Abstract
BackgroundAs an adjunct to physical examination, ultrasound is a potentially attractive option for diagnosing pneumothoraces in the pre-hospital and retrieval environment – and could confer a benefit to patient safety. However, the published evidence supporting non-physicians use of ultrasound in this setting is limited.AimWe aimed to establish if Advanced Retrieval Practitioners (non-physicians) could acquire ultrasound views of the lungs and interpret them with sufficient quality to diagnose pneumothorax in the pre-hospital and retrieval environment when compared to expert review.MethodThe study consisted of an observational trial from April 2017 to April 2018. Twelve (12) patients bilateral lung ultrasound images (24 images) were randomly selected from 87 patients assessed using Point of Care Ultrasound (POCUS) by three Advanced Retrieval Practitioners in the Pre-hospital and Retrieval environment. Two expert reviewers’ evaluated these images to determine ARPs ability to acquire diagnostic quality images and interpret them correctly. CXR results of patients in whom lung ultrasound was undertaken were recorded as the reference standard investigation.ResultsWithin the 22 images considered adequate by the Advanced Retrieval Practitioners, 19 (86.4%, one-tailed McNemar test p = 0.125) were considered adequate on expert review. Of the 19 images mutually considered as adequate, both the Advanced Retrieval Practitioners and the reviewers identified two pneumothoraces which were subsequently confirmed on chest x-ray (Sensitivity 100% and Specificity 100% in technically adequate images). One pneumothorax was detected on CXR in a patient with inadequate ultrasound images. Advanced Retrieval Practitioners were therefore able to both obtain adequate images and correctly diagnose pneumothorax in the pre-hospital environment with 66.6% sensitivity (95%CI 66.6–100%) and 100% specificity (95%CI 81.0–100%) compared to expert review.ConclusionAdvanced Retrieval Practitioners (non-physicians) can obtain diagnostic views of the lungs of sufficient quality to diagnose the presence, or particularly the absence, of pneumothorax in the pre-hospital and retrieval environment. Although Advanced Retrieval Practitioners were less accurate than the expert reviewers at interpreting the quality of the ultrasound images, the result was not statistically significant, despite the ARPs possibly having been at a methodological disadvantage.
Highlights
As an adjunct to physical examination, ultrasound is a potentially attractive option for diagnosing pneumothoraces in the pre-hospital and retrieval environment – and could confer a benefit to patient safety
Within the 22 images considered adequate by the Advanced Retrieval Practitioners, 19 (86.4%, one-tailed McNemar test p = 0.125) were considered adequate on expert review
Of the 19 images mutually considered as adequate, both the Advanced Retrieval Practitioners and the reviewers identified two pneumothoraces which were subsequently confirmed on chest x-ray (Sensitivity 100% and Specificity 100% in technically adequate images)
Summary
As an adjunct to physical examination, ultrasound is a potentially attractive option for diagnosing pneumothoraces in the pre-hospital and retrieval environment – and could confer a benefit to patient safety. In the prehospital setting, using clinical assessment to diagnose pneumothoraces incurs additional challenges mainly related to the environment. Perhaps related to clinician awareness of the implications of missed diagnosis, tension pneumothorax is often over-diagnosed and overtreated in the pre-hospital environment [3]. This has the potential for patient harm, pertaining to the infection risk from emergency surgical procedures performed pre-hospital. Point of Care Ultrasound (POCUS) may facilitate more accurate diagnosis of pneumothorax when compared to clinical examination: potentially reducing unnecessary interventions and their associated risk of morbidity [4]
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