypotension, and dyspnea. On RUSH evaluation, this cardiac image was acquired, showing significant RV dilation with bowing of the septum into the LV. The prosthetic tricuspid valve is shown here, but without color doppler, evaluation of the valve patency is limited. Formal TTE showed a patent tricuspid valve however with moderate to severe tricuspid regurgitation, likely explaining the severe RV overload. Dr. Michael Duerson, PGY4 Denver Health Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735940228572-I61QOZ9W2MSOD2A4GEKS/RHSPSL-ezgif.com-optimize.gif Right Ventricular Dysfunction https://www.thepocusatlas.com/thoracic-aorta-pathology daily 0.75 2025-05-21 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1713500911798-H5FKPVZN33QJ67MNXAP6/image-asset.gif Thoracic Aortic Dissection & Aneurysm - Ascending Thoracic Aortic Aneurysm A 70 y.o. male presented with altered mental status. POCUS echocardiogram performed in the ED revealed an ascending thoracic aortic aneurysm measuring approximately 5 cm in diameter (parasternal long-axis view shown here). A chart review revealed that the patient does indeed have a history of TAA, and a comparison of our findings to a prior CTA demonstrates no significant increase in diameter. Nevertheless, this study demonstrates the utility of POCUS in the rapid and early detection of ascending aortic abnormalities. Alex Schlangen, D.O. PGY-1 EM Resident at Central Michigan University; Andrew Namespetra, MB BCh BAO. @AndrewNamespet1 PGY-3 EM Resident at Central Michigan University https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1713500911798-H5FKPVZN33QJ67MNXAP6/image-asset.gif Thoracic Aortic Dissection & Aneurysm - Ascending Thoracic Aortic Aneurysm A 70 y.o. male presented with altered mental status. POCUS echocardiogram performed in the ED revealed an ascending thoracic aortic aneurysm measuring approximately 5 cm in diameter (parasternal long-axis view shown here). A chart review revealed that the patient does indeed have a history of TAA, and a comparison of our findings to a prior CTA demonstrates no significant increase in diameter. Nevertheless, this study demonstrates the utility of POCUS in the rapid and early detection of ascending aortic abnormalities. Alex Schlangen, D.O. PGY-1 EM Resident at Central Michigan University; Andrew Namespetra, MB BCh BAO. @AndrewNamespet1 PGY-3 EM Resident at Central Michigan University https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616099157962-1SIGFHD0BZJRNEMUGGND/image-asset.gif Thoracic Aortic Dissection & Aneurysm - Aortic Dissection Flap in Arch of Aorta A 65-year-old male presents with shortness of breath (no chest pain) and was found to have a dilated aortic root on CT pulmonary angiogram. POCUS (supra sternal view) showed a dissection flap in the arch of aorta; a finding subsequently confirmed on CT aortagram. Patient was sent for emergency surgical intervention. Dr.Rajasutharsan Kathirgamanathan, Emergency Physician The Northern Hospital, Melbourne, Australia @raj_kathir007 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609963280981-EQMCGMHY49Q3VUHO938I/image-asset.gif Thoracic Aortic Dissection & Aneurysm - Suprasternal View of Type A Dissection Suprasternal notch view shows a mobile intimal dissection flap in the aortic arch. Michael Cover, MD @michaelc0ver https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609962328369-FEAM5A2LLPVQ5J3SVQXV/image-asset.gif Thoracic Aortic Dissection & Aneurysm - Type A Aortic Dissection - Double Valve Sign Type A aortic dissection flap appears as a "second valve" on this parasternal long axis cardiac view. Michael Cover, MD @michaelc0ver https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1591490597104-N1V57YLFG1CJVFU4J5IU/image-asset.gif Thoracic Aortic Dissection & Aneurysm - Descending Thoracic Aortic Dissection Seen on PSLA This is a parasternal long axis view of an elderly male with PMH of hypertension and DM presenting with a dissection of the descending aorta (aka type B aortic dissection). Image courtesy of Robert Jones, DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH Find his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644441397978-XT0F0EM8AAJ6GYRY2MDA/image-asset.gif Thoracic Aortic Dissection & Aneurysm - Descending Thoracic Aorta Flap Seen on Apical 4 Chamber 33 yo male presented with chest/epigastric pain. POCUS is notable for acute aortic dissection as seen in the descending thoracic aorta flap as well as presence of a pericardial effusion. Maxime Gautier https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496100737780-MZEB670QBRSKHI2P3O2P/ezgif.com-optimize+%289%29.gif Thoracic Aortic Dissection & Aneurysm - Aortic Dissection Flap Visualized in Proximal Aorta with Root Dilation This 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, RDMS Assistant Professor of Emergency Medicine Division Chief, Ultrasound Fellowship Director, Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496099872071-TVRA728TRBGQ5G416B6X/ezgif.com-optimize+%282%29.gif Thoracic Aortic Dissection & Aneurysm - Breaking the rule of 3rds - Aortic Dissection with Root Dilation This 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. The rule of thirds states that in parasternal long, the right ventricular outflow tract, the aortic root, and left atrium should roughly be equal size. Any disparity between these can hint at pathology. In this case, the patient had severe and sudden aortic regurgitation and widening of the aortic root consistent with aortic dissection. - Michael Macias, EM Resident Physician PGY-4, Northwestern University https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496101752374-13R84L5INVBYAYFHIO2M/ezgif.com-optimize+%2815%29.gif Thoracic Aortic Dissection & Aneurysm - Type B Thoracic Aortic Dissection Flap on Suprasternal View This 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 hypertension 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, FACEP Clerkship Director ED, Kaweah Delta Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1553994847847-AZX1DMZ1DDYQFK7HE2V5/aortic%2Broot%2Bdilation%2B1.gif Thoracic Aortic Dissection & Aneurysm - Aortic Root Dilation Due to Aortic Dissection A dilated aortic root in a patient with chest pain radiating to the back. Note that the ratio of right ventricular outflow tract, aortic root and left atrium is not 1:1:1. Whilst you may not always see an intimal flap, a dilated aortic root and new aortic regurgitation may indicate aortic dissection. In this case, aortic dissection was subsequently confirmed on CT aortogram. Dr. Cheng https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1553995025833-ADGB6LDQKXUTF5DLWGNK/ezgif.com-optimize%2B%2833%29.gif Thoracic Aortic Dissection & Aneurysm - Aortic Dissection Causing Cardiac Tamponade 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. Right ventricular diastolic collapse can be seen. Claire Heslop - Pediatric Emergency Medicine - University of Toronto Hospital for Sick Children https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522722567318-22UBBIRILQEQ4PTMOHRF/riscinti+dissection+suprasternal.gif Thoracic Aortic Dissection & Aneurysm - Aortic Dissection On Suprasternal View 50 year old mandarin speaking man complains of vague central chest pain. You pursue a routine cardiac workup which is fairly normal. Upon discharging him, the nurse tells you his systolic in now in the 80's. After clenching the likely diagnosis of an Type A Aortic Dissection based on your echo, you confirm by placing the transducer in the patients suprasternal notch, transversely but with the probe marker rotated slightly toward the patient's hip and fan inferiorly. You see a grossly widened aorta and a dissection flap. Dr. Matthew Riscinti - Kings County Emergency Medicine, Dr. Benjamin Clearly - NYU Langone Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572033195908-1IVAIOGLL3UATZFERLKA/ezgif.com-optimize+%288%29.gif Thoracic Aortic Dissection & Aneurysm - Thoracic Aorta Aneurysm with Intramural Thrombus Don’t be distracted by the abnormal cardiac function in this clip…notice deep to the pericardium a thoracic aorta aneurysm is seen with moderate amount of intramural thrombus. Image courtesy of Aventura Ultrasound; Their original Twitter posting can be found here. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1747859864636-81MNVQ0HPS69ALEBVYAE/image-asset.gif Thoracic Aortic Dissection & Aneurysm - Ascending Aortic Aneurysm with Dissection Flap 48 y/o male presents with chest pain for >24 hours. Parasternal Long Axis demonstrates ascending aortic aneurysm with a dissection flap and hemorrhagic pericardial effusion. Patient was transferred to ICU in shock. Contributors: Dr. Adriana Brentegani (@dribrentegani) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, Brasil https://www.thepocusatlas.com/left-ventricular-dysfunction daily 0.75 2024-11-24 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1679936479597-L035E5WHLBA0BXSRY1LB/image-asset.gif Left Ventricular Dysfunction - New Onset Cardiomyopathy with Reduced Ejection Fraction 47 year-old male with no cardiac history presenting with shortness of breath and leg swelling for two weeks found to have new onset cardiomyopathy. POCUS echocardiogram showed significant dilation of the LV on parasternal long axis view with reduced EF; EPSS of 23.7 mm. Formal echocardiogram confirmed findings with additional findings including EF <20%, mild dilation of the LA, RA, and RV. While LV is grossly dilated, the significantly increased EPSS correlates with the dramatically reduced EF. Brent Oldham, MD, MPH, PGY-3, Central Michigan University College of Medicine, Emergency Medicine Dan Dunaske, DO, PGY-1, Central Michigan University College of Medicine, Emergency Medicine Brad Buska, MS4, Central Michigan University College of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1679936479597-L035E5WHLBA0BXSRY1LB/image-asset.gif Left Ventricular Dysfunction - New Onset Cardiomyopathy with Reduced Ejection Fraction 47 year-old male with no cardiac history presenting with shortness of breath and leg swelling for two weeks found to have new onset cardiomyopathy. POCUS echocardiogram showed significant dilation of the LV on parasternal long axis view with reduced EF; EPSS of 23.7 mm. Formal echocardiogram confirmed findings with additional findings including EF <20%, mild dilation of the LA, RA, and RV. While LV is grossly dilated, the significantly increased EPSS correlates with the dramatically reduced EF. Brent Oldham, MD, MPH, PGY-3, Central Michigan University College of Medicine, Emergency Medicine Dan Dunaske, DO, PGY-1, Central Michigan University College of Medicine, Emergency Medicine Brad Buska, MS4, Central Michigan University College of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727202494008-F9K0I0O4VP2F0UHVLBXR/image-asset.gif Left Ventricular Dysfunction - Biventricular Failure 90 y/o F presents with hypotension. Patient was signed out to me by the overnight team with "sepsis" and received 30 cc/kg bolus. Patient began to have SBPs in the 70s again. She was immediately placed on vasopressors and managed for a CHF exacerbation. Image is a slightly obliqued PSAX. John Bowling, DO, Cleveland Clinic Akron General, @BModeBowling The image is slightly oblique giving the LV an oval appearance https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1660331980664-DBBZV6OZB3R9TMCX94T9/image-asset.gif Left Ventricular Dysfunction - Post COVID Myocarditis A 29-year-old patient, with a recent history of mild COVID 19 infection, consulted for a 5-day history of fever, associated with abdominal pain, arthralgia and myalgia. Hypotensive on admission (80/50 mmHg), with HR 100 bpm and echocardiography performed with a convex transducer: LVEF 12%, with global hypokinesia and dilated cavities. The diagnosis of post-COVID myocarditis is made. Dr. Libardo Valencia Chicué https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1680198032131-P2FIQDODZHSKVCF9JZKP/image-asset.gif Left Ventricular Dysfunction - Postpartum Cardiomyopathy This healthy patient presented 3 months postpartum with progressive dyspnea over the past few weeks found to have new postpartum cardiomyopathy with EF about 10-15% as demonstrated in the parasternal long axis view. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1627325133963-8HOQVUXN4EEGCA1BEXEM/image-asset.gif Left Ventricular Dysfunction - Takotsubo Cardiomyopathy on Apical Two Chamber View Apical 2 chamber view showing akinesia of the apical walls characteristic of Takotsubo cardiomyopathy. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625940462925-KVN90L18AO6440SB2I8K/image-asset.gif Left Ventricular Dysfunction - Reduced Ejection Fraction (Parasternal Long Axis View) Patient with systolic heart failure with reduced ejection fraction. Nigist Taddese MBChB Division of Hospital Medicine, John H Stroger Hospital of Cook County https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1625678720565-164GP8E3H9GEU3817ST1/image-asset.gif Left Ventricular Dysfunction - Ventricular Fibrillation Subcostal view of a patient reentering ventricular fibrillation following ROSC. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1626208467520-4XX2W6VYWXAKLWQ9P6H3/image-asset.gif Left Ventricular Dysfunction - Post Myocardial Infarction VSD This patient presented with worsening “GERD” symptoms over the past 8 days, found to have markedly elevated troponin and anterior STEMI on ECG. The parasternal long axis view revealed a ventricular septal defect. Using color doppler, flow can be visualized as the color jet passing across the septum. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611513902014-WGUQWZRFZWOS7W4F1402/image-asset.gif Left Ventricular Dysfunction - Ventricular Fibrillation A middle aged male presents to the ED in cardiac arrest. Pre-hospital assessment showed asystole and AED indicated no shock advised. Subcostal echo revealed a quivering left ventricle indicative of fine ventricular fibrillation. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1611513156001-426NX8KN2RF14GP4I4VB/image-asset.gif Left Ventricular Dysfunction - Takotsubo Cardiomyopathy A 50 year old male with community acquired pneumonia presented to the ED with worsening symptoms, abnormal EKG, and elevated troponin without an obstructing lesion on cath. Bedside echo revealed akinesia of the entire mid and apical left ventricle indicative of Takotsubo cardiomyopathy on apical 2 chamber (left) and apical 4 chamber (right) views. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1602450014790-VT64QU6OKA83IERTWDVX/image-asset.gif Left Ventricular Dysfunction - Drug-induced Cardiomyopathy 52-yo-male with PMH methamphetamine use presented with 1 month history of increasing DOE, orthopnea, and episodic atypical sharp chest pain. EKG revealed LVH with inferolateral T-wave inversions; troponin was indeterminate (making ACS less likely). POCUS demonstrated extremely reduced LVEF leading to a diagnosis of new systolic heart failure. Subsequent formal TTE demonstrated LVEF 10%; left heart cath revealed nonobstructive CAD. Final diagnosis of methamphetamine induced cardiomyopathy was made. Mike Heffler, MD Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594127924882-Y57B02EZULA92KIFF1ZM/image-asset.gif Left Ventricular Dysfunction - Atrial fibrillation A 60-year-old female presented with palpitations; found to have atrial fibrillation. Parasternal long POCUS was notable for both an enlarged LA as well as depressed LV systolic function. These concurrent diagnoses enabled initiation of proper rate-control while also being mindful to not worsen HF exacerbation (avoiding b-blockade). The combination of A.fib as well as LV dysfunction also made this patient particularly high risk of thromboembolic events; she was therefore also initiated on therapeutic anticoagulation. Shahad Al Chalaby, MD. PGY-2, Internal Medicine Highland Hospital, Almeda Health System, Internal Medicine Residency Program. CA, USA @shahad_Chalaby https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592419373594-FPO56YUS6740AI125PZY/image-asset.gif Left Ventricular Dysfunction - Cardiac Standstill A patient presented with out-of-hospital cardiac arrest. POCUS was used to confirm presence of cardiac standstill. Note the absence of movement of the left ventricular free wall. Melissa Myers, MD. Emergency Medicine in Texas. Ultrasound Fellowship Program Director. @melissamyersmd https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1588255324686-1JUBD6ASKX0K9ACMZL5F/image-asset.gif Left Ventricular Dysfunction - LV Thrombus A 50-year-old male presented to the ED with signs/symptoms of acute ischemic cerebrovascular accident (hemiplegia and dyslalia). Head CT confirmed the presence of a subacute ischemic event. Bedside POCUS (apical four chamber view) revealed severe LV global hypokinesis and the presence of an apical thrombus; the likely etiology of his cardioembolic event. Renato Temabli, EM Physician Brazil @JediPocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584982548218-1BE2ZSCFXUISXR273S3T/image-asset.gif Left Ventricular Dysfunction - LV Failure Pictured is an apical 2 chamber view from a 60-year-old female who presented to our ED with acute hypoxic respiratory failure. Note the presence of LVH and LV systolic dysfunction. PLAX view additionally confirmed the presence of critical aortic stenosis; lung views were notable for >3 B-lines per frame; all consistent with her clinical picture of acute cariogenic pulmonary edema. Guillermo A. Obregon MS-4. Central Michigan University Emergency Medicine Residency Additional contributors: Brian Brazeau MD, Harrison Zeitler MD, Therese Mead DO, RDMS, FACEP https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1569011291998-5X46M3UO8MZ2NZWNS488/Takotsubo.gif Left Ventricular Dysfunction - Takotsubo Cardiomyopathy in a Patient with Chest Pain The Case: A 45 year old with history of diabetes presented with chest pain and shortness of breath. Cardiac #POCUS demonstrates LV apical ballooning with basal hypercontraction consistent with Takotsubo. This was confirmed with normal coronaries on cardiac cath. Image courtesy of IUEM Ultrasound Original Twitter Post can be found here. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544999702634-KEW41BOKT13DJ2HOGON9/Takotsubo+cardiomyopathy.gif Left Ventricular Dysfunction - Reverse Takotsubo Cardiomyopathy A 52-year-old female presented to the ED with acute onset of upper abdominal pain and cough productive of frothy, pink sputum. She was ill-appearing, tachypneic, tachycardic, and hypotensive. POCUS revealed severe hypokinesis of the LV basal wall with a hyperdynamic apex, and diffuse B lines in both hemithoraces. She was in cardiogenic shock secondary to basal (aka reverse) Takotsubo cardiomyopathy (TCM). This variant accounts for only ~3% of TCM cases. Interestingly, 6 months ago she suffered from the typical (apical) variant. The recurrence rate in the 1st year is ~1.5%, but having a different variant is even more rare! (The U/S clip has been slowed down to make it easier to visualize the RMWAs.) Dr. Sam Cochran https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522014539925-ZPZ3ROHJ6TE93BOGCXI1/ezgif.com-optimize+%286%29.gif Left Ventricular Dysfunction - Decreased EF (Parasternal Short) An elderly gentleman w/ non-ischemic cardiomyopathy 2/2 meth use and a very poor EF. EPSS was 2.21 when measured in parasternal long axis correlating with severely reduce ejection fraction. Greg Powell, MD - ULCA/Harbor https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522014952193-YUUOYJ4K67LY63QXFQAE/ezgif.com-optimize+%287%29.gif Left Ventricular Dysfunction - Reduced EF (Apical 4 Chamber) An elderly gentleman with non-ischemic cardiomyopathy 2/2 meth use and a very poor EF. EPSS was 2.21 when measured in parasternal long axis correlating with severely reduce ejection fraction. Greg Powell, MD - ULCA/Harbor https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1516664212670-22U2YKBGF7JTYVZO0PFH/ezgif.com-optimize+%282%29.gif Left Ventricular Dysfunction - Ventricular Fibrillation Elderly F w/ PMHx HTN and metastatic cancer arrived as a notification for sudden, witnessed syncope. EMS found PEA on EKG, intubated her, delivered 1 shock by AED, and obtained ROSC after 2 rounds of Epi. During transport she became pulseless again, and a 2nd ROSC was achieved w/ Epi in ED. During pulse check echo was used to evaluate for organized cardiac activity. Echo revealed a mild pericardial effusion w/o tamponade in PLAX, normal cardiac architecture, and absence of organized atrial and ventricular contractions. Disorganized ventricular movement correlated w/ VFib on the monitor. Rescuer pulse palpation is only 78% accurate according to Tibballs and Russell (2008). POCUS in cardiac arrest allows for the assessment of organized cardiac activity w/o a palpable pulse, and for further evaluation of the Hs and Ts in PEA arrest. Given the need to maintain coronary perfusion w/ high quality CPR, the PLAX view is typically the fastest, provides actionable information and can be performed during standard ACLS pulse checks. Tibballs J, Russell P. "Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest." Resuscitation 2008; 78: 135-40. Submitted by Paul Pukurdpol, MD @PaulyPocket https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522014052540-HQ825BUJSSPVUUGN6D6S/ezgif.com-gif-maker+%281%29.gif Left Ventricular Dysfunction - Decreased EF (Parasternal Long) An elderly gentleman w/ non-ischemic cardiomyopathy 2/2 meth use and a very poor EF. EPSS was 2.21 when measured in parasternal long axis correlating with severely reduce ejection fraction. Greg Powell, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509039666680-Q20G1UTR169XO3GV4HNB/Low+EF%2C+effusion+-+Johnson.gif Left Ventricular Dysfunction - Reduced Ejection Fraction (Parasternal Long-Axis View) Parasternal long axis with cardiomyopathy, pericardial effusion, and decreased EF. Dr. Gordon Johnson MD Internist Portland Oregon & Uganda https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1510009899694-SWP3ZOB8ZXHSF18U5TFZ/ezgif.com-optimize.gif Left Ventricular Dysfunction - Takotsubo's Cardiomyopathy WCUME 2017 Submission for "Best POCUS" Bedside Echo of patient with Takotsubo's Cardiomyopathy and a regional tamponade where the effusion is not visible in the parasternal long. Dr. Evan Baines - Augusta, Georgia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496100449035-XPEZ3X7CH756IHMQGZTT/ezgif.com-optimize+%286%29.gif Left Ventricular Dysfunction - Apical Ballooning A 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 (view is flipped with LV on left side of screen) demonstrates hypokinesis & aneurysmal dilation of the apex consistent with Takotsubo's cardiomyopathy. 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 recovery Ilan Ben-Shabat 5th year medical student Aspiring emergency physician https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496100544471-X6A7ZBHGEU282S22H16G/ezgif.com-optimize+%287%29.gif Left Ventricular Dysfunction - Apical Ballooning 2 A 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 cardiomyopathy. 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 recovery Ilan Ben-Shabat 5th year medical student Aspiring emergency physician https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515543381396-ZLRMUA78IOIDV1UA8V2H/ezgif.com-gif-maker.gif Left Ventricular Dysfunction - Moderately Reduced Ejection Fraction - Basal Parasternal Short Axis This image is a basal parasternal short axis view demonstrating a moderately reduced ejection fraction Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Vahtrick) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515618403254-06R6VKWZGPXXWRWTCN0F/ezgif.com-optimize+%2810%29.gif Left Ventricular Dysfunction - Hyperdynamic Left Ventricle (Short) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Fares) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515766726272-5OZFEY1E473WFDB1PKGM/ezgif.com-optimize+%2820%29.gif Left Ventricular Dysfunction - Severe Left Ventricular Failure Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Kaveh Kaynama) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515766835031-L4YNIG3SFHBJWO1A18TG/ezgif.com-optimize+%2822%29.gif Left Ventricular Dysfunction - Severely Reduced EF Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513461691399-85M2DEGNVJY6IAQJS4MB/ezgif.com-optimize+%285%29.gif Left Ventricular Dysfunction - Ventricular Fibrillation Disorganized cardiac activity consistent with ventricular fibrillation. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544580597414-Z846Z8X77WDTAFV24TE0/EPSS_m.png Left Ventricular Dysfunction - Abnormal End Point Septal Separation (EPSS) One way to evaluate cardiac function is to measure the distance from the anterior leaflet of the mitral valve to the septum during diastole. This is known as end point septal separation (EPSS). An EPSS < 7 mm is considered normal, while EPSS > 10 mm suggests decreased cardiac function. This measurement should be obtained in a parasternal long axis view, using M-mode with the cursor placed through the tip of the mitral valve. Image credit: Ultrasound of the Week https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616108694495-TQNHEEYGJSDRAGD4ZC0L/image-asset.gif Left Ventricular Dysfunction - Reduced LV Function 60s M with no known PMH presented to the ED with 3 weeks of progressive dyspnea and bilateral leg edema. POCUS was performed to assess his cardiac function. This clip demonstrates the parasternal long axis and apical 4-chamber views, showing markedly globally reduced LV function, and the endocardium is well seen here. The patient was admitted for further evaluation of his newly diagnosed cardiomyopathy, and formal echocardiography revealed a subtle apical LV thrombus which is not well seen on this POCUS. Dr. Matthew Riscinti Denver Health Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515768080227-RDE6GJA1H4L1QMJOE5E4/ezgif.com-gif-maker+%285%29.gif Left Ventricular Dysfunction - Septal Dyskinesis (Subcostal View) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1602186251078-6CV7RXTQTU8JX3HBONPQ/image-asset.gif Left Ventricular Dysfunction - Bi-ventricular Failure in Vasculitis 24-yo-male who had been diagnosed with granulomatosis with polyangiitis 10 months prior presented with DOE and progressive bilateral lower extremity edema. Clinical suspicion of cardiac dysfunction was confirmed by POCUS; seen here is the apical 5-chamber view, nearly unable to fit on screen due to severity of bi-ventricular dilation and impaired systolic function. Tessa W. Damm, DO Intensivist, Critical Care Medicine & Neurocritical Care. Wisconsin, USA @DrDamm https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598571066292-VATIVQMZBN6J41EYQVK1/low+ef+PSL+jaclyn+walker+.gif Left Ventricular Dysfunction - Biventricular Failure Parasternal Long 50 y/o M PMH methamphetamine abuse presents in respiratory failure with cool, mottled skin and poor capillary refill. Patient was tachycardic, hypothermic with multiple signs of end organ dysfunction. POCUS quickly narrowed the differential by demonstrating clear, severe, reduced ejection fraction by visual estimation and a plethoric IVC without respiratory variation. Patient was ultimately started on dobutamine and transferred to the MICU for treatment of cardiogenic shock. Dr. Jaclyn Walker, Dr. Matthew Riscinti - Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598571051256-EE4DEMW97RN0ER7FBZ09/biventricular+failure+cardiogenic+shock+jaclyn+walker.gif Left Ventricular Dysfunction - Biventricular Failure Apical 4 50 y/o M PMH methamphetamine abuse presents in respiratory failure with cool, mottled skin and poor capillary refill. Patient was tachycardic, hypothermic with multiple signs of end organ dysfunction. POCUS quickly narrowed the differential by demonstrating clear, severe, reduced ejection fraction by visual estimation and a plethoric IVC without respiratory variation. Patient was ultimately started on dobutamine and transferred to the MICU for treatment of cardiogenic shock. Dr. Jaclyn Walker, Dr. Matthew Riscinti - Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1596741711857-XSGR2NCPLTM35S31ZLZE/image-asset.gif Left Ventricular Dysfunction - Parasternal Short Axis: Sepsis-induced cardiomyopathy Seen here is a parasternal short-axis view from a patient who presented with sepsis. POCUS was notable for sepsis-induced cardiomyopathy. Johannes Achenbach https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1596741138210-FAVJEPHYVR3OLAFFXXE8/image-asset.gif Left Ventricular Dysfunction - Sepsis-Induced Cardiomyopathy Pictured is an apical 4 chamber view of a patient who presented with sepsis secondary to lobar pneumonia and was found to have sepsis-induced cardiomyopathy. Appreciate both LV and RV systolic dysfunction. Johannes Achenbach https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515618213710-HIR5TKRE82K0JZNLX0EZ/ezgif.com-optimize+%286%29.gif Left Ventricular Dysfunction - Hyperdynamic State Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Fares) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515618310006-FKYMZDUWOZH4XXP5U026/ezgif.com-optimize+%288%29.gif Left Ventricular Dysfunction - Hyperdynamic State (Long) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Fares) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1513460531072-6L9Q9DIWKE7MUDZQB0XZ/ezgif.com-optimize.gif Left Ventricular Dysfunction - Asystole Fluid bubbles sitting in right ventricle without any signs of cardiac activity. Imaging taken during cardiac arrest resuscitation pulse check. Sukh Singh, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515544752224-L2ORV1GYD3ME8CJEOVHZ/ezgif.com-optimize+%2811%29.gif Left Ventricular Dysfunction - Cardiac Arrest with Agonal Rhythm Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515003142011-582EB0CZBV526E5TLCP2/ezgif.com-optimize.gif Left Ventricular Dysfunction - Asystole Out of hospital arrest brought in by EMS. CPR had been ongoing for 20 minutes without ROSC. Parasternal short axis view at mid papillary level shows complete LV standstill once resuscitation was stopped, confirming the clinical diagnosis. Dr. Cian McDermott - Mater University Hospital Dublin, Ireland https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1663464175331-0C5SWUEM915WF7ETJS08/image-asset.gif Left Ventricular Dysfunction - Regional Wall Motion Abnormality 60s M presented with L arm and axillary pain for 1 day. EKG with subtle ST elevation in II/III and depression in I, aVL without meeting STEMI criteria. HsTrop elevated to about 25,000. POCUS demonstrated hypokinesis of the inferior and lateral walls. Cardiology felt most c/w NSTEMI and missed inferior MI. TTE confirmed regional wall motion abnormalities, and after medical optimization, pt went to cath lab and had RCA occlusion diagnosed and stented. Dr. Spencer Seballos, PGY1 Denver Health Residency in Emergency Medicine https://www.thepocusatlas.com/ivc-abnormal-venous-waveforms daily 0.75 2024-01-11 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697908064893-TNGVA5WV9XK8F5H9NXTC/image-asset.gif IVC & Abnormal Venous Waveforms - Clot At Junction of Right Atrium and IVC This patient initially presented post-operatively to the emergency department with complaints of dyspnea. As we fan through this saggital view of the IVC as it enters the right atrium, we can see hyperechoic structures suggestive of clot formation. An alternative view of this clot from a subxiphoid view can be seen here. The patient was subsequently diagnosed with a DVT that extended into their central femoral vein, at the same leg that was recently operated on. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697908064893-TNGVA5WV9XK8F5H9NXTC/image-asset.gif IVC & Abnormal Venous Waveforms - Clot At Junction of Right Atrium and IVC This patient initially presented post-operatively to the emergency department with complaints of dyspnea. As we fan through this saggital view of the IVC as it enters the right atrium, we can see hyperechoic structures suggestive of clot formation. An alternative view of this clot from a subxiphoid view can be seen here. The patient was subsequently diagnosed with a DVT that extended into their central femoral vein, at the same leg that was recently operated on. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1554690944476-IH6V7WRDVQ4L1RYL9T3H/cardiac+tamponade.gif IVC & Abnormal Venous Waveforms - Look at the IVC in Cardiac Tamponade 58 y/o F with PMHx of metastatic adenocarcinoma of lung presents with progressive SOB for one week. The patient was tachycardic to 103, normotensive, afebrile, mildly tachypneic and saturating 95% on room air. EKG demonstrated sinus tachycardia without electrical alternans. POCUS revealed a large, complex, loculated, anterior pericardial effusion. Sonographic findings of right atrial/ventricle collapse and IVC dilatation confirmed cardiac tamponade. In this long-axis subxiphoid view, the IVC is seen enlarged and has minimal respiratory variation. Common ultrasound findings of cardiac tamponade include: RV end-diastolic collapse, RA systolic collapse, plethoric IVC, septal “bounce”, decrease of mitral valve inflow velocity >25% with inspiration. Echocardiography is the modality of choice to evaluate for pericardial effusion and to assess for cardiovascular compromise (right chamber collapse and IVC). Accurate determination of this patient’s tamponade allowed for rapid surgical intervention. Patient underwent pericardial window with partial pericardiectomy a few hours after presenting to the ED. Dr. Pumarejo, Dr. Tran and Dr. Patel. Aventura Hospital and Medical Center Emergency Medicine. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515618651470-503IG33MZIBA1TZ3JKFU/ezgif.com-optimize+%2814%29.gif IVC & Abnormal Venous Waveforms - Inferior Vena Cava in Hypovolemia (Transverse) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515618507674-50PYVQUN7RCDLLOV1A47/ezgif.com-optimize+%2812%29.gif IVC & Abnormal Venous Waveforms - Inferior Vena Cava in Hypovolemia Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598571060305-UNLA14NU93N0H9JATK17/cardiogenic+shock+plethoric+ivc+jaclyn+walker.gif IVC & Abnormal Venous Waveforms - Plethoric IVC in Biventricular Failure 50 y/o M PMH methamphetamine abuse presents in respiratory failure with cool, mottled skin and poor capillary refill. Patient was tachycardic, hypothermic with multiple signs of end organ dysfunction. POCUS quickly narrowed the differential by demonstrating clear, severe, reduced ejection fraction by visual estimation and a plethoric IVC without respiratory variation. Patient was ultimately started on dobutamine and transferred to the MICU for treatment of cardiogenic shock. Dr. Jaclyn Walker, Dr. Matthew Riscinti - Denver Health Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515617042206-QYRBKO40F99J9AC63UT9/ezgif.com-optimize+%283%29.gif IVC & Abnormal Venous Waveforms - Plethoric Inferior Vena Cava Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496100798543-VU745IRLMT2UL9SYI93J/ezgif.com-optimize+%2810%29.gif IVC & Abnormal Venous Waveforms - IVC Thrombus A 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515543540010-EDUITWSMBCYYP082IFD7/ezgif.com-optimize+%283%29.gif IVC & Abnormal Venous Waveforms - Significantly Enlarged IVC in Acute Heart Failure This is a subxiphoid long axis view of the IVC demonstrating significant enlargement with minimal collapse with respiratory variation. The hepatic vein is also seen entering the IVC and is noted to be quite distended consistent with very high filling pressures. Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Vahtrick) https://www.thepocusatlas.com/other-cardiac-pathology daily 0.75 2025-01-16 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1737049987269-J5NPZJC028VQ2JPH53U2/image-asset.gif Other Cardiac Pathology - Viral vs. Postpartum Cardiomyopathy A4C These images are from a bedside echo performed on a 29-year-old female who presented in significant respiratory distress to the ER. She had no significant medical history besides giving birth a few months prior. Required significant respiratory support and was found to have significantly reduced cardiac function on echo secondary to viral vs. postpartum cardiomyopathy. Dakota Nerland, DO PGY-3; Marion Memmot, DO PGY-1 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1737049987269-J5NPZJC028VQ2JPH53U2/image-asset.gif Other Cardiac Pathology - Viral vs. Postpartum Cardiomyopathy A4C These images are from a bedside echo performed on a 29-year-old female who presented in significant respiratory distress to the ER. She had no significant medical history besides giving birth a few months prior. Required significant respiratory support and was found to have significantly reduced cardiac function on echo secondary to viral vs. postpartum cardiomyopathy. Dakota Nerland, DO PGY-3; Marion Memmot, DO PGY-1 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1729003545340-W4ERFX6ZO5WDKN3OOLYJ/image-asset.gif Other Cardiac Pathology - Migrated Venous Stent Traversing Tricuspid Valve Middle aged male with recent right iliac DVT s/p thrombectomy and venous stent placement is found to have asymptomatic migration of stent into the right heart. In the subxiphoid view, the hyperechoic coiled-appearing stent is seen traversing the tricuspid valve. Percutaneous attempt at removal was unsuccessful, so he ultimately underwent open-heart surgery. Contributed by: Eric Reid, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697908327330-7J2IL1R52BU06C5VOZBD/image-asset.gif Other Cardiac Pathology - Clot Within Right Atrium This patient initially presented post-operatively to the emergency department with complaints of dyspnea. From this subxiphoid view of the heart, we can see a hyperechoic structure suggestive of clot formation. An alternative view of this clot viewed from the right atrium and IVC junction can be seen here, termed “clot-in-transit”. The patient was subsequently diagnosed with a DVT that extended into their central femoral vein. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616443665596-8SM6QHLY76QAGMUBV34Y/image-asset.gif Other Cardiac Pathology - POCUS during Resuscitation This is a PLAX view obtained during CPR . It reveals adequate compressions with the LV “squashing” and obliterating the LV lumen; then subsequently the LV lumen reappearing and recoiling, which allows the LV to refill. Renato Tambelli, @JediPocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638991764542-HVEPW6EL9IX4V5JJQOA5/image-asset.gif Other Cardiac Pathology - LV thrombus, parasternal short axis Parasternal short axis view of a 47yo with PMH non-obstructive CAD incidentally found to have mildly reduced LV systolic function and an echogenic mass in LV extending to outflow tract. Determined to be a large LV thrombus of unknown etiology. Andrew Balster, MD Paul Musgrave, MD (OHSU IM POCUS fellow) @POCUSaurusDx https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638991186859-S9LFFO6WU227AB56FW82/image-asset.gif Other Cardiac Pathology - LV mass/thrombus Parasternal long axis view of a 47yo with PMH non-obstructive CAD incidentally found to have mildly reduced LV systolic function and an echogenic mass in LV extending to outflow tract. Determined to be a large LV thrombus of unknown etiology. Andrew Balstera, MD Paul Musgrave, MD (OHSU IM POCUS Fellow) @POCUSaurusDx https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620334410954-U3AT4Q61TF5ZET7SU5AD/image-asset.gif Other Cardiac Pathology - Pacer Wire Perforation Patient with chest pain with recent history of pacemaker placement. Subxiphoid view reveals the pacer wire in the right ventricle piercing the wall, causing a pericardial effusion. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616081052279-2MA3438ZJYJXD3LA9XWJ/image-asset.gif Other Cardiac Pathology - Venous Air Embolism Pictured here is an apical four chamber view of the heart in a patient who presented for evaluation of dyspnea and was found to be in atrial fibrillation with RVR. POCUS is most notable for the presence of gas bubbles throughout the right atrium and right ventricle. Symptoms of venous air embolism can range from asymptomatic to cardiovascular collapse and death. The presence of venous air embolism may occur due to head or neck surgery, chest trauma, hemodialysis, central vein cannulation, high pressure mechanical ventilation, or thoracentesis. Rupinder Sekhon, MD & Peter Biggane, MD Central Michigan University, Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592498165783-QOA1BE7QHIMK5L5Q2FLS/image-asset.gif Other Cardiac Pathology - Bi-Ventricular Thrombi A 30-year-old male with history of idiopathic heart failure was hospitalized and on mechanical ventilation for COVID-19. POCUS included this subcostal image notable for severe bi-ventricular dysfunction complicated by thrombus formation in the left and right ventricles. Patricia Lopes, Resident of Emergency Medicine at Fortaleza-CE, Brazil @patylopes90 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514384051580-AB2OOPD08GHGETTORPW6/LA+thrombus+jarret+4.gif Other Cardiac Pathology - A Fib with Left Atrial Thrombus (parasternal long) 40 y/o M with atrial fibrillation, off his anticoagulation, presented with shortness of breath and was found to have a left atrial thrombus on POCUS in this parasternal long view. Differentiating a thrombus from an atrial myxoma is difficult, but seeing the object tumble and shoot around the atrium, in the setting of afib, is both dramatic and suggestive of a thrombus. Unfortunately, timing does not differentiate the two since the average myxoma can grow at up to 0.5cm/month. The patient was admitted to the cardiac intensive care unit with full resolution of the thrombus after anticoagulation. Dr. Bryan Jarrett and Dr. John Kilpatrick - SUNY Downstate/Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507876729618-9XFVJKIL6G2STJYDSY4R/Clot+in+Transit.gif Other Cardiac Pathology - Thrombus in Transit Patient in shock. TEE performed as TTE views not obtainable. Midesophageal bicaval view demonstrating what we've dubbed the "RA washing machine". WCUME 2017 Submission for "Best POCUS" Dr. Tom Jelic (@TomJelic) Winnipeg, Canada https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1514383586074-KNK6AJN70IQ6RQ9NGV2O/LA+thrombus+jarret+3.gif Other Cardiac Pathology - A Fib with Left Atrial Thrombus 40 y/o M with atrial fibrillation, off his anticoagulation, presented with shortness of breath and was found to have a left atrial thrombus on POCUS in this apical view. Differentiating a thrombus from an atrial myxoma is difficult, but seeing the object tumble and shoot around the atrium, in the setting of afib, is both dramatic and suggestive of a thrombus. Unfortunately, timing does not differentiate the two since the average myxoma can grow at up to 0.5cm/month. The patient was admitted to the cardiac intensive care unit with full resolution of the thrombus after anticoagulation. Dr. Bryan Jarrett and Dr. John Kilpatrick - SUNY Downstate/Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507867533914-IGEEUO9Y7CFHTU0HTFS3/Transvenous+Pacer.gif Other Cardiac Pathology - Transvenous Pacemaker Guidance WCUME 2017 Submission for "Novel Indication" Confirming Transvenous Pacer Placement with POCUS. Dr. Sarah Medeiros, MD - Sacramento, CA https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496101667893-FLJE0PXEPLFGHPOE9T5D/ezgif.com-optimize+%2814%29.gif Other Cardiac Pathology - The Saline Flush/Bubble Test The 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. 56 y/o M with pneumonia, respiratory distress, intubated, and hemodynamically unstable was started or levophed through a peripheral IV while a right IN was started. The portable x-ray tech wa missing but rapidly flushing saline through the IJ during apical 4 clearly demonstrates saline the R circulation After placing central lines, confirmation by chest x-ray is not always available. When the patient is unstable, delayed use can be consequential. Visualizing the saline swirling in the right side of the heart immediately after a flush is highly predictive of proper catheter tip placement. 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. Leon Chen, NP – Critical Care Medicine Service; Department of Anesthesiology and Critical Care Medicine; Memorial Sloan Kettering Cancer Center; New York, NY https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1496101352249-JOXRD1QMHYMS2RJS0LVY/ezgif.com-optimize+%2812%29.gif Other Cardiac Pathology - AV Canal Defect 3 month old recent immigrant to the United States with Trisomy 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 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1525280035887-0BEYVOPA3MPA16N31FFC/jarrett+truncus+arteriosus+2.gif Other Cardiac Pathology - Truncus Arteriosus Parasternal long view with color doppler of a young male presenting with chest pain and a history of surgically corrected truncus arteriosus including an aortic valve replacement. Notable here is the regurgitant jet just above the aortic outflow tract. The etiology of this jet is uncertain but could represent a persistent VSD despite correction. Dr. Bryan Jarrett - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1525280226444-G5MCPJCZD451O1UUERBP/jarrett+truncus+arteriosus+4.gif Other Cardiac Pathology - Truncus Arteriosus 35 y/o M PMH truncus arteriosus s/p multiple surgeries, bioprosthetic aortic valve, AICD, and recent treatment for endocarditis presents with rectal bleeding and syncope in setting of warfarin use for his chronic DVTs. INR was found to be 1.0. POCUS with pacemaker leads with possible clot vs vegetation attached to the tip. Concern for thrombus given pt's normal INR vs possible infected pacemaker vegetation. Dr. Bryan Jarrett - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1540917470607-NOPYWH948CLGOQHR5ZAV/TEE+ECMO.gif Other Cardiac Pathology - TEE - ECMO Placement Confirmation TEE confirmation of ECMO Cannula done at VCU. Dr. Stenberg https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1617672351160-MAC8TYI3KUYNB8YSR0XM/image-asset.gif Other Cardiac Pathology - Free Peritoneal Fluid seen with Falciform Ligament 50s F found to be in cardiac arrest by EMS in the setting of 3 days hematemesis, achieved ROSC, and this image was seen on POCUS performed by EMS while packaging for transport. This subxiphoid view demonstrates the presence of organized cardiac activity with no large pericardial effusion, but free peritoneal fluid is seen adjacent to the liver, superficial to the diaphragm in this image, and the falciform ligament is also briefly seen. Zachary Hutchins South Metro Fire Rescue, Centennial, CO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644438754165-UT8HU0RAX04YC6772NNL/image-asset.gif Other Cardiac Pathology - Cardiac Amyloidosis Parasternal long axis taken in a patient with clinical suspicion of cardiac amyloidosis. Maxime Gautier https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594934848888-NELINPYT3FIV7O6R3IZ5/ezgif.com-optimize+%284%29.gif Other Cardiac Pathology - Anterior Mediastinal Hematoma Pt presents to ED following an unrestrained head-on MVC with blunt force trauma to chest. Compressing the RV is an anterior mediastinal hematoma seen in this parasternal long axis view secondary to a sternal fracture. Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH View his original post here https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644436533289-U3SPDKJOP3YBBTJWP4WD/image-asset.gif Other Cardiac Pathology - Retained Intracardiac Air A 70 year old male presents 3 days post radiofrequency ablation for atrial fibrillation and atrial flutter. Presented to emergency department with evidence of septic shock, encephalopathy, and hypoxic respiratory failure. The above image shows evidence of air bubbles within the right atrium and ventricle, thought to be iatrogenic in nature after his recent cardiac procedure possibly due to necrotizing infection of the myocardium versus atriotracheal fistula or atrioesophageal fistula. The patient was placed in reverse Trendelenburg position (to mitigate potential embolus to cerebral venous circulation). Fortunately, following flight transfer to another facility, the intracardiac air was no longer visible on CT or echocardiography. Ian Keck https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1657914370127-ZYQGD40157PCK7D7U76N/KJ+mural+thrombus.gif Other Cardiac Pathology - LV Thrombus 40s M with PMH HTN/HLD with no known CHF history presented with BLE edema, dyspnea, orthopnea, and weight gain. POCUS performed shortly after arrival showed markedly reduced LVEF with apical LV thrombus. The patient was initiated on a heparin drip and admitted, where formal TTE and right and left heart caths confirmed HFrEF due to ischemic cardiomyopathy and 3v CAD. Ultimately this patient improved with medical therapy but had an acute massive embolism event to b/l femoral arteries, b/l renal arteries, and SMA about 1 week into his hospitalization despite being on heparin drip while bridging to warfarin. He went to the operating room with vascular surgery and interventional cardiology for extensive thrombectomies as well as angiography but ultimately died after requiring resection of ischemic bowel and later suffering a large hemispheric embolic CVA. Dr. Kathleen Joseph, PGY-4, Denver Health Residency in Emergency Medicine Dr. Cailin Frank, Fellow, Denver Health Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515618084707-5CB2B4QHJW1VOIYGMF3B/ezgif.com-optimize+%284%29.gif Other Cardiac Pathology - Hypertrophic Cardiomyopathy (Long) Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. Kaveh Kaynama) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592328417302-UPP3K1C5L7GD0UN1K7BG/image-asset.gif Other Cardiac Pathology - Bubble Study for CVL Verification A 33-year-old female presented with cocaine-induced chest pain, dyspnea, and clinical evidence of cariogenic shock. CVL was emergently placed and location confirmed via POCUS Bubble Study. Ultrasound verification of CVL placement is possible by visualizing microbubble artifact in the right atrium following injection of saline through the distal port of the CVL. Dr. Victor Bang. Emergency Physician at Hospital das Clínicas de Marília. Co-founder of Pocus Jedi. @vmjbang https://www.thepocusatlas.com/for-review daily 0.75 2026-01-20 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661356474574-FRTHG9RH8VSMX6T0LHNG/image-asset.gif UPLOADS FOR REVIEW - Coronal view and long axis of the MCL at the medial knee 20 y/o M presented with a 4 month history of acut onset L medial knee pain after "twisting" his knee playing soccer and was found to have a high grade tear of the common flexor tendon. Video shows coronal view and long axis of the MCL at the medial knee. The MCL can be seen as a long hyperechoic structure immediately superficial to the joint space, and it is mildly thickened in this video. During ultrasound exam, valgus stress was placed on the knee and gapping can be seen here reflective of impaired integrity of the MCL. Pain was also appreciated with sonopalpation over the MCL. Since the ligament appears intact, but dynamic exam demonstrates gapping of the medial joint, this patient was diagnosed with grade 2 sprain of the MCL. Eben Alexander, DO Devesh Patel, MD Eastern Virginia Medical School https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661356474574-FRTHG9RH8VSMX6T0LHNG/image-asset.gif UPLOADS FOR REVIEW - Coronal view and long axis of the MCL at the medial knee 20 y/o M presented with a 4 month history of acut onset L medial knee pain after "twisting" his knee playing soccer and was found to have a high grade tear of the common flexor tendon. Video shows coronal view and long axis of the MCL at the medial knee. The MCL can be seen as a long hyperechoic structure immediately superficial to the joint space, and it is mildly thickened in this video. During ultrasound exam, valgus stress was placed on the knee and gapping can be seen here reflective of impaired integrity of the MCL. Pain was also appreciated with sonopalpation over the MCL. Since the ligament appears intact, but dynamic exam demonstrates gapping of the medial joint, this patient was diagnosed with grade 2 sprain of the MCL. Eben Alexander, DO Devesh Patel, MD Eastern Virginia Medical School https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661357481925-JRWOUEYI0579Z3275RN2/image-asset.gif UPLOADS FOR REVIEW - Severe HUN Right Kidney 88 y/o female presents with three days abdominal pain, distension, vomiting and worsening on renal function. Hx of previous ovarian cancer with right ureteral stricture (estenosis). Ureteral stent in 2020, recently changed 2 weeks ago. No fever, and currently passing urine without issues. POCUS shows severe HUN to the right. Notice the anatomical distortion of the calyceal collecting system as well as thinning of the renal cortex. Dr Felipe Urriola Perez Resuscitation Fellow The Royal London Hospital ED https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661358946900-ZZEEUTLLCNRMUNFX7Y3Y/image-asset.gif UPLOADS FOR REVIEW - Small sub-pleural consolidation in left lung base 79 y/o patient with 1 week history of malaise, weakness, somnolence and loss of apetite. No cough or SOB, RX unremarkable. POCUS shows small sub-pleural consolidation in left lung base Dr Felipe Urriola P. Resuscitation Fellow The Royal London Hospital ED https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661361246189-V2HPUPD1JR33QE28X69E/image-asset.gif UPLOADS FOR REVIEW - bifid median nerve 30 year old female with incidental finding of bifid median nerve. Video shows scanning proximal to distally in the volar forearm starting at distal third of the forearm and ending in the carpal tunnel. In the distal third of the forearm the median nerve can be seen as one bundle and hyperechoic compared to the surrounding muscles and displays typical "honeycomb" echosignature (hyperechoic perineurium surrounding hypoechoic endoneurium/axons). At the carpal tunnel, the median nerve can be seen as relatively hypoechoic compared to the surrounding hyperechoic tendons. Flexor retinaculum visualized as hyperechoic band immediately superficial to the median nerve in the carpal tunnel. Eben Alexander, DO Devesh Patel, MD Eastern Virginia Medical School https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1660272240652-G2BO8IWXMFCA24ZIPKO6/AAA.gif UPLOADS FOR REVIEW - Aneurysm of the Abdominal Aorta Uncomplicated, nonthrombosed, 3-cm aneurysm of the abdominal aorta Ivan Rancano Garcia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661389848639-BPHSAZNOVTMTQGTV746W/image-asset.gif UPLOADS FOR REVIEW - 445 No caption given https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661390184470-6Z59SWFFRTDC5UINOQ6U/image-asset.gif UPLOADS FOR REVIEW - Sternum Fracture Sternum Fracture 50 y/o female patient who was involved in a recent, low energy RTC as a driver. She attends the ED by her means, stable and able to walk, complaining of central chest pain, which worsens when lying flat. There is no SOB, O2Sat is normal, Lung examination is unremarkable, and Lung POCUS shows no abnormalities. A POCUS scan of the sternum was performed: Identify the skin, fatty and soft tissues from top to bottom. Notice the acoustic shadow (black) deep to the anterior wall of the sternum. Sliding the probe from the sternal manubrium down towards the sternal body, notice the lower echogenicity at the level of the sternal angle. Also, see how the anterior bone cortex is interrupted at the body level, featuring a clear gap located at the centre of the screen at the end of this clip. Dr Felipe Urriola P. Resuscitation Fellow - Emergency Medicine. The Royal London Hospital, Barts Health NHS Trust, London. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661434250036-ON6GZYH54W2H0UDYR61I/image-asset.gif UPLOADS FOR REVIEW - Large Unilateral Right Hydronephrosis woman 64 a, brought to emergency due to abdominal pain, vomiting and nausea, abdominal pocus showed a large unilateral right hydronephrosis. The obstructive primary cause was a pelvic mass still under oncologic investigation. This is a right upper quadrant view, where a grade IV hydronephrosis is observed. This case demonstrates the importance of bedside ultrasound in the differential diagnosis of renal failure in the emergency room. @R_Tambelli https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661434966893-605JXGQ1QXVXAPACTV12/image-asset.gif UPLOADS FOR REVIEW - IVJ Canulation POCUS Insertion of central venous catheter by ultrasound-guided seldinger technique. In this View obtained with a linear Probe on the oblique axis of the internal jugular vein, we observed in-plane the advance of the needle during venous puncture and also the beginning of the passage of the guidewire. POCUS is a key tool to increase the safety of this procedure. @R_Tambelli https://static1.squarespace.com/static/58118909e3df282037abfad7/62e174debd3a4d43db41c2f7/63077cb5a21d5f3d201df59f/1768943846363/ UPLOADS FOR REVIEW - 449 39-year-old man, drinker and smoker, admitted to the emergency room due to fever, weight loss and dyspnea. Lung ultrasound at the bedside showed bilateral pleural effusion with features suggestive of complex effusion.:Plancton Sign - surface sediments in the pleural anechoic fluid and SpiderWeb Sign - multiple images of fibrotic beams, septated areas means a complex pleural fluid. Pleural fluid analisis and pleura biopsy show we a tipical pleural tuberculosis. @R_Tambelli https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661435579873-07F4FZ0LVTIPDZ5Q9AIW/image-asset.gif UPLOADS FOR REVIEW - 450 56 yoM with pmh of many things including COPD and E. fecalis endocarditis of AV, MV, TV s/p TV vegetation debulking and angiovac who presented with COVID hypoxia and meeting SIRS criteria, ended up having E. fecalis bacteremia and was transferred to Bellevue for further vegetation debulking and tx of endocarditis. We did bedside echo which showed the TV vegetations and chronic RVH and right heart strain. Jamie POSPISHIL https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659222368487-LAJS3Y33A6RGKYP5DG8Q/image-asset.gif UPLOADS FOR REVIEW - 413 Ascite Thong Bui https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661435885419-9MEE8G6Q5IE5185NBWDQ/image-asset.jpeg UPLOADS FOR REVIEW - Prepatellar Bursitis Prepatellar bursitis Man, 48 years, mason. The man presented to his General Practitioner because his left knee is swollen. On physical examination, the knee appears swollen and warm. The probe is held in sagittal orientation, with an extended field-of-view ultrasound technique. In the image the distended prepatellar bursa is shown, between skin and patella/patellar tendon, with septation and vegetation. Dario Palini https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661436425918-958HLL43KZETGZ1WE1L0/image-asset.gif UPLOADS FOR REVIEW - Recessive Polycystic Kidney Disease This image of the left upper quadrant of the abdomen shows multiple cystic structures of various sizes surrounding renal pelvis in patient with end stage renal disease on dialysis. This patient has recessive polycystic kidney disease. Please give credit to Dr. Michael Caro, DO, as well. Affiliations: Crozer Chester Medical Center, Upland, PA. Leslie Crosby @LeslieCrosbyMD1 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661436811760-I1FXGY0Z4PX61P1RK0BT/image-asset.gif UPLOADS FOR REVIEW - Acute PE Clot in RA Acute PE clot in RA Samantha King https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664460514573-VAU86OBGP6QE9Z5I9UKN/image-asset.gif UPLOADS FOR REVIEW - Presence of Anechoic Space with Internal Echoes Presence of Anechoic Space with Internal Echoes Dr. Jaime Alejandro Sánchez Gutiérrez Pulmonologist @PLEURALPOCUS https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664461380507-S9UYAZN835O9CZQ6CBX2/image-asset.gif UPLOADS FOR REVIEW - Post-Op Hemothorax Male ICU patient developed respiratory failure and opacified L hemithorax day 2 post-op from TEVAR for Type B aortic dissection. Longitudinal view from L posterior axillary line showed hemothorax with a large intrapleural blood clot and small medial sliver of atelectatic lung. Paradoxical movement with inspiration and absence of air bronchograms assist in distinguishing clot from lung parenchyma. Samuel Eglin, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1665077117037-2RDK83UWSHJUXA67N4LS/image-asset.gif UPLOADS FOR REVIEW - Quadriceps Tendon Rupture 62 year old male presenting with inability to extend his left leg and decreased weight bearing after falling straight down onto his knee on a boat ramp. POCUS was utilized which confirmed quadriceps tendon rupture. The tear and end of the tendon can be visualized on the clip with a significant amount of edema leading towards the patella. When performing tendon ultrasounds of the knees in the setting of decreased knee extension, remember to visualize both patellar and quadriceps tendons as well as contralateral tendons for comparison. Dr. Thomas Taugher, DO; Dr. Michael Bernard, DO; Marko Lubardic, MS4 - Central Michigan University Residency in Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1665078505674-K4OFUUWV4E23TLSJ5EFO/image-asset.gif UPLOADS FOR REVIEW - Central Retinal Artery Occlusion A hyperechoic focus noted in the distal optic nerve using a linear transducer concerning for an acute central retinal artery occlusion. Kody Sacks-Moynihan, MD; Steven Shapiro, DO; Jackie Nguyen, MD; Huy Tran, MD; Gaurav Patel, MD https://static1.squarespace.com/static/58118909e3df282037abfad7/62e174debd3a4d43db41c2f7/634d63dabadb6a12d9fd4e4e/1768943846451/ UPLOADS FOR REVIEW https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1666101530981-2690MNYYXPYL5GHS6BKE/image-asset.gif UPLOADS FOR REVIEW - Viterous Hemorrhage 76 year old male with a PMH of malignant ocular melanoma and blindness of the right eye presented due to right sided headache for the last 2 days. Michael Bernard, DO; Thomas Taugher, DO; Marko Lubardic; Central Michigan University Residency in Emergency Medicine https://static1.squarespace.com/static/58118909e3df282037abfad7/62e174debd3a4d43db41c2f7/63a3b8ce0ef4d901a8070773/1768943846466/ UPLOADS FOR REVIEW https://static1.squarespace.com/static/58118909e3df282037abfad7/62e174debd3a4d43db41c2f7/6421c867efd3c727585083a1/1768943846497/ UPLOADS FOR REVIEW https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1679935608635-PS7E1S0816TQNAHBLXFS/image-asset.gif UPLOADS FOR REVIEW - Pericardial Effusion with Tamponade Physiology in the setting of myxedema coma This clip portrays a pericardial effusion with tamponade physiology found in a patient suffering from myxedema coma after she lost access to her levothyroxine. Jacob Long, Medical Student Alicia Hoban, MD Michael Gomez, DO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1686843550965-IUQJBTRDWMV0FKQK9GJL/image-asset.gif UPLOADS FOR REVIEW - Cardiac Tamponade This is a 58-year-old female with history of metastatic lung cancer who presented with escalating dyspnea. POCUS revealed an anechoic region remaining anterior to the descending aorta with parasternal long axis view highlighting diastolic right ventricular collapse, and subxiphoid view highlighting systolic right atrial collapse. She subsequently went for pericardial window. Krishna Patel, DO Lauren Lowes, DO Julia Tu, MS4 Central Michigan University College of Medicine https://www.thepocusatlas.com/pedscardiac daily 0.75 2025-01-03 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601058949549-07HQX9A8MXUWJOHO5D4R/image-asset.gif Peds-Cardiac - COVID-19 Myocarditis 14 year-old male presents to the ED with chest pain two weeks after being having been diagnosed with COVID-19. Labs were notable for elevated CBC, CRP, ESR, and troponin. POCUS revealed moderately decreased function and LV dilation, consistent with the diagnosis of COVID-19 myocarditis. Paul Khalil, MD and N. Akwesi Poteh, MD at University of Louisville @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601058949549-07HQX9A8MXUWJOHO5D4R/image-asset.gif Peds-Cardiac - COVID-19 Myocarditis 14 year-old male presents to the ED with chest pain two weeks after being having been diagnosed with COVID-19. Labs were notable for elevated CBC, CRP, ESR, and troponin. POCUS revealed moderately decreased function and LV dilation, consistent with the diagnosis of COVID-19 myocarditis. Paul Khalil, MD and N. Akwesi Poteh, MD at University of Louisville @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1645226096022-I5EDFYS8JS67T7E95SM4/image-asset.gif Peds-Cardiac - Cardiac Standstill This is a subcostal view during pulse check in a patient presenting in cardiac arrest. The image demonstrates no organized cardiac movement. Small bubbles can be seen in the cardiac chambers which indicates no significant forward flow. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735775337009-23OW0FBAMH88JF9R01CG/image-asset.gif Peds-Cardiac - Cardiac Arrest Cardiac arrest- standstill. Contributor: Elad Machtey, MD, BC Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735775822260-9UMSRX4A966D8GNG4GK3/image-asset.gif Peds-Cardiac - IVC Hypovolemia 6 year old with vomiting and diarrhea. IVC shows fluid tolerant with significant flattening with respirations. Contributor: Kathryn Pade, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735776182016-PWNHS2GB5J7O063PX4H3/image-asset.gif Peds-Cardiac - Pericardial effusion from lupus 12 year old presenting with persistent tachycardia in the setting of hypertension and proteinuria and hematuria. Found to have lupus nephritis with pericardial effusion. Contributor: Kathryn Pade, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735776525076-XA61EQEUSYL619XTOOO5/image-asset.gif Peds-Cardiac - Familial dilated cardiomyopathy 3 month old presenting with respiratory distress. Found to have familial dilated cardiomyopathy. Contributor: Kathryn Pade, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735777103429-QG4WC8B5DMNL9W9Q32XC/image-asset.gif Peds-Cardiac - Multiple valvular abnormalities in a young boy. RV failure. A 5M stating "my toes hurt." Physical examination shows blue toes. He has a history of congenital sub aortic stenosis with mitral valve regurgitation and stenosis. He was found to have an acute CHF exacerbation with biventricular involvement and mitral stenosis/regurgitation. He was admitted to the PICU on vasopressors. Contributor: John Bowling, DO, Cleveland Clinic Akron General, @BModeBowling https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735780460408-07SYPGY860Y6KNZWBG0T/image-asset.gif Peds-Cardiac - Tetralogy of Fallot Unrepaired Unrepaired Tetralogy of Fallot, seen in this image is ventricular septal defect. Contributor: Kathryn Pade, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735780905306-E7AWIAQYHYJCJM1ZUREZ/image-asset.gif Peds-Cardiac - Tetralogy of Fallot PLAX view of patient with Tetralogy of Fallot with pulmonary atresia demonstrating a moderately dilated and hypertrophied right ventricle. Contributor: Kathryn Pade, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735781464038-Z68GIIR2SXD79VW6CPTW/image-asset.gif Peds-Cardiac - Tachycardia 4 month old, IVC 4 month old with pulmonic stenosis with tachycardia. IVC fluid tolerant. Contributor: Kathryn Pade, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735781938810-I46ZTJKOW5YV3C30XOBD/image-asset.gif Peds-Cardiac - Asystole Cardiac asystole in a 2-month-old. Patient found unresponsive at home in crib, arrived to ED with CPR in progress. Presumed diagnosis of SIDS. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735859331348-4N339B7GEURLZJ0T0QFR/image-asset.gif Peds-Cardiac - IVC Normal Normal IVC in a 4-year-old preschooler. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735859631380-7PYYA8NT4Y9045R0SR0C/image-asset.gif Peds-Cardiac - Older Kid Subcostal Normal subcostal view in a 4-year-old preschooler. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735860317496-JXCLQLQG7ICXPL4LMP3O/image-asset.gif Peds-Cardiac - Older Kid Apical 4 Chamber Normal apical 4 chamber view in a 4-year-old preschooler. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735860755010-OBQ1SAV9A6HQYKLBMK3A/image-asset.gif Peds-Cardiac - Older Kid PSSA apex Normal PSSA apex in a 4-year-old preschooler. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735861107288-M2X4M8TS6GPWJTNEVHB0/image-asset.gif Peds-Cardiac - Older Kid PSLA Normal PSLA in a 4-year-old preschooler. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735861596078-2D120X860DB5SXFE165N/image-asset.gif Peds-Cardiac - IVC Normal Normal IVC in a 9-year-old. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735862079539-CNWA3GDHG6UWVOIH35OV/image-asset.gif Peds-Cardiac - Older Kid Subcostal Normal subcostal view in a 9-year-old. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735862423139-I5KPC1BIDNZ7XEQ4MJW5/image-asset.gif Peds-Cardiac - Older Kid Apical 4 Chamber Normal apical 4 chamber view in a 9-year-old. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735862846553-8L1A9BTW1Y9LQOL7JNSO/image-asset.gif Peds-Cardiac - Older Kid PSSA base Normal PSSA base (aorta) view in a 9-year-old. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735863193756-TQXLXI6034O7EZVL50Z7/image-asset.gif Peds-Cardiac - Older Kid PSSA mid Normal PSSA mid (mitral valve) view in a 9-year-old. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735863572144-P5KZ1YFKNC2RWO8XMHW8/image-asset.gif Peds-Cardiac - Older Kid PSSA apex Normal PSSA apex in a 9-year-old. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735867579261-1T3ETJHIIO6TSZI34QUR/image-asset.gif Peds-Cardiac - Older Kid PSLA Normal PSLA in a 9-year-old. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735868157383-DX2II5Y1VJKX3D4RW36I/image-asset.gif Peds-Cardiac - IVC Normal Normal Toddler IVC. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735868784608-K7HNX10MBKTYOGL4G9DC/image-asset.gif Peds-Cardiac - Toddler Subcostal Normal Toddler Subcostal View. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735869270278-FTUFIQM0AIS0XIJWVZC4/image-asset.gif Peds-Cardiac - Toddler Apical 4 Chamber Normal Toddler Apical 4 chamber. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735869608345-B8F3LOC32X0I1ET6Z36M/image-asset.gif Peds-Cardiac - Toddler PSSA apex Normal Toddler PSSA apex. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735870060663-7KWF5HIU6MXWXZ0B765A/image-asset.gif Peds-Cardiac - Toddler PSLA Normal Toddler PSLA. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735870474937-N0R425S6M4NT4P900XT4/image-asset.gif Peds-Cardiac - IVC Normal Normal neonatal IVC. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735870854502-XVBFMV1BF5VS99JY69VU/image-asset.gif Peds-Cardiac - Neonatal Subcostal Normal neonatal subxiphoid view. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735875692215-PYWJ9N7FSXXMNBYQYZ0R/image-asset.gif Peds-Cardiac - Neonatal Apical 4 Chamber Normal neonatal apical 4 chamber. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735876336787-4X83OT1Q6SPZP2KMPZBC/image-asset.gif Peds-Cardiac - Neonatal PSSA apex Normal PSSA in a neonate. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735877228604-MPI2806AYIC138OHT0EJ/image-asset.gif Peds-Cardiac - Neonatal PSLA Normal Neonatal PSLA. Note thymus anteriorly. Contributor: Jaron Smith, MD Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735877673684-3H59K7OL93YYW0HRG66V/image-asset.gif Peds-Cardiac - Truncus Arteriosus S/P Repair Truncus arteriosus, with the left pulmonary artery arising off the ascending aorta and the right pulmonary artery arising off of the descending aorta, right aortic arch, bilateral superior vena cava without bridging vein. Contributor: Callie Alt, MD, Nicklaus Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735878381535-7O6ASJZRNIUO2ESCEO0G/image-asset.gif Peds-Cardiac - Cardiac arrest - asystole Toddler presenting in asystolic cardiac arrest. PSLX view demonstrating asystole with complete absence of cardiac movement. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735879089196-HRIHB83WEP0UT6DLOLTE/image-asset.gif Peds-Cardiac - SVT Newborn with SVT. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735879494803-SV0Q2FGBLNBF0XEHNO4O/image-asset.gif Peds-Cardiac - VSD Well appearing newborn with murmur. POCUS shows a VSD. Contributor: Nolan Nielsen, MD Nicklaus Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735879809408-NV81F4W6BOW3C7528DY1/image-asset.gif Peds-Cardiac - Older kid PSLA 11 year old male presented to the emergency department with chest pain. Normal cardiac POCUS seen, and after a normal EKG and the chest pain resolved with ibuprofen the patient was discharged home. Contributor: Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735880277159-9N4KYFHRDOREE6120IWD/image-asset.gif Peds-Cardiac - Older kid PSSA mid 11 year old male presented to the emergency department with chest pain. Cardiac POCUS did not reveal any abnormalities and the patient was discharged home after an EKG was performed and the chest pain improved with ibuprofen. Contributor: Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735880877775-ZO91URCF9WOD3HVD29UR/image-asset.gif Peds-Cardiac - Normal Neonatal apical 4 chamber view 20 day old neonate presented with shortness of breath. Cardiac POCUS did not reveal any abnormalities. Contributor: Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735882155971-RN47LKNARNECVJIX3A0K/image-asset.gif Peds-Cardiac - Pericardial Effusion 3 yo with known post viral pericardial effusion who comes to the ED with acute onset shortness of breath. POCUS shows effusion. Cardiology consulted and performed a pericardiocentesis in the cath lab. Contributor: David Lowe, MD Nicklaus Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735882775300-YGUSURYBDL1HHBCA0NHG/image-asset.gif Peds-Cardiac - Thymus Thymus, 10 day old male. Contributors: Ana Ruiz-Castaneda, MD, Paul Khalil. MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735883277745-E2X2IBLQ0F7IFO3M56EX/image-asset.gif Peds-Cardiac - Pericardial Effusion with Tamponade 15 year old with lupus presents with chest pain and shortness of breath. POCUS shows a pericardial effusion with tamponade. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735883760445-3UAFX66Y7T2AQAFEKE9C/image-asset.gif Peds-Cardiac - Ventricular tachycardia Teenager in ventricular tachycardia. Contributor: Peter Gutierrez, MD, FAAP, Emory University School of Medicine/Children's Healthcare of Atlanta, @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735884299181-JVZT1BF64STJ7BGCS6L8/image-asset.gif Peds-Cardiac - Moderate fibrinous pericardial effusion Fibrinous pericardial effusion. Contributor: Peter Gutierrez, MD, FAAP, Emory University School of Medicine/Children's Healthcare of Atlanta, @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735884603055-HMANVQKIU9RTJM0947RH/image-asset.gif Peds-Cardiac - Hypertrophic cardiomyopathy 17 year old male with history of Danon disease resulting in hypertrophic cardiomyopathy. Contributor: Julia Brant, MD, Children's Colorado, @pedipocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735885064786-JHY7AIU22IXELBXA3B4P/image-asset.gif Peds-Cardiac - LVH in pediatric patient 15 year old with chest pain. POCUS shows left ventricular hypertrophy. Referred to cardiology after normal labs. Contributor: Kathryn Pade, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735885467978-G9BXI5RO7T2XA4VR24RR/image-asset.gif Peds-Cardiac - PSSA with moderate effusion Teenage female with COVID-associated pericarditis with moderate effusion. Contributor: Peter Gutierrez, MD, FAAP, Emory University School of Medicine/Children's Healthcare of Atlanta, @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735885946875-CUO43ES3C7O5ZYFOM8T8/image-asset.gif Peds-Cardiac - Small Pericardial Effusion -Subxiphoid Small pericardial effusion in the subxiphoid view. Contributor: Peter Gutierrez, MD, FAAP, Emory University School of Medicine/Children's Healthcare of Atlanta, @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735886235681-3C307NXMRSVE3HYTZ1Y8/image-asset.gif Peds-Cardiac - Apical 4 Chamber showing ASD closed with percutaneous device Apical 4 chamber view showing an ASD occlusion device. Contributor: Peter Gutierrez, MD, FAAP, Emory University School of Medicine/Children's Healthcare of Atlanta, @pocuspete https://www.thepocusatlas.com/pedslung daily 0.75 2026-01-20 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678208368181-9HLLUOYNOJPZ75WL6M8M/pedsptx.jpg Peds-Lung - Lack of Lung Sliding Seen in M-Mode Pediatric patient presenting with shortness of breath. Found to have a large left sided pneumothorax. M-mode tracing shows lack of lung sliding Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678208368181-9HLLUOYNOJPZ75WL6M8M/pedsptx.jpg Peds-Lung - Lack of Lung Sliding Seen in M-Mode Pediatric patient presenting with shortness of breath. Found to have a large left sided pneumothorax. M-mode tracing shows lack of lung sliding Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1725585878165-L3D2B6HJ264SYJIU3LYZ/image-asset.gif Peds-Lung - Esophageal Intubation Intubation attempt into the esophagus of an 8 year old male with respiratory distress. Notice the soft tissue posterior to the trachea moving with the provider attempting the pass the tube. Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1731965978005-A9CI5NSG0XXYU447YUC3/image-asset.gif Peds-Lung - Normal Lung Sliding During FAST Exam 11 year old female presented to the emergency department with a puncture wound to her left chest wall. FAST exam did not reveal any intraabdominal free fluid, and there was lung sliding bilaterally, suggesting no pneumothorax. The patient had her wound explored, repaired, and was discharged home. Contributed by: Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1731965734619-2ONVGMF4SZ1BLLYCTHIL/image-asset.gif Peds-Lung - Esophageal Intubation Intubation attempt into the esophagus of an 8 year old male with respiratory distress, notice the soft tissue posterior to the trachea moving with the provider attempting the pass the tube. Image contributed by: Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664740619784-ZS04EB4YRHNMDRQTBGPT/image-asset.gif Peds-Lung - Normal Lung Slide Normal lung sliding using linear probe Contributor: Peter Gutierrez, MD, FAAP, Emory University School of Medicine/Children's Healthcare of Atlanta, @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664742568680-B33PEDW1TFTDG6RXCGJD/image-asset.gif Peds-Lung - Confluence of B-Lines Toddler with pneumonia; multiple B-lines noted with adjacent area of consolidation. Contributor: Peter Gutierrez, MD, FAAP, Emory University School of Medicine/Children's Healthcare of Atlanta, @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664743299422-F231AUOVS2DKTRE6LI94/lungpoint.gif Peds-Lung - Lung Point Lung point indicative of pneumothorax. Contributor: Peter Gutierrez, MD, FAAP, Emory University School of Medicine/Children's Healthcare of Atlanta, @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664904050365-5CVDLMRV2SZCBOSRCSI0/jrpneumonia.gif Peds-Lung - Lung Consolidation Lung consolidation in a child with fever and cough; faint dynamic air bronchogram seen Contributor: Peter Gutierrez, MD, FAAP, Emory University School of Medicine/Children's Healthcare of Atlanta, @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664904989451-7GVK8ELDSCJTJIHZCMZ1/image-asset.gif Peds-Lung - Large Pleural Effusion Large pleural effusion in a teenager Contributor: Peter Gutierrez, MD, FAAP, Emory University School of Medicine/Children's Healthcare of Atlanta, @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1670688087329-S5MGIE7ZE7ON853R6A0Y/airbronchograms.gif Peds-Lung - Dynamic Air Bronchograms Neonate in respiratory failure status post intubation. The presence of dynamic air bronchograms helps point away from atelectasis. Contributor: Peter Gutierrez, MD, FAAP | Emory University School of Medicine/Children's Healthcare of Atlanta | @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1670690010156-A871WWMALGY3O4M91U3F/image-asset.gif Peds-Lung - Lack of Lung Sliding Lack of lung sliding. Contributor: Peter Gutierrez, MD, FAAP | Emory University School of Medicine/Children's Healthcare of Atlanta | @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678205977525-GPISF4FCRKXI8QETEN9S/loculatedpleuraleff.gif Peds-Lung - Loculated Pleural Effusion 16 yo with initial diagnosis of pneumonia. Worsening shortness of breath. Found to have a loculated pleural effusion on POCUS. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678207122859-0PC9T104EZ0K0UEZME74/pedslunghepatization.gif Peds-Lung - 5 Year Old with Pneumonia 5 y/o with pneumonia- the image demonstrates hepatization of the lung consistent with pneumonia/consolidation. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678207583658-BJDEJXI7I7FBOPR1G0OW/4yopna.gif Peds-Lung - Pneumonia in a 4 Year Old 4 year old M with asthma who presents with respiratory distress and fever. + coronavirus (not COVID-19). POCUS shows focal B lines concerning for pneumonia, bacterial vs viral. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678207945289-HHM7ZSRXSSKEQ8TH986F/pedsnormallungslide.gif Peds-Lung - Normal Lung Sliding with Comet Tails 4 y/o with asthma who presents in respiratory distress. Using the linear probe, normal lung sliding is seen with comet tails. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678208778550-SB0RTXJJH4EJV5MK7ZU3/pedsnolungslide.gif Peds-Lung - No Lung Sliding Pt presented with shortness of breath of sudden onset. Found to have absence of lung sliding consistent with a large pneumothorax that required chest tube placement. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678209129891-TUW3PK5Y5T7EGNJ04EU0/bronchiolitis.gif Peds-Lung - Bronchiolitis 9 month old with respiratory distress. Diffuse confluent B lines found on POCUS consistent with bronchiolitis. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678209423491-CZDC25Q8XFXOA7TQD6XE/empyema.gif Peds-Lung - Empyema of the Lung 15 year old with complex PMH who presented with respiratory distress. CXR shows a large effusion. Bedside ultrasound showed an empyema. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678209768298-WH4J8KBJKK7ENH1E2QPK/subpleuralconsolidation.gif Peds-Lung - Subpleural Consolidation in 3 Year Old 3 y/o with respiratory distress. Found to have a large subpleural consolidation on CXR. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678210126235-YEQB0N0YLIN4EXK7EGJT/atelectasis.gif Peds-Lung - Atelectasis in Neonate 32 weeks premature. 4 weeks of life in the course of weaning from oxygen with respiratory deterioration requiring orotracheal intubation Evidence of lung collapse with static bronchogram in the right upper lobe. Contributor: Mg. Andres Silva Horna, Hospital Cayetano Heredia Piura-Peru https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678210627021-HCY2FTK40XUJMHQZNXPA/pleuraleffustion.gif Peds-Lung - Pleural Effusion from Dengue 4-year-old boy with dengue who presents respiratory distress. Pleural effusion with passive atelectasis (jellyfish sign) is visualized. Contributor: Mg Andrés Fernando Silva Horna; Hospital Cayetano Heredia-Piura https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509193081694-R2U6E028JQW12XG13CI0/Liteplo+-+Tracheal+Stenosis.gif Peds-Lung - Tracheal Stenosis The patient, presenting with stridor, is supine and the airway is seen from the anterior neck in transverse orientation. As the probe is fanned, the bright white line is seen to widen. This column of air moves with inspiration. At its narrowest it is only a few millimeters wide. Growth along the lateral tracheal walls has caused significant tracheal stenosis. In this case, US was used to determine the width of the tracheal column and determine that passage of an ETT would not be feasible. The patient was taken to the OR for an emergent surgical airway. Use of US to estimate tracheal diameter is a novel application. Andrew Liteplo MD, RDMS - Massachusetts General Hospital Chief, Division of Ultrasound in Emergency Medicine Director, Emergency Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1500298984292-QY8L2Q4W5DP7HMXGTNAA/ezgif.com-optimize%28lung_point%29.gif Peds-Lung - Pneumothorax with Lung Point 18 y/o M 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 indicates the transition point between normal pleura with normal lung sliding (on the left side of the image) and where there is air disrupting the pleural space with decreased lung sliding (on the right side of the image). Lung point is a highly specific finding indicating a pneumothorax. Dr. Sathya Subramaniam, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497409700507-V6PH1F3PGYTA2PZKWM3E/hydrocarbon+ingestion+comp.gif Peds-Lung - Hydrocarbon Ingestion with C-Lines 5 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 subpleural consolidations, confirmed with CXR. This imaging finding is similar to findings seen in other consolidative processes. This was suggestive of an aspiration pneumonitis. Dr. Sathya Subramaniam, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1498402983373-3CVJ7JGGK3MCLRZVZPK8/ezgif.com-optimize%28infant_PNA%29.gif Peds-Lung - Infant Pneumonia with C-Lines 11 month old unvaccinated infant 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 present. Dr. Sathya Subramaniam, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1497408790869-5J4UQEDUWM16WZFIB6HZ/hepatization+comp.gif Peds-Lung - Lung Hepatization in 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. 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 appear compared to the actual liver. Dr. Sathya Subramaniam, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509193144803-7R8STX90HZWW29B43DP0/acute+chest+syndrome+w.gif Peds-Lung - Acute Chest Syndrome 6 y/o sickle cell (HbSS) coughing with left-sided chest pain and 1 day of fever. Lungs without crackles, good air entry bilaterally. A consolidative process is seen with a hypoechoic region with posterior enhancement greater than 1 cm in an area where normal A lines should be present. This is highly suggestive of acute chest syndrome given clinical features. Dr. Sathya Subramaniam, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544998047426-AW2D8WW8RX8J4MKUWX22/PNA.gif Peds-Lung - Focal B-lines - Pneumonia 2 years old male with hx of endotracheal intubation secondary to RSV infection presents with 2 days of fever, cough, rhinorrhea and nasal congestion. Denied nausea, emesis, diarrhea, chest pain, syncope, confusion, change in eating patterns and voiding patterns. POCUS demonstrates a focal area of B lines c/w pneumonia (likely viral). Early PNA B lines: short path reverberation artifacts create by fluid filled alveoli. In the appropriate clinical scenario B lines and pleural consolidation suggest PNA. Dr. Carolina Camacho Ruiz - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1544997455215-XKBTGJSI64E708EBOARJ/whiteout+PNA+1.gif Peds-Lung - Pneumonia 3 y/o previously healthy UTD with vaccines. 5 days of cough and fevers. 3 days of abdominal pain, acutely worsening day of presentation with 1 episode of NBNB emesis. Febrile tachypneic and hypoxic to 91% on RA. CXR: white out of right lung. POCUS: Right sided effusion associated with subpleural consolidation and focal b-lines on right lateral view. Dr. Isaac Gordon - Kings County Pediatric Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598024657385-HWGJP6P3FLEMH08NNZXY/image-asset.gif Peds-Lung - Hepatization of the Lung A 15-month-old male presented with cough, fever, and tachypnea of 3-days duration. POCUS revealed findings of right lung consolidation, consistent with pneumonia referred to as hepatization of the lung. Seen here territories above and below the diaphragm show ultrasonographic findings resembling liver parenchyma. Amar Singh, MD. Pediatrics specialist in Louisville, KY https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601048900046-B2TP4I4OEQ96JDAI8HQ9/image-asset.gif Peds-Lung - COVID-19 Pneumonia 14 year-old female known to be SARS-CoV-2 positive presented with chest pain and shortness of breath. POCUS revealed findings consistent with COVID pneumonia including thickened pleura and presence of multiple B-lines. Paul Khalil, MD. Assistant PEM POCUS director at University of Louisville/Norton Children’s @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601049487269-0354YC3IH74DJLX94OEJ/image-asset.gif Peds-Lung - Dynamic Air Bronchograms 15 year-old male with cerebral palsy presents to the ED with hypoxia. Physical exam notable for left lung with decreased air movement on auscultation. POCUS demonstrates dynamic air bronchograms consistent with suspected diagnosis of pneumonia. Paul Khalil, MD. Assistant PEM POCUS director at University of Louisville/Norton Children’s @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1644439909553-4LEHAH7C3AU75BOMIL0V/image-asset.gif Peds-Lung - Acute Chest Syndrome A child with history of sickle cell presented with upper abdominal and back pain and was found to be tachypneic with low grade fever. Ultrasound of the left upper quadrant demonstrated basilar left lung consolidation. Subsequent chest x-ray was interpreted as infiltrate consistent with acute chest syndrome. Michael Cover, @michaelc0ver https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638985374475-7I59ZJIQIS872U7W7O6D/image-asset.gif Peds-Lung - Pediatric Consolidation A 10-year-old patient with no medical background is brought to the ED presenting a 2-day history of dry cough and right subcostal pain. There is neither fever nor shortness of breath. A lung ultrasound was performed following physical examination which prompted the discovery of a consolidation. The probe is slid along 2 intercostal spaces revealing an oddly shaped structure with irregular edges that locates in between normal A-lines. Dr. Felipe Urriola P. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638995062073-BVAQ9Y8ON0E4ZAXTX5EU/image-asset.gif Peds-Lung - Lung Atelectasis After Foreign Body Aspiration 2 yr old child with sudden respiratory distress with O2sat 70%. Child was intubated in prehospital setting by a HEMS physician and POCUS obtained en route to the hospital revealed a completely collapsed (atelectatic) left lung as seen in the clip; right lung was normal. In hospital an aspirated foreign body (a raisin) was removed a from the child’s left main bronchus. Child made a full recovery. Victor Viersen @victor_viersen https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1521664153061-MLG2ZK4YARQD7TMI8J4R/c+lines+camacho.gif Peds-Lung - C-lines - Pneumonia 2 y/o M PMH RSV requiring intubation with 2 days of fevers, cough, rhinorrhea, congestion. POCUS of right posterior lung demonstrates hyperechoic subpleural findings likely generated by the consolidated lung tissue known like C lines consistent with pneumonia. C lines are described as heterogenous hyperechoic irregularities below the pleural line. They are thought to arise from the pulling of the pleural by the consolidated lung tissue. Shred sign is similar to C lines. Is an irregular line distinct from the pleural line due to consolidated lung tissues making contact with the aerated lung that is shredded and irregular. Dr. Carolina Camacho and Dr. Michael Greisinger - Kings County Emergency Medicine https://www.thepocusatlas.com/pedsorbital daily 0.75 2024-01-25 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1670691214993-ZA55B665OKWEAJOXYDT9/retinoblastoma.gif Peds-Orbital - Retinoblastoma Retinoblastoma in a 3-year-old is noticed on the right side of the clip. Associated retinal detachment on the left side. Contributor: Peter Gutierrez, MD, FAAP Emory University School of Medicine/Children's Healthcare of Atlanta, @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1670691214993-ZA55B665OKWEAJOXYDT9/retinoblastoma.gif Peds-Orbital - Retinoblastoma Retinoblastoma in a 3-year-old is noticed on the right side of the clip. Associated retinal detachment on the left side. Contributor: Peter Gutierrez, MD, FAAP Emory University School of Medicine/Children's Healthcare of Atlanta, @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1670693600863-CYUD5ZLRZEI0VE6PUS32/image-asset.gif Peds-Orbital - Optic Disc Drusen Note the hyperechogenic area that represent the drusen in the optic disc. Contributor: Maher M. Abulfaraj, MD, @mahermabulfaraj https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1670694603160-NU9AW0SZOY7UQ43VHX6P/image-asset.gif Peds-Orbital - Retinal Detachment Retinal detachment. Please note how the retina is floating the posterior chamber and is anchored to the optic disc posteriorly. Contributor: Maher M. Abulfaraj, MD, @mahermabulfaraj https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1671038202227-GM3IM7MZ1XK6XWUM9B2Z/ezgif.com-gif-maker.gif Peds-Orbital - Papilledema Optic disc elevation representing papilledema Contributor: Maher M. Abulfaraj, MD, @mahermabulfaraj https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1671038963868-SP4MJCIMV0SEBEXORG3P/papilledema2.gif Peds-Orbital - Papilledema Optic disc elevation representing papilledema Contributor: Maher M. Abulfaraj, MD, @mahermabulfaraj https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1671039786910-M42VQB3C4VWACQGW4YWS/normaleye.gif Peds-Orbital - Normal Eye Normal ocular anatomy, note the cornea, iris and lens anteriorly Contributor: Maher M. Abulfaraj, MD, @mahermabulfaraj https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1671040299496-UQ90F0VJFI7Z56Y4LJVF/retinaldetachment.gif Peds-Orbital - Retinal Detachment 12 year old with subtle retinal detachment (vision 20/400 in affected eye). Dilated eye exam with Inferior retinal detachment from 3 o'clock to 9 o'clock. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1671040767633-FZ37HT2O5Q412MEQM5NT/8yoretinaldetachment.gif Peds-Orbital - Retinal Detachment, 8 yo 8 year old with blurry vision, acuity 20/70 and retinal detachment confirmed by dilated eye exam. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685727429169-P1NXTYNLLDR6GHJYPE49/ezgif.com-optimize+%2820%29.gif Peds-Orbital - Retinal Detachment Retinal detachment in a teenager with acute vision loss. Contributor: Peter Gutierrez, MD FAAP FACEP; Children's Healthcare of Atlanta; @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685727782296-AGQPE572C80MQ5FYDDMM/ezgif.com-optimize+%2821%29.gif Peds-Orbital - Lens Calcification 19 year old female with glaucoma presents with head trauma and abnormality of the lens on CT (calcification) that was subsequently visualized by POCUS. Contributor: Julie Leviter, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685728030246-RZ4JY5RRU7WDG6PT9CXW/ezgif.com-optimize+%2822%29.gif Peds-Orbital - Vitreous Detachment 12 y/o with blurry vision for 1 month. POCUS shows thickening of vitreous in middle of eye / vitreous detachment. Note there is no point of fixation at the base/optic nerve when patient is asked to move eye side to side. This finding differentiates vitreous detachment from retinal detachment. Contributor: Rahul Shah, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685728507103-DFT3EQ6VG1VOKVWXT4ZZ/ezgif.com-gif-maker.jpg Peds-Orbital - Optic Disc Drusen 1 of 2 13 year old with Drusen. Note calcification with absent optic disc elevation and optic nerve sheath diameter < 5 mm on both sides. Dilated eye exam (stained) indicated suspected papilledema. Presented to an optometrist with headache and visual changes. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685728582506-L9HBF51MDQRU05YLT0WB/ezgif.com-gif-maker+%281%29.jpg Peds-Orbital - Optic Disc Drusen 2 of 2 13 year old with Drusen. Note calcification with absent optic disc elevation and optic nerve sheath diameter < 5 mm on both sides. Dilated eye exam (stained) suspected papilledema. Presented to an optometrist with headache and visual changes. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685729597026-R0A0Y1H4QN3F9PAC21XD/ezgif.com-optimize+%2823%29.gif Peds-Orbital - Retinal Detachment 4 16 year old with retinal detachment (tethered to base of globe) after nerf gun injury. Note fixation point at base of the eye originating from optic nerve. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685730361212-4U0JEFJC77VFRZ8DGJKH/ezgif.com-optimize+%2824%29.gif Peds-Orbital - Proliferative Vitreoretinopathy 1 of 2 19 year old with proliferative vitreoretinopathy (PVR) from a suspected chronic/older retinal detachment which had gone undiagnosed for a prolonged period of time. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685730536645-78HXJ7J0SPQ93C6ROMYE/ezgif.com-optimize+%2825%29.gif Peds-Orbital - Proliferative Vitreoretinopathy 2 of 2 19 year old with proliferative vitreoretinopathy (PVR) from a suspected chronic/older retinal detachment which had gone undiagnosed for a prolonged period of time. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1706210789941-QXQH4C4AR05RZGBMNBC3/normalONSD-ezgif.com-optimize.gif Peds-Orbital - Normal ONSD 8 year old female presented with headache for 3 days, ocular ultrasound revealed no increased optic nerve sheath diameter. Measured 3 mm from the posterior border of the eye, the diameter was 3.7 mm, and there was no visualized crescent sign. Contributor: Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1706211901623-UBNWEHYWBYV9HPPUB7IF/0002103-ezgif.com-optimize.gif Peds-Orbital - Vitreous Hemorrhage/Macular Detachment 8 yo male was on a scooter and struck his head on handle. He presented to the ed with blurry vision. POCUS shows vitreous hemorrhage with a retinal detachment. Contributor: Richard Ramirez, MD Nicklaus Children's Hospital https://www.thepocusatlas.com/pedstrauma daily 0.75 2024-10-31 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1726274069307-M3OIZJKUJ2G41KAZFWF6/image-asset.gif Peds-Trauma - Normal RUQ Evaluation Normal RUQ ultrasound. Contributor: Maher M. Abulfaraj, MD, @mahermabulfaraj https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1726274069307-M3OIZJKUJ2G41KAZFWF6/image-asset.gif Peds-Trauma - Normal RUQ Evaluation Normal RUQ ultrasound. Contributor: Maher M. Abulfaraj, MD, @mahermabulfaraj https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727575596414-77T671MGI3PLP0RCH4Y7/image-asset.gif Peds-Trauma - Normal Pelvic Anatomy Normal transverse pelvis view. Contributor: Maher M. Abulfaraj, MD, @mahermabulfaraj https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1729045392436-FUNALOB446PC32DPBEJX/image-asset.gif Peds-Trauma - Positive (abnormal) Pelvic View Sagittal view of the pelvis showing free fluid. Contributor: Maher M. Abulfaraj, MD, @mahermabulfaraj https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1729046486637-PH67B7OMT42YYU2HY4J1/image-asset.gif Peds-Trauma - Free Fluid in LUQ Positive FAST with free fluid in the LUQ. Note anechoic fluid in the sub diaphragmatic recess between the diaphragm and the spleen. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1729047829513-IAPYB2QVFN3HLJTZ1MI8/image-asset.gif Peds-Trauma - eFAST Positive RUQ Child with blunt abdominal trauma and free fluid in RUQ. Contributor: Peter Gutierrez, MD FAAP FACEP; Children's Healthcare of Atlanta; @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1729050185648-62RDBMUM95NYREYTMZPU/image-asset.gif Peds-Trauma - eFAST Positive LUQ Pediatric patient with blunt abdominal trauma and free fluid in LUQ. Contributor: Peter Gutierrez, MD FAAP FACEP; Children's Healthcare of Atlanta; @pocuspete https://www.thepocusatlas.com/pedsmsk daily 0.75 2024-11-24 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1732461824702-05AKJ49FMT4MC5GJWART/radius-ulna-long.gif Peds-MSK - Radius/Ulnar fracture Long Axis (1/2) 11y female with L both bone forearm fx from fall during gym class. Long axis view with clear discontinuity of proximal and distal components of the shaft. Transverse view with transition from single bony cortex to overlap of fracture ends. Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1732461824702-05AKJ49FMT4MC5GJWART/radius-ulna-long.gif Peds-MSK - Radius/Ulnar fracture Long Axis (1/2) 11y female with L both bone forearm fx from fall during gym class. Long axis view with clear discontinuity of proximal and distal components of the shaft. Transverse view with transition from single bony cortex to overlap of fracture ends. Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1732461752674-Y322YESM0E611WLZZ8HT/radisu-ulna-short.gif Peds-MSK - Radius/ Ulna Fracture Transverse (1/2) 11y female with L BB forearm fx from fall during gym class. Long axis view with clear discontinuity of proximal and distal components of the shaft. Transverse view with transition from single bony cortex to overlap of fracture ends. Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1732461298019-8DWQWN6O0M4KY9YIQX4Z/hum-long.gif Peds-MSK - Humerus fracture- long axis (1/2) 12y male presenting with RUE pain after bike injury. POCUS demonstrating proximal humeral fracture. Long axis and short axis views of fracture. Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1732461174870-PJN8BCVBM3ORI66T1CJG/hum+short.gif Peds-MSK - Humerus fracture- short axis (2/2) 12y male presenting with RUE pain after bike injury. POCUS demonstrating proximal humeral fracture. Long axis and short axis views of fracture. Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1727650853724-ORXDCGVJW28CRN2H9PC1/image-asset.gif Peds-MSK - Distal Radius Buckle Fracture Clip shows longitudinal dorsal view of the radius with a "bump" in area of tenderness consistent with a torus or "buckle" fracture in a pediatric patient evaluated following a fall. Miguel Agrait MD CAQ-SM, Eddie Rodriguez MD FPD-AEMUS https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664905809401-S4D9ROL7L3SOLA5LEYVH/image-asset.gif Peds-MSK - Septic Elbow Effusion 8 month old with arm swelling and fever. Longitudinal view of elbow with fluid collection displacing the posterior fat pad. Final diagnosis was septic arthritis of the elbow. Contributor: Antonio Riera, MD, Yale University School of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664989607833-OAB8IWP9LC4RVPPQZN8J/image-asset.gif Peds-MSK - Soft Tissue Edema after Vaccination Longitudinal suprapatellar evaluation with linear probe in a 23 month old with swelling to knee / lower leg after vaccination given in thigh. Note the impressive soft tissue edema. There is no cobblestoning pattern and no fluid collection layering under the quadriceps tendon / no signs of suprapatellar effusion. The patient had a dry arthrocentesis performed under procedural sedation by a consulting service. Contributor: Antonio Riera, MD, Yale University School of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664992034335-2NW6Z3BISKGDXIYGF6HR/image-asset.gif Peds-MSK - Septic Knee Arthritis 17 month old with knee effusion due to septic arthritis. Knee radiography was normal. Note the distal femur, physic and epiphysis seen on the lower part of the screen below the effusion and the hypoechoic non-ossified patella cartilage typically seen in this age. Contributor: Antonio Riera, MD, Yale University School of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664992471113-O8CPL5W328IF3Y7LWZ94/image-asset.gif Peds-MSK - Synovial Plica 11 year old with large knee effusion in the suprapatellar bursa. Note the visible synovial plica membrane Contributor: Antonio Riera, MD Yale University School of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664992740603-CXJIZ2T1PY9HYT5M921M/image-asset.gif Peds-MSK - Knee Effusion 10 year old with moderate size knee effusion in the suprapatellar bursa (seen deep to the quadriceps tendon). Etiology due to lyme arthritis. Contributor: Antonio Riera, MD Yale University School of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664993424509-ZHIPWIV01E4OQLR9FDGF/image-asset.gif Peds-MSK - Knee Lipohemarthrosis-Case Series (1/3) 15 year old female with patella fracture after a fall. Note the large suprapatellar effusion with discrete layering of the echogenic marrow/adipose above the acute hypoechoic blood. The lipohemarthrosis is visible in long and short axis (images 2 and 3 of case series). Contributor: Antonio Riera, MD Yale University School of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664993978199-XCBMGOYTXNA7ZU8FJMLS/image-asset.gif Peds-MSK - Knee Lipohemarthrosis-Case Series (2/3) This is the short axis view of the case series. 15 year old female with patella fracture after a fall. Note the large suprapatellar effusion with discrete layering of the echogenic marrow/adipose above the acute hypoechoic blood. The lipohemarthrosis is visible in long and short axis. Contributor: Antonio Riera, MD Yale University School of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664994321489-DBMEORC2T4QVBVY8B2NS/image-asset.gif Peds-MSK - Knee Lipohemarthrosis-Case Series (3/3) This is the long axis view of the case series. 15 year old female with patella fracture after a fall. Note the large suprapatellar effusion with discrete layering of the echogenic marrow/adipose above the acute hypoechoic blood. The lipohemarthrosis is visible in long and short axis. Contributor: Antonio Riera, MD Yale University School of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1684791010445-Q26ZC59KPPTL2FPJ6BY9/ezgif.com-optimize.gif Peds-MSK - Non-displaced parietal skull fracture (Case Series 1/2) 4 week old with non displaced parietal fracture using water filled glove as stand off. (Case Series 1/2) Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1684791672380-UC2JJLDRF979QMWFRQW7/ezgif.com-optimize+%281%29.gif Peds-MSK - Non-displaced parietal skull fracture (Case Series 2/2) same 4 week old with non-displaced parietal fracture after compression and displacement of fluid from the water filled glove. (Case Series 2/2) Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1684792989643-IPZ6MNQ4EG0L51S13PDC/ezgif.com-optimize+%282%29.gif Peds-MSK - Depressed parietal skull fracture 7 week old with left parietal skull fracture. Note irregular edges on both sides and slightly depressed bony cortex. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1684942270376-JBNV0CWWRSZ061GHKNC3/ezgif.com-optimize+%283%29.gif Peds-MSK - Scalp Hematoma 8 month old with scalp hematoma, no underlying skull fracture. The hematoma is denoted by the hypoechoic protuberance, superficial to the hyperechoic bone. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1684942637246-K0NWQZXHFPCG8MPLAK0N/ezgif.com-gif-maker+%281%29.gif Peds-MSK - Parietal Skull Fracture 9 month old with non-displaced parietal skull fracture. Note the diagonal jagged appearance of bony overlap. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1684942983776-ZBMMCMHPG2Z4VCDYIM52/ezgif.com-gif-maker+%282%29.gif Peds-MSK - Ping Pong Fracture 11 month old with depressed frontal ping pong fracture. These fractures occur when the bone is soft enough to indent rather than outright break. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1684943326515-YNZ5W4RLOE26PXPI60YU/ezgif.com-optimize+%284%29.gif Peds-MSK - Scalp Hematoma 16 year old with large parietal hematoma and no underlying fracture. Bony cortex is intact. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1684943933623-0SPGZI85RLWDVBC3HG48/ezgif.com-optimize+%285%29.gif Peds-MSK - Newborn Clavicle Fracture 2 week old with clavicle fracture from birth trauma. Note the rounded, bony protrusion with disruption of the cortex seen by ultrasound and callous formation seen on x-ray. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1684944291855-WHMZQEZD746NGWJLPQ7T/ezgif.com-optimize+%286%29.gif Peds-MSK - Sprained Ankle 17 yo male inverted his ankle playing basketball. POCUS shows partial tear of the ATFL. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685646445325-D00QN3TC5Y3R0QPYITF2/ezgif.com-optimize+%287%29.gif Peds-MSK - Skull Fracture 9 month-old presented after a 4 foot fall. There was a small frontal hematoma on exam without step off. POCUS was performed with a high frequency transducer over the area of hematoma, and demonstrates the skull as a hyperechoic linear structure, with nondisplaced discontinuity, indicative of a nondisplaced skull fracture. There is also a hypoechoic collection just anterior to the skull, suggestive of an associated hematoma. Contributor: Allie Grither, MD, St Louis Children's Hospital (Washington University in St. Louis), @AGPemMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685646923488-ISHAKIWEWJCY2Y0OPSLE/ezgif.com-optimize+%288%29.gif Peds-MSK - Tibia Fracture 12 year old came in with a fall from a scooter and right lower leg pain and swelling, just above the ankle. POCUS was performed with a high frequency transducer in longitudinal axis of the area of swelling, which demonstrates the tibia as a discontinuous, displaced, hyperechoic linear structure with an associated mixed echotexture collection just anterior to the discontinuity, suggestive of a displaced tibia fracture with hematoma. Contributor: Allie Grither, MD, St. Louis Children's Hospital (Washington University in St. Louis), @AGPemMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685647722186-J2GKOMSVS10RIYI2GA7K/ezgif.com-optimize+%289%29.jpeg Peds-MSK - Skull Fracture 8 month old with fall off the bed with boggy mass palpated in the occiput. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685648160291-I9FQ2JF0GXDRUQKVDZFE/ezgif.com-optimize+%289%29.gif Peds-MSK - Hip Effusion in 6yo 2/2 Transient Synovitis 6 yo with acute onset limp. Afebrile. Decreased ROM of the left hip. POCUS showed a hip effusion consistent with the diagnosis of transient synovitis. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685648672974-T7S4YRGE11R1UD1LTZWY/ezgif.com-optimize+%2810%29.gif Peds-MSK - Normal Fingers 1 of 2 5 yo with normal finger anatomy in a waterbath. Case series 1/2 Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685649027356-Z253K43HKBFLPG0MWJJR/ezgif.com-optimize+%2811%29.gif Peds-MSK - Normal Fingers 2 of 2 5 yo with normal finger anatomy in a waterbath. Case series 2 of 2 Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685649389817-KLW18Y7XFDCRIW4VX0PK/ezgif.com-optimize+%2812%29.gif Peds-MSK - Phalanx Fracture Reduction-Before 5 yo male with a phalanx fracture of the hand in a water bath before and after reduction. Case series 1 of 2 Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685649649501-X3XT9WNQ02AW74HRF4LC/ezgif.com-optimize+%2813%29.gif Peds-MSK - Phalanx Fracture Reduction-After 5 yo male with a phalanx fracture of the hand in a water bath before and after reduction. Case series 2 of 2 Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685724011725-0868CXDQLG6KSQIRDI77/ezgif.com-optimize+%2814%29.gif Peds-MSK - Avulsion Fracture 7 year old with medial malleolus avulsion fracture of the distal tibia. The green arrow points to the gap where the avulsion piece (left of screen) is detached. Note a physis also visible (mid screen). Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685724366581-IV77XWPIOEU6W5T8TGQV/ezgif.com-optimize+%2815%29.gif Peds-MSK - Fibula with Normal Physis 7yo right fibular ultrasound with notable physis on left hand side of screen. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685725047655-I745I3PZ1ZC2R39K4X0Q/ezgif.com-optimize+%2816%29.gif Peds-MSK - Femur Fracture- Case Series, Short Axis Short axis view of 9 year old male with spiral femur fracture with displacement. Note cortical disruption seen at about 5-6 cm in both long and short axis. Case series 1 of 2 Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685725335805-LFB1IOHFB3T45VZQC1WB/ezgif.com-optimize+%2817%29.gif Peds-MSK - Femur Fracture- Case Series, Long Axis Long axis view of 9 year old male with spiral femur fracture with displacement. Note cortical disruption seen at about 5-6 cm in both long and short axis. Case Series 2 of 2 Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685725944499-O3BY126X9L6XO9THO17J/ezgif.com-optimize+%2818%29.gif Peds-MSK - Salter Harris II Fracture 12 year old with SH-II fracture of distal radius. Not the abrupt metaphyseal angulation seen by ultrasound and physeal involvement. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685726205569-FMB3467N9I2QXYENMEXU/ezgif.com-optimize+%2819%29.gif Peds-MSK - Clavicle Fracture 29 month old with a mild, non-displaced clavicle fracture. Note the cortical disruption seen by ultrasound with an overlying small hematoma. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1687969490597-0LR8JOK8M3CX1AW3UKD4/ezgif.com-optimize+%2840%29.gif Peds-MSK - Sternal Fracture 13 year old male who presented with sternal tenderness after a motor vehicle collision, found to have a step-off in the sternum on POCUS, indicating a sternal fracture. POCUS is more accurate than X-ray to identify sternal fracture. Contributor: Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1687970363261-GC34DXSJFX5AJTN8G63H/ezgif.com-gif-maker+%284%29.gif Peds-MSK - Normal Hip Joint 5 year old male presented with a left leg limp, assessment of the affected hip joint did not reveal a pathologic effusion. Contributor: Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1609961854525-2SCIMYE89Y1KVLJOM724/image-asset.gif Peds-MSK - Nursemaid's Elbow Nursemaid's pre and post reduction. Nathan Jia, Orthopedic Resident https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1616093328575-6W3O2OC7QUW0M7480BBT/image-asset.gif Peds-MSK - Shoulder Relocation A 9-year-old female presented with left shoulder pain. She has a history of multiple dislocations and, as seen here on POCUS, is able to reduce the dislocation herself. Julie Klensch, PEM Fellow & Paul Khalil, MD University of Louisville/Norton Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1601048210657-RVGMTUGC6WGSOR5CTBJ9/image-asset.gif Peds-MSK - Ruptured Achilles Tendon 16-year-old male presented with acute onset sharp pain to his LE and inability to bare weight after having landed oddly while playing basketball. POCUS revealed a near-complete disruption of his Achilles Tendon. Paul Khalil, MD. Assistant PEM POCUS director at University of Louisville/Norton Children’s @Khalil3Paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1599260703664-0IHNPMY5BDHC7NVH941G/image-asset.gif Peds-MSK - Mildly Displaced Clavicle Fracture A 15 year old wrestler landed on his right shoulder. POCUS was performed over point of maximal pain demonstrating cortical displacement consistent with a clavicle fracture. Paul Khalil, MD @Khalil3Paul Assistant PEM POCUS Director at University of Louisville/Norton Children’s https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1599260703664-0IHNPMY5BDHC7NVH941G/image-asset.gif Peds-MSK - Mildly Displaced Clavicle Fracture A 15 year old wrestler landed on his right shoulder. POCUS was performed over point of maximal pain demonstrating cortical displacement consistent with a clavicle fracture. Paul Khalil, MD @Khalil3Paul Assistant PEM POCUS Director at University of Louisville/Norton Children’s https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579283346380-YX68Q1OH1ELOXXHDFXWI/image-asset.gif Peds-MSK - Sternal Fracture An 8 year old female presented with chest pain after a fall out of a bouncy house at her neighborhood block party. She has notable bony tenderness to the anterior chest wall over the sternum. POCUS revealed normal lung slide, but on evaluation of the sternum, a fracture was noted. In this clip the fracture is seen on the right as cortical disruption with surrounding trace hypoechoic hematoma formation. On the left side of the screen a normal growth plate is noted. Image courtesy of Dr. Paul Khalil Twitter: @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1693606638154-K2Z6Q28HZDHRXJ4K2S4S/ezgif.com-gif-maker.gif Peds-MSK - Normal Ankle 5y female presenting with swelling, redness, and limp to the R foot. Contralateral normal side imaged for comparison. The normal tibiotalar joint in the long axis is seen here. Since the patient skeletally immature, the distal tibial physis can also be seen. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1725591144744-J8WZVTEQD2HYH6CBDVX1/image-asset.gif Peds-MSK - Posterior fat pad 6 yo male with a supracondylar fracture, POCUS demonstrates a posterior fat pad Paul Khalil MD, Nicklaus Children's Hospital, @khalil3paul https://www.thepocusatlas.com/pedssoft-tissue daily 0.75 2025-01-01 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664990120239-1DCD9NC6BVZUM7LIXTJX/image-asset.gif Peds-Soft Tissue - Soft Tissue Edema after Vaccination Longitudinal suprapatellar evaluation with linear probe in a 23 month old with swelling to knee / lower leg after vaccination given in thigh. Note the impressive soft tissue edema. There is no cobblestoning pattern and no fluid collection layering under the quadriceps tendon / no signs of suprapatellar effusion. The patient had a dry arthrocentesis performed under procedural sedation by a consulting service. Contributor: Antonio Riera, MD, Yale University School of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1664990120239-1DCD9NC6BVZUM7LIXTJX/image-asset.gif Peds-Soft Tissue - Soft Tissue Edema after Vaccination Longitudinal suprapatellar evaluation with linear probe in a 23 month old with swelling to knee / lower leg after vaccination given in thigh. Note the impressive soft tissue edema. There is no cobblestoning pattern and no fluid collection layering under the quadriceps tendon / no signs of suprapatellar effusion. The patient had a dry arthrocentesis performed under procedural sedation by a consulting service. Contributor: Antonio Riera, MD, Yale University School of Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735707183733-BMZBBZUCMZM2C9CKCGLS/image-asset.gif Peds-Soft Tissue - Pilonidal Abscess 12 year old F with pilonidal abscess. Contributor: Kathryn Pade, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735707836683-B0QPKEIRK6W7J80SX6JZ/image-asset.gif Peds-Soft Tissue - Parotitis Right parotitis in a pediatric patient who presented with "jaw swelling". Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735708599771-4S7YF4OWR398X9C0R067/image-asset.gif Peds-Soft Tissue - Cellulitis Hip cellulitis in a teenage female patient. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735709363772-XUJJJZIM4F9ZM7I5175O/image-asset.gif Peds-Soft Tissue - Abscess, pilonidal Abscess of the intergluteal cleft in a female teenage patient consistent with pilonidal abscess. Contributor: Jaron Smith, MD, Phoenix Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735710027755-H6JKHHQSYX0BPY45H6GO/image-asset.gif Peds-Soft Tissue - Necrotizing Fasciitis 11 yo F presents arm pain after accidentally stabbing herself in the arm with a hair pin. On exam she had erythema and crepitus of the site. POCUS shows dirty shadow consistent with necrotizing fasciitis. She was taken to the OR for debridement. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735710684186-908DT705MF8NYFGLLQ08/image-asset.gif Peds-Soft Tissue - Transcervical Peritonsillar Abscess 14 year old male presented with pharyngitis, odynophagia, and hot potato voice. He had mild right unilateral tonsil swelling on exam, but was able to tolerate secretions. POCUS images were obtained with a high frequency transducer of the right submandibular area in transverse plane, and demonstrate a tonsil shown as a mixed echotexture structure with hyperechoic invaginations or "crypts", as well as a relatively hypoechoic collection posterior-lateral to the tonsil suggestive of a peri-tonsillar abscess. Contributor: Allie Grither, St. Louis Children's Hospital (Washington University in St. Louis), @AGPemMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735712992317-6AL7ZGQGHQZM19438HSK/image-asset.gif Peds-Soft Tissue - Glass Foreign Body 11 year old came in with bleeding and pain in the leg after jumping on the bed. On exam there was a small 5 mm skin defect in the left lateral lower leg. POCUS was performed with a high frequency transducer in long axis adjacent to the skin defect. Identified was normal appearing heterogenous subcutaneous tissue anterior to normal appearing striated muscle. Both were partially obscured by a smooth, semi-rounded hyperechoic arc with dense posterior shadowing and reverberation artifact, located just deep to the dermis, concerning for a dense foreign object. The existing skin defect was widened slightly, and a shard of glass was removed. Contributor: Allie Grither, MD, St. Louis Children's Hospital (Washington University in St. Louis), @AGPemMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735713841047-B0URTSQ6BTKV9QHRXJN0/image-asset.gif Peds-Soft Tissue - Retained Splinter 12 yo male with a splinter to the leg that was partially removed. He presented to the ED with redness and swelling of the site. POCUS shows retained FB (wood) with surrounding infection. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735714576476-L3Q7EPA3KVVG71D59XBA/image-asset.gif Peds-Soft Tissue - Parotitis 6 yo with right sided facial swelling. No fever. POCUS shows parotitis without stone. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://www.thepocusatlas.com/pedsnerve-blocks daily 0.75 2025-01-01 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1665089977422-HQIDE97AJM1SZOIPJ39B/image-asset.gif Peds-Nerve Blocks - Fascia Iliaca Nerve Block Fascia iliaca nerve block for 3yo M with left femur fracture Contributor: Julia Brant, MD, Children's Hospital Colorado, @pedipocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1665089977422-HQIDE97AJM1SZOIPJ39B/image-asset.gif Peds-Nerve Blocks - Fascia Iliaca Nerve Block Fascia iliaca nerve block for 3yo M with left femur fracture Contributor: Julia Brant, MD, Children's Hospital Colorado, @pedipocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735702586229-V6UQ4PMZCQKSR8JO512A/image-asset.gif Peds-Nerve Blocks - Fascia Iliaca Nerve Block Fascia iliaca nerve block for 3 yo M with left femur fracture. Contributor: Julia Brant, MD, Children's Hospital Colorado, @pedipocus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735703159759-7XJXY3WHVAHFGD4932YS/image-asset.gif Peds-Nerve Blocks - Posterior Tibial Nerve Block Lidocaine Infiltration 10 year old came in with laceration to the sole of the foot and likely retained foreign body after stepping on broken glass. A posterior tibial nerve block with ultrasound guidance was performed to provide local anesthesia. This is performed slightly superior to the ankle (where the nerve was best viewed in the patient), using in plane technique with a posterior needle approach. Demonstrated here is the tibial artery/vein dyad, with the tibial nerve located just to the right on the image seen, as hydro-dissection of the nerve is being performed with lidocaine to instill local anesthesia directly deep and adjacent to the nerve. The distal tibia is viewed as the hyperechoic structure deep on the screen. Contributor: Allie Grither, MD, St. Louis Children's Hospital (Washington University in St. Louis), @AGPemMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735705624684-0J49SFEW8QLW1YBIQXH6/ezgif.com-optimize+%2811%29.gif Peds-Nerve Blocks - Serratus Anterior Block 16 year old with a spontaneous pneumothorax. Serratus anterior block performed prior to chest tube placement. Not needle coming from the left under serratus muscle and above rib. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735706441308-LXMGCBBYUTHPQCAZ2EFA/image-asset.gif Peds-Nerve Blocks - Median Nerve Block 13 yo male with a palmer laceration. Median nerve block performed with good anesthesia. Needle coming from left of screen. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://www.thepocusatlas.com/pedsbiliary daily 0.75 2024-08-19 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1724103835483-VKCGJ9GSFOSQNN38924S/gallstone1-ezgif.com-optimize.gif Peds-Biliary - Large Gallstone 14 year old patient found to have large gallstone. Shown here is long axis view of the gallbladder, notice the shadowing present from the gallstone as the probe is fanned. Kathryn Pade, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1724103835483-VKCGJ9GSFOSQNN38924S/gallstone1-ezgif.com-optimize.gif Peds-Biliary - Large Gallstone 14 year old patient found to have large gallstone. Shown here is long axis view of the gallbladder, notice the shadowing present from the gallstone as the probe is fanned. Kathryn Pade, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678000472992-Y1TFRDGM43IT98E3XY7R/chole.gif Peds-Biliary - Pericholecystic fluid Healthy 13 year old presented with 2 days of epigastric and RUQ pain, with tenderness in the RUQ on exam. Biliary POCUS was performed with a low frequency, curvilinear transducer. She had a positive Murphy's sign. In the transverse view, the gallbladder is demonstrated with a thickened wall and with adjacent hypoechoic collections suggestive of pericholecystic fluid. She underwent ERCP, was found to have a common bile duct stone, and ultimately went for cholecystectomy. Contributor: Allie Grither, MD, St. Louis Children's Hospital (Washington University in St. Louis), @AGPemMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678001482512-XMILLWJOYFG2T0XA5L7Z/GBW+THICC.gif Peds-Biliary - Thick gallbladder wall 16 y/o F with RUQ pain. POCUS shows a thickened gallbladder wall. In the appropriate setting this could be consistent with cholecystitis though thickening of the gallbladder wall can also be a normal finding following eating a meal. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678002026358-YXZXW2QZDPEZ5VYO8LRG/cholecystitis.gif Peds-Biliary - Thickened gallbladder wall with stones 17 yo M with epigastric and right upper quadrant pain. Unable to tolreate PO. POCUS shows a thickened gallbladder wall with cholelithiasis consistentw tih cholecystitis. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678002565255-HNZUU403YYUW1PN7ALB0/gbpolyp.gif Peds-Biliary - Gallbladder polyp 15 yo presents with abdominal pain. POCUS shows a gallbladder polyp of unknown significance, likely incidental finding. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678002893631-ORA04N384S2UK3MAGGY6/normalgall.gif Peds-Biliary - Normal gallbladder 16 yo with abdominal pain. Normal gallbladder in long axis. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1678113075178-JID1XEG8OANOF4LJGKTE/jpegthatsagif.gif Peds-Biliary - Cholelithiasis 15 year old with right upper abdominal pain No other history On examination, tenderness over right upper/rebound tenderness as well USG abdomen revealed the above image Contributor: Dr Vanitha American Mission Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685730947863-XN5NVI78PUAAFGQU5454/ezgif.com-optimize+%2826%29.gif Peds-Biliary - Normal Gallbladder, Short Axis 16 yo with abdominal pain. POCUS shows a normal gallbladder in short axis. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701715115601-XGVLHCRCPSSUKFQXD0WK/image-asset.jpeg Peds-Biliary - Normal Gallbladder Wall Measurement 15 y/o with epigastric abdominal pain. POCUS shows a normal gallbladder with a normal gallbladder wall measurement. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701715189893-9YV8TH0FO62ZUFT8MF8G/image-asset.jpeg Peds-Biliary - Normal Gallbladder Measurements Normal gallbladder measurements in a 3 year old male. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701715394904-CYP7MTOBFQ7MDP1RF4W7/image-asset.jpeg Peds-Biliary - Normal Common Bile Duct Measurement Normal common bile duct measurement. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701716865312-1GL10BL2NXOZ8CXGIJ4L/ezgif.com-optimize+%2834%29.gif Peds-Biliary - Gallbladder Sludge 13 y/o M with abdominal pain. POCUS shows gallbladder sludge. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701717700890-06NR9654OU3E982KOVNY/ezgif.com-optimize+%2835%29.gif Peds-Biliary - Cholelithiasis with Stone in Neck 15 y/o M with RUQ pain, found to have cholelithiasis without cholecystitis. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1704755766776-D4U9NHXD09P097C7FN9U/DilatedCBD1-ezgif.com-optimize.gif Peds-Biliary - Dilated Common Bile Duct - B-Mode (1/3) 11 year old female with abd pain and emesis. Kicked in stomach by horse 6 weeks prior with grade 4 liver lac. Seen a few days ago with reassuring labs and US. Now with rising aminases and bilirubin. POCUS demonstrated a dilated and edematous gallbladder with sludge, and a dilated CBD and the classic 'double barrel' sign. Contributed by: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1704756096047-BQ9TGNWY1JDIQ309695Z/DilatedCBD1-ezgif.com-optimize.gif Peds-Biliary - Dilated Common Bile Duct - Color Doppler (2/3) 11 year old female with abd pain and emesis. Kicked in stomach by horse 6 weeks prior with grade 4 liver lac. Seen a few days ago with reassuring labs and US. Now with rising aminases and bilirubin. POCUS demonstrated a dilated and edematous gallbladder with sludge, and a dilated CBD and the classic 'double barrel' sign. Contributed by: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1704756210232-8FCDWQXE47P4C12AR62W/DilatedCBD1-ezgif.com-optimize.gif Peds-Biliary - Dilated Common Bile Duct - Measurement (3/3) 11 year old female with abd pain and emesis. Kicked in stomach by horse 6 weeks prior with grade 4 liver lac. Seen a few days ago with reassuring labs and US. Now with rising aminases and bilirubin. POCUS demonstrated a dilated and edematous gallbladder with sludge, and a dilated CBD and the classic 'double barrel' sign. Contributed by: Matthew Moake, MD PhD https://www.thepocusatlas.com/pedsgenit daily 0.75 2026-01-20 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659120963693-H76JWXKREPQ52FL01RZU/image-asset.gif Peds-Genitourinary - Whirlpool Sign 16 yo male who presents with left testicular pain. Exam with horizontal left testicle. POCUS shows blood flow to both testicles, however left distal spermatic cord demonstrates whirlpool sign, consistent with intermittent/partial torsion. Dr. Paul Khalil and Dr. Joshua Kim - University of Louisville @kjosh317 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659120963693-H76JWXKREPQ52FL01RZU/image-asset.gif Peds-Genitourinary - Whirlpool Sign 16 yo male who presents with left testicular pain. Exam with horizontal left testicle. POCUS shows blood flow to both testicles, however left distal spermatic cord demonstrates whirlpool sign, consistent with intermittent/partial torsion. Dr. Paul Khalil and Dr. Joshua Kim - University of Louisville @kjosh317 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685981725347-TNVQZJI6CT5W3370L9DP/ezgif.com-optimize+%2827%29.gif Peds-Genitourinary - Testicles Buddy View Normal testicle buddy view with color. The buddy view is the best place to start when doing as testicular ultrasound to compare the echogenicity, size, blood flow and position of the testicles. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685982074067-TOVSIN2UAZ2S25C4OFTQ/ezgif.com-optimize+%2828%29.gif Peds-Genitourinary - Normal Spermatic Cord Normal spermatic cord. Flow should be linear as apposed to the "corkscrew" sign in torsion. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685982349192-EMZPJV17UONQMH2YNRK5/ezgif.com-optimize+%2829%29.gif Peds-Genitourinary - Torsion of the Appendix Testicle 2 yo male present with testicle pain and swelling. POCUS shows torsion of the appendix of the testicle. Please note hyperechoic appendage of testicle. Contributor: Paul Khalil, MD, Nicklaus Children's Hospital, @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685982972974-NOCSFMAWE8GPZWT2UU40/ezgif.com-optimize+%2830%29.gif Peds-Genitourinary - Spermatic Cord "Corkscrew" 13 yo male presents with intermittent testicular pain. There was some flow to testicle, but when examining spermatic cord flow was twisted (corkscrew sign) indicating partial torsion. Contributor: Paul Khalil, MD and Joshua Kim, DO https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685983357088-QHGV38GWNXO1DWCM3C8X/ezgif.com-optimize+%2831%29.gif Peds-Genitourinary - Prolonged Testicular Torsion 2 yo male with testicular torsion presenting at 48 hrs. Note the twisted spermatic cord, change of echogenicity of testicle and reactive hydrocele. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685983775418-9TB0DWIIVS499RQG619C/ezgif.com-optimize+%2832%29.gif Peds-Genitourinary - Normal Adolescent Uterus Normal adolescent uterus. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685985665341-76L8MYR1YOACUI1B9GGT/ezgif.com-optimize+%2834%29.gif Peds-Genitourinary - Normal Ovary Normal Adolescent Ovary (transabdominal). Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685985993854-P7NVVKOR21JL034W19K4/ezgif.com-optimize+%2835%29.gif Peds-Genitourinary - Testicular Torsion Case Series 1 of 2 14 yo male presents with right testicular pain. POCUS shows high riding testicle with absent flow in buddy view as well as isolated view. Image one is the isolated view. Image 2 depicts buddy view. Case Series 1 of 2 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685986287902-PKUNKZPMU829W6VIXW02/ezgif.com-optimize+%2836%29.gif Peds-Genitourinary - Testicular Torsion Case Series 2 of 2 14 yo male presents with right testicular pain. POCUS shows high riding testicle with absent flow in buddy view as well as isolated view. Image one is the isolated view. Image 2 depicts buddy view. Case Series 2 of 2 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685986601768-K9MW14M2DU8KZJVOWWJ7/ezgif.com-optimize+%2837%29.gif Peds-Genitourinary - Left Sided Testicular Torsion 15 yo M with sudden onset testicular pain (left) and vomiting. POCUS shows decreased flow to the left testicle consistent with torsion. he was taken immediately to the OR. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685986911203-EHF4CCAYDDBF2PEJI94Z/ezgif.com-optimize+%2838%29.gif Peds-Genitourinary - Wilm's Tumor Case Series 2 of 2 Incidental finding of a Wilm's tumor in 3 yo female presenting to the PED with fever and lower abdominal pain. Educational scan that turned out to significantly alter management. Pt had right nephrectomy of localized tumor. Case Series 2 of 2 Contributor: Melinda Tonelli MD, University of Rochester, Rochester NY https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1685987311795-UTQHBP75TPOL6NXBTW68/ezgif.com-optimize+%2839%29.gif Peds-Genitourinary - Wilm's Tumor Case Series 1 of 2 Incidental finding of a Wilm's tumor in 3 yo female presenting to the PED with fever and lower abdominal pain. Educational scan that turned out to significantly alter management. Pt had right nephrectomy of localized tumor. Case Series 1 of 2 Contributor: Melinda Tonelli MD, University of Rochester, Rochester NY https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735715433461-BYAZ7U1MW3987ZZAVPM5/image-asset.gif Peds-Genitourinary - Orchitis (1 of 2) 16 year old male with right testicular pain and swelling presented to the emergency department, a POCUS was done showing increased flow in the left testicle along with surrounding edema. This ultrasound clip demonstrates the enlarged testicle with surrounding edema. Diagnosis of orchitis was made and confirmed with radiology performed ultrasound. Contributor: Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735716108839-TGMO93PM0F4PQ7AQPZ0V/image-asset.gif Peds-Genitourinary - Hernia into Scrotum 14 year old male presented with scrotal swelling, POCUS identified a hernia into the scrotum. This clip shows normal testicles along with bowel in the scrotum. Contributor: Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735716803153-Y20FX25GJ2O2F86NAKTH/image-asset.gif Peds-Genitourinary - Ovarian Teratomas 16 year old female with abdominal/pelvic pain. POCUS demonstrated bilateral ovarian teratomas. Shown here is a transverse pelvic view at the level of the uterine fundus focused in the L adnexa. A large complex mass with mixed hypoechoic and hyperechoic content is seen in the L adnexa, and a second similar-appearing mass can be partially seen in the R adnexa. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735763531780-U8QQITKI44I5EHVQ15KU/image-asset.gif Peds-Genitourinary - Orchitis (2 of 2) 16 year old male with right testicular pain and swelling presented to the emergency department, a POCUS was done showing increased flow in the left testicle along with surrounding edema. This ultrasound clip demonstrates increased flow to the left testicle. This can be better appreciated when compared in a side by side view to the normal testicle. Diagnosis of orchitis was made and confirmed with radiology performed ultrasound. Contributor: Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735763859557-FKJV8E8B6EJ14F4GSFO1/image-asset.gif Peds-Genitourinary - Hydronephrosis 11 year old male presenting for left flank pain and headache. POCUS with severe left sided hydronephrosis without stone. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735764368851-5LRFQYDCXOBXK305NCO3/image-asset.gif Peds-Genitourinary - Severe Hydronephrosis 16 year old with right sided flank pain. Patient found to have severe hydronephrosis. Contributor: Kathryn Pade, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735764872438-KJQDCOA4TUBKCX848Y6Z/image-asset.gif Peds-Genitourinary - Renal Cyst Healthy 7 year old male modeling for educational US scanning. Found to have large simple large renal cyst. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735765395846-Z285AENTF5G0OOWOOFUU/image-asset.gif Peds-Genitourinary - Inguinal Hernia into Scrotum 2 week old with scrotal swelling found to have indirect inguinal hernia. Bowel contents can be seen present in this clip in the scrotum with some surrounding fluid. Contributor: Kathryn Pade, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735773984185-TQS4Q4D7CX5ZPT3WHHVF/image-asset.gif Peds-Genitourinary - Normal Testicle Normal testicular ultrasound in 8 year old with testicular pain. Contributor: Zach Boivin, MD, @ZachBoivinMD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735774359540-RD2QK0SHCXVEY461K838/image-asset.gif Peds-Genitourinary - Normal Kidney 2 year female with history of febrile UTI. Normal right kidney. Note the hypoechoic renal pyramids, which can be misinterpreted as being hydronephrosis. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1735774765837-YS5703Y4NHEIE60WMYAH/image-asset.gif Peds-Genitourinary - Hematocolpos 14 year old female presenting with acute on chronic abdominal pain. Physical exam revealed gross abdominal distension in the pelvic region. She denied hematuria, dysuria, or sensation of incomplete voiding. No menarche reported. In this clip, the patient's bladder is difficult to visualize due to the mass effect of the enlarged, blood-filled vagina. The uterus contains blood as well, but to a much lesser degree than the vagina. Contributor: Jaron Smith, MD Phoenix Children's Hospital https://www.thepocusatlas.com/shoulder-gallery daily 0.75 2023-09-28 https://static1.squarespace.com/static/58118909e3df282037abfad7/t/651506b87b6661370ef90597/1694127847788/ Shoulder Gallery https://static1.squarespace.com/static/58118909e3df282037abfad7/64fa1678b607034bd2c6f0da/64fa56e773a28b6c82cd4cd3/1694127847788/ Shoulder Gallery https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694187853602-TCOB4P4YB8LP5LCOHS92/Number+6.gif Shoulder Gallery - Supraspinatus (Long Axis) Video Six: Supraspinatus (Long axis) -Position: Crass position -Location: Transducer is located sagittally over the greater tuberosity -Scan up and down along the supraspinatus to see proximally and distally https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694187709568-7R1JMM2UIHETNXI6MU8Q/Number+8.gif Shoulder Gallery - Supraspinatus (Short Axis) Video Eight: Supraspinatus (Short Axis) -Position: Crass position -Location: Rotate the transducer 90 degrees from the sagittal view over the greater tuberosity -Scan up and down along the supraspinatus to see proximally and distally https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694187949231-ZPMTIPO8U8QVTTAP526T/Number+9.gif Shoulder Gallery - Supraspinatus (Neutral) Video Nine: Supraspinatus (Neutral position) -Position: Arm flexed to 90 degrees -Location: Transducer is placed coronally over the greater tuberosity -Will only be able to see the distal supraspinatus tendon due shadowing from the acromion. Have the patient abduct arm to 15 degrees to see muscle contraction. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694188011812-X000X3EIZER68EX53TY2/Number+10.gif Shoulder Gallery - Infraspinatus (Long Axis) Video Ten: Infraspinatus (Long axis) -Position: Arm flexed to 90 degrees -Location: Palpate the scapular spine then place the transducer sagittally over the scapular spine then move the transducer inferiorly. Once the infraspinatus and teres minor are identified, rotate the transducer 90 degrees to long axis. -Have the patient externally and internally rotate the arm https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694188071206-VG9BHJS37U2U85D63MCT/Number+11.gif Shoulder Gallery - Infraspinatus/Teres Minor (Long Axis) Video Eleven: Infraspinatus/Teres Minor (Long axis) -Position: Arm flexed to 90 degrees -Location: Palpate the scapular spine then place the transducer sagittally over the scapular spine then move the transducer inferiorly. Once the infraspinatus and teres minor are identified, rotate the transducer 90 degrees to long axis. -Teres minor will be thinner, superficial, and more hyperechoic https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694188392751-1XNGU8BAYXKL5EKP2L0M/Number+12.gif Shoulder Gallery - Infraspinatus / Teres Minor (Short Axis) Video Twelve: Infraspinatus/Teres Minor (Short axis) -Position: Arm flexed to 90 degrees -Location: Palpate the scapular spine then place the transducer sagittally over the scapular spine then move the transducer inferiorly. Once the infraspinatus and teres minor are identified; scan medial to lateral -Teres minor will be thinner, superficial, and more hyperechoic https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1695860745868-SBJ7CE0LGL8VFYS54NAH/1+%28Biceps+Tendon%29.gif Shoulder Gallery - Biceps Tendon/Bicipital Groove (short axis) -Positioning: have the patient supinate their arm -Location: Bicipital groove, found via palpation -Hold the ultrasound transverse across the bicipital groove. Slide the probe distally along the groove’s distribution. https://www.thepocusatlas.com/knee-gallery daily 0.75 2023-09-07 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694113258994-89G3IILPZHDBUIMVSLZT/Biceps+Femoris.gif Knee Gallery - Suprapatellar/quad tendon (Short axis) Position: Knee extended, partially bent. Location: Place the transducer transverse over the superior patella region. Once the quadriceps tendon is identified, scan proximally to evaluate the rectus femoris. Note the vastus medialis (medial) and vastus lateralis (lateral) as they come into view proximally. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694113258994-89G3IILPZHDBUIMVSLZT/Biceps+Femoris.gif Knee Gallery - Suprapatellar/quad tendon (Short axis) Position: Knee extended, partially bent. Location: Place the transducer transverse over the superior patella region. Once the quadriceps tendon is identified, scan proximally to evaluate the rectus femoris. Note the vastus medialis (medial) and vastus lateralis (lateral) as they come into view proximally. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694113258565-E38DXJW195WSDIKJ3X14/IT+Band+Dist-Prox.gif Knee Gallery https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694113277268-OYTKKOZUKG7P9PP0LWZJ/IT+Band+Insertion.gif Knee Gallery https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694113278033-Y7XVO050AYNPH59OWL0M/LCL.gif Knee Gallery https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694113291995-72NULOKXMAOUA8QUL2DC/Long+Axis+Infrapatellar-Patellar+Tendon+Distal-Proximal.gif Knee Gallery https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694113296334-Q50KBE9ZZYZIKW26SZ6P/Long+Axis+Infrapatellar-Patellar+Tendon+Lat-Medial.gif Knee Gallery https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694113309963-GRG4B0SUG7WSVJHREU8X/Long+Axis+Suprapatellar-Quad+Tendon.gif Knee Gallery https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694113312392-H0Z0ZZL2GZ7IC50R5XYB/MCL-Meniscus.gif Knee Gallery https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694113330430-40Q4GDE6HW3EVPIRVEH2/PCL.gif Knee Gallery https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694113335229-NPBBT0KOVJAPOY87O7K3/Posterior+Knee.gif Knee Gallery https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694113347395-QHDX0QJ3UW9177H7KRIA/Short+Axis+Infrapatellar-Patellar+Tendon.gif Knee Gallery https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1694113352052-MW9655037NS7STMYKH6C/Short+Axis+Suprapatellar-Quad+Tendon+Dist-Prox.gif Knee Gallery https://www.thepocusatlas.com/pedsgastrointestinal daily 0.75 2024-08-27 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1724717886401-S7TQGS6Z82WTGDVC0AR9/image-asset.gif Peds-Gastrointestinal - Pediatric Acute Appendicitis Teenage male presenting with abdominal pain worsening over 24 hours, diagnosed with acute appendicitis via POCUS. The clip shows a circular structure which measures at 6.5 mm transversely, representing an acutely inflamed appendix with surrounding anechoic free fluid. POCUS Acute Appendicitis: noncompressible, diameter >6mm, single wall >3mm are direct signs of appendicitis. Use of POCUS for diagnosis of acute appendicits significantly reduces cost and radiation exposure for patients without sacrificing diagnostic accuracy. Mostbeck, G., Adam, E.J., Nielsen, M.B. et al. How to diagnose acute appendicitis: ultrasound first. Insights Imaging 7, 255–263 (2016). Contributor: C. Malcolm Roberson, MD. @ProjectUltraEM https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1724717886401-S7TQGS6Z82WTGDVC0AR9/image-asset.gif Peds-Gastrointestinal - Pediatric Acute Appendicitis Teenage male presenting with abdominal pain worsening over 24 hours, diagnosed with acute appendicitis via POCUS. The clip shows a circular structure which measures at 6.5 mm transversely, representing an acutely inflamed appendix with surrounding anechoic free fluid. POCUS Acute Appendicitis: noncompressible, diameter >6mm, single wall >3mm are direct signs of appendicitis. Use of POCUS for diagnosis of acute appendicits significantly reduces cost and radiation exposure for patients without sacrificing diagnostic accuracy. Mostbeck, G., Adam, E.J., Nielsen, M.B. et al. How to diagnose acute appendicitis: ultrasound first. Insights Imaging 7, 255–263 (2016). Contributor: C. Malcolm Roberson, MD. @ProjectUltraEM https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1530460515518-R7GP8KIKEV9FZHD8A4VM/Appendicitis+Transverse.gif Peds-Gastrointestinal - Appendicitis (2/2) - Transverse 11 y/o M presented with 1 day of periumbilical pain that migrated to the right lower quadrant with nausea, vomiting and anorexia. Ultrasound with high frequency linear probe demonstrates an enlarged appendix with an external diameter of 1.32 cm with trace free fluid posteriorly, as well as a fecalith at the proximal end of the appendix. Surgery was consulted who requested a formal US which was non-diagnostic. Surgery took the patient anyway, and MRI confirmed our findings (including the large diameter). Diagnostic criteria for appendicitis: a non-compressible, aperistaltic, blind ended structure >6mm diameter. Visualizing free fluid, tenderness in that area, and visualizing a fecalith can also add to the diagnosis. See the evidence atlas for more info about POCUS diagnosing appendicitis but when visualizing a diagnostic appendicitis, it carries a positive likelihood ratio of 9.24. PMID: 28214369 Jackie Chiou MS4, Dr. Matthew Riscinti and Dr. Tian Liang - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523826858652-AFBMF3LCVO24RFF8CNFM/ezgif.com-optimize+%2821%29.gif Peds-Gastrointestinal - Pyloric Stenosis Pyloric Stenosis 4 w/o male with forceful vomiting with each feed. Clip fans through hypertrophic pylorus measuring 14mm in diameter and channel length 24mm. It also shows a fluid filled stomach and the "antral nipple sign" - outpouching of pyloric tissue into antrum. The "Pi" π = 3.1415 mnemonic for ballpark measurement cut-offs. >3mm diameter of single muscular wall >14mm transverse diameter of pylorus >15mm channel length Lilly Bellman, MD - PEM /US fellow Harbor-UCLA https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509193614867-O2CWFOKYRSQU842IRAO4/PS+transverse.gif Peds-Gastrointestinal - Pyloric Stenosis (Transverse) 4-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, 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1643824136560-UR5DF7E2HYJKIPTEK1PZ/image-asset.gif Peds-Gastrointestinal - Meckel's Diverticulum 2 year-old male with history of constipation presented with one episode of painless hematochezia that occurred 1 hour prior to arrival. He had a benign abdominal exam. POCUS revealed a focal fluid collection in the RLQ with a bowel wall appearance containing a hyperechoic focus, most suspicious for a Meckel’s diverticulum with fecalith. Surgical resection and pathology confirmed a Meckel's diverticulum. Dr. Kelly McWilliams, PGY-2, Denver Health Residency in Emergency Medicine Dr. Anna Abrams, Pediatric Emergency Medicine Fellow, Childrens Hospital Colorado Dr. Jon Orsborn, Director of Pediatric POCUS, Childrens Hospital Colorado https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1713499787564-HGW2DT0IX1NX1LVDPLG1/image-asset.gif Peds-Gastrointestinal - Pyloric Stenosis - Antral Nipple Sign 3 week old with projectile vomiting, POCUS showed positive astral nipple sign which is a highly specific finding for pyloric stenosis - the redundant pyloric mucosa protrudes into the gastric antrum. The measurements show increased pyloric muscle thickness (>3mm) and increased pyloric longitudinal measurement (>15 - 17 mm) Measurements can be remembered using "Pi Rule" - Pyloric muscle thickness, i.e. diame­ter of a single muscular wall on a transverse image >3 mm - Pyloric transverse diameter >14 mm - Pyloric longitudinal measurement >15 - 17 mm Contributed by: Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1530460508474-Y4ZHZ9JFZHVL76OG6PTA/appendicitis.gif Peds-Gastrointestinal - Appendicitis (1/2) - Longitudinal 11 y/o M presented with 1 day of periumbilical pain that migrated to the right lower quadrant with nausea, vomiting and anorexia. Ultrasound with high frequency linear probe demonstrates an enlarged appendix with an external diameter of 1.32 cm with trace free fluid posteriorly, as well as a fecalith at the proximal end of the appendix. Surgery was consulted who requested a formal US which was non-diagnostic. Surgery took the patient anyway, and MRI confirmed our findings (including the large diameter). Diagnostic criteria for appendicitis: a non-compressible, aperistaltic, blind ended structure >6mm diameter. Visualizing free fluid, tenderness in that area, and visualizing a fecalith can also add to the diagnosis. See the evidence atlas for more info about POCUS diagnosing appendicitis but when visualizing a diagnostic appendicitis, it carries a positive likelihood ratio of 9.24. PMID: 28214369 Jackie Chiou MS4, Dr. Matthew Riscinti and Dr. Tian Liang - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1712614440178-ND6F1MAPD8BP7C1JSQ4U/image-asset.jpeg Peds-Gastrointestinal - Pyloric Stenosis - Antral Nipple Sign with Measurements 3 week old with projectile vomiting, POCUS showed positive astral nipple sign which is a highly specific finding for pyloric stenosis - the redundant pyloric mucosa protrudes into the gastric antrum. The measurements show increased pyloric muscle thickness (>3mm) and increased pyloric longitudinal measurement (>15 - 17 mm) Measurements can be remembered using "Pi Rule" - Pyloric muscle thickness, i.e. diame­ter of a single muscular wall on a transverse image >3 mm - Pyloric transverse diameter >14 mm - Pyloric longitudinal measurement >15 - 17 mm Contributed by: Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1700328291872-VYD44ZLB7AYX12F93753/image-asset.gif Peds-Gastrointestinal - Appendicolith Transverse view of the appendix showing the appendix with intraluminal appendicolith. Contributor: Maher M. Abulfaraj, MD, @mahermabulfaraj https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1700328857928-MVV9ZUUPS4F54Q1SZ85O/image-asset.gif Peds-Gastrointestinal - Ascites Ascites with floating bowel and questionable to-and-fro peristalsis. Contributor: Peter Gutierrez, MD, FAAP, Emory University School of Medicine/Children's Healthcare of Atlanta, @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1700329338978-5U4RF16GZN21QLOIEBKW/image-asset.gif Peds-Gastrointestinal - Pseudokidney Sign - Intussusception 23 month old with ileocolic intussusception. Pseudokidney sign seen here due to oblique orientation of the linear transducer. Contributor: Antonio Riera, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701689422352-1KT8ZBKC0DT23ORSI8B7/image-asset.gif Peds-Gastrointestinal - Esophageal FB 5 yo male presents with swallowed decorative marble. no difficulty breathing. unable to handle secretions. POCUS shows an esophageal FB that was later removed by surgery. Contributor: Paul Khalil, MD Nicklaus Children's Hospital, @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701689809791-9HYU1LREJI7EV3TGVIXY/image-asset.gif Peds-Gastrointestinal - Neuroblastoma 18 mo F sent from PMD for mass in the RUQ. POCUS shows extra renal mass consistent with neuroblastoma that was later confirmed by pathology. Contributor: Paul Khalil, MD Nicklaus Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701690176599-333JXGVAEU3NZLGK8NIQ/ezgif.com-optimize+%282%29.gif Peds-Gastrointestinal - Full stomach 1 Gastric content eval for patient undergoing procedural sedation. With the patient in the right lateral decubitus position the linear probe is placed in a subxiphoid sagittal axis with the probe marker towards the head. The stomach is seen immediately caudal to the liver. The class 5 layer bowel wall of the stomach can be seen containing large volume, mixed echogenicity content. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701690647130-IRF6DIYV2JC33IXKMJQX/ezgif.com-optimize+%284%29.gif Peds-Gastrointestinal - Full stomach 2 Ultrasound used to assess gastric content prior to procedural sedation. Sagittal view in the epigastric region using the curvilinear probe with the patient in the right lateral decubitus position. Probe indicator cephalad. The gastric antrum is seen in the upper right with heavily air-admixed content with dirty shadow obscuring deeper content. The liver is seen in the upper left and the aorta in the deep field. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701692080719-M8HAQMDF7JKCSKO6FO8C/ezgif.com-crop.gif Peds-Gastrointestinal - Pyloric Stenosis 1 Roughly 1m male with projectile emesis. POCUS demonstrated elongated and thickened pylorus with absence of trans-pyloric flow. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701692940456-I5NH1PSPMSJ5Z9VGR38E/ezgif.com-gif-maker.gif Peds-Gastrointestinal - Pyloric Stenosis 2 (1/2) 2+ weeks projectile vomiting. Extreme lab abnormalities including Cl 67. CG4: 7.57/67/34/60, base excess >30, lactate 3.23. The pyloric channel is elongated, thickened, and has an absence of trans-pyloric flow. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701693176733-F40ZEASL52LU9TKTW2HV/ezgif.com-gif-maker+%281%29.gif Peds-Gastrointestinal - Pyloric Stenosis 2 (2/2) 2+ weeks projectile vomiting. Extreme lab abnormalities including Cl 67. CG4: 7.57/67/34/60, base excess >30, lactate 3.23. The pyloric channel is elongated, thickened, and has an absence of trans-pyloric flow. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701694374480-Z6GCJ0402DOS49F2TMEK/ezgif.com-optimize+%289%29.gif Peds-Gastrointestinal - Ileo-ileal intussusception 7y female with N/V and tactile fever. Benign abdominal exam. Note the small size of the intuss. In long axis you can easily track the bowel wall as it folds into itself and see it is slowly sliding in and out a small bit. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701696025343-E58SNU3Q178MBS625IT4/ezgif.com-gif-maker+%282%29.gif Peds-Gastrointestinal - Ileo-ileal Intussuception 2 Toddler with colicky abdominal pain. LUQ with ileo-ileal intuss. Note the smaller size and active peristalsis of the intuss. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701696668719-AOHSYMF62TD3IXY5PPGB/ezgif.com-optimize+%2816%29.gif Peds-Gastrointestinal - Ruptured Appendicitis 3y female with 3d RLQ abd pain, emesis, fever. WBC 8.5 with 73% PMN. CRP 9. POCUS with enlarged appendix with loss of bowel wall architecture, surrounding early fluid collection, fecolith, and mural hyperemia. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701697026981-WM1WFPTL3321CR54E4YF/ezgif.com-optimize+%2817%29.gif Peds-Gastrointestinal - Ruptured Appendicitis 2 6y female with 2d abd pain, fever, nauesea, dysuria. OSH WBC 17.5, pyuria. Long axis view of the appendix draping down into the pelvis. Note how the regular bowel wall architecture is progressively obliterated as the appendix tracks distally into the pelvis, ending in full perforation with early abscess formation and surrounding hyperechoic fat. Contributor: Matthew Moake, MD PhD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701708212069-Q2ONCW5FZL1RN832W0YS/ezgif.com-optimize+%2818%29.gif Peds-Gastrointestinal - Pyloric Stenosis with and without measurements (1/4) 5 wk old male with projectile vomiting. Clips show hypertrophic pyloric stenosis in long axis. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701708316897-1TZ5PISDBU2XSCJ9D0ES/ezgif.com-optimize+%2819%29.gif Peds-Gastrointestinal - Pyloric Stenosis with and without measurements (2/4) 5 wk old male with projectile vomiting. Clips show hypertrophic pyloric stenosis in short axis. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701708527617-PJ5VH71WH0WCJIGUJSAE/longscreenshot.jpeg Peds-Gastrointestinal - Pyloric Stenosis with and without measurements (3/4) 5 wk old male with projectile vomiting. Clips show hypertrophic pyloric stenosis in long axis. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701708805600-79Q5RT1R3ZZTS0WU21P0/ezgif.com-gif-maker+%282%29.jpg Peds-Gastrointestinal - Pyloric Stenosis with and without measurements (4/4) 5 wk old male with projectile vomiting. Clips show hypertrophic pyloric stenosis in short axis. Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701709183095-FN7Z72SPQEJCZYYZI6B4/ezgif.com-optimize+%2820%29.gif Peds-Gastrointestinal - Dengue Ascites 4-year-old boy with severe dengue with free fluid in the abdominal cavity. Contributor: Mg. Andres Silva Horna, Hospital Cayetano Heredia Piura-Peru https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701709601395-7KJ4QB1JLK0BYJY0296I/ezgif.com-optimize+%2821%29.gif Peds-Gastrointestinal - SBO 17 yo male with history of abdominal surgeries (g-tube and fundoplication) and chronic constipation who comes in with lower abdominal pain. POCUS shows stool to and fro (tanga sign). Contributor: Paul Khalil, MD Nicklaus Children's Hospital @khalil3paul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701709911688-5NVWVQ0W4DSLPYHHPUZ6/ezgif.com-gif-maker+%283%29.jpg Peds-Gastrointestinal - Neurofibroma Abdominal Mass 3 yo presents with enlarging abdomen and mass palpated. A large abdominal mass was seen on POCUS. The kidney is seen directly below the mass in the image. Contributor: Kathryn Pade, MD, Rady Children's Hospital San Diego https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701710203755-NX1IRVNT0WZHTV6T5AFG/ezgif.com-optimize+%2822%29.gif Peds-Gastrointestinal - SBO Small bowel obstruction with to and fro peristalsis visualized. Contributor: Peter Gutierrez, MD FAAP FACEP; Children's Healthcare of Atlanta; @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701710545767-8CRYO8AYRQ42G4TJ8D7U/ezgif.com-gif-maker+%284%29.jpg Peds-Gastrointestinal - Ileocolic Intussusception Ileocolic intussusception measuring 4.4cm. Contributor: Peter Gutierrez, MD FAAP FACEP; Children's Healthcare of Atlanta; @pocuspete https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701712016602-ZQE62AE3N35E96F5MAAO/ezgif.com-optimize+%2823%29.gif Peds-Gastrointestinal - Ileocolic LUQ intussusception - Longitudinal & Transverse 3 yo male presented with an episode of abdominal pain and bilious emesis in the morning. He was noted to be sleepy all day at home and passed two bloody diarrheal stools prior to arrival. Point-of-care ultrasound demonstrates ileocolic intussusception in the left upper quadrant. Transverse view demonstrate a "target sign" and longitudinal view demonstrates "sandwich sign" consistent with the diagnosis. Contributor: Megan Musisca, MD, Boston Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701716982556-RGDA0NEF7D9PL2A86R03/appy1.jpg Peds-Gastrointestinal - Appendicitis (1/3) "Fever Vomiting and Abdominal pain 9yr old Tenderness @ McBurney’s point USG : Aperistaltic Dilated with probe tenderness in right iliac region Diameter 6mm plus" Contributor: Dr Vanitha Jagannath https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701716988585-6Q4K0M958YICT5YUY7LJ/appy2.jpg Peds-Gastrointestinal - Appendicitis (2/3) "Fever Vomiting and Abdominal pain 9yr old Tenderness @ McBurney’s point USG : Aperistaltic Dilated with probe tenderness in right iliac region Diameter 6mm plus" Contributor: Dr Vanitha Jagannath https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1701716992892-LDNW0MNFE9EIGPD19JMO/appy3.jpg Peds-Gastrointestinal - Appendicitis (3/3) "Fever Vomiting and Abdominal pain 9yr old Tenderness @ McBurney’s point USG : Aperistaltic Dilated with probe tenderness in right iliac region Diameter 6mm plus" Contributor: Dr Vanitha Jagannath https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1711035168427-JU67D6XXKVO174HVBT01/normalappy.gif Peds-Gastrointestinal - Normal Appendix 1 (1/3) 10 y/o with abdominal pain. Normal appendix identified medial to the iliac vessels. Please see other image in series for doppler. Contributor: Elena Chen, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1711035798435-XC51JZXI3CV6AR5FHJEJ/normalappydopp.gif Peds-Gastrointestinal - Normal Appendix 1 (2/3) 10 y/o with abdominal pain. Normal appendix identified medial to the iliac vessels. Contributor: Elena Chen, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1711036233503-Y4LMKD63YAMMXORW63MP/appymeasurenormal.gif Peds-Gastrointestinal - Normal Appendix 1 (3/3) 10 y/o with abdominal pain. Normal appendix identified medial to the iliac vessels. Contributor: Elena Chen, MD https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1711038182624-OZ0F9TPQ5JPSPEGNN6GU/normalappy2combine.gif Peds-Gastrointestinal - Normal Appendix 2 (1/2) 7 y/o F with abdominal pain. Normal appendix identified. Contributor: Russ Horowitz, MD, Lurie Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1711037015166-JFCKBO4VMREUM57YKEYZ/ezgif.com-overlay.jpg Peds-Gastrointestinal - Normal Appendix 2 (2/2) 7 y/o F with abdominal pain. Normal appendix identified. Outer wall measured 0.48cm in long, 0.46cm in short, and 0.51cm again in a short axis. Contributor: Russ Horowitz, MD, Lurie Children's Hospital https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527400072112-PC6BE4PMRLNG8G5C5IPJ/ezgif.com-optimize+%2848%29.gif Peds-Gastrointestinal - Normal Appendix - Cross Section Measured 14 y/o M with nausea vomiting and and RLQ pain. POCUS visualized a normal appendix is seen. A normal appendix is identified by a blind-ending tubular structure that is <6mm diameter measured from outer wall to outer wall (although 6mm-7mm has also been described). This patient’s appendix was measure to be 5.4mm. Dr. Sathya Subramaniam - Children’s Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509065976151-Z8M7Q4ZH1PQLTJLNKAH0/Liteplo+-+Ascaris.gif Peds-Gastrointestinal - Ascariasis - "Sqworming in your belly is just ascaris as it sounds" A two-year old with an intestinal nematode. Andrew Liteplo MD, RDMS - Massachusetts General Hospital Chief, Division of Ultrasound in Emergency Medicine Director, Emergency Ultrasound Fellowship https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527399934349-GMZNAY10VS84U90EZ1RW/ezgif.com-optimize+%2847%29.gif Peds-Gastrointestinal - Normal Appendix - Cross Section 14 y/o M with nausea vomiting and and RLQ pain. POCUS visualized a normal appendix is seen. A normal appendix is identified by a blind-ending tubular structure that is <6mm diameter measured from outer wall to outer wall (although 6mm-7mm has also been described). This patient’s appendix was measure to be 5.4mm (see still image). Dr. Sathya Subramaniam - Children’s Hospital of Philadelphia https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1498403252719-K5IZ44VZSY7NEWXQPEIO/ezgif.com-optimize%28intuss%29.gif Peds-Gastrointestinal - Intussusception with Target Sign 4-year-old child with vomiting since yesterday, seen in 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1498403659453-6WW1BDKWOES6UUDLDE0G/ezgif.com-optimize%28target_sign%29.gif Peds-Gastrointestinal - Intussusception with Target Sign 4-year-old with colicky abdominal pain, vomiting once this AM, on exam abdomen soft and non-tender and pt well-appearing. POCUS performed demonstrating target sign. A hyperechoic fatty core can be seen within the intussuception inside hypoechoic edematous large bowel on both transverse and longitudinal views. Dr. Sathya Subramaniam, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1499137264795-A41FKWGIHD53FMRDJFO9/ezgif.com-gif-maker+%2822%29.gif Peds-Gastrointestinal - Intussusception - Colicky Abdominal Pain This is a transverse view of the right upper quadrant of an infant who presented with several days of worsening colicky pain. He had decreased appetite, activity and vomiting. Bedside ultrasound revealed evidence of intussusception with extensive surrounding bowel edema likely secondary to delayed presentation. Chris Heberer, DO EM PGY-3 CMU-Saginaw https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1509193422966-GW5SSBEKQHZY0Z1UR8N8/PS+longitudinal.gif Peds-Gastrointestinal - Pyloric Stenosis (Longitudinal) 4-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, 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, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1498405809679-2I1L7PON7QBMLONNHSLA/ezgif.com-optimize%28normal+pylorus%29.gif Peds-Gastrointestinal - 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. Sometimes fluid can be seen passing through the pylorus. Dr. Sathya Subramaniam, Pediatric EM Fellow - Kings County/SUNY Downstate https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1658780210527-V3DK3EZVIUVLSU0KF8TR/image-asset.gif Peds-Gastrointestinal - Normal appendix A teenaged female presented with lower abdominal pain, and underwent POCUS to evaluate for appendicitis. A normal appendix was visualized. Seen here, the appendix is seen as a blind ending pouch with a hyperechoic outer border, a relatively hypoechoic wall, and relatively hyperechoic contents. The normal appendix should be less than 7cm in diameter and should be compressible. This patient ultimately was diagnosed with an alternate etiology of her abdominal pain. Dr. Molly Thiessen Denver Health Medical Center https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1537200019869-0F9KLZ8Z3CTZQOOR4OSD/splenic+sequestration+.gif Peds-Gastrointestinal - Splenic Sequestration 11 y/o F with PMH of sickle cell disease (ss) presents with 2 hours of tactile temperature, chest pain, and vague abdominal pain. Exam demonstrates normal vitals (T99.3) distended abdomen, nonspecific mild tenderness to palpation and enlarged spleen tip to the umbilicus. Ultrasound was used to confirm the size spanning nearly >15cm in length with heterogeneous echogenicity throughout the spleen consistent with splenic sequestration syndrome. Dr. Praneetha Chaganti and Dr. Eddie Rodriguez - Kings County Emergency Medicine https://www.thepocusatlas.com/new-gallery-2 daily 0.75 2024-10-11 https://www.thepocusatlas.com/tee daily 0.75 2024-10-17 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661112252818-179TSONCPJDFXVKFE1ID/434.gif TEE - Mid-Esophageal 4 Chamber View with a Trace Pleural Effusion Mid-Esophageal 4 Chamber View with a trace pleural effusion Duncan McGuire, DO, Emergency Medicine, Beaumont Health https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661112252818-179TSONCPJDFXVKFE1ID/434.gif TEE - Mid-Esophageal 4 Chamber View with a Trace Pleural Effusion Mid-Esophageal 4 Chamber View with a trace pleural effusion Duncan McGuire, DO, Emergency Medicine, Beaumont Health https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661182960669-JE32KFKA56XPWT5NF0XV/image-asset.gif TEE - Normal Mid-Esophageal Long Axis View Normal Mid-Esophageal Long Axis View Duncan McGuire, DO, Emergency Medicine, Beaumont Health https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661267883185-WPWTJ3NXJMY09S7DN1DN/image-asset.gif TEE - Normal Trans-Gastric Short Axis View Normal Trans-Gastric Short Axis View Duncan McGuire, DO, Emergency Medicine, Beaumont Health https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661268497090-X961TSUUGXAY7L51AT8H/image-asset.gif TEE - TEE Normal Aorta Short Axis TEE Normal Aorta Short Axis Duncan McGuire, DO, Emergency Medicine, Beaumont Health https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1661269198690-BU0DR5KSAU5GP2VO04ZO/image-asset.gif TEE - TEE Normal Aorta Long Axis TEE Normal Aorta Long Axis Duncan McGuire, DO, Emergency Medicine, Beaumont Health https://www.thepocusatlas.com/contribute daily 0.75 2022-07-27 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1504333751019-EESNV03C1UPYR9IDF916/The+POCUS+ATLAS-07.png Contribute https://www.thepocusatlas.com/home-1 daily 0.75 2018-05-17 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1504402863862-DFZY5E8OWMNYQFZR8WKA/sp-l01.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501262826864-D66DLZ3XRA525PYFTKNM/ezgif.com-optimize+%2817%29.gif Home - Explore Our Library The Point of Care Ultrasound (POCUS) Atlas is collaborative effort to highlight and advance the use of ultrasound around the world - focusing on rare, exotic and perfectly captured ultrasound images. All of our content is free, open access, and peer-reviewed. It is freely available to be shared and used for global ultrasound education. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1477768065039-349VG8UD1VZ3PJO1IMYT/Blog+Post+Thumbnails-82.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1477768080308-N930EUPAZR89XA47UF8Q/Blog+Post+Thumbnails-83.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1477768096030-2CH4PP12ZYSS0PAVKRNX/Blog+Post+Thumbnails-84.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1477789324644-G3CWHWGMGV3741CKX9VL/Blog+Post+Thumbnails-87.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1629723050564-5ZGGRRXC6CID6Q70YON3/image-asset.png Home - Denver Emergency Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572990143522-9YC5MJATGKTWNLCGT9TU/sonoclipshare.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572990261212-PTXX2WN2W8T7CWW9TGK6/sonogif.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1568231330223-RUP3N3UY4S7TN6F59CCR/B%26Bblack-12.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1698781872362-LTCJD9JT005WH32PZ7MY/5minsono.jpg Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968268719-5U7HWIKEIN3NKFD06QPI/broomedocs.jpg Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968788678-HUD5E7ENFUQ5MSVN7Y9P/emgus.jpeg Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968304446-RHTOZCQ4ZZ9GTAENE8ZX/neum.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968350842-WEIKU906YX3CW2YVJ7JN/ultrasoundpodcast.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968389698-615IM80CFJ3RX4SV4NAM/ddxof.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968273153-KO1W9CDMRH3RRODEISW0/GEL+icon.jpeg Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527819174234-8AOY6XQ4RC74K0S2Y45A/UCSD+Website+Logo+Design-45.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1563378934041-G4PQ8BIAUBIST583Z4NT/EGLS+Logo.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592942995045-ZJN2OXNHPPHMY94PH8Q6/image-asset.png Home - Visible Voices https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1612639768052-R3TKV3IWEJTS69MJOFPW/image-asset.png Home - Wiki EM https://www.thepocusatlas.com/new-page daily 0.75 2017-07-08 https://www.thepocusatlas.com/pediatrics daily 0.75 2022-02-02 https://www.thepocusatlas.com/home daily 0.75 2021-08-23 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527746673149-K9M1EYEJW8RMBPT4N14F/The+POCUS+ATLAS-26.png Image Atlas Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501183594226-6M4TQ5B6JHQ2JRFGZLD3/image-asset.gif Image Atlas Home - Aorta https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501183613544-F155WFSANMH2VA5RLLLT/image-asset.gif Image Atlas Home - Echocardiography https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501183721400-YUZ0VO71JMQ4AHB0S2N6/image-asset.gif Image Atlas Home - GI https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501183785625-H8U4JZYUBGUFY90A4190/image-asset.gif Image Atlas Home - Hepatobiliary https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501217418314-T14TNFL32FYB7FW30OLI/image-asset.gif Image Atlas Home - MSK + Procedures https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501216798646-6ZGNU2ZAV09QBXISDZ7F/image-asset.gif Image Atlas Home - OB-GYN https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501216697451-W4E0Y65TFYQJFXXR7SY1/image-asset.gif Image Atlas Home - Ocular https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501217241115-A9TRV6RS92R1CDG2ZEEU/image-asset.gif Image Atlas Home - Pediatrics https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501182684897-A7KCELIFNOR6AW9PG1DO/image-asset.gif Image Atlas Home - Pulmonary https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1518382467480-AQDGVU0UJMYI9H1AWFKB/twinkle.gif Image Atlas Home - Renal/GU https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507766561528-2MECR06S9UAROBK01NE4/Trauma Image Atlas Home - Trauma https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1546812917536-J1XUCEK53GGUGB5HB20A/ezgif.com-crop+%282%29.gif Image Atlas Home - Soft Tissue https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507767119792-58H0YYGSNA02LVL3ARD8/Radial+Artery+Pseudoaneurysm.gif Image Atlas Home - Vascular https://www.thepocusatlas.com/trauma-teaching daily 0.75 2021-01-25 https://www.thepocusatlas.com/echocardiography-1 daily 0.75 2018-12-17 https://www.thepocusatlas.com/left-ventricle-1 daily 0.75 2021-07-13 https://www.thepocusatlas.com/pericardium daily 0.75 2021-05-09 https://www.thepocusatlas.com/ivc daily 0.75 2018-12-17 https://www.thepocusatlas.com/normal-anatomy daily 0.75 2021-07-10 https://www.thepocusatlas.com/echocardiography-2 daily 0.75 2024-10-17 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/9e1dfdb5-6524-4f74-81ca-1bef7ff2d7e9/noun-maintenance-1785965-FF5F5F.png Echocardiography - Undergoing Maintenance We have reorganized our echo section and all images can be accessed below on this page. We are currently working on category pages (buttons below will be functional soon)! Please excuse the mess during this transition! - The POCUS Atlas Team https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1650151773021-QZLXYT46LD3QJEDONGV5/Untitled-3-08.png Echocardiography https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1650151773530-4P3AG4EMIE0481MIQ6Q6/Untitled-3-09.png Echocardiography https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1650151771702-6BFGCUUG759ZQNFPKGEM/Untitled-3-01.png Echocardiography https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1650151771719-GOK7ZOFJNZNPP7QN85O8/Untitled-3-02.png Echocardiography https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1650151772100-K3F0BAWQ3ZELVKM4CHTT/Untitled-3-03.png Echocardiography https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1650151772155-G9E4JEWXK8FNQMRGJQ4R/Untitled-3-04.png Echocardiography https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1650151772545-R59BI6ZST3PLN3P6H5ZP/Untitled-3-05.png Echocardiography https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1650151773509-KJI2H1V3MRS44WQLSTG3/Untitled-3-10.png Echocardiography https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1650151772584-D2CPDNH6PW2E6UHPPSG1/Untitled-3-06.png Echocardiography https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1650151773012-F6CNRJOZCR1GJYSSYC5M/Untitled-3-07.png Echocardiography https://www.thepocusatlas.com/valves daily 0.75 2021-09-16 https://www.thepocusatlas.com/right-ventricle daily 0.75 2020-09-21 https://www.thepocusatlas.com/left-ventricle daily 0.75 2021-08-05 https://www.thepocusatlas.com/hydro-and-obstruction daily 0.75 2020-07-18 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1531099902499-RBDGA3EMPAJX5O7CYGDI/Screen+Shot+2018-07-08+at+6.31.02+PM.png Hydronephrosis https://www.thepocusatlas.com/legal daily 0.75 2024-11-21 https://www.thepocusatlas.com/viewing-caption-on-mobile-device daily 0.75 2018-03-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1520623245200-4Q8LNOEGGO9B74HF3BIY/tutorial+page.gif Viewing Caption on Mobile Device https://www.thepocusatlas.com/ea-home daily 0.75 2019-11-03 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527746636295-C6IIFRV480DMCP930FY1/The+POCUS+ATLAS-25.png Evidence Atlas Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1547088818498-IN2UD56Y0XMTTN49RVKT/EA+App+Promo+Screen-05.png Evidence Atlas Home - Get the Evidence Atlas App Click here https://www.thepocusatlas.com/ea-echo daily 0.75 2022-12-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523570837633-X5PCU61YBXFN4MY6GJU1/rd.gif Echocardiography Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526329856684-HTYZRVLR4Y1R8PVVXAP4/image.png Echocardiography Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526329861773-6FHOUAKZ5L84I0L5DM6U/original.png Echocardiography Evidence - TAPSE https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526330027513-HN1LPKBCQH1KWLT4QE3J/original.png Echocardiography Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526330070236-6XYFMAGRV2ZZ9D8Q0EUW/original-1.png Echocardiography Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526330127465-4UQK1R580KCZ2LJADKFF/original-2.png Echocardiography Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526330184076-2DY5CUQECAUICIAT2B4C/original.jpg Echocardiography Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526330435099-A52QIGVSR6K8F4RMTYB3/cardiac_function.jpg Echocardiography Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526330436899-YSL0UE3MV1ZP4JQM0K5J/Obtaining_cardiac_Windows-300x229.jpg Echocardiography Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526330556052-1CQOFYXHAM4CE5LCA19L/RHF_Menu-610x458.jpg Echocardiography Evidence https://www.thepocusatlas.com/ea-biliary daily 0.75 2022-12-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523570837633-X5PCU61YBXFN4MY6GJU1/rd.gif Biliary Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526506234073-912U04SMMKFRB5W6A0B2/image.png Biliary Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572815100030-PTR458SSNGMXKCX9NTT0/original.png Biliary Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526506306949-BBSK37O24039ZXJRPO6Q/GB.jpg Biliary Evidence https://www.thepocusatlas.com/ea-pulm daily 0.75 2019-10-28 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523570837633-X5PCU61YBXFN4MY6GJU1/rd.gif Pulmonary Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526441290953-VE65CA60DKAV4A6ZGDOQ/image.png Pulmonary Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526441322326-XTY7B268FBZ8E3ZQXOFG/image-1.png Pulmonary Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526441374820-ZHSVXBPT6T6ARDZOZXHH/image.jpg Pulmonary Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572300816285-5NKWU7KZ4S1IHU31GPL4/79+Ant+Lat+Lung+HF.png Pulmonary Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526441437866-S3NH2QWR5GIRFO49S2II/b-lines-menu-page.001-300x225.jpg Pulmonary Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526441437905-Q5JO5C9I9VDWZKGJ2NSO/Pleural_Effusion.jpg Pulmonary Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526441438377-I7A7GU513DEYD89TP1ZB/PNA.jpg Pulmonary Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526441438370-P3D1XW40VEHQWRA96YLJ/PTX.jpg Pulmonary Evidence https://www.thepocusatlas.com/ea-renal daily 0.75 2022-12-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523570837633-X5PCU61YBXFN4MY6GJU1/rd.gif Renal Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526506759591-G1R20PWAMP7HO5AEEVGB/image.png Renal Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526506820438-UEQLLLWFNSN6U8075KF1/Hydro.jpg Renal Evidence https://www.thepocusatlas.com/ea-orbit daily 0.75 2022-12-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523570837633-X5PCU61YBXFN4MY6GJU1/rd.gif Orbital Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526439772044-TV3FSCXILW9IK466VDCI/image.png Orbital Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526439791410-ANFBXWY4T2TFAZSOWI2V/image-1.png Orbital Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526439989669-FHEQ0XRXAITN0VC7J7KE/5-Min-Sono-ONSD.018-300x225.jpg Orbital Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526440001182-U4664NCJKGDBX2JVWBWT/5-Min-Sono-RD-vs-VD-v2.020.jpg Orbital Evidence https://www.thepocusatlas.com/what-are-likelihood-ratios daily 0.75 2018-12-14 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523570837633-X5PCU61YBXFN4MY6GJU1/rd.gif What Are Likelihood Ratios? https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1524439530435-T77STFJJ0TZV8VSOPIN9/LR.png What Are Likelihood Ratios? https://www.thepocusatlas.com/ea-aorta daily 0.75 2022-12-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523570837633-X5PCU61YBXFN4MY6GJU1/rd.gif Aorta Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526438549702-G049RKDNYG686RGYLW73/AAA.jpg Aorta Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526438580283-7WYEJJSOOC0K499EN2ZL/AD.jpg Aorta Evidence https://www.thepocusatlas.com/ea-bowel daily 0.75 2022-12-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523570837633-X5PCU61YBXFN4MY6GJU1/rd.gif Bowel Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526507139453-KEXUXRHT0VSKL8MEDGSN/image.png Bowel Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526507141242-H1RK4271OLMW2V20M74W/image-1.png Bowel Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1528157885453-F6A7SNDZTR8OREZSHQQK/original.png Bowel Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526507258527-YRARBGELCF168CXGAPCG/SBO.jpg Bowel Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526507258530-I8YMLGY5HGJJW10MQFMA/Appy.jpg Bowel Evidence https://www.thepocusatlas.com/ea-softtissue daily 0.75 2022-12-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523570837633-X5PCU61YBXFN4MY6GJU1/rd.gif Soft Tissue/MSK Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526924547840-IC3J1RSD4WLZKKTDTSUU/image-1.png Soft Tissue/MSK Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1530841579593-TF1TC29UAOUS9A0FXZDO/Screen+Shot+2018-07-05+at+6.46.02+PM.png Soft Tissue/MSK Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526924717279-1RDGI519ACW18JFAUVRW/SoftTissue.jpg Soft Tissue/MSK Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526924717276-ONCIKBAXDOGOXDZDS2ZB/Nec_Fasc.jpg Soft Tissue/MSK Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1530841701958-Q7IRY61PN89IFBAC2WS7/Screen+Shot+2018-07-05+at+6.48.02+PM.png Soft Tissue/MSK Evidence https://www.thepocusatlas.com/ea-obgyn daily 0.75 2022-12-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523570837633-X5PCU61YBXFN4MY6GJU1/rd.gif OB/GYN Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526923652542-G5UI9JBSZX5UO6QHQJ6U/image.png OB/GYN Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526923749581-DYS7EF1LHP1P26EZFOK8/5-Min-Sono-Fetal-Heart-Tones.001-768x576.jpg OB/GYN Evidence https://www.thepocusatlas.com/ea-trauma daily 0.75 2022-12-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523570837633-X5PCU61YBXFN4MY6GJU1/rd.gif Trauma Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526925978784-2EGHKKIX825TSFWKPOJ5/image.png Trauma Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526926015291-VMRB1FNFBFCHJD83CW8Q/image.jpg Trauma Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572815747454-F2SFHYEPORGC171HJD5G/fast+in+pelvis+fx+.png Trauma Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572815763138-R5O6FLA3VMSOX3A0C0AN/peds.png Trauma Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526926065261-9JDYHF3GWO8ZMZL567IP/FAST.jpg Trauma Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526926065235-OBTP2Z6PJ2STS893SYYR/EFAST.jpg Trauma Evidence https://www.thepocusatlas.com/ea-procedure daily 0.75 2019-11-03 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523570837633-X5PCU61YBXFN4MY6GJU1/rd.gif Procedure Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533174083703-YE7DX2FL1MX73YYDKFEB/Riscinti+Gordon+CVC+Confirmation.gif Procedure Evidence A central venous catheter was placed in the right internal jugular under ultrasound guidance and subxiphoid view was obtained. Saline was rapidly flushed through the brown port and turbulent saline can be seen traveling through the right side of the heart. - Dr. Matthew Riscinti and Dr. Isaac Gordon - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526925644473-O9TWQNKCQZO600WQ03IM/image.png Procedure Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526925705837-D50HYPTU2PQ26WZA0F3G/CVC_Confirmation.jpg Procedure Evidence https://www.thepocusatlas.com/ea-dvt daily 0.75 2022-12-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1523570837633-X5PCU61YBXFN4MY6GJU1/rd.gif DVT Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526924088815-IZVC7J8UQPKL7VTPD4HR/image.png DVT Evidence https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1526924128673-PXAVKSOJ6076V3L1KNQ0/DVT.jpg DVT Evidence https://www.thepocusatlas.com/home-2 daily 1.0 2024-04-29 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1504402863862-DFZY5E8OWMNYQFZR8WKA/sp-l01.png Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659460073155-HW3SNL965W3XWFJDAWHO/noun-atlas-1479193-453E3E.png Home - Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659460073633-H8QVKPJQY9511JS7YZ4D/noun-literature-4460602-453E3E.png Home - Evidence Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659460073860-NQCYSDZO8IXH66WO12QX/noun-nerve-4666605-453E3E.png Home - Nerve Block Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1659460074083-YSJRZJFIG8JZCDTKFRYR/noun-video-review-4806914-453E3E.png Home - Image Review https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/85023ddd-a774-477e-9282-dccf66cee977/The+POCUS+ATLAS-110.jpg Home - POCUS Atlas Jr Project We are building the first ever free, open-access pediatric POCUS Atlas! This atlas will be available to use for education around the world. We need your help on this project, find out how you can contribute below. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/a84ee829-dc01-4959-88a4-29ff816895a8/noun-apps-914827-453E3E.jpg Home - Get the App! The POCUS Image Atlas is now available in app form! Download on either iOS or Android! iOS Android https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/2ff7d1e8-7d2d-4fa6-b5a1-dcd344cb3681/IMG_2864_LR+%281%29.jpg Home - Live Course in San Diego! Want to come to an awesome POCUS course in San Diego? Check out our NextGen POCUS: Beyond Essentials for Acute Care Course scheduled for November 6th-8th, 2024! https://www.thepocusatlas.com/acute-heart-failure daily 0.75 2018-08-28 https://www.thepocusatlas.com/colorized-appendicitis-images daily 0.75 2018-08-02 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168901636-1YO93U6KXSWMPWU4LZ9Z/sathya-appendix-landmarks-colorized-labeled.gif Colorized Appendicitis Images - Labeled Colorized Appendix with Landmarks Normal appendix with landmarks highlighted. P=Psoas, Ap=Appendix, Ia=Iliac Artery, Iv=Iliac Vein Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168901673-SM6SJKJ068VFRBO4FCW1/sathya-appendix-landmarks-colorized.gif Colorized Appendicitis Images - Colorized Appendix Landmarks Normal appendix with landmarks highlighted. Green = Psoas Yellow = Appendix Red = Iliac Artery Blue = Iliac Vein Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168904770-Q65PM1BRQ4KUGVYXRMMJ/sathya-appendix-landmarks.gif Colorized Appendicitis Images - 2D Appendix Landmarks Normal appendix with landmarks including the psoas, ilac artery/vein, and the appendix. Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168923765-GL60ZV37DD8Q91QEJYTO/sathya-blind-end-vessels-color-label.gif Colorized Appendicitis Images - Labeled and Colorized Appendix and Landmarks (Longitudinal) Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168923652-2K6A23VVAPUPZKGCLOQH/sathya-blind-end-vessels-colorized.gif Colorized Appendicitis Images - Colorized Appendix with Landmarks (Longitudinal) Yellow = Appendix Red = Iliac Artery Blue = Iliac Vein Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168927436-9NP4WDOVYXYBWTBOZEMS/sathya-blind-end-vessels.gif Colorized Appendicitis Images - 2D Appendix with Landmarks (Longitudinal) Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168933429-QYH2WVTMBNYS4U50FG1G/Sathya-normal-appendix-1-blind-end-colorized-labeled.gif Colorized Appendicitis Images - Labeled and Colorized Appendix and Psoas Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168936705-9SDBP9BEF9PBP7TG4W6G/Sathya-normal-appendix-1-blind-end-colorized.gif Colorized Appendicitis Images - Colorized Appendix and Psoas Red = Appendic Blue = Psoas Images provided by Sathya Subramaniam - Children’s Hospital of Philadelphia, edited by Matthew Riscinti - Kings County Emergency Medicine https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533168938202-URFOUCC7QFKEZORMTIGF/Sathya-normal-appendix-1-blind-end.gif Colorized Appendicitis Images https://www.thepocusatlas.com/ea-app daily 0.75 2019-01-14 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1547082634406-CCNT3DCPGMOAW0VRQ8J0/EA+App+Promo+Screen-04.png The Evidence Atlas App https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1547087818808-8PTS7TVJ3W94L2816SU7/download.png The Evidence Atlas App https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1547087749611-DQ858800QVFU8JP7IHX4/Download_on_the_App_Store_Badge_US-UK_135x40_0824.png The Evidence Atlas App https://www.thepocusatlas.com/bb-soft-tissue daily 0.75 2019-01-27 https://www.thepocusatlas.com/bb-galleries daily 0.75 2020-01-21 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1548628561942-8QKKBTKL99S43LVVXIIO/bblogo.png Copy of Image Atlas Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501183594226-6M4TQ5B6JHQ2JRFGZLD3/image-asset.gif Copy of Image Atlas Home - Aorta https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579642853964-DCRS5S4PN3HSU8PJUCUN/ezgif.com-optimize%28stones_neck%29.gif Copy of Image Atlas Home - Biliary https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501183613544-F155WFSANMH2VA5RLLLT/image-asset.gif Copy of Image Atlas Home - Echocardiography https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501182684897-A7KCELIFNOR6AW9PG1DO/image-asset.gif Copy of Image Atlas Home - Lung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579644849493-123KZH58F21K4Z2PDCOI/ezgif.com-optimize.gif Copy of Image Atlas Home - MSK https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501216798646-6ZGNU2ZAV09QBXISDZ7F/image-asset.gif Copy of Image Atlas Home - Pregnancy https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501216697451-W4E0Y65TFYQJFXXR7SY1/image-asset.gif Copy of Image Atlas Home - Ocular https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1518382467480-AQDGVU0UJMYI9H1AWFKB/twinkle.gif Copy of Image Atlas Home - Renal https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579643995142-GBVCVTTHPO6U0KC47SMM/ezgif.com-optimize%2B%2830%29.gif Copy of Image Atlas Home - SHOCK & Cardiac Arrest https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1546812917536-J1XUCEK53GGUGB5HB20A/ezgif.com-crop+%282%29.gif Copy of Image Atlas Home - Soft Tissue https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1507766561528-2MECR06S9UAROBK01NE4/Trauma Copy of Image Atlas Home - Trauma https://www.thepocusatlas.com/bb-renal daily 0.75 2019-01-27 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1531099902499-RBDGA3EMPAJX5O7CYGDI/Screen+Shot+2018-07-08+at+6.31.02+PM.png Renal Pathology https://www.thepocusatlas.com/bb-echo daily 0.75 2019-01-27 https://www.thepocusatlas.com/bb-aorta daily 0.75 2019-01-27 https://www.thepocusatlas.com/bb-lung daily 0.75 2020-03-22 https://www.thepocusatlas.com/bb-ob daily 0.75 2019-01-27 https://www.thepocusatlas.com/bb-ocular daily 0.75 2019-01-27 https://www.thepocusatlas.com/bb-trauma daily 0.75 2019-01-27 https://www.thepocusatlas.com/images-for-cardiac-arrest-teaching daily 0.75 2020-01-21 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1579643653189-QJWDOHLHEC0U46L3L024/Screen+Shot+2020-01-21+at+1.51.36+PM.png Images in Cardiac Arrest https://www.thepocusatlas.com/tutorials daily 0.75 2019-09-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1568009483694-Q2HPN213S37K5KC6GINQ/how+to+long-37.png Tutorials https://www.thepocusatlas.com/copy-of-aorta-test-colorized daily 0.75 2019-09-09 https://www.thepocusatlas.com/copy-of-aorta-test-colorized-1 daily 0.75 2019-09-15 https://www.thepocusatlas.com/people-of-pocus daily 0.75 2019-10-09 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1570583636116-GN2AR7R8KI0CRFND1639/pop3-45.png People of POCUS https://www.thepocusatlas.com/sonobite-aorta daily 0.75 2019-10-21 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1571694372588-LN2M6C24SKXW1081P0JS/Screen+Shot+2019-10-21+at+2.45.23+PM.png Sonobite: Aorta https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1571694372549-OIOFQGGP6V2E78GY675D/Screen+Shot+2019-10-21+at+2.45.32+PM.png Sonobite: Aorta https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1571694379391-L7G1Y7KUWHQZ1SDYQUBS/Screen+Shot+2019-10-21+at+2.45.49+PM.png Sonobite: Aorta https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1571694379206-DSLR2S41QXYHAU06KY0F/Screen+Shot+2019-10-21+at+2.45.40+PM.png Sonobite: Aorta https://www.thepocusatlas.com/donate daily 0.75 2020-03-16 https://www.thepocusatlas.com/images-of-rv-diastolic-collapse daily 0.75 2019-12-28 https://www.thepocusatlas.com/bb-msk daily 0.75 2020-01-21 https://www.thepocusatlas.com/bb-biliary daily 0.75 2020-01-21 https://www.thepocusatlas.com/dhbetacalc daily 0.75 2020-02-03 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1580739567810-OH1C4O8UIWEKYIQNS0Z7/dh+hs-ctn+algorithim dhbetacalc The Algorithm the Calculator is based off of. https://www.thepocusatlas.com/new-page-1 daily 0.75 2020-03-07 https://www.thepocusatlas.com/covid19 daily 0.75 2021-02-20 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584929730621-S6ALYXTTOYYK9C11PX7O/Screen+Shot+2020-03-22+at+20.03.32.png COVID-19 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584901409902-WFGVHGPV29JVDAV97LMU/Untitled-1-01.png COVID-19 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585763908773-JX5LNO2FKXG590E20AOY/Screen+Shot+2020-04-01+at+11.39.31.png COVID-19 - Denver Health COVID US https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585763918129-V0TZS6KQ772REW3H8KEU/Screen+Shot+2020-04-01+at+11.39.21.png COVID-19 - Denver Health COVID US lung https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1585018288363-SYXQMAHMOER15Z51WSP9/CT+GIF_optimized.gif COVID-19 Chest CT Findings in COVID-19 In a study by Ai et al (n=1014), chest CT was compared to RT-PCR for the diagnosis of COVID-19. Characteristic findings on CT included ground-glass opacities, multifocal patchy consolidation, and/or interstitial changes with a peripheral distribution. In patients with a positive RT-PCR, characteristic findings on chest CT demonstrated a sensitivity of 97% and specificity of 25%. In a small subset of patients with serial RT-PCR performed (initial negative followed by positive result) a positive chest CT was present PRIOR to the positive RT-PCR. Link Image Courtesy of Dr. Marco Garrone (@drmarcogarrone) https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1584900652775-FKWX0F4R6X5KVIZ25LKX/image-asset.png COVID-19 https://www.thepocusatlas.com/ob-dating-atlas-1 daily 0.75 2021-04-21 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1594571248472-8KDT4QLX6DT1CNLN6LUQ/Screen+Shot+2020-07-12+at+9.26.58+AM.png OB Dating Atlas Fetal biometric markers used to assess gestational age and their accuracy based on trimester. [1,2,3] https://www.thepocusatlas.com/about daily 0.75 2024-08-07 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1629723050564-5ZGGRRXC6CID6Q70YON3/image-asset.png About - Denver Emergency Ultrasound https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572990143522-9YC5MJATGKTWNLCGT9TU/sonoclipshare.png About https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1572990261212-PTXX2WN2W8T7CWW9TGK6/sonogif.png About https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1568231330223-RUP3N3UY4S7TN6F59CCR/B%26Bblack-12.png About https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1698781872362-LTCJD9JT005WH32PZ7MY/5minsono.jpg About https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968268719-5U7HWIKEIN3NKFD06QPI/broomedocs.jpg About https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968788678-HUD5E7ENFUQ5MSVN7Y9P/emgus.jpeg About https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968304446-RHTOZCQ4ZZ9GTAENE8ZX/neum.png About https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968350842-WEIKU906YX3CW2YVJ7JN/ultrasoundpodcast.png About https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968389698-615IM80CFJ3RX4SV4NAM/ddxof.png About https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1522968273153-KO1W9CDMRH3RRODEISW0/GEL+icon.jpeg About https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527819174234-8AOY6XQ4RC74K0S2Y45A/UCSD+Website+Logo+Design-45.png About https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1563378934041-G4PQ8BIAUBIST583Z4NT/EGLS+Logo.png About https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1592942995045-ZJN2OXNHPPHMY94PH8Q6/image-asset.png About - Visible Voices https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1612639768052-R3TKV3IWEJTS69MJOFPW/image-asset.png About - Wiki EM https://www.thepocusatlas.com/quiz-testing daily 0.75 2020-08-06 https://www.thepocusatlas.com/shock daily 0.75 2025-01-16 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1600392768992-9U17XDV20MSXS28KHZII/Screen+Shot+2020-09-17+at+6.32.31+PM.png RUSH: Undifferentiated Hypotension Scanning Locations and Probe Orientation for the RUSH Exam https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1599511741921-CVYZNCEQB1AC2V8Q5VBN/V2.%2BColored%2BUltrasound%2BProtocol%2Bin%2BShock.jpg RUSH: Undifferentiated Hypotension Algorithmic Approach to Utilizing the RUSH Exam https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1598400642532-HB4BJVQBB0KXBGEIXR8K/Screen+Shot+2020-08-25+at+5.09.58+PM.png RUSH: Undifferentiated Hypotension https://www.thepocusatlas.com/fixed-scroll-testing daily 0.75 2020-08-01 https://www.thepocusatlas.com/sidebar daily 0.75 2020-09-02 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1596821216344-1G753Q58M35NLDYJK2B3/RUSH+logo-31.png Sidebar https://www.thepocusatlas.com/mobile daily 0.75 2020-10-17 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1602953120004-LMLR6C1SWZABD8GBX0YN/Screen+Shot+2020-10-16+at+9.36.13+AM.png Mobile Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1596912275846-000KK839MHVYW27G0BVI/noun_Search_797713.png Mobile Home https://www.thepocusatlas.com/hepatobiliary-1 daily 0.75 2022-02-18 https://www.thepocusatlas.com/sidebar-nerve-blocks daily 0.75 2025-08-18 https://www.thepocusatlas.com/brachial-plexus daily 0.75 2021-10-10 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628025913327-FKUYANBRS3FETGR5NTPV/Interscalene%2BProbe.jpg Brachial Plexus Upper Extremity Nerve Blocks Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630087467908-YWPKE3INE1SNFQUUMBO8/noun_Target_4189997.png Brachial Plexus Upper Extremity Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630187142792-J0C5WMMMOPVV9E6USQ2U/Interscalene_blank-07.png Brachial Plexus Upper Extremity Nerve Blocks Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630187142986-J10ONMH3WG9O7KI9YBK1/Interscalene-04-04.png Brachial Plexus Upper Extremity Nerve Blocks Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630689690732-JTH6B927CJEVRTU703PX/IMG_0496.jpg Brachial Plexus Upper Extremity Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630176446204-1X0KMTUBNRFVF3ABOUHS/noun_Target_4189997.png Brachial Plexus Upper Extremity Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630187311729-N2V606TUTXMSPWJZ4GUY/Supraclavicular_blank-08.png Brachial Plexus Upper Extremity Nerve Blocks Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630187311826-QEV964CYDHMXHPK4DLO1/Supraclavicular-03-03.png Brachial Plexus Upper Extremity Nerve Blocks Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630689755533-EPRAV3HLR4BJVCQMZBLK/IMG_0502.jpg Brachial Plexus Upper Extremity Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630092711967-J33H4SO4L7XE78HVKBLS/noun_Target_4189997.png Brachial Plexus Upper Extremity Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630185147681-K2IJ3X0TJES5E2WIO35W/Infraclavicular_blank-06.png Brachial Plexus Upper Extremity Nerve Blocks Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1630185147839-4XUV5C898WPTMJO6WKAM/Infraclavicular-05-05.png Brachial Plexus Upper Extremity Nerve Blocks Image Atlas https://www.thepocusatlas.com/aorta1 daily 0.75 2023-04-05 https://www.thepocusatlas.com/gastrointestinal daily 0.75 2025-04-29 https://www.thepocusatlas.com/softtissue-2 daily 0.75 2021-11-18 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1612291422235-99SW73A5NP4J69X0BPNM/ezgif.com-gif-maker+%289%29.gif Soft Tissue - Soft Tissue Layers Color overlay demonstrating the normal layers of soft tissue. https://www.thepocusatlas.com/trauma-atlas daily 0.75 2024-01-11 https://www.thepocusatlas.com/pulmonary daily 0.75 2023-04-24 https://www.thepocusatlas.com/thoracoabdominal-blocks daily 0.75 2022-02-22 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628447243417-AKNLY3Z14H8IFI3EBZ46/Serratus+Anterior+Probe+2.jpg Thoracoabdominal Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628447743718-RFGYMS49BGSNSPMPO4AR/Erector+Spinae+Probe.jpg Thoracoabdominal Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.thepocusatlas.com/lower-extremity-blocks daily 0.75 2023-11-16 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628025895030-GM727ZB1MOUVOSMEE60U/Fascia+Iliaca+Probe.jpg Lower Extremity Nerve Blocks Image Atlas - General Positioning With the patient supine, place the probe in a transverse orientation just inferior to the inguinal crease, in the medial third of the inguinal crease. Identify the femoral artery with the nerve just lateral to it. Laterally, identify the iliacus muscle, with the sartorius muscle superior to this. The fascial plane between these muscles which surrounds the femoral nerve is the fascia iliaca. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1abdb799-f2bf-4069-a090-96da42156eeb/Positioning+2.jpg Lower Extremity Nerve Blocks Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628027114162-ZDEP314DBUHW659AW00W/Popliteal+Sciatic+Probe.jpg Lower Extremity Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628028497732-8VO2US87CNIHU6K9C3VB/Common+Peroneal+Probe.jpg Lower Extremity Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628029477082-GKBF90OQW7I02IY7EIHH/Posterior+Tibial+Probe.jpg Lower Extremity Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.thepocusatlas.com/forearm-blocks daily 0.75 2022-01-23 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632504965717-BYI8MUJMZA2I0LNIU29U/Radial%2BProbe.jpeg Forearm Nerve Blocks Image Atlas - General Positioning The patient shoul https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632505157508-ZQY1Z9C1JDFSES9WPES2/noun_Target_4189997.png Forearm Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632507466834-AQSGAQPP0DU6IQEZNI47/Median-09.png Forearm Nerve Blocks Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632507466680-2GPLS2YIYBLWHIN3M631/Median-10.png Forearm Nerve Blocks Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/da425307-171c-46de-8669-44fe8e8cb6e4/Nerve+Block+Sono+Anatomy-23.png Forearm Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628450153685-9ILS9SU8N0WMATT3DLQB/Radial+Probe.jpg Forearm Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632505157508-ZQY1Z9C1JDFSES9WPES2/noun_Target_4189997.png Forearm Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638717627721-M78K14BTC0PGVV7TMXV3/Forearm_Radial-21.png Forearm Nerve Blocks Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1638717627802-OHZPXTEMDRJAQE2HR83P/Forearm_Radial-22.png Forearm Nerve Blocks Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/5749546c-b010-476f-905a-67937daf7e7b/Nerve+Block+Sono+Anatomy-24.png Forearm Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628450324478-9Y33E79BDZ0YCH660W5B/Radial+Elbow+Probe.jpeg Forearm Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632505157508-ZQY1Z9C1JDFSES9WPES2/noun_Target_4189997.png Forearm Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1642978086567-BXBE2BMTMHJ2A2XAB6IX/Radial+At+Elbow-25.png Forearm Nerve Blocks Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1642978086410-0BZON9Z3DYMKA3JR9R67/Radial+At+Elbow-26.png Forearm Nerve Blocks Image Atlas https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628451373940-6ILXVRYAMGV16HVNQ88D/Ulnar+Probe.jpg Forearm Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1628451548760-QMNT1IGJ1EWEW4SRGGSX/Ulnar+Wrist+Probe.jpeg Forearm Nerve Blocks Image Atlas - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.thepocusatlas.com/nerve-blocks daily 0.75 2025-09-26 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1620268880376-HFPAMKOY54XBBGM0XF4N/DEMSono+logo+final.png Nerve Block Atlas Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632502587658-GM3GW0LETUD3OCQELC1B/Untitled-1-01.png Nerve Block Atlas Home - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1629838392439-6R8Y1IFRKXMDW71NIAZ6/ezgif.com-gif-maker+%2841%29.gif Nerve Block Atlas Home - Interscalene https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632504311950-C84SWIO32E3GJ42YPG6C/ezgif.com-gif-maker+%2872%29.gif Nerve Block Atlas Home - Supraclavicular https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1629838445359-MQD040B6PG6ASH1WCVFF/ezgif.com-gif-maker+%2842%29.gif Nerve Block Atlas Home - Infraclavicular https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632502757049-SUDXPT7K0Z5DVGVVVVLB/Untitled-1-01.png Nerve Block Atlas Home - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1629838709801-R0PZCWI94BH59H95W0E5/ezgif.com-gif-maker+%2845%29.gif Nerve Block Atlas Home - Median https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1629838757539-WK7LL4TXGY8Y37Q3LI3Y/ezgif.com-gif-maker+%2844%29.gif Nerve Block Atlas Home - Radial https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1629838782269-IC9FUVPPBB649XLV5750/ezgif.com-gif-maker+%2847%29.gif Nerve Block Atlas Home - Ulnar https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632502800053-G1M6FI5RICO54WW3J7W5/Untitled-1-02.png Nerve Block Atlas Home - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632500530881-6LPB5CSP87IV8DWYW5UO/ezgif.com-gif-maker+%2863%29.gif Nerve Block Atlas Home - Fascia Iliaca https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1697039712586-SA36FJZ2ZHKCRGH9EVJM/ezgif.com-add-text-2.gif Nerve Block Atlas Home - Transgluteal Sciatic Transgluteal Sciatic https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632500951234-TPTI5Q0L6852L52UPYGL/ezgif.com-gif-maker+%2865%29.gif Nerve Block Atlas Home - Popliteal Sciatic https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632500779592-AIYB82EJTU3BEGME4K78/ezgif.com-gif-maker+%2864%29.gif Nerve Block Atlas Home - Posterior Tibial https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632501075574-4T7J6H1HFMKV36POUJIT/ezgif.com-gif-maker+%2866%29.gif Nerve Block Atlas Home - Peroneal https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632502856204-JA2GQ2J6C86QLST9BK5P/Untitled-1-03.png Nerve Block Atlas Home - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632501634902-EV6CYYYSHWT4CMAINA6B/ezgif.com-gif-maker+%2867%29.gif Nerve Block Atlas Home - Serratus Anterior https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1632501689723-FGMMDOZIJRJ3Q21DI3NQ/ezgif.com-gif-maker+%2868%29.gif Nerve Block Atlas Home - Erector Spinae https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1605816438963-MCHHR8HBK9NVTL1M9CXH/Anatomy+Superficial+Cervical+Plexus.gif Nerve Block Atlas Home - Superficial Cervical Plexus https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/36418e8b-c197-4988-9e35-30649d6de6fc/Untitled-reverse-04.jpg Nerve Block Atlas Home - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.thepocusatlas.com/ocular-atlas daily 0.75 2021-11-18 https://www.thepocusatlas.com/vascular daily 0.75 2023-01-24 https://www.thepocusatlas.com/musculoskeletal daily 0.75 2024-11-24 https://www.thepocusatlas.com/renal-gu daily 0.75 2023-02-26 https://www.thepocusatlas.com/ob-gyn-atlas daily 0.75 2022-02-18 https://www.thepocusatlas.com/superficial-cervical-plexus daily 0.75 2021-09-03 https://www.thepocusatlas.com/sidebar-msk-atlas daily 0.75 2023-09-07 https://www.thepocusatlas.com/home-3 daily 0.75 2021-08-23 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1527746673149-K9M1EYEJW8RMBPT4N14F/The+POCUS+ATLAS-26.png Nerve Block Atlas Home https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501183594226-6M4TQ5B6JHQ2JRFGZLD3/image-asset.gif Nerve Block Atlas Home - Aorta https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501183613544-F155WFSANMH2VA5RLLLT/image-asset.gif Nerve Block Atlas Home - Echocardiography https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501183721400-YUZ0VO71JMQ4AHB0S2N6/image-asset.gif Nerve Block Atlas Home - GI https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501183785625-H8U4JZYUBGUFY90A4190/image-asset.gif Nerve Block Atlas Home - Hepatobiliary https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501217418314-T14TNFL32FYB7FW30OLI/image-asset.gif Nerve Block Atlas Home - MSK + Procedures https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501216798646-6ZGNU2ZAV09QBXISDZ7F/image-asset.gif Nerve Block Atlas Home - OB-GYN https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501216697451-W4E0Y65TFYQJFXXR7SY1/image-asset.gif Nerve Block Atlas Home - Ocular https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1501217241115-A9TRV6RS92R1CDG2ZEEU/image-asset.gif Nerve Block Atlas Home - 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Vascular https://www.thepocusatlas.com/msk-jr daily 0.75 2026-01-20 https://www.thepocusatlas.com/adult-jr-transfer-page daily 0.75 2023-06-28 https://www.thepocusatlas.com/msk-knee daily 0.75 2023-09-08 https://www.thepocusatlas.com/aeus-submit daily 0.75 2023-11-14 https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/d75d7fab-ca6b-4e7c-a221-dd68fffc78cd/aeus+raw.png AEUS Innovation Competition Submissions - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/3dbd1bdf-fe02-48c7-ad4a-f7b5b2c58f3f/iStock-1433768833-2.jpg AEUS Innovation Competition Submissions - Want to disrupt ultrasound? 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