Emergency thoracic ultrasound and clinical risk management

Maria Concetta Interrigi, Francesca M Trovato, Daniela Catalano, Guglielmo M Trovato, Maria Concetta Interrigi, Francesca M Trovato, Daniela Catalano, Guglielmo M Trovato

Abstract

Purpose: Thoracic ultrasound (TUS) has been proposed as an easy-option replacement for chest X-ray (CXR) in emergency diagnosis of pneumonia, pleural effusion, and pneumothorax. We investigated CXR unforeseen diagnosis, subsequently investigated by TUS, considering its usefulness in clinical risk assessment and management and also assessing the sustainability of telementoring.

Patients and methods: This observational report includes a period of 6 months with proactive concurrent adjunctive TUS diagnosis telementoring, which was done using freely available smartphone applications for transfer of images and movies.

Results: Three hundred and seventy emergency TUS scans (excluding trauma patients) were performed and telementored. In 310 cases, no significant chest pathology was detected either by CXR, TUS, or the subsequent work-up; in 24 patients, there was full concordance between TUS and CXR (ten isolated pleural effusion; eleven pleural effusion with lung consolidations; and three lung consolidation without pleural effusion); in ten patients with lung consolidations, abnormalities identified by CXR were not detected by TUS. In 26 patients, only TUS diagnosis criteria of disease were present: in 19 patients, CXR was not diagnostic, ie, substantially negative, but TUS detected these conditions correctly, and these were later confirmed by computed tomography (CT). In seven patients, even if chest disease was identified by CXR, such diagnoses were significantly modified by ultrasound, and CT confirmed that TUS was more appropriate. The overall respective individual performances of CXR and TUS for the diagnosis of a pleural-pulmonary disease in emergency are good, with accuracy >95%.

Conclusion: About 20% of pneumonia cases were detectable only by CXR and 20% only by TUS and not by CXR; ie, about 40% of patients may have been misdiagnosed if, by chance, only one of the two tools had been used. The concurrent use of TUS and CXR increases the overall sensitivity and specificity. The contribution of expert telementoring and final reappraisal is a valuable and sustainable element for emergency physicians' training and performance, contributing reasonably to mitigation of clinical risks.

Keywords: diagnostic performance; echography; pleural effusion; pneumonia; pneumothorax.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Concept map of the context of the risks.
Figure 2
Figure 2
Concept map of clinical risk management.
Figure 3
Figure 3
Concept map of emergency ultrasound uncertainty and risks.
Figure 4
Figure 4
Concept map of emergency ultrasound risk mitigation.

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