1
|
Abstract
The evolution of pleural disease imaging modalities through the years has helped the scientific community understand and treat various disease states. Ultrasound (US) has been an image modality that has reigned superior to those used in the past such as chest X-ray and computed tomographic scan in terms of cost effectiveness, portability, and reduction in unwarranted radiation exposure to patients. Here we provide a succinct review of US use in pleural disease including imaging techniques, identifying safe pleural space for access, and predicting pleural fluid volume and etiology along with specificities regarding trapped lung identification and pleural mass biopsy. We believe bedside chest US is an adjunct to the physical exam adding superior diagnostic abilities. Further research is warranted in more specific aspects of sonographic use such as in fibrinolytic therapy management, evaluation for trapped lung, and the utility of specific modes like the color flow Doppler.
Collapse
|
2
|
Abstract
Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.
Collapse
|
3
|
Lokuge A. Should we ditch the supine chest X ray in early trauma assessment? Australas J Ultrasound Med 2019; 22:245-247. [PMID: 34760565 DOI: 10.1002/ajum.12164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The supine chest X ray is a standard part of early trauma assessment protocols. It is used to rapidly identify potentially life threatening chest injuries. However, latest research shows that chest ultrasound has superior accuracy when compared to supine chest X ray for diagnosing most chest injuries. Is it time we allowed ultrasound to supersede supine chest X ray as the initial investigative modality of choice for the patient with thoracic trauma?
Collapse
Affiliation(s)
- Amaali Lokuge
- Emergency Department Royal Melbourne Hospital (City Campus) Grattan St Parkville Victoria 3050 Australia.,Medicine and Radiology University of Melbourne Parkville
| |
Collapse
|
4
|
Lirette MP, Bailey B, Grant S, Jackson M, Leonard P. Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study. BMJ Paediatr Open 2018; 2:e000304. [PMID: 30116792 PMCID: PMC6089283 DOI: 10.1136/bmjpo-2018-000304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/28/2018] [Accepted: 07/05/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Paediatric clavicle fractures are commonly seen in the emergency department (ED), and the current standard of care is to obtain a radiograph for all suspected clavicle fractures. We are yet to determine whether radiographs add valuable information to clinicians' assessment and therefore if they are necessary in the management of paediatric clavicle fractures. OBJECTIVE To determine whether clinicians can manage paediatric clavicle fractures without radiographs, first by determining the accuracy of clinicians in identifying the presence of a clavicle fracture, and second by evaluating the level of agreement (kappa (κ)) between the ultimate management of children with suspected clavicle fractures and clinicians' blinded prediction prior to the radiograph. METHODS This prospective study enrolled patients presenting to a paediatric ED with a suspected clavicle fracture. Prior to requesting a radiograph, clinicians completed a standardised form, where they predicted the presence of a fracture and their ultimate management based on their clinical findings, and rated their confidence. RESULTS Of the 50 patients aged 7.2±3.9 years included, 40 (80%) had a radiologically proven clavicle fracture, and clinicians were able to accurately identify them (sensitivity 93%, positive predictive value 88%). There were five (50%) patients without a radiological fracture that were treated with broad arm sling. Clinicians' prediction of ultimate management had the highest agreement with the ultimate management of the patient on leaving the ED, compared with clinicians' prediction of the presence of fracture and the final radiograph findings: κ of 0.88 (95% CI 0.64 to 1), 0.67 (95% CI 0.36 to 0.98) and 0.62 (95% CI 0.30 to 0.94), respectively. Thirty-six (72%) of the clinicians felt comfortable treating without radiographs, and this was dependent on their level of training. CONCLUSIONS Clinicians can identify the presence of a fracture and tend to be overconservative in their management. Despite negative radiological findings, some patients were treated as though they had a fracture, based on clinical judgement. This adds evidence that radiographs are not routinely required for uncomplicated paediatric clavicle fractures.
Collapse
Affiliation(s)
- Marie-Pier Lirette
- Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Pediatrics, Royal Hospital for Sick Children, Edinburgh, UK
| | - Benoit Bailey
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Samuel Grant
- Orthopaedics, Royal Blackburn Hospital, Blackburn, UK
| | - Michael Jackson
- Radiology Department, Royal Hospital for Sick Children, Edinburgh, UK
| | - Paul Leonard
- Division of Emergency Medicine, Department of Pediatrics, Royal Hospital for Sick Children, Edinburgh, UK
| |
Collapse
|
5
|
Ketelaars R, Reijnders G, van Geffen GJ, Scheffer GJ, Hoogerwerf N. ABCDE of prehospital ultrasonography: a narrative review. Crit Ultrasound J 2018; 10:17. [PMID: 30088160 PMCID: PMC6081492 DOI: 10.1186/s13089-018-0099-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/25/2018] [Indexed: 02/08/2023] Open
Abstract
Prehospital point-of-care ultrasound used by nonradiologists in emergency medicine is gaining ground. It is feasible on-scene and during aeromedical transport and allows health-care professionals to detect or rule out potential harmful conditions. Consequently, it impacts decision-making in prioritizing care, selecting the best treatment, and the most suitable transport mode and destination. This increasing relevance of prehospital ultrasonography is due to advancements in ultrasound devices and related technology, and to a growing number of applications. This narrative review aims to present an overview of prehospital ultrasonography literature. The focus is on civilian emergency (trauma and non-trauma) setting. Current and potential future applications are discussed, structured according to the airway, breathing, circulation, disability, and environment/exposure (ABCDE) approach. Aside from diagnostic implementation and specific protocols, procedural guidance, therapeutic ultrasound, and challenges are reviewed.
Collapse
Affiliation(s)
- Rein Ketelaars
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands. .,Radboud Institute for Health Sciences, Helicopter Emergency Medical Service Lifeliner 3, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Gabby Reijnders
- Department of Intensive Care, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Geert-Jan van Geffen
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Helicopter Emergency Medical Service Lifeliner 3, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Gert Jan Scheffer
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Nico Hoogerwerf
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Helicopter Emergency Medical Service Lifeliner 3, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| |
Collapse
|
6
|
Liu F, Huang YC, Ng YB, Liang JH. Differentiate pleural effusion from hemothorax after blunt chest trauma; comparison of computed tomography attenuation values. J Acute Med 2016. [DOI: 10.1016/j.jacme.2015.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
7
|
|
8
|
Martinez T, Pasquier P, Swiech A, Kearns K, Dubost C, Mérat S. Lung Ultrasound for Chest Tube Insertion. Am J Emerg Med 2015; 33:1095-6. [DOI: 10.1016/j.ajem.2015.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/11/2015] [Accepted: 04/16/2015] [Indexed: 11/29/2022] Open
|
9
|
Jenkins JA, Gharahbaghian L, Doniger SJ, Bradley S, Crandall S, Spain DA, Williams SR. Sonographic Identification of Tube Thoracostomy Study (SITTS): Confirmation of Intrathoracic Placement. West J Emerg Med 2012; 13:305-11. [PMID: 22942927 PMCID: PMC3421967 DOI: 10.5811/westjem.2011.10.6680] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 06/22/2011] [Accepted: 10/03/2011] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Thoracostomy tubes (TT) are commonly placed in the management of surgical, emergency, and trauma patients and chest radiographs (CXR) and computed tomography (CT) are performed to confirm placement. Ultrasound (US) has not previously been used as a means to confirm intrathoracic placement of chest tubes. This study involves a novel application of US to demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement. METHODS This was an observational proof-of-concept study using a convenience sample of patients with TTs at a tertiary-care university hospital. Bedside US was performed by the primary investigator using first the low-frequency (5-1 MHz) followed by the high-frequency (10-5 MHz) transducers, in both 2-dimensional gray-scale and M-modes in a uniform manner. The TTs were identified in transverse and longitudinal views by starting at the skin entry point and scanning to where the TT passed the pleural line, entering the intrathoracic region. All US images were reviewed by US fellowship-trained emergency physicians. CXRs and CTs were used as the standard for confirmation of TT placement. RESULTS Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10-5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode. CONCLUSION Bedside US can visualize the TT and its entrance into the thoracic cavity and it can distinguish it from the pleural line by a characteristic M-mode pattern. This is best visualized with the high-frequency (10-5 MHz) linear transducer.
Collapse
|
10
|
Perera P, Mailhot T, Riley D, Mandavia D. The RUSH Exam 2012: Rapid Ultrasound in Shock in the Evaluation of the Critically Ill Patient. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.cult.2011.12.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
11
|
|
12
|
Freixinet Gilart J, Hernández Rodríguez H, Martínez Vallina P, Moreno Balsalobre R, Rodríguez Suárez P. Normativa sobre diagnóstico y tratamiento de los traumatismos torácicos. Arch Bronconeumol 2011; 47:41-9. [DOI: 10.1016/j.arbres.2010.05.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 05/29/2010] [Indexed: 10/18/2022]
|
13
|
Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am 2010; 28:29-56, vii. [PMID: 19945597 DOI: 10.1016/j.emc.2009.09.010] [Citation(s) in RCA: 355] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The RUSH exam (Rapid Ultrasound in SHock examination), presented in this article, represents a comprehensive algorithm for the integration of bedside ultrasound into the care of the patient in shock. By focusing on a stepwise evaluation of the shock patient defined here as "Pump, Tank, and Pipes," clinicians will gain crucial anatomic and physiologic data to better care for these patients.
Collapse
Affiliation(s)
- Phillips Perera
- New York Presbyterian Hospital, Columbia University Medical Center, Division of Emergency Medicine, 622 West 168th Street, New York, NY 10032, USA.
| | | | | | | |
Collapse
|
14
|
Wang CY, Liu K, Chia YY, Chen CH. Bedside ultrasonic detection of massive hemothorax due to superior vena cava perforation after hemodialysis catheter insertion. ACTA ACUST UNITED AC 2009; 47:95-8. [PMID: 19527972 DOI: 10.1016/s1875-4597(09)60032-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Hemothorax resulting from perforation of a great vessel is an uncommon but life-threatening complication which may occur during central venous insertion of a hemodialysis catheter. We describe a 78-year-old uremic female who developed unexplained and refractory shock on the completion of percutaneous placement of a hemodialysis catheter in the right subclavian vein under general anesthesia. Bedside transthoracic ultrasound revealed a large anechoic area above the right hemidiaphragm, suggestive of the presence of extensive hemothorax. The diagnosis was further confirmed by prompt drainage of fresh blood from the right thoracostomy tube. Emergent thoracotomy was performed and perforation of the superior vena cava was identified. Hemodynamic stability was restored after surgical repair of the injured vessel, aggressive volume resuscitation and inotropic/vasopressor treatment. This case suggests that portable ultrasonography is an invaluable bedside tool which allows anesthesiologists to made reliable and prompt diagnosis of potentially fatal complications, such as perforation of great central vein due to inadvertent cannulation.
Collapse
Affiliation(s)
- Chi-Ying Wang
- Department of Anesthesiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, R.O.C
| | | | | | | |
Collapse
|
15
|
Moore MA, Wallace EC, Westra SJ. The imaging of paediatric thoracic trauma. Pediatr Radiol 2009; 39:485-96. [PMID: 19151969 DOI: 10.1007/s00247-008-1093-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Revised: 10/23/2008] [Accepted: 11/25/2008] [Indexed: 12/30/2022]
Abstract
Major chest trauma in a child is associated with significant morbidity and mortality. It is most frequently encountered within the context of multisystem injury following high-energy trauma such as a motor vehicle accident. The anatomic-physiologic make-up of children is such that the pattern of ensuing injuries differs from that in their adult counterparts. Pulmonary contusion, pneumothorax, haemothorax and rib fractures are most commonly encountered. Although clinically more serious and potentially life threatening, tracheobronchial tear, aortic rupture and cardiac injuries are seldom observed. The most appropriate imaging algorithm is one tailored to the individual child and is guided by the nature of the traumatic event as well as clinical parameters. Chest radiography remains the first and most important imaging tool in paediatric chest trauma and should be supplemented with US and CT as indicated. Multidetector CT allows for the accurate diagnosis of most traumatic injuries, but should be only used in selected cases as its routine use in all paediatric patients would result in an unacceptably high radiation exposure to a large number of patients without proven clinical benefit. When CT is used, appropriate modifications should be incorporated so as to minimize the radiation dose to the patient whilst preserving diagnostic integrity.
Collapse
Affiliation(s)
- Michael A Moore
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | | | | |
Collapse
|