The value of focused assessment with sonography in trauma examination for the need for operative intervention in blunt torso trauma: a rebuttal to “emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma (review)”, from the Cochrane Collaboration

Abstract

AbstractBackground and significanceThe Cochrane Database of Systematic Reviews published a manuscript critical of the use of the FAST examination. The reference is Stengel D. Bauwens K. Sehouli J. Rademacher G. Mutze S. Ekkernkamp A. Porzsolt F. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma.Cochrane Database of Systematic Reviews. (2):CD004446, 2005.UI: 15846717. The stated objective was the assessment of the “efficiency and effectiveness” of ultrasound-inclusive evaluative algorithms in patients with suspected blunt abdominal trauma (BAT). The primary outcome measures explored were Mortality, CT and DPL use, and laparotomy rates. Little or no benefit was seen and the conclusion was that “there is insufficient evidence from randomized controlled trials to justify promotion” of FAST in patients with BAT. While the review used the same rigorous methods employed in all Cochrane Reviews, it appears that several serious flaws plagued the manuscript. The finest methodological rigor cannot yield usable results, if it is not applied to a clinically relevant question. In a world of increasingly conservative management of BAT, do we need FAST, a rapid, repeatable screening modality at the point-of-care to visualize any amount of free fluid or any degree of organ injury? The obvious answer is no. However, quantifying the value of FAST to predict the need for immediate operative intervention (OR) is essential.MethodsTo rebut this recurrent review, a systematic literature review was conducted using verbatim methodologies as described in the Cochrane Review with the exception of telephone contacts. Data were tabulated and presented descriptively.ResultsOut of 487 citations, 163 articles were fully screened, 11 contained prospectively derived data with FAST results, patient disposition and final diagnoses, and a description of cases considered false negatives or false positives. Of the 2,755 patients, 448 (16%) went to the OR. There were a total of 5 patients with legitimately false-negative diagnoses made based on the FAST: 3 involving inadequate scans and 2 of blunt trauma-induced small bowel perforations without hemoperitoneum.ConclusionThe FAST examination, adequately completed, is a nearly perfect test for predicting a “Need for OR” in patients with blunt torso trauma.