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Ultrasounds for prehospital recognition of tension pneumothorax
Injury, Int. J. Care Injured 45 (2014) 1019–1022
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Letter to the Editor Ultrasounds for prehospital recognition of tension pneumothorax We read with great interest the article of Cantwell et al. [1], assessing an improvement in the prehospital recognition of potential tension pneumothorax in the setting of traumatic chest injury. The authors have emphasised a change in education and clinical practice increase the number of patients receiving needle decompression for a tension pneumothorax in prehospital care. In the era of ultrasonography, thoracic ultrasound (US) was determined as a valuable diagnostic method of pneumothorax in multiple studies. Already in 2001, Dulchavsky et al. [2], diagnosed 37 of 39 pneumothorax with US, 382 trauma patients, with a sensitivity of 94%. Later in 2004, Knudtson et al. reported that US was a reliable test in the diagnosis of pneumothorax with 99.7% specificity, assessing that US were an important adjuvant role to clinical investigation in penetrating trauma [3]. In a study of 204 trauma casualties by Nandipati et al. thoracic US appeared as a simple method and had a higher sensitivity compared to the chest X-ray and clinical examination in detecting pneumothorax (95% vs 79% and 95% respectively) [4]. Further its high sensitivity, thoracic US offer several advantages [5]: high feasibility (the lung can almost always be visualised), rapidity (a critical advantage in extreme emergencies), short learning curve (correctly trained physicians quickly master the signs), absence of radiation, real-time imaging, ability to easily perform dynamic and repeat evaluations at the bedside (without unnecessary delay for patient transport in unstable situations). Thoracic US, easily performed at the bedside in the trauma room, are now incorporated into Advanced Trauma Life Support (ATLS) guidelines as focused assessment with sonography for trauma (FAST) [6]. Due to advancements in technology, portability and miniaturisation in the field of microprocessors, batteries, and digital screens, the use of portable US machines is increasing in the out-ofhospital setting. Ketelaars et al. evaluated the impact of prehospital US thoracic examinations on the care of 281 trauma patients treated by a Netherland helicopter medical service between 2007 and 2010 [7]. US yielded a change of prehospital therapy or management in 21% of the patients (60 patients), and in 4% of the patients (10 patients), the plan to place a chest tube was abandoned. The mean duration of US examination was short (2.77 1.30 min) and should not delay the care. Reducing the time taken for bedside diagnosis of pneumothorax could allow the clinician to take earlier treatment measures. To conclude, we think that, besides ‘‘small changes in clinical practice guidelines, supported by an education and audit program’’ well-described by the authors, thoracic US have a promising role in the out-of-hospital setting,
0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved.
offering diagnostic and therapeutic advantages to improve the management of trauma patients. We would like to know if the authors could provide their opinion and their experience in the thoracic US pre-hospital use to detect tension pneumothorax. Conflict of interest statement The material submitted for publication, including related data, has not been previously published and is not under consideration for publication elsewhere. References [1] Cantwell K, Burgess S, Patrick I, Niggemeyer L, Fitzgerald M, Cameron P, et al. Improvement in the prehospital recognition of tension pneumothorax: the effect of a change to paramedic guidelines and education. Injury 2013 [Epub ahead of print]. [2] Dulchavsky SA, Schwarz KL, Kirkpatrick AW, et al. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma 2001; 50:201–5. [3] Knudtson JL, Dort JM, Helmer SD, Smith RS. Surgeon performed ultrasound for pneumothorax in the trauma suite. J Trauma 2004;56:527–30. [4] Nandipati KC, Allameni 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;42:511–4. [5] Lichtenstein DA, Mezie`re G, Lascols N, Biderman P, Courret JP, Gepner A, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005;33: 1231–1238. [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;57:288–95. [7] Ketelaars R, Hoogerwerf N, Scheffer GJ. Prehospital chest ultrasound by a Dutch helicopter emergency medical service. J Emerg Med 2013;44:811–7.
Jean-Vivien Schaal* Anaesthesiology and Intensive Care Department, Military Teaching Hospital Percy, 101 Avenue Henri Barbusse, 92140 Clamart, France Pierre Pasquier Julie Renner Cle´ment Dubost Ste´phane Me´rat Emergency and Intensive Care Department, Military Teaching Hospital Be´gin, 69 Avenue de Paris, 94163 Saint-Mande´, France *Corresponding author. Tel.: +33 662072859 E-mail address: [email protected] (J.-V. Schaal) http://dx.doi.org/10.1016/j.injury.2013.11.025
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Letter to the Editor Ultrasounds for prehospital recognition of tension pneumothorax We read with great interest the article of Cantwell et al. [1], assessing an improvement in the prehospital recognition of potential tension pneumothorax in the setting of traumatic chest injury. The authors have emphasised a change in education and clinical practice increase the number of patients receiving needle decompression for a tension pneumothorax in prehospital care. In the era of ultrasonography, thoracic ultrasound (US) was determined as a valuable diagnostic method of pneumothorax in multiple studies. Already in 2001, Dulchavsky et al. [2], diagnosed 37 of 39 pneumothorax with US, 382 trauma patients, with a sensitivity of 94%. Later in 2004, Knudtson et al. reported that US was a reliable test in the diagnosis of pneumothorax with 99.7% specificity, assessing that US were an important adjuvant role to clinical investigation in penetrating trauma [3]. In a study of 204 trauma casualties by Nandipati et al. thoracic US appeared as a simple method and had a higher sensitivity compared to the chest X-ray and clinical examination in detecting pneumothorax (95% vs 79% and 95% respectively) [4]. Further its high sensitivity, thoracic US offer several advantages [5]: high feasibility (the lung can almost always be visualised), rapidity (a critical advantage in extreme emergencies), short learning curve (correctly trained physicians quickly master the signs), absence of radiation, real-time imaging, ability to easily perform dynamic and repeat evaluations at the bedside (without unnecessary delay for patient transport in unstable situations). Thoracic US, easily performed at the bedside in the trauma room, are now incorporated into Advanced Trauma Life Support (ATLS) guidelines as focused assessment with sonography for trauma (FAST) [6]. Due to advancements in technology, portability and miniaturisation in the field of microprocessors, batteries, and digital screens, the use of portable US machines is increasing in the out-ofhospital setting. Ketelaars et al. evaluated the impact of prehospital US thoracic examinations on the care of 281 trauma patients treated by a Netherland helicopter medical service between 2007 and 2010 [7]. US yielded a change of prehospital therapy or management in 21% of the patients (60 patients), and in 4% of the patients (10 patients), the plan to place a chest tube was abandoned. The mean duration of US examination was short (2.77 1.30 min) and should not delay the care. Reducing the time taken for bedside diagnosis of pneumothorax could allow the clinician to take earlier treatment measures. To conclude, we think that, besides ‘‘small changes in clinical practice guidelines, supported by an education and audit program’’ well-described by the authors, thoracic US have a promising role in the out-of-hospital setting,
0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved.
offering diagnostic and therapeutic advantages to improve the management of trauma patients. We would like to know if the authors could provide their opinion and their experience in the thoracic US pre-hospital use to detect tension pneumothorax. Conflict of interest statement The material submitted for publication, including related data, has not been previously published and is not under consideration for publication elsewhere. References [1] Cantwell K, Burgess S, Patrick I, Niggemeyer L, Fitzgerald M, Cameron P, et al. Improvement in the prehospital recognition of tension pneumothorax: the effect of a change to paramedic guidelines and education. Injury 2013 [Epub ahead of print]. [2] Dulchavsky SA, Schwarz KL, Kirkpatrick AW, et al. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma 2001; 50:201–5. [3] Knudtson JL, Dort JM, Helmer SD, Smith RS. Surgeon performed ultrasound for pneumothorax in the trauma suite. J Trauma 2004;56:527–30. [4] Nandipati KC, Allameni 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;42:511–4. [5] Lichtenstein DA, Mezie`re G, Lascols N, Biderman P, Courret JP, Gepner A, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005;33: 1231–1238. [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;57:288–95. [7] Ketelaars R, Hoogerwerf N, Scheffer GJ. Prehospital chest ultrasound by a Dutch helicopter emergency medical service. J Emerg Med 2013;44:811–7.
Jean-Vivien Schaal* Anaesthesiology and Intensive Care Department, Military Teaching Hospital Percy, 101 Avenue Henri Barbusse, 92140 Clamart, France Pierre Pasquier Julie Renner Cle´ment Dubost Ste´phane Me´rat Emergency and Intensive Care Department, Military Teaching Hospital Be´gin, 69 Avenue de Paris, 94163 Saint-Mande´, France *Corresponding author. Tel.: +33 662072859 E-mail address: [email protected] (J.-V. Schaal) http://dx.doi.org/10.1016/j.injury.2013.11.025