Ultrasound diagnosis of diaphragmatic rupture

The Use of Angle-Independent M-Mode in the Evaluation of Diaphragmatic Excursion: Towards Improved Accuracy

Assessment of diaphragmatic function has been well described in the intensive care setting as well as in emergency medicine and pediatrics. Conventional M-mode evaluation of diaphragmatic excursion is frequently associated with over and under-estimations of diaphragmatic excursion. Angle-independent M-mode allows free rotation and movement of the analysis line to obtain M-mode images in a direction that more accurately reflects diaphragmatic excursion. In order to provide a standardized approach to the evaluation of diaphragmatic excursion with angle-independent M-mode, we propose a landmark-based approach utilizing the spine in order to target the same diaphragmatic segment consistently throughout the diaphragmatic analysis. While the proposed approach is not intended to replace current methods, it may improve accuracy and inter-rater reliability. The relevant background, as well as three patient cases, are presented demonstrating the use of a landmark-based approach in the emergency department. Angle-independent M-mode may provide a more accurate and consistent evaluation of diaphragmatic excursion, an examination that can be used to guide clinical care and anticipate outcomes.

Diagnostic accuracy of the trans-abdominal ultrasound in the assessment of dysfunctional hemidiaphragm due to non-pulmonic etiology

Background

To evaluate the role of the trans-abdominal ultrasound (TAUS) in the assessment of hemidiaphragmatic dysfunction—due to non-pulmonic causes—as compared to the conventional CT; 36 patients (22 males and 14 females; age range 5 to 84 years) were included in this study.

Results

In CT examination, the dysfunctional hemidiaphragm was considered when either a hernia/post-traumatic defects (present in 19.4% of patients, of which 5.5% were depicted on the right side and 13.8% were existing on the left side), or elevated copulae (present in 80.6% of patients, of which 58.8% were found on the right side (21 patients) and 22.2% were seen on the left side (8 patients).

The TAUS showed a high sensitivity, specificity, PPV, NPV, and over all accuracy {100% (95% CI = 59.04 to 100.00%), 100% (95% CI = 88.06 to 100.00%), 100%, 100%, 100% (95% CI = 90.26 to 100.00%), respectively} in detection of defects and hernias as compared to CT. A high sensitivity, specificity, PPV, NPV, and over all accuracy {96.55% (95% CI = 82.24 to 99.9%), 100% (95% CI=59.04 to 100.00%), 100%, 87.5% (95% CI = 50.50 to 97.96%), 97.22% (95% CI = 85.47 to 99.93%), respectively} were found in detection of thickness and motion abnormalities, and in the detection of subphrenic collections in cases with relevant elevated copula in CT.

Conclusion

Trans-abdominal ultrasound (TAUS) could accurately assess the diaphragmatic thickness and provides a real-time image of a dysfunctional hemidiaphragm due to a diaphragmatic and infradiaphragmatic causes as well as the diaphragmatic defects with high sensitivity and specificity in comparison to CT.

Beyond E-FAST scan in trauma: Diagnosing of traumatic diaphragmatic rupture with bedside ultrasound

Traumatic diaphragmatic rupture is relatively rare, and even more difficult to diagnose. Physical examination often fails to identify this injury, and basic investigation like chest x-ray can miss this half of the time. Although not part of standard FAST (focused assessment with sonography for trauma) ultrasound scan in trauma, bedside ultrasound has the potential to pick up this pathology. This case illustrates that ultrasound in trauma can go beyond standard E-FAST (extended FAST) protocol.