Q: 3. eFAST. AAA. - Case 1

Case 1 97 y.o. female from aged care presents with Abdominal pain and hypotension. NH staff discussed with family, who wished for patient to be transferred to hospital On arrival SBP 60. POCUS done by ED Physician on arrival. Image 1 . AAA Trans view. Large 8.7cm AAA with mural thrombus. Some retroperitoneal free fluid is seen on the image too on the left of the screen. Image 2 . AAA Trans view 2. On this image you see the fluid-filled lumen is < 3cm, with a large mural thrombus. This is a great example of why you should always look and measure outer wall to outer wall. Immediate management priorities changed- for comfort measures only, medications charted PRN. Patient passed away a few hours later with family present. RIP. Utility of POCUS This example shows how a rapid diagnosis with POCUS can be used to help in the holistic care of the patient. A decision was made for palliation and changing the priority to optimising patient comfort, avoiding unnecessary IV access and formal imaging. Learning Points In patients with suspected AAA, only roughly 50% have the classic triad of hypotension, back pain and pulsatile abdominal mass. ED bedside US has been shown to have up to 99% sensitivity for diagnosing AAA in minutes. https://pubmed.ncbi.nlm.nih.gov/23406071/ And once more- beware the subtle mural thrombus!

Q: 5. Lung - Case 2

Case 2 88 y.o. female BIBA sudden onset SOB at home. Hx COPD and IHD. Transferred in on CPAP. SpO2 94%, HR 85 Lung POCUS Right Anterior Superior View- Video. Lung sliding present. Diffuse confluent B-Lines. This B-Line pattern was present in bilateral superior and inferior lung zones, in keeping with Acute Pulmonary Oedema. Utility of POCUS This patient had a rapid CXR showing features of APO. But in the patient with undifferentiated dyspnoea who arrives on CPAP, POCUS can help to rapidly aid your treatment decisions – e.g. APO vs exac COAD. In some cases the diagnoses might not be clear. Treatment decisions RE: inhalers/steroids vs nitrates/diuresis can be made in a couple of minutes. Learning Points Please review the Lung ED Resource attached and look at the flowchart: Diffuse bilateral B-Lines are most commonly only seen in APO, and not usually present in COAD, which has an A-Line profile (horizontal lines). You can get bilateral B-Lines in interstitial pneumonitis, and in pulmonary fibrosis but there often has to be quite a significant exacerbation with “wet chest”.

Q: 10. GB. eFAST. - Case 2

Case 2. 26 y.o. male trauma call Found lying in the driveway after possible MVA initial vitals: HR 80, SBP 120, altered conscious state. POCUS EFAST done by ED Doctor Image 1. LUQ View- Positive. Large volume perisplenic free fluid seen. The patient was intubated soon afterwards. A CT revealed a grade 3 liver laceration and grade 2 splenic injury. The patient became hypotensive in ED despite 2x units PRBCs, and decision was made to take the patient to OR in Bendigo prior to transfer to a major trauma centre. Utility of POCUS POCUS eFAST in trauma is most beneficial in haemodynamically unstable patients who are unable to get to the CT scanner. However a positive eFAST (such as in this case) helped with an early diagnosis of intra-abdominal bleeding, and expedited imaging, plans for emergency packing and transfer. Learning Points Review the EFAST ED Resource and positive POCUS findings in trauma eFAST (pneumothorax/ haemothorax/ free fluid/ haemopericardium). When assessing the LUQ view, ensure to visualise the spleno-diaphragmatic space and perisplenic areas. As in this case, assessing the spleno-renal fossa alone can be falsely negative.

Question 1

1. eFAST. RUSH protocol - Case No. 1

Accepted Answer

Case No. 1 – positive eFAST in Ectopic

23 y.o. G4P1

Presented with abdominal pain and PV bleeding ?ectopic
Obs stable
Bloods sent, formal USS booked, Discussed with O+G- not wanting to come and see the patient pre USS
ED POCUS done after formal USS for teaching purposes

Image 1 – PELVIS LONG view. Significant amount of free fluid in pouch of Douglas (between the rectum and posterior wall of uterus)

Image 2 – PELVIS TRANS. Free fluid seen here between the base of the uterus and the rectum

Image 3- RUQ view. Unfortunately image with kidney in view not saved, but sliver of free fluid in Morrison’s pouch on inferior margin of liver

The patient’s formal Ultrasound was reported as:
“Findings are consistent with a left tubal ectopic pregnancy with rupture”
Serum BetaHCG 889

She was subsequently seen by O+G, and went to theatre where she underwent a laparoscopic L salpingectomy, finding a necrotic L fallopian tube and EBL 600mls. Discharged home the following day.

Utility of POCUS
eFAST is mainly used in trauma assessment, but it is also useful in suspected ectopics.

As with all diagnostic POCUS, the goal is to expedite diagnosis, management and disposition. It does not replace the need for a formal ultrasound. In this case, a quick positive eFAST within a few minutes can help you advocate for your patient’s management by reducing the time to diagnosis and management.
E.g. call O+G and say: “I have a patient with a history and examination consistent with a ruptured ectopic. She has a large amount of free fluid in her pelvis on my bedside ultrasound. I’ve booked a formal USS, but can you come when you can because I think she’ll need theatre.”

Learning Points
In the suspected ectopic patient: Free fluid in Morrison’s Pouch has been shown in some studies to have up to 99.5% Specificity for ruptured ectopic requiring surgical intervention, and 94% Specificity with fluid in Pelvic view.

https://www.thennt.com/lr/pocus-atlas-free-fluid-fast-ectopic-pregnancy-requiring/

The amount of free fluid in positive eFAST POCUS is debated in emergency medicine literature. Most sources report that positive eFAST indicates a minimum of 50ml-500ml free fluid, which is operator dependent. In this case, the large amount of free fluid seen would definitely suggest > 500ml free fluid.

https://link.springer.com/article/10.1007/s003300050861

https://radiopaedia.org/articles/focussed-assessment-with-sonography-for-trauma-fast-scan

Question 2

1. eFAST. RUSH protocol - Case No. 2

Accepted Answer

Case No. 2 – Undifferentiated Shock

A very complex case shared at M+M last week. Thank you Maz, and everyone who cared for the patient. No POCUS images, shared for learning points.

89 y.o. male presented with ?blocked IDC, urinary retention, confusion, then hypotension.

Treated as pneumonia after reviewing CXR (Image 4). CXR was reported as collapse/ consolidation of left lower lobe consistent with infection
Patient subsequently went for CT (image 5) showing a Type A aortic dissection with a large haemorrhagic pericardial effusion. No consolidation/ infection noted.

Patient passed away in ED. RIP.

Utility of POCUS
In this very difficult case, POCUS would not change the patient’s outcome. But it highlights that Lung ultrasound is more sensitive and specific than Chest X-Ray for lung pathology. Note how you can’t really see anything behind the white-out of the left lower lung. This case also lets us consider a protocol of POCUS for unexplained hypotension.

Even if we’re not skilled at identifying aortic dissection flaps, or enlarged aortic roots, or in doing a full lung/ echo scan, a probe placed over this patient’s heart would have identified a very large pericardial effusion.

Learning Points

The Rush Exam Protocol is one method of assessing differentials of shock. It can be remembered using the pneumonia HIMAP (+/- ED)

Heart- Pericardial Effusion/ Tamponade, signs of PE, global LV function

IVC- estimate volume status, assessment of cardiac tamponade

Morrison’s- eFAST exam for free fluid

Aorta- AAA

Pulmonary- Pneumothorax

(E- Ectopic, D- DVT)

I can go through this in person, and will review this again thoroughly in the future.

https://www.pocus.org/resources/rush-exam-protocol/

https://emcrit.org/rush-exam/original-rush-article/

Question 3

2. FELS. DVT.

Accepted Answer

Code Blue Thursday evening 01:00.
Vanessa’s patient, with myself and Neil

75y.o. male
Code blue in Resp Triage-
Peri-arrest episode of unresponsiveness with bradycardia- ventricular escape rhythm 35bpm, patient pale and diaphoretic.
No CPR required. Self-resolved. Resp precautions removed and moved immediately to resus.
Background- Presented with CP and SOBOE 6/7. Worse today, so wife called AV.

GCS improved to 15, SpO2 94% on 2L NP, HR 65, BP 178/95.

ECG- SR 60bpm, unremarkable. No sign of obvious ischaemia/ right heart strain

VBG- pH 7.36, CO2 44, Lactate 2.2

FELS (focussed echo in life support) POCUS done to determine cause of chest pain and peri-arrest

(Technically difficult as very obese patient)

Apical 4 Chamber View (see File 1)
Dilated Right Ventricle with McConnell’s Sign- suspicious for acute PE.

Note- how the right ventricle is almost equal in size to the left ventricle. It should be <2/3 the size in normal patients. So this is markedly dilated.
McConnell’s sign- Akinesia of the mid free wall of the right ventricle with hyper-contractility at the apical wall. This is considered a specific sign for acute PE.

FELS DVT (see File 2)

L Femoral Vein DVT

Note- On compression, the L Femoral Vein isn’t compressible. (vein on right hand side of image, artery on left. Both non-compressible)

Patient was stable enough to go for a CTPA-
Confirming a massive saddle pulmonary embolus extending bilaterally.

He was treated the therapeutic clexane and admitted to ICU.

Inpatient Echo confirmed- Dilated RV with systolic dysfunction and severely elevated pulmonary artery pressure. And inpatient Venous Doppler USS confirmed bilateral DVTs.

Utility of POCUS
In this instance, POCUS helps with early diagnosis and management planning.
The patient wasn’t tachycardic, or hypotensive, and didn’t have an ECG showing features of right heart strain. There were many differentials for his bradycardic peri-arrest episode. PE certainly wasn’t top of my list.
Thankfully, the patient stabilised without treatment.
However, based on the POCUS findings- if he became unstable, or arrested, this would be an indication to initiate thrombolysis immediately. And the POCUS findings would make you consider giving anti-coagulation, and have thrombolysis nearby.

Learning Points
In the unstable patient with chest pain, consider POCUS FELS to look for signs of:
Massive PE, Cardiac Tamponade, Cardiogenic Shock.
If considering PE, a POCUS DVT scan help add more data to confirm the suspicion.

Here is a good recent LITFL article on FELS in PE:
https://litfl.com/bedside-echo-in-pulmonary-embolism/

Question 4

3. eFAST. AAA. - Case 1

Accepted Answer

Case 1
97 y.o. female from aged care presents with Abdominal pain and hypotension.
NH staff discussed with family, who wished for patient to be transferred to hospital

On arrival SBP 60. POCUS done by ED Physician on arrival.

Image 1. AAA Trans view. Large 8.7cm AAA with mural thrombus. Some retroperitoneal free fluid is seen on the image too on the left of the screen.

Image 2. AAA Trans view 2. On this image you see the fluid-filled lumen is < 3cm, with a large mural thrombus. This is a great example of why you should always look and measure outer wall to outer wall.

Immediate management priorities changed- for comfort measures only, medications charted PRN. Patient passed away a few hours later with family present. RIP.

Utility of POCUS
This example shows how a rapid diagnosis with POCUS can be used to help in the holistic care of the patient. A decision was made for palliation and changing the priority to optimising patient comfort, avoiding unnecessary IV access and formal imaging.

Learning Points

In patients with suspected AAA, only roughly 50% have the classic triad of hypotension, back pain and pulsatile abdominal mass. ED bedside US has been shown to have up to 99% sensitivity for diagnosing AAA in minutes.

https://pubmed.ncbi.nlm.nih.gov/23406071/

And once more- beware the subtle mural thrombus!

Question 5

3. eFAST. AAA - Case 2

Accepted Answer

Case 2
49 y.o. female
Presented with L flank pain. Initial diagnosis ?renal colic. CTKUB initially reported as normal.
Bloods and obs unremarkable, ongoing severe pain requiring morphine.
Reviewed by myself and POCUS eFAST:

Video 1. PELVIS view. Small video clip showing free fluid above the bladder and in Pouch of Douglas. eFAST +ve

Review of CTKUB image- free fluid seen. D/W Radiologist and patient booked for repeat CT Abdomen with PV phase contrast to further evaluate:
Grade 3 Splenic Laceration identified.
Hx revisited- possible assault 1/52 earlier not initially described.
Patient was admitted, with subsequent haemodynamic instability and underwent a successful laparoscopic Splenectomy the next day.

Utility of POCUS
In this case with diagnostic uncertainty, and ongoing severe symptoms, FAST was used as an extra investigative tool to further evaluate the cause of pain. Although FAST scans were initially validated as a tool in hypotensive trauma in the 1970s, the use of FAST is expanding. It is now recognised in other settings, such as recognising the need for operative intervention in ectopic pregnancy, and in the RUSH protocol for undifferentiated hypotension. This is an example of the use of FAST as a simple, quick, bedside investigation in non-traumatic abdominal pain to look for free fluid. AAA is another POCUS scan that could have been useful here.

Learning Points

Be aware of the use and limitations of eFAST.
This thorough online article is dense, but goes through a lot about the evolution of eFAST and its uses and limitations:
https://pubs.rsna.org/doi/full/10.1148/radiol.2017160107

Question 6

3. eFAST. AAA - Case 3

Accepted Answer

Case 3

41 y.o. male
L1 Trauma call. High Speed MVA. Peri-arrest at scene. R Tension PTx decompressed
Tachycardic on arrival. Initial eFAST negative

Image 3. RUQ view. No obv free fluid

CT Trauma Series- initial verbal report Abdomen NAD
Patient deteriorated, hypotensive with repeat eFAST positive. Repeat L1 Trauma call made.

Image 4. Repeat RUQ view- free fluid in Morrison’s pouch

Review of CT found R lobe liver contusion with capsular tear and mesenteric laceration.

Patient transferred to theatre at Bendigo for emergency laparotomy and packing- 1L estimated blood loss in abdomen. Patient was subsequently transferred to the Alfred.

Utility of POCUS
Repeat eFAST when trauma patients deteriorate is very useful for checking for progression of intra-abdominal and intra-thoracic injuries. In the unstable patient not responding to MTP resuscitation (such as this example)- we were able to rapidly change the plan from: transfer the patient, to emergency theatre at Bendigo.

Learning Points

eFAST is quick and repeatable! One of its great advantages.

Here’s a couple of unrelated learning points on eFAST generally:

A common misconception is that LUQ free fluid is most commonly seen between the spleen and the kidney. In the supine patient, studies have shown more likelihood of seeing subphrenic fluid or paracolic gutter fluid in the LUQ. This article has a good diagram showing all 3 areas of LUQ free fluid:
https://www.ultrasoundgel.org/posts/Sc2AW3cdMhfZKmhuiGSq6w

An interesting research article about the use of eFAST in stable trauma patients who will need whole body CT, as part of an algorithm to reduce unnecessary portable CXR and Pelvic X-Rays:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4940356/

Question 7

5. Lung - Case 1

Accepted Answer

Case 1

78 y.o. female

Met call from CT guided lung biopsy as outpatient with SBP 85 after L lower lesion lung biopsy. New hypoxia- put on Hudson mask 10L/min, SpO2 95%. Transferred to ED from Radiology for review.

Portable CXR done in Resus - No obvious pneumothorax.

POCUS Lung done in ED Resus - Video.

Lung POCUS L Anterior Superior view. Clear pleural lung sliding on image right, which doesn’t continue across the pleura. No lung sliding on image left. This is a lung point with absent pleural sliding, confirming a pneumothorax.

Lung POCUS L Anterior Superior view. M-mode confirming a lung point with barcode sign on the image left (pneumothorax), and seashore sign on image right (normal lung sliding.)

Patient went on to have a CT- Confirming a small left sided pneumothorax and pleural effusion.

The patient was admitted under AMU. AGSU involvement in case of pneumothorax enlargement, but was treated conservatively. Discharged home a couple of days later.

Utility of POCUS

This patient was managed conservatively. And was probably always going to get a CT Chest to further evaluate. However the time to diagnosis of a post-biopsy pneumothorax was rapidly reduced with POCUS. This is useful information in a rapidly deteriorating patient. It prepares us in case decompression of the left chest is needed. It is also important to know in case the patient might need intubation and positive pressure ventilation.

Learning Points

Lung Point- pretty much has a specificity of 100% for ruling in pneumothorax!
https://pubmed.ncbi.nlm.nih.gov/11126253/

It correlates to the area of the lung where the pneumothorax starts, and excludes most other causes of absent lung sliding (which are diffuse). However, it has a low sensitivity as it can be hard to find and isn’t present in a complete pneumothorax. You only need: absent lung sliding/exclusive horizontal lines/ bar code sign to diagnosis a likely pneumothorax. My advice is don’t go wasting too much time looking for a lung point, but if you see a lung point the diagnosis is clear.

Many studies confirm time and again that POCUS Lung is far more accurate than a CXR for diagnosing pneumothorax, as in this case.
https://www.ncbi.nlm.nih.go/pmc/articles/PMC4386013/

Question 8

5. Lung - Case 2

Accepted Answer

Case 2

88 y.o. female

BIBA sudden onset SOB at home. Hx COPD and IHD.
Transferred in on CPAP. SpO2 94%, HR 85

Lung POCUS Right Anterior Superior View- Video. Lung sliding present. Diffuse confluent B-Lines.

This B-Line pattern was present in bilateral superior and inferior lung zones, in keeping with Acute Pulmonary Oedema.

Utility of POCUS

This patient had a rapid CXR showing features of APO. But in the patient with undifferentiated dyspnoea who arrives on CPAP, POCUS can help to rapidly aid your treatment decisions – e.g. APO vs exac COAD. In some cases the diagnoses might not be clear. Treatment decisions RE: inhalers/steroids vs nitrates/diuresis can be made in a couple of minutes.

Learning Points

Please review the Lung ED Resource attached and look at the flowchart:
Diffuse bilateral B-Lines are most commonly only seen in APO, and not usually present in COAD, which has an A-Line profile (horizontal lines). You can get bilateral B-Lines in interstitial pneumonitis, and in pulmonary fibrosis but there often has to be quite a significant exacerbation with “wet chest”.

Question 9

6. FELS. eFAST. Abdo - Case 1

Accepted Answer

Case 1

50 y.o. male
Background of recent diagnosis metastatic non-small cell lung cancer. Referred to ED after staging scans revealed new pericardial effusion and right pleural effusion. Recent shortness of breath, ET reduced to 20m. On arrival SpO2 93% OA, HR 90, BP 125/80. GOC A.

POCUS FELS (Focussed Echo in Life Support) done in ED Cubicle-
Video 1. FELS POCUS Subxiphoid view. Moderate pericardial effusion. (1-2cm moderate. <1cm small, >2cm large). Global cardiac function normal, and normal chamber sizes.

Video 2. FELS POCUS Subxiphoid IVC view. IVC <2cm and collapsing (>50% variability with inspiration)

Pt was admitted under Oncology with surgical review. The following day had a drop in BP Met call on the ward. Formal TTE- Moderate Pericardial effusion with early features of cardiac tamponade, suggest clinical correlation. Pt underwent an open subxiphoid pericardiocentesis in theatre and was discharged home 2 days later.

Utility of POCUS

Cardiac Tamponade is a clinical diagnosis. However, Ultrasonographic findings of Cardiac Tamponade can really help add information as to whether a patient requires an emergency pericardiocentesis. It can also be used to do an US-guided pericardiocentesis.

In this case, the patient was clinically stable without obvious features of cardiac tamponade on echo. However, it allowed a plan to be made and preparation with equipment nearby in case the patient deteriorated during the shift.

Learning Points

Look at This Video again. Ultrasonographic features of Cardiac Tamponade include: RV Diastolic collapse, Swinging heart and Dilated IVC. If you pause the image (which you can do on the Sonosite machines too) at the point the TV and MV open i.e. early diastole, you will see the RV is not collapsed/ squashed. There is minimal swinging and no fixed, dilated IVC. You don’t need all the features to diagnose tamponade, but in a stable patient there isn’t enough to call this pericardial tamponade (see FELS ED Resource attached).

Having to do an emergency pericardiocentesis in ED is not common. One method described is the US-Guided In-Plane Parasternal Long approach. This would probably be my got to. Here’s an interesting video showing this (please excuse the terrible music and animation):
https://emin5.com/2016/07/11/pericardiocentesis/

Question 10

6. FELS. eFAST. Abdo - Case 2

Accepted Answer

Case 2
25 y.o. female
Pt presents with RIF pain and PV bleeding for 2/52. LMP 2/12 ago. SBP on arrival 70.
Emergency resuscitation with O negative blood. BetaHCG blood drop on BetaHCG urine strip- positive.

POCUS eFAST done in Resus

eFAST POCUS RUQ view. Positive. Free fluid in Morrison’s Pouch between the liver and kidney.

Pt went quickly to the OR and underwent a successful emergency salpingectomy for ectopic pregnancy with 1.7L intra-peritoneal blood and was discharged home the following evening.

Utility of POCUS

I think the ED and inpatient team’s management and rapid disposition was outstanding in this case. A rapid diagnosis was made through BHCG and positive eFAST, while concurrently resuscitating the patient. The POCUS findings rapidly confirm the suspected diagnosis and give information that can be used within seconds to expedite a transfer to the OR without a formal Ultrasound.

Learning Points

In the suspected ectopic patient: Free fluid in Morrison’s Pouch has been shown in some studies to have up to 99.5% Specificity for ruptured ectopic requiring surgical intervention, and 94% Specificity with fluid in Pelvic view.
https://www.thennt.com/lr/pocus-atlas-free-fluid-fast-ectopic-pregnancy-requiring/

The amount of free fluid in positive eFAST POCUS is debated in emergency medicine literature. Most sources report that positive eFAST indicates a minimum of 50ml-500ml free fluid, which is operator dependent. In this case, the large amount of free fluid seen would definitely suggest > 500ml free fluid.
https://link.springer.com/article/10.1007/s003300050861

https://radiopaedia.org/articles/focussed-assessment-with-sonography-for-trauma-fast-scan

Question 11

6. FELS. eFAST. Abdo - Case 3

Accepted Answer

Case 3

85 y.o. female presents with SOBOE. Reduced ET over 1 month, no weight loss but not eaten in the last few days. From home independent. Obs unremarkable. Examination unremarkable except mild abdominal tenderness and lump felt in the abdomen.

Abdominal POCUS. Trans view at Pelvic level. Showing some superficial free fluid and hyperechoic mass with acoustic shadowing.

CT Abdomen confirmed a new diagnosis of 6cm primary colon cancer with extensive metastases to the liver. Patient was admitted for an inpatient colonoscopy confirming metastatic colon carcinoma. Discussion with patient resulted in a decision for conservative management. The pt was admitted under GEM, where she began to deteriorate. Her daughter was given exemption to fly in from Queensland and was present during her last days before the patient passed away. RIP.

Utility of POCUS

This case is mainly for interest purposes and POCUS for abdominal lumps is not expected at ED level. You could also argue that perhaps further investigation could have been done as an outpatient. The finding of a mass on ultrasound simply expedited getting the patient’s diagnosis.

Learning Points

Before doing Ultrasound to assess abdomen and lumps, make sure you learn the 5 ACEM recommended POCUS Exams- eFAST/ AAA/ Lung/ FELS/ US guided IV access. And then get practice looking at normal bowel in ultrasound. Structures like this with acoustic shadowing can occur with dense abdominal matter e.g. gallstones and faecoliths. However cancerous mass fitted best with this clinical picture and the ultrasound image. Normal bowel on ultrasound is usually less hyperechoic, and more grainy and indiscrete.
https://radiopaedia.org/cases/small-bowel-ultrasound-4

Question 12

7. AAA. FELS - Case 1

Accepted Answer

Case 1.

63 yo female present with 2/7 history of sharp thoracic pain radiating to chest and L hand numbness. On arrival HR 65, BP 210/95

CT A- Type B Aortic Dissection radiating from descending thoracic aorta with infarction of L kidney

Bedside POCUS done for interest/ education:

Video 1. AAA POCUS Proximal Trans. Normal Aorta size, no AAA. Intimal flap with pulsatile movement noted in keeping with aortic dissection.

Video 2. AAA POCUS Proximal Trans. Colour doppler showing pulsatile flow through anterior true lumen, and no pulsatile flow in false lumen.

The patient was treated with labetalol infusion, PO Metoprolol and Amlodipine and transferred by ARV to RMH.

Utility of POCUS
Here POCUS was done after diagnosis for educational purposes. Remember that POCUS isn’t sensitive enough to confidently rule out aortic dissection. CTA is the gold standard test. Sensitivities in trained emergency physicians for picking up Aortic Dissection can be as low as 67%, but with a high specificity of 97-100% if findings are seen for Type A Aortic Dissections.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6230344/

Learning Points
In suspected Aortic Dissection, get a CTA asap. If it doesn’t delay CTA, a parasternal long and suprasternal FELS POCUS approach looking for Type A aortic dissection, and then AAA POCUS abdominal aorta ultrasound looking for extension to descending aorta/ Type B aortic dissection can help speed up diagnosis if findings are found. Findings include: intimal flap, dilated aortic root, dilated aorta, pericardial effusion.
This great 4 minute youtube video goes through a systematic way to look for aortic dissection, and positive findings.
https://www.youtube.com/watch?v=Ivrw3M2uJFI

Question 13

7, AAA. FELS - Case 2

Accepted Answer

Case 2.

69 yo female acute onset SOB SpO2 86% OA, RR 28
AZ vaccine 6/7 ago, Wells score = 6.
Bedside POCUS done by Emergency Doctor:

Video 3. FELS POCUS Parasternal Short Axis View PSAX- dilated right ventricle with d-shaped septal bowing.

Video 4. FELS POCUS Apical 4 chamber view APICAL- dilated right ventricle and right atrium, septal bowing, McConnell’s sign (apical hyperkinesis with RV wall hypokinesis)

CTPA-large proximal R) PE, segmental L) PE

Blood results- Platelets 137. The patient was treated after d/w Haematologist with Fundaparinux over Heparin + IVIG due to concern RE: VIPIT (vaccine induced prothrombotic immune thrombocytopaenia) and admitted in Bendigo Hospital.

Utility of POCUS

In the suspected PE patient, POCUS helps with early diagnosis and management planning. Acute right heart strain on Echo in this clinical context suggests a submassive PE as the diagnosis. This patient was stable and managed with anticoagulation however if the patient became unstable or arrested these findings can help in the decision to consider thrombolysis in massive PE.

Learning Points

In the patient with SOB/ chest pain, particularly who is unstable or undifferentiated consider FELS POCUS to look for: submassive or massive PE, cardiac tamponade, cardiogenic shock +/- Lung POCUS.
Please look at FELS ED POCUS (focussed echo in life support) resource sheet, attached and on the Sonosite Exporte machines.
This LITFL article has some good images and a case on FELS in PE:
https://litfl.com/bedside-echo-in-pulmonary-embolism/

Question 14

8. Lung. MSK. - Case 1

Accepted Answer

Case 1

34 y.o.female.
D8 covid positive.
worsening SOB, chest pain, fever.
Temp 38.3, HR 95, SpO2 96 % OA

CXR- Image 1. Report “There is extensive opacity in L mid to lower zone, consistent with pneumonia.”

Lung POCUS done at bedside.
Video 1. Lung POCUS L4 (Left Lateral Inferior). Slightly thickened pleura. Confluent B-line. No consolidation seen.

On discussion with patient, had a cosmetic L breast implant explaining CXR findings!
No Antibiotics given, discharged home with Covid at home monitoring.

Question 15

8. Lung. MSK. - Case 2

Accepted Answer

Case 2.

19 y.o. male
D7 covid positive
fever, SOB, cough.
Temp 39, RR 34, SpO2 98% OA

CXR- Image 2. No obvious consolidation. Reported as unremarkable.

Video 2. Lung POCUS R5 (Right Posterior Superior). Small pleural effusion. Thickened pleura and subpleural consolidation > 1cm in depth.

Patient hypoxic on walk test, admitted to Covid ward.

Utility of POCUS
In case 1, the Lung POCUS findings helped avoid unnecessary antibiotics in case of lobar pneumonia. We know that antibiotics are over-prescribed in Covid. (Image 3.).
In case 2, the patient was flagged as young, healthy and likely home if RR settled. The Lung US findings confirmed lung pathology which can be used as a predictor of bad outcomes. (Image 4.).

Learning Points

We need to be careful to reduce our contact exposure to Covid positive patients and not overuse Lung POCUS. However, if Lung POCUS findings would alter management for the patient, I think lung POCUS may be useful in the following indications:

1. Assessing for Alternative Diagnoses

2. Assessing Covid Severity
3. Intubation

1. In the undifferentiated SOB patient, Lung POCUS can guide management towards APO / Lobar Pneumonia/ P. Effusion/ Pneumothorax.

2. Covid lung pathology often has a characteristic pathological progression beginning in the peripheries with thickened pleura, b-lines and small subpleural consolidations, before spreading superiorly with larger consolidation. This is a prognosis scoring system devised by Dr. Amaali Lokuge at RMH (Image 5.). POCUS features as well as history/exam/vitals can help us decide on disposition and decisions for ventilation therapy.

3. If you have the Ultrasound machine wheeled in and it doesn’t distract from the essentials of trying to secure an airway and CO2 capnography, POCUS can be used on the trachea to assess for oesophageal intubation and lung to rule out mainstem bronchial intubation (Image 6.).

Question 16

8. Lung. MSK. - Case 3

Accepted Answer

Case 3 - Just to avoid a solely Covid email!

29 y.o. male presents with sudden sharp pain back of the heel while running. Thompson test positive.

Bedside POCUS
Image 7. MSK POCUS L Achilles- A ruptured L Achilles tendon, compared to normal appearance on opposite limb.

Patient was placed in an Equinus Splint, discharged with private Orthopaedic follow up.

Utility of POCUS
In some patients physical examination may be limited by pain, or Thompson test might be hard to assess. POCUS can give an immediate diagnosis, particularly when there is no access to formal ultrasound on the same day.

Learning Points

This is not currently in the ACEM Scope of Practice POCUS exams, and there is relatively little research in assessing sensitivity and specificity of ED POCUS in diagnosis of Achilles rupture. There are however many case studies discussing its utility:

https://www.researchgate.net/publication/50398371_Point-of-care_ultrasound_diagnosis_of_acute_Achilles_tendon_rupture_in_the_ED

In Achilles tendinopathy, the Achilles tendon is thickened >1cm at insertion. In Achilles rupture shows separation of the torn ends of the tendon, with acoustic shadowing at the margins of the tear from sound beam refraction. This brief 1-minute video shows how to do MSK POCUS to assess the Achilles Tendon:
https://www.youtube.com/watch?v=s2knTr0e_j0

Question 17

9. Lung. FELS - Case 1

Accepted Answer

Case 1.

47 yo male presents with 24 hours SOB.

PMH: Renal transplant patient
On arrival- SpO2 93% on 6L O2, HR 84, Temp 37.8, BP 183/90
Assumed chest sepsis- given IV Ceftriaxone 2g in Iso, switched to HFNP with no issues. Covid RAT negative. VBG- pH 7.49, pCO2 24, Lactate 1.8.
Patient subsequently had a rapid deterioration, and the alarm was pressed- hypoxia to 75% on HFNP becoming agitated and removing oxygen.
Given Ketamine IV to facilitate BIPAP for Type 1 Respiratory Failure.

POCUS Lung by ED Doctor
Video 1. Left Anterior Superior Lung View– Multiple B-Lines (vertical lines) between rib spaces indicating interstitial oedema.

Same was found on Right Anterior Superior Lung View.

Video 2. Right Lateral Inferior Lung View- Thickened irregular pleura with subpleural consolidation and shred sign (B-lines originating subpleurally) and small pleural effusion indicating possible R sided pneumonia.

Based on POCUS findings- Clinical Impression - APO plus possible chest sepsis
The patient was started on GTN and given Frusemide, with an IDC inserted to treat fluid overload. Azithromycin was added to IV Antibiotics.

Portable CXR was done soon after-
Image 1. Report text: extensive bilateral predominantly perihilar mixed alveolar

interstitial opacification. This has a wide differential diagnosis

including pulmonary oedema and atypical infection.

The patient settled with BIPAP and medical treatment, was able to be weaned back to HFNP and transferred to RMH under the Renal team.

Utility of POCUS

In the undifferentiated acutely SOB patient, Lung POCUS can help rule in/out differential diagnosis of Pneumothorax/ Pulmonary Oedema/ Pneumonia/ Pleural Effusion. In this case, the POCUS findings immediately excluded pneumothorax and guided treatment for APO as well as Pneumonia.

Learning Points

See Lung ED Resource. The flow chart on page 1 is a guide to a systematic way to identify different pathologies. Starting with pleural sliding and then looking at the lung fields. This 4-minute video is a good summary of A-lines, B-lines and findings of pulmonary oedema:
https://www.youtube.com/watch?v=VzgX9ihnmec

Lung POCUS can also be combined with FELS (focussed echo in life support) to look for cardiac as well as lung causes of SOB. There are many POCUS protocols that involve combining these exams. One protocol that does this is the CLUE protocol, involving a rapid abbreviated 2x cardiac, 2x lung view approach (Image 2.)

Question 18

9. Lung. FELS - Case 2

Accepted Answer

Case 2.

A case from RMH ED yesterday.
26 yo female sudden onset chest pain and dizziness.
BIBA pale, diaphoretic and BP 87/59 with brief runs of VT.

PMH: nil but family history of Marfan’s syndrome.

POCUS FELS (focussed echo in life support) done by ED Doctor

Video 3. Parasternal Long Axis Cardiac View (PLAX view)- Hypodynamic heart with an aortic dissection flap seen near the aortic root. Also note no obvious pericardial effusion or flap seen in the descending aorta in this view.

Video 4. Parasternal Short Axis Cardiac View (PSAX view)- Relatively superior view at aortic root level showing aortic dissection flap. Normal sized hypodynamic right ventricle.

The Cardiothoracics team were immediately notified. The patient subsequently arrested, CPR commenced and patient transported immediately to OT without CT. AAA POCUS scan done just before didn’t show obvious dissection flap in abdominal aorta.

The patient is currently in ICU on ECMO post emergent aortic root replacement and CAGS x2.

Utility of POCUS

In this case of undifferentiated unstable chest pain, POCUS FELS identified Type A aortic dissection as a diagnosis rapidly. Despite best attempts to get the patient to CT immediately prior, when the patient arrested the POCUS images shown to the cardiothoracic team gave enough information to take this patient to OR.

Learning Points

See FELS ED Resource. Focussed Echo In Life Support isn’t sensitive enough to rule out aortic dissection, that requires a CT Aortogram. Its main value for ED is in identifying other common differential diagnosis- massive or submassive PE, Pericardial Tamponade, Cardiogenic Shock. However, for those who have done some FELS training, seeing an obvious aortic dissection flap in the basic cardiac views or a suprasternal approach (https://www.youtube.com/watch?v=gv6yZNOIchE) can rule in the diagnosis.

Question 19

10. GB. eFAST. - Case 1

Accepted Answer

Case 1.

47 y.o. female presents with 3 days RUQ pain.

Temp 38, HR 110, BP 130/70

POCUS done by ED Doctor

Video 1. Gallbladder Long View. Thickened GB wall (>3mm), Large gallstone at fundus with shadowing. Biliary sludge with small gallstones in neck of GB. Some pericholecystic fluid.

Double barrel shot gun appearance likely showing a dilated Common Bile Duct measuring 8mm above the portal vein.

Video 2. Common Bile Duct View. Colour doppler showing no flow, confirming the vessel as dilated Common Bile Duct and not blood vessel.

Utility of POCUS

The GB POCUS confirms the likely clinical diagnosis within a few minutes of seeing the patient. This is gallstone cholecystitis and immediately the appropriate antibiotics and surgical referral was made before pending blood results and formal imaging.

Learning Points

Features of cholecystitis on GB POCUS are:
Probe tenderness (sonographic Murphy’s sign), gallbladder wall thickening (>3mm), Gallstones, Biliary sludge, Pericholecystic fluid, CBD distension (roughly>6mm).
This webpage and 5 Minute Sono video attached describe the POCUS technique and findings: https://coreem.net/core/biliary-ultrasound/

The double barrel shotgun sign is a great image to acquire, showing the appearance of a dilated CBD over the portal vein, and colour doppler can differentiate them. This link explains how to get the image:
https://med.emory.edu/departments/emergency-medicine/sections/ultrasound/case-of-the-month/abdominal/double_barrel_shotgun.html

Question 20

10. GB. eFAST. - Case 2

Accepted Answer

Case 2.

26 y.o. male trauma call

Found lying in the driveway after possible MVA
initial vitals:
HR 80, SBP 120, altered conscious state.

POCUS EFAST done by ED Doctor

Image 1. LUQ View- Positive. Large volume perisplenic free fluid seen.

The patient was intubated soon afterwards. A CT revealed a grade 3 liver laceration and grade 2 splenic injury. The patient became hypotensive in ED despite 2x units PRBCs, and decision was made to take the patient to OR in Bendigo prior to transfer to a major trauma centre.

Utility of POCUS

POCUS eFAST in trauma is most beneficial in haemodynamically unstable patients who are unable to get to the CT scanner. However a positive eFAST (such as in this case) helped with an early diagnosis of intra-abdominal bleeding, and expedited imaging, plans for emergency packing and transfer.

Learning Points

Review the EFAST ED Resource and positive POCUS findings in trauma eFAST (pneumothorax/ haemothorax/ free fluid/ haemopericardium). When assessing the LUQ view, ensure to visualise the spleno-diaphragmatic space and perisplenic areas. As in this case, assessing the spleno-renal fossa alone can be falsely negative.

Question 21

11. DVT. AAA. FHR. - Case 1

Accepted Answer

Case 1.

82 y.o. female
Presentation with R lower limb pain awaiting angiogram at Austin Health for possible arterial compromise R ischaemic leg. Had a panic attack at CT Angiogram so unable to complete prior. Referred by GP due to severe pain. On arrival R Leg purple and swollen.

DVT POCUS performed by ED Doctor:

Video 1. Right CFV View- Colour doppler showing good arterial flow through Common and Superficial Femoral Artery. No obvious venous flow in Common Femoral Vein. (R Popliteal artery had adequate flow on DVT POCUS)

Image 1. Right CFV View- Side-by-side uncompressed and compression view showing no compression of R CFV, indicating a R above knee DVT.

Was given IV Midazolam to facilitate CT Angiogram+ Venogram RLL confirming patent arteries with moderate stenoses of SFA bilaterally + Acute Right iliofemoral DVT, in keeping with possible R Phlegmasia Cerulea Dolens. The patient was given a Heparin bolus and infusion before being transferred to Austin Hospital.

Utility of POCUS

In this patient a quick ultrasound identified good arterial flow, and a proximal DVT explaining the symptoms. The time to diagnosis (DVT vs arterial compromise) and ability to discuss this with treating team in tertiary centre was sped up.

Learning Points

While doing a DVT POCUS, you can use colour doppler to assess arterial blood flow. An above knee assessment including the CFV, FV and PV (with some training/practice) can be particularly useful for ruling in DVT.

The first 4 minutes of this youtube video explains how to do a complete above knee DVT POCUS: https://www.youtube.com/watch?v=oo0hPKdtFSQ

Also consider doing an above knee DVT POCUS as an added data point when suspicious of PE Diagnosis. It is part of the extended RUSH protocol, and can useful when having difficulty accessing the torso in arrest/peri-arrest patients: https://emcrit.org/rush-exam/

Question 22

11. DVT. AAA. FHR. - Case 2

Accepted Answer

Case 2.

69 y.o. male

Re-presentation to ambulatory care with groin/back pain. On arrival HR 95, BP 95/60, patient quite slow and vague with answers. Brought into mains cubicle for assessment.

AAA POCUS performed by ED Doctor:
Image 2. Aorta Trans View- AAA seen, 11.6cm transverse diameter. Surrounding retroperitoneal fluid noted in bottom left of image next to aorta suggestive of leak/rupture.

Image 3. Aorta Long View- AAA confirmed on long view. Intramural thrombus and mobile thrombus posteriorly with surrounding fluid.

The surgical team were immediately notified, CT Aortogram done confirming a ruptured infrarenal AAA, and code AAA called. The patient underwent a successful laparotomy and AAA repair.

Utility of POCUS

As with many POCUS exams, time to diagnosis and management can be expedited. In this patient with vague symptoms: stroke and AAA were on the differential list, however a 2-minute Ultrasound identified the diagnosis. The CT was expedited, and the patient was in the OR within about 20 minutes thanks to a great multi-team effort.

Learning Points

AAA POCUS is a Core ED POCUS Exam that approaches close to 100% Specificity and Sensitivity for ruling in AAA. Consider doing AAA POCUS in any patient aged >50 with non-specific abdo pain, lower back pain or hypotension. Review AAA ED Resource for a summary.

If AAA is seen on POCUS, consider the other findings that increase the likelihood of leak/rupture: Size >5cm, Thrombus, Dissection Flap, Discontinuity of vessel wall, Surrounding retroperitoneal haematoma, Free peritoneal fluid.

Fetal Heart Rate Measurement

Trans-abdominal assessment of FHR is possible >8 weeks (technically difficult until >10 weeks) gestation. For first trimester FHR use M-mode as recommended by ASUM and RANZCOG protocols. This is to reduce the theoretical issues of heat generated by doppler ultrasound. See Image 4. On the Sonosite X-Portes in Obstetric Setting on Curvilinear Probe, use M-Mode line over fetal heart beat, “Start” then “Freeze”. Press “Calcs” to measure FHR by placing cursor between 2 peaks corresponding to heart position, tapping screen to get second cursor. The machine will then automatically calculate the FHR.

For second and third trimester pregnancy you can use M-Mode or Doppler measurement- See Image 5. Press “Doppler” on Sonosite X-Porte touchscreen, then place cursor over fetal heart, and same measurement method using “Calcs.” Taking care to make sure you are measuring the section corresponding to fetal heart, and not maternal cardiac reverberations. Please also save the iamges and document your findings on the EMR.

Question 23

12. eFAST. Nerve Blocks. - Case 1

Accepted Answer

Case 1.

60 yo female ambulatory care patient in Bendigo ED.
Mechanical trip and hit back off couch, pleuritic R sided chest pain. Obs were normal.
Examination- tenderness to R chest.

ED POCUS eFAST done by ED Doctor:

Video 1. Right Chest View. Lung Point- Lung sliding at the pleura suddenly stops, then no lung sliding seen. Rib is on the image right. Suggestive of R traumatic pneumothorax.

Image 1. 2 Right Chest Views (M Mode Comparison). Image on the left: Seashore sign indicative of lung sliding and lung pulse seen (transmitted heart beats). Image on the right: Barcode sign showing the starting point of traumatic pneumothorax, absent lung pulse.

The patient was moved to mains department. A Trauma Series CT ordered showing 4 rib fractures and small right haemo-pneumothorax. The patient was admitted under general surgery with APS unit and managed conservatively without ICC.

Utility of POCUS

This patient was probably going to get further imaging after review. The POCUS eFAST sped up the diagnosis of a pneumothorax and expedited the transfer to mains department, CT imaging and referral to general surgery unit.

Learning Points

Please review attached eFAST ED Resource, which includes bilateral lung POCUS to exclude pneumothorax. Many studies confirm time and again that POCUS is more accurate than a CXR for diagnosing pneumothorax: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4386013/

Lung Point- pretty much has a specificity of 100% for ruling in pneumothorax:
https://pubmed.ncbi.nlm.nih.gov/11126253/

It correlates to the area of the lung where the pneumothorax starts, and excludes most other causes of absent lung sliding (which are usually diffuse in the lung). However, it has a low sensitivity as it can be hard to find and isn’t present in a complete pneumothorax. You only need: absent lung sliding/ bar code sign to diagnose a likely pneumothorax. My advice is don’t waste too much time looking for a lung point, but if you see a lung point the diagnosis is clear.

Question 24

12. eFAST. Nerve Blocks. - Case 2

Accepted Answer

Case 2.

67 yo female turning around quickly in playground with grandchildren, felt sudden pain to L ankle. Unable to weightbear afterwards.

Image 2. X-Ray L Ankle- Trimalleolar Fracture. Comminuted distal fibula fracture, medial and posterior tibial malleolar # with dorsal displacement.

Regional Ankle Block by ED Doctor: Adductor Canal + Popliteal Sciatic Nerve Block
Written consent: Risk of LAST, bleeding, infection, failure, nerve injury. Cardiac Monitoring.

Video 2. Adductor Canal block. Sonotap Needle with local anaesthetic injection around femoral nerve in adductor canal, next to femoral artery.

Video 3. Popliteal Sciatic Nerve block. Sonotap Needle with local anaesthetic injection in the popliteal fossa, just superficial to popliteal vein and artery.

The patient's ankle was well anaesthetised, had a closed reduction with Back and U-slab applied, and underwent an inpatient ORIF L ankle.

Question 25

12. eFAST. Nerve Blocks. - Case 3

Accepted Answer

Case 3.

12 yo female hit with footy to L hand.

Image 3. X-Ray L Hand- Salter-Harris II fracture at base of 5^th proximal phalanx, with 20 degrees angulation

Peripheral Nerve Block by ED Doctor (appeared slightly too proximal for ring block):

Ulnar Nerve Block
Written consent: Risk of LAST, bleeding, infection, failure, nerve injury. Cardiac Monitoring.

Video 4. Ulnar Nerve Block. Sonotap Needle with local anaesthetic injection around ulnar nerve, just medial to ulnar artery

The patient had a closed reduction of fracture restoring anatomical alignment, discharged home with ulnar gutter and hand clinic follow up.

Utility of POCUS

In these 2 cases, US-guided regional and peripheral nerve blocks are a possible alternative to procedural sedation. This can save time, and procedural sedation risks in a certain cohort of patients. They also offer a good alternative for analgesia compared to oral and parenteral analgesia.

Learning Points

Consider Femoral Adductor+ Popliteal Sciatic blocks for ankle fractures, and Ulnar nerve blocks for Ulnar territory injuries.

For US-Guided nerve blocks, it is important to firstly have competence in needle-guided techniques and never inject without visualising the needle tip and knowing the anatomy. A sterile technique is essential, as well as cardiac monitoring and consenting for above risks, with good documentation. Document neurovascular assessment prior and consider discussing with orthopaedics team if risk of compartment syndrome.

The “Nerve Block” app is a fantastic resource that guides nerve blocks for each body group, with: indications, contraindications, equipment, prep, US-technique videos. AIU also run a great 2-day ultrasound nerve block course.

Question 26

13. FELS. Renal. Orbit - Case 1

Accepted Answer

Case 1.

38 y.o. male 4^th presentation in 10 days with SOB, dry cough, subjective fevers, reduced ET. Multiple trials of antibiotics not improving symptoms.
O/E: HR 98, BP 140/110, SpO2 95% OA, afebrile

Decision made by ED Doctor to perform POCUS FELS (Focussed Echo in Life Support):

Video 1. PLAX View. Dilated cardiac chambers. Globally hypokinetic
(the LV in particular is enlarged. Both LV and RV have a minimal change between diastole and systole, certainly < 33% difference-indicating global hypokinesis)

Video 2. SUBX View. Dilated IVC. >2cm with minimal respiratory change.

The patient was subsequently referred to cardiology and underwent an inpatient TTE confirming new Biventricular Failure with an Ejection Fraction of 9%, likely Alcoholic Cardiomyopathy. Pt was admitted, started on multiple heart failure medications and subsequently discharged home with clinic follow up.

Utility of POCUS

Heart failure in this young patient was not considered as a main differential diagnosis in previous presentations and until the FELS POCUS exam. The POCUS findings gave a diagnosis that explained the SOB, allowing a cardiology admission and inpatient investigation and treatment.

Learning Points

Review FELS ED Resource. Consider cardiac failure/ cardiogenic shock with echo findings of ventricular hypokinesis, dilated heart chambers, fixed and dilated IVC (and Lung POCUS findings of B-lines).

Question 27

13. FELS. Renal. Orbit - Case 2

Accepted Answer

Case 2.

61 y.o. female with Stage 4 Breast Cancer referred from radiology, after an outpatient CT revealed a large pericardial effusion.
O/E: HR 104, RR 22, SpO2 95% OA, BP 132/82, Temp 37.6

POCUS FELS done by Emergency doctor:

Video 3. SUBX View. Large pericardial effusion 2cm. Strandy hyperechoic material noted in pericardium

Video 4. SUBX View. 2cm IVC, >50% collapse with respiration
Assessing other sonographic features of pericardial tamponade. No obvious swinging heart/fixed dilated IVC/ significant early diastolic R ventricular collapse.
(if you pause the video when the tricuspid valve is open in early diastole, the RV chamber is possibly a little compressed but not collapsed)

Without clinical features of cardiac tamponade, the patient was discussed with thoracic surgery, admitted under Oncology and underwent an inpatient Cardiac Window procedure, removing 600ml of pericardial fluid. The patient was discharged home a week later.

Utility of POCUS

This patient had a known pericardial effusion and normal haemodynamics. FELS POCUS helps reassure us here not to rush in for pericardiocentesis in ED, and helps us communicate our basic echo findings with the inpatient teams. It can be repeated if the patient clinically deteriorates to assess for a developing cardiac tamponade.

Learning Points

Remember Cardiac Tamponade is a clinical diagnosis, and we should be prepared to consider pericardiocentesis in any unstable patients with pericardial effusions. However, if you see a pericardial effusion on ultrasound:
1. Consider differentials to pericardial effusion: i.e. pleural effusion, anterior fat pad
2. Look for sonographic features of pericardial tamponade:
Pericardial effusion + swinging heart/fixed dilated IVC/ inappropriate chamber collapse e.g. early diastolic R ventricular collapse. (Review FELS ED Resource attached)

Question 28

13. FELS. Renal. Orbit - Case 3

Accepted Answer

Case 3.

51 y.o. female presents with 2 days RUQ pain. PMH: known gallstones, AML.
O/E: HR 90, BP 134/82, Temp 36.7, RR 20
ED POCUS GB done by ED Doctor

Image 1. GB TRANS View. Biseptate GB seen with uncomplicated cholelithiasis. GB wall thickness normal (<3mm). No pericholecystic fluid.

Image 2. EFAST RUQ View (done while looking at GB) free fluid noted on inferior tip of liver. eFAST positive.

The R Kidney was noted to be abnormal on eFAST POCUS, and a CT Abdomen was arranged showing: A large retroperitoneal haemorrhage caused by disrupted R Kidney lower pole, likely a ruptured renal angiomyolipoma. The patient was moved to resus and given blood products, and underwent an emergency nephrectomy before being discharged home several days later.

Utility of POCUS

POCUS findings of abominal free fluid and abnormal-looking kidney helped to expedite decision for CT, discussions with general surgeons and preparation of blood products.

Learning Points

In the undifferentiated abdominal pain, a gallbladder ultrasound can help rule in biliary colic/ cholecystitis/ cholangitis. In this case, there was no sonographic features of gallstone cholecystitis: Sonographic Murphy’s, dilated GB wall (>3mm), pericholecystic fluid, dilated CBD (>6mm or >age/10mm). Looking at Morrison’s pouch while you are so close can be worthwhile as in this case, so consider abdominal FAST in some non-traumatic abdominal pain patients.

Question 29

13. FELS. Renal. Orbit - Case 4

Accepted Answer

Case 4.

75 y.o. male presents with 2 days central visual disturbance R eye. Described as a central shadow.

POCUS ORBIT Done by Emergency Doctor

Video 5. R ORBIT VIEW- detached medial aspect of retina, moving with eye movements and tethered at optic nerve, indicative of retinal detachment.

(note how the detached retina doesn’t cross the optic nerve- identified by seeing the posterior middle part of the globe with the linear shadowing behind)

The patient was discussed with the Ophthalmology Registrar at RVEEH, and transferred down to RVEEH ED. Diagnosis of retinal detachment was confirmed and the patient underwent inpatient laser therapy and vitrectomy.

Utility of POCUS

In this case, the POCUS findings immediately gave a diagnosis of Retinal Detachment. This could be communicated to RVEEH, and allow a quick transfer to expedite emergency treatment.

Learning Points

Orbit POCUS can be fantastic for identifying: Posterior Vitreous Detachment, Retinal Detachment, Vitreous Heamorrhage, Dislocated Lens, Dilated Optic Disc as well as many other things! Make sure you always use the “ORBITAL” setting on the linear probe, as it uses much less power and heat on the eye.

The best way to do this is by putting tegaderm over the closed eye, lots of gel and with patient sitting at 30 degrees and assessing the globe in transverse and sagittal view.
https://www.pocus101.com/ocular-ultrasound-made-easy-step-by-step-guide/

Ocular Ultrasound Made Easy: Step-By-Step Guide - POCUS 101

www.pocus101.com

Learn How to Perform Ocular Ultrasound and Recognize All Common Pathology. Retinal Detachment, Posterior Vitreous Detachment, and More!

This website goes through a great description of how to do Orbital POCUS, and Image 3. is a great 1 page visual summary of the pathologies. Remember that PVD crosses the optic disc, whereas retinal detachments do not.

Question 30

14. AAA. eFAST. FELS. - Case 1

Accepted Answer

Case 1.

90 y.o. female from home, brought in by son with dizziness and 1 week mild abdominal pain
HR 87, BP 99/65 (SBP 70 at triage), Temp 34, RR 22

POCUS AAA done by Emergency doctor:
Image 1. Aorta Trans View. 7cm AAA seen with some fluid to the image right of the aorta suggesting leakage/rupture.

General Surgery Registrar was notified and came with patient for urgent CTA- confirming a 7x8cm ruptured AAA with retroperitoneal haematoma, no active contract extravasation.

The patient rapidly became haemodynamically unstable- SBP 60. Discussed with General Surgical consultant and RMH Vascular Team in conjunction with family- for comfort care management. The patient passed away a couple of hours later with family present, and palliative comfort medications charted.

Utility of POCUS

This example shows how a rapid diagnosis of AAA can be seen by the bedside. It helped expedite CT and general surgery involvement. Ultimately in this case, the decision was made for comfort care but this happened with diagnostic certainty and with all relevant specialties involved early.

Learning Points

Review AAA ED Resource. Consider AAA POCUS in particular for elderly patients with abdominal/back pain and especially if low blood pressure. This patient had 1 week of abdominal pain! Not the typical rapid onset history.

ED bedside US has been shown to have up to 99% sensitivity for diagnosing AAA in minutes.

https://pubmed.ncbi.nlm.nih.gov/23406071/

Remember to measure outer wall to outer wall and watch out for subtle mural thrombus.

Question 31

14. AAA. eFAST. FELS. - Case 2

Accepted Answer

Case 2.

32 y.o. female 3m fall from treehouse landing on left side.
Level 3 trauma call. HR 94, BP 103/55 RR 22, SpO2 100% OA
Primary Survey relatively unremarkable. C-spine ok. Chest Clear, normal SpO2, Abdo soft, left sided abdominal tenderness.

POCUS eFAST done by Emergency doctor:
Image 2. LUQ view. FF+ve. Perisplenic free fluid, particularly seen in posterior subphrenic space (low down on the image next to the diaphragm)

Image 3. Pelvis Trans view. FF+ve. Free fluid seen posterior to the bladder and cervix, further evidence of intraperitoneal fluid.

CT Trauma Series was done confirming: Grade 3 Splenic laceration (no active extravasation), haemoperitoneum, L 5^th rib # and L superior pubic rami #.

The patient was admitted under AGSU for 8 days, then discharged with non-operative management.

Utility of POCUS

This example shows how young patients in particular can compensate without significant observation abnormalities despite fractured ribs and haemoperitoneum. In this case, the patient was stable and would have had a CT Trauma series and general surgery admission regardless. However, early diagnosis of haemoperitoneum in trauma can be essential for expediting management decisions.

Learning Points

Consider your clinical question when you are doing eFAST in trauma. Looking for pneumothorax/haemothorax/haemopericardium/haemoperitoneum. Look at eFAST ED Resource to go through the scan technique.

If the patient is most tender in LUQ, really have a good look all the way around the spleen and L kidney. A common misconception is that LUQ free fluid is most commonly seen between the spleen and the kidney. In the supine patient, studies have shown more likelihood of seeing subphrenic fluid or paracolic gutter fluid in the LUQ. This article has a good diagram showing all 3 areas of LUQ free fluid:
https://www.ultrasoundgel.org/posts/Sc2AW3cdMhfZKmhuiGSq6w

Question 32

14. AAA. eFAST. FELS. - Case 3

Accepted Answer

Case 3.

This one at RMH.

43 y.o. male presenting to ED with 3 days SOB, right sided chest pain and right leg pain.
cubicle alarm pressed after patient returned from toilet, syncope and unconscious on floor prior to seeing doctor. The patient was moved to a resus cubicle.
HR 150bpm, SpO2 91% on NRB 15LO2, BP 105/55

POCUS FELS (Focussed Echo in Life Support) done by Emergency doctor:

Video 1. PLAX (Parasternal Long View) showing dilated Right Ventricle. Significantly larger in size than LVOT and Left Atrium.

Video 2. PSAX (Parasternal Short View) dilated RV. Larger than LV. Septal bowing and D-Sign of the left ventricle.

A POCUS DVT scan also confirmed a R above knee DVT. Collaborative discussion was had between ED Consultant and Respiratory Registrar- decision made for thrombolysis in ED with IV Alteplase in setting of syncope and haemodynamic instability prior to CT.
The patient was given 1litre CSL and then transferred to CT confirming large bilateral PE with CT evidence of right heart strain. The patient was started on a noradrenaline infusion as SBP dropped below 90, a heparin infusion and transferred to ICU. Thrombectomy was considered but not needed. The patient was discharged home on Apixaban 4 days later.

Utility of POCUS

The POCUS findings in this case gave the diagnosis of PE as the cause of syncope with haemodynamic instability and evidence of right ventricular dysfunction. This allowed the collaborative decision to thrombolyse prior to CT, and expedited ICU involvement as well as discussion with cardiothoracics regarding thrombectomy.

Learning Points

The normal PLAX view should have roughly 1:1:1 ratio in normal echo between RV: LVOT: LA. The normal PSAX view should have RV <2/3 LV in normal echo without chronic right heart disease.

If you see Echographic evidence of pulmonary embolus, consider a DVT POCUS to look for a source and confirm your suspicions! FELS POCUS in PE helps stratify risk and guide management as well as give prognostic information. Think about the echographic evidence of right heart strain: Dilated RV, Septal Bowing. Dilated IVC. Dilated RA. RV wall hypokinesis. McConnell’s Sign. Intramural thrombus. As described in FELS ED Resource.

Question 33

15. eFAST - Case 1

Accepted Answer

Case 1

27 y.o. male
Code Blue- collapsed at patient drop-off in front of hospital, transported to ED.

Driven to Bendigo in private car with severe abdominal pain. Had been unwell 3/52 with sore throat, GP had sent investigations and notified patient that day that he had Glandular Fever. 1x syncopal episode at home that day.

O/E: Temp 35.6, HR 135, BP 96/73, RR 24, SpO2 98%
Abdo Soft. tender LUQ.

POCUS eFAST done by Emergency Doctor:
Image 1. LUQ view. Showing spleen and persiplenic free fluid. Hyperechoic section above spleen likely represents blood clot. The images confirm the diagnosis of atraumatic splenic rupture in the context of Glandular Fever.

Dual IV Access attained, Blood Transfusion initiated, and referred to AGSU. A CT Abdo/Pelvis was done- Video 1. confirming splenic rupture with large subscapular and perisplenic collection, density suggesting blood.

Discussion was had with the General Surgeon at Bendigo Hospital, and decision made to transfer the patient to another hospital for IR that evening. Patient was transferred with ARV to Austin Hospital where we underwent repeat CT showing increasing volume of blood, received a massive transfusion with 5x PRBCs, 2x Plts, 2x FFP and underwent a successful angioembolisation. He was discharged home a few days later.

Utility of POCUS

The eFAST result of free fluid around the spleen was able to quickly give the diagnosis of ruptured spleen from Glandular fever. This expedited blood transfusion resuscitation, discussion with surgery and CT.

Learning Points

A Code Blue with syncope, hypotension and undifferentiated atraumatic abdominal pain can be quite daunting to face. In this case, while resuscitating, a focussed POCUS with a clinical question can help- e.g. is there LUQ free fluid that would fit the story of ruptured spleen? Review the eFAST ED Resource attached. eFAST can also be used as part of the RUSH protocol for undifferentiated shock, think of the acronym HIMAP, summarised well here on the POCUS atlas website: https://www.thepocusatlas.com/shock

Question 34

15. eFAST - Case 2

Accepted Answer

Case 2

34 y.o. female
7/40 by dates, US at 5 weeks showed possible IUP 2.5mm, nil adnexal masses. Remained positive on urine pregnancy tests. Presented with severe abdominal pain and moved to resus due to vitals: HR 130-150, BP 129/61, Temp 36.2

POCUS eFAST done by Emergency Doctor:
Video 2. RUQ view. Immediately showing large volume free fluid around morrison’s pouch, inferior liver tip and loops of bowel. eFAST positive.

2x large IV access, and PRBCs initiated. O+G were called and arrived immediately, and theatres/anaesthetics were notified. The patient went to theatre within an hour of arrival, confirming a ruptured ectopic and undergoing a mini-laporotomy and salpingectomy with estimated 2L blood loss. The patient was discharged home 2 days later.

Utility of POCUS

This is another example of how eFAST can expedite management in ectopic pregnancy. These patients are young, healthy and often compensate with a normal blood pressure despite litres of blood loss that requires an urgent operation. The eFAST findings were immediately communicated to O+G and helped facilitate early blood products, resuscitation and transfer to OR without waiting for a formal US.

Learning Points

RUQ free fluid in ectopic pregnancy has been shown to be predictive of requiring operative intervention, with a specificity >99%: https://pubmed.ncbi.nlm.nih.gov/17554008/

https://thennt.com/lr/pocus-atlas-free-fluid-fast-ectopic-pregnancy-requiring/

A ruptured corpus luteum can have a similar presentation with haemoperitoneum in women of reproductive age. This can be confusing, especially when ruptured CL occurs during intrauterine pregnancy. Regardless, with haemodynamic instability or large amount of free fluid this is best management by O+G team with urgent laporoscopy/laparotomy.
This is an interesting article/case report on the topic:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544092/

Question 35

16. FELS Cardiac - Case 1

Accepted Answer

51 y.o. male presents with 5 days SOB on background of AML
On arrival- SpO2 100% OA, RR 36, BP 112/80, HR 90

ED POCUS FELS done by Emergency Doctor

Video 1. A4Ch View (Apical 4 Chamber)- Large pericardial effusion (>2cm). R Ventricular Diastolic collapse consistent with tamponade (if you pause the video when the tricuspid valve is open in diastole, the lateral ventricle wall is slightly dented inwards indicating collapse)
Video 2. SUBX View (Subxiphoid)- The RA and RV alternatively collapse giving a see-saw appearance, and there is RA systolic collapse. In this view you also see a slightly swinging heart and floating mass within the pericardium.

Video 3. PLAX View (Parasternal long)- If you pause the video when the mitral valve opens, you can see the right ventricle is compressed in keeping with R ventricular diastolic collapse in tamponade.

The patient was immediately discussed with the Cardiology Registrar, which resulted in a transfer to cathlab for urgent pericardiocentesis. 1.7 litre pericardial effusion was drained with pericardial drain left in-situ. The patient’s blood results included: Platelets 2, and VBG pH 7.0, Lactate 17, Bicarb 3. They received a platelet transfusion and were admitted to ICU in Bendigo before an ARV transfer to a tertiary centre.

Utility of POCUS

POCUS findings here identified pericardial effusion instantly as the cause of SOB in this patient. The echographic features of tamponade helped prioritise the facilitation of urgent pericardiocentesis in cathlab.

Learning Points

Please review the FELS ED Resource and FELS POCUS Video https://youtu.be/npSI_U9is4w. In this example you see multiple echographic features of cardiac tamponade: Large Pericardial effusion (>2cm), swinging heart, R ventricular diastolic collapse. You can also look for a fixed dilated IVC with no respiratory variation. In an unstable patient this presentation may require ED pericardiocentesis, consider an US-guided approach such as lateral to medial in-plane PLAX approach seen in this first photo:
https://www.acep.org/sonoguide/procedures/pericardiocentesis

Question 36

16. FELS Cardiac - Case 2

Accepted Answer

23 y.o. male BIBA with self-inflicted stab wound to the anterior chest.
On arrival- HR 110, SBP 100, SpO2 100% 6LO2, Temp 33.

ED POCUS FELS done by Emergency Doctor
Video 4. Subxiphoid Short Axis View (R and L inverted)- moderate sized pericardial effusion seen anteriorly with clot (greyish matter). No echographic features of cardiac tamponade.

The patient went for CT Chest- showing a moderate haemoneumomediastinum with mild pericardial effusion. No pneumothorax.

The patient was discussed with the on-call surgeon and transferred to a tertiary centre. A formal inpatient echo confirmed a small pericardial effusion with no echographic signs of tamponade. The haemopericardium was conservatively managed, the chest laceration was closed, and the patient discharged home 2 days later.

Utility of POCUS

In this case the POCUS findings rapidly provided a diagnosis of penetrating chest wall trauma with pericardial effusion. The patient was stable enough to go to CT and subsequently get transferred to a tertiary centre. However, this diagnosis allows expedited transfer arrangements, and preparation for an ED thoracotomy. These patients can clinically deteriorate rapidly, so reducing time to definitive care is important.

Learning Points

Consider differentials of what can look like haemopericardium: anterior fat pads, pleural effusions, physiological effusion. Anterior fat pad is usually small <10mm, often slightly grey, not circumferential and moves with the heart. Pleural effusions wrap around posterior to the descending aorta. Physiological cardiac effusions are similarly also small, without clots. In this case, the history and clot seen on ultrasound gives away the diagnosis of haemopericardium.

Question 37

16. FELS Cardiac - Case 3

Accepted Answer

79 y.o. female BIBA with altered conscious state. Hx T2DM on oral hypoglycaemic agents.
Pre-hospital BSL 2.2, treated with glucagon and IV glucose with good effect. A pre-hospital 12 lead ECG showed STE in Leads 1 and V6.

This was discussed with Cardiology and decision made not for STEMI call, and for review in ED. No Chest pain in the presentation.
On arrival- HR 70, BP 123/75, Temp 36, SpO2 99% OA

ED POCUS FELS done by Emergency Doctor
Video 5. PLAX View (Parasternal Long Axis)- Hypodynamic left ventricle with hypokinetic and ballooned apex. Hypercontractile base.

Video 6. A4Ch View (Apical 4 Chamber)- Similarly seen hypodynamic left ventricle with apical ballooning. Hypercontractile base.

The patient had an initial Trop of 1200. They were seen by the cardiology registrar and started on DAPT + Heparin infusion. An Angiogram the next morning was suggestive of Takotsubo Cardiomyopathy, with clean coronary arteries. The patient was discharged home 1/52 later with Aspirin, Beta Blockers and ACE-inhibitor. Gliclazide was ceased and the working diagnosis of the patient’s presentation was possible Takotsubo cardiomyopathy in the setting of hypoglycaemia.

Utility of POCUS

In this case, FELS POCUS didn’t change the management of this STEMI equivalent presentation. The patient was still started on the usual ACS meds and underwent an angiogram. It did however lead to a discussion early on about Takutsubo as a possible diagnosis, and could have been useful if the patients clinical condition deteriorated.

Learning Points

In ED we can often rule in cardiac tamponade, submassive/massive PE and cardiogenic shock. Differentiating regional wall abnormalities in acute coronary syndrome vs Takotsubo’s however is far more complex, and we should be cautious in making this assessment. These FELS images do show the “Octopus trap” appearance in Takotsubo (Image 1.) Takotsubo is caused by a catecholamine surge often in post-menopausal women after a stressful event, and management is usually supportive. The management also depends on if there is LVOT Obstruction (1/3) where ionotropes are avoided.

https://litfl.com/takotsubo-cardiomyopathy-ecg-library/

Question 38

17. DVT/eFAST/AAA - Case 1

Accepted Answer

RMH Case. A 41 y.o. male presents to ambulatory care with back pain.
Initially seen by physio- however history wasn’t typical of MSK back pain so Emergency Doctor was asked to review. History revisited- 2/7 back pain and mild bilateral leg oedema.

Past Medical History of unprovoked PE and DVT 20 years ago abroad, previously anticoagulated, now ceased. IVC filter in situ, and previous thrombophilia screen negative.

ED POCUS AAA done by Emergency Doctor to exclude AAA, and look at IVC.

Image 1. Aorta Trans View. Normal Aorta appearance, with distended looking IVC. No flow was seen in IVC and non-compressible.
Image 2. Aorta Trans View at level of Iliac Arteries. Good flow through bilateral iliac arteries. Bilateral distended iliac veins with no obvious flow and non-compressible.

ED POCUS DVT done by Emergency Doctor
Image 3. R CFV View (Common Femoral Vein)- non-compressible CFV at the level of the great saphenous vein junction.

Proximal DVT was suspected and the patient was booked for a CT Venogram and referred to Vascular with suspected large burden proximal DVTs. A CT Venogram confirmed extensive venous thromboembolism from IVC just below IVC Filter to iliac veins and femoral veins bilaterally. A CTPA was booked which also showed bilateral segmental and subsegmental PEs.

The patient underwent a catheter directed thrombolysis through popliteal approach the following day, followed by a thrombectomy from IVC to inguinal ligament bilaterally. They were transitioned to LMWH and discharged home after 5/7 with life-long Apixaban, and consented for IVC filter removal as an outpatient.

Utility of POCUS

In this case the strange, enlarged appearance of the IVC when performing a AAA POCUS Exam raised the suspicion for a proximal DVT. In practice, this can happen and can lead you to perform a different POCUS exam/ combine POCUS exams. The confirmation of a proximal limb DVT seen helped rule in proximal DVT as a cause for the presentation.

Learning Points

Please review the DVT POCUS Video https://youtu.be/ax0ttMUADQ0 to go through how to perform this exam. This article nicely explains the 3-compression technique and DVT thrombus appearance: https://www.tampaemergencymedicine.org/blog/dvtin123

Question 39

17. DVT/eFAST/AAA - Case 2

Accepted Answer

25 y.o. female presents through ambulatory care with post intercourse abdominal pain
On arrival- HR 118, SBP 135. Urine HCG came back positive. Surprising to patient as LMP 3/52 earlier.

ED POCUS eFAST done by Emergency Doctor

Video 1. RUQ View- Free fluid seen around inferior liver tip. eFAST positive

O+G Registrar was immediately contacted with diagnosis of suspected ruptured ectopic pregnancy vs ruptured corpus luteal cyst with incidental pregnancy. A formal TV USS done shortly afterwards was reported as: Free fluid appearance indicative of haemoperitoneum. R ovary surrounded by blood clots contains a vascular ring without a definite gestational sac. Compatible with R ruptured ectopic pregnancy.

The patient underwent a diagnostic laporoscopy which showed large volume haemoperitoneum, actively bleeding R ovary but no macroscopic evidence of ectopic pregnancy. They were discharged home soon after with EPAS follow up, ongoing IUP noted and rising HCGs.

Utility of POCUS

The eFAST results in this case help to activate early O+G referral, Formal TVUSS time and management that led to this patient undergoing an urgent laparoscopy. Positive eFAST result in pregnancy has been shown to be predictive of operative intervention so this communication often speeds things up. Even the formal TVUSS was incorrect in suspecting a ruptured ectopic in this case.

Learning Points

This case highlights the main differential of ectopic pregnancy vs ruptured corpus luteal cyst + haemoperitoneum when HCG is positive + eFAST positive. This was also discussed in the last Interesting POCUS Cases email. A good reminder of this topic can be read here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544092/
For us in ED, our management is similar- urgent O+G referral and definitive care as active bleeding/ large haemoperitoneum in this cohort requires source control. These patients often compensate well despite significant blood loss.

Question 40

17. DVT/eFAST/AAA - Case 3

Accepted Answer

91 y.o female BIBA with sudden onset dizziness and back/abdo pain. The patient had a known history of 5cm AAA and critical aortic stenosis. Prior to arrival decision made by ED team not for code AAA on arrival.

On arrival- SBP 67.
ED POCUS AAA done by Emergency Doctor

Image 4. Aorta Trans View- 5.3cm AAA with mural thrombus

The images seen were similar to previous CT reports. The patient was treated with fluids and antibiotics to cover sepsis. A repeat CT confirmed unchanged size of 5cm infrarenal AAA with mural thrombus and thrombosis of internal iliac arteries. She improved and was admitted under gen med before transfer to private hospital for ward-level care.

Utility of POCUS

In this case, the unchanged AAA findings were reassuring, and brought up septic shock as a differential quickly. A different POCUS result suggestive of ruptured AAA may have lead to prioritising comfort level care.

Learning Points

Please review the AAA ED Resource Sheet and AAA POCUS Video https://youtu.be/xSEP6XQW-3Y to go through how to perform this exam. Image 4. is a good reminder to measure outer-wall to outer-wall. The inner aspect of the mural thrombus here can be easily mistaken for the outer wall. Also please consider a lateral measurement in Aorta Trans (as per the ED Resource Sheet), as this can often be a larger diameter than the AP measurement.