The efficacy of focused abdominal sonography for trauma (FAST) as a screening tool in the assessment of injured children

Gastrointestinal Perforation with Blunt Abdominal Trauma in Children

Gastrointestinal tract perforation is uncommon in children, accounting for <10% of cases of blunt abdominal trauma. Diagnosis of bowel perforation in children can be challenging due to poor diagnostic imaging accuracy. Intra-abdominal free air is found only in half of the children with bowel perforation. Ultrasound findings are nonspecific and suspicious for perforation in only two-thirds of cases. A computer tomography (CT) scan has a sensitivity and specificity of 50% and 95%, respectively. Surgical decisions should be made based on clinical examination despite normal CT results. Management of bowel perforation in children includes primary repair in 50-70% and resection with anastomosis in 20-40% of cases.

Focused assessment with sonography for trauma in predicting early surgical intervention in hemodynamically unstable children with blunt abdominal trauma

OBJECTIVES

The predictive accuracy and clinical role of the focused assessment with sonography for trauma (FAST) exam in pediatric blunt abdominal trauma are uncertain. This study investigates the performance of the emergency department (ED) FAST exam to predict early surgical intervention and subsequent free fluid (FF) in pediatric trauma patients.

METHODS

Pediatric level 1 trauma patients ages 0 to 15 years with blunt torso trauma at a single trauma center were retrospectively reviewed. After stratification by initial hemodynamic (HD) instability, the association of a positive FAST with (1) early surgical intervention, defined as operative management (laparotomy or open pericardial window) or angiography within 4 hours of ED arrival and (2) presence of FF during early surgical intervention was determined.

RESULTS

Among 508 salvageable pediatric trauma patients with an interpreted FAST exam, 35 (6.9%) had HD instability and 98 (19.3%) were FAST positive. A total of 42 of 508 (8.3%) patients required early surgical intervention, and the sensitivity and specificity of FAST predicting early surgical intervention were 59.5% and 84.3%, respectively. The specificity and positive predictive value of FF during early surgical intervention in FAST-positive HD unstable patients increased from 50% and 90.9% at 4 hours after ED arrival to 100% and 100% at 2 hours after ED arrival, respectively.

CONCLUSIONS

In this large series of injured children, a positive FAST exam improves the ability to predict the need for early surgical intervention, and accuracy is greater for FF in HD unstable patients 2 hours after arrival to the ED.

Reliability of Focused Assessment With Sonography for Trauma in the Diagnosis of Blunt Torso Trauma

Objective:

Focused assessment with sonography for trauma (FAST) is a widely used imaging technique for the diagnosis of blunt abdominal trauma and has its limitations and advantages. A meta-analysis was completed to evaluate the reliability of FAST, in the diagnosis of blunt torso trauma.

Materials and Methods:

A search was completed with Google Scholar, PubMed, National Center for Biotechnology Information (NCBI), MEDLINE, and Medscape databases, from 1993 up to 2020. Eligible studies were included for information about FAST examination of abdominal trauma. The animal research was excluded from this review process. The eligible studies were first categorized and then data analysis was performed, according to specific pathologic conditions. This literature review retrieved studies’ sample size, application, sensitivity, and a specificity of diagnosis using FAST for abdominal trauma.

Results:

In total, 100 articles were identified through the database search. Besides, five articles were identified through other sources. Then, screening was performed, and as such, 46 published studies were included that had a qualitative synthesis.

Conclusion:

FAST has a high sensitivity and specificity in the diagnosis of blunt abdominal trauma. However, a large range of sensitivity and specificity of FAST in the evaluation of torso trauma reveal that sonography is operator, technique, and equipment dependent.

The Utility of the Focused Assessment With Sonography in Trauma Examination in Pediatric Blunt Abdominal Trauma: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the utility of the Point of Care Ultrasound (POCUS) Focused Assessment with Sonography for Trauma (FAST) examination for diagnosis of intra-abdominal injury (IAI) in children presenting with blunt abdominal trauma.

METHODS

We searched medical literature from January 1966 to March 2018 in PubMed, EMBASE, and Web of Science. Prospective studies of POCUS FAST examinations in diagnosing IAI in pediatric trauma were included. Sensitivity, specificity, and likelihood ratios (LR) were calculated using a random-effects model (95% confidence interval). Study quality and bias risk were assessed, and test-treatment threshold estimates were performed.

RESULTS

Eight prospective studies were included encompassing 2135 patients with a weighted prevalence of IAI of 13.5%. Studies had variable quality, with most at risk for partial and differential verification bias. The results from POCUS FAST examinations for IAI showed a pooled sensitivity of 35%, specificity of 96%, LR+ of 10.84, and LR- of 0.64. A positive POCUS FAST posttest probability for IAI (63%) exceeds the upper limit (57%) of our test-treatment threshold model for computed tomography of the abdomen with contrast. A negative POCUS FAST posttest probability for IAI (9%) does not cross the lower limit (0.23%) of our test-treatment threshold model.

CONCLUSIONS

In a hemodynamically stable child presenting with blunt abdominal trauma, a positive POCUS FAST examination result means that IAI is likely, but a negative examination result alone cannot preclude further diagnostic workup for IAI. The need for computed tomography scan may be obviated in a subset of low-risk pediatric blunt abdominal trauma patients presenting with a Glasgow Coma Scale of 14 to 15, a normal abdominal examination result, and a negative POCUS FAST result.

The Predictors for Positive Yield Abdominal Computed Tomography in Pediatric Abdominal Trauma

OBJECTIVES

Abdominal computed tomography (ACT) use in the initial evaluation of pediatric abdominal trauma is liberal in most instances. The aim of this study was to identify the predictors for a positive yield ACT scan in this population.

METHODS

A prospective, cohort, single-center observational study was conducted at Children's Hospital at Westmead, New South Wales, from January 2008 to June 2015 on 240 pediatric abdominal trauma patients who had abdominal computed tomography. Clinical, laboratory, imaging, and interventional variables were explored with univariate and multivariate analyses among children who sustained abdominal trauma.

RESULTS

Of 240 patients, positive ACT scans were found in 161 patients (67%), 112 patients (47%) had intra-abdominal injury, and 20 patients (8%) required invasive therapeutic interventions. Mortality rate was 1.7% (4 patients) due to nonabdominal causes. Multivariate analyses revealed that increasing age (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.02-1.24; P = 0.024), high injury severity score (OR, 1.14; 95% CI, 1.07-1.21; P < 0.001), abnormal abdominal examination (OR, 5.95; 95% CI, 2.08-17.01; P = 0.001), elevated alanine aminotransferase greater than 125 IU/L (OR, 46.28; 95% CI, 2.81-762.49; P = 0.007), abnormal pelvic radiograph (OR, 14.03; 95% CI, 2.39-82.28; P = 0.003), presence of gross hematuria (OR, 4.14; 95% CI, 1.04-18.23; P = 0.044), low initial hematocrit level (less than 30%) (OR, 8.51; 95% CI, 1.14-63.70; P = 0.037), and positive focused assessment with sonography for trauma (OR, 2.61; 95% CI, 1.01-7.28; P = 0.048) remained significantly associated with abnormal ACT scan. In contrast, those who required scanning of other body region(s) were less likely to have abnormal ACT scan (OR, 0.34; 95% CI, 0.14-0.86; P =0.022).

CONCLUSIONS

Integrating the abdominal examination findings, relevant laboratory values, and focused assessment with sonography for trauma results with the physicians' suspicion may aid in stratifying patients for ACT scan. Further efforts should be made to decrease number of normal ACT scans; yet not to increase the number of delayed or missed injures with its inherent morbidity and mortality.

Image-Guided Resuscitation With Limited Transthoracic Echocardiogram in Pediatric Trauma Patients

INTRODUCTION

Limited transthoracic echocardiogram (LTTE) has been shown to be a useful tool in guiding resuscitation in adult trauma patients. Our hypothesis is that image-guided resuscitation in pediatric trauma patients with LTTE is feasible.

METHODS

A retrospective chart review was performed on highest level pediatric trauma alerts (age 18 years or younger) at our level I trauma center during a 6-month period. Patients were divided into 2 groups as follows: those who had LTTE performed (LTTE group) and those who did not have LTTE performed (non-LTTE group).

RESULTS

A total of 31 charts were reviewed; 4 patients were excluded because they died on arrival to the emergency department. Fourteen patients had LTTE performed (LTTE group); 13 patients did not have LTTE performed (non-LTTE group). There was no difference in mechanism of injury, age, injury severity score, weight, or intensive care unit admission between the groups. The LTTE group received significantly less intravenous fluid than the non-LTTE group (1.2 vs 2.3 L, P = 0.0013).Within the LTTE group, 8 patients had "full" inferior vena cava (IVC) and 6 patients had "empty" IVC. There was no difference in injury severity score between these subgroups (P = 0.1018). Less fluid was given in the group labeled with full IVC [1.1 L (0.8-1.2)] than the group with empty IVC [2.4 L (1.7-2.6)], P = 0.0005. Four of the 6 patients with "empty" IVC had a confirmed source of bleeding.

CONCLUSIONS

Limited transthoracic echocardiogram can limit the amount of unnecessary crystalloid resuscitation given to pediatric trauma patients who are not hypovolemic.

Pediatric and adult trauma centers differ in evaluation, treatment, and outcomes for severely injured adolescents

BACKGROUND/PURPOSE

This study aims to investigate differences in imaging, procedure utilization, and clinical outcomes of severely injured adolescents treated at adult versus pediatric trauma centers.

METHODS

The National Trauma Data Bank was queried retrospectively for adolescents, 15-19years old, with a length of stay (LOS) >1day and Injury Severity Score (ISS) >25 treated at adult (ATC) or pediatric (PTC) Level 1 trauma centers from 2007 to 2011. Patient demographics and utilization of imaging and procedures were analyzed. Univariate and multivariate regression analysis was used to compare outcomes.

RESULTS

Of 12,861 adolescents, 51% were treated at ATC. Older age and more nonwhites were seen at ATC (p<0.01). Imaging and invasive procedures were more common at ATC (p<0.01). Shorter LOS (p=0.03) and higher home discharge rates (p<0.01) were seen at PTC. ISS and mortality did not differ. Age, race, ATC care (all p<0.01), and admission systolic blood pressure (SBP) (p=0.03) were predictors of CT utilization. ISS, SBP, and race (p<0.01) were risk factors for overall mortality; SBP (p=0.03) and ISS (p<0.01) predicted death from penetrating injury.

CONCLUSIONS

Severely injured adolescents experience improved outcomes and decreased imaging and invasive procedures without additional mortality risk when treated at PTC. PTC is an appropriate destination for severely injured adolescents.

Focused abdominal sonography for trauma in the clinical evaluation of children with blunt abdominal trauma

Introduction

In pediatric care, the role of focused abdominal sonography in trauma (FAST) remains ill defined. The objective of this study was to assess the sensitivity and specificity of FAST for detecting free peritoneal fluid in children.

Methods

The trauma registry of a single level I pediatric trauma center was queried for the results of FAST examination of consecutive pediatric (<18 years) blunt trauma patients over a period of 36 months, from January 2010 to December 2012. Demographics, type of injuries, FAST results, computerized tomography (CT) results, and operative findings were reviewed.

Results

During the study period, 543 injured pediatric patients (mean age 8.2 ± 5 years) underwent FAST examinations. In 95 (17.5 %) FAST was positive for free peritoneal fluid. CT examination was performed in 219 (40.3 %) children. Positive FAST examination was confirmed by CT scan in 61/73 (83.6 %). CT detected intra-peritoneal fluid in 62/448 (13.8 %) of the patients with negative FAST results. These findings correspond to a sensitivity of 50 %, specificity of 88 %, positive predictive value (PPV) of 84 %, and a negative predictive value (NPV) of 58 %. In patients who had negative FAST results and no CT examination (302), no missed abdominal injury was detected on clinical ground. FAST examination in the young age group (<2 years) yielded lower sensitivity and specificity (36 and 78 % respectively) with a PPV of only 50 %.

Conclusions

This study shows that although a positive FAST evaluation does not necessarily correlate with an IAI, a negative one strongly suggests the absence of an IAI, with a high NPV. These findings are emphasized in the analysis of the subgroup of children less than 2 years of age. FAST examination tempered with sound clinical judgment seems to be an effective tool to discriminate injured children in need of further imaging evaluation.

Focused abdominal ultrasound for blunt trauma in an emergency department without advanced imaging or on-site surgical capability

Objectives:

To determine whether focused abdominal sonogram for trauma (FAST) in a rural hospital provides information that prompts immediate transfer to a tertiary care facility for patients with blunt abdominal trauma who would otherwise be discharged or held for observation.

Methods:

Prior to the study, participating emergency physicians underwent a minimum of 30 hours of ultrasound training. All patients who presented with blunt abdominal trauma to our rural hospital between Mar. 1, 2002, and Apr. 30, 2003, were eligible for study. Following a history and physical examination, the emergency physician documented his or her disposition decision. A FAST was then performed, and the disposition reconsidered in light of the FAST results.

Results:

Sixty-seven FAST exams were performed on 65 patients. Three examinations (4.5%) were true-positive (95% confidence interval [CI] 0.9%–12.5%); 60 (89.6%) were true-negative (95% CI 79.7%–95.7%), 4 (6%) were false-negative (95% CI 1.7%–14.6%) and none (0%) were false-positive (95% CI 0%–5.4%). These values reflect sensitivity, specificity, negative predictive value and positive predictive values of 43%, 100%, 94% and 100% respectively. FAST results did not alter the decision to transfer any patient (0%: 95% CI 0.0%–5.4%), although one positive FAST may have led to an expedited transfer. One of 38 patients who was discharged after a negative FAST study returned 24 hours later because of worsening symptoms, and was ultimately found to have splenic and pancreatic injuries.

Conclusions:

This study failed to demonstrate that FAST improves disposition decisions for patients with blunt abdominal trauma who are evaluated in a hospital without advanced imaging or on-site surgical capability. However, the study is not sufficiently powered to rule out a role for FAST in these circumstances, and our data suggest that up to 5.4% of transfer decisions could be influenced by FAST. Rural emergency physicians should not allow a negative FAST study to override a clinical indication for transfer to a trauma centre; however, positive FAST studies can be used to accelerate transfer for definitive treatment.

The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation

PURPOSE

With increasing concerns about radiation exposure, we questioned whether a structured program of FAST might decrease CT use.

METHODS

All pediatric trauma surgeons in our level 1 pediatric trauma center underwent formal FAST training. Children with potential abdominal trauma and no prior imaging were prospectively evaluated from 10/2/09 to 7/31/11. After physical exam and FAST, the surgeon declared whether the CT could be eliminated.

RESULTS

Of 536 children who arrived without imaging, 183 had potential abdominal trauma. FAST was performed in 128 cases and recorded completely in 88. In 48% (42/88) the surgeon would have elected to cancel the CT based on the FAST and physical exam. One of the 42 cases had a positive FAST and required emergent laparotomy; the others were negative. The sensitivity of FAST for injuries requiring operation or blood transfusion was 87.5%. The sensitivity, specificity, PPV, and NPV in detecting pathologic free fluid were 50%, 85%, 53.8%, and 87.9%.

CONCLUSIONS

True positive FAST exams are uncommon and would rarely direct management. While the negative FAST would have potentially reduced CT use due to practitioner reassurance, this reassurance may be unwarranted given the test's sensitivity.

Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma

OBJECTIVES

Focused assessment of sonography in trauma (FAST) has been shown useful to detect clinically significant hemoperitoneum in adults, but not in children. The objectives were to determine test characteristics for clinically important intraperitoneal free fluid (FF) in pediatric blunt abdominal trauma (BAT) using computed tomography (CT) or surgery as criterion reference and, second, to determine the test characteristics of FAST to detect any amount of intraperitoneal FF as detected by CT.

METHODS

This was a prospective observational study of consecutive children (0-17 years) who required trauma team activation for BAT and received either CT or laparotomy between 2004 and 2007. Experienced physicians performed and interpreted FAST. Clinically important FF was defined as moderate or greater amount of intraperitoneal FF per the radiologist CT report or surgery.

RESULTS

The study enrolled 431 patients, excluded 74, and analyzed data on 357. For the first objective, 23 patients had significant hemoperitoneum (22 on CT and one at surgery). Twelve of the 23 had true-positive FAST (sensitivity = 52%; 95% confidence interval [CI] = 31% to 73%). FAST was true negative in 321 of 334 (specificity = 96%; 95% CI = 93% to 98%). Twelve of 25 patients with positive FAST had significant FF on CT (positive predictive value [PPV] = 48%; 95% CI = 28% to 69%). Of 332 patients with negative FAST, 321 had no significant fluid on CT (negative predictive value [NPV] = 97%; 95% CI = 94% to 98%). Positive likelihood ratio (LR) for FF was 13.4 (95% CI = 6.9 to 26.0) while the negative LR was 0.50 (95% CI = 0.32 to 0.76). Accuracy was 93% (333 of 357, 95% CI = 90% to 96%). For the second objective, test characteristics were as follows: sensitivity = 20% (95% CI = 13% to 30%), specificity = 98% (95% CI = 95% to 99%), PPV = 76% (95% CI = 54% to 90%), NPV = 78% (95% CI = 73% to 82%), positive LR = 9.0 (95% CI = 3.7 to 21.8), negative LR = 0.81 (95% CI = 0.7 to 0.9), and accuracy = 78% (277 of 357, 95% CI = 73% to 82%).

CONCLUSION

In this population of children with BAT, FAST has a low sensitivity for clinically important FF but has high specificity. A positive FAST suggests hemoperitoneum and abdominal injury, while a negative FAST aids little in decision-making.

Ultrasound in trauma

Point-of-care ultrasound is well suited for use in the emergency setting for assessment of the trauma patient. Currently, portable ultrasound machines with high-resolution imaging capability allow trauma patients to be imaged in the pre-hospital setting, emergency departments and operating theatres. In major trauma, ultrasound is used to diagnose life-threatening conditions and to prioritise and guide appropriate interventions. Assessment of the basic haemodynamic state is a very important part of ultrasound use in trauma, but is discussed in more detail elsewhere. Focussed assessment with sonography for Trauma (FAST) rapidly assesses for haemoperitoneum and haemopericardium, and the Extended FAST examination (EFAST) explores for haemothorax, pneumothorax and intravascular filling status. In regional trauma, ultrasound can be used to detect fractures, many vascular injuries, musculoskeletal injuries, testicular injuries and can assess foetal viability in pregnant trauma patients. Ultrasound can also be used at the bedside to guide procedures in trauma, including nerve blocks and vascular access. Importantly, these examinations are being performed by the treating physician in real time, allowing for immediate changes to management of the patient. Controversy remains in determining the best training to ensure competence in this user-dependent imaging modality.

Pediatric FAST and elevated liver transaminases: An effective screening tool in blunt abdominal trauma

BACKGROUND

The current standard for the evaluation of children with blunt abdominal trauma (BAT) consists of physical examination, screening lab values, and computed tomography (CT) scan. We sought to determine if the focused assessment with sonography for trauma (FAST) combined with elevated liver transaminases (AST/ALT) could be used as a screening tool for intra-abdominal injury (IAI) in pediatric patients with BAT.

METHODS

Registry data at a level 1 trauma center was retrospectively reviewed from 1991-2007. Data collected on BAT patients under the age of 16 y included demographics, injury mechanism, ISS, GCS, imaging studies, serum ALT and AST levels, and disposition. AST and ALT were considered positive if either one was >100 IU/L.

RESULTS

Overall, 3171 cases were identified. A total of 1008 (31.8%) patients received CT scan, 1148 (36.2%) had FAST, and 497 (15.7%) patients received both. Of the 497 patients, 400 (87.1%) also had AST and ALT measured. FAST was 50% sensitive, 91% specific, with a positive predictive value (PPV) of 68%, negative predictive value (NPV) of 83%, and accuracy of 80%. Combining FAST with elevated AST or ALT resulted in a statistically significant increase in all measures (sensitivity 88%, specificity 98%, PPV 94%, NPV 96%, accuracy 96%).

CONCLUSIONS

FAST combined with AST or ALT > 100 IU/L is an effective screening tool for IAI in children following BAT. Pediatric patients with a negative FAST and liver transaminases < 100 IU/L should be observed rather than subjected to the radiation risk of CT.

Review of the evidence on the management of blunt renal trauma in pediatric patients

Due to the size and location within the pediatric patient, the kidneys are susceptible to injury from blunt trauma. While it is clear that the goal of management of blunt renal trauma in children is renal preservation, the methods of achieving this goal have not been well established in the current literature. Therefore, we have set out to summarize and clarify the current published information on the management strategies for blunt renal trauma in children. While there is extensive literature available, it consists mostly of retrospective series documenting widely varied management styles. The purpose of this review is to display the current information available and delineate the role for future studies that may allow us to develop consistent management strategies of pediatric patients, who have sustained blunt renal trauma, in a safe and cost-effective manner.

Blunt abdominal trauma: diagnostic performance of contrast-enhanced US in children--initial experience

PURPOSE

To prospectively compare the sensitivity and specificity of ultrasonography (US) with those of contrast material-enhanced US in the depiction of solid organ injuries in children with blunt abdominal trauma, with contrast-enhanced computed tomography (CT) as the reference standard.

MATERIALS AND METHODS

The study protocol was approved by the ethics board, and written informed consent was obtained from parents. US, contrast-enhanced US, and contrast-enhanced CT were performed in 27 consecutive children (19 boys, eight girls; mean age, 8.9 years +/- 2.8 [standard deviation]) with blunt abdominal trauma to determine if solid abdominal organ injuries were present. Sensitivity, specificity, agreement, accuracy, number of lesions correctly identified, and positive and negative predictive values were determined for US and contrast-enhanced US, as compared with contrast-enhanced CT.

RESULTS

In 15 patients, contrast-enhanced CT findings were negative. Contrast-enhanced CT depicted 14 solid organ injuries in 12 patients. Lesions were in the spleen (n = 7), liver (n = 4), right kidney (n = 1), right adrenal gland (n = 1), and pancreas (n = 1). Contrast-enhanced US depicted 13 of the 14 lesions in 12 patients with positive contrast-enhanced CT findings and no lesions in the patients with negative contrast-enhanced CT findings. Unenhanced US depicted free fluid in two of 15 patients with negative contrast-enhanced CT findings and free fluid, parenchymal lesions, or both in eight of 12 patients with positive contrast-enhanced CT findings. Overall, the diagnostic performance of contrast-enhanced US was better than that of US, as sensitivity, specificity, and positive and negative predictive values were 92.2%, 100%, 100%, and 93.8%, respectively.

CONCLUSION

Contrast-enhanced US was almost as accurate as contrast-enhanced CT in depicting solid organ injuries in children.

Effect of emergency department care on outcomes in pediatric trauma: what approaches make a difference in quality of care?

Deriving evidence-based best practice for each phase or setting of trauma care is necessary to maximize best outcomes. There is a paucity of studies examining the association of provider training on pediatric trauma outcomes. Pivotal decisions (whether and where to transfer, diagnostic workup, and initial resuscitation) occur in this setting, yet there is little evidence relating to best practices in those areas. Classic process-performance measures such as time intervals during care (e.g., time to computerized tomography scan, time to operating room, etc.) or utilization measures (American College of Surgeons designation) are commonly used in the trauma center certification process, yet process-outcome links relevant to children are lacking. Although great advances have been made in the trauma care delivered to children, scientific proof is lacking and much more needs to be done to establish the evidence-based need to deliver the highest quality of pediatric trauma care.

Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis

OBJECTIVE

The objective of the study was to obtain the best estimates of the test performance of abdominal ultrasonography (US) for identifying children with intraabdominal injuries (IAIs).

METHODS

We gathered studies on the use of abdominal US in injured children from the following sources: a MEDLINE and Embase search, hand searches of 5 specialty journals and 4 clinical textbooks, the bibliographies of all identified articles, and contact with experts. Both prospective and retrospective studies were included if they used abdominal US for the detection of intraperitoneal fluid or IAIs in blunt trauma patients less than 18 years of age. All authors independently abstracted data from the selected studies. Disagreements between abstractors were resolved by mutual agreement.

RESULTS

Twenty-five articles met the inclusion criteria, and 3838 children evaluated with abdominal US were included. Abdominal US had the following test characteristics for identifying children with hemoperitoneum: sensitivity, 80% (95% confidence interval [CI] 76%-84%); specificity, 96% (95% CI 95%-97%); positive likelihood ratio, 22.9 (95% CI 17.2-30.5); and negative likelihood ratio, 0.2 (95% CI 0.16-0.25). Using the most methodologically rigorous studies, however, yielded the following test characteristics of abdominal US for identifying children with hemoperitoneum: sensitivity, 66% (95% CI 56%-75%); specificity, 95% (95% CI 93%-97%); positive likelihood ratio, 14.5 (95% CI 9.5-22.1); and negative likelihood ratio, 0.36 (95% CI 0.27-0.47).

CONCLUSIONS

Abdominal US has a modest sensitivity for the detection of children with hemoperitoneum; however, its test performance characteristics worsen when only the most methodologically rigorous articles are included. A negative US examination has questionable utility as the sole diagnostic test to rule out the presence of IAI. Because of the high risk of IAI, a hemodynamically stable child with a positive US examination should immediately undergo abdominal computed tomographic scanning.

Physical examination as a reliable tool to predict intra-abdominal injuries in brain-injured children

BACKGROUND

Brain-injured children have been thought to have an unreliable abdominal examination. This study evaluates the reliability of physical examination in the prediction of intra-abdominal injury in brain-injured children.

METHODS

Pediatric patients with a traumatic brain injury or Glasgow Coma Scale (GCS) <15 and intra-abdominal organ injuries were selected. Admission data were reviewed, and findings were tabulated.

RESULTS

Fifty patients had an abnormal abdominal examination. Nineteen of 71 patients with head injury and intra-abdominal organ injuries required laparotomy. These 19 patients had abdominal tenderness, distention, abrasions, and/or a positive focused abdominal sonography for trauma (FAST) scan. Seven of 19 patients had a GCS of 3. Of the 12 patients requiring surgery with GSC 4 to 14, all patients had abnormal physical examinations.

CONCLUSIONS

Patients who required an operation presented with an abnormal examination and/or a positive FAST. These data suggest that examination and/or FAST may reliably identify patients with intra-abdominal organ injuries in need of an operation.

Diagnostic accuracy of surgeon-performed focused abdominal sonography (FAST) in blunt paediatric trauma

AIM

To study the diagnostic accuracy and clinical efficacy of surgeon-performed focused abdominal sonography (FAST) in paediatric blunt abdominal trauma (BAT).

MATERIALS AND METHOD

This was a prospective, single blinded study conducted at The Children's Hospital at Westmead Sydney (CHW). All patients with BAT that justified a trauma call activated on presentation to the Emergency Department (ED) had a FAST performed by the Trauma Fellow. The attending surgical team was blinded to the result of the FAST. An independent radiologist reviewed the FAST pictures, and the findings were compared with computerised tomography (CT), ultrasound (US), laparotomy and the clinical outcome of the patient. Sensitivity, specificity and predictive values were calculated.

RESULTS

A total of 85 patients (39 M; 26 F) were enrolled in the study between February 2002 and January 2003. The age ranged between 4 months and 16 years. The mean Injury Severity Score (ISS) was 6 (range 1-38). FAST was performed in a mean time of 3 min. Inter-rater agreement was 96%. FAST was positive in nine as confirmed by a CT scan of the abdomen. Three patients underwent laparotomy, two for bowel injuries and one for a Grade III liver laceration. Of the remaining 76, 19 had a CT, which showed evidence of intra-abdominal injury in seven patients. There were two false negative studies resulting in a sensitivity of 81%, specificity of 100%, negative predictive value of 97%, positive predictive value of 100% and an accuracy of 97%.

CONCLUSIONS

Surgeon-performed FAST for BAT was safe and accurate with a high specificity. It would seem a potentially valuable tool in the evaluation of paediatric blunt trauma victims for free fluid within the peritoneal cavity.

The efficacy of ultrasonography in hemodynamically stable children with blunt abdominal trauma: a prospective comparison with computed tomography

PURPOSE

In this prospective study we aimed to investigate the diagnostic value of ultrasonography (US) in hemodynamically stable children after blunt abdominal trauma (BAT) using computed tomography (CT) as the gold standard.

MATERIALS AND METHODS

Between 1997 and 2001, 96 children with BAT were evaluated prospectively. CT was performed first, followed by US. US and CT examinations were independently evaluated by two radiologists for free fluid and organ injury. The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of US were assessed regarding CT as the gold standard.

RESULTS

Overall 128 organ injuries were determined in 96 patients with CT; however, 20 (15.6%) of them could not be seen with US. Free intraabdominal fluid (FIF) was seen in 82 of 96 patients by CT (85.4%) and eight of them (9.7%) could not be seen by US. We found that sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of the US for free intra-abdominal fluid were 90.2, 100, 100, 63.6 and 91.7%, respectively.

CONCLUSIONS

US for BAT in children is highly accurate and specific. It is highly sensitive in detecting liver, spleen and kidney injuries whereas its sensitivity is moderate for the detection of gastrointestinal tract (GIT) and pancreatic injuries.

FAST at MACH 20: clinical ultrasound aboard the International Space Station

BACKGROUND

Focused assessment with sonography for trauma (FAST) examination has been proved accurate for diagnosing trauma when performed by nonradiologist physicians. Recent reports have suggested that nonphysicians also may be able to perform the FAST examination reliably. A multipurpose ultrasound system is installed on the International Space Station as a component of the Human Research Facility. Nonphysician crew members aboard the International Space Station receive modest training in hardware operation, sonographic techniques, and remotely guided scanning. This report documents the first FAST examination conducted in space, as part of the sustained effort to maintain the highest possible level of available medical care during long-duration space flight.

METHODS

An International Space Station crew member with minimal sonography training was remotely guided through a FAST examination by an ultrasound imaging expert from Mission Control Center using private real-time two-way audio and a private space-to-ground video downlink (7.5 frames/second). There was a 2-second satellite delay for both video and audio. To facilitate the real-time telemedical ultrasound examination, identical reference cards showing topologic reference points and hardware controls were available to both the crew member and the ground-based expert.

RESULTS

A FAST examination, including four standard abdominal windows, was completed in approximately 5.5 minutes. Following commands from the Mission Control Center-based expert, the crew member acquired all target images without difficulty. The anatomic content and fidelity of the ultrasound video were excellent and would allow clinical decision making.

CONCLUSIONS

It is possible to conduct a remotely guided FAST examination with excellent clinical results and speed, even with a significantly reduced video frame rate and a 2-second communication latency. A wider application of trauma ultrasound applications for remote medicine on earth appears to be possible and warranted.

Bedside limited echocardiography by the emergency physician is accurate during evaluation of the critically ill patient

OBJECTIVE

Echocardiography can be a rapid, noninvasive, objective tool in the assessment of ventricular function and preload during resuscitation of a critically ill or injured child. We sought to determine the accuracy of bedside limited echocardiography by the emergency physician (BLEEP) in estimation of (1) left ventricular function (LVF) and (2) inferior vena cava (IVC) volume, as an indirect measure of preload.

METHODS

We conducted a prospective observational study of a convenience sample of patients who were admitted to our intensive care unit. All patients underwent BLEEP followed by an independent formal echocardiogram by an experienced pediatric echocardiography provider (PEP). IVC volume was assessed by measurement of the maximal diameter of the IVC. LVF was determined by calculating shortening fraction (SF) using M-mode measurements on the parasternal short-axis view at the level of the papillary muscle. An independent blinded pediatric cardiologist reviewed all images for accuracy and quality. Estimates of SF obtained on the BLEEP examination were compared with those obtained by the PEP.

RESULTS

Thirty-one patients were enrolled. The mean age was 5.1 years (range: 23 days-16 years); 48.4% (15 of 31) were girls; 58.1% (18 of 31) were on mechanical ventilatory support at the time of their study. There was good agreement between the emergency physician (EP) and the PEP for estimation of SF (r = 0.78). The mean difference in the estimate of SF between the providers was 4.4% (95% confidence interval: 1.6%-7.2%). This difference in estimate of SF was statistically significant. Similarly, there was good agreement between the EP and the PEP for estimation of IVC volume (r = 0.8). The mean difference in the estimate of IVC diameter by the PEP and the EP was 0.068 mm (95% confidence interval: -0.16 to 0.025 mm). This difference was not statistically significant.

CONCLUSIONS

Our study suggests that PEP sonographers are capable of obtaining images that permit accurate assessment of LVF and IVC volume. BLEEP can be performed with focused training and oversight by a pediatric cardiologist.

CT scan and the pediatric trauma patient--are we overdoing it?

BACKGROUND

Recent literature expresses concern for an increased risk of cancer in children exposed to low-dose radiation during computed tomography (CT). In response, children's hospitals have implemented the ALARA (as low as reasonably achievable) concept, but this is not true at most adult referring institutions. The purpose of this study was to assess the diagnostic necessity of CT in the evaluation of pediatric trauma patients.

METHODS

A retrospective review was conducted of the trauma database at a large, level I, freestanding children's hospital with specific attention to the pattern of CT evaluations.

RESULTS

From January 1999 to October 2003, 1,653 children with traumatic injuries were evaluated by the trauma team, with 1,422 patients undergoing 2,361 CT scans. Overall, 54% of obtained scans were interpreted as normal. Fifty percent of treated patients were transferred from referring hospitals. Approximately half arrived with previous CT scans with 9% of these requiring further imaging. Of the 897 patients that underwent abdominal CT imaging, only 2% were taken to the operating room for an exploratory laparotomy. In addition, of those patients who had abnormal findings on an abdominal CT scan, only 5% underwent surgical exploration.

CONCLUSIONS

CT scans are used with regularity in the initial evaluation of the pediatric trauma patient, and perhaps abdominal CT imaging is being used too frequently. A substantial number of these scans come from referral institutions that may not comply with ALARA. The purported risk of CT radiation questions whether a more selective approach to CT evaluation of the trauma patient should be considered.

Evaluation of shoulder integrity in space: first report of musculoskeletal US on the International Space Station

Investigative procedures were approved by Henry Ford Human Investigation Committee and NASA Johnson Space Center Committee for Protection of Human Subjects. Informed consent was obtained. Authors evaluated ability of nonphysician crewmember to obtain diagnostic-quality musculoskeletal ultrasonographic (US) data of the shoulder by following a just-in-time training algorithm and using real-time remote guidance aboard the International Space Station (ISS). ISS Expedition-9 crewmembers attended a 2.5-hour didactic and hands-on US training session 4 months before launch. Aboard the ISS, they completed a 1-hour computer-based Onboard Proficiency Enhancement program 7 days before examination. Crewmembers did not receive specific training in shoulder anatomy or shoulder US techniques. Evaluation of astronaut shoulder integrity was done by using a Human Research Facility US system. Crew used special positioning techniques for subject and operator to facilitate US in microgravity environment. Common anatomic reference points aided initial probe placement. Real-time US video of shoulder was transmitted to remote experienced sonologists in Telescience Center at Johnson Space Center. Probe manipulation and equipment adjustments were guided with verbal commands from remote sonologists to astronaut operators to complete rotator cuff evaluation. Comprehensive US of crewmember's shoulder included transverse and longitudinal images of biceps and supraspinatus tendons and articular cartilage surface. Total examination time required to guide astronaut operator to acquire necessary images was approximately 15 minutes. Multiple arm and probe positions were used to acquire dynamic video images that were of excellent quality to allow evaluation of shoulder integrity. Postsession download and analysis of high-fidelity US images collected onboard demonstrated additional anatomic detail that could be used to exclude subtle injury. Musculoskeletal US can be performed in space by minimally trained operators by using remote guidance. This technique can be used to evaluate shoulder integrity in symptomatic crewmembers after strenuous extravehicular activities or to monitor microgravity-associated changes in musculoskeletal anatomy. Just-in-time training, combined with remote experienced physician guidance, may provide a useful approach to complex medical tasks performed by nonexperienced personnel in a variety of remote settings, including current and future space programs.

Posterior urethral valves presenting as abdominal distension and undifferentiated shock in a neonate: The role of screening emergency physician-directed bedside ultrasound

We present a case of shock in a 7-week-old neonate with obstructive uropathy secondary to posterior urethral valves (PUV). The antenatal ultrasound and the 2-week maintenance visit were unremarkable. A screening emergency physician directed bedside ultrasound (SEPUS) served to rapidly establish the diagnosis, initiate appropriate management, and facilitate early relief of urinary obstruction. We discuss the potential role of SEPUS in a critically ill neonate and briefly review the management of PUV.

Blunt injury to solid abdominal organs

Injuries to the solid abdominal viscera (spleen, liver, kidney, pancreas) are common in children sustaining trauma by blunt mechanisms. Success with nonoperative management of these injuries has led to recent extensions of this approach to the management of higher-grade more complicated injuries typically treated operatively. This review will discuss the current status of evaluation, management and outcome of children sustaining blunt injury to solid abdominal organs.

Controversies in emergency radiology. CT versus ultrasound in the evaluation of blunt abdominal trauma

There has been controversy regarding ultrasonography (US) versus CT in blunt abdominal trauma (BAT). Each modality has its strengths and weaknesses. US is fast and allows resuscitative efforts to proceed while the patient is being scanned. However, the sensitivity of US is inferior to that of CT, and there is user variability. CT is better at determining the extent, type, and grade of injury, resulting in a more tailored therapeutic plan and safe conservative management of many patients. However, CT involves ionizing radiation, cannot be performed portably, and requires only visual monitoring while scanning. Given each modality's strengths and weaknesses we conclude that CT is the preferred examination when the BAT patient is stable or moderately stable, enough to be taken to CT. If a BAT patient is unstable, US is beneficial in screening for certain injuries or large hemoperitoneum prior to an exploratory laparotomy.

Surgeon-Directed Ultrasound for Trauma is a Predictor of Intra-Abdominal Injury in Children

This study investigated the efficacy of surgeon-directed focused assessment with sonography for trauma (FAST) in conjunction with physical exam (PEx) as a predictor of intra-abdominal injury in children. Injured children (ages ≤17) presenting to a level I trauma center with abdominal trauma were evaluated in the emergency department (ED) by the trauma team of surgical attendings and residents. PEx and FAST were performed immediately upon arrival to the ED and results compared to CT, the standard exam for presence of intra-abdominal injury. Data was collected prospectively from July 1, 2000, until April 30, 2002. One hundred and twenty injured children underwent evaluation of abdominal trauma with PEx, FAST, and abdominal CT. Two patients had false-negative CT scans. Bayesian analysis was applied to the results of the remaining 118 patients. FAST compared with CT findings revealed sensitivity 70 per cent, specificity 100 per cent, positive predictive value 100 per cent, and negative predictive value 92 per cent. FAST results were combined with PEx findings such that either suggestive of intra-abdominal injury was regarded as a “positive exam.” Sensitivity was 100 per cent, specificity 74 per cent, positive predictive value 53 per cent, and negative predictive value 100 per cent. Surgeon-directed FAST with consideration of PEx is a predictor of intra-abdominal injury in children.

Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients

PURPOSE

The use of focused abdominal sonography for trauma (FAST), which detects free fluid in the abdomen and pelvis, for the assessment of blunt abdominal trauma is gaining acceptance worldwide and has been described extensively in the general medical literature. The precise application of this technique in pediatric patients, however, has yet to be established. The aim of this study was to assess the utility of FAST in pediatric trauma patients by comparing the results of this technique with those of CT and explorative laparotomy (ELAP).

METHODS

We retrospectively reviewed the medical records and sonographic examinations of pediatric patients who had sustained multiple traumatic injuries for which they were treated at our hospital during a 20-month period. For all patients, FAST had been the initial screening examination for blunt abdominal trauma. We compared the FAST findings, which had been recorded as positive or negative, with the findings on CT or ELAP, which were considered definitive.

RESULTS

A total of 313 patients (204 boys and 109 girls) with a mean age of 7.1 years were included in the study. The FAST finding had been negative in 274 patients, of whom 201 had had no clinical signs of abdominal injury and had been managed conservatively without complications. CT had been performed in 109 patients and ELAP in 11. FAST had yielded 3 false-negative and 2 false-positive results. The sensitivity, specificity, and accuracy of FAST were 92.5%, 97.2%, and 95.5%, respectively.

CONCLUSIONS

FAST is an effective tool in screening pediatric trauma patients for blunt abdominal trauma.

Early detection of cardiac disease masquerading as acute bronchospasm: The role of bedside limited echocardiography by the emergency physician

We report two cases in which the patients experienced dyspnea, cough, and acute bronchospasm. Pulmonary pathology was initially suspected. Failure to respond to an initial trial of inhaled bronchodilator prompted the use of bedside limited echocardiography by the emergency physician. The potential role of limited echocardiography by the emergency physician as a triage tool in facilitating early diagnosis and emergent therapy, reducing time to final discharge, and enhancing interaction between the pediatric emergency physician and cardiology consultants is highlighted.

Predicting the need for laparotomy in pediatric trauma patients on the basis of the ultrasound score

BACKGROUND

It is possible to quantify the amount of hemoperitoneum seen on focused assessment with sonography for trauma (FAST) using a simple scoring system that had previously been shown to correlate with the need for subsequent laparotomy in adults. A score of 3 or greater was shown to be highly accurate in predicting the need for laparotomy. We hypothesized that this scoring system might also predict the need for laparotomy in pediatric trauma patients.

METHODS

We retrospectively reviewed all records for patients 15 years and younger who underwent FAST after blunt trauma. A "positive" ultrasound examination was defined as one containing free intraperitoneal fluid with or without solid organ injury. The ultrasound score (USS) was defined as the depth of the deepest pocket of fluid collection measured in centimeters plus the number of additional spaces where fluid was seen.

RESULTS

Thirty-eight (19.6%) of 193 patients who had FAST performed had positive ultrasound examinations. Thirty-seven patients with complete records were analyzed. There were no differences between patients with a USS < or = 3.0 and those with a USS > 3.0 in terms of admission pulse, Glasgow Coma Scale score, Injury Severity Score, or the proportion of patients who were initially hypotensive. One of 22 patients with a USS < or = 3.0 required therapeutic laparotomy versus 8 of 15 patients with a USS > 3.0 ( = 0.002). For a USS > 3.0, sensitivity, specificity, and accuracy in predicting therapeutic laparotomy were 89%, 75%, and 78%, respectively.

CONCLUSION

Ultrasound quantification of hemoperitoneum by a simple scoring system may serve as a useful adjunct to traditional clinical parameters in predicting the need for subsequent laparotomy in pediatric patients. Prospective validation with a larger study is required.

Identification of children with intra-abdominal injuries after blunt trauma

STUDY OBJECTIVE

We sought to determine the utility of laboratory testing after adjusting for physical examination findings in the identification of children with intra-abdominal injuries after blunt trauma.

METHODS

The study was a prospective observational series of children younger than 16 years old who sustained blunt trauma and were at risk for intra-abdominal injuries during a 2(1/2)-year period at an urban Level I trauma center. Patients were examined by faculty emergency physicians and underwent standardized laboratory testing. Clinical and laboratory findings were recorded on a standardized data sheet. Intra-abdominal injury was considered present if an injury was documented to the spleen, liver, pancreas, kidney, adrenal glands, or gastrointestinal tract. We performed multiple logistic regression and binary recursive partitioning analyses to identify which physical examination findings and laboratory variables were independently associated with intra-abdominal injury.

RESULTS

Of 1,095 enrolled patients, 107 (10%, 95% confidence interval [CI] 8% to 12%) had intra-abdominal injuries. The mean age was 8.4+/-4.8 years. From both analyses, we identified 6 findings associated with intra-abdominal injury: low systolic blood pressure (adjusted odds ratio [OR] 4.1; 95% CI 1.1 to 15.2), abdominal tenderness (adjusted OR 5.8; 95% CI 3.2 to 10.4), femur fracture (adjusted OR 1.3; 95% CI 0.5 to 3.7), serum aspartate aminotransferase concentration more than 200 U/L or serum alanine aminotransferase concentration more than 125 U/L (adjusted OR 17.4; 95% CI 9.4 to 32.1), urinalysis with more than 5 RBCs per high-powered field (adjusted OR 4.8; 95% CI 2.7 to 8.4), and an initial hematocrit of less than 30% (adjusted OR 2.6; 95% CI 0.9 to 7.5).

CONCLUSION

After adjusting for physical examination findings, laboratory testing contributes significantly to the identification of children with intra-abdominal injuries after blunt trauma.

Practical points in evaluation and resuscitation of the injured child

The ultimate goal of resuscitation of an injured child is delivery of oxygen to intracellular organelles in order to maintain aerobic metabolism. This can be obtained by following ATLS protocols with immediate attention to the "ABCDE's" and compulsive reevaluation of the adequacy of resuscitation maneuvers. After stabilization, seriously injured children should be transferred to trauma centers with established pediatric trauma programs utilizing preexisting transfer agreements and protocols. Pediatric trauma is indeed a team endeavor, requiring the coordinated expertise and teamwork of prehospital EMS providers, trauma team members, and the pediatric trauma and rehabilitation centers. With careful and compulsive communication and coordination, injured children can be returned to their families in better mental and physical condition than pre-injury with reasonable expectation of a full and productive life.

Blunt abdominal trauma in children: evaluation with emergency US

PURPOSE

To assess the accuracy of emergency abdominal ultrasonography (US) in the detection of both hemoperitoneum and parenchymal organ injury in children.

MATERIALS AND METHODS

Imaging findings were recorded prospectively in 744 consecutive children who underwent emergency US from January 1995 to October 1998; free fluid and parenchymal abnormalities of specific organs were also noted. Patients with intraabdominal injuries were identified retrospectively. Computed tomographic (CT) findings, intraoperative findings, and clinical outcome were compared with the initial US findings. Sensitivity, specificity, and positive and negative predictive values were calculated for patients who underwent CT, laparotomy, or both after US.

RESULTS

Seventy-five (10%) of 744 patients had intraabdominal injuries, and US depicted free fluid in 42 of them. US had 56% sensitivity, 97% specificity, 82% positive predictive value, and 91% negative predictive value for detection of hemoperitoneum alone. US helped identify parenchymal abnormalities that corresponded to actual organ injury without accompanying free fluid in nine patients (12%). Inclusion of identification of parenchymal organ injury at US increased the sensitivity of US to 68%, with an accuracy of 92%.

CONCLUSION

US for blunt abdominal trauma in children is highly accurate and specific, but moderately sensitive, for detection of intraabdominal injury.

Minimal pelvic fluid in blunt abdominal trauma in children: the significance of this sonographic finding

PURPOSE

The aim of this study was to evaluate the significance of the ultrasonographic finding of pelvic fluid after blunt abdominal trauma in children as a predictor of an abdominal organ injury.

METHODS

The clinical and imaging data of 183 children with blunt abdominal trauma were reviewed retrospectively. All children had an abdominal sonography as the primary screening study. The ultrasound results were divided into 3 groups: group A, normal examination; group B, pelvic fluid only; group C, peritoneal fluid outside the pelvis. The results of the initial ultrasound examinations were compared with the findings of the CT scan, or a second ultrasound examination or the clinical course during the hospitalization.

RESULTS

Group A included 87 children; group B, 57, and group C, 39. Four abdominal organ injuries were missed by the ultrasound examination. The sensitivity and specificity of the ultrasound examinations to predict organ injury in presence of peritoneal fluid outside the pelvis were, respectively, 89.5% and 96.6%; the positive and negative predictive value were 87.2% and 97.3%. No statistically significant difference was seen between group A and group B, whereas the presence of peritoneal fluid outside the pelvic cavity (group C) was associated strongly with an organ injury (P <.001).

CONCLUSIONS

A normal ultrasound examination or the presence of pelvic fluid are associated with a low probability of an organ injury. In the presence of peritoneal fluid outside the pelvis, the probability of an organ injury is very high.

Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma

PURPOSE

The aim of this study was to evaluate the accuracy of emergency department (ED) ultrasound scan in identifying which children with blunt torso trauma have intraperitoneal fluid associated with intraabdominal injuries (IAI).

METHODS

The authors conducted a prospective, observational study of children (< 16 years old) with blunt trauma who presented to a level 1 trauma center over a 29-month period and underwent abdominal ultrasound scan while in the ED. Ultrasound examinations were ordered at the discretion of the trauma surgeons or ED physicians caring for the patients, performed by trained sonographers, and interpreted at the time of the ultrasound. Ultrasound examinations were interpreted solely for the presence or absence of intraperitoneal fluid. Hypotension was defined as > or = 1 standard deviation below the age-adjusted mean. Patients underwent follow-up to identify those with intraperitoneal fluid and IAI.

RESULTS

A total of 224 pediatric blunt trauma patients had ultrasound scan performed and were enrolled. Thirty-three patients had IAI with intraperitoneal fluid, and ultrasound scan was positive in 27. The accuracy of abdominal ultrasound for detecting intraperitoneal fluid associated with IAI was sensitivity, 82% (95% confidence interval [CI] 65% to 93%); specificity, 95% (95% CI 91% to 97%); positive predictive value, 73% (95% CI 56% to 86%); and negative predictive value, 97% (95% CI 93% to 99%). In the 13 patients who were hypotensive, ultrasound scan correctly identified intraperitoneal fluid in all 7 patients (sensitivity 100%) with IAI, and hemoperitoneum and was negative in all 6 patients (specificity 100%) who did not have hemoperitoneum. Nine patients had IAI without intraperitoneal fluid, and ultrasound scan result was negative for fluid in all 9.

CONCLUSIONS

ED abdominal ultrasound scan used solely for the detection of intraperitoneal fluid in pediatric blunt trauma patients has a modest accuracy. Ultrasonography has the best test performance in those children who are hypotensive and should be obtained early in the ED evaluation of these patients.

Absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography

BACKGROUND

Although the accuracy of focused abdominal sonography for trauma (FAST) in adults has been demonstrated, results of this technique in children have been conflicting with few comparisons against computed tomography (CT), the imaging gold standard.

METHODS

A total of 160 hemodynamically stable pediatric trauma victims referred for abdominal CT initially underwent rapid screening sonography looking for free fluid. Both studies were interpreted in blinded fashion.

RESULTS

Forty-four of the 160 patients had an intraabdominal injury on CT, 24 (55%) of which had normal screening sonography. Fifteen of the 44 (34%) had no free fluid on either modality. Accuracy of sonography compared with CT was 76% with a negative predictive value 81%.

CONCLUSIONS

Sonography for free fluid alone is not reliable to exclude blunt intraabdominal injury in hemodynamically stable children given the considerable percentage of injured patients without free fluid. J Pediatr Surg 36:565-569.