Category Archives: A Life At Risk

04.22.13
by

How have you come to the hospital?

Clinical Scenario It’s just started your night shift, Sara is a young EP, she is going home after an hard day.  Hello - she says tired - could you help me? There is a guy with abdominal pain...

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02.16.13
by

Malaria or just fever?

Clinical Scenario A 35 y/o man is brought to the ED by friends and left there alone, he has high fever, he is from Ghana and he has just arrived, he speaks english not so well and he is confused...

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01.15.13
by

Useless ECG?


Clinical Scenario

A 67 y/o man arrive to the ED by ambulance because of precordial pain since half an hour, during the transport, paramedics perform an ECG that shows a left bundle branch block (LBBB), that patient refers in his history.




They find it unuseful and so they do not transmit it to the cardiologist, is it correct?











Conclusion

When red with passion and deep attention ECG may tell us much more than what we believe, this passion made Sgarbossa find that some modifications are associated with AMI in patient with chest pain and previously known LBBB. As it shows in the images, the most significant is the presence of ST elevetion (STE) >1mm that is concordant with QRS in any derivation, followed by ST depression (STD) >1 mm in lead V1, V2, V3; the presence of this two signs increase significantly the likelihood of AMI.
On the other and the absence of any of the signs studied does not rule out AMI. 


Bibliography

S. Serge Barold et al
Electrocardiographic Diagnosis of Myocardial Infarction during Left Bundle Branch Block 
Cardiol Clin 24 (2006) 377–385 

Sgarbossa EB et al
Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle branch block. 
New Engl J Med 1996;334:481–7. 

McMahon R et al
Left bundle branch block without concordant ST changes is rarely associated with acute coronary occlusion.
Int J Cardiol. 2012 Apr 30. [Epub ahead of print]

http://lifeinthefastlane.com/ecg-library/basics/sgarbossa/

http://youtu.be/jGQajcVgYPM


Ilenia Spallino
01.07.13
by

Is it broken?


Clinical Scenario

Anthony, a 15 y/o student, slipped and fell while playng soccer. The next morning he refers continue pain on the right elbow. “Is it broken?” ask Anthony and his father at the triage desktop?
There is pain and edema near the elbow, no radial pulse deficit, he can fully extend and flex the articulation, there aren’t problem about prono-supination.


The doctor smiles and reassures Anthony and his father, “it’s not broken, RICE is enough!!!”.    

  





Conclusion 

An alert patient who refers an elbow contusion and who presents a fully active range of motion has a very low probability to have a fracture. This is a simple, easy and secure rule that reduces X-Ray and time of stay in ED. 
The reccomendation: “Return if the pain persists”, is always valid.  


Bibliography 

MA Darracq
Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture
AmJ Emerg Med (2008) 26, 779–782 


A.Appelboam.
Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children.
BMJ 2008;337:a2428 doi:10.1136/bmj.a2428 


Ciro Paolillo



12.08.12
by

Atypical or typical, is this the question?



Clinical Scenarios

It is a busy day in your ED:


A 60 y/o female refers a retrosternal pain radiates to right arm that lasts more than 20 minutes. 

A 50 y/o male refers a pressure  in his chest, with tachycardia and sweating.

A 75 y/o female refers a sharp and stabbing pain exacerbates by forceful breathing.

In all cases the ECGs are nondiagnostic.
Do these clinical features help to predict an acute myocardial infarction (AMI)?














Conclusion 

The incipit of the third universal definition of myocardial infarction (ESC guidelines 2012) is: “myocardial infarction can be recognised by clinical features, including ECG findings, elevated values of biochemical markers of myocardial necrosis and by imaging”. 
About clinical features the definition is vague: possible ischaemic symptoms, or  the duration of the pain is usually > 20 min, miocardial infarction may occurr with atypical symptoms.  
The previous pictures are merciless, typical and atipical symptoms have the same value. 

PS: The sweating (only if observed) is the only clinical feature that increases significantly the likelihood of AMI.  



Bibliography 

K Thygesen
Third universal definition of myocardial infarction
Eur Heart J 33, 2551-2567, 2012

R Body
The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes
Resuscitation 81, 281-286, 2010 

Ciro Paolillo
11.17.12
by

Pleuritic Pain, the end of the saga…

Clinical Scenario

A 33 y/o woman, comes to the ED because of a sudden emithorax pain on the left in basal region. The pain is described as stabbing, well localized, it worsen with inspirium …a pleuritic pain, no cough, no fever, not hemoptysis. She smokes, she does not take any medication. 
Chest x ray is normal. You receive blood test: WBC 7.500/mcL, CRP 20 mg/dl , D-dimer 603 ng/ml

We have seen in the previous post that we can’t rule out the possibility to find a radio-occult lesion based on our blood test, but on the other hand specificity is poor, so what are we looking for?
What does pleuritic pain means? 
If you ask wikipedia… the answer is frightful…


What if you ask to your probe?






Conclusion 

Lung ultrasound is considered positive when direct scanning of the painful chest area shows at least one of the following: absence of sliding, B+ pattern, peripheral alveolar consolidation,  irregularity of the pleural line with or without effusion.
Sonographic examination can be limited to the painful thoracic area, thus requiring no more than 1 to 2 minutes. 
It has a very high sensitivity and specificity in detecting any pleural or pulmonary radio-occult condition manifesting as pleuritic pain. 



Bibliography

American Journal of Emergency Medicine (2012) 30, 317–324 
A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED 
Giovanni Volpicelli M et al.

Ilenia Spallino
10.31.12
by

Can we fight against Pulmonary Embolism using the LR’s arrows?


Clinical Scenario

A 80 y/o woman presented to the ED for dyspnoea.
She underwent a knee replacement 2 weeks ago, RR is 24, O2 saturation is 88%. HR is 90, the knee is edematous.
You are going to hunt a pulmonary embolism (PE)
While you phone the radiologist for a thorax CT scan you have an idea:




Can a compression ultrasonography (CUS) helps to avoid a CT?








Conclusion 

Using Wells Score in this setting the PE pretest probability is intermediate (around 30%). 
Effectively the post test probability after a positive CUS is very high. Diagnosing a deep vein thrombosys (DVT) in patients with suspected PE doesn’t require other tests: the treatment of DVT with or without associated PE is the same.  
On the other hand after a negative CUS you need to keep hunting…


Bibliography 

Emergency Medicine Australasia (2005) 17, 322–329
Likelihood ratios increase diagnostic certainty in 
pulmonary embolism 
K Chu and A FT Brown



Journal of Internal Medicine 250: 262-264
Utility of ultrasound imaging of the lower extremities in the diagnostic approach in patients with suspected pulmonary embolism
PS Wells et al
to be continued...
Ciro Paolillo
10.27.12
by

What does it hide behind a negative X-Ray?


Clinical Scenario

A 33 y/o woman, comes to the ED because of a sudden emithorax pain on the left in basal region. The pain is described as stabbing, well localized, it worsen with inspirium …a pleuritic pain, no cough, no fever, not hemoptysis. She smokes, she does not take any medication. 
Chest x ray is normal. You receive blood test: WBC 7.500/mcL, CRP 20 mg/dl , D-dimer 603 ng/ml.



Maybe is not a wall chest pain, but in which direction this test are carrying you?












Conclusion 

As we have seen in previous post there is not a clinical sign that can reduce or increase the probability to find a radio-occult lesion in patient with pleuritic pain, and we left with the question:  “Will we find the answer in blood test?”
As you can see above, the absence of all the three blood parameters, in patient with a normal clinical examination, can alone rule out the possibility to find a radio-occult lesion with an LR- of 0, but what if one of them is positive? We need to go further, but where? Is CT scan the answer?


Bibliography

American Journal of Emergency Medicine (2012) 30, 317–324 
A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED 
Giovanni Volpicelli M et al.

Ilenia Spallino

to be continued...
10.11.12
by

Pleuritic pain and radio-occult lesion

Clinical Scenario

A 33 y/o woman, comes to the ED because of a sudden emithorax pain localized on the left in basal region. The pain is described as stabbing, well localised, it worsen with inspirium …a pleuritic pain, no cough, no fever, not hemoptysis. She smokes, she does not take any madication. Chest x ray is normal. 


Is it a wall chest pain or there migth be something else? 










Conclusion 

In the presence of pleuritic pain the negative predictive value of a negative chest x ray is well known so we are not going to discuss this.
As you easily can see from the images, there is not a clinical sign that can reduce or increase the probability to find a radio-occult lesion in patient with pleuritic pain, it sounds frightful because it might means that we have to performe a thorax CT to every patient compleining of  pleuritic pain…

Will we find the answer in blood test?



NB you might have been upseted by the positive LR of hemoptysis, it is not a writing mistake, it is very intresting because it shows, once more, how LR is much more real than sensitivity and specificity alone.
In this case specificity is very high 96,5%, so why this sign has not weight? What about “Spin”? The same study showes a sensitivity of 3% so low that the positive LR is lower than 1 despite the high specifity!



Bibliography 

American Journal of Emergency Medicine (2012) 30, 317–324 
A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED 
Giovanni Volpicelli M et al.



Ilenia Spallino

to be continued
10.04.12
by

Does procalcitonin have a role in the management of acute appendicitis?



Clinical scenario
A 18 yo man comes to the Ed in the morning because of low abdominal pain, fever and nausea. At palpation there is mild pain in the right inferior quadrant, not guarding.

Could procalcitonin (PTC) helps to exclude quickly an acute appendicitis?



Conclusion
The figures are clear. We cannot use the PCT to rule out an acute appendicitis, but it could be useful  to identify patients that may have complicated appendicitis.
In previous post we have pointed out the poor utility of signs and symptoms alone to screen patients with or without an acute appendicitis.
It’s the same for laboratory tests.  

Bibliography

M. Sand
A prospective bicenter study investigating the diagnostic value of procalcitonin in patients withacute appendicitis.
Eur Surg Res 2009; 43 291-297

JY Wu
Diagnostic role of procalcitonin in patients with suspected appendicitis.
World J Surg 2012 Aug 36 (8) 1744-1749


                                                                                                           Ciro Paolillo



09.07.12
by

Is cervical spine X-ray necessary if there is a distracting injury?

Clinical Scenario
 A 40 yolady arrives in ED by ambulance with neck and spinal immobilization because she fell down a staircare.

 The patient's vital signs are within normal physiological parameters, she is alert, no deficit, remembers all, denies head contusion and neck pain. She complains for a sharp shoulder pain (NRS 10/10), it seems broken.
If I perform the Nexus C-Spine criteria  X Ray is indicated: a distracting injury mandates cervical spine imaging.

How much the presence of distracting injury reduces my sensibility in rule out cervical spine (c-spine) injury?






Conclusion


 Once upon a time nearly all patients who presented in ED with blunt trauma received a cervical spine X-Ray. The clinicians feared to undiagnosed a cervical fracture, with catastrophic consequences for the patients and than for the same doctor, so there were a large number of unnecessary films. The Nexus five criteria simplified our work: it's easy and speedy and especially is high sensitive to rule out a cervical spine injury. The presence of a distracting injury has a negligible impact. 

Is it time to define the Nexus four criteria? 

Bibliography

MK Rose
Clinical clearance of the cervical spine in patients with distracting injuries: it is time to dispel the myth.
JTrauma 2012 vol 73 n 2 pag 498-502.

A Kostantininidis
The presence of a nonthoracic distracting injuries does not affect the initial clinical examination of the cervicalspine in evaluable blunttrauma patients: a prospective observational study.
JTrauma Sept 2011 vol 71 n 3.

Paucis Verbis: distracting injuries in c-spine injuries from Academic Life In Emergency Medicine Sept 2011.



                                                                                                                                            Ciro Paolillo




09.07.12
by

Is cervical spine X-ray necessary if there is a distracting injury?

Clinical Scenario
 A 40 yolady arrives in ED by ambulance with neck and spinal immobilization because she fell down a staircare.

 The patient's vital signs are within normal physiological parameters, she is alert, no deficit, remembers all, denies head contusion and neck pain. She complains for a sharp shoulder pain (NRS 10/10), it seems broken.
If I perform the Nexus C-Spine criteria  X Ray is indicated: a distracting injury mandates cervical spine imaging.

How much the presence of distracting injury reduces my sensibility in rule out cervical spine (c-spine) injury?






Conclusion


 Once upon a time nearly all patients who presented in ED with blunt trauma received a cervical spine X-Ray. The clinicians feared to undiagnosed a cervical fracture, with catastrophic consequences for the patients and than for the same doctor, so there were a large number of unnecessary films. The Nexus five criteria simplified our work: it's easy and speedy and especially is high sensitive to rule out a cervical spine injury. The presence of a distracting injury has a negligible impact. 

Is it time to define the Nexus four criteria? 

Bibliography

MK Rose
Clinical clearance of the cervical spine in patients with distracting injuries: it is time to dispel the myth.
JTrauma 2012 vol 73 n 2 pag 498-502.

A Kostantininidis
The presence of a nonthoracic distracting injuries does not affect the initial clinical examination of the cervicalspine in evaluable blunttrauma patients: a prospective observational study.
JTrauma Sept 2011 vol 71 n 3.

Paucis Verbis: distracting injuries in c-spine injuries from Academic Life In Emergency Medicine Sept 2011.



                                                                                                                                            Ciro Paolillo




08.20.12
by

Cellulitis and the role of laboratory


Clinical Scenario

A 72 y/o woman presented to the ED for swollen and painful leg.
Physical examination shows an erythematous, tender and warm leg. 
Probably it is a cellulitis. 
In previous post we stressed the US use to increase diagnostic accuracy. 



Can WBC or CPR help in the differential diagnoses?  
Do they have a role in the decision to admit the patient to the Hospital?  









Conclusion 

WBC count is not helpful for differential diagnosis, or to determine the route of antibiotics administration, furthermore it has a small weight in the decision to admit a patient to the Hospital. 
An elevated CPR is a better indicator to "rule in" but if negative it's unreliable. 

The routine blood investigation in ED takes another beating.


Bibliography 

G.Phoenix et al
Diagnosis and management of cellulitis.
BMJ 2012 345: e4955 (published 7 Aug 2012).

Ciro Paolillo
08.20.12
by

Cellulitis and the role of laboratory


Clinical Scenario

A 72 y/o woman presented to the ED for swollen and painful leg.
Physical examination shows an erythematous, tender and warm leg. 
Probably it is a cellulitis. 
In previous post we stressed the US use to increase diagnostic accuracy. 



Can WBC or CPR help in the differential diagnoses?  
Do they have a role in the decision to admit the patient to the Hospital?  









Conclusion 

WBC count is not helpful for differential diagnosis, or to determine the route of antibiotics administration, furthermore it has a small weight in the decision to admit a patient to the Hospital. 
An elevated CPR is a better indicator to "rule in" but if negative it's unreliable. 

The routine blood investigation in ED takes another beating.


Bibliography 

G.Phoenix et al
Diagnosis and management of cellulitis.
BMJ 2012 345: e4955 (published 7 Aug 2012).

Ciro Paolillo
08.20.12
by

Cellulitis and the role of laboratory


Clinical Scenario

A 72 y/o woman presented to the ED for swollen and painful leg.
Physical examination shows an erythematous, tender and warm leg. 
Probably it is a cellulitis. 
In previous post we stressed the US use to increase diagnostic accuracy. 



Can WBC or CPR help in the differential diagnoses?  
Do they have a role in the decision to admit the patient to the Hospital?  









Conclusion 

WBC count is not helpful for differential diagnosis, or to determine the route of antibiotics administration, furthermore it has a small weight in the decision to admit a patient to the Hospital. 
An elevated CPR is a better indicator to "rule in" but if negative it's unreliable. 

The routine blood investigation in ED takes another beating.


Bibliography 

G.Phoenix et al
Diagnosis and management of cellulitis.
BMJ 2012 345: e4955 (published 7 Aug 2012).

Ciro Paolillo
07.21.12
by

Goodbye nasogastric lavage!


Clinical Scenario

A 84 yo woman arrives in ED in midnight coming from a nursing because of a reported episode of coffee ground vomiting. 
Respiratory rate, heart rate and blood pressure are normal, abdomen is not distended, hemoglobin level is 10 g/dl. On rectal examination you find normal stool. 
She takes warfarin. 


Can a nasogasric lavage (NGL) contribute to rule out an upper gastrointestinal bleeding (UGB)? 







Conclusion 

NGL has two advantages:
Diagnostic (if positive) 
Help the endoscopist to perform a better exam (remove blood and clots)

On the other hand, NGL has also two disvantages:
It is nasogastric and not nasoduodenal because the pilory is often closed. 
It is one of the most painful procedures performed in ED. 

A negative NGL does not help to rule out an UGB.  Furthermore, nasogastric lavage cannot be used to determine the need of urgent endoscopy, in fact there is no place for NGL in the Blatchford Score.   


Bibliography 

FD Srygley et al.
Does this patient have a severe upper gastrointestinal bleed?
JAMA march 14 2012 vol 307 n. 10

DJ Pallin et al.
Is nasogatric tube lavage in patients with acute upper GI bleeding indicated or antiquated?
Gastrointestinal Endoscopy Nov 2011, vol 74 n.5 


Ciro Paolillo



07.21.12
by

Goodbye nasogastric lavage!


Clinical Scenario

A 84 yo woman arrives in ED in midnight coming from a nursing because of a reported episode of coffee ground vomiting. 
Respiratory rate, heart rate and blood pressure are normal, abdomen is not distended, hemoglobin level is 10 g/dl. On rectal examination you find normal stool. 
She takes warfarin. 


Can a nasogasric lavage (NGL) contribute to rule out an upper gastrointestinal bleeding (UGB)? 







Conclusion 

NGL has two advantages:
Diagnostic (if positive) 
Help the endoscopist to perform a better exam (remove blood and clots)

On the other hand, NGL has also two disvantages:
It is nasogastric and not nasoduodenal because the pilory is often closed. 
It is one of the most painful procedures performed in ED. 

A negative NGL does not help to rule out an UGB.  Furthermore, nasogastric lavage cannot be used to determine the need of urgent endoscopy, in fact there is no place for NGL in the Blatchford Score.   


Bibliography 

FD Srygley et al.
Does this patient have a severe upper gastrointestinal bleed?
JAMA march 14 2012 vol 307 n. 10

DJ Pallin et al.
Is nasogatric tube lavage in patients with acute upper GI bleeding indicated or antiquated?
Gastrointestinal Endoscopy Nov 2011, vol 74 n.5 


Ciro Paolillo



07.21.12
by

Goodbye nasogastric lavage!


Clinical Scenario

A 84 yo woman arrives in ED in midnight coming from a nursing because of a reported episode of coffee ground vomiting. 
Respiratory rate, heart rate and blood pressure are normal, abdomen is not distended, hemoglobin level is 10 g/dl. On rectal examination you find normal stool. 
She takes warfarin. 


Can a nasogasric lavage (NGL) contribute to rule out an upper gastrointestinal bleeding (UGB)? 







Conclusion 

NGL has two advantages:
Diagnostic (if positive) 
Help the endoscopist to perform a better exam (remove blood and clots)

On the other hand, NGL has also two disvantages:
It is nasogastric and not nasoduodenal because the pilory is often closed. 
It is one of the most painful procedures performed in ED. 

A negative NGL does not help to rule out an UGB.  Furthermore, nasogastric lavage cannot be used to determine the need of urgent endoscopy, in fact there is no place for NGL in the Blatchford Score.   


Bibliography 

FD Srygley et al.
Does this patient have a severe upper gastrointestinal bleed?
JAMA march 14 2012 vol 307 n. 10

DJ Pallin et al.
Is nasogatric tube lavage in patients with acute upper GI bleeding indicated or antiquated?
Gastrointestinal Endoscopy Nov 2011, vol 74 n.5 


Ciro Paolillo



07.11.12
by

Can Ultrasound rule out a pneumothorax?





Clinical Scenario

You are allerted for a level 3 trauma from the mountain, a cyclist has fallen going down hill.
You prepar the shock room with everything you may need, dress up, and wait.
A 25 y/o cyclist arrives completely immobilized, you immidiately start to  perform ABCDE as you learned in your recent ATLS course (you feel confident).
First stop is a possible problem in "B" (breathing): he has an ecchimosis on the right emithorax, not crepitation, maybe there is a less vescicular murmur on the same side, but you are not sure (the shock room is very crowded an noisy!), he is slightely tachypnoic (RR is 24), O2 saturation is 96%. ...you go on....in "E" (Exposure) you find an exposed, bleeding, thigh bone fracture that surly is going to need surgery, at the moment you stop the bleeding, stabilize, allert orthopedic...ect...
FAST is normal. You ask for X-Ray : anteroposterior (AP) chest x-ray, pelvis and thigh bone. Confirmed exposed fracture, no signs of pneumothorax, surgery room is ready...
You recently have reeded the previous post and you don't feel confident about a negative thorax x ray, so you decide to "extend" your FAST and on the right emithorax you find a "lung point"...


are you going to let this patient be intubated?









Conclusion 

Ultrasound has a higher sensitivity than the traditional upright anteroposterior chest radiography (CXR) for the detection of a pneumothorax. 
The negative predictive value for lung sliding is reported as 99.2-100%, indicating that the presence of sliding effectively rules out a pneumothorax.
However, the absence of lung sliding does not necessarily indicate that a pneumothorax is present. Lung sliding is abolished in a variety of conditions other than pneumothorax, including acute respiratory distress syndrome (ARDS), pulmonary fibrosis, large consolidations, pleural adhesions, atelectasis, right mainstem intubation, and phrenic nerve paralysis. Specificity values range from 60-99%... it depends on the setting.



Bibliography 

J Emerg Trauma Shock. 2012 Jan;5(1):76-81.
Sonographic diagnosis of pneumothorax.
Husain LF, Hagopian L, Wayman D, Baker WE, Carmody KA.

Ilenia Spallino

07.11.12
by

Can Ultrasound rule out a pneumothorax?





Clinical Scenario

You are allerted for a level 3 trauma from the mountain, a cyclist has fallen going down hill.
You prepar the shock room with everything you may need, dress up, and wait.
A 25 y/o cyclist arrives completely immobilized, you immidiately start to  perform ABCDE as you learned in your recent ATLS course (you feel confident).
First stop is a possible problem in "B" (breathing): he has an ecchimosis on the right emithorax, not crepitation, maybe there is a less vescicular murmur on the same side, but you are not sure (the shock room is very crowded an noisy!), he is slightely tachypnoic (RR is 24), O2 saturation is 96%. ...you go on....in "E" (Exposure) you find an exposed, bleeding, thigh bone fracture that surly is going to need surgery, at the moment you stop the bleeding, stabilize, allert orthopedic...ect...
FAST is normal. You ask for X-Ray : anteroposterior (AP) chest x-ray, pelvis and thigh bone. Confirmed exposed fracture, no signs of pneumothorax, surgery room is ready...
You recently have reeded the previous post and you don't feel confident about a negative thorax x ray, so you decide to "extend" your FAST and on the right emithorax you find a "lung point"...


are you going to let this patient be intubated?









Conclusion 

Ultrasound has a higher sensitivity than the traditional upright anteroposterior chest radiography (CXR) for the detection of a pneumothorax. 
The negative predictive value for lung sliding is reported as 99.2-100%, indicating that the presence of sliding effectively rules out a pneumothorax.
However, the absence of lung sliding does not necessarily indicate that a pneumothorax is present. Lung sliding is abolished in a variety of conditions other than pneumothorax, including acute respiratory distress syndrome (ARDS), pulmonary fibrosis, large consolidations, pleural adhesions, atelectasis, right mainstem intubation, and phrenic nerve paralysis. Specificity values range from 60-99%... it depends on the setting.



Bibliography 

J Emerg Trauma Shock. 2012 Jan;5(1):76-81.
Sonographic diagnosis of pneumothorax.
Husain LF, Hagopian L, Wayman D, Baker WE, Carmody KA.

Ilenia Spallino

07.11.12
by

Can Ultrasound rule out a pneumothorax?





Clinical Scenario

You are allerted for a level 3 trauma from the mountain, a cyclist has fallen going down hill.
You prepar the shock room with everything you may need, dress up, and wait.
A 25 y/o cyclist arrives completely immobilized, you immidiately start to  perform ABCDE as you learned in your recent ATLS course (you feel confident).
First stop is a possible problem in "B" (breathing): he has an ecchimosis on the right emithorax, not crepitation, maybe there is a less vescicular murmur on the same side, but you are not sure (the shock room is very crowded an noisy!), he is slightely tachypnoic (RR is 24), O2 saturation is 96%. ...you go on....in "E" (Exposure) you find an exposed, bleeding, thigh bone fracture that surly is going to need surgery, at the moment you stop the bleeding, stabilize, allert orthopedic...ect...
FAST is normal. You ask for X-Ray : anteroposterior (AP) chest x-ray, pelvis and thigh bone. Confirmed exposed fracture, no signs of pneumothorax, surgery room is ready...
You recently have reeded the previous post and you don't feel confident about a negative thorax x ray, so you decide to "extend" your FAST and on the right emithorax you find a "lung point"...


are you going to let this patient be intubated?









Conclusion 

Ultrasound has a higher sensitivity than the traditional upright anteroposterior chest radiography (CXR) for the detection of a pneumothorax. 
The negative predictive value for lung sliding is reported as 99.2-100%, indicating that the presence of sliding effectively rules out a pneumothorax.
However, the absence of lung sliding does not necessarily indicate that a pneumothorax is present. Lung sliding is abolished in a variety of conditions other than pneumothorax, including acute respiratory distress syndrome (ARDS), pulmonary fibrosis, large consolidations, pleural adhesions, atelectasis, right mainstem intubation, and phrenic nerve paralysis. Specificity values range from 60-99%... it depends on the setting.



Bibliography 

J Emerg Trauma Shock. 2012 Jan;5(1):76-81.
Sonographic diagnosis of pneumothorax.
Husain LF, Hagopian L, Wayman D, Baker WE, Carmody KA.

Ilenia Spallino

07.02.12
by

Thoracic trauma and chest X-Ray


Clinical Scenario

You are alerted for a level 3 trauma coming from the mountain, a cyclist has fallen going down hill.
You prepare the shock room with everything you may need, dress up, and wait.
A 25 y/o cyclist arrives completely immobilized, you immediately start to  perform ABCDE as you learned in your recent ATLS course (...you feel confident).
First stop is a possible problem in "B" (breathing): he has an ecchimosis on the right emithorax, not crepitation, maybe there is a less vescicular murmur on the same side, but you are not sure (the shock room is very crowded an noisy!), he is slightely tachypnoic (RR is 24), O2 saturation is 96%. ...you go on....in "E" (Exposure) you find an exposed, bleeding, thigh bone fracture that surly is going to need surgery, at the moment you stop the bleeding, stabilize, allert orthopedic...ect...
FAST is normal. You ask for X-Ray: anteroposterior (AP) chest x-ray, pelvis and thigh bone. Radiologist confirms exposed fracture, no signs of pneumothorax, surgery room is ready...


...Do you still feel confident?








Conclusion

Supine AP chest radiograph has been reported to have very poor sensitivity for the detection of pneumothorax, as low as 36% to 48% in different studies
Small occult pneumothoraces may be missed on Chest X-Ray during a busy trauma scenario...

Are you going to let this patient be intubated?



Bibliography 

Acad Emerg Med. 2010 Jan;17(1):11-7.
Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma.
Wilkerson RG, Stone MB.

Ilenia Spallino



07.02.12
by

Thoracic trauma and chest X-Ray


Clinical Scenario

You are alerted for a level 3 trauma coming from the mountain, a cyclist has fallen going down hill.
You prepare the shock room with everything you may need, dress up, and wait.
A 25 y/o cyclist arrives completely immobilized, you immediately start to  perform ABCDE as you learned in your recent ATLS course (...you feel confident).
First stop is a possible problem in "B" (breathing): he has an ecchimosis on the right emithorax, not crepitation, maybe there is a less vescicular murmur on the same side, but you are not sure (the shock room is very crowded an noisy!), he is slightely tachypnoic (RR is 24), O2 saturation is 96%. ...you go on....in "E" (Exposure) you find an exposed, bleeding, thigh bone fracture that surly is going to need surgery, at the moment you stop the bleeding, stabilize, allert orthopedic...ect...
FAST is normal. You ask for X-Ray: anteroposterior (AP) chest x-ray, pelvis and thigh bone. Radiologist confirms exposed fracture, no signs of pneumothorax, surgery room is ready...


...Do you still feel confident?








Conclusion

Supine AP chest radiograph has been reported to have very poor sensitivity for the detection of pneumothorax, as low as 36% to 48% in different studies
Small occult pneumothoraces may be missed on Chest X-Ray during a busy trauma scenario...

Are you going to let this patient be intubated?



Bibliography 

Acad Emerg Med. 2010 Jan;17(1):11-7.
Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma.
Wilkerson RG, Stone MB.

Ilenia Spallino



07.02.12
by

Thoracic trauma and chest X-Ray


Clinical Scenario

You are alerted for a level 3 trauma coming from the mountain, a cyclist has fallen going down hill.
You prepare the shock room with everything you may need, dress up, and wait.
A 25 y/o cyclist arrives completely immobilized, you immediately start to  perform ABCDE as you learned in your recent ATLS course (...you feel confident).
First stop is a possible problem in "B" (breathing): he has an ecchimosis on the right emithorax, not crepitation, maybe there is a less vescicular murmur on the same side, but you are not sure (the shock room is very crowded an noisy!), he is slightely tachypnoic (RR is 24), O2 saturation is 96%. ...you go on....in "E" (Exposure) you find an exposed, bleeding, thigh bone fracture that surly is going to need surgery, at the moment you stop the bleeding, stabilize, allert orthopedic...ect...
FAST is normal. You ask for X-Ray: anteroposterior (AP) chest x-ray, pelvis and thigh bone. Radiologist confirms exposed fracture, no signs of pneumothorax, surgery room is ready...


...Do you still feel confident?








Conclusion

Supine AP chest radiograph has been reported to have very poor sensitivity for the detection of pneumothorax, as low as 36% to 48% in different studies
Small occult pneumothoraces may be missed on Chest X-Ray during a busy trauma scenario...

Are you going to let this patient be intubated?



Bibliography 

Acad Emerg Med. 2010 Jan;17(1):11-7.
Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma.
Wilkerson RG, Stone MB.

Ilenia Spallino