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Pocus Evaluating Blunt Thoracic Trauma: a Retrospective Analysis of 18 Months of Emergency Department Activity

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Pocus Evaluating Blunt Thoracic Trauma: a Retrospective Analysis of 18 Months of Emergency Department Activity European Journal of Orthopaedic Surgery & Traumatology (2019) 29:31–35 https://doi.org/10.1007/s00590-018-2283-y ORIGINAL ARTICLE • THORAX - TRAUMA PoCUS evaluating blunt thoracic trauma: a retrospective analysis of 18 months of emergency department activity Alessandro Riccardi1 · Maria Beatrice Spinola1 · Valeria Ghiglione1 · Marco Licenziato1 · Roberto Lerza1 Received: 30 May 2018 / Accepted: 24 July 2018 / Published online: 31 July 2018 © Springer-Verlag France SAS, part of Springer Nature 2018 Abstract Blunt thoracic injury (BTI) constitutes a common presentation in emergency department: rib fractures are the most common injuries. Chest X-ray (CXR) has a limited sensitivity to identify rib fractures. We perform this retrospective study in our emergency department collecting all patients with BTI during an 18-month period. PoCUS was performed prior to acquire CXR or CT. We evaluated 1672 patients with BTI, and we reported rib fractures in 689 patients (41.21%). PoCUS was performed in 190 patients. PoCUS in emergency medicine has an increasing role, especially in BTI, but less clear is its role in detecting ribs fracture. PoCUS seems to be an efective method for diagnosing rib fracture in patients with blunt chest trauma if collaborative and with a well-isolated trauma. We used the trick of patients’ self-positioning probe in the most painful site, and this could reduce the time and the pain of the examination. Keywords Blunt thoracic trauma · Emergency ultrasound · PoCUS Background its applications have become numerous [11]. Studies have reported that ultrasound was more sensitive than X-ray for Blunt thoracic injury (BTI) is a common presentation in the detection of rib fractures and their pulmonary complica- the emergency department (ED) [1–3]. Rib fractures are the tions [3, 6, 12]. Therefore, PoCUS in BTI could be a useful most common (25–40%), and injuries resulting from BTI tool for patient management. Our aim in this study was to are usually revealed on radiographs. Chest X-ray (CXR) investigate the role of US in the detection of rib fractures with rib views has limited sensitivity to identify rib frac- and their complications compared with CXR and to evaluate tures and vary signifcantly among studies [4–6]. Computed its role in BTI. tomography (CT) is considered the gold standard to detect rib fractures and any complication due to BTI, but it exposes patients to substantial amounts of radiation [7]. Serious pul- Materials and methods monary complications, such as pneumothorax, haemothorax and lung contusion, may result from rib fractures [8–10]. We performed this retrospective study in our emergency CXR is only able to detect fuid shifts when trauma-related department (city hospital, 55,000 access/years, Ospedale haemothorax is above a certain level and may miss some San Paolo, Savona) by collecting and retrieving all patients pneumothoraxes and small pulmonary contusions. A delay with BTI and a diagnosis of rib/s fracture/s (using spe- in diagnosing rib fracture-related lung complications can cifc query) during an 18-month period (1 June 2015–31 lead to life-threatening conditions. During the past decade, December 2016). We reviewed clinical records compiled point-of-care ultrasound (PoCUS) has become an impor- by emergency physicians at arrival. PoCUS was performed tant part of emergency physicians’ (EP) daily practice, and and recorded prior to acquiring CXR or CT, using the Esaote MyLab 25 or Esaote MyLab 30 Gold with lin- ear array (12–10 MHz) for evaluating bones, pulmonary * Alessandro Riccardi [email protected] contusions and pneumothoraxes, and the convex array (3.5–6 MHz) for evaluating haemothorax. We evaluated 1 S.C. Medicina e Chirurgia d’Accettazione e d’Urgenza, walking patients with BTI: PoCUS was primarily used to Ospedale San Paolo Savona, Pronto Soccorso, Via Genova, evaluate the exact number of rib fractures (the physician 17100 Savona, Italy Vol.:(0123456789)1 3 sequent confrmation by CXR or CT. InTable CXRorCT. confrmationsequent by ribswith sub fractures revealed PoCUS patients, 173 In Rib fractures (Table PoCUS underwent aCTscan;1patientunderwent only PoCUS, and16patients,after initial aCTscanofthe chest, went amongthese, 33patientsalsounder PoCUS; CXR followed of59.48 years (SD18.541).In173patients,a a meanage with in190patients(27.58%,101male,89female), formed per was in 689patients(41.21%).Inthis group, aPoCUS criteria.reported these, rib Among we fractures exclusion apply didnot 1672 patientswith bluntthoracic We trauma. evaluated 1June2015and31December2016,we Between Results clinical ultrasound. in emergency competency for (SIMEU)”standards di Medicinad’Emergenza-Urgenza andfulflledthe Italiana ultrasound “Società in emergency trained well performing were ultrasound physicians gency the All 8–12). emer lower, 5–7; mid, 1–4; (upper, tion the rib of number loca and well as fractures gender) (age, sites ofthe Baselinedata fractures. includeddemographics numberor defnethe notimeto exact buttheretures was identifythe ofBTIorrib possiblecomplication idly frac rap usedto was the column,PoCUS vertebral involving potentially trauma In patientswith orany multipletrauma rib view. oblique an by posteriora anterior followed CXR, ordered andthe apossible haemothorax, physicians view usedto was probe then, syndrome); theinterstitial convex consolidationorlocalized ble lungcontusion(sub-pleural ofalungpoint)orpossi slidingorpresence of pleural (absence apossiblepneumothorax view supine patientsto sagittalplaced on in plane was BTI. Theprobe to related of the possiblecomplications rib) identifyany andto painful siteswith the the to parallel transducer longaxis inthe most the placethe directly patientsto probe invited 32 18–86). 18–86). 55.29 years (range was The meanage 5 patientsafter fall. withpresented patients rib after pain and cough, Two 1–2. allintherib mid-segment, mean1.14,range were fractures the diagnosedwith not standard radiography; tion whowere diagnosed with rib examina onthe fractures basisofPoCUS 7(3.68%)patientswhowere found 1–4).We (range tures hadameanof1.87ribunderwent aCTscan;andthey frac CXR;noneofthese patients the by rib/s asshown fracture numberandpositionof the exact patientsrevealed walking conductedin145 indetail. PoCUS patient characteristics 1 ). 2 we report we - - - - - - - - - - European Journal of Orthopaedic Surgery & Traumatology (2019)29:31–35 JournalofOrthopaedicTraumatology European Surgery & Table 1 Demographic and trauma distribution of patients with BTI Fall Car accident Motorbike Fall Bicycle Spontaneous Cough Pedestrian Assault Sport accident Iatrogenic accident from height accident (movement) accident (RCP) > 2 m n. 474 53 48 24 23 22 17 11 7 6 4 Mean age 70.63 57.66 53.66 63.88 53.91 67.45 53.63 60.09 47.2 30.17 77 Mean rib 1.87 (range 1.9 (range 2.07 (range 2.6 (range 2.24 (range 1.68 (1–4) 1.13 (range 1.67 (range 2 (range 1–3) 1.33 (range 2 (range 1–3) fractures 1–8) 1–5) 1–8) 1–6) 1–5) 1–3) 1–5) 1–2) in Rx n. CT scan 57 (12.02%) 14 (26.41%) 16 (33.33%) 14 (58.33%) 8 (34.78%) 0 0 6 (54.54%) 0 0 0 Mean rib 4.5 (range 4.93 (range 5.56 (range 4.78 (range 5.25 (range – – 4.1 (range – – – fractures in 2–8) 1–14) 2–18) 1–10) 2–7) 1–7) CT scan 1 3 European Journal of Orthopaedic Surgery & Traumatology (2019) 29:31–35 33 Table 2 173 patients with concordance between POCUS and CXR and CT Mean age 60,034 Side Upper (1–4) 38 Mid (5–8) 124 Lower (9–12) 81 No. ribs fracture <2 95 3–5 64 >5 12 Mean ribs fractures 2,61 Range 1–12 Cause Fall 87 Road accident 67 Fig. 1 PoCUS reveals a rib fracture: the probe was placed in the rib’s Fall from height 10 long axis to look for discontinuity of cortical alignment, visualized as Other 9 a break in the hyperechoic rib margin pneumothorax is already proven [12–15]. While its role in Pneumothorax evaluating chest trauma is clear, its role in detecting rib frac- tures is less clear [16–25]. There is no agreement regarding Seventeen patients (8.94%) presented with pneumothorax. the role of PoCUS in this application because it is a painful PoCUS detected pneumothorax in 16 patients, and it was sub- examination. Although PoCUS examination is superior to sequently confrmed by a CT scans. Seven patients underwent CXR, in many circumstances it is not necessary to report the CXR; however, in 3 patients this technique did not reveal a exact number of fractures, and PoCUS could be a waste of pneumothorax but instead it was confrmed by a CT. Nine time for physician in a busy ED. Turk et al. [26] suggested patients did not undergo a CXR but underwent a CT directly that PoCUS could be reserved for patients who had unex- after PoCUS. In 1 patient, a pneumothorax that was detected plained pain after a negative plain chest radiograph. Inciden- by a CT scan was not detected by either PoCUS or CXR; this tally, the technique of ultrasound scanning for detecting rib was a 57-year-old man, who after a motorbike accident had fractures is not complicated and can easily be learned by an 7 rib fractures and a small pneumothorax with a substantial emergency physician [16]. We used PoCUS in BTI in two mediastinal development. Overall, PoCUS had 100% specifc- diferent conditions: in walking patients and in non-walking ity and 94% sensitivity to detect pneumothorax (PPV 100%, patients. In walking patients with minor trauma, we used a NPV 99.40%). high-frequency (12-MHz) linear transducer directly at the painful site (or we asked to patient to position the probe at Haemothorax these sites). The probe was placed in the rib’s long axis to look for discontinuity of cortical alignment, visualized as a Twenty-seven patients presented with haemothorax (14.21%) break in the hyperechoic rib margin (Fig. 1). PoCUS could that was detected by PoCUS in all cases at arrival. CT con- identify with high precision the site and the number of frac- frmed these fndings in 23 patients (13% had a negative CXR); tures and seemed to be an accurate technique for detecting in 4 cases, CXR confrmed PoCUS.
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