Be consistent. Be thorough. Be consistently thorough.

It’s 2 am when the emergency medical services radio alerts for a level 1 trauma. A young adult man is brought into the emergency department with a gunshot wound to the abdomen. He is hypotensive and tachycardic, and his breathing is labored. You and your team jump into action, anticipating a rapid course to the operating room. You have done these enough times, between your residency training and career at a level 1 trauma center, that your muscle memory kicks in.

The patient’s awake and responsive but ill-appearing. His airway is intact. His breathing is labored, but he seems to respond to supplemental oxygen. Breath sounds are difficult to assess due to body habitus. His pulses are thready, but the nurses are able to establish good intravenous access and start a fluid bolus while prepping emergent blood. He is moving all extremities and when his clothes are removed, a single gunshot wound is appreciable in his mid-abdomen.

The trauma surgeon arrives and wants to take him as rapidly as possible to the operating room. Working quickly, you grab the ultrasound machine and begin the E-FAST ultrasound scan that is engrained into your trauma algorithm. Your subxiphoid view of the heart is negative for pericardial fluid. All three abdominal views have visible free fluid. Despite no external evidence of thoracic trauma, you move the probe up to his chest wall because this is how you were trained. You are surprised to find that there is no lung sliding throughout the right side of the chest. Although unexpected, the presence of a pneumothorax with penetrating abdominal trauma is actually consistent with what Harris et al described in this issue of Baylor University Medical Center Proceedings.¹

A large bore right-sided chest tube is placed and drains mostly air and a small volume of blood. The patient’s dyspnea improves, and his blood pressure also increases. You obtain a quick chest x-ray to confirm tube placement, and the patient proceeds to the operating room with the surgical team for an exploratory laparotomy.

Reflecting on this resuscitation, you believe the patient’s prognosis as well as preoperative course are both improved because of the timely diagnosis of his concomitant pneumothorax and hemoperitoneum from penetrating abdominal trauma. This reflects the authors’ findings in this article that, somewhat unexpectedly, there was a higher association of pneumothorax with hemoperitoneum in penetrating trauma than in blunt trauma.¹

In residency, we train residents to be consistent, be thorough, and be consistently thorough. This decreases chances of error and cognitive biases. We train residents to perform E-FAST ultrasound scans in trauma patients, particularly in those who are unstable. The benefits of these scans in penetrating trauma patients have been debated over the years.^2,3 This study of patterns of findings in penetrating versus blunt trauma, which found that pneumothoraces are more common with hemoperitoneum in penetrating trauma patients than blunt trauma patients, adds leverage to the argument that the scans should be performed in both patient populations. It also emphasizes that all views should consistently be obtained.

While the retrospective approach has its limitations, given that downsides to E-FAST scans are limited or absent, this thoughtful article adds credence to their broad application and increases our awareness of what we may find.

—Andrew Shedd, MD
Vice-Chair of Academics, Residency Program Director,
Baylor All Saints Medical Center, and Professor of Emergency Medicine,
Burnett School of Medicine at TCU, Fort Worth, Texas, USA
Andrew.shedd@bswhealth.org

Disclosure statement

No potential conflict of interest was reported by the author(s).