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Differentiating between giant pulmonary bullae and pneumothorax can pose a challenge in clinical settings. A chest CT scan during the patient's health assessment revealed that approximately 40% of the right chest cavity was filled with air, leading to incomplete expansion of the right lung. The patient was initially misdiagnosed with pneumothorax in the emergency department and subsequently underwent closed thoracic drainage without experiencing any improvement in symptoms. Upon further examination through thoracoscopy, the patient was correctly diagnosed with a giant pulmonary bulla. Upon reviewing the patient's chest CT scan, we were able to identify key distinguishing features between giant pulmonary bullae and pneumothorax., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Yefei Zhan reports financial support was provided by Ningbo No.2 Hospital (Project No. 2023-Y06). Yefei Zhan reports financial support was provided by Ningbo Municipal Health Commission (Project No. 2022-F16). If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Traumatic pneumothorax management has evolved to include the use of smaller caliber tube thoracostomy and even observation alone. Data is limited comparing tube thoracostomy to observation for small traumatic pneumothoraces. We aimed to investigate whether observing patients with a small traumatic pneumothorax on initial chest radiograph (CXR) is associated with improved outcomes compared to tube thoracostomy., Methods: We retrospectively reviewed trauma patients at our level 1 trauma center from January 1, 2016 through December 31, 2020. We included those with a pneumothorax size <30 mm as measured from apex to cupola on initial CXR. We excluded patients with injury severity score ≥ 25, operative requirements, hemothorax, bilateral pneumothoraces, and intensive care unit admission. Patients were grouped by management strategy (observation vs tube thoracostomy). Our primary outcome was length of stay with secondary outcomes of pulmonary infection, failed trial of observation, readmission, and mortality. Results are listed as mean ± standard error of the mean., Results: Of patients who met criteria, 39 were in the observation group, and 34 were in the tube thoracostomy group. Baseline characteristics were similar between the groups. Average pneumothorax size on CXR was 18 ± 1.0 mm in the observation group and 18 ± 0.84 mm in the tube thoracostomy group (p > 0.99). Average pneumothorax sizes on computed tomography were 25 ± 2.1 and 37 ± 3.9 mm in the observation and tube thoracostomy groups, respectively (p = 0.01). Length of stay in the observation group was significantly shorter than the tube thoracostomy group (3.6 ± 0.33 vs 5.8 ± 0.81 days, p < 0.01). While pneumothorax size on computed tomography was associated with tube thoracostomy, only tube thoracostomy correlated with length of stay on multivariable analysis; pneumothorax size on CXR and computed tomography did not. There were no deaths or readmissions in either cohort. One patient in the observation group required tube thoracostomy after 18 h for worsening subcutaneous emphysema, and one patient in the tube thoracostomy group developed an empyema., Conclusions: Select patients with small traumatic pneumothoraces on initial chest radiograph who were treated with observation experienced an average length of stay over two days shorter than those treated with tube thoracostomy. Outcomes were otherwise similar between the two groups suggesting that an observation-first strategy may be a superior treatment approach for these patients., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Lung ultrasound is commonly used for the diagnosis of pneumothorax. However, recognition of pleural sliding is subjective and can be difficult for novice. The primary objective was to compare a novices physician's performance in diagnosing pneumothorax from ultrasound (US) scans either with visual evaluation or with maximum longitudinal pleural strain (MLPS). The secondary objective was to compare the diagnostic relevance of US with visual evaluation or MLPS to diagnose pneumothorax with an intermediately experienced and an expert physician., Methods: We conducted a prospective, observational study in two emergency department and two intensive care unit, between February 2019 and June 2020. We included 99 adult patients with suspected pneumothorax, who received a chest computed tomography (CT). Three physicians with different experience of interpreting US scans (a novice physician, an intermediately experienced physician, and an expert) analyzed the US scans of 99 patients with suspected pneumothorax (50 (51%) with confirmed pneumothorax), which were confirmed by CT scan., Results: With a threshold of 5%, the MLPS sensitivity was 94% (95% CI [83%; 98%]), and the specificity was 100% (95% CI [93%; 100%]). The novice physician had an area under the curve (AUC) with visual analysis of 0.75 (95% CI [0.67; 0.83]) vs 0.86 (95% CI [0.79; 0.94]) with MLPS (p = 0.04). The intermediate physician's AUC for diagnosing pneumothorax with visual analysis was 0.93 (95% CI [0.88; 0.99]) vs 1.00 (95% CI [1.00; 1.00]) with MLPS (p < 0.01) and for the expert physician it was 0.98 (95% CI [0.95;1.00]) vs 0.97 (95% CI [0.93; 1.00]), respectively (p = 0.69)., Conclusion: In our study, speckle tracking analysis improved the accuracy of US for the novice and the intermediate but not the expert sonographer in the diagnosis of pneumothorax., Competing Interests: Declaration of competing interest Xavier Bobbia declares a competing interest as an US teacher for GE (GE Medical Systems Ultrasound) customers. The other authors state that they have no competing interests., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Spontaneous pneumothorax (SP) is characterized by the escape of broncho-alveolar air into presence of air in the pleural space without preceding blunt or penetrating trauma. SP requires prompt diagnosis and treatment. SP is divided into two groups as primary and secondary. Primary SP is usually seen in tall and thin patients with no clinically evident underlying lung disease (especially in tall and thin subjects), whereas secondary SP cases have an underlying lung disease, such as cystic lung disease, cavitary lung lesions, severe asthma, emphysema or pneumonia. Patients with Coronavirus-2019 (COVID-19) may experience the SP during the diagnosis and treatment processes, and it is a significant cause of morbidity. However, late-onset SP after recovering from COVID-19 is unusual. Herein we present a case with post-COVID-19 pulmonary fibrosis-like changes and subsequent late onset spontaneous pneumothorax (SP). We also present the patient's radiological findings., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Catamenial hemothorax is a rare manifestation of thoracic endometriosis syndrome. It is commonly seen associated with pelvic endometriosis in nulliparous reproductive-age women. Most cases are minor and self-limiting. We present a case of a 32-year-old woman who presented with prolonged worsening dyspnea and was found to have a massive hemothorax on evaluation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Both aortic dissection and tension pneumothorax are conditions that require urgent treatments. However, the diagnosis of these emergencies is sometimes challenging because of various symptoms and difficulty obtaining their medical history due to severe conditions. Here, we present the case of a patient with type A aortic dissection associated with tension pneumothorax. This is the second report of such a case worldwide. A 61-year-old man presented to the emergency department with sudden-onset chest and back pain. Upon presentation, his blood pressure was 97/58 mmHg, oxygen saturation on room air was 96%, and respiratory rate was 28 breaths/min. His physical examination revealed no jugular venous distention; however, breath sounds over the left lung were diminished. Bedside chest radiography revealed left tension pneumothorax with mediastinal shift to the right. Needle and chest tube thoracostomies were performed; however, the patient's vital signs did not improve and reexpansion pulmonary edema developed following tube thoracostomy. Contrast-enhanced computed tomography revealed type A thrombosed aortic dissection with bullae in the upper lobe of the left lung. Therefore, the patient was admitted to the intensive care unit, conservatively treated, and discharged without any complications. In conclusion, type A aortic dissection may be associated with tension pneumothorax and should be considered if the patient's vital signs do not improve even after decompression of the tension pneumothorax., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Thoracostomy tube placement is one of the more common procedures performed in the Emergency Department, most commonly for treatment of pneumothorax or hemothorax but occasionally for drainage of empyema or pleural effusion. Thoracostomy may be a life-saving procedure with a wide range of complication rates reported, ranging from 19.4-37%, most commonly extrathoracic placement. Most recent meta-analyses showed a relatively stable complication rate of 19% over the past three decades with the vast majority being benign in nature. We present a case with the rare complication of thoracostomy in which of a small-caliber thoracostomy tube was placed in the left ventricle. Although thoracotomy was performed to remove the catheter, the patient remained virtually asymptomatic and had an uneventful course., (Copyright © 2018. Published by Elsevier Inc.)

Objective: The differential diagnoses of patients presenting with chest pain (CP) and shortness of breath (SOB) are broad and non-specific. We aimed to 1) determine how use of point-of-care ultrasound (POCUS) impacted emergency physicians' differential diagnosis, and 2) evaluate the accuracy of POCUS when compared to chest radiograph (CXR) and composite final diagnosis., Methods: We conducted a prospective observational study in a convenience sample of patients presenting with CP and SOB to the Emergency Department (ED). Treating physicians selected possible diagnoses from a pre-indexed list of possible diagnoses of causes of CP and SOB. The final composite diagnosis from a chart review was determined as the reference standard for the diagnosis. The primary analysis involved calculations of sensitivity and specificity for POCUS identifiable diagnoses in detecting cause of CP and SOB. Additional comparative accuracy analysis with CXRs were conducted., Results: 128 patients with a mean age of 64 ± 17 years were included in the study. Using a reference standard of composite final diagnoses, POCUS had equal or higher specificity to CXR for all indications for which it was used, except for pneumonia. POCUS correctly identified all patients with pneumothorax, pleural effusion and pericardial effusion. In patients with a normal thoracic ultrasound, CXR never provided any actionable clinical information. Adding POCUS to the initial evaluation causes a significant narrowing of the differential diagnoses in which the median differential diagnosis from 5 (IQR 3-6) to 3 (IQR 2-4) p < 0.001., Conclusion: In evaluation of patients with CP and SOB, POCUS is a highly feasible diagnostic test which can assist in narrowing down the differential diagnoses. In patients with a normal thoracic ultrasound, the added value of a CXR may be minimal., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Spontaneous pneumothorax (SP) is a relatively common pathology in emergency medicine; however, scant information is published regarding SPs developing tension physiology in the literature. Risk factors for spontaneous pneumothorax include smoking, family history, and underlying lung disease such as chronic obstructive lung disease (COPD), cystic fibrosis, tuberculosis, among others. Treatment often involves conservative management, needle aspiration, catheter placement, or tube thoracostomy. Tension pneumothorax, however, is a life threatening condition requiring emergent intervention. Case reports have demonstrated large SPs with midline shift but without tension physiology as patients largely remained hemodynamically stable. We report the case of an 18-year-old male presenting to the Emergency Department (ED) with a SP that rapidly developed tension physiology with mediastinal shift and hypotension resolved by needle decompression and CT placement., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Ultrasound is an ideal modality in the emergency department (ED) to assess for pneumothorax given its rapid availability, portability, and repeatability to assess clinical status changes. Certain patient populations and clinical circumstances may present challenges to the performance of this examination. In this article, we review patterns of the presence or absence of lung sliding in the commonly utilized sonographic modes in the ED setting. We also describe a novel technique to evaluate lung sliding using tissue Doppler., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Esophageal perforation due to blunt trauma is a rare clinical condition, and the diagnosis is often difficult because patients have few specific symptoms. Delayed diagnosis may result in a fatal clinical course due to mediastinitis and subsequent sepsis. In this article, we describe a 26-year-old man with esophageal perforation due to blunt chest trauma resulting from a motor vehicle accident. Because a severe disturbance of consciousness masked the patient's trauma-induced thoracic symptoms, we required 11h to diagnose the esophageal perforation. Therefore, the patient developed septic shock due to mediastinitis. However, his subsequent clinical course was good because of prompt combined therapy involving surgical repair and medical treatment after the diagnosis., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Pneumothorax is a pathologic condition in which air is accumulated between the visceral and parietal pleura. After clinical suspicion, in order to diagnose the severity of the condition, imaging is necessary. By using the help of Picture Archiving and Communication Systems (PACS) direct conventional X-rays are converted to gray-scale and this has become a preferred method among many physicians., Methods: Our study design was a case-control study with cross-over design study. Posterior-anterior chest X-rays of patients were evaluated for pneumothorax by 10 expert physicians with at least 3years of experience and who have used inverted gray-scale posterior anterior chest X-ray for diagnosing pneumothorax., Results: The study included posterior anterior chest X-ray images of 268 patients of which 106 were diagnosed with spontaneous pneumothorax and 162 patients used as a control group. The sensitivity of Digital-conventional X-rays was found to be higher than that of inverted gray-scale images (95% CI (2,08-5,04), p<0,01). There was no statistically significant difference between the gold standard and digital-conventional images (95% CI (0,45-2,17), p=0,20), while the evaluations of the gray-scale images were found to be less sensitive for diagnosis (95% CI (3,16-5,67) p<0,01)., Conclusion: Inverted gray-scale imaging is not a superior imaging modality over digital-conventional X-ray for the diagnosis of pneumothorax. Prospective studies should be performed where diagnostic potency of inverted gray-scale radiograms is tested against gold standard chest CT. Further research should compare inverted grayscale to lung ultrasound to assess them as alternatives prior to CT., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To explore the reliability and accuracy of lung ultrasound for diagnosing neonatal pneumothorax., Methods: This study was divided into two phases. (1) In the first phase, from January 2013 to June 2015, 40 patients with confirmed pneumothorax had lung ultrasound examinations performed to identify the sonographic characteristics of neonatal pneumothorax. (2) In the second phase, from July 2015 to August 2016, lung ultrasound was undertaken on 50 newborn infants with severe lung disease who were suspected of having pneumothorax, to evaluate the sonographic accuracy and reliability to diagnose pneumothorax., Results: (1) The main ultrasonic manifestations of pneumothorax are as follows: ① lung sliding disappearance, which was observed in all patients (100%); ② the existence of the pleural line and the A-line, which was also observed in all patients (100%); ③ the lung point, which was found in 75% of the infants with mild-moderate pneumothorax but not found to exist in 25% of the severe pneumothorax patients; ④ the absence of B-lines in the area of the pneumothorax (100% of the pneumothorax patients); and ⑤ no lung consolidation existed in the area of the pneumothorax (100% of the pneumothorax patients). (2) The accuracy and reliability of the lung sonographic signs of lung sliding disappearance as well as the existence of the pleural line and the A-line in diagnosing pneumothorax were as follows: 100% sensitivity, 100% specificity, 100% positive predictive value, and 100% negative predictive value. When the lung point exists, the diagnosis is mild-moderate pneumothorax, whereas if no lung point exists, the diagnosis is severe pneumothorax., Conclusion: Lung ultrasound is accurate and reliable in diagnosing and ruling out neonatal pneumothorax and, in our study, was found to be as accurate as chest X-ray., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Our objective was to measure the diagnostic accuracy of a novel software technology to detect pneumothorax on Brightness (B) mode and Motion (M) mode ultrasonography., Methods: Ultrasonography fellowship-trained emergency physicians performed thoracic ultrasonography at baseline and after surgically creating a pneumothorax in eight intubated, spontaneously breathing porcine subjects. Prior to pneumothorax induction, we captured sagittal M-mode still images and B-mode videos of each intercostal space with a linear array transducer at 4cm of depth. After collection of baseline images, we placed a chest tube, injected air into the pleural space in 250mL increments, and repeated the ultrasonography for pneumothorax volumes of 250mL, 500mL, 750mL, and 1000mL. We confirmed pneumothorax with intrapleural digital manometry and ultrasound by expert sonographers. We exported collected images for interpretation by the software. We treated each individual scan as a single test for interpretation by the software., Results: Excluding indeterminate results, we collected 338M-mode images for which the software demonstrated a sensitivity of 98% (95% confidence interval [CI] 92-99%), specificity of 95% (95% CI 86-99), positive likelihood ratio (LR+) of 21.6 (95% CI 7.1-65), and negative likelihood ratio (LR-) of 0.02 (95% CI 0.008-0.046). Among 364 B-mode videos, the software demonstrated a sensitivity of 86% (95% CI 81-90%), specificity of 85% (81-91%), LR+ of 5.7 (95% CI 3.2-10.2), and LR- of 0.17 (95% CI 0.12-0.22)., Conclusions: This novel technology has potential as a useful adjunct to diagnose pneumothorax on thoracic ultrasonography., (Published by Elsevier Inc.)

Pneumothorax can cause a variety of electrocardiographic changes. ST segment elevation, which is mainly observed in myocardial infarction, can also be induced by pneumothorax. The mechanism is presumed to be a decrease in cardiac output, due to increased intra-thoracic pressure. We encountered a patient with ST segment elevation with minimal pneumothorax. Coronary angiography with ergonovine provocation test and echocardiogram had normal findings. The ST segment elevation was normalized by decreasing the amount of pneumothorax. We reviewed the literature and present possible mechanisms for this condition., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Chest radiography is the initial choice for thoracic imaging. However, the wide availability of computed tomography (CT) has led to a substantial increase in its use in the emergency department (ED). We evaluated the utility of chest CT after a chest X-ray in patients presenting to the ED with non-traumatic thoracic emergencies, and determined if the diagnosis and management decision changed after CT., Methods: The study enrolled 500 consecutive patients with both chest X-rays and CT who presented to the ED with non-traumatic complaints. Chest X-rays and CT images obtained within 12h before any definitive treatment were randomly evaluated in consensus by two radiologists blinded to the clinical information., Results: The chest X-ray and CT image findings were concordant in 49.2% of the 500 patients and this concordance was negatively correlated with patient age. Leading diagnosis and management decisions based on the chest radiograph changed after CT in 35.4% of the study group and this finding was also correlated with age. In 55% of 205 patients, pneumonic infiltrations were undiagnosed with radiography. Pulmonary edema was the most specific (93.3%) and sensitive (85.4%) radiography finding. Posteroanterior chest radiographs taken in the upright position had higher concordance with CT than anteroposterior (AP) radiographs taken in the supine position., Conclusions: Chest CT may be an appropriate imaging choice in patients presenting to the ED for non-traumatic reasons, particularly for elderly patients and when the radiograph is taken with the AP technique in a supine position., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: The objective was to evaluate if existence of hydrothorax in initial chest radiograph predicts treatment outcome in patients with primary spontaneous pneumothorax who received needle thoracostomy., Methods: This is a retrospective cohort study carried out from January 2011 to August 2014 in 1 public hospital in Hong Kong. All consecutive adult patients aged 18years or above who attended the emergency department with the diagnosis of primary spontaneous pneumothorax with needle aspiration performed as primary treatment were included. Age, smoking status, size of pneumothorax, previous history of pneumothorax, aspirated gas volume and presence of hydropneumothorax in initial radiograph were included in the analysis. The outcome was success or failure of the needle aspiration. Logistic regression was used to identify the predicting factors of failure of needle aspiration., Result: There were a total of 127 patients included. Seventy-three patients (57.5%) were successfully treated with no recurrence upon discharge. Among 54 failure cases, 13 patients (10.2%) failed immediately after procedure as evident by chest radiograph and required second treatment. Forty-one patients (32.3%) failed upon subsequent chest radiographs. Multivariate logistic regression showed factors independently associated with the failure of needle aspiration, which included hydropneumothorax in the initial radiograph (odds ratio [OR]=4.47 [1.56i12.83], P=.005), previous history of pneumothorax (OR=3.92 [1.57-9.79], P=.003), and large size of pneumothorax defined as apex-to-cupola distance ≥5cm (OR=2.75 [1.21-6.26], P=.016)., Conclusions: Hydropneumothorax, previous history of pneumothorax, and large size were independent predictors of failure of needle aspiration in treatment of primary spontaneous pneumothorax., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Occult pneumothoraces (PTXs), which are not visible on chest x-ray, may progress to tension PTX. The aim of study was to establish the prevalence of large occult PTXs upon admission of patients with severe blunt trauma, according to prehospital mechanical ventilation., Methods: Patients with severe trauma consecutively admitted to our institution for 5 years were retrospectively analyzed. All patients with blunt thoracic trauma who had undergone computed tomographic (CT) within the first hour of hospitalization were included. Mechanical ventilation was considered as early if it was introduced in the prehospital period or on arrival at the hospital. Occult PTXs were defined as PTXs not visible on chest x-ray. All PTXs were measured on CT scan (largest thickness and vertical dimension). Large occult PTXs were defined by a largest thickness of 30 mm or more., Results: Of the 526 patients studied, 395 (75%) were male, mean age was 37.9 years, mean Injury Severity Score was 22.2, and 247 (47%) received early mechanical ventilation. Of 429 diagnosed PTXs, 296 (69%) were occult. The proportion of occult PTXs classified as large was 11% (95% confidence interval, 8%-15%). The overall prevalence of large occult PTXs was 6% (95% confidence interval, 4%-8%). Both CT measurements and proportion of large occult PTXs were found statistically comparable in patients with or without mechanical ventilation., Conclusions: Six percent of studied patients with severe trauma had a large and occult PTX as soon as admission despite a normal chest x-ray result. The observed sizes and rates of occult PTX were comparable regardless of the initiation of early mechanical ventilation., (Copyright © 2015. Published by Elsevier Inc.)

Study Objective: The objective was to determine if ultrasound (US) can more rapidly confirm central venous catheter (CVC) position in comparison to chest radiography (CXR) in the emergency department., Methods: The study included a convenience sample of emergency department patients with supradiaphragmatic CVCs and a CXR for confirmation. Ultrasound was used for CVC confirmation by visualizing microbubble artifact in the right atrium after injection of saline through the distal port. To evaluate for pneumothorax (PTX), "sliding sign" of the pleura was noted on US of the anterior chest. Blinded chart review was performed to assess CXR timing, catheter position and CVC complications. Student's t test was used to compare US time to CXR performance time and radiologist reading time., Results: Fifty patients were enrolled; 4 were excluded because of inadequate views. Forty-six patients were included in the final analysis. Mean total US time was 5.0 minutes (95% confidence interval [CI], 4.2-5.9) compared to 28.2 minutes (95% CI, 16.8-39.4) for CXR performance with a mean difference of 23.1 minutes (95% CI, -34.5 to -11.8; P < .0002). When comparing only US CVC confirmation time to CXR time, US was an average of 24.0 minutes (95% CI, -35.4 to -12.7; P < .0001) faster. Comparing total US time to radiologist CXR reading time, US was an average of 294 minutes faster (95% CI, -384.5 to -203.5; P < .0000). There were a total of 3 misplaced lines and 2 patients with PTX, all of which were identified correctly on US., Conclusion: Ultrasound can confirm CVC placement and rule out PTX significantly faster than CXR, expediting the use of CVCs in the critically ill., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Lung ultrasound has emerged as a rapid and accurate screening tool for pneumothorax. The lung point sign, a sonographic representation of the point on the chest wall where the pleural layers re-adhere, is 100% specific to confirm the diagnosis. Double lung point sign for a single pneumothorax is extremely unusual and has only been reported twice in the literature. A 49-year-old woman was transported to the emergency department (ED) intubated and sedated with severe head injury. She remained hemodynamically stable without respiratory compromise throughout her ED course. Chest computed tomography was notable for an anterior left pneumothorax with underlying pulmonary contusion. Bedside ultrasound of this region revealed a double lung point sign. Our case report is the first to confirm association of the double lung point sign with a single pneumothorax on corresponding computed tomographic imaging.

Objective: Computed tomography (CT) has become an important tool for the diagnosis of intra-abdominal and chest injuries in patients with blunt trauma. The role of CT in conscious asymptomatic patients with a suspicious mechanism of injury remains controversial. This controversy intensifies in the management of pediatric blunt trauma patients, who are much more susceptible to radiation exposure. The objective of this study was to evaluate the role of abdominal and chest CT imaging in asymptomatic pediatric patients with a suspicious mechanism of injury., Methods: Forty-two pediatric patients up to 15 years old were prospectively enrolled. All patients presented with a suspicious mechanism of blunt trauma and multisystem injury. They were neurologically intact and had no signs of injury to the abdomen or chest. Patients underwent CT imaging of the chest and abdomen as part of the initial evaluation., Results: Thirty-one patients (74%) had a normal CT scan. Two patients of 11 with an abnormal CT scan required a change in management and were referred for observation in the Intensive Care Unit. None of the patients required surgical intervention., Conclusion: The routine use of CT in asymptomatic pediatric patients with a suspicious mechanism of blunt trauma injury is not justified., (Copyright © 2014 Elsevier Inc. All rights reserved.)

There is controversy regarding needle aspiration for primary spontaneous pneumothorax (PSP), with contradictory recommendations between the American College of Chest Physicians consensus statement (2001), which suggests that needle aspiration has little place in the management of PSP, and the British Thoracic Society guidelines (2010), which recommend that needle aspiration be attempted first for all cases of PSP where drainage is deemed necessary. Studies have shown that there is no significant difference between needle aspiration and tube thoracostomy with regard to safety, rates of immediate success, and early failure and has the advantages of decreasing pain and reducing rates of hospital admission and duration of hospital stay compared with tube thoracostomy. Point-of-care ultrasound (US) can facilitate needle aspiration by decreasing the risk of complications and detect pneumothorax resolution during or re-expansion after the procedure. This is a case series where the sonographic finding of the “lung point” on point-of-care US was used to facilitate needle aspiration to monitor pneumothorax resolution during or re-expansion after the procedure. We report 3 cases of PSP in adolescents presenting to the pediatric emergency department (ED), where needle aspiration was safely performed by using US to track the sonographic finding of the lung point. This technique allows the determination of pneumothorax resolution or re-expansion in real time. Point-of-care US may assist in the evaluation and management of spontaneous pneumothorax in the pediatric ED. Ultrasound-assisted needle aspiration may be a safe and less painful option for pediatric ED patients with PSP.

We discuss a 72-year-old woman admitted with acute shortness of breath and severe sharp chest pain several hours after receiving acupuncture therapy. She was subsequently diagnosed as having an iatrogenic pneumothorax secondary to acupuncture. We discuss the complications of acupuncture and why patients should be informed of the risks of such procedures.

Many patients present for emergency services after electric injuries or require defibrillation during emergency services. Although the defibrillation process is safe, skin burns and myocardial injuries are reported after defibrillation procedures. There are limited data about the complications of defibrillation. In the case reported here, a lung injury and a small pneumothorax were observed after defibrillation. To the best of our knowledge, this is the first reported case in which computed tomography is used to demonstrate that a trace of electric current passed through the lung. Computed tomography may be an excellent diagnostic modality to demonstrate the severity and extent of electric injuries to the lung.

Background: The presence of the sonographic sliding lung sign (SLS) is a sensitive indicator for the absence of a pneumothorax. The addition of M-mode ultrasound (US) can be a useful adjunct in detecting the SLS., Objective: The objective of this study is to determine the feasibility of using M-mode US in evaluating the SLS during helicopter transport., Methods: A model simulating human lung was used during image acquisition. M-mode images of the SLS were obtained during 3 distinct phases of transport: without rotor rotation, with rotor rotation while on the ground, and at level flight. Four US-credentialed emergency physicians evaluated M-mode US tracings of the model along with examples from human lungs, both with and without pneumothorax, in random fashion., Results: A total of 104 images were reviewed (26 images per reviewer). All of the M-mode images were correctly identified. Motion artifact was noted on the M-mode tracings taken during rotor rotation, which was greatest during level flight. The rotor artifact was not felt to affect the diagnostic utility of the M-mode US tracing., Conclusion: M-mode US may be used successfully to detect the SLS during helicopter transport., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: We sought to assess the anatomical distribution of traumatic pneumothoraces (PTXs) on chest computed tomography (CT) to develop an optimized protocol for PTX screening with ultrasound in the emergency department (ED)., Methods: We performed a retrospective review of all chest CTs performed in one ED between January 2005 and December 2008 according to presence, location, and size of PTX. Pneumothoraces were then measured and categorized into 14 anatomical regions for each hemithorax., Results: A total of 277 (3.8%) PTXs were identified, with 26 bilateral PTX, on 3636 chest CTs performed during the study period. Etiology was blunt (85%) or penetrating trauma (15%). Eighty-three (45%) PTXs were radiographically occult on initial chest x-ray. One hundred eighty-three (66%) PTX had no chest tube at the time of CT. For both hemithoraces, the distribution demonstrated increasing PTX frequency and size from lateral to medial and from superior to inferior. Region 12 (parasternal, intercostal spaces [ICS] 7-8) was involved in 68% of PTX on either side; region 9 (parasternal, ICS 5-6), in 67% on the left and in 52% on the right; and region 11 (lateral to midclavicular line, ICS 7-8), in 46% on the left and in 53% on the right. The largest anterior-to-posterior PTX dimension was seen in region 12., Conclusions: Our results indicate that 80.4% of right- and 83.7% of left-sided traumatic PTXs would be identified by scanning regions 9, 11, and 12. These findings suggest that a standardized protocol for PTX screening with ultrasound should include these regions., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The aim of this study was to describe a case of a large traumatic pneumothorax (>55%) that resolved completely without intervention. A pneumothorax is the accumulation of air between the visceral and parietal pleura. It can occur spontaneously or be traumatic. Spontaneous pneumothoraces can occur with no underlying lung disease or secondary in nature. The emergency department (ED) treatment of pneumothoraces depends on their size, their etiology, and clinical stability of the patient. The current recommendation is observation in stable patients with <15% pneumothorax and tube thoracostomy in patients with >15% pneumothorax. A 33-year-old woman presented to our ED complaining of right knee and right lateral chest wall pain after falling. Her breath sounds were reported as normal. A chest radiograph was ordered, which showed a large right-sided pneumothorax with tracheal deviation suggestive of a tension pneumothorax. The provider did not appreciate the pneumothorax at the time, and she was subsequently discharged home. The radiograph was over-read in the morning, and several attempts were made to recall the patient but were unsuccessful. Fortunately, the patient returned to the ED for an unrelated complaint approximately 1 month later, and the radiograph was repeated, confirming full resolution of the pneumothorax. She was not treated at another facility during that time. This is a typical manifestation of a traumatic pneumothorax but with an atypical course and outcome. It raises the question of whether, even in the case of traumatic pneumothorax, the threshold for placement of chest tubes could be reconsidered in stable patients.

Background: The presence of the sonographic sliding lung sign (SLS) is a sensitive indicator for the absence of a pneumothorax., Objective: The aim of this study was to determine if prehospital critical care providers (PHCPs) can acquire and maintain the necessary skills to determine the presence or absence of the SLS following a brief tutorial., Methods: This was a blinded randomized observational trial using a cadaveric model. The model was randomized to esophageal intubation (negative SLS) or tracheal intubation (positive SLS), and a SonoSite 180 plus (Bothel, WA) machine was used for the examination. After a 9-month period, the PHCPs were reevaluated without additional instruction., Results: There were 8 PHCPs. A total of 6 intubations were performed yielding a total of 48 trials. The presence or absence of the SLS was correctly identified in 46 of the 48 trials, resulting in a sensitivity and specificity of 96.9% (95% confidence interval [CI], 89.6%-99.1%) and 93.8% (95% CI, 93.8%-79.3%), respectively. At the 9-month follow-up, 7 of the original PHCPs were available to participate. A total of 8 intubations were performed yielding a total of 56 trials. The presence or absence of the SLS was correctly identified in all 56 trials, resulting in a sensitivity and specificity of 100% (95% CI, 93.6%-100%)., Conclusion: Prehospital critical care providers can accurately determine the presence or absence of the sonographic SLS following a brief tutorial and retain the skill set following a 9-month interval., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Lung ultrasound is extremely useful in the bedside diagnosis of pneumothorax. The lung point, which is the sonographic demonstration of the point on the chest wall where the pleural layers adhere again, represents the limit of the pneumothorax extension and allows estimation of its volume. This sonographic sign is not only highly accurate in ruling-in pneumothorax but also helps the clinician in deciding whether to place a chest tube. We report a case of a young patient with spontaneous pneumothorax showing a double lung point. The double lung point is explained by the fact that the air is not free in the pleural space but forms a bulla surrounded by adherent pleural layers. In this case, the ultrasound examination could be confounding and the clinician should be aware of it. This phenomenon is quite rare in the juvenile spontaneous pneumothorax, being more frequent in case of secondary pneumothorax.

Trichloroisocyanuric acid is a high-efficiency and-low toxicity fungicide and bleach. It is commonly used as disinfectant for industrial circulating water, swimming pools, restaurants, and other public places in China. When trichloroisocyanuric acid is put into water, chlorine gas is produced. Chlorine gas is a potent pulmonary irritant that causes acute damage in both the upper and lower respiratory tracts (J Toxicol Clin Toxicol. 1998;36(1-2):87-93). Pneumomediastinum is a rare complication in patients with acute chlorine gas poisoning. A small amount of gas can be asymptomatic, but a large amount of gas entering the mediastinum suddenly will lead to respiratory and circulatory disorder, mediastinal swing, or even cardiopulmonary arrest. Severe chlorine gas poisoning patients usually need mechanical ventilation; if the pneumomediastinum is not found on time, threat to life would be greatly increased. It requires a high index of suspicion for diagnosis and rapid treatment. The proper use of ventilator, timely and effective treatment of original disease, and multiple system organ support had significant impact on the prognosis. The pneumomediastinum case secondary to inhalation of chlorine gas that we report here should remind all emergency department physicians to maintain a high index of suspicion for this disease and seek immediate and proper intervention when treating patients with acute chlorine gas poisoning, once diagnosed, especially in younger patients.

Diaphragmatic rupture (DR) is most commonly seen after a blunt trauma. It rarely occurs spontaneously. Many cases of spontaneous DR followed by strenuous sports activity have been reported in the medical literature. However, there has been no previous report on a case of spontaneous DR after a static sport activity. We report the case of a 29-year old woman who presented to the emergency department (ED) with pain in the epigastric area that started 1 day before visiting the ED during deep breathing in Pilates. The radiography and computed tomography of her chest demonstrated a left diaphragmatic rupture complicated with the perforation of viscera. She immediately underwent left thoracotomy. In addition, primary repair of the diaphragm and stomach was performed. On the basis of our findings, we conclude that spontaneous DR may be caused by a static sport activity, such as Pilates, causing a serious life threatening condition.