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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Monday, November 14, 2016

Deep Sulcus Sign

EM Didactic - November 14, 2016 - By Lakshay Chanana
..."Pneumothorax can sometimes become a difficult diagnosis. Patients don't read textbooks and may not give you a classic presentation such as obvious hypoxia and absent breath sounds. 
When USG is available, start with a quick lung USG but it can be difficult to comment on breath sounds in a patient who is bleeding from nostrils and breathing at 40/min with broken ribs. USG with M-Mode still is your best bet here. CXR cannot be used to rule out a pneumothorax. Another issue is that ED patients are usually supine and a small pneumothorax float anteriorly in the supine position, and if it is not big enough to wrap around the lateral edge of the lung, it may be missed. So we need to be aware of subtle signs on a CXR. The deep sulcus sign is one of the more subtle signs. 
The deep sulcus sign is a dark lateral sulcus where the chest wall meets the diaphragm. The amount of lung in this area is less, so a small amount of air will tend to darken the area making it more prominent.
Take Home:
  • PTx Diagnosis - Begin with History and Clinical exam followed by bedside USG - look for lung sliding (Lung sliding is Normal)
  • Scrutinise the CXR and look for deep sulcus sign but beware of false deep sulcus in COPDs.
  • CT only if high suspicion of Pneumothorax with equivocal USG and CXR