Lung Ultrasound for

Pulmonary Contusions
Samuel A. Dicker, DVM, DACVECC

KEYWORDS
 Lung ultrasound  Pulmonary contusions  Thoracic trauma  Motor vehicle trauma
 Vet BLUE  Alveolar-interstitial syndrome

KEY POINTS
 Lung ultrasound has high sensitivity for rapidly detecting pulmonary contusions.
 Multiple veterinary and human studies suggest that lung ultrasound is more sensitive for
pulmonary contusions than thoracic radiography.
 Lung ultrasound is portable, safe, and radiation-sparing.
 Lung ultrasound does not replace conventional radiography, especially for the diagnosis
of skeletal trauma.
 Diagnosis of pulmonary contusions with lung ultrasound, like any imaging modality, has
limitations, including pneumothorax, pleural effusion, atelectasis, subcutaneous emphy-
sema, and concurrent pulmonary disease.

INTRODUCTION

Rapid and reliable diagnosis of pulmonary contusions (PC) is essential to any veteri-
narian treating trauma patients. PC occur commonly in dogs, cats, and humans that
have sustained blunt force thoracic trauma.1–9 In dogs, severity of PC on thoracic ra-
diographs (TXR) has directly correlated with oxygen supplementation duration and
hospitalization time.1 In humans, severity of PC on thoracic computed tomography
(TCT) is highly predictive of the need for mechanical ventilation and the development
of acute respiratory distress syndrome.2,3,10
Lung ultrasound (LUS) has been documented to effectively and safely diagnose
PC in multiple prospective animal and human studies with high sensitivity and high
specificity. LUS relies on ultrasonographic artifacts to diagnose normal lung or
lung with increased extravascular lung water (B-lines and signs of consolidation,
including shred sign, tissue sign, nodule sign, and wedge sign) at the pulmonary-
pleural surface.6–9,11–23
Portable ultrasonography has become standard of care in most small animal veter-
inary practices treating emergencies, and its increased prevalence is largely due to

Veterinary Emergency & Referral Group, 196 4th Avenue, Brooklyn, NY 11217, USA
E-mail address: dicker.sam@gmail.com

Vet Clin Small Anim 51 (2021) 1141–1151

https://doi.org/10.1016/j.cvsm.2021.07.001 vetsmall.theclinics.com
0195-5616/21/ª 2021 Elsevier Inc. All rights reserved.
1142 Dicker

marked improvements in technology, image quality, as well as increased portability,

affordability, and ubiquity of operator skill. The diagnosis of PC with LUS allows the
clinician to obtain rapid and reliable information about the status of the patient’s lungs.
Point-of-care ultrasound (POCUS) can rapidly diagnose PC as well as concurrent
injury to allow for ongoing resuscitative efforts without the immediate need for trans-
porting the potentially unstable patient to the radiology suite. Furthermore, TXR re-
quires patient positioning in various recumbencies, potential for worsened alveolar
ventilation, increased patient stress, and potential staff exposure to radiation.
Although TCT imaging times are shortening and image quality continues to improve,
TCT is typically limited to referral practices and commonly uses some degree of pa-
tient restraint or sedation.

IMAGING FINDINGS

Most aspects of LUS remain the same regardless of imaging protocol. In brief, with
normal lung, the pulmonary-pleural line is identified, which is where the visceral pul-
monary pleura contacts the costal parietal pleura. As the animal breathes, the
pulmonary-pleural line “slides” to and fro; this “lung sliding” or “pleural glide” sign in-
dicates lack of pneumothorax (PTX). With PTX, the pulmonary-pleural lung sliding sign
is absent. It should be noted that LUS diagnosis of PTX is highly correlative with so-
nographer experience and skill and is discussed later in the article.7,8,24–26 A-lines
are horizontal lines that originate from the pulmonary-pleural line and are air reverber-
ation artifacts. A-lines are present with normal aerated lung and with PTX. When alveoli
begin filling with edema, this creates an ultrasonographic artifact called B-lines
(Fig. 1). B-lines are created by the ultrasound waves interacting with the fluid-air inter-
face in the alveoli on the surface of lung that creates a hyperechoic, nonfading, laser-
like, vertical line originating from the pulmonary-pleural line and extending to the
bottom of the ultrasound screen. These B-lines move in synchrony with phases of
respiration and obliterate A-lines. B-lines can be quantified and increase as pulmonary
edema increases.7,9,11–22 With an increasing amount of pulmonary edema, alveoli
become devoid of air; the lung parenchyma can now be sonographically visualized,
and it appears more tissuelike, similar to liver. LUS signs of consolidation have
been termed “shred sign,” representing an air bronchogram, and “tissue sign,” repre-
senting hepatization.
Collectively, any fluid in the lung is termed alveolar-interstitial syndrome
(AIS).6–9,11–23 LUS identification of AIS is not necessarily diagnostic for PC because
AIS may indicate any type of pulmonary edema. The cause of AIS in a particular patient
must be correlated with anatomic locations of edema and patient signalment, history,
as well as other physical examination and diagnostic imaging findings.7 Because pre-
vious studies determined that small numbers of B-lines are occasionally seen in
healthy dogs and cats with radiographically normal lungs, most studies suggest that
there must be greater than 3 B-lines (or signs of consolidation) present in order to
be considered positive for increased extravascular lung water (edema) on LUS.15

IMAGING PROTOCOLS
Veterinary Brief Lung Ultrasound Examination
The Veterinary Brief Lung Ultrasound Examination (Vet BLUE) protocol was adapted
from the Bedside Lung Ultrasound Examination in people and was first described in
dogs and cats by Lisciandro and colleagues.12,15 The Vet BLUE protocol was used
to study PC in a study of motor vehicle trauma in dogs.7 The Vet BLUE protocol con-
sists of 4 bilaterally applied thoracic acoustic windows (8 total acoustic windows),
 Lung Ultrasound for Pulmonary Contusions 1143

Fig. 1. The Vet BLUE. The patient may be in sternal recumbency or standing. The ultrasound
probe is held horizontally (perpendicular to the long axis of the ribs) at 4 specific acoustic
windows on each hemithorax. Lung pathologic condition is noted in real time. Ideally, video
images are recorded for post hoc review ability. Below the illustration, still B-mode images
with corresponding illustrations depict (A) normal LUS with no B-lines (left) compared with
(B) abnormal LUS with B-lines (right). (Reproduced with permission from Ward JL, Lisciandro
GR, Keene BW, et al. Accuracy of point-of-care lung ultrasonography for the diagnosis of
cardiogenic pulmonary edema in dogs and cats with acute dyspnea. J Am Vet Med Assoc
2017;250(6):666-675.)

referred to as the caudodorsal (Cd), perihilar (Ph), middle (Md), and cranial (Cr) lung
regions (see Fig. 1). Dogs are best imaged standing or in sternal recumbency to avoid
atelectasis.19,27 Hair is not clipped; the fur is parted to the skin, and a small amount of
70% isopropyl alcohol is applied at each acoustic window. If wounds are present,
sterile ultrasound gel may be applied in lieu of alcohol. The ultrasound probe marker
is directed cranially, and the probe is placed between 2 ribs, yielding the “gator sign,”
also described as the “bat sign” in human medical literature.12,13,18,19 The ultrasound
probe is fanned dorsally and ventrally to optimize visualization of the pulmonary-
pleural line as well as to record the maximum number of B-lines at each acoustic
window.7,15
A potential downfall of the Vet BLUE protocol is that the entire lung surface is not
imaged, and acoustic windows are limited to 4 acoustic windows per hemithorax.
However, the Vet BLUE protocol was designed to be rapid and easily repeated.7 In
addition, more recent adaptations of the Vet BLUE protocol include imaging at least
1 intercostal space cranial to and 1 intercostal space caudal to the initial acoustic win-
dow, limiting the amount of lung surface left unimaged.20 The author typically performs
1144 Dicker

an adaptation of the Vet BLUE protocol by fanning the ultrasound probe dorsally and
ventrally as well as sliding the ultrasound probe dorsally and ventrally in each inter-
costal space at each Vet BLUE site in order to image more lung surface area. As an
alternative to lifting the probe from the skin when good contact has been made, gentle
traction on moveable skin may be used while moving the ultrasound probe to image
adjacent lung, especially in smaller animals and animals with pliable skin.

Veterinary-Focused Assessment with Sonography for Trauma–Airway, Breathing,

Circulation, Disability, and Exposure
The Veterinary-focused Assessment with Sonography for Trauma–Airway, Breathing,
Circulation, Disability, and Exposure (VetFAST-ABCDE) is an adaptation of the FAST-
ABCDE protocol used in human point-of-care emergency ultrasound protocols.8,28
This protocol combines multiple POCUS techniques to assess thoracic and abdom-
inal injury, cardiovascular status, as well as optic nerve diameter to assess presumed
changes in intracranial pressure. For the purpose of this article, only the thoracic scan-
ning technique (Breathing) will be discussed. For LUS, hair is clipped in the middle
third of the thorax from the fourth to the seventh rib bilaterally (Fig. 2 ). In order to im-
age the thorax, the skin is gently grasped and moved in several directions. The probe
marker is directed cranially. The probe is slid dorsally and ventrally along the inter-
costal spaces between the fourth and ninth ribs on the left and right hemithoraces.8
Potential downsides of the VetFAST-ABCDE protocol include only imaging between
the fourth and ninth ribs (leaving certain acoustic windows, particularly the cranioven-
tral and para-axillary regions, unimaged), time required to clip the patient’s hair, and

Fig. 2. Clipping fur is typically not required to perform a diagnostic LUS study. Parting of the
fur usually provides an adequate acoustic window. The VetFAST-ABCDE protocol involves
clipping fur in the center of each hemithorax and gently grasping and moving the skin to
allow for visualization of all possible acoustic windows on the lateral aspects of the thorax.
The ultrasound probe marker is directed cranially, and the probe is slid between the fourth
and ninth intercostal spaces. (Reproduced with permission from Armenise A, Boysen RS,
Rudloff E, et al. Veterinary-focused assessment with sonography for trauma-airway, breath-
ing, circulation, disability and exposure: a prospective observational study in 64 canine
trauma patients. J Small Amim Prac 2019;60:173-182.)
 Lung Ultrasound for Pulmonary Contusions 1145

potentially unnecessarily clipping hair, which may be aesthetically unappealing to an-

imal owners, especially in animals with minor injury that are ultimately not admitted to
the hospital. An accurate LUS image is typically achievable without clipping
hair.7,15,17–25

VETERINARY STUDIES

The study by Dicker and colleagues7 was a prospective observational study exam-
ining the utility of LUS for diagnosing PC. The case population consisted of 29 dogs
that sustained blunt force motor vehicle trauma and had thoracic imaging within 24
hours of presentation. Comparative imaging included LUS (Vet BLUE protocol),
TXR, and TCT, and all 3 imaging modalities were completed within 30 minutes of
one another. TCT was used as the gold standard. If PTX was identified on LUS,
thoracocentesis was performed before full Vet BLUE protocol image acquisition.
Dogs were considered positive for PC if greater than 3 total B-lines were identified.
Twenty-one of 29 dogs were positive for PC on gold-standard TCT (72.4% preva-
lence). Vet BLUE was 90.5% sensitive (19/21 dogs) and 87.5% specific (7/8 dogs)
for PC, whereas TXR was only 66.7% sensitive (14/21 dogs) and 87.5% specific (7/
8 dogs) for PC. This study concluded that Vet BLUE had high sensitivity for diag-
nosis of PC, higher than TXR, and provided a reliable diagnosis of trauma-
induced PC. Of the 32 dogs enrolled in the study, 3 dogs were excluded from
statistical analyses. One dog had severe subcutaneous emphysema (SQE), and 2
dogs had large-volume pleural effusion (PE) (hemothorax). The Vet BLUE protocol
used was an older protocol that surveyed only a single intercostal space at each
Vet BLUE acoustic window; it is possible the newer, updated Vet BLUE protocol
(imaging 1 intercostal space cranial and caudal to each Vet BLUE acoustic window)
may have yielded higher sensitivity. Additional limiting factors for Vet BLUE are later
discussed in this article.
LUS is limited to imaging the pulmonary-pleural surface and therefore only lung
pathologic condition that reaches the lung periphery. Thus, LUS cannot detect deeper
pulmonary pathologic condition. In this study, the radiologist examined if PC extended
to the pulmonary-pleural interface on TCT. Interestingly, all 21 dogs true positive for
PC on TCT had some degree of PC reach the pulmonary-parietal pleural interface
on TCT, indicating that LUS should identify these as PC-positive dogs (Fig. 3). Two
dogs in the study were falsely negative for PC on Vet BLUE for unexplained reasons.7
Armenise and colleagues8 performed LUS using the VetFAST-ABCDE protocol as
well as standard TXR on 64 dogs with blunt and/or penetrating trauma and reported
similar findings. AIS consistent with PC were identified in 30/64 dogs (47% cases)
on LUS and only 19/64 dogs (29.7% cases) on TXR. All of the dogs positive for PC
on TXR were positive for PC on LUS. TCT was not used.8 Both studies indicate that
LUS has high sensitivity for diagnosis of PC, higher than TXR.7,8

HUMAN STUDIES

Multiple human trauma studies demonstrated the high sensitivity of LUS compared
with the TCT “gold standard,” and that LUS outperforms TXR for detecting PC.6,9 In
a study purely aimed at determining the diagnostic accuracy of PC, Soldati and col-
leagues9 determined that LUS was 94.6% sensitive and 96.1% specific for identifying
PC when compared with TCT, and TXR were 27% sensitive and 100% specific for PC.
This study excluded patients with “PTX of any size or subcutaneous emphysema
(SQE) large enough to compromise the quality of the examination, in the examiner’s
opinion.”9 However, SQE may be less problematic in dogs than in people. In the
1146 Dicker

Fig. 3. A 2-year-old male neutered Chihuahua mix that was positive for PC on Vet BLUE,
TXR, and TCT. (A) LUS image at the left Vet BLUE middle lung region with signs of consol-
idation (dashed arrows) and confluent B-lines (scored as infinite) (solid arrows). (B) Ventro-
dorsal TXR (combined with lateral radiographs, not shown) scored as positive for PC with an
alveolar pattern in the right Vet BLUE caudodorsal and left Vet BLUE middle lung regions
(circle). (C) Thoracic CT image of PC in both the left and the right lungs. Some degree of
PC (solid arrows) reaches the pulmonary-pleural surface, and other regions of PC are
more central (dashed arrows), the latter which are not visible with LUS. (Reproduced with
permission from Dicker SA, Lisciandro GR, Newell SM, Johnson JA. Diagnosis of pulmonary
contusions with point-of-care lung ultrasonography and thoracic radiography compared to
thoracic computed tomography in dogs with motor vehicle trauma: 29 Cases (2017-2018). J
Vet Emerg Crit Care. 2020;1–9.)

original Thoracic Focused Assessment with Sonography for Trauma (TFAST) study,
5% (7/138) of dogs had SQE, none of which were disqualified from TFAST imaging.24
The investigators stated that gentle probe pressure displaced the SQE in order to
identify the pulmonary-pleural line, allowing for PTX and LUS assessment.24
LUS has the ability to diagnose multiple manifestations of thoracic trauma, including
PC, PTX, and hemothorax in human trauma patients. Hyacinthe and colleagues
concluded that LUS had greater sensitivity than combined clinical examination and
chest radiography for the diagnosis of PC.6 LUS was 61% sensitive and 80% specific
for diagnosis of PC, whereas clinical examination and TXR were 29% sensitive and
94% specific for diagnosis of PC. The investigators postulated that LUS achieved a
lower sensitivity compared with previous studies (such as Soldati and colleagues9)
because these studies excluded certain patients, such as those with SQE or those
who required mechanical ventilation.6,9 Furthermore, the investigators emphasized
that PTX or hemothorax may have prevented a diagnosis of PC. The study findings
highlight that multiple manifestations of thoracic trauma are often present in a single
patient, and PC are often accompanied by limiting confounding variables, such as
PTX, PE, and SQE (see next section, Limitations and Confounding Variables).6

LIMITATIONS AND CONFOUNDING VARIABLES

Pneumothorax
Because ultrasound poorly penetrates air, PTX precludes ultrasonographic visualiza-
tion of the lung parenchyma and renders is it impossible to assess for PC at affected
acoustic windows. Therefore, the clinician’s proper identification of PTX via LUS is of
utmost importance as to not mistake lack of pulmonary pathologic condition with
normal aerated lung surface. Ultrasonographic evidence of PTX is diagnosed by
lack of “lung sliding” and identifying the “lung point” along with other LUS imaging
strategies (see Søren R. Boysen’s article, “Lung Ultrasound for Pneumothorax in
 Lung Ultrasound for Pulmonary Contusions 1147

Dogs and Cats,” in this issue). Correct ultrasonographic identification of PTX varies
highly with sonographer experience and study protocol. These studies suggest and
the author’s opinion is that experienced sonographers infrequently misidentify clini-
cally relevant PTX.8,24–26 Therapeutic thoracocentesis allows for visualizing the pulmo-
nary parenchyma; however, an indeterminate amount of time may be required for
atelectasis to resolve (see the later section Atelectasis).7,27
Pleural Effusion
PE may be identified with any imaging modality, and LUS is no exception. Hemothorax
is not an uncommon manifestation of thoracic trauma. PE can cause pressure atelec-
tasis, causing an increased “fluid-air” artifact as seen with pulmonary AIS. Thus, PE
may lead to B-lines or even signs of lung consolidation deep to the PE on the ultra-
sound screen, making a true diagnosis of PC confounded.6,7 Large volumes of PE
may require therapeutic thoracocentesis if clinically indicated. Serial LUS may help
differentiate pressure atelectasis from true PC postdrainage techniques with atelec-
tasis likely to resolve more quickly than PC.
Subcutaneous Emphysema
SQE is not uncommon with trauma. In the case of SQE, air artifact in the subcutaneous
space potentially creates “E-lines,” which are vertical hyperechoic beams similar to
B-lines.23 These E-lines do not move synchronously with respiration and originate
from the subcutaneous tissue rather than the pulmonary-pleural line. As a general
rule, if the pulmonary-pleural line (ie, gator sign) cannot be identified, then LUS cannot
be performed accurately. Moreover, SQE may be noted on physical examination. SQE
is generally surmountable with gentle ultrasound probe pressure that displaces the
subcutaneous air so that the pulmonary-pleural line may be accurately identified.24
In patients with SQE over rib fractures, the sonographer can avoid additional ultra-
sound probe pressure to avoid patient discomfort.7
Cutaneous Wounds
In cases of open wounds or degloving injuries, the clinician must make a judgment as
to whether ultrasound imaging may cause more harm, such as causing pain or noso-
comial wound contamination. If wounds are small, isopropyl alcohol may be
substituted with an aqueous-based sterile ultrasound gel. The ultrasound probe
should either be clean or covered with a sterile probe cover (or surgical glove).
Underlying Comorbidities
Although increased numbers of B-lines in trauma are likely PC, they are not pathogno-
monic and may indicate increased extravascular lung water of various causes,
including acute or chronic pulmonary conditions. LUS serves as an excellent
screening and monitoring tool for lung surface pathologic condition in traumatized
dogs, but the presence of AIS does not necessarily indicate PC.7,8,11–23 Dogs who
sustain trauma, particularly those involved in motor vehicle trauma, are typically young
dogs unlikely to have pulmonary or cardiac disease.17,18,20–22 In an epidemiologic
study in the United Kingdom, the median age for dogs in road traffic accidents was
2.5 years.29 In 1 study, dogs with motor vehicle trauma had a mean age of 3.3 years
(3.0 years, standard deviation).7 Another study describes the median age of trauma
patients was 4 years.8 Thus, younger dogs having recently sustained trauma with AIS
on LUS likely indicate PC, but other manifestations of trauma, such as neurogenic pul-
monary edema (eg, head trauma), negative pressure pulmonary edema (eg, strangu-
lation or drowning), or nontraumatic causes of AIS, should be considered. Patient
1148 Dicker

history, signalment, and the entire clinical profile are necessary when diagnosing PC
on any imaging modality for accurate interpretation.

Atelectasis
Areas of lung atelectasis may yield a false positive for AIS or PC on any imaging mo-
dality. Atelectasis causes an increased “fluid-air” artifact as seen with AIS. Atelectasis
is typically affected by recumbency, sedation, and patient ventilatory capability.30 An
advantage of LUS compared with TXR or TCT is that sedation is not required, and pa-
tients are typically imaged in sternal recumbency or standing to avoid atelectasis.7 Ex-
amples of trauma patients that may have atelectasis on presentation include patients
in lateral recumbency for a prolonged period of time, those hypoventilating, or those
having received sedation.30–32

OTHER IMAGING MODALITIES

LUS for diagnosis of PC in conjunction with other POCUS protocols (ie, AFAST
[Abdominal Focused Assessment with Sonography for Trauma], TFAST) is an excel-
lent triage tool for rapid, reliable, and real-time results.25,33 Although most trauma pa-
tients are destined for radiography, LUS is particularly useful for initial and serial
assessment of hospitalized trauma patients without the delay in imaging and potential
risk of transportation to the radiology suite. LUS, however, does not replace conven-
tional TXR or advanced imaging, such as TCT, for thoracic trauma patients, especially
for assessing skeletal fractures, diaphragmatic hernia, and mediastinal injuries. Addi-
tional imaging, such as TXR and TCT, when indicated, should be used in conjunction
with LUS and other FAST findings.34,35

USE OF ACOUSTIC COUPLING MEDIUM

Large amounts of acoustic coupling medium are seldom needed and should be
avoided. Isopropyl alcohol, ultrasound gel, and sterile saline are often used as acous-
tic coupling medium for ultrasound. The author rarely uses ultrasound gel for LUS
because only certain acoustic windows are imaged. The patient’s skin can often be
gently moved to image multiple acoustic windows. The hair can most often be parted
to the skin at the intended acoustic window, and isopropyl alcohol can be applied in a
small quantity. Many animals being screened for PC are in shock or respiratory
distress. Application of large volumes of isopropyl alcohol is unnecessary for most
LUS imaging and may cause or worsen hypothermia. Alcohol fumes may be noxious
to both the operator and the animal, especially if the animal is then placed into a
confined oxygen kennel. Furthermore, isopropyl alcohol is flammable and thus serves
as a fire hazard if electrical defibrillation is subsequently needed.36

SUMMARY

LUS is a rapid and reliable way to diagnose PC in patients who have sustained trauma,
especially in young dogs with low probability of preexisting pulmonary comorbidities.
LUS diagnosis of PC exceeds that of TXR in multiple animal and human studies. Diag-
nosis of PC with LUS is an essential tool for any small animal emergency clinician, and
it may be easily learned. The sonographer should understand potential caveats for
proper diagnosis of LUS with PC, including PTX, PE, atelectasis, and SQE. LUS
does not replace conventional TXR or TCT, especially for diagnosis of skeletal trauma
and deeper pulmonary pathologic condition. LUS should be used concurrently with
 Lung Ultrasound for Pulmonary Contusions 1149

other POCUS trauma protocols to rapidly optimize the clinician’s assessment of the
patient’s clinical picture.

DISCLOSURE

The author discloses no conflicts of interest.

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