point of care ultrasound versus chest x-ray in detection
TRANSCRIPT
Point of Care Ultrasound versus Chest X-ray in Detection of Pneumothorax Prior to Removal of Tube
Thoracostomy in Trauma Patients
Benjamin Mati, MD | Javier Romero, MDVentura County Medical Center
Ventura CA
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Ultrasound
• Well-validated for ruling out pneumothorax (PTX)– Lung sliding and comet tails
• Compared to chest X-Ray (CXR) for detection of traumatic PTX– More sensitive
– More specific
– Less expensive
– Faster
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Clinically significant PTX (CS-PTX):
• CXR: >10% per attending radiologist• Ultrasound: loss of comet tails and/or sliding sign at >1 intercostal space (ICS)
Prospective non-inferiority study
Inclusion criteria:
• Trauma patients with tube thoracostomy (TT)
Exclusion criteria:
• Severe subcutaneous emphysema• Adhesions of pleura• Thoracic skin injuries• Restrictive lung diseases• Painful skin lesions• Painful fractures
Methods
Blinded to CXR, POCUS operator made binary decisions
Final management decided by trauma team based on CXR
POCUS prior to CXR to assess for residual PTX when:• TT to water seal for 12-24 hr• < 200mL drained over 12-24 hr
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POCUS operators were POCUS trained family medicine residents:• 30min focused lung ultrasound training and• At least 10 proctored lung US exams (including 5 positive for PTX)
• 7 CS-PTX reaccumulations were found on subsequent CXR:
• 3 pre-removal exams were POCUS negative and CXR negative
• 3 pre-removal exams were POCUS positive and CXR negative
• 1 pre-removal exam was POCUS positive and CXR positive
Table 1:
Total Subjects 42
Total Studies 62
Avg BMI 26
Subjects w/confirmed rib Fx 29
Avg POCUS time 4min
ResultsTable 2:
CS-PTXCXR
CS-PTX No CS-PTX
POCUSCS-PTX 4 16
No CS-PTX 0 42
• No CS-PTX seen on CXR were missed on POCUS
• 10 non CS-PTX were seen on CXR but not seen on POCUS
• 16 CS-PTX seen on POCUS were not seen on CXR
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Table 2:
Total PTXCXR
PTX No PTX
POCUSPTX 19 18
No PTX 10 42
Clinically significant PTX (CS-PTX):• CXR: >10% per attending radiologist• Ultrasound: loss of comet tails and/or sliding sign at >1 intercostal space (ICS)
Table 3:
Pre-removal exam for Subsequent CS-PTX Reaccumulations
CXR
CS-PTX No CS-PTX
POCUSCS-PTX 1 3
No CS-PTX 0 3
Table 3:
Pre-removal exam when all PTXReaccumulation Occurred
CXR
PTX No PTX
POCUSPTX 1 4
No PTX 0 12
Conclusions
• No CS-PTX seen on CXR were missed by POCUS
• POCUS is non-inferior to CXR in detecting CS-PTX prior to the removal of TT in simple (ie: single TT) trauma patients
• A POCUS-based algorithm assessing for PTX prior to removal of TT deserves further considerations
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