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Prehospital ultrasound thoracic examination to improve decision making, triage, and care in blunt trauma
American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Prehospital ultrasound thoracic examination to improve decision making, triage, and care in blunt trauma Abstract Prehospital acute blunt thoracic trauma care remains difficult. Among then, diagnosis of atelectasis with ultrasound remains rare and unusual. We report the case of a worker who had a sharp chest pain currently after using a jackhammer. First clinical examination suspected a left tension pneumothorax but ruled out by sliding sign in left hemithorax ultrasound (US) examination. The right upper thoracic scan showed a well-defined lung point, a “hepatization” appearance with static air bronchograms, a diaphragm elevation and a dextrocardia in B mode, and a pseudobarcode with no lung pulse in Time Motion (TM) mode. A “rip’s organ absent sign” excluded the hypothesis of an acute diaphragmatic rupture. An atelectasis was at once suspected and confirmed at hospital by tomodensitometry. Diaphragmatic injury can be suspected when “rip’s absent organ sign,” diaphragm poor movement or elevation, liver sliding sign, subphrenic effusion, or spleen or liver intrathoracic presence. Unusually, these signs can put diagnosis in a wrong track as described in our case report. Lung pulse, absent sliding sign, or hemidiaphragm standstill is highly suspect of atelectasis but cannot be established formally. However, in patients with alveolar consolidation displaying air bronchograms, the dynamic air bronchograms indicated lung contusion, distinguishing it from atelectasis. Static air bronchograms were seen in most atelectases and one-third of cases of contusion or pneumonia. Fast scan can be useful to evoke atelectasis in blunt trauma. Differential diagnoses such as diaphragmatic rupture or consolidation could be discarded. Ultrasound examination could justify a precise semiological description. Prehospital acute blunt thoracic trauma care remains difficult. In Europe, a third of the major trauma patients present a thoracic trauma and a quarter of them is potentially lethal [1,2]. Because of advancements in technology, use of portable US machine in the outof-hospital setting is increasingly feasible [3]. It has diagnostic and therapeutic advantages and may therefore improve management and treatment of patients presenting acute blunt thoracic trauma [4]. Among then, diagnosis of atelectasis with US remains rare and unusual. We report the case of a 44-year-old worker who had a sharp chest pain currently after using a jackhammer. A mobile intensive care unit was dispatched to the scene. Ten minutes after the call, the medical team arrived on field and diagnosed acute dyspnea with a breath rate at 39 per minute, oximetry at 88% with 15 L/min oxygen facial bag mask. He was tachycardic at 140 beats per minute, with blood pressure to 78/50 mm Hg. Rapidly, acute respiratory distress became uncontrolled with hypoxemia, agitation, and sweets. Rapid sequence intubation was therefore performed. Direct laryngoscopy showed
blood in the upper airway. Mechanical ventilation was standard, with tidal volume at 400 mL (6 mL/kg), breath rate at 16 per minute, fraction of inspired oxygen at 1. Hypoxemia was rapidly corrected. Peak inspiratory pressure ventilator was also increased up to 60 mm Hg, pulse oxygen saturation at less than 80%, and end-tidal CO2 oximetry (EtCO2) up to 60 mm Hg. A new clinical examination showed relative left percussion hyperresonance, absent right vesicular murmur, and heart sound in the right hemithorax. A left tension pneumothorax was suspected. A chest US examination was realized. Sliding sign was found in each point of the left hemithorax and ruled out a left pneumothorax. The right upper thoracic scan showed in 2B mode a well-defined lung point and a “hepatization” appearance with static air bronchograms (Fig. 1). In TM mode, there was a pseudobarcode with no lung pulse. We also noticed a diaphragm elevation and a dextrocardia. A “rip’s organ absent sign” excluded the hypothesis of an acute diaphragmatic rupture. An atelectasis was at once suspected. Ventilator settings were also modified with high breath frequency (around 30 breaths per minute) and low tidal volume (4 mL/kg). At hospital arrival, pulse oxygen saturation was around 92% and EtCO2 was 50 mm Hg. Chest x-ray confirmed the right heart deviation associated with a lung alveolar condensation (Fig. 2). Tomodensitometry confirmed atelectasis due to upper lobe bronchus blood obstruction. Hospital treatment with iterative bronchial
Lung point, end slinding Rib
Static air bronchograms
Fig. 1. Sagittal thoracic right view. The entire right upper lobe was consolidated. This also allowed visualization of the consolidated lung (“hepatization”) with great vessels. Trails of gas locules can be seen within the more solid tissue representing air bronchograms.
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Brun P-M, et al, Prehospital ultrasound thoracic examination to improve decision making, triage, and care in blunt trauma, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2013.12.063
2
P-M. Brun et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx Table Potentially lethal thoracic injury adapted from Yamamoto et al [8] Immediate
Occult
Airway obstruction Flail chest Tension pneumothorax Hemothorax Open pneumothorax Cardiac tamponnade
Vascular injury Tracheobronchial injury Esophageal rupture Pulmonary contusion Diaphragmatic injury Myocardial contusion
pneumonia [11]. In such situation, tomodensitometry or fibroscopy is essential to formally establish diagnosis. Fast scan can be useful to evoke atelectasis in blunt trauma. Differential diagnoses such as diaphragmatic rupture or consolidation could be discarded. Ultrasound examination could justify a precise semiological description all of signs such as lung pulse, sliding sign, lack of rip’s organ sign, diaphragm movement, and air bronchograms of the lung hepatitization. Pierre-Marie Brun MD Department of Emergency Medicine and Intensive Care HIA Desgenettes, Lyon, France E-mail address: [email protected]
Fig. 2. Anteroposterior chest x-ray admission.
fibroscopy allowed mechanical ventilation weaning at 48 hours and hospital discharge after 15 days. Several studies have proven better clinical performance with pleuropulmonary scan [5,6]. Review of the clinical literature confirms the key point that US chest examination especially in traumatized patient may improve management and treatment with rapid detection of 7 of the 12 potential lethal injuries (Table) [7,8]. The cornerstone of semiological pleuropulmonary US interpretation remains the pleural line, with static (A and B line) or dynamic sign in B (lung sliding, lung point) and M mode (seashore with normal sliding sign vs barcode, lung pulse as the detection of the subtle cardiac, lung point where normal pleural interface contacts the boundary of the pneumothorax). In addition, pneumothorax diagnosis needs no sliding sign and B lines, exclusive A lines, and barcode or in a lucky way lung point in M mode [9]. Recent studies confirm the superiority of US examination when compared with x-ray concerning pneumothorax diagnosis [7,9]. Pleural effusion diagnosis needs floating and freely rippling lung in fluid or sinusoid sign visualization by respiratory interpleural variation in M mode. Diaphragmatic injury can be suspected when “rip’s absent organ sign,” diaphragm poor movement or elevation, liver sliding sign, subphrenic effusion, or spleen or liver intrathoracic presence [3]. Unusually, these signs can put diagnosis in a wrong track as described in our case report. Atelectasis US diagnosis is difficult. Lung pulse, absent sliding sign, or hemidiaphragm standstill is highly suspect but cannot be established formally [10]. In our case lung pulse was missing, as described in 10%, absent sliding sign was available as classically observed in 100% of cases, and the right hemidiaphragm course was not visualized [10]. However, in patients with alveolar consolidation displaying air bronchograms, the dynamic air bronchograms indicated lung contusion, distinguishing it from atelectasis. Static air bronchograms were seen in most atelectases and one-third of cases of contusion or
Jacques Bessereau MD Daniel Levy MD Xavier Billieres MD Nathalie Fournier MD Francois Kerbaul MD, PhD Department of Emergency Medicine and Intensive Care Timone University Hospital, Marseille, France http://dx.doi.org/10.1016/j.ajem.2013.12.063 References [1] Shorr RM, Crittenden M, Indeck M, Hartunian SL, Rodriguez A. Blunt thoracic trauma. Analysis of 515 patients. Ann Surg 1987;206(2):200–5. [2] LoCicero 3rd J, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am 1989;69(1):15–9. [3] Gangahar R., Doshi D. Fast scan in the diagnosis of acute diaphragmatic rupture. Am J Emerg Med. 2010;28(3):387 e1-3. [4] Flint L, Meredith JW, Schwab CW, Trunkey D, Rue LW, Taheri PA. Trauma: contemporary principles and therapy. In: Wilkins LW, ed.: Wolter Kluwers 2008. [5] Rippey JCR, Royse AG. Ultrasound in trauma. Best Pract Res Clin Anaesthesiol 2009;23(3):343–62. [6] Kirkpatrick AW, Sirois M, Laupland KB, Liu D, Rowan K, Ball CG, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the extended focused assessment with sonography for trauma (EFAST). J Trauma 2004;57(2): 288–95. [7] Nandipati KC, Allamaneni S, Kakarla R, Wong A, Richards N, Satterfield J, et al. Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax: Experience at a community-based level I trauma center. Injury 2011;42(5):511–4. [8] Yamamoto L, Schroeder C, Morley D, Beliveau C. Thoracic trauma: the deadly dozen. Crit Care Nurs Q 2005;28(1):22–40. [9] Lichtenstein DA, Meziere G, Lascols N, Biderman P, Courret JP, Gepner A, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005;33(6):1231–8. [10] Soldati G, Testa A, Silva FR, Carbone L, Portale G, Silveri NG. Chest ultrasonography in lung contusion. Chest 2006;130(2):533–8. [11] Lichtenstein D, Mezière G, Seitz J. The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis. Chest 2009;135 (6):1421–5.
Please cite this article as: Brun P-M, et al, Prehospital ultrasound thoracic examination to improve decision making, triage, and care in blunt trauma, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2013.12.063
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Prehospital ultrasound thoracic examination to improve decision making, triage, and care in blunt trauma Abstract Prehospital acute blunt thoracic trauma care remains difficult. Among then, diagnosis of atelectasis with ultrasound remains rare and unusual. We report the case of a worker who had a sharp chest pain currently after using a jackhammer. First clinical examination suspected a left tension pneumothorax but ruled out by sliding sign in left hemithorax ultrasound (US) examination. The right upper thoracic scan showed a well-defined lung point, a “hepatization” appearance with static air bronchograms, a diaphragm elevation and a dextrocardia in B mode, and a pseudobarcode with no lung pulse in Time Motion (TM) mode. A “rip’s organ absent sign” excluded the hypothesis of an acute diaphragmatic rupture. An atelectasis was at once suspected and confirmed at hospital by tomodensitometry. Diaphragmatic injury can be suspected when “rip’s absent organ sign,” diaphragm poor movement or elevation, liver sliding sign, subphrenic effusion, or spleen or liver intrathoracic presence. Unusually, these signs can put diagnosis in a wrong track as described in our case report. Lung pulse, absent sliding sign, or hemidiaphragm standstill is highly suspect of atelectasis but cannot be established formally. However, in patients with alveolar consolidation displaying air bronchograms, the dynamic air bronchograms indicated lung contusion, distinguishing it from atelectasis. Static air bronchograms were seen in most atelectases and one-third of cases of contusion or pneumonia. Fast scan can be useful to evoke atelectasis in blunt trauma. Differential diagnoses such as diaphragmatic rupture or consolidation could be discarded. Ultrasound examination could justify a precise semiological description. Prehospital acute blunt thoracic trauma care remains difficult. In Europe, a third of the major trauma patients present a thoracic trauma and a quarter of them is potentially lethal [1,2]. Because of advancements in technology, use of portable US machine in the outof-hospital setting is increasingly feasible [3]. It has diagnostic and therapeutic advantages and may therefore improve management and treatment of patients presenting acute blunt thoracic trauma [4]. Among then, diagnosis of atelectasis with US remains rare and unusual. We report the case of a 44-year-old worker who had a sharp chest pain currently after using a jackhammer. A mobile intensive care unit was dispatched to the scene. Ten minutes after the call, the medical team arrived on field and diagnosed acute dyspnea with a breath rate at 39 per minute, oximetry at 88% with 15 L/min oxygen facial bag mask. He was tachycardic at 140 beats per minute, with blood pressure to 78/50 mm Hg. Rapidly, acute respiratory distress became uncontrolled with hypoxemia, agitation, and sweets. Rapid sequence intubation was therefore performed. Direct laryngoscopy showed
blood in the upper airway. Mechanical ventilation was standard, with tidal volume at 400 mL (6 mL/kg), breath rate at 16 per minute, fraction of inspired oxygen at 1. Hypoxemia was rapidly corrected. Peak inspiratory pressure ventilator was also increased up to 60 mm Hg, pulse oxygen saturation at less than 80%, and end-tidal CO2 oximetry (EtCO2) up to 60 mm Hg. A new clinical examination showed relative left percussion hyperresonance, absent right vesicular murmur, and heart sound in the right hemithorax. A left tension pneumothorax was suspected. A chest US examination was realized. Sliding sign was found in each point of the left hemithorax and ruled out a left pneumothorax. The right upper thoracic scan showed in 2B mode a well-defined lung point and a “hepatization” appearance with static air bronchograms (Fig. 1). In TM mode, there was a pseudobarcode with no lung pulse. We also noticed a diaphragm elevation and a dextrocardia. A “rip’s organ absent sign” excluded the hypothesis of an acute diaphragmatic rupture. An atelectasis was at once suspected. Ventilator settings were also modified with high breath frequency (around 30 breaths per minute) and low tidal volume (4 mL/kg). At hospital arrival, pulse oxygen saturation was around 92% and EtCO2 was 50 mm Hg. Chest x-ray confirmed the right heart deviation associated with a lung alveolar condensation (Fig. 2). Tomodensitometry confirmed atelectasis due to upper lobe bronchus blood obstruction. Hospital treatment with iterative bronchial
Lung point, end slinding Rib
Static air bronchograms
Fig. 1. Sagittal thoracic right view. The entire right upper lobe was consolidated. This also allowed visualization of the consolidated lung (“hepatization”) with great vessels. Trails of gas locules can be seen within the more solid tissue representing air bronchograms.
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Brun P-M, et al, Prehospital ultrasound thoracic examination to improve decision making, triage, and care in blunt trauma, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2013.12.063
2
P-M. Brun et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx Table Potentially lethal thoracic injury adapted from Yamamoto et al [8] Immediate
Occult
Airway obstruction Flail chest Tension pneumothorax Hemothorax Open pneumothorax Cardiac tamponnade
Vascular injury Tracheobronchial injury Esophageal rupture Pulmonary contusion Diaphragmatic injury Myocardial contusion
pneumonia [11]. In such situation, tomodensitometry or fibroscopy is essential to formally establish diagnosis. Fast scan can be useful to evoke atelectasis in blunt trauma. Differential diagnoses such as diaphragmatic rupture or consolidation could be discarded. Ultrasound examination could justify a precise semiological description all of signs such as lung pulse, sliding sign, lack of rip’s organ sign, diaphragm movement, and air bronchograms of the lung hepatitization. Pierre-Marie Brun MD Department of Emergency Medicine and Intensive Care HIA Desgenettes, Lyon, France E-mail address: [email protected]
Fig. 2. Anteroposterior chest x-ray admission.
fibroscopy allowed mechanical ventilation weaning at 48 hours and hospital discharge after 15 days. Several studies have proven better clinical performance with pleuropulmonary scan [5,6]. Review of the clinical literature confirms the key point that US chest examination especially in traumatized patient may improve management and treatment with rapid detection of 7 of the 12 potential lethal injuries (Table) [7,8]. The cornerstone of semiological pleuropulmonary US interpretation remains the pleural line, with static (A and B line) or dynamic sign in B (lung sliding, lung point) and M mode (seashore with normal sliding sign vs barcode, lung pulse as the detection of the subtle cardiac, lung point where normal pleural interface contacts the boundary of the pneumothorax). In addition, pneumothorax diagnosis needs no sliding sign and B lines, exclusive A lines, and barcode or in a lucky way lung point in M mode [9]. Recent studies confirm the superiority of US examination when compared with x-ray concerning pneumothorax diagnosis [7,9]. Pleural effusion diagnosis needs floating and freely rippling lung in fluid or sinusoid sign visualization by respiratory interpleural variation in M mode. Diaphragmatic injury can be suspected when “rip’s absent organ sign,” diaphragm poor movement or elevation, liver sliding sign, subphrenic effusion, or spleen or liver intrathoracic presence [3]. Unusually, these signs can put diagnosis in a wrong track as described in our case report. Atelectasis US diagnosis is difficult. Lung pulse, absent sliding sign, or hemidiaphragm standstill is highly suspect but cannot be established formally [10]. In our case lung pulse was missing, as described in 10%, absent sliding sign was available as classically observed in 100% of cases, and the right hemidiaphragm course was not visualized [10]. However, in patients with alveolar consolidation displaying air bronchograms, the dynamic air bronchograms indicated lung contusion, distinguishing it from atelectasis. Static air bronchograms were seen in most atelectases and one-third of cases of contusion or
Jacques Bessereau MD Daniel Levy MD Xavier Billieres MD Nathalie Fournier MD Francois Kerbaul MD, PhD Department of Emergency Medicine and Intensive Care Timone University Hospital, Marseille, France http://dx.doi.org/10.1016/j.ajem.2013.12.063 References [1] Shorr RM, Crittenden M, Indeck M, Hartunian SL, Rodriguez A. Blunt thoracic trauma. Analysis of 515 patients. Ann Surg 1987;206(2):200–5. [2] LoCicero 3rd J, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am 1989;69(1):15–9. [3] Gangahar R., Doshi D. Fast scan in the diagnosis of acute diaphragmatic rupture. Am J Emerg Med. 2010;28(3):387 e1-3. [4] Flint L, Meredith JW, Schwab CW, Trunkey D, Rue LW, Taheri PA. Trauma: contemporary principles and therapy. In: Wilkins LW, ed.: Wolter Kluwers 2008. [5] Rippey JCR, Royse AG. Ultrasound in trauma. Best Pract Res Clin Anaesthesiol 2009;23(3):343–62. [6] Kirkpatrick AW, Sirois M, Laupland KB, Liu D, Rowan K, Ball CG, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the extended focused assessment with sonography for trauma (EFAST). J Trauma 2004;57(2): 288–95. [7] Nandipati KC, Allamaneni S, Kakarla R, Wong A, Richards N, Satterfield J, et al. Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax: Experience at a community-based level I trauma center. Injury 2011;42(5):511–4. [8] Yamamoto L, Schroeder C, Morley D, Beliveau C. Thoracic trauma: the deadly dozen. Crit Care Nurs Q 2005;28(1):22–40. [9] Lichtenstein DA, Meziere G, Lascols N, Biderman P, Courret JP, Gepner A, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005;33(6):1231–8. [10] Soldati G, Testa A, Silva FR, Carbone L, Portale G, Silveri NG. Chest ultrasonography in lung contusion. Chest 2006;130(2):533–8. [11] Lichtenstein D, Mezière G, Seitz J. The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis. Chest 2009;135 (6):1421–5.
Please cite this article as: Brun P-M, et al, Prehospital ultrasound thoracic examination to improve decision making, triage, and care in blunt trauma, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2013.12.063