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Three Part Question

In [patients who present to the emergency department with blunt thoracic trauma], how accurate is [bedside ultrasound] compared to [standard chest x-rays] in the [diagnosis of rib fractures]?

Clinical Scenario

-A 35 y/o male presents to the ER following a low speed MVA. Patient was a restrained driver hit on the front passenger side while turning into a parking lot. He had no LOC and was able to ambulate following the accident. He presents with chest pain on the right and pain with inspiration. Patient is GCS 15 on arrival with HR 88, BP 145/75, RR 18, O2 sat 97% RA, T 37.

Search Strategy

Medline 1966-05/17 using PubMed, Cochrane Library (2017), and Embase

[(Ultrasonics or ultrasound or ultrasonography) AND (rib fracture or thoracic injury or chest trauma)]. Limit to English language

Search Outcome

166 studies were identified; only one trial investigated bedside ultrasound performed by emergency clinicians.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Elizabeth Lalande, Chantal Guimont, Marcel Edmond, Marc Charles Parent, Claude Topping, Brice Lion 2016 Canada	Convenience sample of 96 total patients. -Adults, aged 18 and older, presenting to the emergency department after sustaining blunt thoracic t rauma and with clinical suspicion of rib fractures. -Exclusions: -greater than 96 hours post trauma -hemodynamic instability -GCS 14 or less -with other significant traumatic injury	Investigational study	65% of EP concluded that PoCUS was a feasible option for diagnosing rib fractures with a VAS of 63.	PoCUS is a feasible option in the diagnosis of rib fractures in EP patients.	1. Patients were included based on physician suspicion of rib fractures following blunt thoracic trauma. Thus, it seems patients were not randomized. This was a convenience sample. 2. Results were not compared to a gold standard — neither US or Xray are gold standard. CT thorax is gold standard, but results of US and Xray were not compared to CT results on patients included in the study. 3. US is operator dependent and the EPs included had no prior experience with US for diagnosis of rib fractures (they did have at least 9 years of US experience however).
			15% of PoCUS were limited by patient discomfort.	Patient discomfort was the largest limiting factor in PoCUS.
			29% of patients were diagnosed with rib fractures by PoCUS, not seen on CXR.	PoCUS is able to detect rib fractures not seen by CXR.
			11 of 65 patients had rib fractures diagnosed with CXR, not seen on PoCUS.	PoCUS is not 100% reliable in detection of rib fractures.

Clinical Bottom Line

In patients who present to the emergency department with blunt thoracic trauma, PoCUS is a feasible technique for identifying rib fractures when compared to standard chest X-ray.

References

1. Elizabeth Lalande, Chantal Guimont, Marcel Edmond, Marc Charles Parent, Claude Topping, Brice Lion Feasibility of emergency department point-of-care ultrasound for rib fracture diagnosis in minor thoracic injury. Cambridge University Press 2016, 1-7