Cardiopulmonary exercise testing diagnosis of myocardial suppression

was carried out. The patient’s condition started deteriorating immediately and he became more tachypnoeic and dyspnoeic, with an oxygen saturation of 88%. A chest drain was inserted on the left side, but the patient became increasingly hypoxic, had seizures and progressed to a Pulseless Electrical Activity cardiac arrest. Cardiopulmonary resuscitation was started and the trachea intubated. With ongoing resuscitation, an ultrasound examination of the heart, using a 7 MHz linear ultrasound probe (SonoSite ; Bothell, Washington, DC, USA), showed no evidence of cardiac tamponade and examination of the both anterior lung fields showed an absence of sliding of the pleura on the right side indicating a possible pneumothorax. Based on this, a chest drain was immediately inserted on the right side and the patient had a return of spontaneous circulation within one resuscitation cycle of chest drain placement. The arrest lasted approximately 10 min. A review of the initial X-ray revealed that it was wrongly labelled for laterality and the intial needle decompression and chest drain had been performed on the wrong side. The patient made an uneventful recovery. A subsequent CT scan showed extensive bullous disease. In normal subjects when an ultrasound of the chest is done, the interface between the soft tissues of the chest wall and the aerated lung creates a hyperechogenic line which moves in synchrony with respiration; the lung sliding sign. The sign disappears when there is a pneumothorax. Based on the absence of the sliding sign, Soldati et al. [3] report a 92% sensitivity and 99.4% specificity for diagnosing occult pneumothoraces when compared to the gold standard of spiral CT, whereas chest X-ray had 52% sensitivity and 100% specificity. Ultrasound guided diagnostic imaging is already a part of the assessment abdominal trauma in adult trauma life support (ATLS Royal College of Surgeons of England, London, UK). Outside this however, its use in emergency situations seems to be fairly limited. The majority of life threatening conditions occur out of hours, when immediate expert help in imaging techniques is unavailable. In our case, the trainee involved was trained in ultrasound techniques and this proved decisive in the successful resuscitation. Currently, ultrasound equipment may not be readily available everywhere that in-hospital cardiac arrests occur. Training trainees operating in areas where it is available would improve confidence and readiness to use ultrasound imaging in emergencies. This would decrease our reliance on radiography, replacing it with the quicker, less cumbersome technique that is ultrasound imaging.