All right, good morning, everybody. Happy, as always, happy Friday. Welcome to this week's AMSSM Sports Ultrasound Case Series. We are fortunate and excited today to have our friends out at Duke. And this is going to be a bit of a different format, which I'm actually pretty excited about. We've had, you know, very well done, you know, primary MSK presentations previously by single fellows. And this is going to be a bit different in that the three fellows from Duke, so Brent, Eric, and Ben, they pre-recorded their live, they're alive and live, and they're with us on this talk, but they pre-recorded their lecture. So they're going to share the screen and play their video, and then they'll be live for questions afterwards. But their talk today is on pneumothorax, so thoracobdominal trauma, which is a bit different than what we've had previously. So a little bit of a different flavor to this week, which I think will be great and I'm excited about. Just quickly, housekeeping stuff. So we're off next week, as always. And then the following week, Dr. Bill Berrigan out at Emory is going to talk about some, I believe, unless this has changed from rotator cuff pathology, I believe that's changed. It might be brachial plexitis. Regardless, there's a teaser, so you'll have to tune in to find out what Bill's talking about. So regardless, again, so we've got three fellows from Duke. So we've got Ben Ferry, who's primary medicine trained, trained out in Charleston. Got Eric Friedman. He is one of our friendly emergency medicine trained docs, trained out in Baltimore. And then Brent Pickett is another emergency medicine trained fellow from, or not from, but trained out in South Bend. So like I said, they have a pre-recorded video, they're going to play that. They are here live for questions and their cases on pneumothorax. Thanks for the intro, Dr. Cruz, and we'll get this started. ...fellows here at Duke University. Hi, my name is Brent Pickett, I'm one of the primary care sports medicine fellows here at Duke University, and I'll be presenting today with my co-fellows, Eric Friedman and Ben Ferry. And today we're going to present a case of one of our Duke collegiate athletes that presented with shortness of breath after competition and how we use ultrasound to help evaluate this athlete, get them treated, and then eventually get them back to playing. We don't have any relevant financial disclosures, so we do want to disclose that we are somewhat bummed that Coach K will be stepping down after next year, but we're excited to see Duke basketball back on top come next season. But other than that, no real financial disclosures. So our objective today with our presentation, we have a couple that we'd like to go over. The first is to review the protocol for ultrasound evaluation of the abdomen and thorax, specifically in this collegiate athlete in his presenting case that we'll go over, as well as discuss the advantages, as well as the limitations of ultrasound in evaluation of these specific pathologies, you know, mostly centering around pathology within the chest, but also in the abdomen, as well as how to complete a formal ultrasound report and how to document what you did, what you saw, and what you recommend. So case study, our patient is a 21-year-old collegiate lacrosse player here at Duke who during competition suffered a blow to the left lower chest and upper abdomen, didn't really have any significant past medical history, hadn't really experienced anything like this before. The initial assessment performed by our sideline physician, Eric Friedman, showed mild tenderness and palpation over the left lower thorax and upper abdomen, didn't have any subjective shortness of breath, and really was pretty stable on the sideline without any concern for any significant pathology. So after return to campus following the game, several hours following the game, the patient noted interval development of shortness of breath. He also had persistence of pain in that same area that was evaluated on the sideline of the left anterior chest and left upper abdomen that he said had gotten worse. So physical exam there in the training room, the patient looked mildly uncomfortable, but was in no acute distress. You can see his vitals there on that second line, everything largely within normal limits, nothing terribly concerning. Cardiovascular exam was fine. On his pulmonary exam, his breath sounds were equal, bilateral, there weren't any concerning findings to auscultation, and his abdominal exam showed mild tenderness, palpation in the left upper quadrant, but didn't have any rebound or guarding or rigidity or anything like that. So as far as things that we were considering at the time, as far as the differential goes, obviously pneumothorax was very close to the top of the list. Also concerned for rib cartilage injury or contusion, possibly even a rib fracture in the area, exercise-induced pulmonary edema, as well as a possible splenic injury given the location and nature of his pain. So in order to augment our physical exam and try and pin down a more specific diagnosis for this patient, we decided to use ultrasound there in the training room, which luckily we had available. So as far as augmenting the physical exam with ultrasound for this abdominal thoracic scanning protocol, first thing you want to take into consideration is patient positioning. So we place the patient's supine on the treatment table in order to best facilitate scanning for both the abdomen and the thorax, and then probe selection, obviously you're not going to get the same picture with each probe. So the curvilinear transducer is generally used for the abdominal assessment, and then the high-frequency linear transducer is better for the thoracic and pleural assessment, where a lot more of those structures are more superficial. So we're going to get a little bit more in depth about the protocol we use and the images that we obtain, and for that I'll turn it over to my esteemed emergency department co-fellow, Eric Friedman. Thank you, Dr. Pickett. So for the fast exam, not to be confused with the slow exam like what they do over at UNC. Just kidding, they're great over there. It just wouldn't be a Duke talk without giving a little ribbon over to UNC. But anyway, so the fast exam, there's four probe positions. You want to do the right upper quadrant, left upper quadrant, pelvic or bladder, as well as a sub-xiphoid view to look at the heart. The data's pretty variable about the exact sensitivity of a fast exam, and some of it depends on how quickly after the injury and other things, but it's about 40% sensitive, and it's about over 95% specific for peritoneal free fluid concerning for an intra-abdominal injury and bleeding. So going through the fast exam here, so the first view that we'll talk about is the sub-xiphoid view. So as you can see kind of on the left here is a normal sub-xiphoid view, so you can see the heart, no free fluid, that hypoechoic free fluid around there. And then on the right side, you do see free fluid around the heart concerning for that pericardial effusion and injury there. Moving right along to the right upper quadrant view, here on the left you can see a normal view, and you're looking at the interface between the liver as well as the right kidney, and you want to look in between there and look for any hypoechoic areas, but also I want to give mention to the caudal tip of the liver here, and you also want to take a look there to make sure there's no free fluid around there, because sometimes the blood can hide there. And on the right here, we have our positive red arrow sign showing the hypoechoic abnormal fast exam here, showing that free fluid in between the kidney and the liver concerning for intra-abdominal injury. Moving along to the left upper quadrant view, we have the spleen and the kidney, and here I want to mention you want to make sure you look between the spleen and the kidney, but actually even more commonly, the free fluid goes between the spleen and the diaphragm as documented in this right picture here. So you can see the spleen and the kidney interface actually looks good. There's no free fluid there, but luckily this sonographer looked above the spleen as well and saw the free fluid. And then the bladder view, so you usually want to actually get both a transverse and a longitudinal on the bladder view, but looking on or look at the transverse here, looking at a normal, you don't see any hypoechoic around the bladder other than the hypoechoic fluid or urine inside the bladder, but you can see kind of the bladder wall there closing it off. And here you can see the bladder wall closing off the hypoechoic urine, but then there's also some free fluid or blood there, so this is another abnormal exam. So for the eFAST, you would just do here for the pulmonary views, you would just do the R1 view here looking for pneumothoraces, but I'm going to talk about a complete pulmonary ultrasound evaluation as well, so we know how to do that as well. So for the first view is this midclavicular line at the second intercostal space, you want to have your probe up and down in orientation, and like Dr. Pickett was saying, the linear probe would be best for this because you're looking for pneumothoraces, which is a pretty superficial view. However, in the sake of time, if you're doing a FAST exam, you can do this with a curvilinear as well as a phase array probe as well. So this would be the view here, obviously on both sides. The next would be the midaxillary line around the sixth or seventh intercostal space, and the purpose here is to kind of evaluate those lateral lung fields. And then the last view is the intersection of the posterior axillary line in a rib space between the 10th and 12th ribs, depending on which side you're on. So here's the right side, this little gif here, and you're looking at the liver with some lung sliding above. So you want to see the kind of the diaphragm and then everything above, because this is usually where the pleural effusions sit, and then a lot of times you can see those consolidations, which could represent as isolated B lines just in this lung view. And if there was a pleural effusion, you'd see hypochoic above the diaphragm, as opposed to below the diaphragm, you worry about an intraabdominal injury would be above the diaphragm, which you don't see here. This is normal. So here's a normal lung ultrasound, this would be in that first position, that second intercostal space, that midclavicular line, and you can see here, this is a rib here, and then we don't see the other rib over here, it's a little cut off, but you can see some good lung sliding here, some people describe it as ants marching on a log, if you want to think about it that way. And then this is our patient here, so these are real, real ultrasound views. So here's a rib here, here's a rib here, and you can see here there's absolutely no lung sliding there, consistent with pneumothorax, and you can see kind of his muscles moving, but no actual lung sliding. And then here is another view of our patient, so this is another rib space, and you can see actually a transition point, so you can see lung sliding in half this rib space, but the other half, there is absolutely no lung sliding. So this is consistent with the transition point here, you can see the lines coming down of the lung sliding as well, and Dr. Ferry will talk about that a little bit later. So the other thing, if you're unsure, if you can't see it with the naked eye, you can always do M-mode on the ultrasound and drop that line right through the middle of that lung. Here you can see a normal seashore sign, and you can see kind of the waves crashing down on the beach here. And then if there was a pneumothorax and there was no lung sliding, you would get this barcode or stratosphere sign, as you can see, it kind of looks like a barcode. So I'm going to kick this next part to Dr. Ferry to talk about a little bit of the stats behind these ultrasound evaluations, and to bring us home. All right, thanks Eric. So just to recap, kind of a few of the things that we're looking for here as part of our comprehensive pulmonary evaluation. So first, we're looking for the presence or absence of lung slide. In addition to that, we're looking for the presence or absence of B-line. So even in the absence of lung slide, if you see a B-line, that effectively rules out the diagnosis of pneumothorax. Additionally, like Eric highlighted, we're using M-mode for additional evaluation, looking for that expected normal seashore sign, and if that's absent, if we're seeing the stratosphere or barcode sign, another indicator for pneumothorax. And then finally, the transition point, which we were able to identify in our specific patient. So that's a focal transition point where there's an absence of lung sliding. We're not seeing B-lines with it. We're not seeing kind of the comet tail sign going along with that. Various studies have looked at this. Overall, the sensitivity is good, and the specificity is even better, closer to 100%. So you see this study from 2000 that gave a sensitivity of 67% associated with identification of a transition point and a specificity of near 100%. Additionally, looking through the literature, there's various or a range of different sensitivities and specificities. Across the board, sensitivity probably is ranging somewhere from the 60% to 70% range up to 80% to 90% for identification of a pneumothorax. From a specificity standpoint, again, it's even higher, usually 95-plus percent. If you're identifying absence of lung slide at a specific transition point, no B-lines with it, that's very specific for pneumothorax. And a couple things, you know, it's not a perfect test, so a couple of the things that you would want to consider. If you do see absence of lung slide, these are less likely to be identified in kind of a young, otherwise healthy athletic population, but things to keep in mind nonetheless. If the patient has a history of prior thoracic surgery, the presence of pulmonary blebs, the presence of significant atelectasis or lower consolidation, if there was a large parenchymal tumor, or if this was a more massive, larger-scale injury associated with total lung collapse, those could all be alternative reasons that you're not going to see lung slide outside of just pneumothorax. So one of the other common modalities that we use to evaluate for pneumothorax is a chest x-ray. You can see here the sensitivity from this specific study is wide-ranging, you know, somewhere between the order of 28 and 75 percent. Specificity is high, again, but comparing between ultrasound evaluation and chest x-ray, usually your sensitivity is actually a little bit higher with ultrasound evaluation. So particularly at the point of care, usually we're going to have a little more ready access to that, particularly in our training room setting. So I think a nice modality to use. We'll talk now a little bit about the ultrasound report that we would generate for both the FAST exam and a more complete pulmonary evaluation. So you see here you have the date, performing provider, location, and probes used. Specifically noting that given kind of the somewhat lower acuity, we're able to more selectively use the curvilinear transducer for the intra-abdominal exam and the high frequency linear transducer for the pulmonary exam. And we'll read through the full report itself, but a couple highlights. So under the cardiac section, we're commenting primarily on the absence of an anechoic fluid collection in the pericardial space. The same is true with the abdominal exam. So commenting on a few anatomic areas of interest, but primarily highlighting the absence of anechoic collections in the perihepatic and perisplenic space, as well as the bladder. And then on the pulmonary evaluation, we give a little more specific mention of the different anatomic landmarks that Eric already went through with us. And commenting on our use of M mode, the presence or absence of B lines. And again, describing objectively what we find. And then in the impression, kind of bringing it home, we're all together. The findings in our patients are that a clear transition point, which was identified at the level of the second intercostal space at the midclavicular line, and the absence of any intra-abdominal free fluid or pericardial effusion. All of this suggests the absence of significant intra-abdominal fluid and the presence of anapical pneumothorax. So in follow-up and wrap-up for our case, our athlete was sent to the emergency room for further evaluation. A confirmatory chest x-ray was obtained that did confirm the diagnosis of left apical pneumothorax. He was placed on 100% non-rebreather for a number of hours and was ultimately able to be discharged from the emergency room. He underwent subsequent evaluation and a subsequent chest x-ray that showed interval resolution of the pneumothorax, and he was able to successfully return to play later this season. This is not meant to be kind of an all-encompassing discussion about return to play after pneumothorax, but just to kind of bring the case home. So there's no consensus guidelines out there. Usually, it's taking an average of three to four weeks post-injury to return to play. Keep in mind the flying restriction after such an injury. So if you do identify this on the road with something like a portable ultrasound, there's going to be some implications for travel back to kind of your home campus, potentially. So usually, you're obtaining a repeat chest x-ray just to ensure resolution of the pneumothorax prior to return. And with that, that concludes our presentation. So thank you for your attention this morning. Special thanks to our primary care sports medicine faculty team here who have been so supportive throughout this year. And with that, we'll take any questions. All right. Great job, guys. That was well done. And again, I think that was a really nice change of pace. This isn't something that we commonly see, you know, unless we're doing a lot of sideline coverage. And I guess even if you are doing a lot of sideline coverage, it's still not something, you know, all that common that you're going to run into. I had a whole list of points I was going to make, but you guys touched on pretty much all of them. So well done. Well done to you. I think a couple things or a couple points just to reemphasize. So the use of a linear transducer here is important because, you know, most of these pneumothoraces are going to be quite superficial. So having access to that is important. Conversely, you know, if this, you know, seems like a pneumothorax, but maybe it's not, you know, having access to a curvilinear transducer makes some sense here as well because that's probably your preferred transducer for, you know, evaluation of pulmonary edema and some deeper structures. So if you have access to both, I think that makes things easier. If you don't and you had to pick one, you know, all these portable units only have one, your linear transducer is the way to go. You guys made the point about chest x-ray versus pneumothorax, versus ultrasound for pneumothorax. And the sensitivity is significantly higher, you know, essentially double, you know, around 90% sensitivity for ultrasound versus 45 or so, depending on the literature for a chest x-ray. So the sensitivity is significantly higher, you know, and conversely, both are rather specific, right? I mean, both are rather specific, right? So you can see it and it's probably real. I don't tend to use M mode all that much. I do like to look for the little ants marching on the log. That's a good analogy. So that's usually my go-to. And then, you know, presence of a long point, once you see that, you know, your diagnosis there is done and you, you know, you probably don't have to do all that much more. Let me see if I have anything else I wanted to say. I think, yeah, I think that's all that I had. But yeah, you guys, that was really well done. All the highlights and high points were made. And that image of the long point that you have was actually a really good image or video, I should say. So great job. Great job to you all. Anybody else have any questions, comments, concerns? Any Tar Heel fans want to take a stab back at Eric for his comment? Bring it on. Okay. All right. Well, then we will wrap this. So Ben, Eric, and Brent, thanks again for doing this. As I said, very well done, great change of pace, a very different topic than what we've had. So great job and thanks again. I appreciate you guys doing this. One other point. So as with most things, I was wrong when I spoke earlier. So Bill is presenting in two weeks. However, he's presenting a case of a subcoracoid cyst resulting in a brachial plexopathy or plexitis. So not rotiger cuff, subcoracoid cyst, disregard what I said previously. And that'll be two weeks on June 25th. Otherwise, everybody have a great Friday, great weekend. And Ben, Eric, Brent, thanks again, guys. Thanks for having us. Appreciate the opportunity. All right. See you guys. Stay safe.

3rd Edition, CASE 33

3rd Edition

Lung

pneumothorax

sports ultrasound

thoracoabdominal trauma

FAST exam

diagnostic imaging

return-to-play