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