Can Routine Trauma Bay Chest X-ray Be Bypassed

with an Extended Focused Assessment with

Sonography for Trauma Examination?
MICHAEL C. SOULT, M.D., LEONARD J. WEIRETER, M.D., REBECCA C. BRITT, M.D., JAY N. COLLINS, M.D.,
TIMOTHY J. NOVOSEL, M.D., SCOTT F. REED, M.D., L. D. BRITT, M.D., M.P.H.

From the Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia

The objective of this study was to investigate the feasibility of using ultrasound (US) in place of
portable chest x-ray (CXR) for the rapid detection of a traumatic pneumothorax (PTX) requiring
urgent decompression in the trauma bay. All patients who presented as a trauma alert to a single
institution from August 2011 to May 2012 underwent an extended focused assessment with so-
nography for trauma (FAST). The thoracic cavity was examined using four-view US imaging and
were interpreted by a chief resident (Postgraduate Year 4) or attending staff. US results were
compared with CXR and chest computed tomography (CT) scans, when obtained. The average age
was 37.8 years and 68 per cent of the patients were male. Blunt injury occurred in 87 per cent and
penetrating injury in 12 per cent of activations. US was able to predict the absence of PTX on CXR
with a sensitivity of 93.8 per cent, specificity of 98 per cent, and a negative predictive value of 99.9
per cent compared with CXR. The only missed PTX seen on CXR was a small, low anterior,
loculated PTX that was stable for transport to CT. The use of thoracic US during the FAST can
rapidly and safely detect the absence of a clinically significant PTX. US can replace routine CXR
obtained in the trauma bay and allow more rapid initiation of definitive imaging studies.

(PTXs) remains a serious in-
P NEUMOTHORACIES
trathoracic injury after blunt trauma and it has
been shown that PTXs are found in one-fifth of major
blunt trauma victims.1 Prompt diagnosis and treatment
are needed to prevent significant complications and
potentially death.
Chest x-ray (CXR) and computed tomography (CT)
remain the imaging studies commonly used for the
evaluation of PTX. However, it has been shown supine
CXRs fail to demonstrate a significant number of
PTXs.2–5 CT remains the gold standard for the di-
agnosis of PTX, yet it requires the transport of criti-
cally injured patients and can delay the diagnosis.6
First described 30 years ago by Rantanen, ultrasound
(US) can be used for the evaluation of PTX.7, 8 The
sensitivity of thoracic US continues to improve and it
has been found to be more sensitive than CXR for the
detection of PTXs.9–14 Ultrasound is routinely used in
the evaluation of trauma patients in the focused as-
sessment with sonography for trauma (FAST) exami-
nation and there have been reports that the extended
Presented as a podium presentation at the Southeastern Surgical
Congress, Jacksonville, Florida, February 9-12, 2013.
Address correspondence and reprint requests to Leonard
J. Weireter, M.D., 825 Fairfax Avenue, Hof heimer Hall, Suite 610,
Norfolk, VA 23507. E-mail: weiretlj@evms.edu.
FAST (eFAST) is effective for the diagnosis of trau-
matic PTX.4, 6, 9, 15–17 The objective of this study was
to investigate the feasibility of using US in place of
portable CXR for the rapid detection of a traumatic PTX
requiring urgent decompression in the trauma bay.
Methods
This was a retrospectively reviewed, prospective pro-
cess improvement project performed at the Level I
trauma center at Sentara Norfolk General Hospital in
conjunction with the Eastern Virginia Medical School
(EVMS) Department of Surgery. All patients who were
older than 16 years old and presented as trauma activa-
tions, between August 2011 and May 2012, underwent
an eFAST as part of their initial workup. Portable CXRs
were performed in the trauma bay after eFAST exami-
nation. The thoracic cavity was evaluated with four-view
US imaging using the linear L25x 13- to 6-MHz probe
(M-Turbo; SonoSite, Bothell, WA) in both B and M
modes. All US findings were documented and interpreted
by a chief resident (Postgraduate Year 4) or attending
staff. Chest CTs were ordered at the discretion of the
primary team based on clinical findings and were per-
formed on a GE 16-detector scanner (General Electric,
Piscataway, NJ).

336
No. 4 BYPASS X-RAYS WITH EXTENDED FAST EXAMINATION
Charts were reviewed for patient age, sex, mecha-
nism of injury, Injury Severity Score (ISS), and im-
aging results. Data was analyzed using MedCalc
(Belgium). Mean and standard deviation were used for
continuous variables. Categorical variables were de-
scribed as a fraction and percentage. Comparison of
each imaging modality was made using sensitivity,
specificity, negative predictive value (NPV), and pos-
itive predictive value (PPV). The Institutional Review
Board at EVMS approved the study.
Results
Trauma activation was initiated on 1302 patients
during the study period. One hundred two patients
were excluded because no CXR was performed in the
trauma bay. An additional 273 patients were excluded
as a result of lack of chief resident or attending-level
interpretation of the US images. Ultrasound images
were evaluated to determine if a pleural slide was
present as well as classic US artifacts of a normal
pleural slide. These included ‘‘comet-tails,’’ which are
reverberation artifacts, and the ‘‘seashore sign,’’ which
is caused by the moving thoracic cavity against the
static lung. A PTX was suspected on US when there
was loss of pleural slide and presence of the ‘‘strato-
sphere sign’’ caused by the loss of the static lung below
the pleural surface (Fig. 1).
The remaining 927 patients underwent both thoracic
US and CXR evaluation. Of these 927 patients, 345
patients also underwent a CT of the chest. Patients
were an average of 37.8 years old, predominately male
(68%), and had an average ISS of 6.27. Trauma acti-
vations were initiated mainly for patients who sus-
tained blunt trauma (87%) compared with penetrating
trauma (12%), whereas the remaining activations were
for patients who sustained a burn injury (1%). More
PTXs were detected by CT than US or CXR (Table 1).
Ultrasound had a 99.9 per cent NPV for detecting the
presence of a PTX based on CXR results (Table 2).
FIG. 1. Ultrasound evaluation for pneumothorax: (A) normal slide along the pleural surface (arrow) and ‘‘comet-tail’’ artifacts (ar-
rowheads). (B) Normal pleural slide demonstrated by ‘‘seashore sign.’’ (C) No evidence of slide as demonstrated by the ‘‘stratosphere
sign.’’
? Soult et al. 337
When compared with CT, the sensitivity of US
(39.7%) was better than the sensitivity of CXR
(23.5%) for detecting a PTX (Tables 2 and 3). Portable
CXR had a 100 per cent PPV for the detection of PTX
when compared with CT. However, both US and CXR
failed to detect PTXs that were subsequently seen on
CT (Table 4). All patients requiring thoracostomy tube
(TT) based on clinical and CXR findings were detected
by US. No patient with the absence of PTX on US
had an adverse outcome during their continued trauma
evaluation.
A TT was placed in 45 patients during the study.
During the initial trauma evaluation, 24 patients had
a TT placed for a PTX. US was able to detect a PTX in
22 of the patients requiring TT for PTX. One patient
required a TT after an iatrogenic injury after central
line placement. The only missed PTX was in a pa-
tient who was found to have a loculated, low anterior
PTX on both CXR and CT. The patient was stable
throughout examination and during transport for ad-
ditional imaging. Eight patients required a TT for
a PTX found on both US and CT that was not present
on CXR. However, all of these patients were stable
during their initial examination and during transport,
facilitating delayed insertion of the TT until after
completion of all imaging. A TT was placed for
evacuation of hemothorax (HTX) in 13 patients. All of
these patients had no evidence of PTX on CXR or US.
Five of these patients subsequently were found to have
a small PTX on CT imaging. Thirty-five patients had
evidence of PTX on CT that was not seen on CXR.
These patients did not undergo immediate TT place-
ment and were observed for changes in clinical status.
US detected a PTX in four of the patients who were
observed.
Discussion
Rapid evaluation and diagnosis of life-threatening
conditions has always been the mainstay of the trauma
338 THE AMERICAN SURGEON April 2015 Vol. 81

evaluation. After completion of the primary survey, The supine anteroposterior CXR has been the initial
imaging is highly relied on as adjunct to the physical thoracic evaluation during a trauma examination. Its
examination. Throughout the past decade, imaging use is primarily to screen for PTX, HTX, fractures, and
technology has continued to improve and those im- aortic injury. Unfortunately, studies continue to dem-
provements have allowed the evolution of trauma al- onstrate it has a low sensitivity in diagnosing many
gorithms. Early versions of advanced trauma life critical injuries, missing PTX in 30 to 40 per cent of
support guidelines called for the use of plain films for patients and 5 to 15 per cent of blunt thoracic aorta
the evaluation of the cervical spine, chest, and pelvis. injuries.5, 18–21 CT remains the gold standard for the
With faster scan times and better resolution of images, diagnosis of these injuries but exposes the patient to
CT has largely supplanted the use of plain films in the a higher level of radiation, requires patients be stable
evaluation of the cervical spine and pelvis. However, for transport, and adds additional time to diagnosis. As
the role of the CXR in the trauma bay has not been radiation exposure continues to increase in trauma
evaluated. patients, attempts are being made to provide more di-
rected imaging to the chest.22, 23 Thus, as US imaging
has improved, its role continues to advance in the
TABLE 1. Patient Characteristics
initial evaluation of a trauma patient.
Age (years) The shift from traditional imaging to the use of US
Mean ± standard deviation 37.8 ± 16.7
Range 16–93 has occurred for rapid diagnosis in the trauma patient
Sex as seen in the shift from diagnostic peritoneal lavage to
Male 629 (68%) the FAST examination. Many studies have shown that
Female 298 (32%) US has been shown to be able to detect a traumatic
ISS
Mean ± standard deviation 6.27 ± 8.57 PTX.2, 4, 6 This study confirms these previous find-
Range 0–75 ings, detecting all but one PTX seen on CXR. More
MOI importantly, this study demonstrated that the ability to
MVC 433 (46%) rule out a clinically significant PTX in the trauma bay
Fall 130 (14%)
MCC 88 (9%) was 99.9 per cent. By using US as a part of the eFAST,
Automobile vs pedestrian 76 (8%) patients could be moved out of the trauma bay to re-
GSW 61 (7%) ceive more definitive imaging much quicker than
Stabbing 53 (6%)
Assault 42 (5%) currently occurs while awaiting CXR results. Given
Other 44 (5%) the low sensitivity of the CXR, this would also allow
PTX by imaging a more appropriate study to be obtained in a more
CXR 16 (2%) expedient fashion.
US 33 (4%)
CT 68 (7%) The use of US provides a more sensitive method for
determining the presence of a PTX than CXR. This
ISS, Injury Severity Score; MOI, method of injury; MVC, was originally shown by Kirkpatrick et al. in 2004 and
motor vehicle collision; MCC, motorcycle collision; GSW,
gunshot wound; PTX, pneumothorax; CXR, chest x-ray; US, has been consistently been supported over the past
ultrasound; CT, computed tomography. decade.4, 6, 9, 15–17 This study confirms these findings

TABLE 2. Radiographic Findings from US Compared with CXR for the Evaluation of Pneumothorax
CXR
Positive Negative
US Positive 15 18 PPV 4 45.5%
Negative 1 893 NPV 4 99.9%
Sensitivity 4 93.8% Specificity 4 98.0%
US, ultrasound; CXR, chest x-ray; PPV, positive predictive value; NPV, negative predictive value.

TABLE 3. Radiographic Findings from US Compared with CT for the Evaluation of Pneumothorax
CT
Positive Negative
US Positive 27 2 PPV 4 93%
Negative 41 275 NPV 4 87%
Sensitivity 4 39.7% Specificity 4 99.3%
US, ultrasound; CT, computed tomography; PPV, positive predictive value; NPV, negative predictive value.
No. 4 BYPASS X-RAYS WITH EXTENDED FAST EXAMINATION
TABLE 4. Radiographic Findings from CXR Compared with CT for the Evaluation of Pneumothorax
Positive
CXR Positive 16
Negative 52
Sensitivity 4 23.5%
CXR, chest x-ray; CT, computed tomography; PPV, positive predictive value; NPV, negative predictive value.
with US (39.7%) having a better sensitivity than CXR
(23.5%) when compared with CT. However, given the
large number of occult PTXs that were observed
without the need for intervention, the significance of
occult PTXs continues to be debated. Additionally,
all patients who required a TT to be placed before
movement from the trauma bay were detected by US.
Given the sensitivity of US to detect clinically signif-
icant PTXs, patients can be further managed based on
US and clinical findings.
Although US was able to determine adequately the
absence of a PTX, there are limitations to a positive
finding. In this study, only two false-positive PTXs
were seen on US compared with CT. However, only
one-third of the patients in this study underwent chest
CT. It is possible that if all patients had received CT
imaging that the number of false-positives would have
increased. It has been shown there are a number of
instances where US has limited ability to adequately
evaluate a lung slide. Patients with subcutaneous air,
emphysema, or who have had previous pleurodesis/
decortication have limited slide on US examination
suggesting a pneumothorax.14, 24–26 Also, patients with
large body habitus often make the evaluation more
difficult, sometimes causing inadequate pleural evalu-
ation. Given the number of situations that cause a false-
positive finding of PTX, it is recommended that more
definitive imaging be used for the evaluation of these
patients.
Conclusion
The use of thoracic US during the eFAST can rapidly
and safely detect the absence of a clinically significant
PTX. In combination with the clinical examination, US
findings concerning for PTX can aid in the decision for
treatment. However, US findings concerning for PTX
in a stable patient require further imaging to confirm
these findings. US evaluation can replace routine CXR
obtained in the trauma bay and allow for more rapid
transport and initiation of definitive imaging studies.
Acknowledgments
We thank Ms. Rusty Kidd the trauma database registrar
for her assistance with data collection. We also thank the
? Soult et al. 339
CT
Negative
0 PPV 4 100%
277 NPV 4 84%
Specificity 4 100%
chief residents: Drs. Alan Chap, Kara Friend, Rebecca
Lofgren, Nancy Longfors, Matthew Noorbakhsh, and Troy
Shell for their assistance interpreting US findings.
REFERENCES
1. Di Bartolomeo S, Sanson G, Nardi G, et al. A population-
based study on pneumothorax in severely traumatized patients.
J Trauma 2001;51:677–82.
2. Rowan KR, Kirkpatrick AW, Liu D, et al. Traumatic pneu-
mothorax detection with thoracic US: correlation with chest radi-
ography and CT—initial experience. Radiology 2002;225:210–4.
3. Ball CG, Hameed SM, Evans D, et al. Occult pneumothorax in
the mechanically ventilated trauma patient. Can J Surg 2003;46:373–9.
4. Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held
thoracic sonography for detecting post-traumatic pneumothoraces:
the extended focused assessment with sonography for trauma
(EFAST). J Trauma Inj Infect Crit Care 2004;57:288–95.
5. Ball CG, Kirkpatrick AW, Laupland KB, et al. Factors related
to the failure of radiographic recognition of occult posttraumatic
pneumothoraces. Am J Surg 2005;189:541–6; discussion 546.
6. Nandipati KC, Allamaneni S, Kakarla R, et al. Extended
focused assessment with sonography for trauma (EFAST) in the
diagnosis of pneumothorax: experience at a community based level
I trauma center. Injury 2011;42:511–4.
7. Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling
out pneumothorax in the critically ill: lung sliding. Chest 1995;
108:1345–8.
8. Rantanen NW. Diseases of the thorax. Vet Clin North Am
Equine Pract 1986;2:49–66.
9. Zhang M, Liu ZH, Yang JX, et al. Rapid detection of pneu-
mothorax by ultrasonography in patients with multiple trauma. Crit
Care 2006;10:R112.
10. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound
and supine anteroposterior chest radiographs for the identification of
pneumothorax after blunt trauma. Acad Emerg Med 2010;17:11–7.
11. Saucier S, Motyka C, Killu K. Ultrasonography versus chest
radiography after chest tube removal for the detection of pneu-
mothorax. AACN Adv Crit Care 2010;21:34–8.
12. Verniquet A, Kakel R. The value of ultrasound in detecting
pneumothorax. Can J Anaesth 2011;58:118; author reply 118–9.
13. Nagarsheth K, Kurek S. Ultrasound detection of pneumo-
thorax compared with chest X-ray and computed tomography scan.
Am Surg 2011;77:480–4.
14. Ding W, Shen Y, Yang J, et al. Diagnosis of pneumothorax
by radiography and ultrasonography: a meta-analysis. Chest 2011;
140:859–66.
15. Knudtson JL, Dort JM, Helmer SD, et al. Surgeon-
performed ultrasound for pneumothorax in the trauma suite.
J Trauma Inj Infect Crit Care 2004;56:527–30.
340 THE AMERICAN SURGEON
16. Stone MB. Ultrasound diagnosis of traumatic pneumotho-
rax. J Emerg Trauma Shock 2008;1:19–20.
17. Mariani PJ, Wittick L. Pneumothorax diagnosis by extended
focused assessment with sonography for trauma. J Ultrasound Med
2009;28:1601; author reply 1602.
18. Plurad D, Green D, Demetriades D, et al. The increasing use
of chest computed tomography for trauma: is it being overutilized?
J Trauma 2007;62:631–5.
19. Ekeh AP, Peterson W, Woods RJ, et al. Is chest x-ray an
adequate screening tool for the diagnosis of blunt thoracic aortic
injury? J Trauma 2008;65:1088–92.
20. Exadaktylos AK, Duwe J, Eckstein F, et al. The role of
contrast-enhanced spiral CT imaging versus chest X-rays in sur-
gical therapeutic concepts and thoracic aortic injury: a 29-year
Swiss retrospective analysis of aortic surgery. Cardiovasc J S Afr
2005;16:162–5.
April 2015 Vol. 81
21. Demetriades D. Blunt thoracic aortic injuries: crossing the
Rubicon. J Am Coll Surg 2012;214:247–59.
22. Ahmadinia K, Smucker JB, Nash CL, et al. Radiation ex-
posure has increased in trauma patients over time. J Trauma Acute
Care Surg 2012;72:410–5.
23. Rodriguez RM, Hendey GW, Mower W, et al. Derivation of
a decision instrument for selective chest radiography in blunt
trauma. J Trauma 2011;71:549–53.
24. Slater A, Goodwin M, Anderson KE, et al. COPD can
mimic the appearance of pneumothorax on thoracic ultrasound.
Chest 2006;129:545–50.
25. Chung MJ, Goo JM, Im JG, et al. Value of high-resolution
ultrasound in detecting a pneumothorax. Eur Radiol 2005;15:930–5.
26. Gillman LM, Alkadi A, Kirkpatrick AW. The ‘pseudo-lung
point’ sign: all focal respiratory coupled alternating pleural patterns
are not diagnostic of a pneumothorax. J Trauma 2009;67:672–3.