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Hughey S, Daugherty L, Nicholson A, DeYoung H. Point-of-Care Ultrasound in Austere Environments. Wilderness Environ Med 2023; 34:260-262. [PMID: 36934029 DOI: 10.1016/j.wem.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/05/2023] [Accepted: 01/18/2023] [Indexed: 03/18/2023]
Affiliation(s)
- Scott Hughey
- Department of Anesthesiology and Pain Medicine, Naval Hospital Okinawa, Okinawa, Japan; Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA
| | | | - Ashton Nicholson
- Department of Anesthesiology and Pain Medicine, Naval Hospital Okinawa, Okinawa, Japan
| | - Henry DeYoung
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA; Department of Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, VA
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2
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Johnson GGRJ, Jelic T, Derksen A, Unger B, Zeiler FA, Ziesmann MT, Gillman LM. Accuracy of Optic Nerve Sheath Diameter Measurements in Pocket-Sized Ultrasound Devices in a Simulation Model. Front Med (Lausanne) 2022; 9:831778. [PMID: 35308521 PMCID: PMC8924410 DOI: 10.3389/fmed.2022.831778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Transorbital sonographic measurement of optic nerve sheath diameter (ONSD) is an emerging non-invasive technique for the identification and monitoring of intracranial hypertension. In recent years, new pocket ultrasound devices have become available, and it is uncertain if they have the resolution to measure such small structures appropriately as compared to their predecessors. In this study, we measure the performance of three ultrasound units on a simulation model to establish their precision and accuracy. Methods ONSD was measured by three expert point-of-care sonographers using ultrasound machines three times on each of seven discrete ONS model sizes ranging from 3.5 to 7.9 mm. Two pocket ultrasounds (IVIZ, Sonosite, and Lumify, Philips) and one standard-sized portable ultrasound (M-Turbo, Sonosite) were used. Measurements were analyzed for mean error and variance and tested for significance using blocked covariance matrix regression analyses. Results The devices differed in their variances (Lumify: 0.19 mm2, M-Turbo: 0.26 mm2, IVIZ: 0.34 mm2) and their mean error (Lumify: -0.05 mm, M-Turbo: 0.10 mm, IVIZ: -0.10 mm). The difference in mean error between users is not significant (p = 0.45), but there is a significant difference in mean error between devices (p = 0.02). Conclusions Accurate ONSD measurement is possible utilizing pocket-sized ultrasound, and in some cases, may be more accurate than larger portable ultrasound units. While the differences in these devices were statistically significant, all three were highly accurate, with one pocket device (Lumify) outperforming the rest. Further study in human subjects should be conducted prior to using pocket ultrasound devices for in vivo diagnosis of intracranial hypertension.
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Affiliation(s)
| | - Tomislav Jelic
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Angela Derksen
- Emergency Department, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Bertram Unger
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada.,Department of Anatomy and Cell Science, University of Manitoba, Winnipeg, MB, Canada.,Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.,Centre on Aging, University of Manitoba, Winnipeg, MB, Canada.,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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3
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Point-of-Care Lung Ultrasonography: A Clinical Update for the Emergency Nurse Practitioner. Adv Emerg Nurs J 2021; 43:279-292. [PMID: 34699417 DOI: 10.1097/tme.0000000000000373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Since the introduction of ultrasonography, clinicians have discovered different uses for embedding this technology in the clinical setting. The use of point-of-care ultrasonography has gained a lot of interest in the emergency department. It is a procedure that a clinician can rapidly utilize to triage, risk stratify, evaluate, and monitor the patient's condition. The COVID-19 pandemic has highlighted the significance and application of ultrasonography in identifying and managing patients presenting with lung pathology in the emergency setting.
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Correa Restrepo J, Restrepo-Moreno M, Peláez LG, Díaz Cadavid RD, López-Vasco Y, Alejandra Rojas M, Mejía Toro DA, Morales Uribe CH. Radiografía de tórax de control en pacientes con neumotórax postraumático asintomático. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. El trauma de tórax tiene alta incidencia y el neumotórax es el hallazgo más frecuente. La literatura es escasa sobre qué hacer con los pacientes asintomáticos y con neumotórax por trauma de tórax penetrante.
El objetivo de este estudio fue evaluar cuáles son los hallazgos de la radiografía de control de los pacientes con trauma de tórax penetrante que no son llevados inicialmente a cirugía, y su utilidad para determinar la necesidad de un tratamiento adicional.
Métodos. Se realizó un estudio retrospectivo de cohorte, incluyendo pacientes mayores de 15 años que ingresaron por trauma de tórax penetrante entre enero de 2015 y diciembre de 2017 y que no requirieron manejo quirúrgico inicial. Se analizaron los resultados de la radiografía de tórax, el tiempo de su toma y la conducta decidida según los hallazgos en los pacientes dejados inicialmente bajo observación.
Resultados. Se incluyeron 1.554 pacientes, cuya edad promedio fue de 30 años, 92,5 % del sexo masculino y 97% con herida por arma cortopunzante. Se dejaron 361 pacientes bajo observación con radiografía de control, de los cuales 186 (51,5 %) no presentaban alteraciones en su radiografía inicial, 142 tenían neumotórax menor del 30 % y 33 tenían neumotórax mayor del 30 %, hemoneumotórax o hemotórax. Se requirió toracostomía cerrada como conducta final en 78 casos, esternotomía o toracotomía en 2 casos y 281 se dieron de alta.
Conclusión. En pacientes asintomáticos con neumotórax pequeño o moderado y sin otras lesiones significativas, podrían ser innecesarios los largos tiempos de observación, las radiografías y la toracostomía cerrada.
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5
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Efremov SM, Kuzkov VV, Fot EV, Kirov MY, Ponomarev DN, Lakhin RE, Kokarev EA. Lung Ultrasonography and Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 34:3113-3124. [PMID: 32144058 DOI: 10.1053/j.jvca.2020.01.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/14/2020] [Accepted: 01/15/2020] [Indexed: 02/06/2023]
Abstract
Pulmonary complications are common after cardiac surgery and are closely related to postoperative heart failure and adverse outcomes. Lung ultrasonography (LUS) is currently a widely accepted diagnostic approach with well-established methodology, nomenclature, accuracy, and prognostic value in numerous clinical conditions. The advantages of LUS are universally recognized and include bedside applicability, high diagnostic sensitivity and reproducibility, no radiation exposure, and low cost. However, routine perioperative ultrasonography during cardiac surgery generally is limited to echocardiography, diagnosis of pleural effusion, and as a diagnostic tool for postoperative complications in different organs, and few studies have explored the clinical outcomes in relation to LUS among cardiac patients. This narrative review presents the clinical evidence regarding LUS application in intensive care and during the perioperative period for cardiac surgery. Furthermore, this review describes the methodology and the diagnostic and prognostic accuracies of LUS. A summary of ongoing clinical trials evaluating the clinical outcomes related to LUS also is provided. Finally, this review discusses the rationale for upcoming clinical research regarding whether routine use of LUS can modify current intensive care practice and potentially affect the clinical outcomes after cardiac surgery.
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Affiliation(s)
- Sergey M Efremov
- Department of Anesthesiology and Intensive Care, Saint Petersburg State University Hospital, St. Petersburg, Russian Federation.
| | - Vsevolod V Kuzkov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russian Federation
| | - Evgenia V Fot
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russian Federation
| | - Mikhail Y Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russian Federation
| | - Dmitry N Ponomarev
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Roman E Lakhin
- Department of Anesthesiology and Intensive Care, S.M. Kirov Military Medical Academy of the Ministry of Defense of Russian Federation, St. Petersburg, Russian Federation
| | - Evgenii A Kokarev
- Department of Intensive Care, Primorsky Regional General Hospital #1, Vladivostok, Russian Federation
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A Case Report of Acute Airway Compromise due to Subcutaneous Emphysema. Case Rep Med 2018; 2018:3103061. [PMID: 30595698 PMCID: PMC6286736 DOI: 10.1155/2018/3103061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/26/2018] [Accepted: 11/11/2018] [Indexed: 12/29/2022] Open
Abstract
In the acute management of a trauma patient, airway patency is of utmost importance. The present case describes a male patient who presented with delayed severe upper airway obstruction secondary to massive subcutaneous emphysema following blunt traumatic injury two days previously. Airway compromise is a rarely described but serious complication of subcutaneous emphysema. Current management of subcutaneous emphysema and its association with pneumothorax is summarized. Early decompression of underlying pneumothoraces in patients with significant subcutaneous emphysema should be performed to avoid this rare complication.
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Depiction of pneumothoraces in a large animal model using x-ray dark-field radiography. Sci Rep 2018; 8:2602. [PMID: 29422512 PMCID: PMC5805747 DOI: 10.1038/s41598-018-20985-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 01/29/2018] [Indexed: 11/08/2022] Open
Abstract
The aim of this study was to assess the diagnostic value of x-ray dark-field radiography to detect pneumothoraces in a pig model. Eight pigs were imaged with an experimental grating-based large-animal dark-field scanner before and after induction of a unilateral pneumothorax. Image contrast-to-noise ratios between lung tissue and the air-filled pleural cavity were quantified for transmission and dark-field radiograms. The projected area in the object plane of the inflated lung was measured in dark-field images to quantify the collapse of lung parenchyma due to a pneumothorax. Means and standard deviations for lung sizes and signal intensities from dark-field and transmission images were tested for statistical significance using Student's two-tailed t-test for paired samples. The contrast-to-noise ratio between the air-filled pleural space of lateral pneumothoraces and lung tissue was significantly higher in the dark-field (3.65 ± 0.9) than in the transmission images (1.13 ± 1.1; p = 0.002). In case of dorsally located pneumothoraces, a significant decrease (-20.5%; p > 0.0001) in the projected area of inflated lung parenchyma was found after a pneumothorax was induced. Therefore, the detection of pneumothoraces in x-ray dark-field radiography was facilitated compared to transmission imaging in a large animal model.
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9
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Hefny AF, Kunhivalappil FT, Matev N, Avila NA, Bashir MO, Abu-Zidan FM. Management of computed tomography-detected pneumothorax in patients with blunt trauma: experience from a community-based hospital. Singapore Med J 2017; 59:150-154. [PMID: 28741012 DOI: 10.11622/smedj.2017074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Diagnoses of pneumothorax, especially occult pneumothorax, have increased as the use of computed tomography (CT) for imaging trauma patients becomes near-routine. However, the need for chest tube insertion remains controversial. We aimed to study the management of pneumothorax detected on CT among patients with blunt trauma, including the decision for tube thoracostomy, in a community-based hospital. METHODS Chest CT scans of patients with blunt trauma treated at Al Rahba Hospital, Abu Dhabi, United Arab Emirates, from October 2010 to October 2014 were retrospectively studied. Variables studied included demography, mechanism of injury, endotracheal intubation, pneumothorax volume, chest tube insertion, Injury Severity Score, hospital length of stay and mortality. RESULTS CT was performed in 703 patients with blunt trauma. Overall, pneumothorax was detected on CT for 74 (10.5%) patients. Among the 65 patients for whom pneumothorax was detected before chest tube insertion, 25 (38.5%) needed chest tube insertion, while 40 (61.5%) did not. Backward stepwise likelihood regression showed that independent factors that significantly predicted chest tube insertion were endotracheal intubation (p = 0.01), non-United Arab Emirates nationality (p = 0.01) and pneumothorax volume (p = 0.03). The receiver operating characteristic curve showed that the best pneumothorax volume that predicted chest tube insertion was 30 mL. CONCLUSION Chest tube was inserted in less than half of the patients with blunt trauma for whom pneumothorax was detected on CT. Pneumothorax volume should be considered in decision-making regarding chest tube insertion. Conservative treatment may be sufficient for pneumothorax of volume < 30 mL.
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Affiliation(s)
- Ashraf F Hefny
- Department of Surgery, Al Rahba Hospital, Abu Dhabi, United Arab Emirates.,Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Nikolay Matev
- Department of Radiology, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
| | - Norman A Avila
- Trauma Registry Program, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
| | - Masoud O Bashir
- Department of Surgery, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
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Relative device stability of anterior versus axillary needle decompression for tension pneumothorax during casualty movement. J Trauma Acute Care Surg 2017; 83:S136-S141. [DOI: 10.1097/ta.0000000000001488] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sauter TC, Hoess S, Lehmann B, Exadaktylos AK, Haider DG. Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Emerg Med J 2017; 34:568-572. [PMID: 28500086 PMCID: PMC5574379 DOI: 10.1136/emermed-2016-205980] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 02/15/2017] [Accepted: 04/12/2017] [Indexed: 11/25/2022]
Abstract
Background Extended focused assessment with sonography for trauma (eFAST) has been shown to have moderate sensitivity for detection of pneumothorax in trauma. Little is known about the location or size of missed pneumothoraces or clinical predictors of pneumothoraces in patients with false-negative eFAST. Methods This retrospective cross-sectional study includes all patients with multiple blunt trauma diagnosed with pneumothorax who underwent both eFAST and CT performed in the ED of a level 1 trauma centre in Switzerland between 1 June 2012 and 30 September 2014. Sensitivity of eFAST for pneumothorax was determined using CT as the gold standard. Demographic and clinical characteristics of those who had a pneumothorax detected by eFAST and those who did not were compared using the Mann-Whitney U or Pearson’s χ2 tests. Univariate binary logistic regression models were used to identify predictors for pneumothoraces in patients with negative eFAST examination. Results The study included 109 patients. Overall sensitivity for pneumothorax on eFAST was 0.59 and 0.81 for pneumothoraces requiring treatment. Compared with those detected by eFAST, missed pneumothoraces were less likely to be ventral (30 (47.6%) vs 4 (9.3%), p <0.001) and more likely to be apical and basal (7 (11.1%) vs 15 (34.9%), p=0.003; 11 (17.5%) vs 18 (41.9%), p=0.008, respectively). The missed pneumothoraces were smaller than the detected pneumothoraces (left side: 30.7±17.4 vs 12.1±13.9 mm; right side: 30.2±10.1 vs 6.9±10.2 mm, both p <0.001). No clinical variables were identified which predicted pneumothoraces in falsely negative eFAST. Among those pneumothoraces missed by eFAST, 30% required tube thoracostomy compared with 88.9% of those detected with eFAST. Conclusion In our study, pneumothoraces missed by eFAST were smaller and in atypical locations compared with those detected by eFAST and needed thoracic drainage less often.
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Affiliation(s)
- Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Simon Hoess
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Beat Lehmann
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Dominik G Haider
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern, Switzerland
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Richards JR, McGahan JP. Focused Assessment with Sonography in Trauma (FAST) in 2017: What Radiologists Can Learn. Radiology 2017; 283:30-48. [DOI: 10.1148/radiol.2017160107] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- John R. Richards
- From the Departments of Emergency Medicine (J.R.R.) and Radiology (J.P.M.), University of California, Davis Medical Center, 4860 Y St, Sacramento, CA 95817
| | - John P. McGahan
- From the Departments of Emergency Medicine (J.R.R.) and Radiology (J.P.M.), University of California, Davis Medical Center, 4860 Y St, Sacramento, CA 95817
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Bledsoe J, Liepert AE, Allen TL, Dong L, Hemingway J, Majercik S, Gardner S, Stevens MH. The salutary effect of an integrated system on the rate of repeat CT scanning in transferred trauma patients: Improved costs and efficiencies. Am J Surg 2017; 214:198-200. [PMID: 28283179 DOI: 10.1016/j.amjsurg.2016.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 10/05/2016] [Accepted: 10/24/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Duplication of Computed Tomography (CT) scanning in trauma patients has been a source of quality waste in healthcare and potential harm for patients. Integrated and regional health systems have been shown to promote opportunities for efficiencies, cost savings and increased safety. METHODS This study evaluated traumatically injured patients who required transfer to a Level One Trauma Center (TC) from either within a vertically integrated healthcare system (IN) or from an out-of-network (OON) hospital. RESULTS We found the rate of repeat CT scanning, radiology costs and total costs for day one of hospitalization to be significantly lower for trauma patients transferred from an IN hospital as compared to those patients transferred from OON hospitals. CONCLUSION The inefficiencies and waste often associated with transferred patients can be mitigated and strategies to do so are necessary to reduce costs in the current healthcare environment.
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Affiliation(s)
- Joseph Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.
| | - Amy E Liepert
- Department of Surgery: Trauma, Acute Care Surgery and Critical Care, University of Wisconsin Medical Center, Madison, WI, USA
| | - Todd L Allen
- Institute for Health Care Delivery and Research, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Li Dong
- Institute for Health Care Delivery and Research, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Jamon Hemingway
- Institute for Health Care Delivery and Research, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Sarah Majercik
- Department of Surgery & Division of Trauma, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Scott Gardner
- Department of Surgery & Division of Trauma, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Mark H Stevens
- Department of Surgery & Division of Trauma, Intermountain Medical Center, Salt Lake City, UT, USA
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14
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Affiliation(s)
- S-Y Liu
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
| | - I-T Tsai
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
| | - P-J Yang
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
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15
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Matsumoto S, Sekine K, Funabiki T, Orita T, Shimizu M, Hayashida K, Kazamaki T, Suzuki T, Kishikawa M, Yamazaki M, Kitano M. Diagnostic accuracy of oblique chest radiograph for occult pneumothorax: comparison with ultrasonography. World J Emerg Surg 2016; 11:5. [PMID: 26766962 PMCID: PMC4711032 DOI: 10.1186/s13017-016-0061-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 01/03/2016] [Indexed: 11/11/2022] Open
Abstract
Backgraound An occult pneumothorax is a pneumothorax that is not seen on a supine chest X-ray but is detected by computed tomography scanning. However, critical patients are difficult to transport to the computed tomography suite. We previously reported a method to detect occult pneumothorax using oblique chest radiography (OXR). Several authors have also reported that ultrasonography is an effective technique for detecting occult pneumothorax. The aim of this study was to evaluate the usefulness of OXR in the diagnosis of the occult pneumothorax and to compare OXR with ultrasonography. Methods All consecutive blunt chest trauma patients with clinically suspected pneumothorax on arrival at the emergency department were prospectively included at our tertiary-care center. The patients underwent OXR and ultrasonography, and underwent computed tomography scans as the gold standard. Occult pneumothorax size on computed tomography was classified as minuscule, anterior, or anterolateral. Results One hundred and fifty-nine patients were enrolled. Of the 70 occult pneumothoraces found in the 318 thoraces, 19 were minuscule, 32 were anterior, and 19 were anterolateral. The sensitivity and specificity of OXR for detecting occult pneumothorax was 61.4 % and 99.2 %, respectively. The sensitivity and specificity of lung ultrasonography was 62.9 % and 98.8 %, respectively. Among 27 occult pneumothoraces that could not be detected by OXR, 16 were minuscule and 21 could be conservatively managed without thoracostomy. Conclusion OXR appears to be as good method as lung ultrasonography in the detection of large occult pneumothorax. In trauma patients who are difficult to transfer to computed tomography scan, OXR may be effective at detecting occult pneumothorax with a risk of progression.
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Affiliation(s)
- Shokei Matsumoto
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa 230-0012 Japan
| | - Kazuhiko Sekine
- Department of Emergency Medicine, Saiseikai Central Hospital, 1-4-17 Mita, Minato, Tokyo, 108-0073 Japan
| | - Tomohiro Funabiki
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa 230-0012 Japan
| | - Tomohiko Orita
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa 230-0012 Japan
| | - Masayuki Shimizu
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa 230-0012 Japan
| | - Kei Hayashida
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa 230-0012 Japan
| | - Taku Kazamaki
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa 230-0012 Japan
| | - Tatsuya Suzuki
- Department of Radiological Technology, Saiseikai Yokohamashi Tobu Hospital, 3-6-2 Shimosueyoshi, Tsurumi-ku,, Yokohama-shi, 230-0011 Japan
| | - Masanobu Kishikawa
- Division of Emergency Medicine, Fukuoka City Hospital, 13-1 Yoshizukahonmachi, Hakata-ku, Fukuoka, 812-0046 Japan
| | - Motoyasu Yamazaki
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa 230-0012 Japan
| | - Mitsuhide Kitano
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa 230-0012 Japan
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Wongwaisayawan S, Suwannanon R, Prachanukool T, Sricharoen P, Saksobhavivat N, Kaewlai R. Trauma Ultrasound. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:2543-2561. [DOI: 10.1016/j.ultrasmedbio.2015.05.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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17
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Charbit J, Millet I, Maury C, Conte B, Roustan JP, Taourel P, Capdevila X. Prevalence of large and occult pneumothoraces in patients with severe blunt trauma upon hospital admission: experience of 526 cases in a French level 1 trauma center. Am J Emerg Med 2015; 33:796-801. [PMID: 25881742 DOI: 10.1016/j.ajem.2015.03.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 03/24/2015] [Accepted: 03/26/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Occult pneumothoraces (PTXs), which are not visible on chest x-ray, may progress to tension PTX. The aim of study was to establish the prevalence of large occult PTXs upon admission of patients with severe blunt trauma, according to prehospital mechanical ventilation. METHODS Patients with severe trauma consecutively admitted to our institution for 5 years were retrospectively analyzed. All patients with blunt thoracic trauma who had undergone computed tomographic (CT) within the first hour of hospitalization were included. Mechanical ventilation was considered as early if it was introduced in the prehospital period or on arrival at the hospital. Occult PTXs were defined as PTXs not visible on chest x-ray. All PTXs were measured on CT scan (largest thickness and vertical dimension). Large occult PTXs were defined by a largest thickness of 30 mm or more. RESULTS Of the 526 patients studied, 395 (75%) were male, mean age was 37.9 years, mean Injury Severity Score was 22.2, and 247 (47%) received early mechanical ventilation. Of 429 diagnosed PTXs, 296 (69%) were occult. The proportion of occult PTXs classified as large was 11% (95% confidence interval, 8%-15%). The overall prevalence of large occult PTXs was 6% (95% confidence interval, 4%-8%). Both CT measurements and proportion of large occult PTXs were found statistically comparable in patients with or without mechanical ventilation. CONCLUSIONS Six percent of studied patients with severe trauma had a large and occult PTX as soon as admission despite a normal chest x-ray result. The observed sizes and rates of occult PTX were comparable regardless of the initiation of early mechanical ventilation.
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Affiliation(s)
- Jonathan Charbit
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France; Montpellier I University, Montpellier, France.
| | - Ingrid Millet
- Montpellier I University, Montpellier, France; Department of Radiology, Lapeyronie University Hospital, Montpellier, France
| | - Camille Maury
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Benjamin Conte
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Jean-Paul Roustan
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Patrice Taourel
- Montpellier I University, Montpellier, France; Department of Radiology, Lapeyronie University Hospital, Montpellier, France
| | - Xavier Capdevila
- Trauma Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France; Montpellier I University, Montpellier, France; Institut National de la Santé et de la Recherche Médicale, Equipe soutenue par la Région et l'Inserm U1046 (X.C.), Montpellier, France
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Williams SR, Perera P, Gharahbaghian L. The FAST and E-FAST in 2013: trauma ultrasonography: overview, practical techniques, controversies, and new frontiers. Crit Care Clin 2014; 30:119-50, vi. [PMID: 24295843 DOI: 10.1016/j.ccc.2013.08.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This article reviews important literature on the FAST and E-FAST examinations in adults. It also reviews key pitfalls, limitations, and controversies. A practical "how-to" guide is presented. Lastly, new frontiers are explored.
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Affiliation(s)
- Sarah R Williams
- Division of Emergency Medicine, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive Alway Building, M121, Stanford, CA 93405, USA.
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19
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Bitar ZI, Ibrahim M, el-Emam HS, Bitar MZ. Normal chest X-ray should not mislead. BMJ Case Rep 2013; 2013:bcr-2013-201688. [PMID: 24306430 DOI: 10.1136/bcr-2013-201688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A lung ultrasound (US) can be routinely performed at the bedside by a trained intensive care unit physician and may provide accurate information about a lung's status that has diagnostic and therapeutic relevance. Oesophageal perforations are rare, and due to the rarity of this type of perforation and its non-specific presentation, the diagnosis and treatment are delayed, leading to a high mortality rate. We present a 70-year-old woman with a postoesophagoscopy perforated oesophagus. Lung US detected pneumothorax and mild pleural effusion that were not present on the postoperative chest X-ray. The early detection of the perforation led to a good outcome.
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20
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Sofia S. Bedside US imaging in multiple trauma patients. Part 1: US findings and techniques. J Ultrasound 2013; 16:147-59. [PMID: 24432169 DOI: 10.1007/s40477-013-0047-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 09/21/2013] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES The aim of this review article is to present the current views and visions of the role of ultrasound (US) in the management of patients with multiple trauma. The article is divided into two parts. Part 1 (US findings and techniques) will mainly deal with the technical aspects of US imaging in trauma patients and is written also for educational purposes. Part 2 (pathophysiology and US imaging in trauma patients) will deal with integration of US in the clinical and pathophysiological management of multiple trauma patients. METHODS A non-systematic review of the literature through PubMed search (restricted to the last 10 years) of original articles and review articles. RESULTS 80 publications were selected for Part 1. Of these 80 articles, the author selected 50 according to personal criteria on the basis of their innovative or original contents (48 original articles and 2 literature review articles); 19 articles were furthermore extracted from the references of the selected publications. The information extracted from these 69 publications was organized into sections dealing with different fields of applications of US imaging in multiple trauma patients. CONCLUSIONS US imaging in trauma has evolved from the initial use, i.e., early diagnosis of peritoneal effusion (focused abdominal sonography for trauma), to a wider use known as resuscitative ultrasonography, and is today considered as an extension of physical examination to implement a more effective approach to clinical problems and increase the timeliness and safety of interventions.
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Affiliation(s)
- Soccorsa Sofia
- Department of Emergency Medicine and Urgent Care, Ospedale Maggiore, Largo Bartolo Nigrisoli 2, 40135 Bologna, Italy
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21
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Occult pneumothoraces in critical care: a prospective multicenter randomized controlled trial of pleural drainage for mechanically ventilated trauma patients with occult pneumothoraces. J Trauma Acute Care Surg 2013; 74:747-54; discussion 754-5. [PMID: 23425731 DOI: 10.1097/ta.0b013e3182827158] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with an occult pneumothoraces (OPTXs) may be at risk of tension pneumothoraces (TPTXs) without drainage or pleural drainage complications if treated. METHODS Adults with traumatic OPTXs and requiring positive-pressure ventilation (PPV) were randomized to pleural drainage or observation (one side only enrolled if bilateral). All subsequent care and method of pleural drainage was per attending physician discretion. The primary outcome was a composite of respiratory distress (RD) (need for urgent pleural drainage, acute/sustained increases in O2 requirements, ventilator dysynchrony, and/or charted respiratory events). RESULTS Ninety severely injured patients (mean [SD], Injury Severity Score [ISS], 33 [11]) were studied at four centers: Calgary (55), Toronto (27), Quebec (6), and Sherbrooke (3). Forty were randomized to tube thoracostomy, and 50 were randomized to observation. The risk of RD was similar between the observation and tube thoracostomy groups (relative risk, 0.71; 95% confidence interval, 0.40-1.27). There was no difference in mortality or intensive care unit (ICU), ventilator, or hospital days between groups. In those observed, 20% required subsequent pleural drainage (40% PTX progression, 60% pleural fluid, and 20% other). One observed patient (2%) undergoing PPV at enrollment had a TPTX, which was treated with urgent tube thoracostomy without sequelae. Drainage complications occurred in 15% of those randomized to drainage, while suboptimal tube thoracostomy position occurred in an additional 15%. There were three times (24% vs. 8%) more failures and more RDs (p = 0.01) among those observed with OPTXs requiring sustained PPV versus just for an operation, which increases threefold after a week in the ICU (p = 0.07). CONCLUSION Our results suggest that OPTXs may be safely observed in hemodynamically stable patients undergoing PPV just for an operation, although one third of those requiring a week or more of ICU care received drainage, and TPTXs still occur. Complications of pleural drainage remain unacceptably high, and future work should attempt to delineate specific factors among those observed that warrant prophylactic drainage. LEVEL OF EVIDENCE Therapeutic study, level III.
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Abstract
Blunt chest wall trauma accounts for a large proportion of all trauma presentations to the Emergency Departments in the United Kingdom and has a high reported incidence of morbidity and mortality. The difficulty in the assessment and management of this patient group arises from the possibility that the patient may develop potentially life-threatening complications up to approximately 72 h post-injury, even in patients who have sustained what is initially considered a minor injury. Limited consensus currently exists in the literature regarding optimal assessment or management strategies for this patient group. The aim of this review is to provide an overview of current research investigating the optimal assessment and management strategies for the blunt chest wall trauma patient.
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Affiliation(s)
- Ceri Battle
- Physiotherapy Department, Morriston Hospital, Swansea, UK
- College of Medicine, Swansea University, Swansea, UK
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23
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Husain LF, Hagopian L, Wayman D, Baker WE, Carmody KA. Sonographic diagnosis of pneumothorax. J Emerg Trauma Shock 2012; 5:76-81. [PMID: 22416161 PMCID: PMC3299161 DOI: 10.4103/0974-2700.93116] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 06/06/2011] [Indexed: 12/16/2022] Open
Abstract
Lung sonography has rapidly emerged as a reliable technique in the evaluation of various thoracic diseases. One important, well-established application is the diagnosis of a pneumothorax. Prompt and accurate diagnosis of a pneumothorax in the management of a critical patient can prevent the progression into a life-threatening situation. Sonographic signs, including 'lung sliding', 'B-lines' or 'comet tail artifacts', 'A-lines', and 'the lung point sign' can help in the diagnosis of a pneumothorax. Ultrasound has a higher sensitivity than the traditional upright anteroposterior chest radiography (CXR) for the detection of a pneumothorax. Small occult pneumothoraces may be missed on CXR during a busy trauma scenario, and CXR may not always be feasible in critically ill patients. Computed tomography, the gold standard for the detection of pneumothorax, requires patients to be transported out of the clinical area, compromising their hemodynamic stability and delaying the diagnosis. As ultrasound machines have become more portable and easier to use, lung sonography now allows a rapid evaluation of an unstable patient, at the bedside. These advantages combined with the low cost and ease of use, have allowed thoracic sonography to become a useful modality in many clinical settings.
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Affiliation(s)
- Lubna F Husain
- Department of Emergency Medicine, Boston Medical Center, Boston, MA, USA
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24
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Aukema TS, Beenen LFM, Hietbrink F, Leenen LPH. Initial assessment of chest X-ray in thoracic trauma patients: Awareness of specific injuries. World J Radiol 2012; 4:48-52. [PMID: 22423318 PMCID: PMC3304093 DOI: 10.4329/wjr.v4.i2.48] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2011] [Revised: 09/07/2011] [Accepted: 09/14/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the reported injuries on initial assessment of the chest X-ray (CXR) in thoracic trauma patients to a second read performed by a dedicated trauma radiologist.
METHODS: By retrospective analysis of a prospective database, 712 patients with an injury to the chest admitted to the University Medical Center Utrecht were studied. All patients with a CXR were included in the study. Every CXR was re-evaluated by a trauma radiologist, who was blinded for the initial results. The findings of the trauma radiologist regarding rib fractures, pneumothoraces, hemothoraces and lung contusions were compared with the initial reports from the trauma team, derived from the original patient files.
RESULTS: A total of 516 patients with both thorax trauma and an initial CXR were included in the study. After re-evaluation of the initial CXR significantly more lung contusions (53.3% vs 34.1%, P < 0.001), hemothoraces (17.8% vs 11.0%, P < 0.001) and pneumothoraces (34.4% vs 26.4%, P < 0.001) were detected. During initial assessment significantly more rib fractures were reported (69.8% vs 62.3%, P < 0.001).
CONCLUSION: During the initial assessment of a CXR from trauma patients in the emergency department, a significant number of treatment-dictating injuries are missed. More awareness for these specific injuries is needed.
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25
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Ha YR. Initial evaluation of a trauma patient using an ultrasound. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2012. [DOI: 10.5124/jkma.2012.55.11.1097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Young-Rock Ha
- Emergency Department, Bundang Jesang Hospital, Seongnam, Korea
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26
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Ball CG, Roberts DJ, Kirkpatrick AW, Feliciano DV, Kortbeek JB, Datta I, Laupland KB, Brar M. Can cervical spine computed tomography assist in detecting occult pneumothoraces? Injury 2012; 43:51-4. [PMID: 21999936 DOI: 10.1016/j.injury.2011.09.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 08/13/2011] [Accepted: 09/19/2011] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Screening CT often detects posttraumatic pneumothoraces that were not diagnosed on a preceding supine anteroposterior chest radiograph (occult pneumothoraces (OPTXs)). Because abdominal CT imaging misses OPTXs in the upper thorax, the objective of this study was to evaluate the utility of cervical spine (C-spine) CT screening for diagnosing OPTXs. METHODS A dual-institution (Foothills Medical Centre and Grady Memorial Hospital) retrospective review of consecutive OPTXs was performed. The accuracy of various CT screening protocols in detecting OPTXs was compared. RESULTS OPTXs were detected in 75 patients. Patient demographics and injury characteristics were similar between centres (65% male; 97% blunt mechanism; 29% hemodynamically unstable; mean ISS=27; mean length of stay=22 days; mortality=9%)(p>0.05). Patients received either abdominal (41%) or thoraco-abdominal (59%) CT imaging. Most patients (89%) also underwent C-spine CT imaging. OPTXs were evident on thoracic CT in 100% (44/44), abdominal CT in 83% (62/75), and C-spine CT in 82% (55/67) of cases. All patients with OPTXs identified solely on thoracic CT (i.e. not abdominal) who also underwent imaging of their C-spine could have had their OTPXs diagnosed by using the pulmonary windows setting of their C-spine CT series. Combining C-spine and abdominal CT screening diagnosed all OPTXs (67/67) detected on thoracic CT, for patients who also underwent these investigations. CONCLUSIONS OPTXs were evident on thoracic (and not abdominal) CT in 17% of severely injured patients. For patients who also underwent C-spine imaging, all OPTXs isolated to thoracic CT could be diagnosed by using the pulmonary windows setting of their C-spine CT imaging protocol. All OPTXs, regardless of intra-thoracic location, could also be detected by combining C-spine and abdominal CT screening.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, The University of Calgary, Trauma Services Foothills Medical Centre, 1403-29 Street N.W., T2N 2T9 Calgary, Alberta, Canada.
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Abstract
Severe chest trauma, blunt or penetrating, is responsible for up to 25% of traumatic deaths in North America. Respiratory compromise is the most frequent dramatic presentation in blunt trauma, while injuries to the heart and great vessels pose the greatest risk of immediate death following penetrating trauma. More than 80% of patients will be managed with interventions that can be performed in the emergency department. This article reviews the presentation, diagnosis, and management of the most important thoracic injuries. A structured approach to the acutely unstable patient is proposed to guide resuscitation decisions.
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28
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Ding W, Shen Y, Yang J, He X, Zhang M. Diagnosis of pneumothorax by radiography and ultrasonography: a meta-analysis. Chest 2011; 140:859-866. [PMID: 21546439 DOI: 10.1378/chest.10-2946] [Citation(s) in RCA: 211] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE This study compares, by meta-analysis, the use of anterior-posterior chest radiography (CR) with transthoracic ultrasonography for the diagnosis of pneumothorax. METHODS English-language articles on the performance of CR and ultrasonography in the diagnosis of a pneumothorax were selected. In eligible studies, data were recalculated, and the forest plots and summary receiver operating characteristic (sROC) curves were analyzed. RESULTS Pooled sensitivity and specificity were 0.88 and 0.99, respectively, for ultrasonography, and 0.52 and 1.00, respectively, for CR. For ultrasonography performed by clinicians other than radiologists, pooled sensitivity and specificity were 0.89 and 0.99, respectively. The sROC areas under the curve were compared, and no significant differences between ultrasonography and CR were found. Meta-regression analysis implied that the operator is strongly associated with accuracy (relative diagnostic OR, 0.21; 95% CI, 0.05-0.96; P = .0455). CONCLUSIONS The meta-analysis indicated that bedside ultrasonography performed by clinicians had higher sensitivity and similar specificity compared with CR in the diagnosis of pneumothorax, but the accuracy of ultrasonography in the diagnosis of pneumothorax depended on the skill of the operators.
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Affiliation(s)
- Wu Ding
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University, School of Medicine and Research Institute of Emergency Medicine, Zhejiang University, Hangzhou, China
| | - Yuehong Shen
- Department of Burns, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jianxin Yang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University, School of Medicine and Research Institute of Emergency Medicine, Zhejiang University, Hangzhou, China
| | - Xiaojun He
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University, School of Medicine and Research Institute of Emergency Medicine, Zhejiang University, Hangzhou, China
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University, School of Medicine and Research Institute of Emergency Medicine, Zhejiang University, Hangzhou, China.
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Abstract
BACKGROUND As utilization of computed tomography (CT) scans in the evaluation of trauma patients increases, pneumothoraces (PTXs) seen on CT but not on chest X-ray (CXR), known as occult PTXs (OPTXs), are becoming more prevalent. The incidence of PTXs simply missed on CXR among OPTXs is unclear. A previous retrospective review of CXRs at our institution generally confirmed the occult versus missed designation, but lower fidelity images may have biased this determination. Thus, we repeated this evaluation using the high-quality images and improved the methodology. METHODS The 70 Digital Imaging and Communications in Medicine (DICOM)-quality CXR images were randomly selected from two prospectively collected trauma databases including 22 normal, 5 overt PTX, and 43 study OPTX images. All CXR images were corroborated with multidetector CT imaging. Two blinded fellowship-trained radiologists reviewed and evaluated all the images on an IMPAX viewer. RESULTS All images were deemed "adequate" except for one CXR by a single reviewer. For PTX diagnosis, agreement was 60% for overt PTXs, 86% for normal CXRs, and 81% for study OPTXs, yielding a kappa statistic of 0.51 (95% confidence interval, 0.22-0.81) indicating moderate agreement. Considering only the cases where the reviewers agreed, 80% of the study OPTXs were truly occult versus missed (95% confidence interval, 63-92%). In the 7 missed PTXs, subcutaneous emphysema (5), pleural line (3), and deep sulcus sign (2) were detected. CONCLUSION We estimate that 80% of PTXs considered occult in the trauma room were truly occult. The most common missed sign was subcutaneous emphysema. PTXs are poorly assessed by CXR, and accurate diagnosis should focus on other imaging modalities.
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Omar HR, Abdelmalak H, Mangar D, Rashad R, Helal E, Camporesi EM. Occult pneumothorax, revisited. J Trauma Manag Outcomes 2010; 4:12. [PMID: 21034445 PMCID: PMC2984474 DOI: 10.1186/1752-2897-4-12] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 10/29/2010] [Indexed: 11/10/2022]
Abstract
Pneumothorax is a recognized cause of preventable death following chest wall trauma where a simple intervention can be life saving. In cases of trauma patients where cervical spine immobilization is mandatory, supine AP chest radiograph is the most practical initial study. It is however not as sensitive as CT chest for early detection of a pneumothorax. "Occult" pneumothorax is an accepted definition of an existing but usually a clinically and radiologically silent disturbance that in most patients can be tolerated while other more urgent trauma needs are attended to. However, in certain patients, especially those on mechanical ventilation (with subsequent increase of intrapleural air with positive pressure ventilation), missing the diagnosis of pneumothorax can be deleterious with fatal consequences. This review will discuss the occult pneumothorax in the context of 3 radiological examples, which will further emphasize the entity. Because a negative AP chest radiograph can dangerously delay its recognition, we recommend that any trauma victim presenting to the emergency department with symptoms of respiratory distress should be screened with either thoracic ultrasonography or chest CT scan to avoid missing a pneumothorax.
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Affiliation(s)
- Hesham R Omar
- Departement of Internal Medicine, Mercy Hospital and Medical Center, Chicago, Illinois, USA.
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32
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Affiliation(s)
- Fabrizio Elia
- High Dependency Unit, Ospedale San Giovanni, Bosco, Torino, Italy.
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33
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Opening Pandora’s box: the potential benefit of the expanded FAST exam is partially confounded by the unknowns regarding the significance of the occult pneumothorax. Crit Ultrasound J 2010. [DOI: 10.1007/s13089-010-0024-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Introduction
Point of care (POC) ultrasound brings another powerful dimension to the physical examination of the critically ill. A contemporary challenge for all care providers, however, is how to best incorporate ultrasound into contemporary algorithms of care. When POC ultrasound corroborates pre-examination clinical suspicion, incorporation of the findings into decision-making is easier. When POC ultrasound generates new or unexpected findings, decision-making may be more difficult, especially with conditions that were previously not appreciated with older diagnostic technologies. Pneumothoraces (PTXs), previously seen only on computed tomography and not on supine chest radiographs known as occult pneumothoraces (OPTXs), which are now increasingly appreciated on POC ultrasound, are such an example.
Methods
The relevant literature concerning POC ultrasound and PTXs was reviewed after an electronic search using PubMed supplemented by ongoing research by the Canadian Trauma Trials Collaborative of the Trauma Association of Canada.
Results
OPTXs are frequently encountered in the critically injured who often require mechanical ventilation with positive pressure breathing (PPB). Standard recommendations for post-traumatic PTXs and the setting of PPB mandate chest drainage, recognizing a significant rate of complications related to this procedure itself. Whether these standard recommendations generated in response to obvious overt PTXs apply to these more subtle OPTXs is currently unknown, and evidence-based recommendations regarding appropriate therapy are impossible due to the lack of clinical studies.
Conclusions
OPTXs are a condition that illustrates how incorporation of POC ultrasound findings brings further responsibilities to critically appraise the significance of these findings in terms of patient outcomes and overall care. Adequately powered and adequately followed-up clinical trials addressing the treatment are required.
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Gillman LM, Ball CG, Panebianco N, Al-Kadi A, Kirkpatrick AW. Clinician performed resuscitative ultrasonography for the initial evaluation and resuscitation of trauma. Scand J Trauma Resusc Emerg Med 2009; 17:34. [PMID: 19660123 PMCID: PMC2734531 DOI: 10.1186/1757-7241-17-34] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Accepted: 08/06/2009] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Traumatic injury is a leading cause of morbidity and mortality in developed countries worldwide. Recent studies suggest that many deaths are preventable if injuries are recognized and treated in an expeditious manner - the so called 'golden hour' of trauma. Ultrasound revolutionized the care of the trauma patient with the introduction of the FAST (Focused Assessment with Sonography for Trauma) examination; a rapid assessment of the hemodynamically unstable patient to identify the presence of peritoneal and/or pericardial fluid. Since that time the use of ultrasound has expanded to include a rapid assessment of almost every facet of the trauma patient. As a result, ultrasound is not only viewed as a diagnostic test, but actually as an extension of the physical exam. METHODS A review of the medical literature was performed and articles pertaining to ultrasound-assisted assessment of the trauma patient were obtained. The literature selected was based on the preference and clinical expertise of authors. DISCUSSION In this review we explore the benefits and pitfalls of applying resuscitative ultrasound to every aspect of the initial assessment of the critically injured trauma patient.
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Affiliation(s)
- Lawrence M Gillman
- Regional Trauma Services, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Surgery, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
| | - Chad G Ball
- Regional Trauma Services, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
| | - Nova Panebianco
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Azzam Al-Kadi
- Regional Trauma Services, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
| | - Andrew W Kirkpatrick
- Regional Trauma Services, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Surgery, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Critical Care Medicine, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
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