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POCUS = Better ED throughput

June 5, 2014 3 Comments

The E-FAST exam is often discussed in the lit for the evaluation of major trauma cases. But I must use it at least as often in minor trauma. I recently saw a 44 y.o. male who had fallen off a ladder and landed on his right side on hard ground. The fall occurred on the day prior to presentation. His only complaint was right lateral chest wall pain. Which scans should be done in a patient like this? It depends on the presentation, but typical scans include looking for free fluid in the abdomen, a hemothorax, a pneumothorax, a pericardial effusion (sometimes), and a rib fracture. Most of these scans are usually negative, but doing these scans makes care safer. The one scan that is often positive is this one.

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The video above shows the probe being slid along the long axis of a rib until a stepoff consistent with a fracture is visualized. The video below shows the probe being slid caudad from one rib to a lower rib. A stepoff is seen along both ribs.

Cincopa WordPress plugin

These videos demonstrate 2 minimally displaced rib fractures. The other scans, along with the absence of gross hematuria on history, ruled out the bad stuff in this patient. The patient was discharged 20 minutes later with a certain diagnosis. Before the POCUS/EDE era, such a patient would have commonly had a chest x-ray (an inferior test!), possibly with rib views, to look for rib fractures and associated complications such as a pneumothorax. The patient would have usually been in the ED for an extra 1-2 hours. And the diagnosis would have been less certain since x-rays often miss rib fractures. Plus our clinical eval can easily miss occult internal injuries. With negative POCUS scans, these injuries are quickly ruled out in the low-risk patient. And the patient goes home WAY FASTER!

Summing up…consider these POCUS scans in the minor thoracic trauma scenario:

Thoracic EDE for pneumothorax and hemothorax
Abdominal EDE for intraperitoneal blood
Cardiac EDE for traumatic pericardial effusion
Fracture EDE for fractures

Comments (3)

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  1. Lloyd Gordon says:

    Very nice videos. I’ve never found Rib #’s before and this inspires me to try again. Thanks.

  2. Tom O'Graphy says:

    Interesting and elegant method for diagnosis of minor trauma : seeing the fracture, ruling out the pneumothorax. My first fear was that it will be painful for the patient to “touch” him with the probe (I’m just a beginner with US).
    Just the problem of a “not so minor” trauma with a contusion on spleen, liver, kidney. The emergency ultrasound can not be as accurate as another imagery and may falsely reassuring.
    Anyway good videos, I add them in references on my topic on rib fractures.

  3. Really not that painful for most patients. Just use enough gel and a light touch. Definitely not for ruling out internal injuries in patients where your gestalt is telling you that the patient is beyond the low-risk category.

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