Elsevier

Injury

Volume 46, Issue 5, May 2015, Pages 817-821
Injury

Do we really rely on fast for decision-making in the management of blunt abdominal trauma?

https://doi.org/10.1016/j.injury.2014.11.023Get rights and content

Abstract

Introduction

The Focused Assessment with Sonography in Trauma examination (FAST) is currently taught and recommended in the ATLS®, often as an addendum to the primary survey for patients with blunt abdominal trauma. Although it is non-invasive and rapidly performed at bedside, the utility of FAST in blunt abdominal trauma has been questioned. We designed this study to examine our hypothesis that FAST is not an efficacious screening tool for identifying intra-abdominal injuries.

Methods

We performed a retrospective chart review of all patients with confirmatory diagnosis of blunt abdominal injuries with CT and/or laparotomy for a period of 1.5 years (from 7/2009 to 11/2010). FAST was performed by ED residents and considered positive when free intra-abdominal fluid was visualized. Abdominal CT, or exploratory laparotomy findings were used as confirmation of intra-abdominal injury.

Results

A total of 1671 blunt trauma patients were admitted to and evaluated in the Emergency Department during a 1½ year period and 146 patients were confirmed intra-abdominal injuries by CT and/or laparotomy. Intraoperative findings include injuries to the liver, spleen, kidneys, and bowels. In 114 hemodynamically stable patients, FAST was positive in 25 patients, with a sensitivity of 22%. In 32 hemodynamically unstable patients, FAST was positive in 9 patients, with a sensitivity of 28%. A free peritoneal fluid and splenic injury are associated with a positive FAST on univariate analysis, and are the independent predictors for a positive FAST on multiple logistic regression.

Conclusion

FAST has a very low sensitivity in detecting blunt intraabdominal injury. In hemodynamically stable patients, a negative FAST without a CT may result in missed intra-abdominal injuries. In hemodynamically unstable blunt trauma patients, with clear physical findings on examination, the decision for exploratory laparotomy should not be distracted by a negative FAST.

Introduction

The detection of closed abdominal injury remains a challenge for trauma surgeons, especially when a patient presents with multiple trauma. Either false-positive or false-negative findings in the diagnosis carries a risk of severe complications. The Focused Assessment with Sonography in Trauma (FAST) is a non-invasive bedside test that can be performed in conjunction with resuscitation. The application of FAST has been taught in the Advanced Trauma Life Support® (ATLS®), and recommended as the screening tool of choice for early diagnostic investigations in patients with suspected blunt abdominal trauma. It has been used for more than 20 years [1], as an addendum to the primary survey. FAST is universally available in almost all trauma centres in the United States and other countries where ATLS has been adapted. Ultrasound is portable and can be repeated throughout resuscitation and during any period of observation. The ultrasound based clinical pathways enhance the speed of primary trauma assessment, reduce the exposure of ionizing radiation and cut costs. However, the role of FAST in the diagnosis of intraabdominal injuries has not been well established. FAST compares unfavourably with computed tomography (CT) in the diagnosis of blunt intraabdominal injuries. Thus far, it is not clear whether FAST can be safely used as a tool for identifying intraabdominal injuries and obviating the use of CT before a laparotomy is performed.

We therefore performed this retrospective study to evaluate whether FAST examination is reliable as a primary tool for the assessment of intraabdominal injury and to determine if a CT scan can be obviated before the decision-making of management of patients with blunt trauma. Our hypothesis is that FAST examination is not reliable for decision-making in the management of patients with blunt abdominal trauma.

Section snippets

Materials and methods

This study was approved by the institutional review board (IRB) of the University at Buffalo, the State University of New York. We retrospectively identified consecutive patients with intraabdominal injuries from our Trauma Registry from July 2009 through December 2010. These patients were identified with the International Classification of Diseases (ICD, 9th edition) diagnosis codes of intra-abdominal injuries, including 863 (GI), 864 (liver), 865 (spleen), 866 (kidney), 867 (pelvic organs),

Results

For the 1½ year study period, 1671 blunt trauma patients were admitted to and evaluated in the Emergency Department at our institute with an average ISS score of 23. A total of 142 patients were confirmed with CT scan (53 of them underwent surgical interventions), and 4 patients were confirmed only with intraoperative findings of blunt intraabdominal injuries without CT scan (Fig. 1). Of those 32 hypotensive patients with intraabdominal injury, three patients were directly taken to the

Discussion

The objective of this study was to evaluate how precise and reliable FAST is as a primary tool for the initial assessment of injury in blunt abdominal trauma patient. Our study demonstrated that, contrary to previous study, FAST has a very low sensitivity in the diagnosis of blunt intraabdominal injuries, as only free peritoneal fluid and splenic injury are associated with a positive FAST exam. The results proved our hypothesis that FAST examination is not reliable for decision-making in the

Conflict of interest

The authors declare no conflict of interest.

Financial disclosures

None.

Acknowledgment

The authors thank Ms. Elizabeth Bevilacqua for her assistance with the preparation of the manuscript.

References (17)

  • J.A. Chambers et al.

    Ultrasound in abdominal trauma: an alternative to peritoneal lavage

    Arch Emerg Med

    (1988)
  • J.P. McGahan et al.

    The focused abdominal sonography for trauma scan: pearls and pitfalls

    J Ultrasound Med

    (2002)
  • M.P. Federle et al.

    Hemoperitoneum studied by computed tomography

    Radiology

    (1983)
  • P. Tso et al.

    Sonography in blunt abdominal trauma: a preliminary progress report

    J Trauma

    (1992)
  • M.G. McKenney et al.

    1,000 consecutive ultrasounds for blunt abdominal trauma

    J Trauma

    (1996)
  • B.C. Lee et al.

    The utility of sonography for the triage of blunt abdominal trauma patients to exploratory laparotomy

    AJR

    (2007)
  • A. Rodriguez et al.

    Recognition of intra-abdominal injury in blunt trauma victims. A prospective study comparing physical examination with peritoneal lavage

    Am Surg

    (1982)
  • B. Natarajan et al.

    FAST scan: is it worth doing in hemodynamically stable blunt trauma patients?

    Surgery

    (2010)
There are more references available in the full text version of this article.

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This paper was partly presented as a poster at the 71st Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery, Kauai, Hawaii, September 2012.

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