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

Abstract

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.

Diagnostic Accuracy of History, Physical Examination, and Bedside Ultrasound for Diagnosis of Extremity Fractures in the Emergency Department: A Systematic Review

“…11 EPs have become more adept at fracture diagnosis through independent review of US and radiographic imaging, and many researchers have examined the ability of EPs to obtain US imaging and diagnose fracture. 12,13 Additionally, bedside US has excellent diagnostic test characteristics when performed by EPs compared to radiologists in the diagnostic evaluation for soft tissue infections, 14 cholecystitis, 15 pneumothorax, 16 or ruling out ectopic pregnancy.…”

Impact of the practice of "Extended Focused Assessment with Sonography for Trauma" (e-FAST) on clinical decision in the emergency department

“…[7][8][9][10] Bilgisayarlı tomografi (BT), karıniçi yaralanma ve pnömotoraks saptanmasında, altın standart olmakla birlikte, son yıllarda yapılan çalışmalarla, acil servis hastalarında pnömotoraks değerlendirmesinde, USG'nin duyarlı-lığının yüksek olduğu bilinmektedir. [7][8][9][10][11] Küçük boyutlu olanları, konservatif olarak tedavi edilebilse de, bir çoklu travma hastasında operasyon esnasında veya sonrasında, uygulanacak pozitif basınçlı ventilasyon, pnömotoraksın, tüp torakostomi (TT) gereksinimi yaratabilecek boyutlara veya tansiyon pnömotoraksa dönüşmesine sebep olabilir. Bu yüzden hangi boyutta olursa olsun pnömotoraks varlığının bilinmesi önem-lidir.…”

A Study on the Evaluation of Pneumothorax by Imaging Methods in Patients Presenting to Emergency Department for Blunt Thoracic Trauma

“…However, the American College of Emergency Physicians' guides indicate that at least 25-50 chest US examinations are required to gain competence in this field. [13] In our study, all physicians were trained to use chest US for PNX diagnosis and each had already performed minimum 150 chest US examinations before our study. It is accepted that the effectiveness of US would increase if US is performed and interpreted by the physician who examines the patient.…”

“…[8] Several studies have indicated that US has higher sensitivity and selectivity than direct radiography for the detection of PNX, [3,[9][10][11] and the reliability of US has been confirmed by CT in some series. [12] The number of studies, which concentrate only on the detection of PNX by chest US performed by emergency physicians in blunt thoracic trauma (BTT) patients, is low, [13] and the group of patients in these studies is also small. The current study was designed considering the need for more comprehensive studies in the field.…”