World J Surg DOI 10.1007/s00268-015-3046-0
REPLY, LETTER TO THE EDITOR
Ultrasound Diagnosis of Pneumothorax in Blunt Trauma: Reply Yassir Abdulrahman1 • Ayman El-Menyar2,3 • Hassan Al-Thani1
Ó Socie´te´ Internationale de Chirurgie 2015
Thank you for your comments. We do agree that the ultrasound operator should have passed the learning curve before participating in such a study by a proper credentialing process. One of our aims was to demonstrate the importance of the learning curve of the operators, which was clear in our discussion. In most of the studies that were included in the meta analysis [1] cited by Dr. Fikri, the chest ultrasound was done by an expert sonographer or radiologist, both of which have no role in the initial resuscitation of the multiple injury patient according to ATLS protocols, a core point of our study. Furthermore, our trauma surgeons had few hours hands-on training before the start of the blinded study; this time is exactly what is needed to be added to the ATLS course rather than to involve them in prolonged and detailed courses. The learning curve was discussed clearly in the results and discussion parts of our study. Regarding the calculation in Table 2, we are confused about what Dr. Fikri meant. We used the number of the hemithoraces having pneumothorax. In the methods section, we mentioned v2 and student-t tests for comparison between the groups (categorical and continuous variables, respectively). This was applicable in the earlier drafts; however, the analysis was
& Yassir Abdulrahman [email protected] 1
Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
2
Clinical Research, Hamad General Hospital, Doha, Qatar
3
Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
not added to the final draft except for v2 test that was prepared for Figure. 2. Dr Fikri stated that the authors have excluded the most important group (tension pneumothorax) which would benefit from ultrasound and acute care including needle thoracocentesis and chest tube insertion before CT scan. Doing ultrasound did not actually change the management in the reported patients because all chest tubes were inserted after CT scan. We do believe that tension pneumothorax diagnosis depends solely on clinical examination that to be proven by a CXR; failure to diagnose a tension pneumothorax in a patient on clinical basis is considered a failure in critical clinical judgment in chest trauma. Thus, the tension pneumothorax does not need the X-ray, ultrasound, or the CT scan to initiate the needle thoracocentesis or the chest tube insertion. We think that Dr. Fikri is pointing to a group of patients that are with impending tension pneumothorax (but still having stable vitals) rather than a full picture of a tension pneumothorax. This group was not excluded. Moreover, any intervention whether needle decompression or chest tube insertion before CT scan or CXR will be an exclusion criteria, as the origin of the pneumothorax discovered later cannot be addressed precisely, whether this was from the initial trauma or from the interventional procedure itself (iatrogenic). Furthermore, Dr. Fikri has mentioned that the definition of EFAST has to be more precise. The authors recommended EFAST to be introduced as an adjunct in ATLS algorithm. EFAST is a specific terminology which consists of examining eight sonographic points (8 p’s) to detect fluid in the Peri-hepatic, Peri-splenic, Pelvic, Pericardiac, right Pleural recess, and left Pleura recess areas; and to detect right Pneumothorax and left Pneumothorax
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World J Surg
[2, 3]. The authors addressed only the last 2 p’s of the EFAST. The definition of EFAST and the eight points are well known to the authors and are well described in the literature [2, 3]. Our aim of the study was not to redefine the investigatory tool rather than to test the sensitivity of the EFAST in pneumothorax in blunt chest trauma patient. As Dr. Fikri said, it is merely to test the last 2 P’s in the EFAST, upon which we carefully designed our study and clearly reached the conclusion.
123
References 1. Alrajab S, Youssef AM, Akkus NI, Caldito G (2013) Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis. Crit Care 17:R208 2. Mohammad A, Hefny AF, Abu-Zidan FM (2014) Focused Assessment Sonography for Trauma (FAST) training: a systematic review. World J Surg 38:1009–1018. doi:10.1007/s00268-013-2408-8 3. Zago M (2014) Introduction and focused questions. In: Zago M (ed) Essential US for trauma: E-FAST, 1st edn. Springer, Italia, pp 15–18
REPLY, LETTER TO THE EDITOR
Ultrasound Diagnosis of Pneumothorax in Blunt Trauma: Reply Yassir Abdulrahman1 • Ayman El-Menyar2,3 • Hassan Al-Thani1
Ó Socie´te´ Internationale de Chirurgie 2015
Thank you for your comments. We do agree that the ultrasound operator should have passed the learning curve before participating in such a study by a proper credentialing process. One of our aims was to demonstrate the importance of the learning curve of the operators, which was clear in our discussion. In most of the studies that were included in the meta analysis [1] cited by Dr. Fikri, the chest ultrasound was done by an expert sonographer or radiologist, both of which have no role in the initial resuscitation of the multiple injury patient according to ATLS protocols, a core point of our study. Furthermore, our trauma surgeons had few hours hands-on training before the start of the blinded study; this time is exactly what is needed to be added to the ATLS course rather than to involve them in prolonged and detailed courses. The learning curve was discussed clearly in the results and discussion parts of our study. Regarding the calculation in Table 2, we are confused about what Dr. Fikri meant. We used the number of the hemithoraces having pneumothorax. In the methods section, we mentioned v2 and student-t tests for comparison between the groups (categorical and continuous variables, respectively). This was applicable in the earlier drafts; however, the analysis was
& Yassir Abdulrahman [email protected] 1
Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar
2
Clinical Research, Hamad General Hospital, Doha, Qatar
3
Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
not added to the final draft except for v2 test that was prepared for Figure. 2. Dr Fikri stated that the authors have excluded the most important group (tension pneumothorax) which would benefit from ultrasound and acute care including needle thoracocentesis and chest tube insertion before CT scan. Doing ultrasound did not actually change the management in the reported patients because all chest tubes were inserted after CT scan. We do believe that tension pneumothorax diagnosis depends solely on clinical examination that to be proven by a CXR; failure to diagnose a tension pneumothorax in a patient on clinical basis is considered a failure in critical clinical judgment in chest trauma. Thus, the tension pneumothorax does not need the X-ray, ultrasound, or the CT scan to initiate the needle thoracocentesis or the chest tube insertion. We think that Dr. Fikri is pointing to a group of patients that are with impending tension pneumothorax (but still having stable vitals) rather than a full picture of a tension pneumothorax. This group was not excluded. Moreover, any intervention whether needle decompression or chest tube insertion before CT scan or CXR will be an exclusion criteria, as the origin of the pneumothorax discovered later cannot be addressed precisely, whether this was from the initial trauma or from the interventional procedure itself (iatrogenic). Furthermore, Dr. Fikri has mentioned that the definition of EFAST has to be more precise. The authors recommended EFAST to be introduced as an adjunct in ATLS algorithm. EFAST is a specific terminology which consists of examining eight sonographic points (8 p’s) to detect fluid in the Peri-hepatic, Peri-splenic, Pelvic, Pericardiac, right Pleural recess, and left Pleura recess areas; and to detect right Pneumothorax and left Pneumothorax
123
World J Surg
[2, 3]. The authors addressed only the last 2 p’s of the EFAST. The definition of EFAST and the eight points are well known to the authors and are well described in the literature [2, 3]. Our aim of the study was not to redefine the investigatory tool rather than to test the sensitivity of the EFAST in pneumothorax in blunt chest trauma patient. As Dr. Fikri said, it is merely to test the last 2 P’s in the EFAST, upon which we carefully designed our study and clearly reached the conclusion.
123
References 1. Alrajab S, Youssef AM, Akkus NI, Caldito G (2013) Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis. Crit Care 17:R208 2. Mohammad A, Hefny AF, Abu-Zidan FM (2014) Focused Assessment Sonography for Trauma (FAST) training: a systematic review. World J Surg 38:1009–1018. doi:10.1007/s00268-013-2408-8 3. Zago M (2014) Introduction and focused questions. In: Zago M (ed) Essential US for trauma: E-FAST, 1st edn. Springer, Italia, pp 15–18
