don’t jump the gun…

the case.

an elderly male is bought to ED following a high-speed motor vehicle accident having driven his car into a tree at ~100 km/h. He is complaining of severe chest pain & trouble breathing.

Primary survey: 

A. Patent & protected. C-spine immobilised.

B. RR 20. SaO2 99%. Symmetrical chest movement but reduced left-sided air entry. No subcutaneous emphysema.

C. P 100/min. BP 146/80. Warm & perfused. No active bleeding.

D. GCS 15. PEARL (4mm). Moving all 4 limbs.

E. Afebrile. BSL 8. Swollen, deformed LEFT ankle.

You perform your EFAST exam. (There is NO free-fluid in the abdomen & the pericardial view is normal).

[DDET EFAST – right side]

2D lung ultrasound: Preservation of pleural sliding with presence of comet-tail artefact – ie. no pneumothorax.

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[DDET EFAST – left side]

2D lung ultrasound: Poorly visualised lung sliding. No comet-tail artefacts. Highly suspicious for pneumothorax.

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[DDET Now ask yourself; “What are you going to do now?”]

Are you going to place a chest drain on this information ?

Do you get his CT first ??

Would would you do ???

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[DDET Here is his mobile CXR]

This CXR could easily be explained by a traumatic blunt aortic injury, especially given the mechanism of action. The patients overall clinical picture & haemodynamic stability however, made this less likely.

It was at this point that the patients’ wife arrived to explain that he had recently been diagnosed with a left-sided lung cancer which was inoperable.

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[DDET Discussion…]

False positive pneumothorax

I have previously posted on FALSE POSITIVE FAST EXAMS with respect to the abdominal component of the study.

Firstly; some quick revision…
MAKING the DIAGNOSIS of PNEUMOTHORAX on ULTRASOUND.

Requires the following three steps.

1. abolished lung sliding
2. stratosphere (bar-code) sign on M-mode
3. presence of a lung point

CAUSES of FALSE POSITIVE PNEUMOTHORAX.

• Bullous lung disease
• Main-stem bronchial intubation
• Inflammatory adherence.
  • ARDS
  • Pleurodesis
• Pulmonary contusion/consolidation
• Atelectasis
• Severe pulmonary fibrosis
• Phrenic nerve palsy

Check out this great review on Ultrasound for Pneumothorax at R.E.B.E.L EM…

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[DDET References.]

1. Volpicelli, G., Elbarbary, M., Blaivas, M., Lichtenstein, D. A., Mathis, G., Kirkpatrick, A. W., et al. (2012). International evidence-based recommendations for point-of-care lung ultrasound. Intensive care medicine, 38(4), 577–591. doi:10.1007/s00134-012-2513-4
2. Lichtenstein, D. A. (2014). Lung ultrasound in the critically ill. Annals of intensive care, 4(1), 1. doi:10.1186/2110-5820-4-1
3. Zhang, M., Liu, Z.-H., Yang, J.-X., Gan, J.-X., Xu, S.-W., You, X.-D., & Jiang, G.-Y. (2006). Rapid detection of pneumothorax by ultrasonography in patients with multiple trauma. Critical care (London, England), 10(4), R112. doi:10.1186/cc5004
4. Nandipati, K. C., Allamaneni, S., Kakarla, R., Wong, A., Richards, N., Satterfield, J., et al. (2011). Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax: experience at a community based level I trauma center. Injury, 42(5), 511–514. doi:10.1016/j.injury.2010.01.105lhop
5. Slater, A., Goodwin, M., Anderson, K. E., & Gleeson, F. V. (2006). COPD can mimic the appearance of pneumothorax on thoracic ultrasound. Chest, 129(3), 545–550. doi:10.1378/chest.129.3.545

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