The Value of Abdominal and Pelvic CT Scan in Trauma Patients With Low Injury Severity Score and High Glasgow Coma Scale

Introduction Computed tomography scans became the mainstay of emergency department (ED) evaluation of trauma patients including those with a high Glasgow Coma Scale (GCS) and a low Injury Severity Score (ISS). We elected to find the value of abdominal and pelvic CT in patients with negative physical examination and Focused Assessment of Sonography for Trauma (FAST) on arrival to the ED. Methods This study is a retrospective analysis of 901 consecutive patients from 2017 to 2019 who presented to the ED with level 2 and 3 activation criteria. Each patient received a physical examination, CT abdomen and pelvis, and FAST exam. Data were collected on external factor including GCS, ISS, age, sex, comorbidities, anticoagulation use, and surgical intervention. The patients were divided into 2 groups, Group A and B. Group A consisted of patients with a negative physical exam, FAST, and CT result. Group B included patients with a negative physical exam and FAST exam with positive CT findings. Statistical analysis was done using a Student’s t-test and chi-square test for significance value of P < .05. Institutional Review Board approval was obtained for this study. Results A total of 901 patients were analyzed which included 489 (54.3%) male and 412 (45.7%) female with a mean age of 56.2 (SD = 22.62) years. Out of the 901 patients, 461 patients received a physical, FAST, and CT exam. Group A consisted of 442 (95.9%) patients and Group B had 19 (4.1%) patients. Both groups were similar in GCS and ISS scoring with no significance difference in age, sex, comorbidities, and anticoagulation use. There was a significant difference in the ICU and hospital mean length of stay when CT scan was positive [2 (SD = 4.23) days vs. .6 (SD = 1.33) days with P < .0001 and 4.57 (SD ± 4.17) days vs. 2.5 (SD = 2.00) days with P < .0001, respectively]. The CT findings of the 19 patients in group B consisted of 6 incidentalomas, 5 vertebral compression fractures, 4 pelvic bone fractures, 1 minor liver contusion, 1 non-specific bowel thickening, 1 non-displaced rib fracture, and 1 case of small amount of free fluid in the pelvis. None of the CT findings required surgical intervention. Conclusion Computed tomography of the abdomen and pelvis in trauma patients with high GCS and low ISS with initial negative physical and FAST examination did not provide additional critical information.

Independent learning of the sonographic FAST exam technique using a tablet-based training module

Objective: The aim of this study is to determine if a specific tablet-based training module can be used as an effective tool for independently training novice sonographers in the components of the focused assessment for sonography in trauma (FAST) exam.Design: Participants attended a 15-minute orientation presentation followed by a 2-hour ultrasound scanning workshop where they used a novel tablet-based training module to learn the components of the FAST exam independently.Setting: This study took place at an accredited United States college of osteopathic medicine.Participants: Thirty-two first-year medical student volunteers without any prior ultrasound training in abdominal scanning.Interventions: Training activities included brief didactic training and participation in an independent learning FAST exam workshop.Main outcome measures: Participants filled out subjective pre- and post-training self-confidence questionnaires and were objectively assessed and scored on their scanning skills.Results: Comparison of the pre- and post-training subjective questionnaires showed a statistically significant (p 0.001) increase in participant confidence in performing all components of the FAST exam. During skill evaluation, participants collectively demonstrated correct technique in 366 (82 percent) of the 448 total FAST exam scanning tasks they attempted.Conclusions: Based on these findings, the authors believe that learning to perform the FAST exam with this digital training module is an effective means of independently acquiring ultrasound skill. Digital ultrasound training modules like this one could have several useful applications, such as serving as an educational resource, or functioning as a point-of- care scanning adjunct to medical professionals in underdeveloped and rural areas where formal ultrasound training is not available.

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

BackgroundThe 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.MethodsThe 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.ResultsFourteen 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.ConclusionsThis 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.

MP12: Abdominal ultrasound image acquisition and interpretation by novice practitioners after minimal training on a simulated patient model

Introduction: The FAST exam – Focused Assessment with Sonography in Trauma - is a rapid test using ultrasound to identify sonographic evidence of hemorrhage within the abdomen. In the prehospital setting, the information from a FAST examination can help triage patients, direct patients to the most appropriate facilities, assist with management strategies and potentially expedite time to definitive intervention. Few studies examine the accuracy of paramedic-only-performed FAST examinations. However, despite the potential benefits to the Canadian prehospital system, a potential barrier to implementation is the tremendous financial and operational burden if paramedics require prolonged ultrasound training courses. In this study, we conducted a double-blinded observational study comparing the accuracy of paramedic-performed FAST versus physician-performed tests on a sonographic Phantom, after a one-hour didactic training session. Methods: The interpretation of paramedic performed FAST exams was compared to the interpretation of physician performed FAST examinations on a mannequin model. The mannequin utilized in this study was a realistic model of a human torso where fluid could be injected into the abdomen to create a realistic ultrasound image of abdominal free fluid. Participants were required to scan the mannequin twice, once with 300 mL of fluid instilled and once with the abdomen free of fluid. Participants were blinded to the status of hemoperitoneum. The primary outcome of the study was accuracy rate of FAST examination by paramedics compared to emergency room physicians. Results were compared using the Chi-square test. Differences in accuracy rate were deemed significant if p < 0.05. Total scan time was reported using means, standard deviations and 95% CIs and was compared between groups using standard t-test. Results: Fourteen critical care flight paramedics and four emergency physicians were voluntarily recruited. The critical care paramedics were ultrasound-naive whereas the emergency physicians had ultrasound training. The correct interpretation of FAST scans was comparable between the two groups 85.6% and 87.5% (Δ1.79 95%CI -33.85 to 21.82, p = 0.90) for paramedics and emergency physicians respectively. Total scan time differed between groups but did not reach statistical significance. Paramedics took longer to complete the FAST examination with a mean (SD) time to complete the two scans of 10.35 (3.43) minutes compared to 7.34 (2.74) minutes for physicians, (Δ3.01 minutes 95%CI -0.97 to 7.00, p = 0.13). Conclusion: This study determined that critical care paramedics were able 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 ultrasound in prehospital programs to determine the most appropriate transport destination and aid in the triage of trauma patients while limiting the financial and logistical burden of ultrasound training.

Is FAST Too FAST?

Blunt abdominal trauma is common in pediatric trauma. This chapter discusses a child who presents to the emergency department with left upper quadrant pain after being struck by a motor vehicle. The point-of-care focused assessment with sonography for trauma (FAST) examination provides quick, reliable information on bleeding into the peritoneal, pericardial, and pleural spaces in the setting of trauma. The FAST exam is highly sensitive for identification of hemoperitoneum but is less accurate for ruling out hemoperitoneum and intra-abdominal injury. Discussion of the trauma evaluation and utility of the FAST examination in the context of pediatric blunt abdominal trauma is presented.

When Boo Boos Are Bad

Blunt abdominal trauma in the pediatric patient with patterned bruising, such as the seatbelt sign or the handlebar sign, are highly associated with intra-abdominal injury. Laboratory studies are recommended to assess for solid organ injury, while imaging recommendations include consideration of a focused assessment with sonography in trauma (FAST) exam or computerized tomography of the abdomen and pelvis. Further, it is crucial to have a high index of suspicion for nonaccidental trauma in children with abdominal bruising and no clear history of injury.