Current role of emergency ultrasound of the chest

Lung Ultrasound Signs: The Beginning. Part 3-An Accademia di Ecografia Toracica Comprehensive Review on Ultrasonographic Signs and Real Needs

Over the last 20 years, scientific literature and interest on chest/lung ultrasound (LUS) have exponentially increased. Interpreting mixed-anatomical and artifactual-pictures determined the need of a proposal of a new nomenclature of artifacts and signs to simplify learning, spread, and implementation of this technique. The aim of this review is to collect and analyze different signs and artifacts reported in the history of chest ultrasound regarding normal lung, pleural pathologies, and lung consolidations. By reviewing the possible physical and anatomical interpretation of these artifacts and signs reported in the literature, this work aims to present the AdET (Accademia di Ecografia Toracica) proposal of nomenclature and to bring order between published studies.

Development of an Automated Ultrasound Signal Indicator of Lung Interstitial Syndrome

OBJECTIVES

The number and distribution of lung ultrasound (LUS) imaging artifacts termed B-lines correlate with the presence of acute lung disease such as infection, acute respiratory distress syndrome (ARDS), and pulmonary edema. Detection and interpretation of B-lines require dedicated training and is machine and operator-dependent. The goal of this study was to identify radio frequency (RF) signal features associated with B-lines in a cohort of patients with cardiogenic pulmonary edema. A quantitative signal indicator could then be used in a single-element, non-imaging, wearable, automated lung ultrasound sensor (LUSS) for continuous hands-free monitoring of lung fluid.

METHODS

In this prospective study a 10-zone LUS exam was performed in 16 participants, including 12 patients admitted with acute cardiogenic pulmonary edema (mean age 60 ± 12 years) and 4 healthy controls (mean age 44 ± 21). Overall,160 individual LUS video clips were recorded. The LUS exams were performed with a phased array probe driven by an open-platform ultrasound system with simultaneous RF signal collection. RF data were analyzed offline for candidate B-line indicators based on signal amplitude, temporal variability, and frequency spectrum; blinded independent review of LUS images for the presence or absence of B-lines served as ground truth. Predictive performance of the signal indicators was determined with receiving operator characteristic (ROC) analysis with k-fold cross-validation.

RESULTS

Two RF signal features-temporal variability of signal amplitude at large depths and at the pleural line-were strongly associated with B-line presence. The sensitivity and specificity of a combinatorial indicator were 93.2 and 58.5%, respectively, with cross-validated area under the ROC curve (AUC) of 0.91 (95% CI = 0.80-0.94).

CONCLUSION

A combinatorial signal indicator for use with single-element non-imaging LUSS was developed to facilitate continuous monitoring of lung fluid in patients with respiratory illness.

Point-of-care ultrasound diagnosis of skull fracture in Chinese children 0–6 years old with scalp hematoma from minor head trauma: A preliminary prospective observational study

Background

Previous studies have suggested that point-of-care ultrasound could help to evaluate and diagnose pediatric skull fracture for the closed scalp hematoma from blunt trauma. However, relevant data in Chinese children are missing, especially in children 0-6 years old.

Objectives

Our study aimed to evaluate the efficacy of point-of-care ultrasound to diagnose skull fracture in children 0-6 years old with scalp hematoma in China.

Methods

We performed a prospective observational study and screened children 0-6 years old with closed scalp hematoma and a Glasgow coma scale of 14-15 at Hospital in China. Enrolled children (N = 152) were first evaluated for skull fracture with point-of-care ultrasound by the emergency physician and then received a head computed tomography scan.

Results

The point-of-care ultrasound examination and computed tomography scan revealed skull fracture in 13 (8.6%) and 12 (7.9%) children, respectively. The kappa test showed a satisfactory agreement between two examinations (P < 0.0001), with kappa = 0.87 (95% confidence interval, i.e., 95% CI, [0.69, 1.00]) and area under the curve = 0.95 (95% CI [0.86, 1], P < 0.0001). The point-of-care ultrasound examination had the sensitivity of 91.7% (95% CI [62.5%, 100%]), specificity of 98.6% (95% CI [94.6%, 100%]), positive predictive value of 84.6% (95% CI [56.5%, 96.9%]), negative predictive value of 99.2% (95% CI [95.6%, 100%]), and accuracy of 98.0% (95% CI [94.1%, 99.6%]).

Conclusions

While our study is preliminary in nature, our findings may guide future larger studies in assessing the utility of point-of-care ultrasound examination in diagnosing skull fractures in children with scalp hematoma from minor head trauma.

Lung Ultrasound Artifacts Interpreted as Pathology Footprints

Background: The original observation that lung ultrasound provides information regarding the physical state of the organ, rather than the anatomical details related to the disease, has reinforced the idea that the observed acoustic signs represent artifacts. However, the definition of artifact does not appear adequate since pulmonary ultrasound signs have shown valuable diagnostic accuracy, which has been usefully exploited by physicians in numerous pathologies. Method: A specific method has been used over the years to analyze lung ultrasound data and to convert artefactual information into anatomical information. Results: A physical explanation of the genesis of the acoustic signs is provided, and the relationship between their visual characteristics and the surface histopathology of the lung is illustrated. Two important sources of potential signal alteration are also highlighted. Conclusions: The acoustic signs are generated by acoustic traps that progressively release previously trapped energy. Consequently, the acoustic signs highlight the presence of acoustic traps and quantitatively describe their distribution on the lung surface; they are not artifacts, but pathology footprints and anatomical information. Moreover, the impact of the dynamic focusing algorithms and the impact of different probes on the visual aspect of the acoustic signs should not be neglected.

Ultrasound during the COVID-19 Pandemic: A Global Approach

SARS-CoV-2 (severe acute respiratory syndrome Coronavirus-2) rapidly spread worldwide as COVID-19 (Coronavirus disease 2019), causing a costly and deadly pandemic. Different pulmonary manifestations represent this syndrome's most common clinical manifestations, together with the cardiovascular complications frequently observed in these patients. Ultrasound (US) evaluations of the lungs, heart, and lower limbs may be helpful in the diagnosis, follow-up, and prognosis of patients with COVID-19. Moreover, POCUS (point-of-care ultrasound) protocols are particularly useful for patients admitted to intensive care units. The present review aimed to highlight the clinical conditions during the SARS-CoV-2 pandemic in which the US represents a crucial diagnostic tool.

Lung ultrasound in the diagnosis of COVID-19-associated pneumonia

Over the past decades, lung ultrasound in the diagnosis of lung diseases has become widespread. Ultrasound examination has a number of advantages (no radiation exposure, real-time imaging, clear visualization of the subpleural lung regions and costophrenic angles), which make it possible to use ultrasound to monitor the dynamics of pneumonia in children and pregnant women. Currently, in the context of the COVID-19 pandemic, lung ultrasound is widely used due to its high diagnostic efficiency, which is comparable with classical radiography and X-ray computed tomography (CT) by a number of parameters.

The article describes the method of lung ultrasound and the radiographic pattern of COVID-19-associated pneumonia. It also provides a review of the literature, according to which the severity of pneumonia was determined, depending on the radiographic pattern, and the need for a lung ultrasound was identified.

The article indicates that information on assessment of the radiographic pattern of the lungs at runtime in different variants of the course of coronavirus infection, as well as many methodological issues, including the frequency of second-look lung ultrasound, has not been sufficiently studied.

Pseudohemothorax induced by residual contrast medium mimicking aortic dissection rupture

Hemothorax is an urgent condition, and its accurate diagnosis and the identification of the cause are important. Herein, we report a case of a 74-year-old man with end-stage renal disease who was presented with high-concentration pleural effusion owing to residual contrast medium. The case required differentiation from hemothorax owing to an aortic dissection and its rupture. In patients with end-stage renal disease, noncontrast-enhanced computed tomography after contrast-enhanced computed tomography may result in high-concentration pleural effusion owing to the existence of residual contrast medium. This realization is important to determine whether high-concentration pleural effusion symptoms reflect an urgent hemothorax case possibly related to an imminent rupture of an aortic aneurysm or intrathoracic penetration of aortic dissection, and whether invasive procedures, such as thoracentesis, ought to be avoided.

Focused Cardiac Ultrasound to Detect Pre-capillary Pulmonary Hypertension

Background

Early recognition of pre-capillary (PC) pulmonary hypertension (PH) benefits dogs, allowing earlier treatment and improving prognosis. The value of focused cardiac ultrasound (FCU) to diagnose PH and assess its severity has not been investigated yet.

Hypothesis

A subjective 10-point FCU pulmonary hypertension score (PHS) allows diagnosis and assessment of severity of PCPH.

Animals

This study involved fifty client-owned dogs.

Methods

Dogs, recruited between September 2017 and February 2020, were classified into four categories (no, mild, moderate, and severe PH; C1 to C4, respectively). C1 and C2, and C3 and C4 were regrouped as group 1 and group 2, respectively. A blinded general practitioner assessed four FCU cineloops. Five echocardiographic parameters were subjectively scored, resulting in a total score of 0–10. Non-parametric tests compared global scores between categories and groups. A receiver operating characteristic (ROC) curve determined the cutoff value to differentiate group 1 and group 2. A gray zone approach allowed diagnosing or excluding moderate to severe PH with 90% certitude.

Results

Global scores were significantly higher for C4 than for C1, C2, and C3. Global scores of G2 were significantly higher than G1. The ROC curve indicated a cutoff value of 5, discriminating group 1 from group 2 with a sensitivity of 77% and a specificity of 100%. A score of ≥5/10 allowed diagnosing moderate to severe PH with ≥90% certainty while a score of ≤2/10 excluded PH with ≥90% certainty.

Conclusions and Clinical Significance

Moderate to severe PCPH can be accurately detected by non-cardiologists using a 10-point FCU PHS score.

Ten Years of Pediatric Lung Ultrasound: A Narrative Review

Lung diseases are the most common conditions in newborns, infants, and children and are also the primary cause of death in children younger than 5 years old. Traditionally, the lung was not thought to be a target for an ultrasound due to its inability to penetrate the gas-filled anatomical structures. With the deepening of knowledge on ultrasound in recent years, it is now known that the affected lung produces ultrasound artifacts resulting from the abnormal tissue/gas/tissue interface when ultrasound sound waves penetrate lung tissue. Over the years, the application of lung ultrasound (LUS) has changed and its main indications in the pediatric population have expanded. This review analyzed the studies on lung ultrasound in pediatrics, published from 2010 to 2020, with the aim of highlighting the usefulness of LUS in pediatrics. It also described the normal and abnormal appearances of the pediatric lung on ultrasound as well as the benefits, limitations, and possible future challenges of this modality.

Lung ultrasound in a tertiary intensive care unit population: a diagnostic accuracy study

BACKGROUND

Evidence from previous studies comparing lung ultrasound to thoracic computed tomography (CT) in intensive care unit (ICU) patients is limited due to multiple methodologic weaknesses. While addressing methodologic weaknesses of previous studies, the primary aim of this study is to investigate the diagnostic accuracy of lung ultrasound in a tertiary ICU population.

METHODS

This is a single-center, prospective diagnostic accuracy study conducted at a tertiary ICU in the Netherlands. Critically ill patients undergoing thoracic CT for any clinical indication were included. Patients were excluded if time between the index and reference test was over eight hours. Index test and reference test consisted of 6-zone lung ultrasound and thoracic CT, respectively. Hemithoraces were classified by the index and reference test as follows: consolidation, interstitial syndrome, pneumothorax and pleural effusion. Sensitivity, specificity, positive and negative likelihood ratio were estimated.

RESULTS

In total, 87 patients were included of which eight exceeded the time limit and were subsequently excluded. In total, there were 147 respiratory conditions in 79 patients. The estimated sensitivity and specificity to detect consolidation were 0.76 (95%CI: 0.68 to 0.82) and 0.92 (0.87 to 0.96), respectively. For interstitial syndrome they were 0.60 (95%CI: 0.48 to 0.71) and 0.69 (95%CI: 0.58 to 0.79). For pneumothorax they were 0.59 (95%CI: 0.33 to 0.82) and 0.97 (95%CI: 0.93 to 0.99). For pleural effusion they were 0.85 (95%CI: 0.77 to 0.91) and 0.77 (95%CI: 0.62 to 0.88).

CONCLUSIONS

In conclusion, lung ultrasound is an adequate diagnostic modality in a tertiary ICU population to detect consolidations, interstitial syndrome, pneumothorax and pleural effusion. Moreover, one should be careful not to interpret lung ultrasound results in deterministic fashion as multiple respiratory conditions can be present in one patient. Trial registration This study was retrospectively registered at Netherlands Trial Register on March 17, 2021, with registration number NL9344.

The use of intraoperative bedside lung ultrasound in optimizing positive end expiratory pressure in obese patients undergoing laparoscopic bariatric surgeries

BACKGROUND

Anesthetic management of patients with obesity undergoing laparoscopic abdominal surgeries requires careful plan for intraoperative mechanical ventilation aiming to avoid lung atelectasis and/or overdistention. There are conflicting data on the optimum positive end expiratory pressure (PEEP) during these surgeries. We hypothesized that lung ultrasound could be used for PEEP titration during laparoscopic surgery.

OBJECTIVE

The purpose of this study is to evaluate the effectiveness of intraoperative individualized lung ultrasound-guided PEEP in obese patients undergoing laparoscopic bariatric surgery on intraoperative partial arterial oxygen tension (PaO₂) and early postoperative pulmonary complications.

METHODS

A randomized controlled trial included 40 adult patients with body mass index (BMI) > 35 kg/m² undergoing laparoscopic bariatric surgery. Patients were randomized into: control group (n = 20) who received PEEP 4 cm.H₂ O and ultrasound-guided group (n = 20) who received individualized lung ultrasound stepwise PEEP. All patients received volume-controlled ventilation with a tidal volume of 6 mL/kg of ideal weight and a fraction of inspired oxygen of .5. The primary outcome was the difference in partial arterial oxygen tension (PaO₂) between the control group and the ultrasound-guided group. The secondary outcomes included the incidence of early postoperative pulmonary atelectasis, respiratory failure, bronchospasm, hypoxia or pneumothorax.

SETTINGS

General surgery operating theatre at Cairo University hospitals.

RESULTS

Ultrasound-guided group showed higher PO₂ after PEEP optimization and postoperatively compared with control group (P = .005, and P = .01 respectively). Also, ultrasound-guided group showed no postoperative complications compared with control group that had 5 cases who developed postoperative pulmonary complications in the form of hypoxia and basal collapse in the first 24 hour postoperatively chest x ray (0% versus 25%, P = .047).

CONCLUSION

In patients with obesity undergoing laparoscopic bariatric surgery, the use of lung ultrasound individualized stepwise PEEP approach improved oxygenation, compliance and reduced the incidence of postoperative pulmonary atelectasis and hypoxia without causing hemodynamic instability.

Artifactual Lung Ultrasonography: It Is a Matter of Traps, Order, and Disorder

When inspecting the lung with standard ultrasound B-mode imaging, numerous artifacts can be visualized. These artifacts are useful to recognize and evaluate several pathological conditions in Emergency and Intensive Care Medicine. More recently, the interest of the Pulmonologists has turned to the echographic study of the interstitial pathology of the lung. In fact, all lung pathologies which increase the density of the tissue, and do not consolidate the organ, are characterized by the presence of ultrasound artifacts. Many studies of the past have only assessed the number of vertical artifacts (generally known as B-Lines) as a sign of disease severity. However, recent observations suggest that the appearance of the individual artifacts, their variability, and their internal structure, may play a role for a non-invasive characterization of the surface of the lungs, directing the diagnoses and identifying groups of diseases. In this review, we discuss the meaning of lung ultrasound artifacts, and introduce hypothesis on the correlation between their presence and the structural variation of the sub-pleural tissue in light of current knowledge of the acoustic properties of the pleural plane.

Vital Role of Ultrasound in the Era of COVID-19: Arriving at the Right Diagnosis Real Time

Ultrasound has become an integral part for assessment of critically ill patients. It has helped in diagnosing and treating critically ill patients. The added advantage of ultrasonography is that it is a fantastic diagnostic tool that is easily available at the bedside, repeatable, more objective, and has a steep learning curve. It has become fifth vital assessment along with inspection, palpation, percussion, and auscultation. In the current scenario of COVID-19 pandemic, the disease caused by virus ranges from mild influenza-like illness to severe acute respiratory illness (SARI). Among the patients developing SARI, few require hospitalization and might need intensive care management. As a critical care specialist, we need to keep our antenna up to look for other causes for SARI due to non-COVID etiology as well. This article describes algorithmic approach and vital role of ultrasonography while managing patients with respiratory distress.

How to cite this article

Havaldar AA. Vital Role of Ultrasound in the Era of COVID-19: Arriving at the Right Diagnosis Real Time. Indian J Crit Care Med 2020;24(7):563-564.

Extended-FAST plus MDCT in pneumothorax diagnosis of major trauma: time to revisit ATLS imaging approach?

BACKGROUND AND OBJECTIVE

Pneumothorax (PNX) detection is of the utmost clinical relevance because it may quickly progress to cause hemodynamic instability as a consequence of invasive ventilation. Radiography is characterized by a low sensitivity to detect this disease; in recent years, chest ultrasound (US) has gained increased visibility in the diagnosis of acute respiratory emergencies including PNX. The aim of this retrospective study was to evaluate the clinical impact of extended focused assessment with sonography in trauma (E-FAST) during the past 6 years of experience with this technique in our Level I trauma center.

METHODS

Between January 2013 and December 2018, we performed a retrospective case-series study including 3320 consecutive patients admitted to the emergency department of our hospital because of major trauma. Extended-US was always performed and reported immediately after FAST during primary survey and before multidetector computed tomography (MDCT) scans. The presence of PNX was determined using the well-known accepted US criteria. US findings were compared with computed tomography (CT) findings, the reference standard for PNX detection.

RESULTS

Of the 6640 lungs observed with E-FAST, there were 1244 PNX cases, while 1328 PNX cases were detected either on the basis of MDCT or on the basis of the presence of air flush during the thoracic decompression in the emergency room. Among the 84 false negatives, 12 patients had subcutaneous emphysema, 38 had a body mass index higher than 27, 6 had a thoracic wall hematoma, and 4 had chest penetrating trauma. There were 10 false positives in the diagnosis of PNX at US examination, with mild extension and not clinically significant. The overall sensitivity of E-FAST for PNX detection was 93.6% (1244/1328), the specificity of E-FAST was 99.8% (5312/5322), the negative predictive value (NPV) was 98.4% (5312/5396), and the positive predictive value (PPV) was 99.2% (1328/1338).

CONCLUSION

Our results demonstrate that bedside thoracic US is characterized by a very good accuracy in the diagnostic work-up of major trauma patients, even in difficult conditions, allowing rapid diagnosis of PNX.

ADVANCES IN KNOWLEDGE

The novelty of this research lies in the possibility of diagnosing potential life-threatening conditions in a very short time by means of US, thus proposing a revision of the Advanced Trauma Life Support (ATLS) guidelines in order to incorporate it in the work-up of high-energy injured patients.

Diagnosis of pulmonary embolism: Following the evidence from suspicion to certainty

Accurate, timely and cost-effective identification of pulmonary embolism remains a diagnostic challenge. This article reviews the pulmonary embolism diagnostic process with a focus on the best practice advice from the American College of Physicians. Benefits and risks of each diagnostic step are discussed. Emerging diagnostic tools, not included in the algorithm, are briefly reviewed.

Focused Cardiac Ultrasound in Pediatric Pulmonary Hypertension

We present 2 cases of pediatric pulmonary hypertension presenting with respiratory distress. Focused cardiac ultrasound revealed findings consistent with right ventricular dilatation and elevated right ventricular pressure. These findings, in conjunction with the clinical presentation, allowed for early identification and rapid evaluation of a pathologic process that can often go unidentified. In this report, we review the relevant aspects of focused cardiac ultrasound in the setting of pulmonary hypertension.

Diagnostic Performance of 6-Point Lung Ultrasound in ICU Patients: A Comparison with Chest X-Ray and CT Thorax

Objective

To evaluate the diagnostic performance of a rapid bedside 6-point lung ultrasonography (LUS) performed by an intensive care unit (ICU) physician for detection of four common pathological conditions of the lung, such as alveolar consolidation, pleural effusion, interstitial syndrome and pneumothorax, in critically ill patients and its comparison with bedside chest X-ray (CXR) and high-resolution computed tomography (CT) scan of the thorax. Volume of pleural effusion measured by LUS and CT thorax was also compared.

Methods

This was a cross-sectional, observational study of 90 adult patients with an acute lung injury score of ≥1 admitted to the medical-surgical ICU. They were examined by CXR and 6-point LUS as per BLUE protocol at bedside, followed by CT thorax in the radiology department.

Results

The sensitivity of 6-point LUS for detecting alveolar consolidation, pleural effusion, interstitial syndrome and pneumothorax was 76%, 88%, 83% and 89%, respectively, which was remarkably higher than that of CXR. The specificity of LUS was 100% for all pathologies, which was again notably higher than that of CXR except for interstitial syndrome for which it was 88.5%. Measurement of volume of pleural effusion by LUS was comparable and had a strong absolute agreement with CT thorax.

Conclusion

6-Point LUS can be a useful diagnostic tool and is better than CXR in diagnosing respiratory pathologies in critically ill patients. Owing to the comparable diagnostic performance of LUS and CT scan and with increasing evidence in favour of LUS, the requirement of CT thorax can be reduced. Radiation hazards associated with CXR and CT, as well as potentially risky transfer of patients to CT room, can also be minimised.

Agreement between chest ultrasonography and chest X-ray in patients who have undergone thoracic surgery: preliminary results

Background

Chest Ultrasonography (chest US) has shown good sensibility in detecting pneumothorax, pleural effusions and peripheral consolidations and it can be performed bedside.

Objectives

The aim of the study was to analyze agreement between chest US and chest X-ray in patients who have undergone thoracic surgery and discuss cases of discordance.

Methods

Patients undergoing thoracic surgery were retrospectively selected. Patients underwent routinely Chest X-ray (CXR) during the first 48 h after surgery. Chest US have been routinely performed in all selected patients in the same date of CXR. Chest US operators were blind to both reports and images of CXR. Ultrasonographic findings regarding pneumothorax (PNX), subcutaneous emphysema (SCE), lung consolidations (LC), pleural effusions (PE) and hemi-diaphragm position were collected and compared to corresponding CXR findings. Inter-rater agreement between two techniques was determined by Cohen's kappa-coefficient.

Results

Twenty-four patients were selected. Inter-rater agreement showed a moderate magnitude for PNX (Cohen's Kappa 0.5), a slight/fair magnitude for SCE (Cohen's Kappa 0.21), a fair magnitude for PE (Cohen's Kappa 0.39), no agreement for LCs (Cohen's Kappa 0.06), high levels of agreement for position of hemi-diaphragm (Cohen's Kappa 0.7).

Conclusion

Analysis of agreement between chest X-ray and chest US showed that ultrasonography is able to detect important findings for surgeons. Limitations and advantages have been found for both chest X-ray and chest US. Knowing the limits of each one is important to really justify and optimize the use of ionizing radiations.

Thoracic damage control surgery

Thoracic damage control surgery (TDCS) is a decision making tool and derivate of the damage control concept (DCC), where physiological stabilization has a priority over anatomical reconstruction under the pressure of time. Intrathoracic haemorrhage control and pleural decompression are the two main immediate tasks of TDCS, while definitive procedures follow when the patient is stabilised in 24-48 hours. The focus of the thoracic surgeon is on the prevention of the haemorrhage induced coagulopathy, metabolic acidosis and hypothermy formed triad of death. Surgical haemorrhage control and pleural space decompression are to be performed. The individual patients benefit from TDCS procedures whose condition is too severe for a complex immediate reconstruction (polytrauma). Life threatening chest injuries in multiple/mass casualty scenarios in civilian and military environment alike are triaged and treated accordingly. Onset of acute mismatch between the resources (available hands, OP theaters, resources, hardware) and the needs (number and severity of chest trauma cases), a mindset shift should take place, where time and space the two main limiting factors. Airway obstruction, tension haemo/pneumothorax falls into the preventable death category. Chest drainage and emergency thoracotomy are the two main procedures offered by TDCS. An intervention structured organ/injury specific list of procedures is detailed. This is a mix of emergency surgery and cardiothoracic surgery, where less is more. TDSC is not the Holy Grail found to solve all complex thoracic trauma cases, but is a good tool to increase the chance for survival in challenging, and frequently quite hopeless situations.

Distribution of alveolar-interstitial syndrome in dogs and cats with respiratory distress as assessed by lung ultrasound versus thoracic radiographs

OBJECTIVE

To assess distribution of alveolar-interstitial syndrome (AIS) detected by lung ultrasound (LUS) compared to thoracic radiographs (TXR).

DESIGN

Prospective study.

SETTING

University teaching hospital.

ANIMALS

Seventy-six dogs and 24 cats with acute respiratory distress or tachypnea.

INTERVENTIONS

Patients underwent LUS and TXR within 6 hours. Lung ultrasound images were scored for presence and quantity of B-lines in 4 lung quadrants (right cranial, right caudal, left cranial, left caudal). An individual LUS quadrant was scored positive if > 3 B-lines were observed within a single intercostal space. Dorsoventral TXR were scored for presence of AIS in the same 4 quadrants. An individual TXR quadrant was scored positive if infiltrate was present in ≥ 25% of the quadrant. Medical records were evaluated for final diagnosis.

MEASUREMENTS AND MAIN RESULTS

Quadrant-by-quadrant spatial agreement in assigning AIS using LUS versus TXR was fair (K = 0.24 - 0.56). Lung ultrasound scored a higher number of quadrants positive per patient (2.65 ± 1.59 vs. 2.13 ± 1.48; P = 0.012). Patterns of distribution of AIS differed significantly based on final diagnosis. Patients with left-sided congestive heart failure were more likely to have diffuse AIS on LUS (P < 0.001) or bilateral caudal AIS on TXR (P = 0.04) while patients with noncardiac disease were more likely to have absence of AIS in all quadrants using either modality (P < 0.001). Differences in spatial distribution of AIS were also noted among disease subcategories.

CONCLUSIONS

Lung ultrasound and TXR were both useful to detect and categorize distribution of alveolar or interstitial pulmonary pathology. Spatial agreement between modalities was only fair. Overall, LUS detected a higher incidence of AIS compared to TXR. Both modalities detected differences in distribution of AIS based on final diagnosis, suggesting that a regional pattern-based approach to thoracic imaging may prove diagnostically useful.

Thoracoabdominal Injuries

Trauma to the thorax and abdomen can occur during participation in sports. This chapter reviews some of the more common presentations of such injuries and how such injuries should be best managed. Thoracic injuries reviewed include internal injuries such as pneumothorax, pulmonary contusion, hemothorax, commotio cordis, and cardiac contusion. Chest wall injuries are also reviewed such as rib fractures, costochondritis, and slipping rib syndrome plus sternal and scapular fractures. Abdominal injuries reviewed are focused on internal organ trauma to the spleen and liver, kidney, pancreas, and bowel. There is attention to the effect of Epstein-Barr virus and infectious mononucleosis, seen very frequently in high school and collegiate athletes. Finally, groin pain and athletic pubalgia are described.

In addition to anatomy and clinical presentation, imaging modalities that characterize such trauma are reviewed for each diagnosis. Prevention of thoracoabdominal injuries and return-to-play decisions are described at the chapter conclusion.

Lung ultrasound in internal medicine efficiently drives the management of patients with heart failure and speeds up the discharge time

Lung ultrasound (LUS) is a valid tool for the assessment of heart failure (HF) through the quantification of the B-lines. This study in HF patients aims to evaluate if LUS: (1) can accelerate the discharge time; (2) can efficiently drive diuretic therapy dosage; and (3) may have better performance compared to the amino-terminal portion of B type natriuretic peptide (NT-proBNP) levels in monitoring HF recovery. A consecutive sample of 120 HF patients was admitted from the Emergency Department (ED) to the Internal Medicine Department (Verona University Hospital). The Chest X-ray (CXR) group underwent standard CXR examination on admission and discharge. The LUS group underwent LUS on admission, 24, 48 and 72 h later, and on discharge. The Inferior Cava Vein Collapsibility Index, ICVCI, and the NT-proBNP were assessed. LUS discharge time was significantly shorter if compared to CXR group (p < 0.01). During hospitalization, the LUS group underwent an increased number of diuretic dosage modulations compared to the CXR group (p < 0.001). There was a stronger association between partial pressure of oxygen in arterial blood (PaO₂) and B-lines compared to the association between PaO₂ and NT-proBNP both on admission and on discharge (p < 0.001). The B-lines numbers were significantly higher on admission in patients with more severe HF, and the ICVCI was inversely associated with B-lines number (p < 0.001). The potential of LUS in tailoring diuretic therapy and accelerating the discharge time in HF patients is confirmed. Until the technique comes into common use in different departments, it is plausible that LUS will evolve with different facets.

Accuracy of point-of-care lung ultrasonography for the diagnosis of cardiogenic pulmonary edema in dogs and cats with acute dyspnea

OBJECTIVE To determine the accuracy of a point-of-care lung ultrasonography (LUS) protocol designed to diagnose cardiogenic pulmonary edema (CPE) in dyspneic dogs and cats. DESIGN Diagnostic test evaluation. ANIMALS 76 dogs and 24 cats evaluated for dyspnea. PROCEDURES Dogs and cats were evaluated by LUS; B lines were counted at 4 anatomic sites on each hemithorax. A site was scored as positive when > 3 B lines were identified. Animals with ≥ 2 positive sites identified on each hemithorax were considered positive for CPE. Medical records were evaluated to obtain a final diagnosis (reference standard) for calculation of the sensitivity and specificity of LUS and thoracic radiography for the diagnosis of CPE. RESULTS Dogs and cats with a final diagnosis of CPE had a higher number of positive LUS sites than did those with noncardiac causes of dyspnea. Overall sensitivity and specificity of LUS for the diagnosis of CPE were 84% and 74%, respectively, and these values were similar to those of thoracic radiography (85% and 87%, respectively). Use of LUS generally led to the misdiagnosis of CPE (ie, a false-positive result) in animals with diffuse interstitial or alveolar disease. Interobserver agreement on LUS results was high (κ > 0.85). CONCLUSIONS AND CLINICAL RELEVANCE LUS was useful for predicting CPE as the cause of dyspnea in dogs and cats, although this technique could not be used to differentiate CPE from other causes of diffuse interstitial or alveolar disease. Point-of-care LUS has promise as a diagnostic tool for dyspneic dogs and cats.

Lung ultrasound: a useful tool in the assessment of the dyspnoeic patient in the emergency department. Fact or fiction?

Patients with respiratory distress present a frequent and challenging dilemma for emergency physicians (EPs). The accurate diagnosis and treatment of the underlying pathology is vitally important in these sick patients to ensure the best outcome and minimise harm from unnecessary treatments. Within the last decade, studies have shown lung ultrasonography (LU) to be valuable in the accurate diagnosis of a variety of lung pathologies, including cardiogenic pulmonary oedema, pleural effusion, pneumothorax, haemothorax and pneumonia. However, despite advances in techniques and the evidence for the use of LU in the diagnosis of respiratory pathology, it remains poorly understood and rarely used by EPs. This clinical review article provides an overview of LU and its relevance as a diagnostic aid to the detection of respiratory pathology in the Emergency Department (ED).

The comparison of radiography and point-of-care ultrasonography in the diagnosis and management of metatarsal fractures

OBJECTIVE

It was aimed to compare the efficacy of point-of-care ultrasonography (POCUS) with radiography in the diagnosis and management of metatarsal fracture (MTF).

METHODS

Patients aged 5-55 years admitted to emergency room due to low-energy, simple extremity trauma and had a suspected MTF, were included in this prospective study. Patients were evaluated by two different emergency physicians in the emergency room. The first physician performed POCUS examination. Second physician evaluated the radiography images. The obtained results were compared.

RESULTS

Seventy-two patients were enrolled in the study. Fracture was detected in 39% by radiography and in 43% of patients by POCUS. Multiple MTFs were identified in 5% of patients. Compared with radiography, POCUS had a sensitivity of 93%, specificity of 89%, positive predictive value of 84% and a negative predictive value of 95% (95% CI, 83-98%) in the detection of fractures. While soft tissue edema was seen in 61% of patients by POCUS, soft tissue edema with hematoma was detected in 14%. Compared with radiography, the sensitivity and specificity of POCUS in the decision for surgery were 100% and 98% (95% CI, 97-100%), respectively, whereas its sensitivity and specificity were both 100% in the decision for reduction.

CONCLUSION

In our study, we demonstrated that POCUS could be applied with success in the diagnosis and treatment of MTF in low-energy injuries. POCUS can be used as an alternative to radiography in the emergency rooms due to being easy to learn and practice and availability of soft tissue examination along with bone tissue examination.

Lung ultrasound in internal medicine: training and clinical practice

Background

Lung ultrasound (LUS) represents an emerging technique for bedside chest imaging in different clinical settings. A standardized approach allows the diagnosis, the quantification, and the follow-up of different conditions for which acute respiratory failure is the main clinical presentation. The aim of this study was to test what skill targets could be achieved in LUS, with a short-training course offered to 19 Medical Doctors attending the certification board school in Internal Medicine at the University of Verona, Italy.

Methods

The training course (theoretical and practical) consisted of 9 h subdivided in 4 days. Each trainee examined three healthy volunteers during the first day that was also the day of the theoretical lessons. Moreover, they examined nine patients per day (a total of 27 patients). Trainees were tested in the recognition of the basic signs in LUS, the managing of the Bedside Lung Ultrasound Evaluation (the BLUE protocol), and the recognition of the broad clinical scenarios recognized by the LUS. Kappa statistic was used to calculate the inter-observer agreement (trainees/tutor).

Results

Twenty-seven patients were examined by the 19 trainees (ten trainees had previous limited experience in general ultrasound). The agreement among the trainees and the tutor in the recognition of the LUS basic signs and in the recognition of the BLUE protocol profiles ranged from “fair” to “excellent”. In particular, the agreement among the trainees and the tutor in the final LUS diagnosis was “excellent” for the recognition of the interstitial syndrome and the pleural effusion, “substantial” for the recognition of the normal lung, and “moderate” for the recognition of consolidation and pneumothorax. LUS outcome gave useful information and drove change in therapy in 16 patients. It affected immediate management in nine patients. The concordance between the previous X chest ray and LUS was observed in 21 patients.

Conclusions

A short training in LUS provided good proficiency in the recognition only of the main signs of the BLUE protocol, but allowed a correct LUS diagnosis in the Internal Medicine most frequent clinical settings of acute respiratory failure. This study supports incorporating LUS into Internal Medicine fellowship training programs.

Diagnostic Bedside Ultrasonography for Acute Respiratory Failure and Severe Hypoxemia in the Medical Intensive Care Unit: Basics and Comprehensive Approaches

Bedside goal-directed ultrasound is a powerful tool for rapid differential diagnosis and monitoring of cardiopulmonary disease in the critically ill patient population. The bedside intensivist is in a unique position to integrate ultrasound findings with the overall clinical situation. Medically critically ill patients who require urgent bedside diagnostic assessment fall into 2 categories: (1) acute respiratory failure and (2) hemodynamic derangements. The first portion of this review outlines the diagnostic role of bedside ultrasound in the medically critically ill patient population for the diagnosis and treatment of acute respiratory failure, acute respiratory distress, and severe hypoxemia. The second portion will focus on the diagnostic role of ultrasound for the evaluation and treatment of shock states, as well as describe protocolized approaches for evaluation of shock during cardiopulmonary resuscitation. Different respiratory system pathologies that result in acute respiratory failure (such as increased interstitial fluid, alveolar consolidation, pleural effusion) cause characteristic ultrasonographic findings; diaphragmatic assessment may also add information. Intracardiac shunting can cause severe hypoxemia. Protocolized approaches for the evaluation of patients with acute respiratory failure or distress are discussed.

Incremental value of thoracic ultrasound in intensive care units: Indications, uses, and applications

Emergency physicians are required to care for unstable patients with life-threatening conditions, and thus must make decisions that are both quick and precise about unclear clinical situations. There is increasing consensus in favor of using ultrasound as a real-time bedside clinical tool for clinicians in emergency settings alongside the irreplaceable use of historical and physical examinations. B-mode sonography is an old technology that was first proposed for medical applications more than 50 years ago. Its application in the diagnosis of thoracic diseases has always been considered limited, due to the presence of air in the lung and the presence of the bones of the thoracic cage, which prevent the progression of the ultrasound beam. However, the close relationship between air and water in the lungs causes a variety of artifacts on ultrasounds. At the bedside, thoracic ultrasound is based primarily on the analysis of these artifacts, with the aim of improving accuracy and safety in the diagnosis and therapy of the various varieties of pulmonary pathologic diseases which are predominantly “water-rich” or “air-rich”. The indications, contraindications, advantages, disadvantages, and techniques of thoracic ultrasound and its related procedures are analyzed in the present review.

Ultrasound-Guided Parasternal Block Allows Optimal Pain Relief and Ventilation Improvement After a Sternal Fracture

Introduction

Sternal fractures are a painful condition which can result in pulmonary morbidity if not treated promptly. The management of isolated fractures has changed from hospital to home-based treatment, provided other major injuries have been excluded. Pain management is the mainstay of treatment. In this case report, we describe how a parasternal block under ultrasound guidance for sternal fracture provided better analgesia thereby improving ventilation.

Case report

A 26-year-old man was admitted to the emergency department following a road traffic accident. His initial evaluation revealed a radio-cubital displaced fracture at the elbow level with severe tenderness over the sternum. Chest X-ray on admission did not reveal any abnormality. On preoperative checkup he was found to have altered chest mechanics with severe pain and tenderness over the sternum. Arterial blood gas (ABG) analysis showed respiratory acidosis. Pulmonary electrical impedance tomography showed hypoventilation of anterior portions of both lungs. An ultrasound examination of the sternum showed a fractured sternum with complete disjunction. An ultrasound-guided bilateral parasternal block was performed which resulted in efficient analgesia and thereby improved his ventilation as indicated by the improvement in ABG.

Conclusion

Timely and proper analgesia can reduce the pulmonary morbidity in sternal fractures. Of the various analgesic techniques, parasternal block under ultrasound guidance is a relatively simple, safe, and target-specific procedure that can provide efficient pain relief.

Electronic supplementary material

The online version of this article (doi:10.1007/s40122-016-0050-5) contains supplementary material, which is available to authorized users.

Bedside sonographic measurement of optic nerve sheath diameter as a predictor of intracranial pressure in ED

BACKGROUND

Ocular ultrasonography of optic nerve sheath diameter (ONSD) to determine intracranial pressure (ICP) has become favorable in recent years.

OBJECTIVE

To demonstrate the efficacy of ONSD measurement in determining the ICP increase due to nontraumatic events in the emergency department.

METHODS

A total of 100 patients with suspected nontraumatic intracranial event were enrolled in this prospective study. Patients were divided equally into 2 groups including 50 patients as group I with pathology on cranial computed tomography (CT) and group II with normal cranial CT. Prior to CT scans, patients underwent ONSD measurement by a radiologist using 11- and 14-MHz transducers.

RESULTS

The ONSD values of groups I and II were 5.4±1.1and 4.1±0.5mm, respectively. Optic nerve sheath diameter was found to be larger on the side of lesion in patients with a lesion (P<.05). The cutoff value of the difference between ONSD values of both eyes in the presence of pathology was determined as 0.45 (sensitivity, 80%; specificity, 60%; the area under the curve, 0.794; 95% confidence interval, 0.705-0.883). The between-ONSD and midline shift size was statistically significant (r=0.366, P=.009). The cutoff value of ONSD for the detection of midline shift was determined as 5.3mm (sensitivity, 70%; specificity, 74%; the area under the curve, 0.728; 95% confidence interval, 0.585-0.871).

CONCLUSION

Optic nerve sheath diameter measurement via bedside ocular ultrasonography in patients with suspected intracranial event in the emergency department is a useful method to determine ICP increase and its severity.

Diagnostic validity of ultrasonography in evaluation of pulmonary thromboembolism

Background:

Diagnosis of pulmonary embolism (PE) remains difficult due to its nonspecific symptoms and signs. Therefore, many patients die undiagnosed or untreated. We decided to study the sensitivity, specificity, and accuracy of ultrasonography in the diagnosis of pulmonary thromboembolism.

Materials and Methods:

In this prospective study, 77 patients with clinically suspected PE in the emergency department of Isfahan Al-Zahra Hospital were enrolled from September 2011 to September 2012. At first, they were evaluated by thoracic ultrasonography (TUS) and then divided into four groups based on their TUS findings. Multi-slice computed tomography (MSCT) was the reference method in this study performed within 24 h from admission. MSCT scans were interpreted by a radiologist who was unaware of the TUS results. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPVs) of thoracic ultrasonography were determined.

Results:

PE diagnosis was confirmed by MSCT in 25 patients and 54 hypoechoic lesions were detected by TUS with the average size of 16.4 mm × 11.1 mm. In our study, sensitivity, specificity, PPV, NPV, and accuracy of TUS for PE diagnosis were 84%, 94.2%, 87.5%, and 92.5%, respectively.

Conclusion:

TUS is an inexpensive, safe and easily available method for timely diagnosis and treatment of PE in emergency department and its NPV is high for cases with low scores for Wells criteria who had a normal or possible TUS findings. It is also specific in the diagnosis of PE in cases with high scores Wells criteria who have confirmed or probable TUS findings.

The irregular diaphragmatic pleural interface: a novel sonographic sign facilitating the diagnosis of pneumonia

Pneumonia, a disease that has been reported to be the sixth leading cause of death in the United States, has worsening mortality with delays in diagnosis. As the history and physical examination are excessively inaccurate in the diagnosis of pneumonia, we often rely on chest radiography to rule in or out disease. However, it is found to lack sufficient accuracy when computed tomography is used as the reference standard. Sonography has emerged as a viable alternative to chest radiography in the diagnosis of pneumonia. Here, we describe a novel sonographic sign that can be used to assist in the diagnosis of pneumonia.

[Basic lung ultrasound. Part 2. Parenchymal diseases]

In this second part, an analysis is made of the pathology of lung parenchyma. This text is structured into different sections, including the study of atelectasias, pneumonia and abscess, interstitial/alveolar or Blines patterns, and finally an analysis is made of pulmonary embolism. With this second part, the basic knowledge to develop lung ultrasound in the anesthesia department has been presented.

Anesthetic techniques influence the induction of pulmonary capillary hemorrhage during diagnostic ultrasound scanning in rats

OBJECTIVES

Pulmonary capillary hemorrhage can be induced by diagnostic ultrasound (US) during direct pulmonary US scanning in rats. The influence of specific anesthetic techniques on this bioeffect was examined.

METHODS

Ketamine plus xylazine has been used previously. In this study, the influence of intraperitoneal injections of ketamine and pentobarbital, inhalational isoflurane, and the supplemental use of xylazine with ketamine and isoflurane was tested. A diagnostic US machine with a 7.6-MHz linear array was used to image the right lung of anesthetized rats in a warmed water bath at different mechanical index (MI) settings. Pulmonary capillary hemorrhage was assessed by measuring comet tail artifacts in the image and by morphometry of the hemorrhagic areas on excised lungs.

RESULTS

Pulmonary capillary hemorrhage was greatest for pentobarbital, lower for inhalational isoflurane, and lowest for ketamine anesthesia, with occurrence thresholds at MIs of about 0.44, 0.8, and 0.8, respectively. Addition of xylazine produced a substantial increase in hemorrhage and a significant proportion of hemorrhage occurrence for ketamine at an MI of 0.7 (P < .01) and for isoflurane at an MI of 0.52 (P < .01).

CONCLUSIONS

Ketamine plus xylazine and pentobarbital yield lower thresholds than ketamine or isoflurane alone by nearly a factor of 2 in MI. These results suggest that the choice of the anesthetic agent substantially modifies the relative risks of pulmonary capillary hemorrhage from pulmonary US.

Postobstructive pulmonary edema in the setting of aspiration and air travel

BACKGROUND

Postobstructive pulmonary edema (POPE)-also referred to as negative pressure pulmonary edema-occurs with deep inspiration against a closed glottis or obstructed airway. The result can be life threatening, however, most cases have a self-limited presentation and resolve with supportive care.

OBJECTIVE

Our aim was to critically evaluate a previously unreported mechanism in the exacerbation of POPE.

CASE REPORT

This is a report of a 50-year-old woman who experienced an acute episode of hypoxia and altered mental status aboard a transcontinental flight. Her presentation was suggestive of pulmonary embolus. However, a detailed history yielded an episode of preflight choking relieved by the Heimlich maneuver. After 2 days of supportive care she was discharged with a complete return to baseline.

CONCLUSIONS

Subclinical cases of POPE can be exacerbated by the low atmospheric pressure experienced on commercial airlines. With early recognition and supportive treatment, the patient returned to baseline before her discharge 2 days later. Making the diagnoses of POPE is not always straightforward for the practitioner and necessitates a broad differential. Initial supportive care focusing on maximizing respiratory support is critical.

Ultrasound assessment of ex vivo lung tissue properties using a fluid-filled negative pressure bath

A relationship between tendon stress and strain and ultrasonic echo intensity has previously been defined in tendons, demonstrating a correlation between tissue stiffness and echo intensity. An analogous relationship between volume-dependent pressure changes and echo intensity changes in inflating lungs would indicate a correlation between lung compliance and echo intensity. Lung compliance is an important metric to diagnose pathologies which affect lung tissue mechanics, such as emphysema and cystic fibrosis. The goal of this study is to demonstrate a correlation between ultrasound echo intensity and lung tissue mechanics in an ex vivo model using a fluid-filled negative pressure bath design which provides a controlled environment for ultrasonic and mechanical measurements. Lungs from 4 male Sprague-Dawley rats were removed and mechanically tested via inflation and deflation in a negative pressure chamber filled with hetastarch. Specific volumes (1, 2, 3, and 4 mL) were removed from the chamber using a syringe to create negative pressure, which resulted in lung inflation. A pressure transducer recorded the pressure around the lungs. From these data, lung compliance was calculated. Ultrasound images were captured through the chamber wall to determine echo intensity (grayscale brightness in the ultrasound image), which was then related to mechanical parameters. Ultrasound images of the lung were successfully captured through the chamber wall with sufficient resolution to deduce echo intensity changes in the lung tissue. Echo intensity (0-255 scale) increased with volumetric changes (18.4 ± 5.5, 22.6 ± 5.1, 26.1 ± 7.5, and 42.9 ± 19.5 for volumetric changes of 1, 2, 3, and 4 mL) in a pattern similar to pressure (-6.8 ± 1.7, -6.8 ± 1.4, -9.4 ± 0.7, and -16.9 ± 6.8 cm H2O for 1, 2, 3, and 4 mL), reflecting changes in lung compliance. Measured rat lung tissue compliance was comparable to reported values from ex vivo lungs (0.178 ± 0.067, 0.378 ± 0.051, 0.427 ± 0.062, and 0.350 ± 0.160 mL/cm H20 for 1, 2, 3, and 4 mL), supporting proof of concept for the experimental method. Changes in echo intensity reflected changes in lung compliance in this ex vivo model, thus, supporting our hypothesis that the stiffness-related changes in echo intensity originally seen in tendon can be similarly detected in lung tissue. The presented ultrasound-based methods allowed measurement of local lung tissue compliance in a controlled environment, however, the methods could be expanded to facilitate both ex vivo and in vivo studies.

Ultrasound artifacts mimicking pleural sliding after pneumonectomy

STUDY OBJECTIVE

To determine the presence of pleural sliding on chest ultrasonography (US) in a series of patients admitted to a surgical intensive care unit (SICU).

DESIGN

Prospective, observational study.

SETTING

16-bed SICU of a University hospital.

PATIENTS

8 patients (7 men, 1 woman), aged 64 - 73 years (mean 67.5 yrs). Seven patients underwent pneumonectomy for pulmonary neoplasms; one patient underwent an atypical lung resection after having undergone a pneumonectomy one year before.

INTERVENTIONS

None.

MEASUREMENTS

Chest ultrasounds were performed during mechanical ventilation and spontaneous ventilation after endotracheal tube removal. In both examinations, pleural sliding was searched bilaterally in brightness mode (B-mode) and motion mode (M-mode) on the anterior thoracic wall in the least gravitationally dependent areas.

RESULTS

During mechanical ventilation, pleural sliding was always absent on the side of the pneumonectomy and present on the other side. During spontaneous ventilation, some artifacts mimicking pleural sliding were noted on the side of the pneumonectomy both in B-mode and M-mode (presence of the seashore sign) in all patients, except for the one patient who had undergone a pneumonectomy one year earlier. Those artifacts became more pronounced during deep breaths.

CONCLUSIONS

Ultrasound artifacts mimicking pleural sliding may be observed in the absence of the lung and may originate from the activity of intercostal muscles since they become more evident during deep breathing.

Management of pneumothoraces detected on chest computed tomography: can anatomical location identify patients who can be managed expectantly?

BACKGROUND

Pneumothorax (PTX) can be readily detected by computed tomography (CT) or ultrasound. However, management of PTX in hemodynamically stable patients remains controversial.

STUDY OBJECTIVES

We sought to investigate whether a distinct anatomical distribution of PTX along prespecified chest zones as detected by CT can be described in patients with or without subsequent chest tube thoracotomy (CTT), thus potentially allowing the extended focused assessment with sonography for trauma (EFAST) ultrasound examination to guide PTX management.

METHODS

We performed a retrospective review of chest CT scans performed in the emergency department (ED) of a Level I trauma center. CT scans were analyzed for PTX distribution according to a chest zone model. Medical records of subjects with PTX were reviewed for subsequent CTT.

RESULTS

Of 3636 chest CT scans performed, 183 PTX (156 patients) were detected without CTT at the time of CT scan (69% male, mean age 42 years). Of these, 66 subjects (40%) underwent CTT; 43 chest tubes (63%) were placed in the ED, 9 (13%) during hospitalization and 9 (13%) in the operating room. Median time to CTT was 140 min (interquartile range 52-199). Initial hemodynamic parameters, need for surgery, and need for mechanical ventilation were similar in both groups (p > 0.05 for all). Anatomical distribution and size of PTX were similar in the two groups.

CONCLUSION

Although the majority of patients with traumatic PTX could be managed conservatively, we did not identify a characteristic anatomical PTX pattern, which could identify subjects who may not require CTT.

Lung ultrasound in community-acquired pneumonia and in interstitial lung diseases

Lung ultrasound (LUS) is an accurate tool for the diagnosis and follow-up of pneumonia in adults as well as in children. LUS is at least as accurate as chest radiography in diagnosing pneumonia. The most important parenchymal criterion is the positive air bronchogram within an echopoor area. Among pleural criteria, basal effusion was most often detected. The presence of multiple diffuse bilateral B-lines on lung examination indicates the interstitial syndrome (IS). For further differential diagnosis, an integrated consideration of history, clinical examination, LUS and echocardiography should be performed. LUS is an excellent tool for IS screening. Repeated LUS control examinations may reflect the dynamics of IS under therapy and so LUS may serve as a therapy guide. .

A delayed case of tension pneumopericardium after total gastrectomy

A case of tension pneumopericardium that occurred after total gastrectomy in an 80 year old woman is presented. There have been some prior case reports of pneumopericardium that occurred during positive pressure ventilation; in this patient hypotension due to tension pneumopericardium occurred after extubation. Return of spontaneous ventilation with negative-pressure breathing may have induced air aspiration into the pericardial sac from the abdominal cavity.

Emergency ultrasound of the chest

Thoracic ultrasound is a noninvasive and portable diagnostic tool which is highly indicated for an initial workup of thoracic emergencies. The suspicion of a pneumothorax, pneumonia, pulmonary embolism or a lung contusion after trauma can be quickly assessed using ultrasound. Main advantages are its good availability and the steep learning curve. Another advantage of thoracic sonography is that this rapid, symptom-based examination has a high sensitivity and specificity. However, a disadvantage is that only pleura-affecting lesions or lesions visible through a sound window, e.g. an effusion or a subpleural consolidation, can be reached.