Management if patient was tachypneic/hypotensive based on CXR?
This was a skin fold which can mimic PTX on CXR. POCUS and ultimately CT scan to assess for other traumatic injuries were negative for findings of PTX. Old case so I don't have POCUS clips but was normal.
If you look closely at the chest X-ray you can see lung markings peripheral to the fold, the line extends caudal to lung border, and the absence of the white line sign. Don't confuse skin fold with PTX. Skin fold aside, how good is supine CXR for PTX?
Supine CXR common in critical med/surg patients. Poor sensitivity for PTX. 50+% false negatives! Here is Cochrane review comparing CXR vs POCUS.…
Thoracic ultrasound highly sensitive and specific. Absence of lung sliding (shown) is highly suggestive of PTX-but not definitive for diagnosis.
Here is lung sliding. Remember this is not a qualitative assessment. It is an all-or-none.
For thoracic POCUS you can use any probe. Settings are important. Focus zone at pleural line, turn off harmonics and compound imaging, and increase gain in far field--will improve visualization of B lines (and potentially lung sliding)…
Lung point is the definitive sonographic finding for PTX. Shown here. This is where you have the PTX abutting with the opposed parietal and visceral pleura.
Due to the high sensitivity, you can even see very small pneumothoraces---Double lung point (2 lung points). For peds POCUS users, different from your double lung point used to diagnose TTN.
Power of Thoracic Ultrasound. Here is lung re-expansion after placement of pigtail catheter seen real-time.
I feel Thoracic u/s is particularly useful in supine patients, critically ill pts, those with abnormal CXRs, COVID-19 in isolation, and post thoracic procedures. Here is patient with no so normal CXR and sudden onset dyspnea--?PTX.
Thoracic POCUS showed lung sliding throughout along with evaluating for pleural effusions and pleural patterns.
What about patients with bullae and a non-diagnostic CXR for PTX? Thoracic ultrasound has been shown to be very useful here in differentiating between the two with the evaluation of lung sliding. Sens 97.5% and Spec 100%
Meant not a quantitative assessment---All-or-none

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More from @RJonesSonoEM

12 Jan
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Known distal UVJ stone. Has new rt flank pain. Mild hydro but what else? #POCUS #IMPOCUS #FOAMed #FOAMus #MedEd #MedTwitter @ACEP_EUS @SeeWithSound @PhilipsPOCUS @IMPOCUSFocus @medpedshosp @NephroP @jminardi21 @HeyDrNik @TomJelic @cianmcdermott @MH_EMultrasound @thepocusatlas
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Differentiating portal venous gas from pneumobilia on ultrasound. See thread. #POCUS #FOAMus #FOAMed #IMPOCUS #MedEd #MedTwitter #ultrasound @ACEP_EUS @USIGcleveland @MetroHealth_EM @aedrake65
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Case 1. Which is present?
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Pt-Bilat LE pain/swelling 5 days.Prior hx of unprovoked DVT/PE years ago but off meds due to insurance. See thread. POCUS DVT #POCUS #IMPOCUS #FOAMed #FOAMus #MedEd #FOAMcc @ACEP_EUS @medpedshosp @cianmcdermott @jminardi21 @grepmeded @siddharth_dugar @msiuba @NephroP @SonoStache
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Adhikari and colleague article showed 6.3% false neg rate due to prox isolated DVT with 2-point compression. Limitations of POCUS prox compression DVT exam go beyond just missing isolated/focal DVT.
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12 May 20
Patient with RUQ abdominal pain. Difficulty finding GB. Pt denies history of prior abdominal surgery and no scars seen. See thread. #POCUS #IMPOCUS #FOAMed #FOAMus #MedEd #MedStudentTwitter @medpedshosp @NephroP @grepmeded @cianmcdermott @ACEP_EUS @PhilipsPOCUS
GB Sag and TRV sweeps. GB not seen. No surgical clips seen. Contracted GB, agenesis of GB, ectopic location of GB, prior removal (and patient forgot--it does happen)?
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24 Mar 20
Short image tweetorial on thoracic ultrasound findings in pneumonia. #POCUS #IMPOCUS #FOAMed #FOAMus #Medtwitter #Meded #COVID19 @medpedshosp @cianmcdermott @msiuba @siddharth_dugar @grepmeded @NephroP @emresidents
Normal lung ultrasound. A-profile with thin pleural line with lung sliding. Linear transducer used.
Irregular pleural line with patchy B-lines. Seen in viral (including COVID19) and bacterial pneumonia. This patient had mycoplasma pneumonia. Linear probe used.
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