Accuracy of FAST scan in blunt abdominal trauma in a major London trauma centre

Using Right-Sided Roll to Improve Reliability of Focused Assessment with Sonography in Trauma: An Eastern Association for the Surgery of Trauma Multicenter Prospective Study

BACKGROUND

The Focused Assessment Sonography in Trauma (FAST) examination is the standard of care for detecting hemoperitoneum in hypotensive blunt trauma patients. A pilot study demonstrated earlier identification of intra-abdominal fluid via FAST after right-sided roll (FASTeR) when compared with the standard FAST. The purpose of this study was to evaluate this phenomenon prospectively in hypotensive blunt trauma patients.

STUDY DESIGN

An Eastern Association for the Surgery of Trauma-approved multicenter prospective trial was performed June 2016 to October 2020 at 8 designated trauma centers. Hypotensive adult blunt trauma patients were included. A traditional FAST examination was performed. After this, the secondary survey logroll for back examination was standardized to the patient's right side. A repeat supine right upper quadrant ultrasound view was obtained. The presence or absence of hemoperitoneum was confirmed by CT scan or intraoperative findings. FAST and FASTeR were compared using receiver operating characteristics. The area under the curve was calculated.

RESULTS

A total of 182 patients met inclusion criteria. A total of 65 patients (35.7%) had hemoperitoneum on CT scan or intraoperative findings. The sensitivity of FASTeR was 47.7%, and of FAST was 40.0% (p = 0.019). The receiver operating characteristics area under the curve of the FASTeR examination was 0.717 vs 0.687 for the FAST examination (p = 0.091).

CONCLUSIONS

Addition of a right upper quadrant view after right-sided roll does improve the sensitivity of the FAST examination while maintaining the standard positive predictive value. We demonstrate a trend that does not reach statistical significance about the overall accuracy. This multicenter prospective trial was underpowered to reveal a statistically significant difference in the overall accuracy as measured by the receiver operating characteristics area under the curve.

Validity of physical examination in the thorax and abdomen of intoxicated trauma patients following a fall: An exploratory retrospective review

Background

Whole-Body Computerized Topography (WBCT) scans can be used to identify injuries related to trauma in intoxicated patients who often cannot provide a reliable history. While WBCT scans are associated with a decreased mortality and hospital stay in patients with a high energy mechanism of injury, their utility in intoxicated patients following a fall remain unclear. The objective of this study was to evaluate the validity of physical examination in the thorax and abdomen to identify injuries in the intoxicated patient following a fall when compared to WBCT scan findings.

Methods

A retrospective chart review was performed over a two-year period of intoxicated trauma patients who were found down secondary to a witnessed fall <20 ft, GCS > 8 and not requiring intubation. Documented physical examination findings were compared to WBCT results. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. A t-test was used to identify differences between clinical variables of false-negative and true-negative physical examinations.

Results

A total of 523 intoxicated patients presented to the ED with 43 meeting the inclusion criteria. All patients had an injury that required admission to the hospital. Of 19 patients with a positive chest CT, 13 had a negative physical exam, for sensitivity of 32% and specificity of 96%. Of eight patients with a positive abdominal CT, six had a negative physical exam, sensitivity and specificity were 16% and 98% respectively. No clinical variables were found to be different between falsely negative and true negative physical exam results.

Conclusion

In the acutely intoxicated trauma patient, physical examination findings of the thorax and abdomen were associated with a low validity, having missed an unacceptably high number of injuries, when compared to WBCT scans.

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.