Clinician-performed focused sonography for the resuscitation of trauma

Full head-to-head comparison of ultrasonography and CT scan in volumetric quantification of pleural effusion: a systematic review and meta-analysis

Pleural effusion is a very common clinical finding. Quantifying pleural effusion volume and its response to treatment over time has become increasingly important for clinicians, which is currently performed via computed tomography (CT) or drainage. To determine and compare ultrasonography (US), CT, and drainage agreements in pleural effusion volumetry. Protocol pre-registration was performed a priori at ( https://osf.io/rnugd/ ). We searched PubMed, Web of Science, Embase, and Cochrane Library for studies up to January 7, 2024. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2), QUADAS-C, and Consensus-based Standards for the selection of health Measurement Instruments (COSMIN). Volumetric performances of CT, US, and drainage in assessment of pleural effusion volume were evaluated through both aggregated data (AD) and individual participant data (IPD) analyses. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Six studies were included with 446 pleural effusion lesions. AD results showed a perfect level of agreement with pooled Pearson correlation and intraclass correlation coefficient (ICC) of 0.933 and 0.948 between US and CT. IPD results demonstrated a high level of agreement between US and CT, with Finn's coefficient, ICC, concordance correlation coefficient (CCC), and Pearson correlation coefficient values of 0.856, 0.855, 0.854, and 0.860, respectively. Also, both results showed an overall perfect level of agreement between US and drainage. As for comparing the three combinations, US vs. CT and US vs. drainage were both superior to CT vs. drainage, suggesting the US is a good option for pleural effusion volumetric assessment. Ultrasound provides a highly reliable, to-the-point, cost-effective, and noninvasive method for the assessment of pleural effusion volume and is a great alternative to CT or drainage.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

INTRODUCTION

Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines.

MATERIAL AND METHODS

The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.

RESULTS

This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy.

CONCLUSIONS

Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

INTRODUCTION

Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines.

MATERIAL AND METHODS

The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.

RESULTS

This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy.

CONCLUSION

Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.

New International Guidelines and Consensus on the Use of Lung Ultrasound

Following the innovations and new discoveries of the last 10 years in the field of lung ultrasound (LUS), a multidisciplinary panel of international LUS experts from six countries and from different fields (clinical and technical) reviewed and updated the original international consensus for point-of-care LUS, dated 2012. As a result, a total of 20 statements have been produced. Each statement is complemented by guidelines and future developments proposals. The statements are furthermore classified based on their nature as technical (5), clinical (11), educational (3), and safety (1) statements.

The State of Point-of-Care Ultrasound Training in Undergraduate Medical Education: Findings From a National Survey

PURPOSE

The primary aim of this study was to evaluate the current state of point-of-care ultrasound (POCUS) integration in undergraduate medical education (UME) at MD-granting medical schools in the United States.

METHOD

In 2020, 154 clinical ultrasound directors and curricular deans at MD-granting medical schools were surveyed. The 25-question survey collected data about school characteristics, barriers to POCUS training implementation, and POCUS curriculum details. Descriptive analysis was conducted using frequency and percentage distributions.

RESULTS

One hundred twenty-two (79%) of 154 schools responded to the survey, of which 36 were multicampus. Sixty-nine (57%) schools had an approved POCUS curriculum, with 10 (8%) offering a longitudinal 4-year curriculum. For a majority of schools, POCUS instruction was required during the first year (86%) and second year (68%). Forty-two (61%) schools were teaching fundamentals, diagnostic, and procedural ultrasound. One hundred fifteen (94%) schools identified barriers to implementing POCUS training in UME, which included lack of trained faculty (63%), lack of time in current curricula (54%), and lack of equipment (44%). Seven (6%) schools identified no barriers.

CONCLUSIONS

Over half of the responding medical schools in the United States had integrated POCUS instruction into their UME curricula. Despite this, a very small portion had a longitudinal curriculum and multiple barriers existed for implementation, with the most common being lack of trained faculty. The data from this study can be used by schools planning to add or expand POCUS instruction within their current curricula.

Empowering the willing: the feasibility of tele-mentored self-performed pleural ultrasound assessment for the surveillance of lung health

BACKGROUND

SARS-CoV-2 infection, manifesting as COVID-19 pneumonia, constitutes a global pandemic that is disrupting health-care systems. Most patients who are infected are asymptomatic/pauci-symptomatic can safely self-isolate at home. However, even previously healthy individuals can deteriorate rapidly with life-threatening respiratory failure characterized by disproportionate hypoxemic failure compared to symptoms. Ultrasound findings have been proposed as an early indicator of progression to severe disease. Furthermore, ultrasound is a safe imaging modality that can be performed by novice users remotely guided by experts. We thus examined the feasibility of utilizing common household informatic-technologies to facilitate self-performed lung ultrasound.

METHODS

A lung ultrasound expert remotely mentored and guided participants to image their own chests with a hand-held ultrasound transducer. The results were evaluated in real time by the mentor, and independently scored by three independent experts [planned a priori]. The primary outcomes were feasibility in obtaining good-quality interpretable images from each anatomic location recommended for COVID-19 diagnosis.

RESULTS

Twenty-seven adults volunteered. All could be guided to obtain images of the pleura of the 8 anterior and lateral lung zones (216/216 attempts). These images were rated as interpretable by the 3 experts in 99.8% (647/648) of reviews. Fully imaging one's posterior region was harder; only 108/162 (66%) of image acquisitions was possible. Of these, 99.3% of images were interpretable in blinded evaluations. However, 52/54 (96%) of participants could image their lower posterior lung bases, where COVID-19 is most common, with 99.3% rated as interpretable.

CONCLUSIONS

Ultrasound-novice adults at risk for COVID-19 deterioration can be successfully mentored using freely available software and low-cost ultrasound devices to provide meaningful lung ultrasound surveillance of themselves that could potentially stratify asymptomatic/paucisymptomatic patients with early risk factors for serious disease. Further studies examining practical logistics should be conducted.

TRIAL REGISTRATION

ID ISRCTN/77929274 on 07/03/2015.

Pioneering Remotely Piloted Aerial Systems (Drone) Delivery of a Remotely Telementored Ultrasound Capability for Self Diagnosis and Assessment of Vulnerable Populations-the Sky Is the Limit

Remotely Piloted Aerial Systems (RPAS) are poised to revolutionize healthcare in out-of-hospital settings, either from necessity or practicality, especially for remote locations. RPAS have been successfully used for surveillance, search and rescue, delivery, and equipping drones with telemedical capabilities being considered. However, we know of no previous consideration of RPAS-delivered tele-ultrasound capabilities. Of all imaging technologies, ultrasound is the most portable and capable of providing real-time point-of-care information regarding anatomy, physiology, and procedural guidance. Moreover, remotely guided ultrasound including self-performed has been a backbone of medical care on the International Space Station since construction. The TeleMentored Ultrasound Supported Medical Interventions Group of the University of Calgary partnered with the Southern Alberta Institute of Technology to demonstrate RPAS delivery of a smartphone-supported tele-ultrasound system by the SwissDrones SDO50 RPAS. Upon receipt of the sanitized probe, a completely ultrasound-naïve volunteer was guided by a remote expert located 100 km away using online video conferencing (Zoom), to conduct a self-performed lung ultrasound examination. It proved feasible for the volunteer to examine their anterior chest, sides, and lower back bilaterally, correlating with standard recommended examinations in trauma/critical care, including the critical locations of a detailed COVID-19 lung diagnosis/surveillance examination. We contend that drone-delivered telemedicine including a tele-ultrasound capability could be leveraged to enhance point-of-care diagnostic accuracy in catastrophic emergencies, and allow diagnostic capabilities to be delivered to vulnerable populations in remote locations for whom transport is impractical or undesirable, speeding response times, or obviating the risk of disease transmission depending on the circumstances.

Reliability of transcranial sonography for assessment of brain midline shift in adult neurocritical patients: a systematic review and meta-analysis

INTRODUCTION

The aim of this systematic review and meta-analysis was to determine the reliability of transcranial sonography as an alternative to computed tomography for evaluation of brain midline shift in adult neurocritical patients.

EVIDENCE AQUISITION

The PubMed, EMBASE, Cochrane Library, Scopus and Web of Science databases were searched. Original studies evaluating brain midline shift in adult neurocritical patients using both transcranial sonography and computed tomography were eligible. Primary outcome measure was concordance between both methods as quantified in terms of concordance correlation coefficient. Secondary outcome measure was limits of agreement, defined as mean difference between sonography and computed tomography plus and minus 1.96 standard deviations.

EVIDENCE SYNTHESIS

Twelve studies (574 patients, 689 examinations) were eligible. Ten studies (416 patients, 492 examinations) provided adequate data for evaluation of concordance. Pooling of effect sizes showed strong concordance between both methods (concordance correlation coefficient, 0.91; 95% CI, 0.87 to 0.94). Two missing studies were imputed and effect size was adjusted to 0.88 (95% CI, 0.81 to 0.93). Nine studies (442 patients, 571 examinations) provided adequate data for estimation of limits of agreement. Pooling of effect sizes showed a bias of -0.53 mm (95% limits of agreement, -1.22 to 0.16 mm). Four missing studies were imputed and bias was adjusted to -0.68 mm (95% limits of agreement, -1.31 to -0.04 mm).

CONCLUSIONS

Transcranial sonography may serve as reliable alternative to computed tomography for evaluation of brain midline shift in adult neurocritical patients. Both methods have strong concordance with acceptably narrow limits of agreement.

Too fast, or not fast enough? The FAST exam in patients with non-compressible torso hemorrhage

BACKGROUND

Focused assessment with sonography for trauma (FAST) performance metrics are unknown in patients with non-compressible torso hemorrhage (NCTH).

METHODS

Retrospective review of a dedicated NCTH database from four level 1 trauma centers (2008-2012). NCTH was defined as (1) named axial torso vessel disruption; (2) AIS chest or abdomen >2 with shock (base deficit < -4) or truncal operation in ≤ 90 min; or (3) pelvic fracture with ring disruption. Patients were grouped by cavity of hemorrhage source and by shock (SBP ≤ 90).

RESULTS

274 patients had a FAST prior to diagnosis of NCTH. FAST was positive in 51% of patients with abdominal/pelvic hemorrhage for a false negative rate (FNR) of 49%. FNR was higher for pelvic (61%) versus abdominal (43%) sources (p = 0.02). There was no difference between FAST negative or positive patients for ISS, shock, length of stay, or mortality (all p = NS). FNR was not improved among the subgroup of NCTH patients with shock (p = NS).

CONCLUSION

FAST identified abdominal/pelvic hemorrhage in approximately half of NCTH patients, and this was not improved among patients presenting with shock.

The focused assessment with sonography in trauma (FAST) in hypotensive injured patients frequently fails to identify the need for laparotomy: a multi-institutional pragmatic study

Background

The ability of focused assessment with sonography for trauma (FAST) to detect clinically significant hemorrhage in hypotensive injured patients remains unclear. We sought to describe the sensitivity and specificity of FAST using findings at laparotomy as the confirmatory test.

Methods

Patients from the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study that had a systolic blood pressure < 90mm Hg and underwent FAST were analysed. Results were compared with findings at laparotomy. A therapeutic laparotomy (T-LAP) was defined as an abdominal operation within 6 hours in which a definitive procedure was performed. The sensitivity and specificity of FAST were calculated.

Results

The cohort included 317 patients that underwent FAST (108 positive, 209 negative). T-LAP was performed in 69% (n=75) of FAST(+) patients and 22% (n=48) of FAST(−) patients. FAST had a sensitivity of 62% and specificity of 83%.

Conclusions

In our multicenter cohort, 22% of FAST(−) patients underwent T-LAP within 6 hours of admission. In hypotensive patients with a negative FAST, clinicians should still maintain a high index of suspicion for significant abdominal hemorrhage.

Level of evidence

Level IV.

Telepresent Focused Assessment With Sonography for Trauma Examination Training Versus Traditional Training for Medical Students: A Simulation-Based Pilot Study

OBJECTIVES

Telepresent education is becoming an important modality in medical education, as it provides a means for instructors to lead education sessions via videoconferencing technologies. This study aimed to compare the effectiveness of telepresent ultrasound training versus traditional in-person ultrasound training.

METHODS

Medical student cohorts were educated by either traditional in-person instruction or telementoring on how to perform a focused assessment with sonography for trauma (FAST) examination. Effectiveness was evaluated by pre- and post-multiple-choice tests (knowledge), confidence surveys, and summative simulation scenarios (hands-on FAST simulation). Formative simulation scenario debriefings were evaluated by each student using the Debriefing Assessment for Simulation in Healthcare student version (DASH-SV).

RESULTS

Each method of instruction had significant increases in knowledge, confidence, and hands-on FAST simulation performance (P < .05). The collective increase in knowledge was greater for the in-person group, whereas the improvement in FAST examination performance during simulations was greater for the telementored group. Confidence gains were comparable between the groups. The DASH-SV scores were significantly higher for the in-person group for each criterion; however, both methods were deemed effective via median scoring.

CONCLUSIONS

Telepresent education is a viable option for teaching the FAST examination to medical students.

Diagnostic Accuracy of Focused Assessment with Sonography for Blunt Abdominal Trauma in Pediatric Patients Performed by Emergency Medicine Residents versus Radiology Residents

INTRODUCTION

Focused assessment with sonography for trauma (FAST) has been shown to be useful to detect intraperitoneal free fluid in patients with blunt abdominal trauma (BAT).

OBJECTIVE

We compared the diagnostic accuracy of FAST performed by emergency medicine residents (EMRs) and radiology residents (RRs) in pediatric patients with BAT.

METHOD

In this prospective study, pediatric patients with BAT and high energy trauma who were referred to the emergency department (ED) at Al-Zahra and Kashani hospitals in Isfahan, Iran, were evaluated using FAST, first by EMRs and subsequently by RRs. The reports provided by the two resident groups were compared with the final outcome based on the results of the abdominal computed tomography (CT), operative exploration, and clinical observation.

RESULTS

A total of 101 patients with a median age of 6.75 ± 3.2 years were enrolled in the study between January 2013 and May 2014. These patients were evaluated using FAST, first by EMRs and subsequently by RRs. A good diagnostic agreement was noted between the results of the FAST scans performed by EMRs and RRs (κ = 0.865, P < 0.001). The sensitivity, specificity, positive and negative predictive values, and accuracy in evaluating the intraperitoneal free fluid were 72.2%, 85.5%, 52%, 93.3%, and 83.2%, respectively, when FAST was performed by EMRs and 72.2%, 86.7%, 54.2%, 93.5%, and 84.2%, respectively, when FAST was performed by RRs. No significant differences were seen between the EMR- and RR-performed FAST.

CONCLUSION

In this study, FAST performed by EMRs had acceptable diagnostic value, similar to that performed by RRs, in patients with BAT.

Recent Developments in Tele-Ultrasonography

A long-standing trend that will continue to grow in healthcare is providing high quality services for all the patient, no matter the distance and no matter the place. One approach currently being used to increase population access to healthcare services is telemedicine. This narrative review presents one branch of e-health, in particular the use of teleultrasonography (TUS) in clinical practice, the challenges and barriers encountered. Current advances in ultrasound technology, including the growth of portable and small ultrasound devices have increased the range of applications of TUS, from traumatic patients in emergency medicine, maternal ultrasound and even for monitoring and screening for chronic illnesses. Even though some barriers are still looking for a solution, like standardized training and protocols, errors in data acquisition, the lack of trained professionals to operate in remote areas, TUS has the potential to redesign future health care systems.

Prehospital Echocardiography During Resuscitation Impacts Treatment in a Physician-Staffed Helicopter Emergency Medical Service: an Observational Study

BACKGROUND

Patients in cardiac arrest must receive algorithm-based management such as basic life support and advanced (cardiac) life support. International guidelines dictate diagnosing and treating any factor that may have caused the arrest or may be complicating the resuscitation. Ultrasound may be of potential value in this process and can be used in a prehospital setting. The objective is to evaluate the use of prehospital ultrasound during traumatic and non-traumatic CPR and determine its impact on prehospital treatment decisions in a Dutch helicopter emergency medical service (HEMS).

METHODS

We conducted an observational study in cardiac arrest patients, of any cause, in whom the Nijmegen HEMS performed CPR with concurrent echocardiography. The participating physicians had to adhere to Advanced Life Support protocols as per standard operating procedure. Simultaneous with the interruptions of chest compressions to allow for heart rhythm analysis, ultrasound-trained HEMS physicians performed echocardiography according to study protocol. The HEMS nurse and physician recorded patient data and data on impacted (supported or altered) patient treatment decisions.

RESULTS

From February 2014 through November 2016, we included 56 patients who underwent 102 ultrasound examinations. Sixty-two (61%) ultrasound examinations impacted 78 treatment decisions in 49 patients (88%). The impacted treatment was related to termination of CPR in 32 (57%), fluid management (14%), drugs selection and doses (14%), and choice of destination hospital (5%). Causes of cardiac arrest included trauma (48%), cardiac (21%), medical (14%), asphyxia (9%), and other (7%).

CONCLUSION

Prehospital echocardiography has an impact on patient treatment and may be a useful tool to support decision-making during CPR in a Dutch HEMS.

Point-of-Care Ultrasound to Diagnose Postpericardiotomy Syndrome in a Child

We report a case of a patient presenting with abdominal pain after cardiac surgery who was noted on point-of-care ultrasound (POCUS) to have pericardial and pleural effusion, in addition to ascites. The most notable findings were pleural and pericardial effusions, which combined with symptomatology met criteria for postpericardiotomy syndrome. Point-of-care ultrasound expedited the diagnosis of a pericardial effusion with impending tamponade and transfer for pericardiocentesis and placement of pericardial drain.

Integration of Ultrasound in Medical Education at United States Medical Schools: A National Survey of Directors' Experiences

OBJECTIVES

Despite the rise of ultrasound in medical education (USMED), multiple barriers impede the implementation of such curricula in medical schools. No studies to date have surveyed individuals who are successfully championing USMED programs. This study aimed to investigate the experiences with ultrasound integration as perceived by active USMED directors across the United States.

METHODS

In 2014, all allopathic and osteopathic medical schools in the United States were contacted regarding their status with ultrasound education. For schools with required point-of-care ultrasound curricula, we identified the USMED directors in charge of the ultrasound programs and sent them a 27-question survey. The survey included background information about the directors, ultrasound program details, the barriers directors faced toward implementation, and the directors' attitudes toward ultrasound education.

RESULTS

One-hundred seventy-three medical schools were contacted, and 48 (27.7%) reported having a formal USMED curriculum. Thirty-six USMED directors responded to the survey. The average number of years of USMED curriculum integration was 2.8 years (SD, 2.9). Mandatory ultrasound curricula had most commonly been implemented into years 1 and 2 of medical school (71.4% and 62.9%, respectively). The most common barriers faced by these directors when implementing their ultrasound programs were the lack of funding for faculty/ equipment (52.9%) and lack of time in current medical curricula (50.0%).

CONCLUSIONS

Financial commitments and the full schedules of medical schools are the current prevailing roadblocks to implementation of ultrasound education. Experiences drawn from current USMED directors in this study may be used to help programs starting their own curricula.

Integration of Ultrasound in Undergraduate Medical Education at the California Medical Schools: A Discussion of Common Challenges and Strategies From the UMeCali Experience

Since the first medical student ultrasound electives became available more than a decade ago, ultrasound in undergraduate medical education has gained increasing popularity. More than a dozen medical schools have fully integrated ultrasound education in their curricula, with several dozen more institutions planning to follow suit. Starting in June 2012, a working group of emergency ultrasound faculty at the California medical schools began to meet to discuss barriers as well as innovative approaches to implementing ultrasound education in undergraduate medical education. It became clear that an ongoing collaborative could be formed to discuss barriers, exchange ideas, and lend support for this initiative. The group, termed Ultrasound in Medical Education, California (UMeCali), was formed with 2 main goals: to exchange ideas and resources in facilitating ultrasound education and to develop a white paper to discuss our experiences. Five common themes integral to successful ultrasound education in undergraduate medical education are discussed in this article: (1) initiating an ultrasound education program; (2) the role of medical student involvement; (3) integration of ultrasound in the preclinical years; (4) developing longitudinal ultrasound education; and (5) addressing competency.

A Comparative Analysis of Diagnostic Accuracy of Focused Assessment With Sonography for Trauma Performed by Emergency Medicine and Radiology Residents

BACKGROUND

Focused assessment with sonography in trauma (FAST) is a method for prompt detection of the abdominal free fluid in patients with abdominal trauma.

OBJECTIVES

This study was conducted to compare the diagnostic accuracy of FAST performed by emergency medicine residents (EMR) and radiology residents (RRs) in detecting peritoneal free fluids.

PATIENTS AND METHODS

Patients triaged in the emergency department with blunt abdominal trauma, high energy trauma, and multiple traumas underwent a FAST examination by EMRs and RRs with the same techniques to obtain the standard views. Ultrasound findings for free fluid in peritoneal cavity for each patient (positive/negative) were compared with the results of computed tomography, operative exploration, or observation as the final outcome.

RESULTS

A total of 138 patients were included in the final analysis. Good diagnostic agreement was noted between the results of FAST scans performed by EMRs and RRs (κ = 0.701, P < 0.001), also between the results of EMRs-performed FAST and the final outcome (κ = 0.830, P < 0.0010), and finally between the results of RRs-performed FAST and final outcome (κ = 0.795, P < 0.001). No significant differences were noted between EMRs- and RRs-performed FASTs regarding sensitivity (84.6% vs 84.6%), specificity (98.4% vs 97.6%), positive predictive value (84.6% vs 84.6%), and negative predictive value (98.4% vs 98.4%).

CONCLUSIONS

Trained EMRs like their fellow RRs have the ability to perform FAST scan with high diagnostic value in patients with blunt abdominal trauma.

International evidence-based recommendations for focused cardiac ultrasound

BACKGROUND

Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use.

METHODS

The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method.

RESULTS

During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients.

CONCLUSIONS

This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

The WHO ultrasonography protocol for assessing hepatic morbidity due to Schistosoma mansoni. Acceptance and evolution over 12 years

The aim of this study is to review the worldwide acceptance of the World Health Organization (WHO) ultrasound protocol for assessing hepatosplenic morbidity due to Schistosoma mansoni since its publication in 2000. A PubMed literature research using the keywords "schistosomiasis and ultrasound," "schistosomiasis and ultrasonography," and "S. mansoni and ultrasound" from 2001 to 2012 was performed. Case reports, reviews, reports on abnormalities due to parasites other than S. mansoni, organ involvement other than the human liver, and reports where ultrasound method was not described were excluded. Six studies were retrieved from other Brazilian sources. Sixty studies on 37,424 patients from 15 countries were analyzed. The WHO protocol was applied with increasing frequency from 43.75% in the years 2001 to 2004 to 84.61% in 2009 to 2012. Results obtained using the pictorial image pattern approach of the protocol are reported in 38/41 studies, whereas measurements of portal branch walls were applied in 19/41 and results reported in 2/41 studies only. The practical usefulness of the pictorial approach of the WHO protocol is confirmed by its wide acceptance. This approach alone proved satisfactory in terms of reproducibility, assessment of evolution of pathology, and comparability between different settings. The measurements of portal branches, also part of the protocol, may be omitted without losing relevant information since results obtained by these measurements are nonspecific. This would save resources by reducing the time required for each examination. It is also more feasible for examiners who are not specialized in medical imaging. As with all protocols, incipient liver fibrosis is difficult to distinguish from normal ultrasound findings of the liver. The ability of this protocol to predict complications in severe cases should be further evaluated in a higher number of patients.

What's new in operative trauma surgery in the last 10 years

PURPOSE OF REVIEW

This article reviews the latest operative trauma surgery techniques and strategies, which have been published in the last 10 years. Many of the articles we reviewed come directly from combat surgery experience and may be also applied to the severely injured civilian trauma patient and in the context of terrorist attacks on civilian populations.

RECENT FINDINGS

We reviewed the most important innovations in operative trauma surgery; the use of ultrasound and computed tomography in the preoperative evaluation of the penetrating trauma patient, the use of temporary vascular shunts, the current management of military wounds, the use of preperitoneal packing in pelvic fractures and the management of the multiple traumatic amputation patient.

SUMMARY

The last 10 years of conflict has produced a wealth of experience and novel techniques in operative trauma surgery. The articles we review here are essential for the contemporary care of the severely injured trauma patient, whether they are card for in a level 1 trauma center or in a field hospital at the edge of a battlefield.

The FAST and E-FAST in 2013: trauma ultrasonography: overview, practical techniques, controversies, and new frontiers

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.

Pericardiocentesis in trauma: a systematic review

BACKGROUND

Pericardiocentesis (PCC) had been taught as a mandatory skill in the Advanced Trauma Life Support (ATLS®) course as a bridge to definitive surgical therapy for traumatic pericardial tamponade since its inception in 1978. Immediate thoracotomy for penetrating trauma to the heart and chest has resulted in the decreased use of PCC in trauma. PCC is now offered as an optional skill in the ninth edition of the ATLS®. A review of the literature regarding the use and effectiveness of PCC in traumatic pericardial tamponade in the modern era is necessary to better define its current role in trauma care.

METHODS

Scientific publications from 1970 to 2010 involving PCC after trauma were identified. The Preferred Reporting Items for Systematic reviews and Meta-Analyses was used. Human studies describing acute traumatic tamponade were included. Publications involving nontraumatic or chronic pericardial tamponade from effusions caused by inflammatory, infectious, or neoplastic etiology were excluded. Publications were categorized by level of evidence.

RESULTS

Of the 135 publications identified, 27 were included, composing of 2,094 trauma patients with suspected cardiac tamponade. The reported use of PCC decreased from 45.9% of patients in the period 1970 to 1979 down to 6.4% of patients in the period between 2000 and 2010 (p < 0.05). Reported rates describing the use of PCC as the sole intervention decreased from 13.7% in the period 1970 to 1979 to 2.1% in the period 2000 to 2010 (p < 0.05). Survival analysis after PCC was possible for 380 patients. Overall survival following PCC was 83.4% (n = 317) and 91.8% (n = 145) when used as the sole intervention. In patients who received PCC then thoracotomy, survival rate was 79.5% (n = 178).

CONCLUSION

Studies on the use of PCC for trauma are limited and biased toward survivors. The reported survival rate is high. There remains a limited role for PCC in nontrauma centers where definitive surgical management is not immediately available and transport time to a higher level of care facility supports the use of temporary decompression by PCC.

LEVEL OF EVIDENCE

Systematic review, level III.

Conformational conversion of prion protein in prion diseases

Prion diseases are a group of infectious fatal neurodegenerative diseases. The conformational conversion of a cellular prion protein (PrP(C)) into an abnormal misfolded isoform (PrP(Sc)) is the key event in prion diseases pathology. Under normal conditions, the high-energy barrier separates PrP(C) from PrP(Sc) isoform. However, pathogenic mutations, modifications as well as some cofactors, such as glycosaminoglycans, nucleic acids, and lipids, could modulate the conformational conversion process. Understanding the mechanism of conformational conversion of prion protein is essential for the biomedical research and the treatment of prion diseases. Particularly, the characterization of cofactors interacting with prion protein might provide new diagnostic and therapeutic strategies.

Potential Use of Remote Telesonography as a Transformational Technology in Underresourced and/or Remote Settings

Mortality and morbidity from traumatic injury are twofold higher in rural compared to urban areas. Furthermore, the greater the distance a patient resides from an organized trauma system, the greater the likelihood of an adverse outcome. Delay in timely diagnosis and treatment contributes to this penalty, regardless of whether the inherent barriers are geographic, cultural, or socioeconomic. Since ultrasound is noninvasive, cost-effective, and portable, it is becoming increasingly useful for remote/underresourced (R/UR) settings to avoid lengthy patient travel to relatively inaccessible medical centers. Ultrasonography is a user-dependent, technical skill, and many, if not most, front-line care providers will not have this advanced training. This is particularly true if care is being provided by out-of-hospital, “nontraditional” providers. The human exploration of space has forced the utilization of information technology (IT) to allow remote experts to guide distant untrained care providers in point-of-care ultrasound to diagnose and manage both acute and chronic illness or injuries. This paradigm potentially brings advanced diagnostic imaging to any medical interaction in a setting with internet connectivity. This paper summarizes the current literature surrounding the development of teleultrasound as a transformational technology and its application to underresourced settings.

Just-in-time cost-effective off-the-shelf remote telementoring of paramedical personnel in bedside lung sonography-a technical case study

PURPOSE

Remote telementored ultrasound (RTMUS) is a new discipline that allows a remote expert to guide variably experienced clinical responders through focused ultrasound examinations. We used the examination of the pleural spaces after tube thoracostomy (TT) removal by a nurse with no prior ultrasound experience as an illustrative but highly accurate example of the technique using a simple cost-effective system.

MATERIALS AND METHODS

The image outputs of a handheld ultrasound machine and a head-mounted Web camera were input into a customized graphical user interface and streamed over a freely available voice over Internet protocol system that allowed two-way audio and visual communication between the novice examiner and the remote expert. The bedside nurse was then guided to examine the anterior chest of a patient who had recently had bilateral TTs removed. The team sought to determine the presence or absence of any recurrent pneumothoraces using the standard criteria for the ultrasound diagnosis of post-removal pneumothorax (PTXs). An upright chest radiograph (CXR) was obtained immediately after the RTMUS examination.

RESULTS

The RTMUS system enabled the novice user to learn how to hold the ultrasound probe, where to place it on the chest, and thereafter to diagnose a subtle unilateral PTX characterized as "tiny" on the subsequent formal CXR report.

CONCLUSIONS

As ultrasound has almost limitless clinical utility, using simple but advanced informatics and communication technologies has potential to improve worldwide healthcare delivery. RTMUS could be used both to enhance the information content as well as to digitally document important physiologic findings in any clinical encounter wherever a portable ultrasound and Internet connectivity are available.

The sonographic diagnosis of pneumothorax

Ultrasound is a modality now available to all physicians and can help in making rapid decisions, particularly with critically ill patients. This article reviews the basis of the use of sonography for the diagnosis of pneumothorax.

[Preclinical management of multiples injuries: S3 guideline]

The guidelines follow the priorities established by the A-B-C-D-E scheme. They focus on the treatment of actual disturbances of vital functions and not so much on their anticipated development. Important recommendations with regard to the indication for intubation and ventilation, fluid therapy, diagnosis and treatment of severe chest injuries (tension pneumothorax in particular), management of severe traumatic brain injury, pelvic and vertebral injuries, priorities in the management of extremity fractures as well as indications for the choice of the receiving hospital are given. The recommendations are discussed in view of future concerns and developments.

The song remains the same although the instruments are changing: complications following selective non-operative management of blunt spleen trauma: a retrospective review of patients at a level I trauma centre from 1996 to 2007

BACKGROUND

Despite a widespread shift to selective non-operative management (SNOM) for blunt splenic trauma, there remains uncertainty regarding the role of adjuncts such as interventional radiological techniques, the need for follow-up imaging, and the incidence of long-term complications. We evaluated the success of SNOM (including splenic artery embolization, SAE) for the management of blunt splenic injuries in severely injured patients.

METHODS

Retrospective review (1996-2007) of the Alberta Trauma Registry and health records for blunt splenic trauma patients, aged 18 and older, with injury severity scores of 12 or greater, admitted to the Foothills Medical Centre.

RESULTS

Among 538 eligible patients, 150 (26%) underwent early operative intervention. The proportion of patients managed by SNOM rose from 50 to 78% over the study period, with an overall success rate of SNOM of 87%, while injury acuity remained unchanged over time. Among SNOM failures, 65% underwent surgery within 24 hours of admission. Splenic arterial embolization (SAE) was used in only 7% of patients managed non-operatively, although at least 21% of failed SNOM had contrast extravasation potentially amenable to SAE. Among Calgary residents undergoing SNOM, hospital readmission within six months was required in three (2%), all of whom who required emergent intervention (splenectomy 2, SAE 1) and in whom none had post-discharge follow-up imaging. Overall, the use of post-discharge follow-up CT imaging was low following SNOM (10%), and thus no CT images identified occult hemorrhage or pseudoaneurysm. We observed seven cases of delayed splenic rupture in our population which occurred from five days to two months following initial injury. Three of these occurred in the post-discharge period requiring readmission and intervention.

CONCLUSIONS

SNOM was the initial treatment strategy for most patients with blunt splenic trauma with 13% requiring subsequent operative intervention intended for the spleen. Cases of delayed splenic rupture occurred up to two months following initial injury. The low use of both follow-up imaging and SAE make assessment of the utility of these adjuncts difficult and adherence to formalized protocols will be required to fully assess the benefit of multi-modality management strategies.

[How should anesthesiologists perform ultrasound examinations? Diagnostic use of ultrasound in emergency and intensive care and medicine]

Ultrasound imaging has attained great significance as a tool for diagnostics in emergency and intensive care medicine. The major advantages of this technique are its instantaneous bedside availability and the possibility to perform repeatable examinations. These advantages are based on recent developments, such as portable ultrasound devices offering excellent imaging quality as well as a quick-start-function. Ultrasound imaging in critically ill patients is frequently performed under pressure of time depending on the current acute physical state. All standard examinations in echocardiography, vascular, abdominal and thoracic ultrasound scanning can be applied in these patients. Based on the clinical scenario the duration of examinations may vary from seconds during cardiopulmonary resuscitations to time-consuming repeated scanning. The transition from basic to subject-specific detailed examinations is flowing and has to be adjusted to local conditions. In the field of emergency and intensive care medicine the technique used is whole-body sonography. The goal is to classify the patient's present physical state and to define a targeted therapeutic approach. The characteristics of whole-body sonography are similar to the field of anesthesiology which is an interdisciplinary one. Currently, these characteristics deserve more attention in training in sonography.

Evaluating emergency ultrasound training in India

Background:

In countries with fully developed emergency medicine systems, emergency ultrasound (EUS) plays an important role in the assessment and treatment of critically ill patients.

Methods:

The authors sought to introduce EUS to a group of doctors working in the emergency departments (EDs) in India through an intensive 4-day adult and pediatric ultrasound course held at the Apex Trauma Center and EM division of the All India Institute of Medical Sciences in New Delhi. The workshop was evaluated with a survey questionnaire and a hands-on practical test. The questionnaire was designed to assess the current state of EUS in India's EDs, and to identify potential barriers to the incorporation of EUS into current EM practice. The EUS course consisted of a general introductory didactic session followed by pediatric, abdominal and trauma, cardiothoracic, obstetrical and gynecologic, and vascular modules. Each module had a didactic session followed by handson applications with live models and/or simulators. A post-course survey questionnaire was given to the participants, and there was a practical test on the final day of the course. The ultrasound images taken by the participants were digitally recorded, and were subsequently graded for their accuracy by independent observers, residency, and/or fellowship trained in EUS.

Results:

There were a total of 42 participants who completed the workshop and took the practical examination; 32 participants filled in the course evaluation survey. Twenty-four (75%) participants had no prior experience with EUS, 5 (16%) had some experience, and 3 (9%) had significant experience. During the practical examination, 38 of 42 participants (90%) were able to identify Morison's pouch on the focused abdominal sonography for trauma (FAST) examination, and 32 (76%) were able to obtain a parasternal long axis cardiac view and identify the left ventricle. The inferior vena cava was identified as it crosses the diaphragm into the right atrium by 20 (48%) participants. All participants felt they would be able to incorporate what they had learned into their practice, and indicated that they were advocates for further training of non-radiologist clinicians in the use of ED ultrasound.

Conclusion:

After this introductory workshop in EUS, the participants were comfortable in their ability to use the ultrasound machine. Participants deemed it particularly useful for certain ED applications, particularly the FAST examination, the lung examination, and vascular access.

Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma

OBJECTIVES

Focused assessment of sonography in trauma (FAST) has been shown useful to detect clinically significant hemoperitoneum in adults, but not in children. The objectives were to determine test characteristics for clinically important intraperitoneal free fluid (FF) in pediatric blunt abdominal trauma (BAT) using computed tomography (CT) or surgery as criterion reference and, second, to determine the test characteristics of FAST to detect any amount of intraperitoneal FF as detected by CT.

METHODS

This was a prospective observational study of consecutive children (0-17 years) who required trauma team activation for BAT and received either CT or laparotomy between 2004 and 2007. Experienced physicians performed and interpreted FAST. Clinically important FF was defined as moderate or greater amount of intraperitoneal FF per the radiologist CT report or surgery.

RESULTS

The study enrolled 431 patients, excluded 74, and analyzed data on 357. For the first objective, 23 patients had significant hemoperitoneum (22 on CT and one at surgery). Twelve of the 23 had true-positive FAST (sensitivity = 52%; 95% confidence interval [CI] = 31% to 73%). FAST was true negative in 321 of 334 (specificity = 96%; 95% CI = 93% to 98%). Twelve of 25 patients with positive FAST had significant FF on CT (positive predictive value [PPV] = 48%; 95% CI = 28% to 69%). Of 332 patients with negative FAST, 321 had no significant fluid on CT (negative predictive value [NPV] = 97%; 95% CI = 94% to 98%). Positive likelihood ratio (LR) for FF was 13.4 (95% CI = 6.9 to 26.0) while the negative LR was 0.50 (95% CI = 0.32 to 0.76). Accuracy was 93% (333 of 357, 95% CI = 90% to 96%). For the second objective, test characteristics were as follows: sensitivity = 20% (95% CI = 13% to 30%), specificity = 98% (95% CI = 95% to 99%), PPV = 76% (95% CI = 54% to 90%), NPV = 78% (95% CI = 73% to 82%), positive LR = 9.0 (95% CI = 3.7 to 21.8), negative LR = 0.81 (95% CI = 0.7 to 0.9), and accuracy = 78% (277 of 357, 95% CI = 73% to 82%).

CONCLUSION

In this population of children with BAT, FAST has a low sensitivity for clinically important FF but has high specificity. A positive FAST suggests hemoperitoneum and abdominal injury, while a negative FAST aids little in decision-making.

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

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.

Whole-body ultrasound in the intensive care unit: a new role for an aged technique

Management of critically ill patients requires rapid and safe diagnostic techniques. Ultrasonography has become an indispensable tool that supplements physical examination in the intensive care unit. It enables early recognition of neurological emergencies, assists the diagnosis of abdominal and lung pathologies, and provides real-time information on the cardiac performance of critically ill patients. Furthermore, it detects possible infectious sites and renders therapeutic invasive procedures more convenient and less complicated. Whole-body ultrasound in the hands of adequately trained intensivists has the ability to reinvigorate the physical examination, without subjecting the patient to excessive irradiation and the risks of transport.

Clinician performed resuscitative ultrasonography for the initial evaluation and resuscitation of trauma

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.

The clinical and technical evaluation of a remote telementored telesonography system during the acute resuscitation and transfer of the injured patient

BACKGROUND

Ultrasound (US) has an ever increasing scope in the evaluation of trauma, but relies greatly on operator experience. NASA has refined telesongraphy (TS) protocols for traumatic injury, especially in reference to mentoring inexperienced users. We hypothesized that such TS might benefit remote terrestrial caregivers. We thus explored using real-time US and video communication between a remote (Banff) and central (Calgary) site during acute trauma resuscitations.

METHODS

A existing internet link, allowing bidirectional videoconferencing and unidirectional US transmission was used between the Banff and Calgary ERs. Protocols to direct or observe an extended focused assessment with sonography for trauma (EFAST) were adapted from NASA algorithms. A call rota was established. Technical feasibility was ascertained through review of completed checklists. Involved personnel were interviewed with a semistructured interview.

RESULTS

In addition to three normal volunteers, 20 acute clinical examinations were completed. Technical challenges requiring solution included initiating US; audio and video communications; image freezing; and US transmission delays. FAST exams were completed in all cases and EFASTs in 14. The critical anatomic features of a diagnostic examination were identified in 98% of all FAST exams and a 100% of all EFASTs that were attempted. Enhancement of clinical care included confirmation of five cases of hemoperitoneum and two pneumothoraces (PTXs), as well as educational benefits. Remote personnel were appreciative of the remote direction particularly when instructions were given sequentially in simple, nontechnical language.

CONCLUSIONS

The remote real-time guidance or observation of an EFAST using TS appears feasible. Most technical problems were quickly overcome. Further evaluation of this approach and technology is warranted in more remote settings with less experienced personnel.

Snowboarding injuries: a review of the literature and an analysis of the potential use of portable ultrasound for mountainside diagnostics

Snowboarding has become a popular recreational and professional sport. Participants suffer a variety of injuries, especially of the extremities, that require medical evaluation. This article reviews the reported injuries to both leisure and elite athletes. To many, an injured extremity requires travel to a medical facility for accurate evaluation. Musculoskeletal ultrasound is an accurate and portable technology that can be used for real time, mountainside diagnoses of these injuries.

Ultrasound in the surgical intensive care unit

PURPOSE OF REVIEW

Critically ill patients are subjected to a variety of diagnostic and therapeutic procedures. It is desirable to make these interventions as timely, safe, and effective as possible. Bedside ultrasound and echocardiography are tools that allow for diagnosis of many conditions, without subjecting the patient to radiation, dye, and the risks of transport. In addition, ultrasound guidance of procedures may improve safety and efficacy. This review analyzes the literature on ultrasound and echocardiography use in the ICU.

RECENT FINDINGS

There is evidence supporting the use of bedside echocardiography and ultrasound for the diagnosis of chest, abdominal, and other pathologic conditions in the ICU. There is also evidence to support ultrasound guidance of vascular access and other procedures. There are multiple reports of novel uses of bedside echocardiography and ultrasound in the ICU.

SUMMARY

There is substantial literature supporting ultrasound and bedside limited echocardiography in the critical care setting. In addition, there are frequent reports of new applications for these technologies in the literature. The role of ultrasound and bedside limited echocardiography in the critical care setting is likely to expand in the future and become a part of daily care in every surgical intensive care unit.

Diagnostic accuracy of bedside ultrasonography in the ICU: feasibility of detecting pulmonary effusion and lung contusion in patients on respiratory support after severe blunt thoracic trauma

BACKGROUND

Blunt thoracic trauma is a major concern in critically ill patients. Repeated lung diagnostic evaluations are needed in order to follow up the clinical situation and the results of the therapeutic strategies. The aim of this prospective clinical study was to evaluate the possible role of lung ultrasound (LU) compared with bedside radiography (CXR) and computed tomography (CT) used as the gold standard in the evaluation of trauma patients admitted to the intensive care unit with acute respiratory failure.

METHOD

A total of 15 thoracic trauma patients were studied at intensive care unit (ICU) arrival (T1) and 48 h later (T2) with CT, CXR and LU. We evaluated the presence of pleural effusion (PE) and lung contusion (LC). For this purpose the lung parenchyma was divided into 12 regions so that we could compare 180 lung regions at T1 and T2, respectively.

RESULTS

Sensitivity of ultrasound was 0.94 for PE and 0.86 for LC while specificity 0.99 and 0.97, respectively. The likelihood ratio was 94 (rho(+)) and 0.06 (rho(-)) for PE and 28.6 (rho(+)) and 0.14 (rho(-)) for LC.

CONCLUSIONS

Ultrasound provides a reliable noninvasive, bedside method for the assessment of chest trauma patients with acute respiratory failure in the ICU.