Extension of the Thoracic Spine Sign: A New Sonographic Marker of Pleural Effusion

Airway and Thoracic Ultrasound

Airway and thoracic ultrasound applications can provide critical information to improve patient safety for procedures and management of pulmonary conditions. Emergency physicians should utilize airway ultrasound in the preparation for an anatomically and/or physiologically difficult airway, which may include site demarcation for surgical airway planning. Thoracic ultrasound is useful in the prompt evaluation of a dyspneic patient. This article underscores the crucial role of airway and thoracic ultrasound in emergency medicine, emphasizing its utility for assessing difficult airways, planning surgical airways, and promptly evaluating dyspneic patients.

Resuscitative Ultrasound and Protocols

The management of patients in shock or arrest is a critical aspect of emergency medicine and critical care. Rapid and accurate assessment is paramount in determining the underlying causes and initiating timely interventions. This article provides a summary of essential ultrasound protocols for the critically ill patient including the extended focused assessment with sonography for trauma (EFAST), rapid ultrasound for shock and hypotension (RUSH), and sonography in hypotension and cardiac arrest in the emergency department (SHoC-ED).

Sonography of the pleura

The CME review presented here is intended to explain the significance of pleural sonography to the interested reader and to provide information on its application. At the beginning of sonography in the 80 s of the 20th centuries, with the possible resolution of the devices at that time, the pleura could only be perceived as a white line. Due to the high impedance differences, the pleura can be delineated particularly well. With the increasing high-resolution devices of more than 10 MHz, even a normal pleura with a thickness of 0.2 mm can be assessed. This article explains the special features of the examination technique with knowledge of the pre-test probability and describes the indications for pleural sonography. Pleural sonography has a high value in emergency and intensive care medicine, preclinical, outpatient and inpatient, in the general practitioner as well as in the specialist practice of pneumologists. The special features in childhood (pediatrics) as well as in geriatrics are presented. The recognition of a pneumothorax even in difficult situations as well as the assessment of pleural effusion are explained. With the high-resolution technology, both the pleura itself and small subpleural consolidations can be assessed and used diagnostically. Both the direct and indirect sonographic signs and accompanying symptoms are described, and the concrete clinical significance of sonography is presented. The significance and criteria of conventional brightness-encoded B-scan, colour Doppler sonography (CDS) with or without spectral analysis of the Doppler signal (SDS) and contrast medium ultrasound (CEUS) are outlined. Elastography and ultrasound-guided interventions are also mentioned. A related further paper deals with the diseases of the lung parenchyma and another paper with the diseases of the thoracic wall, diaphragm and mediastinum.

Guidance for clinical practice using emergency and point-of-care ultrasonography

Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

Lung Ultrasonographic Signs in Pulmonary Disease - A Video Review

Lung ultrasound (US) is a well-established imaging tool in the inpatient and critical care setting. It has proven its worth in the rapid bedside diagnosis of a variety of conditions pertaining to the lungs and the thorax. Lung US was initially introduced as a bedside imaging tool to evaluate the size and characteristics of pleural effusion. Over the years, the field of lung ultrasonography has rapidly expanded introducing nuances in image interpretation. Numerous primary and secondary signs have been described in the literature to identify both normal and abnormal findings. The primary signs can help narrow the list of differential diagnoses, whereas the addition of secondary signs help create an imaging pattern facilitating the confirmation of diagnosis or recognition of the underlying disease process. These wide variety of signs and patterns can present a challenge to the learning of lung ultrasonography, particularly to a novice user. We sought to compile a comprehensive list of these findings to serve as a useful resource to aid effortless adoption of lung ultrasonography in clinical practice. In this review, we narrate the evolution of lung US, describe common protocols applied in performance of the lung US, and illustrate a comprehensive list of common lung US signs and patterns along with their differential diagnosis and clinical utility.

Point-of-Care Lung Ultrasonography: A Clinical Update for the Emergency Nurse Practitioner

Since the introduction of ultrasonography, clinicians have discovered different uses for embedding this technology in the clinical setting. The use of point-of-care ultrasonography has gained a lot of interest in the emergency department. It is a procedure that a clinician can rapidly utilize to triage, risk stratify, evaluate, and monitor the patient's condition. The COVID-19 pandemic has highlighted the significance and application of ultrasonography in identifying and managing patients presenting with lung pathology in the emergency setting.

The Focused Assessment with Sonography in Cancer (FASC) Examination

Malignant effusions occur frequently in patients with cancer and are important to diagnose and treat. In this report, we describe a novel point-of-care ultrasound (POCUS) protocol to rapidly identify pleural effusion, pericardial effusion, and ascites: The Focused Assessment with Sonography in Cancer (FASC). This protocol utilizes six standard sonographic positions to identify the presence of fluid in common anatomic spaces. The FASC examination is intended for widespread use by oncologists and other clinicians who treat patients with cancer.

Extension of the thoracic spine sign as a diagnostic marker for thoracic trauma

INTRODUCTION

The initial evaluation of patients with thoracic trauma remains a diagnostic challenge for surgery and emergency physicians. Chest sonography plays a key role in the approach for this group of patients, through extended and focused evaluation with trauma sonography (E-FAST).

OBJECTIVES

To establish the diagnostic performance of the extension of the thoracic spine sign using chest sonography in trauma to diagnose hemothorax and compare it with the gold standard test chest computed tomography (CT).

METHODS

This prospective observational study was conducted over 1 year. Patients who attended the emergency room with closed or penetrating thoracic or thoraco-abdominal trauma, an indication for a chest CT as part of a diagnostic evaluation according to institutional protocols, and who previously underwent a chest sonogram to determine the extent of the thoracic spine sign to diagnose hemothorax. Sonographic results were compared to a radiologist's interpretation of the chest CT. The radiologists were blinded to the initial sonogram interpretation.

RESULTS

Seventy-six patients were enrolled with an average age of 32 years. They mainly had closed trauma, which accounted for 77.6% of samples, and 222 chest images were taken. The sensitivity and specificity for this study were 78.7% and 92.6%, respectively, with a positive predictive value and negative predictive value of 65% and 97.8%, respectively.

CONCLUSIONS

Extension of the thoracic spine sign allows rapid identification of the presence, and more precisely, the absence of pleural effusion. This, therefore, allows an appropriate diagnosis and approach in the emergency room in patients with chest trauma.

Better With Ultrasound: Thoracic Ultrasound

Ultrasound examination of the thorax is superior to chest radiograph or physical examination for diagnosing common conditions such as pneumonia, pulmonary edema, pleural effusion, and pneumothorax. The basic skill set is straightforward to learn, quick to perform, repeatable, and does not involve patient transport, harmful ionizing radiation, or waiting time. This paper outlines the basic building blocks that makeup a thoracic ultrasound examination, regardless of which specific scanning protocol is performed. Narrative videos and illustrative figures demonstrating these techniques are included.

Tracheal, Lung, and Diaphragmatic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care

Today, proficiency in cardiopulmonary ultrasound is considered essential for anesthesiologists and critical care physicians. Conventional 2-dimensional images, however, do not permit optimal characterization of specific conditions (eg, diaphragmatic paralysis, major atelectasis, and pneumothorax) that may have relevant clinical implications in critical care and perioperative settings. By contrast, M-mode (motion-based) ultrasonographic imaging modality offers the highest temporal resolution in ultrasonography; this modality, therefore, can provide important information in ultrasound-driven approaches performed by anesthesiologists and intensivists for diagnosis, monitoring, and procedural guidance. Despite its practicability, M-mode has been progressively abandoned in echocardiography and is often underused in lung and diaphragmatic ultrasound. This review describes contemporary applications of M-mode ultrasonography in the practice of critical care and perioperative medicine. Information presented for each clinical application includes image acquisition and interpretation, evidence-based clinical implications in critically ill and surgical patients, and main limitations. The article focuses on tracheal, lung, and diaphragmatic ultrasound. It reviews tracheal ultrasound for procedural guidance during endotracheal intubation, confirmation of correct tube placement, and detection of esophageal intubation; lung ultrasound for the confirmation of endotracheal and endobronchial (selective) intubation and for the diagnosis of pneumothorax, alveolar-interstitial syndrome (cardiogenic v noncardiogenic pulmonary edema), pulmonary consolidation (pneumonia v major atelectasis) and pleural effusion; and diaphragmatic ultrasound for the diagnosis of diaphragmatic dysfunction and prediction of extubation success.

Resuscitative Cardiopulmonary Ultrasound and Transesophageal Echocardiography in the Emergency Department

Resuscitative ultrasound describes point-of-care applications that provide diagnostic information, physiologic monitoring, and procedural guidance in critically ill patients. This article reviews the evaluation of ventricular function, identification of pericardial effusion and tamponade, evaluation of preload and fluid responsiveness, and hemodynamic monitoring, as some of the main applications where this modality can help emergency physicians during resuscitation of critically ill patients.

Point-of-care Ultrasonography for Detecting the Etiology of Unexplained Acute Respiratory and Chest Complaints in the Emergency Department: A Prospective Analysis

Introduction  Point-of-care ultrasound (POCUS) is increasingly used as a diagnostic tool in emergency departments. As the number and type of POCUS protocols expand, there is a need to validate their efficacy in comparison with current diagnostic standards. This study compares POCUS to chest radiography in patients with undifferentiated respiratory or chest complaints. Methods A prospective convenience sample of 59 adult patients were enrolled from those presenting with unexplained acute respiratory or chest complaints (and having orders for chest radiography) to a single emergency department in an academic tertiary-care hospital. After a brief educational session, a medical student, blinded to chest radiograph results, performed and interpreted images from the modified Rapid Assessment of Dyspnea in Ultrasound (RADiUS) protocol. The images were reviewed by a blinded ultrasound fellowship-trained emergency physician and compared to chest radiography upon chart review. The primary "gold standard" endpoint diagnosis was the diagnosis at discharge. A secondary analysis was performed using the chest computed tomography (CT) diagnosis as the endpoint diagnosis in the subset of patients with chest CTs. Results When using diagnosis at discharge as the endpoint diagnosis, the modified RADiUS protocol had a higher sensitivity (79% vs. 67%) and lower specificity (71% vs. 83%) than chest radiography. When using chest CT diagnosis as the endpoint diagnosis (in the subset of patients with chest CTs), the modified RADiUS protocol had a higher sensitivity (76% vs. 65%) and lower specificity (71% vs. 100%) than chest radiography. The medical student performed and interpreted the 59 POCUS scans with 92% accuracy. Conclusion The sensitivity and specificity of POCUS using the modified RADiUS protocol was not significantly different than chest radiography. In addition, a medical student was able to perform the protocol and interpret scans with a high level of accuracy. POCUS has potential value for diagnosing the etiology of undifferentiated acute respiratory and chest complaints in adult patients presenting to the emergency department, but larger clinical validation studies are required.

I-AIM (Indication, Acquisition, Interpretation, Medical Decision-making) Framework for Point of Care Lung Ultrasound

The I-AIM (Indication, Acquisition, Interpretation, Medical decision-making) model is a conceptive framework uniquely applicable to every point of care ultrasound application. We present a systematic comprehensive approach to lung ultrasound based on the I-AIM framework.

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