UOTW #92

A 35 year old previously healthy female presents with right sided chest pain after a motorcycle crash.  She describes the pain as worse with deep inspiration over her right anterior chest.  Her vital signs are as follows: T 98°F (36.67°C) HR 110, BP 130/80, RR 18, 98% on RA.  On examination she is mildly distressed with bilateral breath sounds, diffusely tender to palpation over her right anterior chest. 

Bedside ultrasound of patient’s lungs is performed and demonstrates the following:

What do the images show? What is the diagnosis? (Click the button for the answer!)

Answer

 

Unilateral B-lines consistent with pulmonary contusion. 

This ultrasound demonstrates focal B lines isolated to the patient’s right upper and middle lung. Pneumothorax can be ruled out by the presence of B lines with normal lung sliding.¹ B lines suggest increased density within the lung tissue, most commonly from fluid. They can be seen on ultrasound in several different disease processes; including pulmonary edema, pneumonia, and pulmonary contusion. 2  Additional findings that can be seen with pulmonary contusions include pleural line abnormalities and subpleural consolidations.3,4 In the context of this patient’s traumatic injury, isolated B lines represent pulmonary contusion. The patient received a CT scan of her chest (seen blow), confirming the diagnosis, and was subsequently admitted for supportive care and observation.

Pearls:

    • Pulmonary contusions are the most common lung injury in patients with blunt chest trauma, with an incidence of roughly 25%.3
    • They often occur from compression-decompression injuries such as high speed MVC’s, which cause direct injury to the lung parenchyma with resulting hemorrhage and edema.4
    • Diagnosis can be made with bedside ultrasound by using the curvilinear probe and identifying the presence of focal B lines, pleural line abnormalities, and subpleural consolidations. 2,3
    • The presence of B lines has near 100% sensitivity of ruling out pneumothorax. 1
    • Sensitivity and specificity for diagnosis of pulmonary contusion on lung ultrasound is 92% and 89%, respectively. In the same study, chest radiography was found to be 44% sensitive and 98% specific. Therefore, ultrasonography is a superior screening method than conventional chest radiography for pulmonary contusion.6
    • The treatment of pulmonary contusion involves maintenance of adequate ventilation and pain control.5
    • Early diagnosis is key as many patients are at high risk of developing subsequent pneumonias or ARDS.3,4

 

Case Courtesy of Jack Yancey, MD
Case Written by Jacob Avila, MD

References

    1. Soldati G, Sher S, Copetti R. If you see the contusion, there is no pneumothorax. Am J Emerg Med. 2010; 28(1):106-7; author reply 107-8. [PMID: 20006213]
    2. Soldati G, Sher S, Testa A. Lung and ultrasound: time to “reflect”. Eur Rev Med Pharmacol Sci. 2011; 15(2):223-7. [PMID: 21434491]
    3. Stone MB, Secko MA. Bedside ultrasound diagnosis of pulmonary contusion. Pediatr Emerg Care. 2009; 25(12):854-5. [PMID: 20016357]
    4. Soldati G, Testa A, Silva FR, Carbone L, Portale G, Silveri NG. Chest ultrasonography in lung contusion. Chest. 2006; 130(2):533-8. [PMID: 16899855]
    5. Jones D, Nelson A, Ma OJ. Pulmonary Trauma. In: Tintinalli’s Emergency Medicine A Comprehensive Study Guide. 8th ed. McGraw-Hill Education; 2016:1744-1746.
    6. Hosseini M, Ghelichkhani P, Baikpour M, et al. Diagnostic Accuracy of Ultrasonography and Radiography in Detection of Pulmonary Contusion; a Systematic Review and Meta-Analysis. Emerg (Tehran). 2015;3(4):127–136.


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