Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis

The Efficiency of Focused Assessment with Sonography for Trauma in Pediatric Patients with Blunt Torso Trauma

Introduction

Focused Assessment with Sonography for Trauma (FAST) has attracted attention for its use in the detection of intra-abdominal pathology for pediatric patients. However, computed tomography (CT) remains the gold standard for the assessment of blunt torso trauma. The study examines the effectiveness of FAST both in the detection of intra-abdominal pathology in pediatric patients (<19 years) with blunt torso trauma and in the determination of the need for CT for further examination.

Methods

The study was designed as a retrospective observational investigation of diagnostic value. The pediatric patients who were admitted to the Emergency Department with blunt torso trauma between January 2013 and October 2016 were included in the study. The sample of the study comprised 255 patients who met the inclusion criteria. The primary outcome was the effectiveness of FAST in the detection of intra-abdominal pathology and the determination of the need for CT. The secondary outcome was to identify the agreement between CT and FAST for intra-abdominal injuries. The Chi-square test and Fisher's exact test were used for comparisons. A logistic regression model was developed to determine the variables that independently affect the agreement between FAST and CT.

Results

FAST was determined to have low sensitivity (20.3%) despite its high specificity (87%). However; FAST had a good negative likelihood ratio. There was a poor agreement between CT and FAST in terms of the presence of both intra-abdominal and intrathoracic injuries in pediatric patients with blunt trunk trauma. The error rate of FAST increased by five-fold, especially in the presence of concomitant thorax trauma. However, FAST had a good negative likelihood ratio.

Conclusion

FAST should not be regarded as an equivalent tool to CT for pediatric patients with blunt torso trauma. It is, instead, a noteworthy complementary tool that is a negative predictor.

Establishing the international research priorities for pediatric emergency medicine point-of-care ultrasound: A modified Delphi study

BACKGROUND

The Pediatric Emergency Medicine (PEM) Point-of-care Ultrasound (POCUS) Network (P2Network) was established in 2014 to provide a platform for international collaboration among experts, including multicenter research. The objective of this study was to use expert consensus to identify and prioritize PEM POCUS topics, to inform future collaborative multicenter research.

METHODS

Online surveys were administered in a two-stage, modified Delphi study. A steering committee of 16 PEM POCUS experts was identified within the P2Network, with representation from the United States, Canada, Italy, and Australia. We solicited the participation of international PEM POCUS experts through professional society mailing lists, research networks, social media, and "word of mouth." After each round, responses were refined by the steering committee before being reissued to participants to determine the ranking of all the research questions based on means and to identify the high-level consensus topics. The final stage was a modified Hanlon process of prioritization round (HPP), which emphasized relevance, impact, and feasibility.

RESULTS

Fifty-four eligible participants (16.6%) provided 191 items to Survey 1 (Round 1). These were refined and consolidated into 52 research questions by the steering committee. These were issued for rating in Survey 2 (Round 2), which had 45 participants. At the completion of Round 2, all questions were ranked with six research questions reaching high-level consensus. Thirty-one research questions with mean ratings above neutral were selected for the HPP round. Highly ranked topics included clinical applications of POCUS to evaluate and manage children with shock, cardiac arrest, thoracoabdominal trauma, suspected cardiac failure, atraumatic limp, and intussusception.

CONCLUSIONS

This consensus study has established a research agenda to inform future international multicenter PEM POCUS trials. This study has highlighted the ongoing need for high-quality evidence for PEM POCUS applications to guide clinical practice.

Accuracy of Focused Assessment with Sonography for Trauma (FAST) in Blunt Abdominal Trauma

Purpose

This study aimed to evaluate the accuracy and outcomes of focused assessment with sonography for trauma (FAST) and determine the factors associated with true-positive FAST results.

Methods

The FAST results from 2016 to 2020 were retrospectively reviewed. Cases involving penetrating injury, transfer from other hospitals, age ≤ 16 years, prehospital arrest, and no confirmatory test were excluded. Intra-abdominal fluid was confirmed using computed tomography or operative findings. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Demographic data, injury characteristics, and outcomes were compared between true-positive and false-negative results. Logistic regression was used to identify the factors associated with true-positive results.

Results

Of 2,758 patients, 163 and 2,595 patients showed positive and negative results, respectively. True positives were 135 and true negatives were 2325. The overall sensitivity, specificity, PPV, and NPV were 33.3%, 98.8%, 82.8%, and 89.6%, respectively. The sensitivity increased to 49.1% in patients with initial systolic blood pressure (SBP) ≤ 90 mmHg. The true-positive group showed a lower SBP and Glasgow Coma Scale score and a higher laparotomy rate than the false-negative group. However, mortality showed no significant difference. In logistic regression analysis, hollow viscus injury (1.820 [1.123–2.949], P=0.015) and the lowest SBP (0.988 [0.980–0.997], P=0.009) were associated with true-positive results compared to false-negative results.

Conclusion

The overall sensitivity of FAST was low; therefore, it should be performed in selected patients such as SBP ≤ 90 mmHg. Because of its low sensitivity and no influence on outcome, physicians should not rely solely on FAST.

Assessment of Pattern of Abdominal Injury over a Two-Year Period at St Paul’s Hospital Millenium Medical College and AaBET Hospital, Addis Ababa, Ethiopia: A Retrospective Study

Background. Globally, injury continues to be an important cause of morbidity and mortality both in developed and developing countries. Abdominal injuries are among the major causes of trauma admissions. This study aimed to assess patterns of abdominal injury at AaBET and St. Paul’s Hospital Millennium Medical College. Methods. A cross-sectional study was done on all adult patients who sustained abdominal injuries presented to the emergency department and managed at AaBET and St. Paul’s Hospital Millennium Medical College over a two-year period from January 2018 to December 2019. Results. A total of 165 abdominal injured patients presented during the study period. Among those patients, 140 (84.8%) were male, with a male-to-female ratio of 5.61. The mean age of patients was 29.3 years. 85 (51.5%) of the patients sustained penetrating injuries. 53 (32.1%) patients sustained road traffic accidents, 47 (32.1%) had stab injuries, and 34 (20.6%) had gunshots. Thirty-four (20.6%) of the patients were managed conservatively and 79.4% (n = 131) were managed surgically. The commonest complications found were shock (n = 20 (12.1%)), peritonitis (n = 18(10.9%)), HAP (n = 9 (5.5%)), and surgical site infection (n = 4 (2.4%)).The mortality rate was 3.6% (n = 6), of which 4 (67%) had the penetrating mechanism of injury. Conclusion. Abdominal trauma predominantly affects the male and economically productive age. The three main causes of abdominal injuries in this study were road traffic accidents, stab injuries, and gunshots, which require increased public awareness of the need to prevent road traffic accidents and to handle weapons and sharp items properly.

External validation of a pediatric decision rule for blunt abdominal trauma

INTRODUCTION

Blunt traumatic injuries are a leading cause of morbidity and mortality in the pediatric population. Contrast-enhanced multidetector computed tomography is the best imaging tool for screening patients at risk of blunt abdominal injury. The Pediatric Emergency Care Applied Research Network (PECARN) abdominal rule was derived to identify patients at low risk for significant abdominal injury who do not require imaging.

METHODS

We conducted a retrospective review of pediatric patients with blunt trauma to validate the PECARN rule in a non-pediatric specialized hospital from February 3, 2013, through December 31, 2019. We excluded those with penetrating or mild isolated head injury. The PECARN decision rule was retrospectively applied for the presence of a therapeutic intervention, defined as a laparotomy, angiographic embolization, blood transfusion, or administration of intravenous fluids for pancreatic or gastrointestinal injury. Sensitivity and specificity analysis were conducted along with the negative and positive predictive values.

RESULTS

A total of 794 patients were included in the final analysis; 23 patients met the primary outcome for an acute intervention. The PECARN clinical decision rule (CDR) had a sensitivity of 91.3%, a negative predictive value of 99.5, and a negative likelihood ration of 0.16.

CONCLUSION

In a non-pediatric specialty hospital, the PECARN blunt abdominal CDR performed with comparable sensitivity and negative predictive value to the derivation and external validation study performed at specialized children's hospitals.

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.

Low-density Isolated Intraperitoneal Free Fluid in Pediatric Blunt Trauma Is Not Associated With Abdominal Injury

OBJECTIVES

Isolated intraperitoneal free fluid (IIFF) is defined as intraperitoneal fluid seen on computed tomography (CT) without identifiable injury. In a hemodynamically stable patient, this finding creates a challenge for physicians regarding the next steps in management because the clinical significance of this fluid is not completely understood. We hypothesized that pediatric blunt trauma patients with a finding of simple IIFF on CT would not have clinically significant intraabdominal injury.

METHODS

A retrospective review (2009-2018) was conducted of all pediatric blunt trauma patients who underwent CT scan of the abdomen/pelvis at our institution. All patients with scans performed at our institution with the finding of IIFF were included. Scans were reviewed to measure the Hounsfield Units (HU) of the intraabdominal fluid. Groups were stratified into HU > 25 and HU ≤ 25, below accepted cutoffs for acute blood, and clinical outcomes were reviewed.

RESULTS

A total of 413 patients had free fluid on CT abdomen/pelvis with 279 (68%) having only the finding of IIFF. The HU was 25 or less in 236 (85%) patients. No patients in the HU ≤ 25 group required operative exploration or had examination findings to indicate they had intraabdominal injury. Four (9%) patients in the HU > 25 required laparotomy (P < 0.0001). No patients in the HU ≤ 25 group required further workup or hospital admission over concern for intraabdominal injury.

CONCLUSIONS

Pediatric blunt trauma patients with HU of 25 or less IIFF and a nonperitonitic physical examination did not require operative exploration or further workup for intraabdominal injury. In the absence of other injuries, it is safe to discharge these patients without further workup.

Credentialing Pediatric Emergency Medicine Faculty in Point-of-Care Ultrasound: Expert Guidelines

ABSTRACT

As point-of-care ultrasound (POCUS) becomes standard practice in pediatric emergency medicine (PEM), it is important to have benchmarks in place for credentialing PEM faculty in POCUS. Faculty must be systematically trained and assessed for competency in order to be credentialed in POCUS and granted privileges by an individual institution. Recommendations on credentialing PEM faculty are needed to ensure appropriate, consistent, and responsible use of this diagnostic and procedural tool. It is our intention that these guidelines will serve as a framework for credentialing faculty in PEM POCUS.

Pediatric Blunt Abdominal Trauma and Point-of-Care Ultrasound

ABSTRACT

Blunt abdominal trauma (BAT) accounts for most trauma in children. Although the focused assessment with sonography in trauma (FAST) is considered standard of care in the evaluation of adults with traumatic injuries, there is limited evidence to support its use as an isolated evaluation tool for intra-abdominal injury as a result of BAT in children. Although a positive FAST examination could obviate the need for a computed tomography scan before OR evaluation in a hemodynamically unstable patient, a negative FAST examination cannot exclude intra-abdominal injury as a result of BAT in isolation. In this article, we review the evaluation of BAT in children, describe the evaluation for free intraperitoneal fluid and pericardial fluid using the FAST examination, and discuss the limitations of the FAST examination in pediatric patients.

Reevaluation of FAST Sensitivity in Pediatric Blunt Abdominal Trauma Patients: Should We Redefine the Qualitative Threshold for Significant Hemoperitoneum?

BACKGROUND

The utility of the focused assessment with sonography in trauma (FAST) examination in hemodynamically stable pediatric blunt abdominal trauma (BAT) patients is controversial.We report our 3-year experience with FAST performance to detect greater than physiologic amounts of intraperitoneal fluid after BAT.

METHODS

We performed a retrospective chart review of all FAST examinations performed from July 2015 to June 2018 at a level I pediatric trauma center. The main outcome of interest was the performance of a concerning FAST (cFAST) compared with a computed tomography scan diagnosis for greater than physiologic levels of free fluid (FF) and clinical follow-up. A cFAST was defined by the presence of any FF in the upper abdomen or by a moderate to large amount of FF present in the pelvis. The interobserver reliability of cFASTwas assessed with Cohen κ coefficient. Locations of FF were assessed.

RESULTS

A total of 448 FAST cases were eligible for review. The median age was 11 years with 64% male. Thirty-one FAST examinations (6.9%) were positive for some amount of FF; 18 (4.0%) were cFASTs. In the cFAST group, 11 patients (61%) were hemodynamically stable. The cFAST had a sensitivity of 89% (95% confidence interval [CI], 65%-99%), specificity of 99% (95% CI, 98%-100%), positive predictive value of 89% (95% CI, 67%-97%), and negative predictive value of 99% (95% CI, 98%-100%). The positive and negative likelihood ratios were 191 (95% CI, 47-769) and 0.11 (95% CI, 0.03-0.41). The κ coefficient for cFASTwas 0.72 with 86% agreement. Free fluid on cFAST cases was observed in the pelvis (78%), right upper quadrant (44%), and left upper quadrant (44%).

CONCLUSIONS

In pediatric BAT patients, a cFAST has acceptable sensitivity and remains a highly specific test to rule in greater than physiologic quantities of FF with confidence.

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.

Selective Computed Tomography (CT) Imaging is Superior to Liberal CT Imaging in the Hemodynamically Normal Pediatric Blunt Trauma Patient

BACKGROUND

The optimal imaging strategy in hemodynamically stable pediatric blunt trauma remains to be defined. The purpose of this study was to determine the differences between selective and liberal computed tomography (CT) strategy in a pediatric trauma population with respect to radiation exposure and outcomes.

METHODS

We performed a retrospective analysis of hemodynamically stable blunt pediatric trauma patients (≤16 y) who were admitted to a Level I trauma center between 2013-2016. Patients were stratified into selective and liberal imaging cohorts. Univariate and multivariate regression analyses were used to compare outcomes between the groups. Outcomes included radiation dose, hospital and ICU length of stay, complications and mortality.

RESULTS

Of the 485 patients included, 176 underwent liberal and 309 selective CT imaging. The liberal cohort were more likely to be severely injured (ISS>15: 34.1 versus 8.4%, P< 0.001). The odds of exposure to a radiation dose of >15 mSv were higher with liberal scanning in patients with both ISS > 15 (OR 2.78, 95% CI 1.76-5.19, P< 0.001) and ISS ≤ 15 (OR 3.41, 95% CI 2.19-8.44, P < 0.001). Adjusted outcomes regarding mortality, ICU length of stay, and complications were similar between the cohorts.

CONCLUSION

Selective CT imaging in hemodynamically stable blunt pediatric trauma patients was associated with reduced radiation exposure and similar outcomes when compared to a liberal CT strategy.

Isolated low-grade solid organ injuries in children following blunt abdominal trauma: Is it time to consider discharge from the emergency department?

INTRODUCTION

Acute intervention (AI) for solid organ injury (SOI) is rare in hemodynamically stable children. Pediatric guidelines recommend admission with follow-up laboratories, even for low-grade injuries.

METHODS

Data sets from two large multicenter prospective observational studies were used to analyze a cohort of children (age, <17 years) with grade I to III SOI following blunt abdominal trauma. Children with hollow viscus injuries were excluded. Patients were divided into (a) those with or without other major injuries (OMIs) (traumatic brain injury, hemothorax or pneumothorax, pelvic fracture, urgent orthopedic or neurosurgical operations) and (b) with grade I or II versus grade III injuries. Outcomes included AIs (transfusion, angiography, abdominal operation) and disposition (admission unit and length of stay).

RESULTS

There were 14,232 children enrolled in the two studies, and 791 patients had a SOI (5.6%). After excluding patients with hollow viscus injuries and higher-grade SOIs, 517 patients with a grade I to III SOI were included, and 262 of these had no OMI. Among patients with no OMI, none of 148 patients with grade I or II SOI underwent AI, while only 3 of 114 patients with grade III injuries underwent AI (3 transfusions/1 angioembolization). All three had hemoperitoneum; two of three had an additional organ with a grade II injury. Among grade I and II SOIs with no OMI, 28 (18.9%) of 148 were admitted to an intensive care unit, 110 (74.3%) of 148 to floor, and 7 (4.7%) of 148 discharged home from emergency department; median length of stay 2 days. Among grade III SOIs with no OMI, 38 (33.3%) of 114 were admitted to an intensive care unit and 61.4% to the floor; median length of stay was 4 days. Among 255 patients with a grade I to III SOI and other major organ system injuries, 31 (12.2%) underwent AI.

CONCLUSION

No patient with a grade I and II SOI and no OMI following blunt abdominal trauma received intervention, suggesting that patients with low-grade SOI without OMIs could be safely observed and discharged from the emergency department.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

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.

Fifteen-minute consultation: Imaging in paediatric major trauma

With trauma being a leading cause of death for children, identifying all sustained injuries remains a priority for clinicians, and imaging is a key diagnostic tool to ensure that is achieved. However, children have a greater risk of detrimental effects of ionising radiation than adults. Clinicians therefore have to balance limiting their patients' radiation exposure to 'as low as reasonably achievable' with the need for diagnostic accuracy. But what is 'reasonable' in major trauma can be confusing. This article aims to clarify the current guidance on which body part to scan and when in paediatric major trauma.

Test characteristics of focused assessment with sonography for trauma (FAST), repeated FAST, and clinical exam in prediction of intra-abdominal injury in children with blunt trauma

PURPOSE

In children with blunt abdominal trauma (BAT), focused assessment of sonography in trauma (FAST) has been reported with low sensitivity, on the whole, in the detection of intra-abdominal injuries (IAI). The aim of the present study was to assess test characteristics of FAST using different strategies including repeated FAST (reFAST), and physical exam findings.

METHODS

This retrospective study evaluated BAT pediatric patients with stable hemodynamics who underwent computed tomography (CT). Demographic data, initial physical examination, and results of FAST, reFAST (if done), and CT imaging were recorded. Different strategies of FAST were cross-tabulated with CT as the gold standard and test characteristics including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were interpreted.

RESULTS

129 patients with a mean age of 8.6 ± 4.7 were studied and 74% were male. Comparing CT-positive and -negative groups, from the demographic and clinical findings, only positive physical exam (tenderness or ecchymosis) was significantly higher in the CT-positive group (59% vs. 17%; p < 0.01). In a multivariate analysis, positive FAST modality and clinical exam remained independent predictors for a positive CT result (likelihood ratios of 34.6 and 6.4, respectively). Out of the different diagnostic strategies for the prediction of IAI, the best overall performance resulted from the FAST-reFAST-tenderness protocol with sensitivity, specificity, PPV, NPV, and accuracy of 87%, 77%, 70%, 91%, and 81%.

CONCLUSION

For children with blunt abdominal trauma, physical examination plus FAST and reFAST as needed, seems to have reasonable sensitivity, specificity, and accuracy in detecting intra-abdominal injuries and may reduce the need for CT scans.

Negative Focused Abdominal Sonography for Trauma examination predicts successful nonoperative management in pediatric solid organ injury: A prospective Arizona-Texas-Oklahoma-Memphis-Arkansas + Consortium study

BACKGROUND

Focused Abdominal Sonography for Trauma (FAST) examination has long been proven useful in the management of adult trauma patients, however, its utility in pediatric trauma patients is not as proven. Our goal was to evaluate the utility of a FAST examination in predicting the success or failure of nonoperative management (NOM) of blunt liver and/or spleen (BLSI) in the pediatric trauma population.

METHODS

A retrospective analysis of a prospective observational study of patients younger than 18 years presenting with BLSI to one of ten Level I pediatric trauma centers between April 2013 and January 2016. 1,008 patients were enrolled and 292 had a FAST examination recorded. We analyzed failure of NOM of BLSI in the pediatric trauma population. We then compared FAST examination alone or in combination with the pediatric age adjusted shock index (SIPA) as it relates to success of NOM of BLSI.

RESULTS

Focused Abdominal Sonography for Trauma examination had a negative predictive value (NPV) of 97% and positive predictive value (PPV) of 13%. The odds ratio of failing with a positive FAST examination was 4.9 and with a negative FAST was 0.20. When combined with SIPA, a positive FAST examination and SIPA had a PPV of 17%, and an odds ratio for failure of 4.9. The combination of negative FAST and SIPA had an NPV of 96%, and the odds ratio for failure was 0.20.

CONCLUSION

Negative FAST is predictive of successful NOM of BLSI. The addition of a positive or negative SIPA score did not affect the PPV or NPV significantly. Focused Abdominal Sonography for Trauma examination may be useful clinically in determining which patients are not at risk for failure of NOM of BLSI and do not require monitoring in an intensive care setting.

LEVEL OF EVIDENCE

Prognostic study, level IV; therapeutic/care management, level IV.

Initial focused assessment with sonography in trauma versus initial CT for patients with haemodynamically stable torso trauma

OBJECTIVE

Focused assessment with sonography in trauma (FAST) examination is a widely known initial evaluation for patients with trauma. However, it remains unclear whether FAST contributes to patient survival in patients with haemodynamically stable trauma. In this study, we compared in-hospital mortality and length of stay between patients undergoing initial FAST vs initial CT for haemodynamically stable torso trauma.

METHODS

This was a retrospective cohort study using data from 264 major emergency hospitals in the Japan Trauma Data Bank between 2004 and 2016. Patients were included if they had torso trauma with a chest or abdomen abbreviated injury scale score of ≥3 and systolic blood pressure of ≥100 mm Hg at hospital arrival. Eligible patients were divided into those who underwent initial FAST and those who underwent initial CT. Multivariable logistic regression analysis for in-hospital mortality and multivariable linear regression for length of stay were performed to compare the initial FAST and initial CT groups with adjustment for patient backgrounds while also adjusting for within-hospital clustering using a generalised estimating equation.

RESULTS

There were 9942 patients; 8558 underwent initial FAST and 1384 underwent initial CT. Multivariable logistic regression showed no significant difference in in-hospital mortality between the initial FAST and initial CT groups (OR 1.37, 95% CI 0.94 to 1.99, p=0.10). Multivariable linear regression revealed that the initial FAST group had a significantly longer length of stay than the initial CT group (difference: 3.5 days; 95% CI 1.0 to 5.9, p<0.01).

CONCLUSIONS

In-hospital mortality was not significantly different between the initial FAST and initial CT groups for patients with haemodynamically stable torso trauma. Initial CT should be considered in patients with haemodynamically stable torso trauma.

External validation of a five-variable clinical prediction rule for identifying children at very low risk for intra-abdominal injury after blunt abdominal trauma

BACKGROUND

A clinical prediction rule was previously developed by the Pediatric Surgery Research Collaborative (PedSRC) to identify patients at very low risk for intra-abdominal injury (IAI) and intra-abdominal injury receiving an acute intervention (IAI-I) who could safely avoid abdominal computed tomography (CT) scans after blunt abdominal trauma (BAT). Our objective was to externally validate the rule.

METHODS

The public-use dataset was obtained from the Pediatric Emergency Care Applied Research Network (PECARN) Intra-abdominal Injury Study. Patients 16 years of age and younger with chest x-ray, completed abdominal history and physical examination, aspartate aminotransferase (AST), and amylase or lipase collected within 6 hours of arrival were included. We excluded patients who presented greater than 6 hours after injury or missing any of the five clinical prediction variables from the PedSRC prediction rule.

RESULTS

We included 2,435 patients from the PECARN dataset, with a mean age of 9.4 years. There were 235 patients with IAI (9.7%) and 60 patients with IAI-I (2.5%). The clinical prediction rule had a sensitivity of 97.5% for IAI and 100% for IAI-I. In patients with no abnormality in any of the five prediction rule variables, the rule had a negative predictive value of 99.3% for IAI and 100.0% for IAI-I. Of the "very low-risk" patients identified by the rule, 46.8% underwent abdominal CT imaging.

CONCLUSIONS

A highly sensitive clinical prediction rule using history and abdominal physical examination, laboratory values, and chest x-ray was successfully validated using a large public-access dataset of pediatric BAT patients.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level III; therapeutic care/management study, level IV.

Too fast, or not fast enough? The FAST exam in patients with non-compressible torso hemorrhage

BACKGROUND

Focused assessment with sonography for trauma (FAST) performance metrics are unknown in patients with non-compressible torso hemorrhage (NCTH).

METHODS

Retrospective review of a dedicated NCTH database from four level 1 trauma centers (2008-2012). NCTH was defined as (1) named axial torso vessel disruption; (2) AIS chest or abdomen >2 with shock (base deficit < -4) or truncal operation in ≤ 90 min; or (3) pelvic fracture with ring disruption. Patients were grouped by cavity of hemorrhage source and by shock (SBP ≤ 90).

RESULTS

274 patients had a FAST prior to diagnosis of NCTH. FAST was positive in 51% of patients with abdominal/pelvic hemorrhage for a false negative rate (FNR) of 49%. FNR was higher for pelvic (61%) versus abdominal (43%) sources (p = 0.02). There was no difference between FAST negative or positive patients for ISS, shock, length of stay, or mortality (all p = NS). FNR was not improved among the subgroup of NCTH patients with shock (p = NS).

CONCLUSION

FAST identified abdominal/pelvic hemorrhage in approximately half of NCTH patients, and this was not improved among patients presenting with shock.

Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma

BACKGROUND

Point-of-care sonography (POCS) has emerged as the screening modality of choice for suspected body trauma in many emergency departments worldwide. Its best known application is FAST (focused abdominal sonography for trauma). The technology is almost ubiquitously available, can be performed during resuscitation, and does not expose patients or staff to radiation. While many authors have stressed the high specificity of POCS, its sensitivity varied markedly across studies. This review aimed to compile the current best evidence about the diagnostic accuracy of POCS imaging protocols in the setting of blunt thoracoabdominal trauma.

OBJECTIVES

To determine the diagnostic accuracy of POCS for detecting and excluding free fluid, organ injuries, vascular lesions, and other injuries (e.g. pneumothorax) compared to a diagnostic reference standard (i.e. computed tomography (CT), magnetic resonance imaging (MRI), thoracoscopy or thoracotomy, laparoscopy or laparotomy, autopsy, or any combination of these) in patients with blunt trauma.

SEARCH METHODS

We searched Ovid MEDLINE (1946 to July 2017) and Ovid Embase (1974 to July 2017), as well as PubMed (1947 to July 2017), employing a prospectively defined literature and data retrieval strategy. We also screened the Cochrane Library, Google Scholar, and BIOSIS for potentially relevant citations, and scanned the reference lists of full-text papers for articles missed by the electronic search. We performed a top-up search on 6 December 2018, and identified eight new studies which may be incorporated into the first update of this review.

SELECTION CRITERIA

We assessed studies for eligibility using predefined inclusion and exclusion criteria. We included either prospective or retrospective diagnostic cohort studies that enrolled patients of any age and gender who sustained any type of blunt injury in a civilian scenario. Eligible studies had to provide sufficient information to construct a 2 x 2 table of diagnostic accuracy to allow for calculating sensitivity, specificity, and other indices of diagnostic test accuracy.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts, and full texts of reports using a prespecified data extraction form. Methodological quality of individual studies was rated by the QUADAS-2 instrument (the revised and updated version of the original Quality Assessment of Diagnostic Accuracy Studies list of items). We calculated sensitivity and specificity with 95% confidence intervals (CI), tabulated the pairs of sensitivity and specificity with CI, and depicted these estimates by coupled forest plots using Review Manager 5 (RevMan 5). For pooling summary estimates of sensitivity and specificity, and investigating heterogeneity across studies, we fitted a bivariate model using Stata 14.0.

MAIN RESULTS

We included 34 studies with 8635 participants in this review. Summary estimates of sensitivity and specificity were 0.74 (95% CI 0.65 to 0.81) and 0.96 (95% CI 0.94 to 0.98). Pooled positive and negative likelihood ratios were estimated at 18.5 (95% CI 10.8 to 40.5) and 0.27 (95% CI 0.19 to 0.37), respectively. There was substantial heterogeneity across studies, and the reported accuracy of POCS strongly depended on the population and affected body area. In children, pooled sensitivity of POCS was 0.63 (95% CI 0.46 to 0.77), as compared to 0.78 (95% CI 0.69 to 0.84) in an adult or mixed population. Associated specificity in children was 0.91 (95% CI 0.81 to 0.96) and in an adult or mixed population 0.97 (95% CI 0.96 to 0.99). For abdominal trauma, POCS had a sensitivity of 0.68 (95% CI 0.59 to 0.75) and a specificity of 0.95 (95% CI 0.92 to 0.97). For chest injuries, sensitivity and specificity were calculated at 0.96 (95% CI 0.88 to 0.99) and 0.99 (95% CI 0.97 to 1.00). If we consider the results of all 34 included studies in a virtual population of 1000 patients, based on the observed median prevalence (pretest probability) of thoracoabdominal trauma of 28%, POCS would miss 73 patients with injuries and falsely suggest the presence of injuries in another 29 patients. Furthermore, in a virtual population of 1000 children, based on the observed median prevalence (pretest probability) of thoracoabdominal trauma of 31%, POCS would miss 118 children with injuries and falsely suggest the presence of injuries in another 62 children.

AUTHORS' CONCLUSIONS

In patients with suspected blunt thoracoabdominal trauma, positive POCS findings are helpful for guiding treatment decisions. However, with regard to abdominal trauma, a negative POCS exam does not rule out injuries and must be verified by a reference test such as CT. This is of particular importance in paediatric trauma, where the sensitivity of POCS is poor. Based on a small number of studies in a mixed population, POCS may have a higher sensitivity in chest injuries. This warrants larger, confirmatory trials to affirm the accuracy of POCS for diagnosing thoracic trauma.

Recent Advances in Technology and Its Applications to Pediatric Emergency Care

Advances in technology are continuously transforming medical care, including pediatric emergency medicine. The increasing adoption of point-of-care ultrasound examination can improve timely diagnoses without radiation and aids the performance of common procedures. The recent dramatic increase in electronic health record adoption offers an opportunity for enhanced clinical decision-making support. Simulation training and advances in technologies can provide continued proficiency training despite decreasing opportunities for pediatric procedures and cardiorespiratory resuscitation performance. This article reviews these and other recent advances in technology that have had the greatest impact on the current practice of pediatric emergency medicine.

Review of bedside surgeon-performed ultrasound in pediatric patients

PURPOSE

Pediatric surgeon performed bedside ultrasound (PSPBUS) is a targeted examination that is diagnostic or therapeutic. The aim of this paper is to review literature involving PSPBUS.

METHODS

PSPBUS practices reviewed in this paper include central venous catheter placement, physiologic assessment (volume status and echocardiography), hypertrophic pyloric stenosis diagnosis, appendicitis diagnosis, the Focused Assessment with Sonography for Trauma (FAST), thoracic evaluation, and soft tissue infection evaluation.

RESULTS

There are no standards for the practice of PSPBUS.

CONCLUSIONS

As the role of the pediatric surgeon continues to evolve, PSPBUS will influence practice patterns, disease diagnosis, and patient management.

TYPE OF STUDY

Review Article.

LEVEL OF EVIDENCE

Level III.

Variation in training and use of the focused assessment with sonography in trauma (FAST)

BACKGROUND

Training in ultrasound is variable among residents and practicing traumatologists. Focused Assessment with Sonography in Trauma (FAST) may be underused in non-urbanized areas, possibly due to lack of training.

METHODS

State trauma registry data from January 2014-June 2016 were reviewed for FAST results. Trauma practitioners were surveyed querying training, confidence, and obstacles to performing FAST.

RESULTS

12,855 records revealed highest FAST use at the urban Level II center (39%, p < 0.0001). Despite similar injury patterns, non-urban/Level III centers' frequency of FAST was only 1-28%. 39 practitioners were surveyed, those with training (54%) were more likely to use FAST (p < 0.05). 61% of practitioners outside the Level II center cited lack of confidence in their ability to perform FAST as the primary reason for omitting the exam.

CONCLUSIONS

FAST is relatively underused in non-urbanized areas of the state. Lack of confidence in ability to perform FAST was cited as the primary barrier.