POCUS = Better ED throughput

The E-FAST exam is often discussed in the lit for the evaluation of major trauma cases. But I must use it at least as often in minor trauma. I recently saw a 44 y.o. male who had fallen off a ladder and landed on his right side on hard ground. The fall occurred on the day prior to presentation. His only complaint was right lateral chest wall pain. Which scans should be done in a patient like this? It depends on the presentation, but typical scans include looking for free fluid in the abdomen, a hemothorax, a pneumothorax, a pericardial effusion (sometimes), and a rib fracture. Most of these scans are usually negative, but doing these scans makes care safer. The one scan that is often positive is this one.

The video above shows the probe being slid along the long axis of a rib until a stepoff consistent with a fracture is visualized. The video below shows the probe being slid caudad from one rib to a lower rib. A stepoff is seen along both ribs.

These videos demonstrate 2 minimally displaced rib fractures. The other scans, along with the absence of gross hematuria on history, ruled out the bad stuff in this patient. The patient was discharged 20 minutes later with a certain diagnosis. Before the POCUS/EDE era, such a patient would have commonly had a chest x-ray (an inferior test!), possibly with rib views, to look for rib fractures and associated complications such as a pneumothorax. The patient would have usually been in the ED for an extra 1-2 hours. And the diagnosis would have been less certain since x-rays often miss rib fractures. Plus our clinical eval can easily miss occult internal injuries. With negative POCUS scans, these injuries are quickly ruled out in the low-risk patient. And the patient goes home WAY FASTER!

Summing up…consider these POCUS scans in the minor thoracic trauma scenario:

Thoracic EDE for pneumothorax and hemothorax
Abdominal EDE for intraperitoneal blood
Cardiac EDE for traumatic pericardial effusion
Fracture EDE for fractures