Case # 13: What Lies Beneath

A 30 year old male presents to the emergency department after blunt trauma to the face from an altercation. He notes he was punched several times in the face but did not pass out. His exam is notable for significant right periorbital ecchymosis and edema with inability to open his eye. You are unable to perform a direct eye exam given the significant periorbital swelling.  A CT maxillofacial is performed which shows an isolated right inferior orbital wall fracture.

Vitals: T 98.6 HR 85 BP 142/81  RR 14 O2 98% on RA

Prior to ENT consultation, a bedside ultrasound of the orbits is performed.  In spite of being unable to open the eye, what can you tell your consultant regarding your exam?

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Answer and Learning Points

Answer

Using ultrasound as an adjunct to your exam, you are able to tell the consultant that there is a normal appearing, reactive pupil and that the extra-ocular movements of the eye are intact. The consultant is appreciative over the phone and is happy to come in and see the patient whom after evaluation is discharged home with close outpatient follow up.

Learning Points

It is often the case where a patient suffers such significant facial trauma that a complete physical exam of the orbit due to periorbital swelling is not possible. Ultrasound can be a critical tool in these cases to provide useful information to assess for multiple potential pathologies. Previous studies have shown the ability of ocular ultrasound in trauma to detect elevated intracranial pressure (via optic nerve sheath diameter), retinal detachment, vitreous hemorrhage, and retrobulbar hematoma. It can also be used for early detection of muscular entrapment in the case of an orbital wall fracture, as well as performed serially for pupillary response in patients with significant neurological injury at risk for deterioration and potential herniation.

  • To evaluate extraocular movements:
    • Prepare the patient by laying the bed backwards and having their face parallel to the ceiling,  supporting the patient's head and neck with a pillow or blanket.
    • (Optional) Place a tegaderm over the eye. If you do, ensure there is no air between the tegaderm and the eyelid.
    • Place a small amount of ultrasound gel on the closed eyelid  and prepare the linear probe with the gain turned almost all the way up.
    • Stabilize your hand on the patient's nasal bridge or zygoma, with the probe marker to your left, and place the probe transverse on the orbit with minimal pressure being applied directly to the eye. This is very important in trauma as the area is likely painful and theoretically the patient could have a ruptured globe.
    • Adjust the depth to ensure the optic nerve is just visualized at the bottom of the screen. The anterior chamber and lens should be used as visual landmarks to ensure you are in proper location.
    • Next, have the patient look left and right, then turn the probe to a sagittal orientation and have the patient look up and down. During these maneuvers you should be evaluating for symmetric movements of the orbit in each direction.
    • If you do not appreciate symmetric movements of the orbit in all directions then you may have entrapment of an extraocular muscle.
  • To evaluate for pupillary response and shape:
    • Be sure to dim the lights in the room prior to performing this exam to allow for an adequate pupillary response.
    • Gently apply the linear probe with gel in a transverse plane just inferior to the eye, angling superiorly towards the patient's head (Depending on the location of the swelling around the eye, you can also place the probe superior to the eye, angling inferiorly towards the patient's feet).
    • Keep flattening out your probe angle relative to the skin until you have a cross section of the pupil and iris in view.
    • The pupil should be evaluated for symmetry as an asymmetric or oblong pupil could suggest globe rupture. You can then shine a light in the affected or non-affected eye (consensual light reflex) and observe the pupil for constriction.

 

Author

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

    1. Blaivas M. Bedside emergency department ultrasonography in the evaluation of ocular pathology. Acad Emerg Med 2000;7:947-50.
    2. Blaivas M, Theodoro D, Sierzenski P. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med 2002;9(8):791-9.
    3. Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med 2008;15(2):201-4.
    4. Tayal VS, Neulander M, Norton HJ, et al. Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann Emerg Med 2007;49(4):508-14.
    5. Harries A, et al. Ultrasound assessment of extraocular movements and pupillary light reflex in ocular trauma. Am J Emerg Med 2010 28(8):956-9.

Comparison of Four Views to Single-View Ultrasound Protocols to Identify Clinically Significant Pneumothorax

Background

Ultrasound has become a key adjunct for the initial evaluation of trauma patients in the emergency department (ED), with the eFAST, or extended focused assessment with sonography in trauma examination, including lung evaluation for the presence of a pneumothorax (PTX) or hemothorax. While prior research has shown ultrasound (US) to be very effective at identifying a PTX [1], there is no standardized imaging protocol that has been shown be superior to others. The two most common approaches are a single view of each hemithorax and four views of each hemithorax [2] —this paper sets out to determine if the single view strategy is sufficient to identify a clinically significant PTX.

Comparison of Four Views to Single-view Ultrasound Protocols to Identify Clinically Significant Pneumothorax

 

Clinical Question

Does the single-view or four-view lung US technique have a higher diagnostic accuracy for the identification of clinically significant PTX in trauma patients?

Methods & Study Design

  • Population
    • The study was conducted at a single urban academic ED with an annual volume of 130,000 patients and a dedicated Level I trauma service staffed by trauma surgeons and EM physicians. Adult patients with acute traumatic injury who were undergoing a CT scan of the chest as part of their clinical care were eligible for enrollment.
  • Intervention
    • Patients were assigned to one of two imaging protocols, a single view of each hemithorax or four views of each hemithorax prior to any CT imaging being done, with US images obtained by emergency physicians or the attending trauma surgeon using a 7.5-Mhz (5- to 10-MHz) linear array transducer. US exams were performed by both residents and attending physicians who had been credentialed in both US protocols.
  • Outcomes
    • Researchers looked for the ability of US to identify clinically significant PTX requiring chest tube placement; a PTX was considered clinically insignificant if the radiologist, who was blinded to the US interpretation, read the CT scan as a thin collection of air up to 1 cm thick in the greatest slice or seen on fewer than five contiguous slices.
  • Design
    • This was a randomized, prospective trial on trauma patients.
  • Excluded
    • The study excluded any patient who was too unstable and required clinical care that prevented performing a chest wall US, patients with a chest tube in place prior to arrival, children, pregnant women, and prisoners.

Results

    • For clinically significant PTX, CXR showed a sensitivity of 48.0% and specificity of 100%, a single view US showed a sensitivity of 93.0% and a specificity of 99.2%, and four views showed a sensitivity of 93.3% and specificity of 98.0%. There was no statistically significant difference in either sensitivity or specificity when comparing single view and four-view for clinically significant or any PTX.

Strengths & Limitations

  • Strengths
    • Randomized, prospective trial
    • 100% agreement between the initial US read by the performing provider and the study author, for a Cohen’s kappa of 1
  • Limitations
    • Study was conducted at a single center with a limited number of US operators
    • Standard prehospital approach to spinal immobilization that results in placement of patients supine on a long board - in areas where this approach may differ (e.g., patients arrive semirecumbent or upright), the positioning of a PTX in the chest may be altered, rendering a single view of the anterior chest wall less accurate
    • As this study was a convenience sample that required the treating physician to remember to enroll the patient and randomize them prior to performing the US, there is a possibility of selection bias

Author's Conclusions

"The sensitivities are equivalent for both a single view and four views of each hemithorax when using point-of-care ultrasound to evaluate for a clinically significant pneumothorax in the trauma population.  The additional time required for additional views should be weighed against the lack of additional diagnostic accuracy when evaluating critically ill and time-sensitive trauma patients in the ED."

Our Conclusions

Although not all PTXs are located anteriorly and multiple views of each hemithorax may be thought to maximize sensitivity and/or allow the physician to be able to attempt to quantify the size of the PTX, performing eight views instead of two views during the eFAST requires extra time while adding no diagnostic value.  From this study, it appears that a single view on each side of the thorax is sufficient to detect clinically significant PTXs on trauma patients.

As with any diagnostic tool, it is important to remember its limitations. Specifically, the US exams in this study were done in supine patients, who were brought in by EMS in a supine position, allowing the pneumothorax to move to the most anterior portion of the chest. Caution should be taken when applying the test characteristics of this study to patients that are not in the supine position. There was also one patient who had a significant PTX that was missed by US and required a chest tube. This patient had received a needle decompression by prehospital providers and was randomized to a single anterior US chest view that was performed just lateral to the needle insertion site which may have led to false negative US exam. It appears this specific group of patients may benefit from a more comprehensive four-view lung examination.

 

The Bottom Line

A single anterior view on each side of the chest in a supine patient is sufficient to detect clinically significant pneumothoraces.

Authors

This post was written by Ben Foorman, MS4 at UCSF. It was edited by Michael Macias, MD.

References

    1. Lichtenstein DA, e. (2017). Ultrasound diagnosis of occult pneumothorax. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 28 July 2017, from https://www.ncbi.nlm.nih.gov/pubmed/15942336
    2. Blaivas M, e. (2017). A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 28 July 2017, from https://www.ncbi.nlm.nih.gov/pubmed/16141018
    3. Helland G, e. (2017). Comparison of Four Views to Single-view Ultrasound Protocols to Identify Clinically Significant Pneumothorax. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 28 July 2017, from https://www.ncbi.nlm.nih.gov/pubmed/27428394

Does This Adult Patient Have a Blunt Intra-abdominal Injury?

Background

Trauma is the leading cause of death in those younger than 45 years in the United States. Around 80% of injuries are due to blunt trauma with 20% involving penetrating trauma. It is blunt trauma, however, that carries substantial diagnostic challenges due to complex injury patterns and difficult management strategies. This paper sets out to review and summarize the comparisons of different techniques in diagnosis of intra-abdominal injury via physical exam findings, laboratory values, and imaging including bedside ultrasound. 

Does This Adult Patient Have a Blunt Intra-abdominal Injury? 

Clinical Question

How accurate and reliable are existing symptoms, signs, laboratory tests and bedside imaging studies at diagnosing intra-abdominal injury following blunt abdominal trauma?

Methods & Study Design

  • Population
    • The study analyzed 12 papers that assessed clinical examination and 22 papers to assess role of FAST in identifying intra-abdominal injury. Sample sizes ranged from 117 to 3435 patients. All studies defined inclusion criteria as adult patients with any blunt abdominal trauma except for 2 studies that included only adult patients in motor vehicle collisions.
  • Intervention
    • This particular paper focused on the likelihood ratios of various approaches in predicting intra-abdominal injury including: physical exam findings (i.e rebound tenderness, abdominal distention, guarding, seat belt sign, and hypotension), laboratory tests (i.e.  base deficit, hematuria, elevated transaminases and anemia), and FAST examination.
  • Outcomes
    • Researchers measured specificity, sensitivity, positive likelihood and negative likelihood of the various physical exam, laboratory, and imaging findings associated with blunt trauma.
  • Design
    • This is a meta-analysis of numerous prospective studies looking at blunt abdominal trauma.
  • Excluded
    • The publishers chose to include studies that were prospective, with consecutive enrollment and blinding, and included a reference standard (i.e.  abdominal CT, DPL, laparotomy, autopsy, or clinical course to detect intra-abdominal injury or hemoperitoneum).

Results

Strengths & Limitations

  • Strengths
    • Analyzed the biggest publications from top-trauma centers focusing on strength of statistical analysis.
    • Created subcategories of studies that focused on FAST in order to ascertain if any of the information was skewed.
  • Limitations
    • This is a 2012 study that only focused on papers older than 2007, excluding any new techniques and standards as well as imaging advancements of the last decade.
    • They did not review studies for clinical outcome, so cannot draw conclusions regarding how change in bedside exam and procedures impact patient care post diagnosis.
    • As with all large meta-analysis studies there is always risk of significant heterogeneity from varying study inclusion/exclusion criteria making generalizability complex.

Author's Conclusions

“Bedside ultrasonography has the highest accuracy of all individual findings, but a normal result does not rule out an intra-abdominal injury. Combinations of clinical findings may be most useful to determine which patients do not require further evaluation, but the ideal combination of variables for identifying patients without intra-abdominal injury requires further study.”

Our Conclusions

Overall, this paper reinforces the strength of bedside ultrasonography (adjusted positive LR of 30) as a diagnostic tool of intra-abdominal injury following blunt trauma compared to physical exam and laboratory findings. This reinforces ultrasounds role as the best tool to "rule-in" an intra-abdominal injury. However, it also elucidates a relatively poor sensitivity of the FAST exam, making it a poor tool to "rule-out." This is important as it urges physicians to not rely solely on a negative FAST exam when ruling out intra-abdominal injury but consider other factors including clinical gestalt, mechanism of injury, physical exam and laboratory work up.

Additionally, to better understand the magnitude of this paper's findings it is important to known what a likelihood ratio really tells us. The following image is a quick way to think about likelihood ratios. A positive likelihood ratio of 2 should increase your probability of disease ( resulting in your post test probability) by 15%, 5 by 30% and 10 by 45%. Likewise a negative likelihood ratio of 0.5 should decrease your probability of disease by 15%, 0.2 by 30% and 0.1 by 45%.

The Bottom Line

Bedside ultrasonography is a highly specific diagnostic tool to rule in  intra-abdominal injury following blunt trauma but should be used in conjunction with clinical gestalt, physical exam findings and laboratory values when ruling out injury.

Authors

This post was written by Olga Miakicheve, MS4 at UCSD. It was edited by Michael Macias, MD.

References

    1. Simel, D. (2012). Does This Adult Patient Have a Blunt Intra-abdominal Injury?. JAMA, 307(14), 1517. doi:10.1001/jama.2012.422

FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy

Background

The emergency resuscitative thoracotomy (RT), aka The ED Thoracotomy, is a procedure performed as a last-ditch effort during resuscitation of a patient in traumatic arrest or impending traumatic arrest. Unfortunately despite physicians’ best efforts, outcomes for this procedure are generally poor. The largest review of outcomes after RT performed in the emergency department found an overall survival of 7.4% (8.8% for penetrating injury, 1.4% for blunt injury), with good neurological outcomes present in 92.4% of surviving patients [2]. Furthermore, given the lack of high quality evidence on this procedure, there are no universal guidelines that exist to determine optimal candidates [3,4]. Point-of-care ultrasound has become a core adjunct in evaluation of the trauma patient, however there is minimal data evaluating its utility in determining which trauma patients may benefit from RT [5].

FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation

Clinical Question

Can the Focused Assessment Using Sonography for Trauma (FAST) predict survival after a RT in patients presenting to the emergency department in traumatic cardiac arrest?

Methods & Study Design

  • Population
    • All penetrating trauma patients with absent vital signs and blunt trauma patients with a loss of vital signs en route or in the resuscitation bay that underwent RT.
  • Intervention
    • A FAST exam was performed just prior to RT to assess for the presence or absence of a pericardial effusion and cardiac motion.
  • Outcomes
    • Survival to Discharge or Organ Donation
  • Design
    • Prospective, observational study performed at a single academic level-1 trauma center
  • Excluded
    • Patients who were taken directly to the OR for an emergent or urgent thoracotomy were excluded.
    • Patients who did not have a FAST exam performed prior to RT were excluded from analysis

Results

    • 223 patients underwent RT, 187 underwent analysis (36 had no FAST performed)
      • Primary Outcome
        • Survival: 3.2%
        • Organ Donation: 1.6%

Strengths & Limitations

  • Strengths
    • First large, prospective observation study on emergency RT
    • Sensitivity analysis performed to include patients who had inadequate views obtained
  • Limitations
    • Study performed at a high-volume, single academic level-1 trauma center with which may skew generalizability
    • Residents who had formal training in the FAST exam performed all ultrasound scans. Many emergency medicine physicians are not credentialed in ultrasound or FAST examination

Author's Conclusions

"In summary, for the patients that arrived to hospital and underwent a FAST examination, all survivors and organ donors had visible cardiac motion. If no cardiac motion or pericardial effusion was seen, the survival was zero. Ultrasound was, therefore, able to effectively identify those patients who had the potential to survive the RT and discriminate them from those who did not. Utilizing ultrasound would have resulted in the avoidance of a significant proportion of thoracotomies which were ultimately found to be futile.”

Our Conclusions

This is a well done study examining the utility of the FAST exam in identifying which patients will potentially benefit from emergency RT. One may look at the primary outcomes of this study and think that the very low overall survival rate (3.2%) does not jive with previously reported studies. However, it is important to note that during the study period, 21 patients who had a penetrating cardiac injury and went straight to the OR for thoracotomy, were excluded. All of these patients survived. If we were to incorporate this number into the the final analysis, survival would be ~13% which fits better with previous data. But that isn’t the point of this study. The big question that I feel is appropriately answered is which patient population can we safely avoid undertaking an emergency RT, knowing it is futile. While resource utilization for a procedure of this magnitude may be less burdensome at an academic level-1 trauma center, performing a RT in an emergency department where this is rare occurrence requires a much larger undertaking by the staff. The new data from this study, demonstrates that patients who did not have cardiac motion or a pericardial effusion on initial FAST had a zero survival rate. This is practice changing, especially for providers who rarely perform this procedure. If an experienced trauma team performing this procedure had zero survival rate in patients with no cardiac motion or pericardial effusion, it is safe to say that a provider with less experience will not perform better. Furthermore, having real time data to share with the entire resuscitation team during a traumatic arrest can provide closure to the team and a sense that performing any further heroic procedures is futile.

The Bottom Line

The FAST exam is a critical adjunct in traumatic patients and should be applied to all cases of traumatic arrest in order to determine the utility of performing an emergency RT.

References

    1. Inaba K, e. (2017). FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 4 July 2017, from https://www.ncbi.nlm.nih.gov/pubmed/26258320
    2. Rhee PM, e. (2017). Survival after emergency department thoracotomy: review of published data from the past 25 years. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 4 July 2017, from https://www.ncbi.nlm.nih.gov/pubmed/10703853
    3. Seamon MJ, e. (2017). An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association ... - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 4 July 2017, from https://www.ncbi.nlm.nih.gov/pubmed/26091330
    4. Burlew CC, e. (2017). Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 4 July 2017, from https://www.ncbi.nlm.nih.gov/pubmed/23188227
    5. Moore EE, e. (2017). Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 4 July 2017, from https://www.ncbi.nlm.nih.gov/pubmed/21307731