Article, Emergency Medicine

Ability of a new pocket echoscopic device to detect abdominal and pleural effusion in blunt trauma patients

Correspondence

knowledge. As with chest compressions and artificial respira- tion, it is convenient for nonmedical professionals to learn.

In addition to the normal requirements for CPR, the 3 essential points to CPR-BPLE are direction of ftexion, amount of pressure required, and continuity.

If the steps are followed properly, there will be no further damage to the patient. Precautions should be taken to avoid excessive or improper force, which may damage the abdomen.

Li Xiang MD Huang Hui MD Fang Jindong MD Liu Jing MD Fang Li MD

Department of Intensive Medicine Lu’an Municipal Hospital

Mozitan Street, Lu’an, Anhui Province 237000, China

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2012.11.006

References

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  2. Carr BG, Kahn JM, Merchant RM, et al. Inter-hospital variability in postcardiac arrest mortality. Resuscitation 2009;80:30-4.
  3. Redding JS, Nebraska O. Abdominal compression in cardiopulmonary resuscitation. Anesth Analg 1971;50:668-75.
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  5. Bircher N, Safar P, Stewart R. A comparison of standard, “MAST”- augmented, and open-chest CPR in dogs. Crit Care Med 1980;8:147-52.
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  7. Babbs CF. CPR techniques that combine chest and abdominal compression and decompression: hemodynamic insights from a spreadsheet model. Circulation 1999;100:2146-52.
  8. Wenzel V, Lindner KH, Prengel AW, et al. Effect of phased chest and abdominal compression-decompression cardiopulmonary resuscitation on myocardial and cerebral blood flow in pigs. Crit Care Med 2000;28: 1107-12.

Ability of a new pocket echoscopic device to detect abdominal and pleural effusion in blunt trauma patientsB,BB

To the Editor,

In the early minutes of trauma care, emergency ultrasound can assist the frontline clinician with a goal-directed

? Confticts of Interest: MB received honoraria from Edwards Life- sciences as a lecturer.

?? Sources of support: Only departmental funds were used for this

study. No external funds were obtained.

437

Fig. The new ultraminiaturized ultrasound (Vscan; GE Healthcare; Wauwatosa, WI).

assessment that can immediately confirm or rule out certain life-threatening conditions and guide the initial resuscitative management in hemodynamically unstable patients [1-3]. To improve the accessibility of ultrasound in emergency and Prehospital medicine, a new type of ultra-miniaturized Ultrasound device based on 2-dimensional imaging has been recently developed (Fig.). Its true portability and ease of use make real the concept of ultrasonic stethoscope as an extension of the physical examination in various clinical settings [4]. Until now, it has been mainly evaluated for the real-time qualitative assessment of focused Cardiac abnormalities with a good-to-excellent agreement compared with a full-feature echocardiographic device and significant time saving [5-8].

Table 1 Main characteristics of patients

Population characteristics n = 57

Age (y) 37 +- 17

Sex, F/M (n) 11/46

SAPS II 24 +- 19

RTS 11 +- 2

MGAP 25 +- 5

Heart rate (bpm) 90 +- 25

Mean arterial pressure (mm Hg) 81 +- 20

Invasive mechanical ventilation 24 (42)

Norepinephrine support 14 (25)

Etiologies for emergency admission:

Road accident 40 (70)

Fall 14 (25)

Brawl 3 (5)

Data are expressed as mean +- SD or as number (percentage). Abbreviations: MGAP, Mechanism-Glasgow Coma Scale-Age-Arterial Pressure; RTS, Revised Trauma Score; SAPS II, Simplified Acute

Physiology Score.

438 Correspondence

Table 2 Ability of miniaturized echocardiographic system to diagnose pleural or Abdominal effusion in blunt trauma patients

Se (%)

Sp (%)

PPV (%)

NPV (%)

LR+

LR-

Abdominal effusion

85 (58-96)

95 (85-99)

85 (58-96)

95 (85-99)

19 (5-74)

0.16 (0.04-0.58)

n = 13

Pleural effusion

89 (67-99)

97 (87-100)

94 (73-99)

95 (83-99)

35 (5-242)

0.11 (0.03-0.42)

n = 18

Value (95% CI). Abbreviations: LR+, positive likelihood ratio; LR-, negative likelihood ratio.

Emergency ultrasonography should not be limited to the exploration of the heart, but the ability of the new PUD to detect pleural and/or abdominal effusion in blunt trauma patients has not yet been assessed. The main purpose of this study was thus to evaluate the diagnostic capacity of this new pocket ultrasound device (PUD) for the detection of peritoneal or Pleural effusions in blunt trauma patients compared with computed tomographic (CT) scan in emergency settings.

During a 4-month period, patients triaged to the resuscitation room of the emergency department for chest or abdominal trauma requiring CT scan were included, unless at least one of the investigators was unavailable. The indication for CT scan was left to the discretion of the clinician when hemodynamic status was stabilized by Initial resuscitation. During the initial management, each eligible patient was systematically screened for identification of peritoneal or pleural effusion by a focused ultrasound investigation using the new PUD. The investigators, both experienced in emergency ultrasound, should not be involved in the patient’s management and were unaware of the results found by the alternative imaging device. Image quality was subjectively assessed as excellent, good, or poor depending on the quality of the display of anatomical structures. When all data were collected, the duration of the examination was recorded. For each clinical question, data recorded were considered positive, negative, or undeter- mined to calculate the Sensitivity , Specificity , positive and negative predictive values (PPV and NPV), and their 95% confidence interval (CI). This prospective, single- center, observational study was approved by the local ethics committee. Comparison between standard transthoracic echocardiography and PUD for Focused cardiac ultrasound from this cohort has already been published [6].

During the study period, 57 patients who underwent a CT

scan and a focused ultrasound (US) examination with the PUD

Table 3 Ability of PUD to diagnose abdominal effusion according to the interhepatorenal, intersplenorenal, and suprapubic spaces

were included. Their main characteristics are shown in Table 1. All US scans were completed within 3 minutes with a mean duration of 188 +- 68 seconds. Overall imaging quality was judged good to excellent in 100% patients. The ability of the PUD to diagnose abdominal or pleural effusion compared with CT scan is shown in Table 2. Regarding chest assessment, the investigators incorrectly concluded once in a pleural effusion using the PUD instead of an extrapleural hematoma identified on CT scan. In 2 patients, the device incorrectly indicated the absence of pleural effusion, but ultrasound exploration was hampered by subcutaneous emphysema. When considering only severe pleural effusion (n = 11) defined by a pleura- pulmonary distance greater than 5 cm [9], the Se and Sp of the PUD were both 100% (95% CI, 100%-100%). For the evaluation of abdominal effusion, the PUD concluded in 2 false peritoneal effusions instead of retroperitoneal effusions. Moreover, it indicated a false negative in 2 patients, whereas CT scan identified an isolated pelvic effusion. In both cases, the US evaluation was performed when the bladder was empty. The ability of the PUD to diagnose abdominal effusion according to the interhepatorenal, intersplenorenal, and suprapubic spaces is shown in Table 3.

To our knowledge, this is the first clinical study evaluating

the Diagnostic ability of a new PUD for the rapid detection of pleural or peritoneal effusion in blunt trauma patients, complementing previously published studies in different clinical situations [5-8,10]. Considering focused assessment with sonography for trauma, our results are in agreement with previous studies evaluating the diagnostic capabilities of handheld ultrasound in emergency settings in which a full Abdominal examination was completed in less than 5 minutes with 73% to 99% Se and 94% to 98% Sp [11]. In this context, Focused Assessment with Sonography for Trauma using the new PUD may be of interest considering its widespread availability and ease of use compared with standard devices,

Se (%)

Sp (%)

PPV (%)

NPV (%)

LR+

LR-

Interhepatorenal

91 (62-98)

98 (89-100)

91 (62-98)

98 (89-100)

42 (6-293)

0.09 (0.01-0.60)

n = 11

Intersplenorenal

89 (57-98)

96 (86-99)

80 (49-94)

98 (89-100)

21 (5-84)

0.12 (0.02-0.74)

n = 9

Suprapubic

58 (32-80)

96 (86-99)

78 (45-94)

90 (79-96)

14 (3-58)

0.43 (0.22-0.85)

n = 12

Value (95% CI).

Correspondence 439

offering time-saving assessment, and complementing the inherent limitations of the physical examination in prehospital or emergency settings [12].

In conclusion, this new ultraportable echoscope can be successfully used by appropriately trained physicians for the primary assessment of blunt trauma patients and is reliable for the real-time detection of pleural and abdominal effusion.

Cedric Carrie : Resident Francois Delaunay MD Nicolas Morel MD Philippe Revel MD Emergency Department CHU de Bordeaux

F-33000 Bordeaux, France

Gerard Janvier MD, PhD Matthieu Biais MD Emergency Department CHU de Bordeaux

F-33000 Bordeaux, France Univ. Bordeaux Segalen

F-33000 Bordeaux, France E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2012.11.008

References

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  5. Amiel JB, Grumann A, Lheritier G, Clavel M, Francois B, Pichon N, et al. Assessment of left ventricular ejection fraction using an ultrasonic stethoscope in critically ill patients. Crit Care 2012;16(1):R29.
  6. Biais M, Carrie C, Delaunay F, Morel N, Revel P, Janvier G. Evaluation of a new pocket echoscopic device for focused cardiac ultrasonography in an emergency setting. Crit Care 2012;16(3):R82.
  7. Lafitte S, Alimazighi N, Reant P, Dijos M, Zaroui A, Mignot A, et al. Validation of the smallest pocket echoscopic device’s diagnostic capabilities in heart investigation. Ultrasound Med Biol 2011;37(5): 798-804.
  8. De Backer D, Fagnoul D. Pocket ultrasound devices for focused echocardiography. Crit Care 2012;16(3):134.
  9. Roch A, Bojan M, Michelet P, Romain F, Bregeon F, Papazian L, et al. Usefulness of ultrasonography in predicting pleural effusions N 500 mL

diagnosis of unilateral pleural effusions and ultrasound-guided thoracentesis. Interact Cardiovasc Thorac Surg 2012;15(4):596-601.

  1. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011;364(8):749-57.
  2. Tazarourte K, Dekadjevi H, Desmettre T, Tourtier JP, Trueba F, Schiano P. Focused assessment with sonography in trauma prehospital triage: an important tool. Crit Care Med 2010;38(6):1501-2 [author reply 2].

Wellens’ syndrome and clinical significance of T-wave inversion in anterior precordial leadsB

To the Editor,

We thank Hartman et al [1] for their wonderful article by the title of “The use of a 4-step algorithm in the electrocardio- graphic diagnosis of ST-segment elevation myocardial infarc- tion by novice interpreters.” The authors presented the excellent algorithm that helps detect ST-segment elevation myocardial infarction n the prehospital and other nonemergency depart- ment (ED) settings. In addition, we would like to emphasize the clinical significance of T-wave inversion in anterior precordial leads is an acute coronary syndrome as well.

We recently had a 64-year-old white man who presented to the ED with a chief complaint of substernal chest heaviness that woke him up from sleep. He also reported a 5-month history of shortness of breath on exertion. His medical history was significant for diabetes type 2 and depression. Patient’s chest pain had resolved at presentation. His initial electrocardiogram (ECG) and troponin-I were unremarkable. He was admitted for observation. However, his second ECG, which was performed 6 hours later, showed new biphasic T waves in anterior leads without any pathologic Q waves or ST-segment elevations (Fig.).

His second troponin was also elevated at 2 ng/mL, and the diagnosis of Wellens’ syndrome was made. He underwent urgent coronary angiography and was found to have 80% stenosis at the proximal part of left anterior descending artery, which was fixed with a bare metal stent. He did well after the coronary angiography and did not report any recurrent chest pain.

Wellens’ syndrome or LAD coronary T-wave syndrome is an acute coronary syndrome characterized by ECG changes of symmetric, deeply inverted T waves or biphasic T waves in the anterior leads with preserved R wave progression and without Pathologic Q waves and ST- segment elevation. Interestingly, pain is usually resolved at the time of these ECG changes. These ECG findings are suggestive of significant LAD stenosis, and patients are at high risk for anterior wall myocardial infarction [2]. The sensitivity, specificity, and positive predictor value of T- wave inversion for significant LAD stenosis is 69%, 89%, and 86%, respectively [3].

in patients receiving mechanical ventilation. Chest 2005;127(1):224-32.

  1. Lisi M, Cameli M, Mondillo S, Luzzi L, Zaca V, Cameli P, et al. Incremental value of pocket-sized imaging device for bedside

? Authorship: All authors had access to data and participated in writing the manuscript.

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