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P013: A new efficient and accurate scanning protocol for traumatic pneumothorax
- A. Bignucolo, C. Acton, R. Ohle, S. Socransky
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 21 / Issue S1 / May 2019
- Published online by Cambridge University Press:
- 02 May 2019, p. S67
- Print publication:
- May 2019
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- Article
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Introduction: According to the International Evidence-Based Recommendations for Point-of-Care Lung Ultrasound published in 2012, the sonographic technique for evaluating a patient for a pneumothorax (PTX) “consists of exploration of the least gravitationally dependent areas progressing more laterally” in the supine patient. However, there is a wide variety of scanning protocols in the literature with varying accuracy and complexity. We sought to derive an efficient and accurate scanning protocol for diagnosing pneumothorax using point of care ultrasound in trauma. Methods: We performed a retrospective chart review of a tertiary care trauma registry from Nov 2006 to Aug 2016. We included patients with a PTX diagnosed on computed tomography (CT). Patients were excluded if they did not have an identifiable PTX on the CT scan or if they underwent a tube thoracostomy prior to the CT scan. Penetrating and blunt trauma were eligible. Data were extracted with a standardized data collection tool and 20% of charts reviewed by two reviewers. Pre defined zones were used to map area of PTXs on CT. Sensitivity, specificity and 95% CI are reported for presence of PTXs in each individual or combination of lung zones as identified on CT scan. Results: Data were collection yielded 170 traumatic PTX on chest CT with an average age of 44.2 and 77.8% male. The kappa for data extraction was 0.88. 19.4% of patients had bilateral PTX leading to a total sample size of 203. The average ISS score was 20.7 and 93% of patients survived to discharge. The length of ICU stay and hospital stay was 3.7 and 11.2 days respectively. The most accurate and efficient protocol would involve scanning the inferior border of the clavicle at the para-sternal border and again at the mid-clavicular line down to the cardiac (left hemithorax) and liver lung points (right hemithorax). The sensitivity of this scanning area in the detection of PTXs was 91.6% (95% CI 86.9-95%,). Limiting the area to the most anterior point of the chest wall increased the risk of missing a PTX (Sensitivity 89.7% (95%CI 84.6-93.5)). Conclusion: We have derived an evidence-based standardized accurate and efficient scanning protocol to rule out a pneumothorax on point of care ultrasound.
LO04: Canadian best practice diagnostic algorithm for acute aortic syndrome
- R. Ohle, S. McIsaac, J. Yan, K. Yadav, P. Jetty, R. Atoui, N. Fortino, B. Wilson, N. Coffey, T. Scott, A. Cournoyer, F. Rubens, D. Savage, D. Ansell, J. Middaugh, A. Gupta, B. Bittira, Y. Callaway, S. Bignucolo, B. Mc Ardle, E. Lang
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 21 / Issue S1 / May 2019
- Published online by Cambridge University Press:
- 02 May 2019, pp. S7-S8
- Print publication:
- May 2019
-
- Article
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- You have access Access
- Export citation
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Introduction: Acute aortic syndrome (AAS) is a time sensitive aortic catastrophe that is often misdiagnosed. There are currently no Canadian guidelines to aid in diagnosis. Our goal was to adapt the existing American Heart Association (AHA) and European Society of Cardiology (ESC) diagnostic algorithms for AAS into a Canadian evidence based best practices algorithm targeted for emergency medicine physicians. Methods: We chose to adapt existing high-quality clinical practice guidelines (CPG) previously developed by the AHA/ESC using the GRADE ADOLOPMENT approach. We created a National Advisory Committee consisting of 21 members from across Canada including academic, community and remote/rural emergency physicians/nurses, cardiothoracic and cardiovascular surgeons, cardiac anesthesiologists, critical care physicians, cardiologist, radiologists and patient representatives. The Advisory Committee communicated through multiple teleconference meetings, emails and a one-day in person meeting. The panel prioritized questions and outcomes, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations. The algorithm was prepared and revised through feedback and discussions and through an iterative process until consensus was achieved. Results: The diagnostic algorithm is comprised of an updated pre test probability assessment tool with further testing recommendations based on risk level. The updated tool incorporates likelihood of an alternative diagnosis and point of care ultrasound. The final best practice diagnostic algorithm defined risk levels as Low (0.5% no further testing), Moderate (0.6-5% further testing required) and High ( >5% computed tomography, magnetic resonance imaging, trans esophageal echocardiography). During the consensus and feedback processes, we addressed a number of issues and concerns. D-dimer can be used to reduce probability of AAS in an intermediate risk group, but should not be used in a low or high-risk group. Ultrasound was incorporated as a bedside clinical examination option in pre test probability assessment for aortic insufficiency, abdominal/thoracic aortic aneurysms. Conclusion: We have created the first Canadian best practice diagnostic algorithm for AAS. We hope this diagnostic algorithm will standardize and improve diagnosis of AAS in all emergency departments across Canada.