Focused Abdominal Sonography In Trauma Research Articles

Economic and clinical benefits of immediate total-body CT in the diagnostic approach to polytraumatized patients: a descriptive analysis through a literature review.

Major trauma is an event causing injuries that may determine an immediate or potential risk to the patient survival. A correct management of major trauma is decisive in reducing disability, which has relevance both from the point of view of the quality of life of the single individual and from the point of view of health expenditure. The primary clinical approach to the polytraumatized patients is managed, in most cases, as outlined in the guidelines of Advanced Trauma Life Support, proposing conventional radiological investigations, such as chest and pelvis x-ray, and of FAST (focused abdominal sonography in trauma)/E-FAST (extended FAST) examinations, followed by selective targeted computed tomography (CT). This approach is questionable and is increasingly common in clinical practice the adoption of the immediate total-body CT in the diagnostic approach to the hemodynamically stable polytraumatized patient. However, the potential advantages of such conduct both in terms of clinical benefits and in terms of cost-effectiveness still need to be discussed. The objective of this review article consists of a descriptive analysis of the economic and clinical benefits of the adoption of immediate total-body CT in polytrauma patients through a literature review.

Clinicoradiological Predictors of Severity of Traumatic Intra-Abdominal Injury in Pediatric Patients: A Retrospective Study.

BackgroundAdequate assessment of traumatic injury in patients of all age groups is essential for timely intervention and prevention of mortality and morbidity. This study aimed to assess the value of certain clinical as well as radiological factors as predictors of severity of the intra-abdominal injury as detected on computed tomography (CT) and to review the guidelines, protocols, and practices followed in imaging of abdominal trauma in patients of pediatric age group.MethodsThis retrospective observational study included 263 pediatric patients (18 years of age or younger) who presented to the emergency department (ED) with a history of trauma to the abdomen. The study was conducted over a period of 12 months. Correlation of five variables, i.e., age of the child, focused abdominal sonography in trauma (FAST) status, mechanism of injury, presenting complaints and clinical features (hypotension, tachycardia, etc), fractures identified on trauma X-ray series, was done with CT findings (severity of injury). All five variables were statistically analyzed and p-values were derived for age, mechanism of injury, presenting complaints, clinical features, and trauma x-ray series, while parameters like sensitivity and specificity were determined for FAST statusResultsAll variables well correlated with the severity of injury with p-values <0.05. On multivariate analysis, FAST status had the highest (47.94) odds ratio among the five variables for predicting severe intra-abdominal injury while vital signs had the lowest (0.076). Further, age group of 0-4 years was found most prone to higher grades of injury with odds ratio of 7.83. Motor vehicle crash had odds ratio of 26.6 for severe injury, the highest among mechanisms of injury. While for FAST status, sensitivity was found to be 89.4%, specificity 85%, and negative predictive value 90%, trauma series radiographs had a sensitivity of 42.27%, specificity of 77.85% and negative predictive value of 60.55%.ConclusionClinical parameters and traditional imaging techniques can predict the severity of injury on CT and guide further imaging and intervention.

Accuracy of FAST (Focused Abdominal Sonography in Trauma) scan in diagnosis of significant abdominal trauma using CT abdomen as gold standard.

Objectives: The aim of this research work is to find out the precision of FAST scan in detection of the significant abdominal trauma with the utilization of the CT abdomen considering it as a gold standard. Study Design: Cross Sectional study. Setting: Department of Radiology and Department of Emergency in Holy Family Hospital, Rawalpindi. Period: Six months from March, 2019 to September 2019. Material &amp; Methods: Total 120 patients of both genders having age from 16 to 65 years who were presented in the Department of Trauma emergency. Both were the participants of this research work. We carried out CT of abdomen and FAST scan for every patient. We also calculated the sensitivity, PPV, NPV, specificity and overall accuracy rate of the FAST scan. Results: There were 80.80% (n: 97) male patients and 19.20% (n: 23) patients were females. We found 28.30% (n: 34) patients as positive in FAST scan and 22.50% (n: 27) patients as positive on CT of abdomen. FAST scan’s accuracy, NPV, PPV, sensitivity and specificity were present as 84.20%, 93%, 61.80%, 77.8% and 86% respectively. Conclusion: FAST scan permits the identification of the free fluid gathered in various regions of the abdomen cavity because of the BAT with high rate of sensitivity, PPV, NPV and specificity.

Outcomes in splenic injury at a high volume tertiary care centre

Background: The objective of the present study was to study the outcomes of patients following splenic injury at a tertiary care centre.Methods: This prospective study was conducted over a period of 2 years, from January 2017 to December 2018, at Dayanand Medical College and Hospital, Ludhiana to include all patients presenting to the emergency department with splenic injury diagnosed on focused abdominal sonography in trauma (FAST)/contrast enhanced computed tomography (CECT) abdomen. 60 cases were studied over this time-period. After thorough a work-up, patients were either managed conservatively or by surgical intervention. The results were recorded in a predesigned proforma and the statistics were analyzed to determine the outcome of splenic injury patients at DMCH, Ludhiana.Results: Among 10% of cases were Grade-V (American Association for Surgery in Trauma (AAST) grading), all of whom required surgical intervention. 3.3% of cases with lesser grade of injury required surgical intervention due to other reasons. 86.7% were managed conservatively. Mean length of stay was 10.9 days. 83.4% of cases were discharged in stable condition with 13.3% cases being discharged against medical advice and a mortality rate of 3.3%.Conclusions: Majority of patients (86.7%) with splenic injury can be managed conservatively. Surgical intervention is only indicated in patients with Grade-V AAST injury (10%) or in patients with concomitant injury to other organs requiring laparotomy (3.3%). In essence, early diagnosis with FAST and CECT abdomen is the cornerstone in the management of splenic injury, which can help trauma surgeons establish an early management protocol for the better outcome of patients with splenic injury. However, a study with greater sample size is required to further establish the principles of management of splenic trauma in this region.

EFAST Simulation Training for Trauma Providers.

Current trauma recommendations include completing chest and pelvis radiographs and Focused Abdominal Sonography in Trauma (FAST) examination in the trauma bay; however, expanding literature indicates that thoracic ultrasound scans are more sensitive than chest radiography in the detection of pneumothorax. In an urban, Level II trauma center in central Ohio, the author implemented an evidence-based practice project. This project focused on a lack of provider knowledge of the expanded Focused Abdominal Sonography in Trauma (eFAST) examination. The training consisted of a lecture and a simulation training session. To monitor the success of the implementation, pre- and postimplementation testing of the provider's competence with the eFAST technique using the Objective Structured Assessment of Ultrasound Skills (OSAUS) was completed. The pre- and posttest implementation showed an increase of the OSAUS score by 16.9%. The author also reviewed charts pre- and postimplementation to demonstrate the utilization rates of eFAST. After training, the utilization rates increased by 66% (p < .05). Overall, the project implementation was a success and demonstrated the importance of frequent literature review and implementation of this literature into practice.

Splenic injuries in blunt trauma of the abdomen presenting to the emergency department of a large tertiary care hospital in South India

Background: Trauma is an increasing cause of morbidity and mortality in India. Blunt injury to the abdomen frequently results in life-threatening splenic injuries. Materials and Methods: This was a retrospective observational study of all patients more than 18 years old presenting to our emergency department with blunt abdominal trauma resulting in a splenic injury between 2006 and 2011. Details of the incident, injuries, and outcome were noted. Results: During the study of 2006–2011, 51 patients with splenic injury following blunt trauma to the abdomen were enrolled. There was a significant male predominance (94.1%). Road traffic accident (RTA) was the predominant mode of injury (66.7%) followed by fall from height (25.5%). On examination, the majority of the patients (82.4%) had abdominal tenderness while abdominal distension and guarding were seen in 60.8% and 31.4% of patients, respectively. A third (35.3%) of the patients was hypotensive at presentation. All the patients were started on crystalloids while blood products were transfused in 70.6% of the patients. Splenic injury was diagnosed during the primary survey in 92% of the patients. Emergency department (ED) physicians diagnosed free fluid and solid organ injuries on focused abdominal sonography in trauma (FAST) in 80.4% and 47.1% of patients, respectively. Computed tomography scan of the abdomen was performed in 57% of the patients. More than half (58.8%) were managed conservatively. The mortality rate was 10%. Conclusions: RTAs are the most common cause of splenic injury. ED physicians are quite reliable in diagnosing free fluid in the abdomen with FAST. Aggressive fluid resuscitation with blood products is the key to survival in both conservatively and surgically managed patients.

Laparoscopic Management of Stab Wound of Anterior Abdominal Wall: A Prospective Stud

Background: The anterior abdominal wall is one of the most common regions affected in penetrating stab wound injuries. Tradionally, wound exploration and exploratory laparotomy are used as a diagnostic and therapeutic modality in the management of such injuries. Recently, laparoscopy has gained popularity in the management of such cases with favorable results in carefully selected patients. The aim of the present study was to assess the role of laparoscopy in the diagnosis and management of patients with stab wounds of the anterior abdominal wall. Patients and methods: 52 hemodynamically stable patients with stab wound of the anterior abdominal wall were included in this study at the emergency department of Ain Shams University Hospitals. Patients were selectively subjected to, physical examinations, focused abdominal sonography in trauma (FAST), computed tomography (CT), exploratory laparotomy, diagnostic and therapeutic laparoscopy. Results: Out of 39 patients that underwent laparoscopy, the laparoscopy succeeded to rule out visceral injury in 14 patients (35.9%) and was nontherapeutic in 5 patients (12.8%). 17 patients (43.6%) needed therapeutic management through laparoscopy and conversion to open laparotomy was done in 3 patients (7.7%). One case of missed injury with laparoscopy was recorded (accuracy 97.4%). Conclusion: Laparoscopy is a feasible and useful modality for evaluating and managing hemodynamically stable patients with abdominal stab wounds. Increased use of laparoscopy will help to decrease the rate of negative and nontherapeutic laparotomies, thus lowering morbidity and decreasing length of hospitalization.

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

IntroductionIn 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.MethodsThe 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.ResultsDuring 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 %.ConclusionsThis 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.

Is it possible to use transaminases for deciding on surgical or non-operative treatment for blunt liver trauma?

We aimed to research the relation of transaminase levels in blunt liver trauma (BLT) with the intensity of the trauma and the use of transaminase levels for deciding on surgical or non-operative treatment. In all, 44 patients with BLT diagnosed by computerized tomography (CT) were involved in this retrospective study. By testing the correlation of the transaminase levels and the grade of liver injury with receiver operator characteristics (ROC), area under the curve (AUC) was calculated; besides, the sensitivity, specificity, and cut-off values of transaminases were calculated separately for the grades. Moreover, same method was repeated for the surgically and non-operatively treated patients. Cut-off value was assessed for surgical and non-operative treatments. The efficiency of transaminases in deciding non-operative treatment was compared with that of other methods using ROC test applied on focused abdominal sonography in trauma (FAST), hemodynamic instability, blood replacement rate, aspartate aminotransferase (AST), and alanine aminotransferase (ALT). It was observed that the AUC, sensitivity, and specificity increased correspondingly with the grade rise of transaminase levels in BLT. In the selection of non-operative treatment/surgery, following values have been confirmed: AUC for AST: 0.851 (sensitivity: 86%, specificity: 73%, cut-off value: 498 U/L), AUC for ALT: 0.880 (sensitivity: 86%, specificity: 81%, cut-off value: 498 U/L), AUC for replacement: 0.948 (sensitivity: 86%, specificity: 94%), AUC for hemodynamic instability: 0.902 (sensitivity: 86%, specificity: 94%), and AUC for FAST: 0.642 (sensitivity: 57%, specificity: 75%). It was found that in BLT, transaminases can predict the injury rating with higher accuracy as the grade rises, and they outrival FAST in terms of determining the need for laparotomy.

The use of FAST scan by paramedics in mass-casualty incidents: a simulation study.

The Focused Abdominal Sonography in Trauma (FAST) scan is used to detect free fluid in the peritoneal cavity, or pericardium, to quickly assess for injuries needing immediate surgical intervention. Mass-casualty incidents (MCIs) are settings where paramedics must make triage decisions in minutes. The Simple Triage and Rapid Transport (START) system is used to prioritize transport. The FAST scan can be added to the triage of critical patients, and may aid in triage. This was a single-blinded, randomized control trial. Ten paramedics with field experience were trained with an ultrasound machine in the performance of the FAST scan. Two weeks were allowed to pass before testing to simulate the time between training of standard procedures and their implementation. On test day, five peritoneal dialysis patients with instilled dialysis fluid and five matched control patients were placed in a room in a random order where the paramedics performed FAST scans on each patient. The paramedics were assessed by declaring positive or negative for each evaluation, as well as being timed for the total exercise. Of the ninety tests (one paramedic dropped out due to family emergency), the paramedics had a mean accuracy of 60% and median of 62% (range 40%-80%). There was a statistically significant higher false-positive rate of 59% than false-negative rate of 41% (P < .01). Sensitivity was 67% with a specificity of 56%. Average time taken was 1,218 seconds (121.8 seconds per patient) with a range of 735-1,701 seconds and a median of 1,108 seconds. In this simulation study, paramedics had difficulty performing FAST scans with a high degree of accuracy. However, they were more apt to call a patient positive, limiting the likelihood for false-negative triage.

Systematic review: effect of whole-body computed tomography on mortality in trauma patients.

:Background:The initial diagnostic evaluation and management of trauma patients is mainly based on Advanced Trauma Life Support (ATLS) guidelines worldwide. Based on ATLS principles, conventional diagnostics such as conventional radiography (CR) and focused abdominal sonography in trauma (FAST) should precede selective use of CT. Whole-body CT (WBCT) is highly accurate and allows detection of life threatening injuries with good sensitivity and specificity. WBCT is faster than conventional diagnostics and saves more time in management of trauma patients. This study aims to review studies investigating the effect of WBCT on mortality in trauma patients.Methods:Literatures were found by searching keywords in Medline, PubMed and Cochrane library. The relevant articles were selected by two independent reviewers based on title, abstract and introduction sections. Full-texts of selected articles were reviewed and those investigating effect of WBCT on mortality in trauma patients were included.Results:Searching the keywords in Medline and PubMed resulted in 178 and 167 articles, respectively. Nine studies met the inclusion criteria and were reviewed. These included 8 retrospective and 1 prospective cohort studies. Mortality was measured as mortality rate or standardised mortality ratio (SMR) in the included studies.Conclusions:Unlike previous systematic reviews, this review indicates that use of WBCT in blunt trauma patients is associated with reduced overall mortality rate and that WBCT can potentially improve the probability of survival in haemodynamically stable and unstable blunt trauma patients. High quality RCTs are required to describe a causal relationship between WBCT and mortality in trauma patients.

Battlefield radiology

With the increasing tempo of military conflicts in the last decade, much has been learnt about imaging battlefield casualties in the acute setting. Ultrasound in the form of focused abdominal sonography in trauma (FAST) has proven invaluable in emergency triage of patients for immediate surgery. Multidetector CT allows accurate determination of battlefield trauma injuries. It permits the surgeons and anaesthetists to plan their interventions more thoroughly and to be made aware of clinically occult injuries. There are common injury patterns associated with blast injury, gunshot wounds and blunt trauma. While this body of knowledge is most applicable to the battlefield, there are parallels with peacetime radiology, particularly in terrorist attacks and industrial accidents. This pictorial review is based on the experiences of a UK radiologist deployed in Afghanistan in 2010.

FAST as a predictor of clinical outcome in blunt abdominal trauma

Background. Peer-reviewed literature demonstrates increasing support for the use of focused abdominal sonography in trauma (FAST) in the setting of blunt trauma, one study demonstrating the sensitivity and specificity of FAST for the detection of free fluid to be 0.64 - 0.98 and 0.86 - 1.00, respectively, compared with abdominal CT. Utilising ultrasound in trauma triage increases efficiency and cost-effectiveness and reduces reliance on CT, compared with using CT alone. There is little evidence to support relying solely on a negative FAST and physical examination for patient management.&#x0D; Method. A retrospective descriptive study of 172 adult patients who received FAST for the evaluation of blunt abdominal trauma between 22 July 2007 and 21 January 2008 at Tygerberg Hospital was performed. Ultrasound findings were correlated with CT scan findings, operative findings if managed surgically, clinical outcomes whether managed surgically or conservatively, as well as postmortem findings in deceased patients.&#x0D; Results. FAST was negative in 147 (85.5%) patients. Twenty-four (16.3%) of these patients died from all-cause mortality, none of which was due to intra-abdominal injury. &#x0D; Seven patients with negative FAST underwent CT scan owing to change in clinical course, and 3 patients with negative FAST underwent laparotomy owing to change in clinical course, with positive findings in 2 patients – a bowel injury requiring resection (not seen on CT) and a diaphragmatic rupture seen on CXR. A negative FAST was shown to be an excellent predictor for the absence of significant intra-abdominal trauma.&#x0D; The mortality rate among 25 FAST positive patients was 24% (N=6). Only one of these patients (with a splenic rupture) was suspected to have died from abdominal pathology.

Evaluating clinical abdominal scoring system in predicting the necessity of laparotomy in blunt abdominal trauma

Objectives Trauma is among the leading causes of death. Medical management of blunt abdominal trauma (BAT) relies on judging patients for whom laparotomy is mandatory. This study aimed to determine BAT patients' signs, as well as paraclinical data, and to clarify the accuracy, sensitivity, specificity, positive and negative predictive value of clinical abdominal scoring system (CASS), a new scoring system based on clinical signs, in predicting whether a BAT patient needs laparotomy or not. Methods Totally 400 patients suspected of BAT that arrived at the emergency department of two university hospitals in Tehran from March 20, 2007 to March 19, 2009 were included in this study. They were evaluated for age, sex, type of trauma, systolic blood pressure, Glasgow coma scale (GCS), pulse rate, time of presentation after trauma, abdominal clinical findings, respiratory rate, temperature, hemoglobin (Hb) concentration, focused abdominal sonography in trauma (FAST) and CASS. Results Our measurements showed that CASS had an accuracy of 94%, sensitivity of 100%, specificity of 88%, positive predictive value of 90% and negative predictive value of 100% in determining the necessity of laparotomy in BAT patients. Moreover, in our analysis, systolic blood pressure, GCS, pulse rate, Hb concentration, time of presentation after trauma, abdominal clinical findings and FAST were also shown to be helpful in confirming the need for laparotomy (P<0.05). Conclusion CASS is a promising scoring system in rapid detection of the need for laparotomy as well as in minimizing auxiliary expense for further evaluation in BAT patients, thus to promote the cost-benefit ratio and accuracy of diagnosis.

Emergency Medicine Ultrasound Simulation (US/S) Case Scenario Package

OPEN ACCESSApril 5, 2010Emergency Medicine Ultrasound Simulation (US/S) Case Scenario Package Leo Kobayashi, MD, Marc Shapiro, MD, Arun Nagdev, MD, Frantz Gibbs, MD Leo Kobayashi, MD The Warren Alpert Medical School of Brown University Google Scholar More articles by this author , Marc Shapiro, MD The Warren Alpert Medical School of Brown University Google Scholar More articles by this author , Arun Nagdev, MD The Warren Alpert Medical School of Brown University Google Scholar More articles by this author , Frantz Gibbs, MD The Warren Alpert Medical School of Brown University Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.531 SectionsAboutAbstract ToolsDownload Citations ShareFacebookTwitterEmail AbstractAbstractThis resource consists of a modular package containing five high-fidelity full-body simulation case scenarios with supplemental bedside emergency department ultrasound videos (deidentified) to assist in emergency medicine decision-making training. Developed for our emergency medicine residency curriculum, this ultrasound simulation program supplements established educational interventions in which residents learn basic emergency ultrasound principles and are mentored individually in standard image-acquisition techniques on consenting patients. Emergency ultrasound and medical simulation faculty collaborated on a program to help trainees apply bedside sonography in real time to critical patient care decisions inside a risk-free learning environment. To generate simulated images necessary for emergency ultrasound application training, we compiled a PC-based sonographic image library of deidentified normal and pathologic findings. To minimize cost, a donated laptop was loaded with imaging software and the sonographic library, attached to a nonfunctioning ultrasound probe, and placed on an IKEA cart approximating commercially available emergency ultrasound stands. The five cases feature high-acuity simulation scenarios with occult but profound pathology requiring rapid decision making based on appropriate emergency ultrasound utilization: (1) right ventricular strain accompanying pulseless electrical activity from massive pulmonary embolism, (2) pericardial tamponade in a hypotensive uremic patient, (3) serial FAST (focused abdominal sonography in trauma) exams with interim development of detectable hemoperitoneum in a trauma patient, (4) Morrison's pouch fluid in a hypotensive female with ruptured ectopic pregnancy, and (5) leaking abdominal aortic aneurysm in an elderly patient with back pain. The inclusion of sonographic movie files in the clinical scenarios adds significantly to simulation verisimilitude for participants. This course has been incorporated in the Warren Alpert Medical School's emergency medicine residency education program at Brown University. Educational Objectives By the end of this resource, learners will be able to: Integrate simulated ultrasonographic findings with manikin-based simulation scenarios to apply bedside sonography in real time to critical patient care decisions.Understand the features of five high-acuity trauma and medical patients.Assist in education of diagnosis and management of massive pulmonary embolism, pericardial tamponade/cardiogenic shock, multitrauma, ectopic pregnancy, and abdominal aortic aneurysm. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Society for Academic Emergency Medicine.doc World Congress Ultrasound 2006.doc USS Session Image1 RIHMSC.jpg USS Session Image2 RIHMSC.jpg Sim Ultrasound Cart RIHMSC.jpg USS Laerdal SimMan Programming USS Case 1 USS Case 2 USS Case 3 USS Case 4 USS Case 5 To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. Copyright & Permissions© 2010 Kobayashi et al. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.KeywordsEctopic PregnancyPulmonary EmbolismPericardial EffusionAbdominal Aortic AneurismMulti-Trauma Disclosures None to report. Funding/Support None to report. Loading ...

Ultrasonographic Determination of Pubic Symphyseal Widening in Trauma: The FAST-PS Study

The focused abdominal sonography in trauma (FAST) examination is a routine component of the initial work-up of trauma patients. However, it does not identify patients with retroperitoneal hemorrhage associated with significant pelvic trauma. A wide pubic symphysis (PS) is indicative of an open book pelvic fracture and a high risk of retroperitoneal bleeding. We hypothesized that an ultrasound image of the PS as part of the FAST examination (FAST-PS) would be an accurate method to determine if pubic symphysis diastasis was present. This is a comparative study of a diagnostic test on a convenience sample of 23 trauma patients at a Level 1 Trauma Center. The PS was measured sonographically in the Emergency Department (ED) and post-mortem (PM) at the State Medical Examiner. The ultrasound (US) measurements were then compared with PS width on anterior-posterior pelvis radiograph. Twenty-three trauma patients were evaluated with both plain radiographs and US (11 PM, 12 ED). Four patients had radiographic PS widening (3 PM, 1 ED) and 19 patients had radiographically normal PS width; all were correctly identified with US. US measurements were compared with plain X-ray study by Bland-Altman plot. With one exception, US measurements were within 2 standard deviations of the radiographic measurements and, therefore, have excellent agreement. The only exception was a patient with pubic symphysis wider than the US probe. Bedside ultrasound examination may be able to identify pubic symphysis widening in trauma patients. This potentially could lead to faster application of a pelvic binder and tamponade of bleeding.

Focused abdominal sonography in trauma (FAST)

Dabigatran is an oral anticoagulant directly acting as thrombin inhibitor. The monoclonal antibody idarucizumab was developed to reverse its anticoagulatory effects after application of a standardized dose. Following administration, dabigatran plasma level rebounds have been reported but its consequences are not fully understood. We report a case of a multiple-trauma patient under dabigatran treatment suffering from secondary bleeding relapse after initially successful reversal with idarucizumab. Stabilisation of the patient's coagulopathy and subsequent bleeding was not achieved until application of an additional dose of idarucizumab. We conclude that patients treated with dabigatran and presenting with active bleeding require close attention to its reversal with standard doses of idarucizumab. Screening for thrombin time was shown beneficial in early detection of dabigatran rebound in this case.

Feasibility of FAST examination performance with ultrasound contrast

The Focused Abdominal Sonography in Trauma (FAST) examination has several limitations, among which is the inability to reliably detect solid organ injury. We sought to evaluate the feasibility of ultrasound contrast use during a FAST examination and its effect on the ability to delineate vasculature in the spleen and liver from hilum to capsule on simulated patients. This prospective observational case control study was conducted at an urban community hospital Emergency Department (ED) that is a level I trauma facility. During a FAST examination, the liver and spleen were scanned in entirety to evaluate contrast opacification of blood vessels and a latent phase highlighting the parenchyma of the liver and spleen. Each physician, hospital credentialed for the use of emergency ultrasound, scanned the liver and spleen both before and after contrast administration. Five milliliters of contrast were mixed with 16 mL of normal saline and then injected 4 mL at a time through an 18-gauge anticubital catheter. All examinations were successfully completed before contrast agent dissipation. The mean time to complete the FAST examination with interrogation of the liver and spleen was 1 min 42 s (range 1 min 22 s to 2 min 5 s). The mean time to initial visualization of contrast was 15 s (range 12 to 18 s). The latent phase of the ultrasound contrast when the liver or spleen began to shimmer, an effect that would outline hematomas not actively bleeding, occurred at a mean time of 54 s (range 45 s to 1 min 9 s). The ultrasound contrast disappeared at a mean of 2 min 52 s (range of 2 min 16 s to 3 min 33 s). In conclusion, ultrasound contrast use is feasible during the FAST examination and allows enhanced evaluation of solid organ parenchyma during evaluation for solid organ injury.

Use of an Objective Structured Clinical Examination (OSCE) for the assessment of physician performance in the ultrasound evaluation of trauma.

A reliable means of assessing physician competency in performing ultrasound (US) is critical for training and credentialing. Objective Structured Clinical Examinations (OSCE) have been used successfully to assess clinical competency in other areas of surgical education but have not been applied previously to trauma ultrasound training. The objectives of this study were to assess physician performance in the focused abdominal sonography in trauma (FAST) examination by using a specifically designed OSCE, and to determine whether the OSCE detects differences in two determinants of competency (knowledge acquisition and clinical interpretation skills). Eighty-two physicians in surgery (n = 49) and emergency medicine (n = 33) at a Level I trauma center were evaluated. All participated in a FAST course consisting of didactic sessions on US physics, indications, and technique, FAST examination videos, and a hands-on session with human models. The OSCE consisted of two parts: written examination that assessed factual knowledge, and videotape of real-time US examinations that assessed interpretation skills. The OSCE was administered before and after the FAST course. Significant improvements in postcourse OSCE scores were observed for factual knowledge (52.5 +/- 2.0 vs. 87.5 +/- 1.1, p < 0.001) and interpretation skills (27.2 +/- 1.4 vs. 62.9 +/- 1.3, p < 0.007). Scores for US interpretation were significantly lower than those for factual knowledge at both precourse (27.2 +/- 1.4 vs. 52.5 - 2.0, p < 0.001) and postcourse (62.9 +/- 1.3 vs. 87.5 +/- 1.1, p < 0.01). No performance differences were observed between surgeons and emergency medicine physicians and no effect of training level on test scores was observed. Knowledge acquisition and US interpretation skills can be assessed reliably with a specifically designed OSCE. Although both skills improved after participation in a FAST course, US interpretation scores were consistently lower than those for factual knowledge. This study supports the use of the objective structured clinical examination in both the design of ultrasound teaching programs and the assessment of physician competency.

A radiologist’s perspective

Focused abdominal sonography in trauma (FAST) has in many centres replaced the diagnostic peritoneal lavage (DPL) for the early assessment of acute blunt abdominal trauma. In many cases a negative FAST obviates the need for further imaging and intervention. In well-trained hands, it is a very specific and relatively sensitive test for the detection of hemoperitoneum and has the advantage over DPL of being noninvasive. However, the introduction of this exam has raised many contentious issues around indications for the study, as well as who should perform and interpret the study. Ironically, the question of who should perform the test has in many ways overshadowed the issue of whether it should be performed at all.