Focused Assessment With Sonography In Trauma Scans Research Articles

How many is enough? Measuring the number of FAST exams needed by emergency medicine trainees to reach competence

BackgroundFor patients with blunt abdominal trauma, the Focused Assessment with Sonography in Trauma (FAST) exam is the initial imaging modality employed to diagnose and risk stratify. A positive FAST exam in this patient population denotes intraperitoneal hemorrhage. In a hemodynamically unstable patient, it necessitates rapid surgical intervention. Ultrasound is highly dependent on the operator’s ability to obtain quality images for interpretation. Failure to obtain adequate images prevents accurate interpretation and reduce its diagnostic accuracy. Previous studies evaluating whether the FAST exam can be improved solely by experience had conflicting results. None of those studies used an objective method to evaluate the FAST exam’s quality. Our study aimed to objectively determine the number of FAST exams required by an emergency medicine (EM) resident to reach sufficient quality for independent scanning.Methods59 first-year EM residents from a single site were included in this study. All FAST exams that were saved in the Qpath archival system by the 59 EM residents, whether the exam was performed for educational or clinical purposes, were reviewed, and scored using a Task-Specific Checklist (TSC) score. This score is an objective way to assess the proficiency and quality of the FAST scan. The TSC was based on whether the imaging of 24 specific anatomic landmarks, split into four anatomic regions, was completed successfully or not. The AEMUS (Advanced EM Ultrasonography) faculty provided feedback to trainees wither electronically via Qpath or at the bedside. According to the quality of ultrasound imaging and competence (QUICK Score), if the average TSC score for the first 10 exams was 18 or higher, the resident was considered an expert. However, if the resident failed to achieve that score, we skipped the first exam performed by the resident and the average score for the second through eleventh exams was then calculated. If the resident did not achieve the desired result, the first and second exams were skipped and the average score for the remaining 10 exams was determined. This sequence was repeated until the resident achieved an average score of 18 or higher on their TSC score.ResultsIn total, 663 FAST scans performed by EM residents were scored. The average number of FAST exams needed for independent scanning is 11.23 (95% CI, 10.6-11.85). 66.1% of enrolled residents achieved an average score of 18 or higher in their first 10 FAST exams, and 33.8% of residents required more than 10 scans. The average scores for the right upper quadrant (RUQ), left upper quadrant (LUQ), pelvic, and subxiphoid views were 5 (95% CI, 4.88–5.1), 4.7 (95% CI, 4.59–4.8), 5.1 (95% CI, 4.96–5.24), and 3.7 (95% CI 3.6–3.8) respectively.ConclusionThis study demonstrated that when constructive feedback on each FAST exam was given, the average first-year emergency medicine resident achieves competency in performing FAST exams independently after completing 10–12 (average of 11.23) FAST exams. Further research is required to validate the findings.

Comparing the Ability of FAST and CT scan in Determining Free Fluid in Stable Patients with Blunt Abdominal Trauma

Background: Blunt abdominal trauma (BAT) has a high rate of morbidity and mortality. In the past few years, focused assessment with sonography in trauma (FAST) and computerized tomography (CT) scan have been extensively utilized and studied in management of BAT. The present study aims to compare the diagnostic accuracy of FAST and CT scan in detection of free fluid in BAT patients.
 Methods: In this cross-sectional study, patients with BAT were evaluated by both FAST and CT scans in Shahid Sadoughi Hospital, Yazd, Iran, from May 2017 to February 2018. The results were compared and the sensitivity, specificity, and accuracy of FAST and CT scan were calculated. In addition, the accuracy of FASTs performed by emergency medicine residents (EMR) was compared with those procedures performed by radiology residents (RR) in detecting abdominal free fluid following blunt trauma.
 Results: In this study, 175 patients were participated and most of them were males. The commonest cause of trauma was a road traffic accident (RTA). When FAST was performed by EMRs, sensitivity was 96.3%, specificity 75%, 60% positive and 98.1% negative predictive values and 94.8% accuracy in true evaluating free fluid , and Sensitivity 97.5%, specificity 83.3%, 71.4% positive and 98.8% negative predictive values when FAST was performed by RRs.
 Conclusion: Based on this study finding, it seems that FAST is highly sensitive, specific and accurate in the initial evaluation of patients with BAT.

Abdominal ultrasound image acquisition and interpretation by novice practitioners after minimal training on a simulated patient model.

The Focused Assessment with Sonography in Trauma (FAST) exam is a rapid ultrasound test to identify evidence of hemorrhage within the abdomen. Few studies examine the accuracy of paramedic performed FAST examinations. The duration of an ultrasound training program remains controversial. This study's purpose was to assess the accuracy of paramedic FAST exam interpretation following a one hour didactic training session. The interpretation of paramedic performed FAST exams was compared to the interpretation of physician performed FAST examinations on a mannequin model containing 300ml of free fluid following a one hour didactic training course. Results were compared using the Chi-square test. Differences in accuracy rate were deemed significant if p < 0.05. Fourteen critical care flight paramedics and four emergency physicians were voluntarily recruited. The critical care paramedics were mostly ultrasound-naive whereas the emergency physicians all had ultrasound training. The correct interpretation of FAST scans was comparable between the two groups with accuracy of 85.6% and 87.5% (∆1.79 95%CI -33.85 to 21.82, p = 0.90) for paramedics and emergency physicians respectively. This study determined that critical care paramedics were able to use ultrasound to detect free fluid on a simulated mannequin model and interpret the FAST exam with a similar accuracy as experienced emergency physicians following a one hour training course. This suggests the potential use of prehospital ultrasound to aid in the triage and transport decisions of trauma patients while limiting the financial and logistical burden of ultrasound training.

Point-of-care ultrasound for FAST and AAA in rural New Zealand: quality and impact on patient care.

Point-of-care ultrasound (POCUS) has the potential to improve access to diagnostic imaging for rural communities. This article evaluates the sensitivity and specificity, impact on patient care, quality and safety of two common POCUS examinations - focused assessment with sonography in trauma (FAST) and aortic aneurysm (AAA) - in the rural context. This study is a subgroup analysis of a larger study into POCUS in rural New Zealand. Twenty-eight physicians in six New Zealand rural hospitals, with limited access to formal diagnostic imaging, completed a questionnaire before and after POCUS scans to assess the extent to which it altered diagnostic certainty and patient disposition (discharge v admission to rural hospital v transfer to urban hospital). The investigators and a specialist panel reviewed images for technical quality and accuracy of interpretation, and patient clinical records, to determine accuracy of the POCUS findings and their impact on patient care. For FAST and AAA scans respectively, sensitivities were 75% and 100%, and specificities 100% and 93%; rural doctors correctly interpreted their POCUS images for 97% and 91% of scans. The proportions of scans that had either a 'significant' or 'major' impact on patient care were 17% and 31%. POCUS resulted in the disposition being de-escalated for 15% and 10% of patients and escalated for 5% and 3% of patients. In the rural context, POCUS AAA is a reliable 'rule out' test for ruptured abdominal aortic aneurysm and FAST scan has a role as a 'rule in' test for solid organ injury. These findings are consistent with larger studies in the emergency medicine literature.

Emergency Focused Assessment with Sonography in Blunt Trauma Abdomen.

Background:Focused assessment with sonography in trauma (FAST) being a rapid noninvasive examination is used primarily to evaluate for the evidence of traumatic free fluid suggestive of injury in the peritoneal, pericardial, and pleural cavities. It is widely recognized as a mainstream emergency skill in the management of trauma.Aim:The aim of the study is to evaluate the accuracy of FAST in patients presenting with blunt abdominal trauma.Methods:Data were collected prospectively from FAST scans conducted in blunt trauma abdomen (BTA) patients. Positive and negative FAST scans were confirmed either with contrast-enhanced computed tomography (CECT) abdomen or with exploratory laparotomy, thus dividing it further into four groups, i.e., true-positive, false-positive, true-negative, and false-negative scans. After collecting the data, accuracy of FAST was calculated.Results:In this study, a total of 104 patients were included. The mean age was 38.17 years. Most common cause of BTA was road traffic accident. The overall sensitivity, specificity, and accuracy of FAST were 69.8%, 92.1%, and 80.8%, respectively.Conclusion:This study showed that FAST is of paramount importance in patients who are hemodynamically unstable as it has a high positive predictive value. However, a FAST-negative result should always be confirmed by other modalities.

A Comparative Analysis of Diagnostic Accuracy of Focused Assessment With Sonography for Trauma Performed by Emergency Medicine and Radiology Residents.

Background:Focused assessment with sonography in trauma (FAST) is a method for prompt detection of the abdominal free fluid in patients with abdominal trauma.Objectives:This study was conducted to compare the diagnostic accuracy of FAST performed by emergency medicine residents (EMR) and radiology residents (RRs) in detecting peritoneal free fluids.Patients and Methods:Patients triaged in the emergency department with blunt abdominal trauma, high energy trauma, and multiple traumas underwent a FAST examination by EMRs and RRs with the same techniques to obtain the standard views. Ultrasound findings for free fluid in peritoneal cavity for each patient (positive/negative) were compared with the results of computed tomography, operative exploration, or observation as the final outcome.Results:A total of 138 patients were included in the final analysis. Good diagnostic agreement was noted between the results of FAST scans performed by EMRs and RRs (κ = 0.701, P < 0.001), also between the results of EMRs-performed FAST and the final outcome (κ = 0.830, P < 0.0010), and finally between the results of RRs-performed FAST and final outcome (κ = 0.795, P < 0.001). No significant differences were noted between EMRs- and RRs-performed FASTs regarding sensitivity (84.6% vs 84.6%), specificity (98.4% vs 97.6%), positive predictive value (84.6% vs 84.6%), and negative predictive value (98.4% vs 98.4%).Conclusions:Trained EMRs like their fellow RRs have the ability to perform FAST scan with high diagnostic value in patients with blunt abdominal trauma.

Focused Assessment with Sonography in Trauma (FAST) Scans Are Not Sufficiently Sensitive to Rule out Significant Injury in Pediatric Trauma Patients

Aim: To assess the sensitivity and specificity of FAST scans in pediatric trauma in a dedicated pediatric trauma centre. Method: A 3-year (2008-2011) analysis of prospectively collected data looking at the results of FAST scans compared to Computed Tomography (CT) or laparotomy findings. Results: There were 482 pediatric trauma calls of which 166 patients had suspected intra-abdominal injury. 163 patients underwent CT scans of which 89 (55%) had FAST scans prior to CT. 3 patients had FAST scans without CT; 1 patient went straight to theatre (positive FAST) and 2 patients died in the department before any further imaging. The sensitivity of FAST scans to detect abdominal injury is 23% and the specificity is 97%. The injuries missed on FAST scan were: liver lacerations (n = 3), splenic lacerations (n = 5), 1 combined liver and kidney injury and 1 combined splenic injury and small bowel perforation. Conclusions: FAST scans in trauma have a low sensitivity in pediatric patients with the possibility of missing significant intra-abdominal injury. They do not obviate the need for CT scan when clinical suspicion is high.

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

Blunt abdominal trauma (BAT) is a leading cause of morbidity and mortality. Rapid diagnosis and treatment with the Advanced Trauma Life Support guidelines are vital, leading to the development of focused assessment with sonography in trauma (FAST).

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

IntroductionBlunt abdominal trauma (BAT) is a leading cause of morbidity and mortality. Rapid diagnosis and treatment with the Advanced Trauma Life Support guidelines are vital, leading to the development of Focused Assessment with Sonography in Trauma (FAST). MethodsA retrospective study carried out from January 2007–2008 on all patients who presented with BAT and underwent FAST scan. All patients subsequently had a CT scan within 2 h of admission or a laparotomy within two days. The presence of intra-peritoneal free fluid was interpreted as positive. Results100 patients with BAT presented; 71 had complete data. The accuracy of FAST in BAT was 59.2%; in these 31 (43.7%) were confirmed by CT and 11 (15%) by laparotomy. There were 29 (40.8%) inaccurate FAST scans, all confirmed by CT. FAST had a specificity of 94.7% (95% CI: 0.75–0.99) and sensitivity of 46.2% (95% CI: 0.33–0.60). Positive Predictive Value of 0.96 (0.81–0.99) and Negative Predictive Value of 0.39 (0.26–0.54). Fisher's exact test shows positive FAST is significantly associated with Intra-abdominal pathology (p = 0.001). Cohen's chance corrected agreement was 0.3. 21 out of 28 who underwent laparotomies had positive FAST results indicating accuracy of 75% (95% CI: 57%–87%). ConclusionPatients with false negative scans, requiring therapeutic laparotomy is concerning. In unstable patients FAST may help in triaging and identifying those requiring laparotomy. Negative FAST scans do not exclude abdominal injury. Further randomised control trials are recommended if the role of FAST is to be better understood.

Is Basic Emergency Ultrasound Training Feasible as Part of Standard Undergraduate Medical Education?

Bedside ultrasonography is regularly used by surgeons and emergency physicians to perform focused assessment with sonography in trauma (FAST) in acutely-injured patients. Despite this, there is no formal ultrasound training in UK undergraduate curricula and postgraduate accreditation remains difficult to achieve. This study aims to assess the feasibility of teaching basic ultrasound skills to undergraduates using FAST scanning as a model module. Students were enrolled in a 5-hour theoretical and practical FAST scanning course. Ultrasound scanning competencies were ascertained using a 1-hour formal objective structured clinical examination (OSCE) assessment consisting of case-based discussions, problem-solving exercises, a complete FAST scan on a human volunteer, and free fluid detection exercises in organic simulators. A questionnaire was used to ascertain students' opinion on ultrasonography in undergraduate training. Twenty-five volunteer medical students (years 3 and 5) from a London medical school. Students did not have prior experience of formal ultrasound training. The mean score achieved in the summative assessment was 86%. Eighty-five percent of students completed a full FAST scan at an adequate level of performance in under 6 minutes. The feedback survey indicated that all students felt confident in operating the ultrasound apparatus and were able to obtain good quality images at the end of the 5-hour course. Eighty-eight percent of students thought ultrasonography was relevant to their training; all students intended to seek formal ultrasound accreditation; 92% believed ultrasound training should be a regular component of the curriculum; and 96% of students preferred using cart-based ultrasound machines rather than hand-held devices. Undergraduate ultrasound tuition is an achievable educational goal which is well received by medical students. Medical schools need to consider the formal introduction of ultrasound teaching in their curricula to equip future doctors with relevant skill sets. The role of handheld ultrasound machines requires further investigation.

FAST scan in the diagnosis of acute diaphragmatic rupture

Focused assessment with sonography in trauma (FAST) scan can be used by emergency physicians in the diagnosis of diaphragmatic rupture in blunt abdominal trauma. We introduce a new feature 'Rip's absent organ sign' on FAST scan in the diagnosis of acute diaphragmatic rupture.

Validation of nurse-performed FAST ultrasound

Background Patients presenting to Emergency Departments (EDs) with abdominal trauma benefit from FAST (Focused Assessment with Sonography in Trauma). Not all doctor members of the trauma team are credentialed in FAST; therefore occasionally no one is available in the hospital to undertake a FAST. Hence, the aim of this study was to determine the accuracy of nurse-performed FAST as a practical alternative where suitably trained doctors are not available. Methods This was a prospective study of a convenience sample of patients with multisystem trauma in whom abdominal injury was clinically suspected. Senior nurses trained in FAST performed and reported FAST scans for each patient. Accuracy of nurse-performed FAST was determined by comparing results with computerised tomography (CT) scan or operation report. Results 242 indicated nurse-performed FAST scans were included in the study. Nurse-performed FAST demonstrated sensitivity of 84.4% (95% CI 72.1–92.2) and specificity of 98.4% (CI 94.9–99.6), a positive predictive value (PPV) of 94.2% (CI 83.1–98.5) and a negative predictive value (NPV) of 95.3% (91.0–97.7). Overall accuracy of nurse-performed FAST for the detection of free fluid was 95.0% (95% CI 91.3–97.3). Conclusion This study demonstrates that, in a convenience sample of injured patients, nurse-performed FAST achieved similar accuracy to previously published results of doctor-performed FAST. Future studies with greater patient numbers would be valuable.

The accuracy of focused assessment with sonography in trauma (FAST) in blunt trauma patients: Experience of an Australian major trauma service

Focused assessment with sonography for trauma (FAST) is a method for detecting haemoperitoneum in trauma patients on initial assessment in the Emergency Department. The aim of this paper is to present an Australian trauma centre's experience with FAST as a tool to screen for intraabdominal free fluid in patient's sustaining blunt truncal trauma. Over a 63-month period, FAST scans were prospectively studied and compared with findings from a gold-standard investigation, either computed tomography (CT) or laparotomy. 463 FAST results were collected prospectively from 463 patients. 53 scans were excluded due to lack of a corresponding confirmatory gold-standard test. Overall sensitivity, specificity, positive and negative predictive values for FAST in detecting free fluid were 78%, 97%, 91%, 93%, respectively. Analysis of the credentialed operators demonstrated an improvement in accuracy (sensitivity 80%, specificity 100%, positive predictive value 100%, negative predictive value 94%). These findings are comparable with documented international experience. The study demonstrates that the use of non-radiologist performed FAST in the detection of free fluid is safe and accurate within an Australian Trauma Centre.