Acute thoracic symptoms are common among adults visiting emergency departments in the United States. Adults with these symptoms constitute a large burden on the overall resources used in the emergency department. The wide range of possible causes can make a definitive diagnosis challenging, even after clinical evaluation and initial laboratory testing. In addition to radiography and computed tomography, thoracic ultrasonography (US) is an alternative imaging modality that can be readily performed in real time at the patient's bedside to help diagnose many thoracic diseases manifesting acutely and in the trauma setting. Advantages of US include availability, relatively low cost, and lack of ionizing radiation. Emergency thoracic US consists of two main parts, lung and pleura US and focused cardiac US, which are closely related. Acoustic mismatches among aerated lungs, pleura, chest wall, and pathologic conditions produce artifacts useful for diagnosis of pneumothorax and pulmonary edema and help in detection of subpleural, pleural, and chest wall pathologic conditions such as pneumonia, pleural effusion, and fractures. Visual assessment of cardiac contractility and detection of right ventricular dilatation and pericardial effusion at focused cardiac US are critical in patients presenting with acute dyspnea and trauma. Additional US examinations of the inferior vena cava for noninvasive volume assessment and of the groin areas for detection of deep venous thrombosis are often performed at the same time. This multiorgan US approach can provide valuable information for emergency treatment of both traumatic and nontraumatic thoracic diseases involving the lungs, pleura, chest wall, heart, and vascular system. Online supplemental material is available for this article. (©)RSNA, 2016.

The congenital absence of the left circumflex artery (LCx) is a very rare congenital anomaly of coronary arteries, but it is benign. Currently, the best modality for the diagnosis of coronary anomalies is computed tomography coronary angiography (CTCA). We report a case of congenitally absent LCx with an atypical chest pain.

Ultrasound plays a pivotal role in the evaluation of acute trauma patients through the use of multi-site scanning encompassing abdominal, cardiothoracic, vascular and skeletal scans. In a high-speed polytrauma setting, because exsanguinations are the primary cause of trauma morbidity and mortality, ultrasound is used for quick and accurate detection of hemorrhages in the pericardial, pleural, and peritoneal cavities during the primary Advanced Trauma Life Support (ATLS) survey. Volume status can be assessed non-invasively with ultrasound of the inferior vena cava (IVC), which is a useful tool in the initial phase and follow-up evaluations. Pneumothorax can also be quickly detected with ultrasound. During the secondary survey and in patients sustaining low-speed or localized trauma, ultrasound can be used to help detect abdominal organ injuries. This is particularly helpful in patients in whom hemoperitoneum is not identified on an initial scan because findings of organ injuries will expedite the next test, often computed tomography (CT). Moreover, ultrasound can assist in detection of fractures easily obscured on radiography, such as rib and sternal fractures.

ObjectivesThis study aims to determine the correlation of the caval index, inferior vena cava (IVC) diameter, and central venous pressure (CVP) in patients with shock in the emergency room.Materials and methodsThis is a prospective double-blind observational study conducted in the emergency room of a tertiary care center. All patients who presented with shock and had a central venous catheter insertion performed were enrolled. The caval index was calculated as a relative decrease in the IVC diameter during the normal respiratory cycle. The correlation of CVP and the caval index were calculated by Pearson’s product–moment correlation coefficient.ResultsAmong the 30 patients enrolled, the median age was 59.90±21.81 years and 17 (56.7%) patients were men. The summary statistics that were generated for the participants’ characteristics were divided into CVP <10 cm H2O, 10–15 cm H2O, and >15 cm H2O. The correlation of the CVP measurement with the ultrasound IVC caval index was r=−0.721 (P=0.000) by two-dimensional mode ultrasound and r=−0.647 (P=0.001) by M-mode. The correlations of CVP with the end-expiratory IVC diameter were r=0.551 (P=0.002) by two-dimensional mode ultrasound and r=0.492 (P=0.008) by M-mode. The sensitivity and specificity of the caval index were calculated to predict the CVP. The results showed that the cut-off points of the caval index were 30, 20, and 10 at CVP levels <10 cm H2O, 10–15 cm H2O, and >15 cm H2O, respectively.ConclusionThe caval index calculated from the IVC diameter measured by bedside ultrasound in the emergency room has a good correlation with CVP.

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