World J Surg DOI 10.1007/s00268-015-3014-8


Ultrasound Diagnosis of Pneumothorax in Blunt Trauma Fikri M. Abu-Zidan

Ó Socie´te´ Internationale de Chirurgie 2015

Dear Editor I have read with great interest the recently published article of Abdulrahman et al. [1]. The authors have to be congratulated for their excellent prospective study which highlights important points to discuss. First, it is important that the ultrasound operator should have passed the learning curve before participating in such a study by a proper credentialing process [2]. Figure 5 shows that the error rate of the eight operators varied between 5 % (2/39) and 80 % (4/5) which is one of the contributing factors for the reduced sensitivity of the present study. A recent meta-analysis that have included 13 prospective blinded studies showed that ultrasound had a pooled sensitivity of 78.6 % in diagnosing pneumothorax [3] which is much higher than the present study (43 %). Second, the calculations in Table 2 should be changed because it was based on the number of hemi-thoraces. The authors have instead used the number of patients who had pneumothorax (n = 75) in their calculation instead of the hemi-thoraces having pneumothorax (n = 83). The calculated prior probability will vary accordingly, 13.6 % (83/ 610) compared with 24.6 % (75/305). That is important when using the likelihood ratio nomogram to find the posttest probability of the pneumothorax [4]. Third, the authors state that they have used v2 and Student’s t test for comparison between the groups. I note that none of these tests were actually used in the results section.

F. M. Abu-Zidan (&) Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates e-mail: [email protected]

Forth, the authors have excluded the most important group (tension pneumothorax) who would have benefitted 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. The present study addresses the value of ultrasound as a diagnostic tool and not as a management tool which are completely two different issues. Fifth, 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, peri-cardiac, right pleural recess, and left pleura recess areas; and to detect right pneumothroax and left pneumothorax [2, 5]. The authors addressed only the last 2 p’s of the EFAST. Finally, I hope that these comments will be useful for the design of future studies in this important area.

References 1. Abdulrahman Y, Musthafa S, Hakim SY, Nabir S, Qanbar A, Mahmood I, Siddiqui T, Hussein WA, Ali HH, Afifi I, El-Menyar A, Al-Thani H (2015) Utility of extended FAST in blunt chest trauma: is it the time to be used in the ATLS algorithm? World J Surg 39:172–178. doi:10.1007/s00268-014-2781-y 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/s00268-0132408-8 3. 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


World J Surg 4. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB (2000) Evidence-based medicine: How to practice and teach EBM, 2nd edition. Churchill Livingstone, Edinburgh, p 67–93


5. Zago M (2014) Introduction and focused questions. In: Zago M (ed). Essential US for trauma: E-FAST, 1st edition. SpringerVerlag Italia, Italy, p 15–18

Ultrasound Diagnosis of Pneumothorax in Blunt Trauma.

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