Detection of occult pneumothoraces in the significantly injured adult with blunt trauma.

BACKGROUND: Identification of pneumothoraces is essential during the initial assessment of major injury. Prompt intervention is crucial for effective resuscitation and for subsequent safe management. Historically, emergency departments have relied on chest X-ray for detection of pneumothoraces. More recently, the increasing availability of computed tomography (CT) has provided a more sensitive means of detection. Occult pneumothoraces are those that are missed on clinical examination and chest X-ray, but are detected on subsequent CT. OBJECTIVE: To determine the incidence of occult pneumothoraces and their impact on subsequent management. PATIENTS: All blunt trauma patients with CT scans from a single, large, adult emergency department in 1 year. METHODS: Patient records were analysed to determine the proportion of pneumothoraces detected on CT that had not been previously detected on chest X-ray. Records were further examined to determine how many occult pneumothoraces required additional management after detection. RESULTS: In all, 134 blunt trauma patients required a CT scan. Thirty-five pneumothoraces were detected in 27 patients; 15 were occult. Six of these 15 were managed with intercostal drain insertion, all proceeding to mechanical ventilation. Of the eight patients (one bilateral) managed observantly, all had uncomplicated recoveries. CT was significantly more sensitive in the detection of pneumothoraces (P=0.03). Retrospective review by a radiology specialist identified three chest X-rays that had findings (deep sulcus sign and prominent cardiac outline) that were suggestive of pneumothorax. CONCLUSIONS: A sufficiently high proportion of pneumothoraces is missed on chest X-ray to advocate a low threshold for use of CT in the early assessment of blunt trauma patients, especially if mechanical ventilation is required for ongoing management.     

Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax

Needle aspiration is a recognised emergency treatment of spontaneous pneumothorax and in the case of suspected tension is usually performed before chest radiography. Three cases are described of apparent life threatening haemorrhage after anterior aspiration in the second intercostal space, mid-clavicular line (2ICS MCL) requiring resuscitation, and transfer to a cardiothoracic unit. In these patients there was no evidence of haemothorax on initial presentation. Lateral needle aspiration, in the site recommended for chest drain insertion, the 5th intercostal space, anterior axillary line (5ICS ALL) is technically easy and may be a potentially safer option for decompressing pneumothoraces.     

Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma

Objectives: Supine anteroposterior (AP) chest radiographs in patients with blunt trauma have poor sensitivity for the identification of pneumothorax. Ultrasound (US) has been proposed as an alternative screening test for pneumothorax in this population. The authors conducted an evidence‐based review of the medical literature to compare sensitivity of bedside US and AP chest radiographs in identifying pneumothorax after blunt trauma. Methods: MEDLINE and EMBASE databases were searched for trials from 1965 through June 2009 using a search strategy derived from the following PICO formulation of our clinical question: patients included adult (18 + years) emergency department (ED) patients in whom pneumothorax was suspected after blunt trauma. The intervention was thoracic ultrasonography for the detection of pneumothorax. The comparator was the supine AP chest radiograph during the initial evaluation of the patient. The outcome was the diagnostic performance of US in identifying the presence of pneumothorax in the study population. The criterion standard for the presence or absence of pneumothorax was computed tomography (CT) of the chest or a rush of air during thoracostomy tube placement (in unstable patients). Prospective, observational trials of emergency physician (EP)‐performed thoracic US were included. Trials in which the exams were performed by radiologists or surgeons, or trials that investigated patients suffering penetrating trauma or with spontaneous or iatrogenic pneumothoraces, were excluded. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. Data analysis consisted of test performance (sensitivity and specificity, with 95% confidence intervals [CIs]) of thoracic US and supine AP chest radiography. Results: Four prospective observational studies were identified, with a total of 606 subjects who met the inclusion and exclusion criteria. The sensitivity and specificity of US for the detection of pneumothorax ranged from 86% to 98% and 97% to 100%, respectively. The sensitivity of supine AP chest radiographs for the detection of pneumothorax ranged from 28% to 75%. The specificity of supine AP chest radiographs was 100% in all included studies. Conclusions: This evidence‐based review suggests that bedside thoracic US is a more sensitive screening test than supine AP chest radiography for the detection of pneumothorax in adult patients with blunt chest trauma. ACADEMIC EMERGENCY MEDICINE 2010; 17:11–17 © 2010 by the Society for Academic Emergency Medicine     

Ultrasound‐assisted aspiration of loculated pneumothorax: A new technique

In this report, we describe a new sonographic (US) technique that can assist in the aspiration of a loculated pneumothorax. Patients may develop loculated pneumothorax as a result of such conditions as pleural malignancy or pleural infection or after undergoing thoracic surgery. Often the loculated pneumothorax is outside of safe areas, and chest tubes need to be placed near vital structures. This report presents the cases of three patients with iatrogenic loculated pneumothorax that required aspiration. We used US to assist in the placement of chest tubes, and we describe our technique of US‐assisted aspiration of loculated pneumothorax. The procedure is a new approach to a common problem in chest medicine that may increase the safety of treatment. © 2015 Wiley Periodicals, Inc. J Clin Ultrasound 44 :326–330, 2016     

Sonographic diagnosis of bilateral pneumothorax following an acupuncture session

We present the case of a 57‐year‐old woman who presented with the acute onset of chest pain and dyspnea, which started while undergoing acupuncture for neck pain. A bedside ultrasound revealed bilateral pneumothoraces, which were confirmed radiographically. We discuss the details of the case, the sonographic features of pneumothorax, and the role of bedside ultrasonography in the assessment of an acutely dyspneic patient. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound 42 :27–29, 2014     

Chest sonography versus lateral decubitus radiography in the diagnosis of small pleural effusions

PURPOSE: The aim of this prospective study was to assess the value of chest sonography in the radiologic diagnosis of small pleural effusions (relative to expiratory lateral decubitus radiography) and to suggest gray-scale sonographic criteria for detecting the presence of small pleural effusions. METHODS: Patients referred for abdominal or chest sonographic evaluation for various reasons were also examined for sonographic features of pleural effusion from May 1, 1997, until January 31, 2000. Patients who had evidence of small pleural effusions were included. Patients with no such evidence served as a control group. Subsequently, all patients underwent erect posteroanterior and expiratory lateral decubitus chest radiography. RESULTS: On chest sonography, 52 patients were found to have small pleural effusions. The control group consisted of 17 patients. The mean thickness of the pleural effusion was 9.2 mm on sonography and 7.6 mm on expiratory lateral decubitus radiography (p < 0.01). Compared with radiologic examination, chest sonography had a positive predictive value of 92% in the diagnosis of small pleural effusions in our study population. CONCLUSIONS: Chest sonography showed a high degree of accuracy relative to that of lateral decubitus chest radiography in the diagnosis of small pleural effusions, which appeared as thin (usually 15 mm thick or less) anechoic areas that changed shape with the phases of respiration.     

eFAST exam errors at a level 1 trauma center: A retrospective cohort study

ObjectivesExtended Focused Assessment with Sonography for Trauma (eFAST) ultrasound exams are central to the care of the unstable trauma patient. We examined six years of eFAST quality assurance data to identify the most common reasons for false positive and false negative eFAST exams.MethodsThis was an observational, retrospective cohort study of trauma activation patients evaluated in an urban, academic Level 1 trauma center. All eFAST exams that were identified as false positive or false negative exams compared with computed tomography (CT) imaging were included.Results4860 eFAST exams were performed on trauma patients. 1450 (29.8%) were undocumented, technically limited, or incomplete (missing images). Of the 3410 remaining exams, 180 (5.27%) were true positive and 3128 (91.7%) were true negative. 27 (0.79%) exams were identified as false positive and 75 (2.19%) were identified as false negative. Of the false positive scans, 7 had no CT scan and 8 had correct real-time trauma paper documentation of eFAST exam results when compared to CT and were excluded, leaving 12 false positive scans. Of the false negative scans, 11 were excluded for concordant documentation in real-time trauma room paper documentation, 20 were excluded for no CT scan, and 2 were excluded as incomplete, leaving 42 false negative scans. Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam were the most common source of errors.ConclusionThe eFAST exams in trauma activation patients are highly accurate. Unfortunately poor documentation and technically limited/incomplete studies represent 29.8% of our eFAST exams.Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam are the most common source of errors.     

Emergency ultrasound in the acute assessment of haemothorax

Aims: To evaluate thoracic ultrasound for the detection of haemothorax in patients with thoracic trauma against established investigations.

Methods: Thoracic ultrasound was performed as an extension of the standard focused assessment with sonography for trauma (FAST) protocol used at the Queen's Medical Centre for the assessment of adult patients with torso trauma. Fluid was sought in both pleural cavities using a hand portable ultrasound system by one of two non-radiologists trained in FAST. Findings were compared against subsequent investigations/procedures performed at the discretion of the attending emergency physician—supine chest radiography, intercostal drain, computed tomography, or thoracotomy. The sensitivity of the technique and the time taken to diagnosis for each investigation were recorded.

Results: Sixty one patients, 54 (89%) after blunt trauma, underwent thoracic ultrasound evaluation during the study. Twelve patients had a haemothorax detected by ultrasound and confirmed by computed tomography or by tube thoracostomy. Four haemothoraces detected on ultrasound were not apparent on trauma chest radiography. There were 12 true positives, 48 true negatives, no false positives, and one false negative scan. The sensitivity of ultrasound was 92% and specificity 100% with a positive predictive value of 100% and negative predictive value 98% for the detection of haemothorax after trauma.

Conclusions: Emergency ultrasound of the chest performed as part of the primary survey of the traumatised patient can rapidly and accurately diagnose haemothorax and is a valuable tool to augment the immediate clinical assessment of these patients.

     

床旁超声对外伤性气胸的诊断价值

目的以CT为标准比较床旁超声、仰卧位X线胸片对气胸的诊断价值。方法46例钝性胸外伤患者均作了床旁超声、仰卧位X线胸片检查，并对结果和CT片进行比较。结果31／46例（34侧）患者口检查发现气胸，其中28例（30侧）超声检查也发现，10例在仰卧位X线胸片发现，2侧超声结果假阳性患者CT检查证实为肺大泡。超声检查对气胸的敏感性88.2％（30／34侧），特异性96．6％（56／58侧），阳性预测值93．8％（30／32侧），阴性预测值93．3％（56／60侧）；而仰卧位胸片的敏感性35．3％（12／34侧），特异性100％（58／58侧），阳性预测值100％（12／12侧），阴性预测值72．5％（58／80侧）。结论本研究结果表明，床旁超声检查对外伤性气胸的诊断敏感性、准确度比仰卧位X线胸片好，和CT检查结果相似。     

The comet-tail artifact: an ultrasound sign ruling out pneumothorax

Objective: Ultrasound artifacts arising from the lung–wall interface are either vertical (comet-tail artifacts) or horizontal. The significance of these artifacts for the diagnosis of pneumothorax was assessed. Design: Prospective clinical study. Setting: The medical ICU of a university-affiliated teaching hospital. Patients: We compared 41 complete pneumothoraces with 146 hemithoraces in 73 critically ill patients in which computed tomography showed absence of pneumothorax. Measurements: The anterior chest wall was investigated in supine patients using a portable device. The test was defined as positive for complete pneumothorax when only horizontal artifacts were visible, and negative when artifacts arising from the pleural line and spreading up to the edge of the screen (referred to as “comet-tail artifacts”) were present. Results: The feasibility was 98 %. Ultrasound showed exclusive horizontal artifacts in all 41 analyzable cases of complete pneumothorax. In the pneumothorax-free group, “comet-tail artifacts” were present in 87 cases and exclusive horizontal artifacts in 56. Ultrasound as well as computed tomography showed anterior consolidation or anterior pleural effusion in three cases. Horizontal artifacts had a sensitivity and a negative predictive value of 100 % and a specificity of 60 % for the diagnosis of pneumothorax. Horizontal artifacts and absent lung sliding, when combined, had a sensitivity and a negative predictive value of 100 % and a specificity of 96.5 %. Conclusions: Ultrasound detection of the “comet-tail artifact” at the anterior chest wall allows complete pneumothorax to be discounted. Received: 11 February 1998 Accepted: 3 February 1999     

A Prospective Comparison of Supine Chest Radiography and Bedside Ultrasound for the Diagnosis of Traumatic Pneumothorax

Background: Supine anteroposterior (AP) chest radiography may not detect the presence of a small or medium pneumothorax (PTX) in trauma patients. Objectives: To compare the sensitivity and specificity of bedside ultrasound (US) in the emergency department (ED) with supine portable AP chest radiography for the detection of PTX in trauma patients, and to determine whether US can grade the size of the PTX. Methods: This was a prospective, single‐blinded study with convenience sampling, based on researcher availability, of blunt trauma patients at a Level 1 trauma center with an annual census of 75,000 patients. Enrollment criteria were adult trauma patients receiving computed tomography (CT) of the abdomen and pelvis (which includes lung windows at the authors' institution). Patients in whom the examination could not be completed were excluded. During the initial evaluation, attending emergency physicians performed bedside trauma US examinations to determine the presence of a sliding lung sign to rule out PTX. Portable, supine AP chest radiographs were evaluated by an attending trauma physician, blinded to the results of the thoracic US. The CT results (used as the criterion standard), or air release on chest tube placement, were compared with US and chest radiograph findings. Sensitivities and specificities with 95% confidence intervals (95% CIs) were calculated for US and AP chest radiography for the detection of PTX, and Spearman's rank correlation was used to evaluate for the ability of US to predict the size of the PTX on CT. Results: A total of 176 patients were enrolled in the study over an eight‐month period. Twelve patients had a chest tube placed prior to CT. Pneumothorax was detected in 53 (30%) patients by US, and 40 (23%) by chest radiography. There were 53 (30%) true positives by CT or on chest tube placement. The sensitivity for chest radiography was 75.5% (95% CI = 61.7% to 86.2%) and the specificity was 100% (95% CI = 97.1% to 100%). The sensitivity for US was 98.1% (95% CI = 89.9% to 99.9%) and the specificity was 99.2% (95% CI = 95.6% to 99.9%). The positive likelihood ratio for a PTX was 121. Spearman's rank correlation showed at ρ of 0.82. Conclusions: With CT as the criterion standard, US is more sensitive than flat AP chest radiography in the diagnosis of traumatic PTX. Furthermore, US allowed sonologists to differentiate between small, medium, and large PTXs with good agreement with CT results.     

Detection of pneumothorax by accident and emergency officers and radiologists on single chest films.

To assess whether an accurate diagnosis of pneumothorax can be made on a single chest film, 233 pairs of inspiratory (I) and expiratory (E) chest films taken in an accident and emergency (A&E) department for suspected pneumothorax were reviewed by two A&E officers and three radiologists. The films were assessed for the presence of pneumothorax by viewing the I film in isolation and, after an interval, by viewing the paired I and E films together. Fifty-four of the patients had a pneumothorax. The five observers missed 23 pneumothoraces (8.5% of total) on the I film alone which were correctly diagnosed on the paired I and E films, the three radiologists missed 10/162 pneumothoraces on the I film alone which were correctly identified on the I and E films (6%) and the two A&E officers 13/108 (12.5%). The use of a single inspiratory chest film for suspected pneumothorax could result in pneumothoraces being missed, particularly by less experienced observers and therefore we believe that paired I and E films should continue to be used routinely for suspected pneumothorax.     

The ultrasonographic deep sulcus sign in traumatic pneumothorax

A series of 186 patients with blunt chest trauma was studied with transthoracic ultrasonography to diagnose pneumothorax and to evaluate its size and location. The results were compared with bedside chest radiography and spiral CT scan. The prevalence of pneumothorax on CT scan was 56/186 (30.1%). Pneumothorax was proven on radiography in 30/56 cases without false positive results: "radiographic deep sulcus sign" was evident in 3/29 cases, 26/29 cases being occult. The ultrasound study demonstrated the presence of pneumothorax in 55/56 patients: one occult pneumothorax was missed and no false positive results were observed. The CT scan differed of +/-2.3 cm (range 1-5 cm) from the US study in evaluating size and location of pneumothorax. In conclusion, ultrasound study may detect occult pneumothorax undiagnosed by standard plain radiography. It reflects accurately the extent of pneumothorax if compared with CT scan, outlining the "ultrasonographic deep sulcus sign" on anterior chest wall.     

Case of the month: Buffalo chest: a case of bilateral pneumothoraces due to pleuropleural communication

Simultaneous spontaneous bilateral pneumothoraces, the presentation of separate right and left pneumothoraces together, is a rare event. The pleural cavities in humans are separated completely and the only previous reports of pleuropleural communication have been associated with major invasive thoracic procedures, specifically mediastinal surgery. The term “buffalo chest” has been coined for the condition on the basis that the buffalo or bison has a single pleural cavity, one of the few mammals to do so. We present the case of a woman with a past history of a single right sided spontaneous pneumothorax but no major thoracic surgery, who presented to the emergency department with a second spontaneous right pneumothorax that was under tension. After thoracostomy, she was found to have bilateral pneumothoraces which resolved with a unilateral chest drain demonstrating pleuropleural communication. We believe this to be the first reported case of such a presentation in the literature. The case demonstrates an unusual emergency presentation of a rare anatomical anomaly.     

Iatrogenic pneumothorax related to mechanical ventilation

Pneumothorax is a potentially lethal complication associated with mechanical ventilation. Most of the patients with pneumothorax from mechanical ventilation have underlying lung diseases; pneumothorax is rare in intubated patients with normal lungs. Tension pneumothorax is more common in ventilated patients with prompt recognition and treatment of pneumothorax being important to minimize morbidity and mortality. Underlying lung diseases are associated with ventilator-related pneumothorax with pneumothoraces occurring most commonly during the early phase of mechanical ventilation. The diagnosis of pneumothorax in critical illness is established from the patients’ history, physical examination and radiological investigation, although the appearances of a pneumothorax on a supine radiograph may be different from the classic appearance on an erect radiograph. For this reason, ultrasonography is beneficial for excluding the diagnosis of pneumothorax. Respiration-dependent movement of the visceral pleura and lung surface with respect to the parietal pleura and chest wall can be easily visualized with transthoracic sonography given that the presence of air in the pleural space prevents sonographic visualization of visceral pleura movements. Mechanically ventilated patients with a pneumothorax require tube thoracostomy placement because of the high risk of tension pneumothorax. Small-bore catheters are now preferred in the majority of ventilated patients. Furthermore, if there are clinical signs of a tension pneumothorax, emergency needle decompression followed by tube thoracostomy is widely advocated. Patients with pneumothorax related to mechanical ventilation who have tension pneumothorax, a higher acute physiology and chronic health evaluation II score or PaO₂/FiO₂ < 200 mmHg were found to have higher mortality.     

Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis

Introduction

Ultrasonography is being increasingly utilized in acute care settings with expanding applications. Pneumothorax evaluation by ultrasonography is a fast, safe, easy and inexpensive alternative to chest radiographs. In this review, we provide a comprehensive analysis of the current literature comparing ultrasonography and chest radiography for the diagnosis of pneumothorax.

Methods

We searched English-language articles in MEDLINE, EMBASE and Cochrane Library dealing with both ultrasonography and chest radiography for diagnosis of pneumothorax. In eligible studies that met strict inclusion criteria, we conducted a meta-analysis to evaluate the diagnostic accuracy of pleural ultrasonography in comparison with chest radiography for the diagnosis of pneumothorax.

Results

We reviewed 601 articles and selected 25 original research articles for detailed review. Only 13 articles met all of our inclusion criteria and were included in the final analysis. One study used lung sliding sign alone, 12 studies used lung sliding and comet tail signs, and 6 studies searched for lung point in addition to the other two signs. Ultrasonography had a pooled sensitivity of 78.6% (95% CI, 68.1 to 98.1) and a specificity of 98.4% (95% CI, 97.3 to 99.5). Chest radiography had a pooled sensitivity of 39.8% (95% CI, 29.4 to 50.3) and a specificity of 99.3% (95% CI, 98.4 to 100). Our meta-regression and subgroup analyses indicate that consecutive sampling of patients compared to convenience sampling provided higher sensitivity results for both ultrasonography and chest radiography. Consecutive versus nonconsecutive sampling and trauma versus nontrauma settings were significant sources of heterogeneity. In addition, subgroup analysis showed significant variations related to operator and type of probe used.

Conclusions

Our study indicates that ultrasonography is more accurate than chest radiography for detection of pneumothorax. The results support the previous investigations in this field, add new valuable information obtained from subgroup analysis, and provide accurate estimates for the performance parameters of both bedside ultrasonography and chest radiography for pneumothorax evaluation.     

Small-bore catheter versus chest tube drainage for pneumothorax

Study Objective

The aim of the study was to compare the effectiveness of drainage via a single-lumen (5F catheter) central venous catheter (CVC) to a conventional (14-20F catheter) chest tube (CT) for the management of pneumothoraces, including primary spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP), and traumatic and iatrogenic pneumothoraces.

Patients

All consecutive patients admitted to the intermediate intensive care unit of a university hospital for pneumothorax were retrospectively screened over an 8-year period. Patients were preferentially treated using CT from 2003 to 2007 and using CVC from 2008 to 2010. Drainage failure was defined as the need for a second drainage procedure or for surgery.

Results

Of 212 patients included, 117 (55%) had PSP, 28 (13%) had SSP associated with chronic obstructive pulmonary disease, 19 (9%) had traumatic pneumothorax, and 48 (23%) had iatrogenic pneumothorax. The failure rate was 23% in PSP, 36% in SSP, 16% in traumatic pneumothorax, and only 2% in iatrogenic pneumothorax. After adjustment, iatrogenic pneumothorax was the only factor that had an influence on drainage failure. The failure rate was similar between the 112 patients treated using CVC and the 100 patients treated using CT (18% vs 21%, P = .60). However, the durations of drainage (3.3 ± 1.9 vs 4.6 ± 2.6 days, P < .01) and of hospital stay were significantly shorter in patients treated using CVC as compared with CT.

Conclusion

Our findings suggest that drainage via a catheter or via a CT is similarly effective in the management of pneumothorax. We recommend considering drainage via a small-bore catheter as a first-line treatment in patients with pneumothorax, whatever its cause.     

Residents Should Not Independently Perform Focused Abdominal Sonography for Trauma After 10 Training Examinations

Objectives. To assess whether 10 focused abdominal sonography for trauma (FAST) examinations could be used as a minimum standard for training, as suggested previously. Methods. This was a retrospective review of patients with abdominal trauma who underwent resident‐performed FAST examinations before surgical or Department of Radiology evaluation. Results. Six hundred ninety‐eight patients were examined by resident‐performed FAST followed by reference standard evaluations. Four hundred twelve patients were evaluated by residents who previously performed 10 FAST examinations; 154 were evaluated by 29 residents performing their 11th through 30th examinations; and 258 were evaluated by 10 residents performing their 31st and subsequent examinations. The results of resident‐performed FAST for intraperitoneal free fluid were as follows: 11 to 20 examinations—sensitivity, 73.9% (95% confidence interval, 51.3%–88.9%); specificity, 98.8% (92.5%–99.9%); true‐positive findings, 17; true‐negative, 81; false‐positive, 1; false‐negative, 6; total patients, 105; 21 to 30 examinations—sensitivity, 100% (73.2%–100%); specificity, 97.1% (83.3%–99.9%); true‐positive, 14; true‐negative, 34; false‐positive, 1; false‐negative, 0; total patients, 49; 31 and more examinations—sensitivity, 94.8% (88.6%–97.9%); specificity, 98.6% (94.5%–99.8%); true‐positive, 110; true‐negative, 140; false‐positive, 2; false‐negative, 6; total patients, 258. Conclusions. The suggestion that 10 examinations could be used as a minimum standard for training in FAST examinations was not validated.     

Prospective analysis of the effect of physician experience with the FAST examination in reducing the use of CT scans

Objective: The objective of this study was to examine the effect of ultrasound experience level on emergency physicians’ Focused Assessment with Sonography for Trauma (FAST) exam accuracy and emergency physicians’ confidence in using FAST findings to assist in managing patients with blunt trauma. Methods: This prospective, consecutive enrolment study evaluated adult trauma team activation blunt trauma patients. Based on the number of post‐training FAST exams carried out, 11 attending emergency physicians were grouped into A (<25 exams, n = 4), B (26–50 exams, n = 4) or C (>50 exams, n = 3). The FAST exam was carried out prior to other diagnostic studies. The emergency physicians were asked to prospectively judge their perception of the need for surgery, abdominal CT or no further tests. All study patients ultimately underwent CT, diagnostic peritoneal lavage or laparotomy. Among each physician group, the number of subsequent CT scans deemed necessary by the emergency physician after a ‘normal’ FAST was calculated and compared. Results: Accuracy was greatest in group C. Sixty‐nine of 80 patients in group A had a normal FAST exam; emergency physicians deemed CT necessary in 68/69 cases (99%; confidence interval [CI] 92–100%). Eighty‐two of 98 patients in group C had a normal FAST exam; emergency physicians deemed CT necessary in 19/82 cases (23%; CI 15–34%). Physicians in groups B and C were less likely to order CT after a normal FAST than group A (P < 0.001). Conclusions: FAST accuracy was greatest among more experienced emergency physicians. A normal FAST exam assisted more experienced emergency physicians with the perceived need to order significantly fewer CT scans than less experienced emergency physicians.     

Management and outcome of spontaneous pneumothoraces at three urban EDs

Objective: Spontaneous pneumothoraces predominantly affect young people. Substantial morbidity arises from the disease, invasive procedures and hospitalization. The literature is inconsistent regarding optimal management. This retrospective study aimed to define factors affecting the outcome of these patients. Methods: Patients were identified from databases at three EDs for explicit retrospective medical record review. Iatrogenic and traumatic pneumothoraces were excluded. Data collected included demographic details, treatment and outcome. The primary outcome was failure of initial treatment, defined as the need for a second treatment modality (including inpatient pleurodesis for persistent air leak) or re‐presentation within 5 days of treatment cessation. Associations with the primary outcome in primary spontaneous pneumothorax were assessed using logistic regression. Results: One hundred and twenty‐one spontaneous pneumothoraces were identified. There was poor correlation between clinician estimates and objective measurement of pneumothorax size. Pneumothorax size, measured using the average interpleural distance method, was the only independent predictor of treatment failure. Initial treatment modality demonstrated a confounder relationship with outcome. Subgroup analysis for patients treated with continuous pleural drainage compared small and large calibre drainage tubes, with no significant difference found. Conclusions: Objective measurement of pneumothorax size was the only independent predictor of treatment failure, with initial treatment modality having a confounding effect. Algorithms regarding initial treatment modalities are usually based on pneumothorax size and presence or absence of symptoms. The present study illustrates the importance of objective assessment of pneumothorax size in both clinical research and clinical practice.