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Transthoracic ultrasonography to diagnose pneumothorax in trauma
  1. Usman Jaffer, Senior House Officer,
  2. Duncan McAuley, Special Registrar
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK; s.carley1btinternet.com

    Abstract

    A short cut review was carried out to establish whether transthoracic ultrasound can be used to diagnose pneumothoraces in trauma patients. A total of 46 papers were found using the reported search, of which four represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

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    Report by Usman Jaffer, Senior House OfficerSearch checked by Duncan McAuley, Special Registrar

    Clinical scenario

    A 35 year old male is brought into the emergency department after falling from a height. He is tachypnoeic and tachycardic and has tenderness in the left anterior chest and left upper abdomen. Your department has an ultrasound scanner and this is used to assess the patient’s abdomen. You wonder whether it could also be used to diagnose a pneumothorax.

    Three part question

    In a [patient with chest trauma] can [transthoracic ultrasonography] accurately diagnose [a traumatic pneumothorax].

    Search strategy

    Medline 1951 to December 2004 using the Dialog Datastar interface. [(pneumothorax#.W.DE OR pneumothorax) AND (ultrason$12) AND (wounds.and.injuries#.DE. OR trauma)]

    Editor’s note: In OVID Medline an equivalent search strategy would be: [exp pneumothorax/OR pneumothorax.mp] AND [ultras$12.mp] AND [exp wounds and injuries/OR trauma.mp]

    Search outcome

    Altogether 46 papers were found of which four were relevant to the three part question (table 1).

    Table 1

    Comments

    These studies were relatively small and only two were obviously blinded. Sensitivity for pneumothorax reported varied between 58.9% and 100% and specificity varied between 94% and 100%. It is interesting to note that the study with the lowest sensitivity used CT as part of the gold standard. In such cases CT may be able to find small pneumothoraces not visible on CXR. The clinical relevance of such small pneumothoraces in the resuscitation room is debatable (unless intermittent positive pressure ventilator (IPPV) is being considered). All ultrasound examinations are known to be operator dependent. There is some variation in the ultrasonographic signs used to confirm pneumothorax.

    CLINICAL BOTTOM LINE

    Rapid and accurate bedside ultrasound performed by emergency physicians can be used to diagnose pneumothorax after chest trauma. The clinical role of this in the resuscitation of trauma patients is not clear.

    Report by Usman Jaffer, Senior House OfficerSearch checked by Duncan McAuley, Special Registrar

    References

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