Not so FAST

BACKGROUND: Focused assessment with sonography for trauma (FAST) as a screening tool in the evaluation of blunt abdominal trauma will lead to underdiagnosis of abdominal injuries and may have an impact on treatment and outcome in trauma patients. METHODS: From October 2001 to June 2002, a protocol for evaluating hemodynamically stable trauma patients with suspected blunt abdominal injury (BAI) admitted to our institution was implemented using FAST examination as a screening tool for BAI and computed tomographic (CT) scanning of the abdomen and pelvis as a confirmatory test. At the completion of the secondary survey, patients underwent a four-view FAST examination (Sonosite, Bothell, WA) followed within 1 hour by an abdominal/pelvic CT scan. The FAST examination was considered positive if it demonstrated evidence of free intra-abdominal fluid. Clinical, laboratory, and imaging results were recorded at admission, and FAST examination results were compared with CT scan findings, noting the discordance. RESULTS: Patients with suspicion for BAI were evaluated according to protocol (n = 372). Thirteen cases were excluded for inadequate FAST examinations, leaving 359 patients for analysis. There were 313 true-negative FAST examinations, 16 true-positives, 22 false-negatives, and 8 false-positives. Using CT scanning as the confirmatory test for hemoperitoneum, FAST examination had a sensitivity of 42%, a specificity of 98%, a positive predictive value of 67%, a negative predictive value of 93%, and an accuracy of 92%; chi analysis showed significant discordance between FAST examination and CT scan (5.85%, < 0.001). Six patients with false-negative FAST examinations required laparotomy for intra-abdominal injuries; 16 patients required admission for nonoperative management of injury. Of the 313 true-negative FAST examinations, 19 patients were noted to have intra-abdominal injuries without hemoperitoneum and 11 patients were noted to have retroperitoneal injuries. CONCLUSION: Use of FAST examination as a screening tool for BAI in the hemodynamically stable trauma patient results in underdiagnosis of intra-abdominal injury. This may have an impact on treatment and outcome in trauma patients. Hemodynamically stable patients with suspected BAI should undergo routine CT scanning.     

Isolated free fluid on computed tomographic scan in blunt abdominal trauma: a systematic review of incidence and management

BACKGROUND: Abdominal computed tomographic (CT) scan is accepted as the primary diagnostic modality in stable patients with blunt abdominal trauma. A recent survey of 328 trauma surgeons demonstrated marked variation in the management of patients with head injuries and the finding of free intra-abdominal fluid without solid organ injury on CT scan. This study was undertaken to attempt to determine what to do when free fluid without solid organ injury is seen on abdominal CT scan in patients with blunt trauma. METHODS: Articles concerning the incidence and significance of free intra-abdominal fluid on CT scan of blunt trauma patients without solid organ injury were systematically reviewed. A MEDLINE search was performed using terms such as tomography-x-ray computed, wounds-nonpenetrating, small intestine/injuries, time factors, and abdominal trauma and diagnostic tests. Bibliographies of pertinent articles were reviewed. Appropriate articles were evaluated for quality and data were combined to reach a conclusion. RESULTS: Meta-analysis could not be performed because no randomized, prospective, controlled trials could be found. Forty-one articles were excluded from the analysis because they looked at only patients with known injuries to intestine, diaphragm, or pancreas and the investigation of the CT scan findings did not include negative scans. Ten articles, which described CT scan results for all patients presenting with blunt abdominal trauma for a defined period of time, formed the basis of this study. Isolated free fluid was seen in 463 (2.8%) of over 16,000 blunt trauma patients scanned. A therapeutic laparotomy was performed in only 122 (27%) of these patients. CONCLUSION: The isolated finding of free intra-abdominal fluid on CT scan in patients with blunt trauma and no solid organ injury does not warrant laparotomy. Alert patients may be followed with physical examination. Patients with altered mental status should undergo diagnostic peritoneal lavage.     

Abdominal ultrasound examination in pregnant blunt trauma patients

BACKGROUND: The ability of abdominal ultrasound to detect intraperitoneal fluid in the pregnant trauma patient has been questioned. METHODS: Pregnant blunt trauma patients admitted to a Level I trauma center during an 8-year period were reviewed. Ultrasound examinations were used to detect intraperitoneal fluid and considered positive if such fluid was identified. RESULTS: One hundred twenty-seven (61%) of 208 pregnant patients had abdominal ultrasound during initial evaluation in the emergency department. Seven patients had intra-abdominal injuries, and six had documented hemoperitoneum. Ultrasound identified intraperitoneal fluid in five of these six patients (sensitivity, 83%; 95% confidence interval, 36-100%). In the 120 patients without intra-abdominal injury, ultrasound was negative in 117 (specificity, 98%; 95% confidence interval, 93-100%). The three patients without intra-abdominal injury but with a positive ultrasound had the following: serous intraperitoneal fluid and no injuries at laparotomy (one) and uneventful clinical courses of observation (two). CONCLUSION: The sensitivity and specificity of abdominal ultrasonography in pregnant trauma patients is similar to that seen in nonpregnant patients. Occasional false negatives occur and a negative initial examination should not be used as conclusive evidence that intra-abdominal injury is not present. Ultrasound has the advantages of no radiation exposure.     

Jejunal transection following trivial trauma: Case report and review of literature

IntroductionSevere hollow organ injury following trivial blunt abdominal trauma is uncommon. If it occurs it can easily be missed during routine clinical evaluation. Though less than ten cases of jejunal transection following trivial trauma have been reported in literature, this is the first case of jejunal transection occurring in a patient who fell while walking.Case presentationWe report a 32 year old female Ugandan, who walked into the emergency room due to abdominal pain following a fall while walking. She was found to be hemodynamically stable and was initially hesitant to do further investigations but finally accepted to go for abdominal ultrasound scan and a chest x-ray. Abdominal ultrasound scan noted free peritoneal fluid and erect chest radiograph revealed a pneumoperitoneum. She was admitted for an exploratory laparotomy. At laparotomy we found a complete jejunal transection with mesenteric laceration. Primary anastomosis was done; the patient had an uneventful recovery and was discharged on the tenth postoperative day.DiscussionAny trauma to the abdomen can potentially cause devastating injury to hollow viscera and should therefore be evaluated thoroughly.ConclusionThis case demonstrates that even in a resource limited setting, basic investigations like an abdominal ultrasound scan and erect chest radiographs are important when managing a patient with blunt abdominal trauma even though the injury seems trivial.     

Minimal pelvic fluid in blunt abdominal trauma in children: the significance of this sonographic finding

PURPOSE: The aim of this study was to evaluate the significance of the ultrasonographic finding of pelvic fluid after blunt abdominal trauma in children as a predictor of an abdominal organ injury. METHODS: The clinical and imaging data of 183 children with blunt abdominal trauma were reviewed retrospectively. All children had an abdominal sonography as the primary screening study. The ultrasound results were divided into 3 groups: group A, normal examination; group B, pelvic fluid only; group C, peritoneal fluid outside the pelvis. The results of the initial ultrasound examinations were compared with the findings of the CT scan, or a second ultrasound examination or the clinical course during the hospitalization. RESULTS: Group A included 87 children; group B, 57, and group C, 39. Four abdominal organ injuries were missed by the ultrasound examination. The sensitivity and specificity of the ultrasound examinations to predict organ injury in presence of peritoneal fluid outside the pelvis were, respectively, 89.5% and 96.6%; the positive and negative predictive value were 87.2% and 97.3%. No statistically significant difference was seen between group A and group B, whereas the presence of peritoneal fluid outside the pelvic cavity (group C) was associated strongly with an organ injury (P <.001). CONCLUSIONS: A normal ultrasound examination or the presence of pelvic fluid are associated with a low probability of an organ injury. In the presence of peritoneal fluid outside the pelvis, the probability of an organ injury is very high.     

Stellungnahme zur „präklinischen Sonographie“

With the continuing development of mobile ultrasound equipment, trauma patients can already be examined at the site of the accident or during transport. This could lead to a more rapid diagnosis, and better planned and more effective clinical care. The care of polytraumatized patients requires the quickest possible transport to a hospital for surgical treatment, especially if a blunt abdominal trauma is expected. In such cases, an ultrasound examination does not gain any time, even if an intra-abdominal injury or an accumulation body fluid is found, because emergency care and the maintenance of vital functions take first priority. An ultrasound examination is extremely operator dependent and can lead to false negative results. In the case of trauma patients this can be fatal. Many emergency practitioners lack adequate training in ultrasonography, and even an experienced operator can miss an accumulation of body fluid in the abdomen. In addition, ultrasonography, which must be carried out on a naked part of the body at the accident site or during transport, can be a burden for the patient. A basic improvement in emergency medicine through the use of ultrasound can, therefore, not be expected.     

Free fluid on abdominal computed tomography without solid organ injury after blunt abdominal injury does not mandate celiotomy

BACKGROUND: Mandatory celiotomy has been proposed for all patients with unexplained free fluid on abdominal computed tomography (CT) scanning after blunt abdominal injury. This recommendation has been based upon retrospective data and concerns over the potential morbidity from the late diagnosis of blunt intestinal injury. This study examined the rate of intestinal injury in patients with free fluid on abdominal CT after blunt abdominal trauma. METHODS: This study was a multicenter prospective series of all patients with blunt abdominal trauma admitted to four level I trauma centers over 22 months. Data were collected concurrently at the time of patient enrollment and included demographics, injury severity score, findings on CT scan, and presence or absence of blunt intestinal injury. This database was specifically queried for those patients who had free fluid without solid organ injury. RESULTS: In all, 2,299 patients were evaluated. Free fluid was present in 265. Of these, 90 patients had isolated free fluid with only 7 having a blunt intestinal injury. Conversely, 91% of patients with free fluid did not. All patients with free fluid were observed for a mean of 8 days (95% confidence interval 6.1 to 10.4, range 1 to 131). There were no missed injuries. CONCLUSIONS: Free fluid on abdominal CT scan does not mandate celiotomy. Serial observation with the possible use of other adjunctive tests is recommended.     

The management of blunt abdominal trauma patients with computed tomography scan findings of free peritoneal fluid and no evidence of solid organ injury

Modalities available for the diagnosis of blunt abdominal traumatic (BAT) injuries include focused abdominal sonography for trauma, diagnostic peritoneal lavage, and computed tomography (CT) of the abdomen/pelvis. Hollow viscous and/or mesenteric injury (HVI/MI) can still be challenging to diagnose. Specifically, there is debate as to the proper management of BAT when CT findings include free peritoneal fluid but no evidence of solid organ injury (SOI). Our objective was to determine the incidence of HVI/MI and to evaluate the management of BAT patients with CT findings of peritoneal fluid without evidence of SOI. An Institutional Review Board-approved retrospective chart review was conducted of all BAT patients with peritoneal fluid on CT admitted to Kern Medical Center from January 1, 2003 to July 31, 2004. A total of 2651 trauma admissions yielded 79 patients. Fourteen of these had no evidence of SOI. Nonoperative management was successful in only 2 of these 14, whereas 12 required an operation, with 11 being therapeutic. Trigger to operate and time from presentation to laparotomy was hypotension in three patients (164 minutes), signs of HVI/MI on CT in two patients (235 minutes), diaphragm injury on CT in one patient (95 minutes), and for peritoneal signs in six patients (508 minutes). In BAT patients with peritoneal fluid on CT without evidence of SOI, there should be a high suspicion of HVI/MI. Relying on increasing abdominal tenderness to trigger laparotomy can result in delayed treatment.     

Ischemic caused small intestine perforation 15 days after car accident. Destiny or avoidable complication?

Intraabdominal organ lesions after blunt abdominal injuries often are missed, especially in the contest of a polytrauma because of the absence of obvious clinical injury signs, difficult examination conditions of an intubated patient and the possibility of secondary development of lesions. For an exact recognition of the abdominal injuries a standard diagnostic procedure is necessary. Clinical and laboratory parameters which determine the circulatory situation, initial abdominal ultrasound, x-ray and follow up examinations are indispensable. In equivocal situations CAT scan respectively angiography are recommended. The correct initial diagnosis of intestinal perforations still is problematic and requires repeated examinations. We report the case of a patient with initial blunt abdominal injury and a non dislocated Weber-A-fracture after a car accident. 15 days after trauma the patient was seen with the clinical signs of an acute abdomen. After emergency laparotomy an ischemic necrosis of the ileum, covered with net, was seen.     

Ischemic caused small intestine perforation 15 days after car accident. Destiny or avoidable complication? Schicksal oder vermeidbare Komplikation?

Intraabdominal organ lesions after blunt abdominal injuries often are missed, especially in the contest of a polytrauma because of the absence of obvious clinical injury signs, difficult examination conditions of an intubated patient and the possibility of secondary development of lesions. For an exact recognition of the abdominal injuries a standard diagnostic procedure is necessary. Clinical and laboratory parameters which determine the circulatory situation, initial abdominal ultrasound, x-ray and follow up examinations are indispensable. In equivocal situations CAT scan respectively angiography are recommended. The correct initial diagnosis of intestinal perforations still is problematic and requires repeated examinations. We report the case of a patient with initial blunt abdominal injury and a non dislocated Weber-A-fracture after a car accident. 15 days after trauma the patient was seen with the clinical signs of an acute abdomen. After emergency laparotomy an ischemic necrosis of the ileum, covered with net, was seen.     

Moderne Diagnostik des Bauchtraumas

In case of suspected intra-abdominal injury, fast transport of the patient to a suitable hospital is of high priority. The initial clinical examination aims at identifying patients with potentially life-threatening bleeding that require emergency surgery. In patients with penetrating trauma, laparoscopy is favoured to exclude suspected perforation of the peritoneum. If a peritoneal perforation is identified, exploratory laparotomy is recommended to exclude or treat lacerations of the hollow viscus. Although clinical examination should be performed its sensitivity and specificity of up to 82% and 45%, respectively, are not sufficient as the sole screening method. For the further diagnostic workup, diagnostic peritoneal lavage has been completely replaced by abdominal ultrasound examination in Germany and many other countries. Focussing not only on the detection of free abdominal fluid but also searching for parenchymal organ lesions and performing repeated examinations increases accuracy up to 96%, with specificity of 99.8% and sensitivity of 72.1%. Computed abdominal tomography with a helical scanner with and without intravenous contrast media is currently the gold standard of imaging techniques to identify traumatic abdominal injuries. A sensitivity of 97.2% and specificity of 94.7% can be achieved. False negative findings must be expected with hollow organ injuries. Serial clinical and ultrasound examinations as well as lab testing in conjunction with repeated CT may help to identify such lesions. Increased intra-abdominal pressure (IAP) with consecutive abdominal compartment syndrome and multiple organ dysfunction is a delayed complication from conditions such as severe intra-abdominal bleeding, major bleeding from pelvic ring fractures, and profuse fluid resuscitation. The IAP should be measured routinely in patients at risk, and decompression laparotomy may be indicated with pressures of higher than 20 mmHg.     

An Unusual Case of Blunt Abdominal Trauma: A Bleeding and Ruptured GallBladder Managed by Laparoscopy

An isolated gall-bladder injury after blunt abdominal trauma is rare. Intraluminal bleeding with a perforation and an intra-abdominal haemorrhage is even rarer. Early diagnosis is difficult, even with a CT-scan or an US-scan available. Clinical suspicion, serial clinical examination and repeated imaging, can prevent mortality and morbidity. We present a case where laparoscopy was used to diagnose and treat an isolated gall-bladder lesion after blunt abdominal trauma.     

An unusual case of blunt abdominal trauma: A bleeding and ruptured gall-bladder managed by laparoscopy

An isolated gall-bladder injury after blunt abdominal trauma is rare. Intraluminal bleeding with a perforation and an intra-abdominal haemorrhage is even rarer. Early diagnosis is difficult, even with a CT-scan or an US-scan available. Clinical suspicion, serial clinical examination and repeated imaging, can prevent mortality and morbidity. We present a case where laparoscopy was used to diagnose and treat an isolated gall-bladder lesion after blunt abdominal trauma.     

Abdominal CT scanning for trauma: how low can we go?

PURPOSE: computed tomography (CT) of the abdomen is an established, albeit expensive and perhaps overused, diagnostic modality for the evaluation of the injured patient. We developed a practice management guideline for blunt abdominal trauma intended to reduce the percentage of negative CT scans, yet minimize delayed recognition of injury and non-therapeutic laparotomy. PROCEDURES: between April 1996 and March 1997, 1147 adult patients at risk for blunt abdominal injury were admitted to our Level I trauma centre and underwent abdominal evaluation according to the practice management guideline. MAIN FINDINGS: abdominal CT was performed in 522 patients (45%), and 441 scans were negative (85%). Delayed recognition of injury and non-therapeutic laparotomy rates were low, 4% and 1.6%, respectively. PRINCIPAL CONCLUSION: abdominal CT scanning in trauma patients can achieve low non-therapeutic laparotomy and delayed recognition of injury rates but at the expense of high negative CT scan rates. Greater reliance on the physical examination and perhaps abdominal ultrasound may reduce negative CT scan rates and yet preserve low non-therapeutic laparotomy and delayed recognition of injury rates.     

Diagnosis of Bowel Injuries from Blunt Abdominal Trauma

Abstract Background: Patients with bowel injuries resulting from blunt abdominal trauma show no reliable clinical or radiologic signs on initial examination. The mechanism of injury is the only element of some diagnostic value. Intestinal injury may be evaluated by ultrasonography (US), plain abdominal radiographs, computed tomography (CT), and diagnostic laparoscopy. This paper is a retrospective study of diagnostic procedures used in 45 consecutive patients with bowel injuries who presented at our center between October 1996 and December 2001. Patients and Methods: Of 45 patients (mean age 40 years), nine suffered isolated bowel injuries and 36 presented with concomitant injuries. The mechanism of trauma was traffic accident in 30 of 45 patients (in 16 of these 30 patients compression by a seat belt), strong blow to the abdomen in eight, fall from a height in five, and other causes in two patients. US was done in 43 of 45 patients, plain abdominal radiographs in 22, CT in six, peritoneal lavage in one, and diagnostic laparoscopy in one. Results: 37 of 43 patients were evaluated by US immediately upon arrival; in four patients there was a delay in diagnosis of 1 day, and in two patients a delay of several days. At initial sonography, free intraperitoneal fluid was identified in 32 of the 43 patients; in most of them (n = 15) the amount of free fluid was rather small. Free fluid was absent in eleven of 43 patients; yet seven of these eleven patients demonstrated free fluid upon repeat examination.In nine of 32 patients, an increased amount of free fluid was identified upon repeat examination. Two of 43 patients, evaluated 3 and 9 days after arrival, respectively, showed dense intraperitoneal fluid, suggestive of peritonitis. US identified intestinal injuries in 14 of 43 patients; in all of them, the diagnosis was established upon repeat examination or delayed initial examination. Radiographs were performed in 22 of 45 patients (18 of them suffering perforation) and verified the pneumoperitoneum in nine of 18 patients with perforation. CT scanning identified intestinal injury in four of six patients. 17 of 45 patients were operated immediately in the Surgical Emergency Unit, 15 patients in the first 24 h, eight patients 2 days after admission, and five patients > 2 days (max. 9 days) after admission. In our series of 45 patients, there were four deaths, and only two (4.4%) were associated with bowel injury. Conclusion: In patients presenting with a typical mechanism of trauma and an abdominal bruise, plain radiographs should be taken in addition to initial US to identify the presence of free air. In patients with negative radiologic and US findings and in those demonstrating a small quantity of free fluid, US scanning should be repeated soon after the initial evaluation and, if necessary, a CT scan should be taken. The use of laparoscopy is indicated in unclear cases. According to our experience, a judicious and timely decision for laparotomy can only be based on the combination of the mechanism of injury, clinical picture, and results of properly planned diagnostic tests.     

High-intensity ultrasound treatment of blunt abdominal solid organ injury: an animal model

BACKGROUND: High-intensity focused ultrasound (HIFU) is effective in producing hemostasis in injuries from organ lacerations and punctures in animals but has not been evaluated in impact injuries. METHOD: High-energy blows were applied to 11 heparinized and anesthetized pigs, resulting in solid organ injury. HIFU was applied to injuries via laparotomy. The animals were closed, administered saline, observed under general anesthesia for 3.6 +/- 0.4 hours, reopened, and inspected, and abdominal free fluid was aspirated. RESULTS: Organ hemostasis was achieved (mean +/- SD) with 15 +/- 6 minutes of HIFU treatment and 54 +/- 3 minutes of operating time, and 18.8 +/- 13.1 mL/kg of blood was recovered from the abdomen. One animal died from an untreated occult injury to a large vein. HIFU-treated sites were hemostatic at relaparotomy, with 8.6 +/- 6.2 mL/kg abdominal serosanguinous fluid recovered. CONCLUSION: HIFU is effective in producing hemostasis by direct treatment of injured parenchyma in blunt trauma.     

Pitfall in insertion of suprapubic catheter in patients with spinal cord injuries

OBJECTIVE: To report an unusual presentation of a misplaced suprapubic catheter (SPC) in a spinal cord injury (SCI) patient. DESIGN: A case report of a SCI patient in whom a SPC was 'partially misplaced' in an emergency. SETTING: London Spinal Injuries Unit, Stanmore, UK. SUBJECT: A 33-year-old man who sustained a C5 SCI in a road traffic accident 6 months ago. He had an indwelling urethral catheter, which blocked off and repeated attempts to reinsert another one per urethra were unsuccessful. MAIN OUTCOME MEASURE: A SPC was inserted in an emergency at the bedside, as he developed autonomic dysreflexia. The catheter initially drained clear urine but subsequently the flow became intermittent. He also started complaining of lower abdominal discomfort. RESULTS: The abdominal examination was unremarkable without signs of peritonism. An ultrasound scan of the abdomen revealed the eye of the catheter in the bladder but the balloon had been inflated in the subcutaneous tissues. It was reinserted under cystoscopic control in the operating theatre. CONCLUSION: The insertion of a SPC in a neuropathic patient can be a challenge even for an experienced urologist. As these patients often have small capacity bladders, the SPC should be inserted under cystoscopic control wherever possible. However if they are inserted blindly there should be a high index of suspicion for the potential complication of a misplaced catheter. The patient should undergo regular abdominal examination and an ultrasound scan should be performed as soon as possible for confirmation.     

The hand-held ultrasound examination for penetrating abdominal trauma

BACKGROUND: An evaluation of hand-held ultrasonography (US) in the assessment of penetrating torso trauma has not yet been reported. METHODS: A 2.4 kg hand-held ultrasound device was used to examine penetrating trauma victims in an exam designated as the Hand-Held Focused Assessment with Sonography for Trauma (HHFAST). Results were compared with other US examinations including formal FAST (FFAST), computed tomography, diagnostic peritoneal lavage, operative and autopsy findings, and serial examination. Performance considered both the detection of fluid and injuries requiring intervention. RESULTS: The HHFAST was excellent for detecting free intraperitoneal fluid, which had 100% specificity for peritoneal penetration, but was only moderately sensitive for injuries requiring therapy. CONCLUSIONS: Hand-held sonography can quickly detect intraperitoneal fluid, which has good test performance in determining the presence of an intra-abdominal injury. Negative FAST examinations after penetrating trauma should be followed up with another diagnostic modality.     

The diagnosis of gastrointestinal tract injuries resulting from blunt trauma.

BACKGROUND: This review studies the efficacy of the methods of assessment of the abdomen in blunt trauma for the detection of gastrointestinal tract injuries (GITI). METHODS: MEDLINE searches of English language publications on the subjects of diagnostic peritoneal lavage, abdominal computed tomography (CT) in blunt trauma and gastrointestinal tract injuries between 1980 and 1998 were used to identify relevant material. Earlier publications were identified from reference lists. The methodology, data and conclusions of all studies were examined in detail. The contemporary roles of clinical assessment, diagnostic peritoneal lavage, CT and other diagnostic modalities in detection of significant GITI were determined based on the best available evidence. CONCLUSIONS: The most accurate and safest methods of assessment of the abdomen in haemodynamically unstable patients with suspected abdominal injuries following blunt trauma are immediate laparotomy or diagnostic peritoneal lavage (DPL). The goal of assessment of the abdomen in stable patients is to accurately define the site and extent of intra-abdominal injury, in order that further management may be tailored to the specific injuries. The most recent evidence suggests that CT of the abdomen fulfils these criteria better than the other modalities of assessment available. The risk of overlooking a significant GITI on CT scan is minimal provided that unexplained free fluid, bowel wall thickening or enhancement, mesenteric fat streaking and bowel dilatation are taken as evidence of GITI. When scan quality is suboptimal or expert interpretation is unavailable, DPL is recommended. Fully cooperative patients with negligible abdominal signs can be safely observed clinically.     

Secondary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma

INTRODUCTION: Approximately one third of stable patients with significant intra-abdominal injury do not have significant intraperitoneal blood evident on admission. We hypothesized that a delayed, repeat ultrasound study (Secondary Ultrasound--SUS) will reveal additional intra-abdominal injuries and hemoperitoneum. METHODS: We performed a prospective observational study of trauma patients at our Level I trauma center from April 2003 to December 2003. Patients underwent an initial ultrasound (US), followed by a SUS examination within 24 hours of admission. Patients not eligible for a SUS because of early discharge, operative intervention or death were excluded. All US and SUS exams were performed and evaluated by surgical/emergency medicine house staff or surgical attendings. RESULTS: Five hundred forty-seven patients had both an initial US and a SUS examination. The sensitivity of the initial US in this patient population was 31.1% and increased to 72.1% on SUS (p < 0.001) for intra-abdominal injury or intra-abdominal fluid. The specificity for the initial US was 99.8% and 99.8% for SUS. The negative predictive value was 92.0% for the initial US and increased to 96.6% for SUS (p = 0.002). The accuracy of the initial ultrasound was 92.1% and increased to 96.7% on the SUS (p < 0.002). No patient with a negative SUS after 4 hours developed clinically significant hemoperitoneum. CONCLUSION: A secondary ultrasound of the abdomen significantly increases the sensitivity of ultrasound to detect intra-abdominal injury.