A comparison of sonographic examinations for trauma performed by surgeons and radiologists

Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury

BACKGROUND

Although the routine use of FAST (focused assessment with sonography for trauma) in the evaluation of trauma victims is increasing, to our knowledge, a prospective comparison of contemporary adult trauma victims managed with and without FAST has not been reported in North America.

METHODS

Adult victims of blunt trauma for whom there was a suspicion of abdominal injury were managed with one of two diagnostic algorithms, FAST or no-FAST. The two algorithms were compared for diagnostic accuracy, cost, time, and delayed diagnoses.

RESULTS

Among 706 patients (mean Injury Severity Score, 23), 460 were managed with FAST and 246 with no-FAST. The two groups were similar with respect to age, Injury Severity Score, prehospital time, and mortality (p = not significant). There were 3 of 460 (0.7%) delayed diagnoses in the FAST group and 4 of 246 (1.6%) in the no-FAST group (p = not significant). The diagnostic accuracy for the FAST and no-FAST algorithms was 99% and 98%, respectfully. The FAST and no-FAST algorithms led to similar rates of laparotomy, 13% and 14%, respectfully, but nonoperative management was more common in the no-FAST group (p < 0.01). The mean diagnostic cost for the FAST algorithm was $156, compared with $540 with the no-FAST algorithm (p < 0.0001) and the mean time required for diagnostic work-up was 53 minutes with the FAST algorithm, compared with 151 minutes with the no-FAST algorithm (p < 0.0001).

CONCLUSION

This study has provided prospective evidence that a FAST-based algorithm for blunt abdominal injury was more rapid, less expensive, and as accurate as an algorithm that used computed tomography or diagnostic peritoneal lavage only. Trauma centers are encouraged to incorporate a FAST-based algorithm into their initial management of blunt trauma victims.

Hemoperitoneum as the sole indicator of abdominal visceral injuries: a potential limitation of screening abdominal US for trauma

PURPOSE

To determine, at screening ultrasonography, the prevalence, severity, and clinical outcome of clinically important abdominal visceral injuries, without associated hemoperitoneum, that result from blunt abdominal trauma.

MATERIALS AND METHODS

Computed tomography (CT) was performed at admission in 466 patients with visceral injury. A retrospective review was performed of findings from surgery and contrast material-enhanced spiral and conventional CT performed to verify abdominal visceral injuries in 467 (4%) of 11,188 patients with blunt trauma. These patients were admitted to a level 1 trauma center over 33 months to determine the presence of hemoperitoneum and to identify the grade of injury. Medical records of patients with abdominal visceral injury without hemoperitoneum were reviewed for the management required and for results of focused abdominal sonography for trauma (FAST).

RESULTS

A total of 575 abdominal visceral injuries were identified at CT and/or surgery. Findings of CT at admission (n = 156) and of surgery (n = 1) revealed no evidence of hemoperitoneum in 157 (34%) patients with abdominal visceral injury; 26 (17%) of whom also had negative FAST studies. Abdominal visceral injuries diagnosed in patients without hemoperitoneum included 57 (27%) of 210 splenic injuries, 71 (34%) of 206 hepatic injuries, 30 (48%) of 63 renal injuries, four (11%) of 35 mesenteric injuries, and two (29%) of seven pancreatic injuries. Surgical and/or angiographic intervention was required in 26 (17%) patients without hemoperitoneum.

CONCLUSION

Reliance on the presence of hemoperitoneum as the sole indicator of abdominal visceral injury limits the value of FAST as a screening diagnostic modality for patients who sustain blunt abdominal trauma.

The role of ultrasound in the assessment of the trauma patient

Ultrasound assessment of the patient with blunt abdominal trauma will enhance diagnostic accuracy and facilitate decision making about the need for urgent surgery. Numerous studies have reported the role of ultrasound in the assessment of the trauma patient. Focused ultrasound has been shown to compare in sensitivity to diagnostic peritoneal lavage and is helpful in assessing the need for a laparotomy. Ultrasound is safe, cheap and portable. The investigation is non-invasive and painless. The trauma ultrasound scan can be completed in under 3 minutes and should be performed during the initial trauma assessment. The technique is not difficult to learn. Advances in technology are likely to make portable ultrasound increasingly appropriate to rural clinical practice. Detection of haemoperitoneum will be more accurate when ultrasound is available in the early care of trauma on a 24 hour basis and, to achieve this, clinicians managing trauma will need to become competent in the application of the focused ultrasound exam.

Injuries of the gastrointestinal tract from blunt trauma in children: a 12-year experience at a designated pediatric trauma center

INTRODUCTION

Nonoperative management of solid organ injury from blunt trauma in children has focused concern on potential delays in diagnosis of hollow viscus injury with resultant increases in morbidity, mortality, and cost. This study of a large pediatric trauma database will review the issues of difficulty and/or delay in diagnosis as it relates specifically to definitive treatment and outcome.

METHODS

We surveyed 11,592 consecutive admissions to a designated pediatric trauma center from 1985 to 1997 to identify children with documented injury of the gastrointestinal (GI) tract from blunt trauma. The records were extensively analyzed specifically in regard to mechanism of injury, type and site of injury, time to diagnosis, operative treatment, complications, and final outcome.

RESULTS

The 79 children identified, 4 months to 17 years old, included 27 females and 52 males. Mechanism of injury included 15 restrained and 7 unrestrained passengers, 15 pedestrians, 15 child abuse victims, 10 bike handlebar intrusions, 8 discrete blows to the abdomen, 4 bike versus auto, 3 falls, and 2 crush injuries. There were 51 perforations, 6 avulsions, and 22 lesser injuries including contusions. Injury of the small bowel was most common, 44 cases, followed by the duodenum, 18 cases, colon, 17 cases, and stomach, 6 cases. In 45 children, diagnosis was made quickly by a combination of obvious clinical findings, plain x-ray and/or initial computed tomographic findings mandating urgent operative intervention. Diagnosis was delayed beyond 4 hours in 34 children, beyond 24 hours in 17 children and was made by persistent clinical suspicion, aided by delayed computed tomographic findings of bowel wall edema or unexplained fluid. The six deaths were caused by severe head injury. Complications included two delayed abscesses and two cases of intestinal obstruction. All 73 survivors left the hospital with normal bowel function.

CONCLUSIONS

Injury to the GI tract from blunt trauma in children is uncommon (<1%). The majority of GI tract injuries (60%) are caused by a discrete point of energy transfer such as a seatbelt (19%), a handle bar (13%), or a blow from abuse (19%), or other blows and is unique to this population. Although diagnosis may be difficult and often delayed, this did not result in excessive morbidity or mortality. Safe and effective treatment of GI tract injuries is compatible with nonoperative management of most other injuries associated with blunt abdominal trauma in children, while reducing the risk of nontherapeutic laparotomy.