Extended-FAST plus MDCT in pneumothorax diagnosis of major trauma: time to revisit ATLS imaging approach?

Abstract

Background and objective
Pneumothorax (PNX) detection is of the utmost clinical relevance because it may quickly progress to cause hemodynamic instability as a consequence of invasive ventilation. Radiography is characterized by a low sensitivity to detect this disease; in recent years, chest ultrasound (US) has gained increased visibility in the diagnosis of acute respiratory emergencies including PNX. The aim of this retrospective study was to evaluate the clinical impact of extended focused assessment with sonography in trauma (E-FAST) during the past 6 years of experience with this technique in our Level I trauma center.

Methods
Between January 2013 and December 2018, we performed a retrospective case-series study including 3320 consecutive patients admitted to the emergency department of our hospital because of major trauma. Extended-US was always performed and reported immediately after FAST during primary survey and before multidetector computed tomography (MDCT) scans. The presence of PNX was determined using the well-known accepted US criteria. US findings were compared with computed tomography (CT) findings, the reference standard for PNX detection.

Results
Of the 6640 lungs observed with E-FAST, there were 1244 PNX cases, while 1328 PNX cases were detected either on the basis of MDCT or on the basis of the presence of air flush during the thoracic decompression in the emergency room. Among the 84 false negatives, 12 patients had subcutaneous emphysema, 38 had a body mass index higher than 27, 6 had a thoracic wall hematoma, and 4 had chest penetrating trauma. There were 10 false positives in the diagnosis of PNX at US examination, with mild extension and not clinically significant. The overall sensitivity of E-FAST for PNX detection was 93.6% (1244/1328), the specificity of E-FAST was 99.8% (5312/5322), the negative predictive value (NPV) was 98.4% (5312/5396), and the positive predictive value (PPV) was 99.2% (1328/1338).

Conclusion
Our results demonstrate that bedside thoracic US is characterized by a very good accuracy in the diagnostic work-up of major trauma patients, even in difficult conditions, allowing rapid diagnosis of PNX.

Advances in knowledge
The novelty of this research lies in the possibility of diagnosing potential life-threatening conditions in a very short time by means of US, thus proposing a revision of the Advanced Trauma Life Support (ATLS) guidelines in order to incorporate it in the work-up of high-energy injured patients.

Full text

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Journal of Ultrasound (2019) 22:461–469
https://doi.org/10.1007/s40477-019-00410-4
ORIGINAL PAPER
Extended‑FAST plusMDCT inpneumothorax diagnosis ofmajor
trauma: time torevisit ATLS imaging approach?
StefaniaIanniello1 · ClaudiaLuciaPiccolo2· MargheritaTrinci1· ClaudioA.AjmoneCat3· VittorioMiele4
Received: 27 May 2019 / Accepted: 8 October 2019 / Published online: 4 November 2019
© Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB) 2019
Abstract
Background and objective Pneumothorax (PNX) detection is of the utmost clinical relevance because it may quickly progress
to cause hemodynamic instability as a consequence of invasive ventilation. Radiography is characterized by a low sensi-
tivity to detect this disease; in recent years, chest ultrasound (US) has gained increased visibility in the diagnosis of acute
respiratory emergencies including PNX. The aim of this retrospective study was to evaluate the clinical impact of extended
focused assessment with sonography in trauma (E-FAST) during the past 6years of experience with this technique in our
Level I trauma center.
Methods Between January 2013 and December 2018, we performed a retrospective case-series study including 3320 con-
secutive patients admitted to the emergency department of our hospital because of major trauma. Extended-US was always
performed and reported immediately after FAST during primary survey and before multidetector computed tomography
(MDCT) scans. The presence of PNX was determined using the well-known accepted US criteria. US findings were compared
with computed tomography (CT) findings, the reference standard for PNX detection.
Results Of the 6640 lungs observed with E-FAST, there were 1244 PNX cases, while 1328 PNX cases were detected either
on the basis of MDCT or on the basis of the presence of air flush during the thoracic decompression in the emergency room.
Among the 84 false negatives, 12 patients had subcutaneous emphysema, 38 had a body mass index higher than 27, 6 had
a thoracic wall hematoma, and 4 had chest penetrating trauma. There were 10 false positives in the diagnosis of PNX at US
examination, with mild extension and not clinically significant. The overall sensitivity of E-FAST for PNX detection was
93.6% (1244/1328), the specificity of E-FAST was 99.8% (5312/5322), the negative predictive value (NPV) was 98.4%
(5312/5396), and the positive predictive value (PPV) was 99.2% (1328/1338).
Conclusion Our results demonstrate that bedside thoracic US is characterized by a very good accuracy in the diagnostic
work-up of major trauma patients, even in difficult conditions, allowing rapid diagnosis of PNX.
Advances in knowledge The novelty of this research lies in the possibility of diagnosing potential life-threatening conditions
in a very short time by means of US, thus proposing a revision of the Advanced Trauma Life Support (ATLS) guidelines in
order to incorporate it in the work-up of high-energy injured patients.
Keywords Thoracic ultrasound· Pneumothorax· Major trauma· Extended-FAST· Advanced trauma life support
Background
Misdiagnosed pneumothorax (PNX) can quickly become
life-threatening, so PNX requires early diagnosis and urgent
treatment [1]. The literature has demonstrated that supine
chest radiograph (CR) is a low-sensitive examination (about
50–60%) for detecting this disease [2–10], although until
now the Advanced Trauma Life Support (ATLS) procedure
considered it a basic examination for first-line pneumotho-
rax diagnosis during major trauma primary survey [11]. A
pneumothorax recognized on a computed tomography (CT)
* Stefania Ianniello
stefianni66@gmail.com
1 Department ofEmergency Radiology, San Camillo Hospital-
Rome, Rome, Italy
2 Department ofMedicine andHealth Science, University
ofMolise, Campobasso, Italy
3 Shock andTrauma Intensive Care Unit, San Camillo
Hospital-Level I Trauma Center-Rome, Rome, Italy
4 Department ofRadiology, Careggi University Hospital,
Florence, Italy

462 Journal of Ultrasound (2019) 22:461–469
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scan, but not seen on a previous supine CR, is defined as an
“occult pneumothorax” (OP); it accounts for 52–63% of all
traumatic pneumothoraces. Although CT is the gold stand-
ard diagnostic test for the identification of pneumothorax,
it is limited by radiation exposure and by the difficulty of
transporting unstable patients to the CT scan room [12–16].
For more than a decade, chest ultrasound (US) has found
its way into the emergency and critical care setting, and has
now become a feasible tool for the diagnosis of acute res-
piratory emergencies, including, but not limited to, PNX
[17]. In a meta-analysis by Ding etal. [5], who compared
the use of anteroposterior chest radiography with thoracic
ultrasonography for the diagnosis of pneumothorax, pooled
sensitivity and specificity were 88% and 99%, respectively,
for ultrasonography and 52% and 100%, respectively, for
CR. These results are encouraging because they underline
the capability of US to recognize even the smallest pneu-
mothoraces, hence avoiding serious potential consequences
such as tension pneumothorax, especially in mechanically
ventilated patients.
In patients with major trauma, after the initial focused
assessment with sonography in trauma (FAST) survey, the
US examination is extended to the thorax to rule out hemo-
thorax and pneumothorax; this “extended-to-thorax” exami-
nation is called extended-FAST (E-FAST).
In a trauma setting, the E-FAST examination is usually
performed in hypotensive and hemodynamically unstable
patients because it helps determine whether immediate
surgery is needed before the patient undergoes a multide-
tector computed tomography (MDCT) evaluation. Taking
into consideration, however, the time interval from arrival
to performing the MDCT, it would be advisable to perform
the evaluation (during primary survey time) in order to avoid
unexpected findings such as OP.
The aim of this retrospective study was to evaluate the
clinical impact of a new imaging approach in a trauma-
dedicated logistical context (shock room, CT room, oper-
ating room strictly closed, emergency radiologist, and a
trauma team for 24h a day, 7days a week), extended only
to E-FAST, during primary survey and with whole-body
multidetector computed tomography (WB-MDCT) as the
secondary survey, for the past 3years of experience in our
Level I trauma center.
Methods
Study protocol
We performed a retrospective case-series study that included
3320 consecutive patients admitted to the emergency depart-
ment of our hospital (Level I trauma center) between January
2013 and December 2018 because of major trauma (Injury
Severity Scale, or ISS, ≥ 15). Patients were eligible for inclu-
sion in the present study if they had undergone chest US
as part of the E-FAST examination before the WB-MDCT
examination, the OR (operating room) for damage control,
and the placement of a thoracostomy tube. All the E-FAST
examinations were performed by the attending trauma radi-
ologists (with at least 20years of experience in clinical
US and 5years of experience in thoracic US and MDCT
examinations) both at bedside and in the emergency room;
the examinations were recorded on video. Extended (to the
thorax)-US was always performed and reported immediately
after FAST during primary survey (within the first 5min
after the arrival of the patient) and before the WB-MDCT
scans. Due to the need to immobilize the patient, the thoracic
investigation included an examination of the anterior and
lateral wall only, not the posterior one.
The presence of pneumothorax was determined using the
well-known accepted US criteria (absence of lung sliding
and lung pulse, loss of B lines, and identification of the lung
point).
The WB-MDCT images were read by a staff radiologist
without knowledge of the US findings. For every patient, the
arrival time in the emergency department, time of E-FAST,
and time of MDCT were recorded. The final US reports and
images were reviewed by two authors of this paper and by
independent lecturers and compared with MDCT images for
verification; all the images and reports have been collected
by our RIS/PACS system.
Technical equipment
In our institution, E-FAST is performed at the bedside,
inside the shock room, with the patient in the supine posi-
tion, by using a US imaging unit (Esaote MyLab75, Italy)
equipped with a 7.5–10MHz linear probe. The linear high
-frequency probe (7.5–10MHz) is suitable for the visuali-
zation of the pleural line [18–20]; the convex probes are
meant to evaluate the peritoneal cavity and the pericardium,
and the lateral hemithoraces are used to detect hemothorax.
WB-MDCT is performed using a 16-channel CT scanning
unit (CT LightSpeed 16, GE Medical Systems, Milwaukee,
Wis.); intravenous contrast material (Visipaque 320mg/ml,
GE Medical Systems, Milwaukee, Wis.) is always employed
for the evaluation of whole-body trauma. MDCT sections
were obtained with contiguous 2mm axial sections from
the apicothorax to the symphysis pubis at a pitch of 1.5;
mediastinal and lung windows were then recorded on the
PACS system.
Sonographic semeiology
Sonographic evaluation for pneumothorax begins from the
anteroinferior chest wall and then moves on to the lateral

463Journal of Ultrasound (2019) 22:461–469
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chest. The patients were examined in the supine position,
placing the probe at the second to fourth intercostal spaces
anteriorly and at the sixth to eighth spaces in the mid-axil-
lary line (Fig.1). The presence of pneumothorax was recog-
nized using the well-known US criteria: the disappearance
of lung sliding and the loss of the comet-tail artifact at the
pleural interface [18–23].The lung sliding represents the
twinkling movement visible at the pleural line, correspond-
ing to the contact of the visceral pleura with the parietal
pleura. In the presence of a pneumothorax, the air between
the two pleural layers causes abolition of the lung sliding,
and the pleural line appears static. The B lines, which appear
as comet-tail artifacts, arise from the pleural line, spread
up without fading to the edge of the screen, and are syn-
chronous with the respiratory movements. They become vis-
ible when a marked difference in acoustic impedance exists
between an object and its surroundings. US detection of the
comet-tail artifact allows pneumothorax to be ruled out.
When these two signs are present in the anteroinferior
chest area, one should check the lateral inferior chest wall
for the lung point. This sign is defined as the border between
aerated lung and pneumothorax; it confirms the diagnosis
of pneumothorax with a specificity of 100% [21], and its
location provides information about the extent and severity
of pneumothorax (Figs.2, 3).
The diagnostic algorithm used to define the sonographic
diagnosis of pneumothorax is shown in Fig.4.
Statistical analysis
Estimates of sensitivity, specificity, positive predictive
value, negative predictive value, and overall accuracy were
calculated for E-FAST using MDCT as the reference stand-
ard for pneumothorax detection in all patients. Ninety-five
percent confidence intervals (CIs) based on a binomial dis-
tribution were calculated for all the estimates using a statisti-
cal software program (SPSS 10).
Furthermore, the same values were calculated separately
for each year of evaluation to take into account an extended
learning curve. In those patients in which US showed mas-
sive pneumothorax and in which a chest drainage was placed
before MDCT, we considered the escape or aspiration of
intrapleural air at the time of drainage in the emergency
room (as documented in case history), a criterion that is sug-
gestive of the presence of pneumothorax. The right and left
lungs were considered separately for each patient (Fig.5).
Results
Between January 2013 and December 2018, 3320 consecu-
tive major traumatic patients (ISS ≥ 15) were admitted to our
emergency department (1844 men and 1476 women, with
a median age of 41years and an age range of 18–81years).
Of these patients, 3088 suffered a blunt trauma, and 232 a
penetrating trauma; these patients underwent an E-FAST at
admission in the emergency room (during primary survey,
from 0 to 5min after the patient’s arrival) for the detec-
tion of pneumothorax, hemothorax, hemopericardium, and
hemoperitoneum. E-FAST, followed by WB-MDCT, was
performed in all patients. Chest X-ray (XR) and pelvis XR
were performed only in unstable patients upon arrival in the
OR; cervical spine XR was not performed at all. WB-MDCT
is our choice of secondary survey; a three-phase or two-
phase technique was decided upon case by case based on the
specific findings. The technical advantages of performing a
WB-MDCT are summarized in Table1.
These patients represent our study population (a total of
6640 hemithoraces). The results about the diagnostic perfor-
mance of thoracic US are summarized in Table1.
The time interval between US and WB-MDCT ranged
from 10 to 75min (median 36min), depending on the clini-
cal conditions at admission and the necessity for urgent
maneuvers. Out of 6640 lungs in 3320 patients, E-FAST
detected 1244 pneumothoraces, while 1328 pneumothoraces
were detected either on the basis of MDCT or on the basis
of the presence of air flush during thoracic decompression
in the emergency room. Of these, 236 pneumothoraces were
bilateral, and 1092 were monolateral. US missed 84 out of
1328 cases (6.3%) of pneumothorax; 54 out of 84 (64%) of
them were mild (thickness less than 5mm at the MDCT
scan), 30 out of 84 (36%) were moderate (extension at the
basal anterior region; thickness less than 2cm), and none
of them were massive. Of these, 84 cases were false nega-
tive, 12 patients had subcutaneous emphysema, 38 had a
Fig. 1 Pneumothorax extension, evaluation based on lung point local-
ization (modified from Volpicelli etal., Intensive Care 2010). a Near
the parasternal line: mild, b until the anterior axillar line: moderate, c
until the posterior axillar line: massive

464 Journal of Ultrasound (2019) 22:461–469
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body mass index (BMI) higher than 27, 3 had a thoracic wall
hematoma, and 4 had chest penetrating trauma. There were
10 (out of 1328) false positives (all emphysematous bullae)
in the diagnosis of pneumothorax at US examination, with
mild extension; they were not clinically significant and not
treated.
For the thoracic US results, all false negatives occurred
during the initial five E-FAST examinations performed
by each radiologist; likewise, there is no evidence for
an association with false positives, since all occurred
in emphysematous patients. Consequently, the overall
sensitivity of E-FAST for pneumothorax detection was
93.6% (1244/1328), the specificity of E-FAST was 99.8%
(5312/5322), the negative predictive value (NPV) was 98.4%
(5312/5396), and the positive predictive value (PPV) was
99.2% (1328/1338). Over the past 3years of experience in
our Level I trauma center, the overall diagnostic accuracy
of this diagnostic tool for pneumothorax in major trauma in
the emergency room was 98.6%. The 95% CIs for sensitivity
and specificity of transthoracic sonography were 84–100%
and 90.5–100%, respectively.
The median time to recognize a pneumothorax diagno-
sis by means of E-FAST was 3min (1–5min). E-FAST
does not prevent each step of the primary survey, but it has
become strictly connected to it. Furthermore, it is repeatable
every time it is needed, if hemodynamic conditions change
(Table2).
Discussion
Since the late 1990s, MDCT has been considered the imag-
ing modality of choice in patients who sustained major
trauma [24–27]. Nowadays, there is a trend toward an
Fig. 2 Thoracic US and E-FAST in a male patient who sustained a
fall. a Absence of pleural sliding in the right lung and B lines: lung
point identified on AAL, US diagnosis of moderate pneumothorax
in an unstable patient, and immediate pleural tube drainage with the
escape of intrapleural air in the emergency room. b, c M-mode of the
same case. In c, we can see the inhomogeneous “seashore” sign, a
typical depiction of pleural sliding; on the right side of the image, the
typical homogeneous depiction of the absence of pleural sliding. US
diagnosis and documentation of moderate pneumothorax. CT scan
on axial (d) and sagittal reconstruction (e) confirms the diagnosis of
moderate right pneumothorax

465Journal of Ultrasound (2019) 22:461–469
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increasing involvement of US, performed in association
with MDCT, for the immediate evaluation of these patients,
especially in Europe [28–38].
One of the most frequent life-threatening conditions
encountered in this kind of trauma is pneumo-thorax, whose
detection is of the utmost clinical relevance because it may
quickly progress to cause hemodynamic instability as a con-
sequence of invasive ventilation.
Bedsides, radiography has a notorious low accuracy in
detecting pneumothorax, with values of sensitivities ranging
between 50 and 90% [39–46]. The recognition of specific
dynamic sonographic artifacts at the pleural line led to bed-
side US sensitivity values that are quite similar to the sen-
sitivity values of CT scans [47]. The encouraging results
coming from several studies performed on this topic, along
with the logistic advantages of performing thoracic US at
bedside patients, led ultrasonography to be incorporated into
the ATLS guidelines as FAST [11].
A systematic review performed by Alrajhi etal. [48],
involving 1047 patients, reported a sensitivity of 90.0% (95%
Fig. 3 CT scan and thoracic US and E-FAST in a male patient who
sustained a severe fall trauma. a The CT scan on the axial plane
shows a small pneumothorax on the anterior chest wall associated
with a parenchymal laceration (arrow) and wide areas of lung con-
tusions in the right lower lobe (head arrow). b The CT scan on the
coronal plane clearly demonstrates the contusions in both the lungs. c
Lung US performed on the right side depicts a wide area of parenchy-
mal consolidation (arrow) along with thick B lines and expression of
contusions (head arrows). d Lung US on the left lung shows several B
lines (arrows) and expression of parenchymal contusions

466 Journal of Ultrasound (2019) 22:461–469
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CI 86.5–93.9) and a specificity of 98.2% (95% CI 97.0–99.0)
for US. The same values for chest XR were, respectively,
50.2% (95% CI 43.5–57.0) and 99.4% (95% CI 98.3–99.8).
A study reported by Soldati etal. [2] showed that only 13 out
of 25 pneumothoraces were revealed by chest radiography
(sensitivity: 52%; specificity: 100%), whereas 23 out of 25
pneumothoraces (92%) were identified by US with one false-
positive result (sensitivity: 92%; specificity: 99.4%). They
also reported that US had high sensitivity in the diagnosis
of OP. Similarly, in a study by Nandipati etal., US and CT
results were similar in 95% of the cases [49].
In our study, we investigated the diagnostic performance
of thoracic US examination to rapidly detect pneumothorax
during the initial evaluation of majorly injured patients in
the emergency room.
Fig. 4 The diagnostic algorithm
used to define the sonographic
diagnosis of pneumothorax
(modified from Volpicelli etal.,
Intensive Care 2010)
Fig. 5 Sensitivity, specificity, accuracy during first three years of
experience
Table 1 Diagnostic performance values of Extended (to thorax) ultra-
sound
Parameters Thoracic
ultrasound
(%)
Overall sensitivity (%) 93.6
Specificity (%) 99.8
FP rate (%) 0.7
FN rate (%) 6.3
PPV (%) 99.2
NPV (%) 98.4
Overall accuracy (%) 98.6
Table 2 Advantages to perform a whole-body CT scan
MDCT as the gold standard in the assessment of major trauma
1. Whole body evaluation
Hemoperitoneum, hemoretroperitoneum
Active bleeding
Grading of parenchymal lesions
Vascular injuries
Musculoskeletal injuries
2. Rapid acquisition
3. Reconstructions: MIP, MPR, VR.
4. Can drive the therapeutic management
4. Reproducible:
Not operator dependent
Less prone to motion artifacts

467Journal of Ultrasound (2019) 22:461–469
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In the emergency department of our hospital, patients
suspected of having PNX on physical examination undergo
immediate tube or needle thoracostomy without awaiting
imaging studies [16]; those patients were excluded from
the present study. In those patients who do not require
immediate invasive interventions, a bedside US exami-
nation is performed immediately, during the primary
survey, by a trauma radiologist. The patient undergoes a
WB-MDCT examination immediately after the E-FAST
examination if hemoperitoneum is absent; otherwise, if
there is suspicion of solid organ injury that requires urgent
surgical exploration, the CT examination takes place
immediately after the laparotomy for damage control.
In our study, we evaluated the accuracy of E-FAST in
the detection of pneumothorax using MDCT as the refer-
ence standard examination. In those patients in which US
recognized a massive pneumothorax and in which a chest
drainage was placed before CT, we used the air flush at
the time of chest drainage as a criterion to confirm the US
diagnosis.
According to our results, E-FAST proved to be a rapid
and useful test for discovering pneumothorax with an overall
diagnostic accuracy of 98.6%. There were 10 false-positive
cases in the diagnosis of pneumothorax at US examination,
caused by emphysematous bullae. In our study, 12 cases of
significant subcutaneous emphysema caused false determi-
nation of the presence of pneumothorax. The most frequent
association with false negative (45%) was the association
with high BMI. In our series, US missed 84 out of 1328
cases of pneumothorax, 54 of which were not immediate life-
threatening with a thickness of less than 5mm at the MDCT
scan. Pneumothorax was bilateral in 236 of our cases, but
this fact did not affect the sensitivity of the E-FAST.
Several limitations of our study should, however, be taken
into account. First, this is a retrospective study, meaning
that US examinations were performed by different opera-
tors with different skills. All the operators of the radiology
staff performed thoracic US under the most difficult condi-
tions, including the restricted time interval required to carry
out the examination, poor logistic organization (performing
US at bedside and during the execution of other diagnostic
maneuvers), and noncollaborative patients, but nevertheless
the diagnostic performance of E-FAST was high.
Second, as this was a retrospective study, we could not
evaluate the accuracy of US in predicting the extension of
pneumothorax in comparison with MDCT. The extension
of PNX allows semiquantification of its volume, accurately
discriminating between mild, moderate, and massive cases.
This information can drive treatment decision-making in
most cases of PNX, even if the final decision depends on the
clinical condition of the patient: for example, in mechani-
cally ventilated patients, even a moderate PNX requires the
insertion of a chest tube.
Our mortality rate within 24h for hypertensive pneumo-
thorax (0%) and our mortality for every traumatic lesion
within 28days (14% at first neurologic lesions) seem to
demonstrate that this proposal of a new radiological ATLS
approach (E-FAST + WB-MDCT) has good results, reduces
time (E-FAST within 5min; WB-MDCT within 40min),
and decreases the many diagnostic steps between clinical
suspicion and definitive proof of injuries that require imme-
diate therapeutic maneuvers. Beyond pneumothorax diagno-
sis, further studies will need to be conducted to analyze the
clinical impact for every single traumatic lesion.
Conclusions
According to the ATLS recommendations, the following
imaging studies are systematically performed at the resus-
citation area for the initial evaluation of any trauma patients
involved in a high-energy accident or with loss of conscious-
ness [11]:
1. An anteroposterior (AP) chest radiograph
2. An AP pelvic radiograph
3. A lateral cervical spine radiograph
4. An abdominal sonograph
5. As soon as the vital functions have been stabilized, the
patient is brought in the CT facility to undergo a total
body CT examination.
6. Conventional radiograph examination of the limbs is
usually performed immediately after CT, provided that
it does not delay a life-saving procedure.
This approach can be considered anachronistic by now,
because it dates back to an era when thoracic US was not as
widespread and standardized as it is now [50].
Our results, in agreement with some previous studies
[51], demonstrate that bedside thoracic US is characterized
by very good accuracy in the diagnostic work-up of major
trauma patients, even in difficult conditions, allowing rapid
diagnosis of pneumothorax.
In our trauma room, thoracic US is always used during
FAST in which time-saving is very important to guarantee
immediate treatment. A protocol limited to the anterolat-
eral chest wall is sufficient to definitely rule out pneumo-
thorax because our MDCT analysis (with patients lying in
the supine position) of OP showed that the anterior area was
involved in almost all the cases.
In the perspective of a new radiological ATLS approach,
E-FAST during primary survey, together with WB-MDCT as
secondary survey, seems to demonstrate high enough accu-
racy to avoid pneumothorax-related death; the CT scanner
should be placed very close to or at best in the trauma room.
Further studies will be needed to strengthen this approach.

468 Journal of Ultrasound (2019) 22:461–469
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Author contributions SI and VM performed the data interpretation and
the critical revision. CL Piccolo contributed to the writing of the study,
the study design data analysis and data interpretation. MT and CAA-C
contributed to literature search and critical revision.
Funding No funding was provided.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval This article does not contain any studies with partici-
pants or animals performed by any of the authors.
Informed consent No patient information is included in this study.
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