• Education Resources

Intersting ED POCUS Cases

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.


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.



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.



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:

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.


And once more- beware the subtle mural thrombus!

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:

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:

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:


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!

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.

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”.

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):

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.

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.


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.

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.

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.


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: