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Point-of-care ultrasound thoracic “Quick Look” identifies potentially dangerous chest tube insertion sites

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European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Purpose

Emergency and trauma physicians typically rely on anatomic landmarks to determine the proper intercostal space for emergent tube thoracostomy. However, physicians using this technique select a potentially dangerous insertion site too inferior in nearly one-third of cases, which have the potential to result in subdiaphragmatic puncture. We investigated a point-of-care ultrasound (POCUS) thoracic “Quick Look” procedure as a technique to allow visualization of underlying structures to avoid tube misplacement.

Methods

We performed an observational study of adult emergency department patients and their treating physicians. The patient’s emergency physician was asked to rapidly identify and mark a hypothetical tube thoracostomy insertion site on the patient’s chest wall. An ultrasound fellow then performed a POCUS thoracic “Quick Look” exam with a phased-array probe placed directly over the marked site. Over one regular respiratory cycle, the identification of standard lung pattern was considered a negative scan whereas visualization of the diaphragm with underlying liver or spleen was considered a positive scan. Time for completion of the “Quick Look” scan was measured and inter-rater reliability was determined through image review by a single, blinded ultrasound director.

Results

Seventy-six thoracic “Quick Look” scans were performed on patient subjects, of which 17% (13/76, 95%CI 8–26%) were positive. The average time for performing the “Quick Look” exam was 43 s (95%CI 30–57). Inter-rater reliability of the thoracic “Quick Look” was excellent (κ = 0.95).

Conclusion

Thoracic “Quick Look” exams performed at mock chest tube insertion sites demonstrated potentially dangerous insertions in 17% of the cases. POCUS thoracic “Quick Look” may be a rapid and reliable technique that improves safety when placing an emergent chest tube.

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Acknowledgements

We thank the residents and attendings at Allegheny General Hospital’s Emergency Department who participated in mock chest tube insertion site scenarios with enrolled patients. This research was presented in 2017 at the following locations: Society for Academic Emergency Medicine Annual Meeting. Lightening Oral Presentation. Orlando, FL. May 17, 2017. Society for Academic Emergency Medicine Mid-Atlantic Regional Research Conference. Washington, DC. March 11, 2017.

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Correspondence to William A. Johnjulio.

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The authors have no relevant financial or non-financial interests to disclose.

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This study was performed in line with the principles and ethical standards as displayed in the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by Allegheny General Hospital’s Institutional Review Board.

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Lieurance, R., Scheatzle, M., Johnjulio, W.A. et al. Point-of-care ultrasound thoracic “Quick Look” identifies potentially dangerous chest tube insertion sites. Eur J Trauma Emerg Surg 49, 777–783 (2023). https://doi.org/10.1007/s00068-022-02109-4

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