A Potential Pitfall of Using Focused Assessment With Sonography for Trauma in Pediatric Trauma

Prospective studies have shown sensitivities of 73% to 88% and specificities of 98% to 100% for using the focused assessment with sonography for trauma (FAST) examination to identify free fluid in adult trauma patients. However, the efficacy of FAST examinations for pediatric trauma patients has not been well defined, and studies looking at diagnostic performance have had varied results. We describe 3 cases of the potential pitfalls of the pediatric FAST examination in pediatric trauma patients using an advanced‐processing ultrasound machine. We hypothesize several etiologies for these false‐positive findings in the setting of advanced image‐processing capabilities of point‐of‐care ultrasound. We also discuss the reevaluation of clinical algorithms and interpretation practices when using the FAST examination in pediatric trauma.     

The Double-Line Sign: A False Positive Finding on the Focused Assessment with Sonography for Trauma (FAST) Examination

Background: Emergency physicians commonly perform Focused Assessment with Sonography for Trauma (FAST) examinations to evaluate for free intraperitoneal fluid. Many ultrasound findings can be misinterpreted as free fluid, resulting in false-positive FAST examinations. Objectives: To describe a previously unreported ultrasound finding that can be misinterpreted as free intraperitoneal fluid. Case Report: A 32-year-old man was stabbed in the left upper abdomen. A FAST examination was performed and a right perinephric fat pad was interpreted as showing free fluid in Morison's pouch. After transfer to a trauma center, a repeat FAST examination revealed no signs of intraperitoneal free fluid. Wound exploration showed no signs of penetration into the peritoneal cavity. Conclusions: When performing a FAST examination, a wedge-shaped hypoechoic area in Morison's pouch that is bounded on both sides by echogenic lines (the “FAST Double-Line Sign”) is likely to represent perinephric fat and may result in a false-positive FAST examination.     

The Focused Abdominal Sonography for Trauma (FAST) Examination: Considerations and Recommendations for Training Physicians in the Use of a New Clinical Tool

Focused abdominal sonography for trauma (FAST) is being used by growing numbers of emergency physicians and surgeons because it has proven to be an accurate, rapid, and repeatable bedside test for evaluating abdominal trauma victims. Controversy exists about the optimal means of FAST education and the number of examinations necessary to demonstrate competency. Most FAST educators agree that FAST education should consist of three phases: didactic, practical, and experiential. This article summarizes options and preliminary recommendations suitable for developing a FAST curriculum.     

Sonographic Detection of Pneumothorax by Radiology Residents as Part of Extended Focused Assessment With Sonography for Trauma

Objective. The purpose of this study was to assess the accuracy of sonographic pneumothorax detection by radiology residents as a part of extended focused assessment with sonography for trauma (eFAST). Methods. In a prospective study, a sonographic search for pneumothoraces was performed as part of a standard FAST examination by the on‐call resident. Each lung field was scanned at the second to fourth anterior intercostal spaces and the sixth to eighth midaxillary line intercostal spaces. A normal pleural interface was identified by the presence of parietal‐over‐visceral pleural sliding with “comet tail” artifacts behind. Absence of these normal features indicated a pneumothorax. The sonographic diagnosis was correlated with supine chest radiography and chest computed tomography (CT). Results. A total of 338 lung fields in 169 patients were included in the study. Patients underwent eFAST, chest radiography, and chest CT when clinically indicated. Chest CT was considered the reference standard examination. Computed tomography identified 43 pneumothoraces (13%): 34 small and 9 moderate. On chest radiography, 7 pneumothoraces (16%) were identified. Extended FAST identified 23 pneumothoraces (53%). Compared with CT, eFAST had sensitivity of 47%, specificity of 99%, a positive predictive value of 87%, and a negative predictive value of 93%. All of the moderate pneumothoraces were identified by eFAST. Twenty small pneumothoraces missed by eFAST did not require drainage during the hospitalization period. Conclusions. Extended FAST performed by residents is an accurate and efficient tool for early detection of clinically important pneumothoraces.     

Image Segmentation and Machine Learning for Detection of Abdominal Free Fluid in Focused Assessment With Sonography for Trauma Examinations

The objective of this pilot study was to test the feasibility of automating the detection of abdominal free fluid in focused assessment with sonography for trauma (FAST) examinations. Perihepatic views from 10 FAST examinations with positive results and 10 FAST examinations with negative results were used. The sensitivity and specificity compared to manual classification by trained physicians was evaluated. The sensitivity and specificity (95% confidence interval) were 100% (69.2%–100%) and 90.0% (55.5%–99.8%), respectively. These findings suggest that computerized detection of free fluid on abdominal ultrasound images may be sensitive and specific enough to aid clinicians in their interpretation of a FAST examination.     

Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians

Objectives

To evaluate the introduction of a focussed assessment with sonography in trauma (FAST) scan into the early assessment of trauma patients in the UK.

Methods

The setting was an inner city teaching hospital emergency department (annual attendance 100 000). All patients aged 16 or over admitted to the resuscitation room after blunt trauma were included in a prospective observational study. Patients had a FAST scan performed at the end of the primary survey. Results were compared to results of other investigations, laparotomy, postmortem examination, or observation.

Results

153 patients were entered into the study. The sensitivity of the FAST scan was 78% and specificity was 99%.

Conclusion

FAST is a highly specific “rule in” technique and is useful in the initial assessment of trauma patients. Emergency physicians can perform FAST after a brief training period.     

Systematic Sonography for Detection of Occult Wounds in Trauma

Treating victims of penetrating trauma is challenging, especially in a mass‐casualty or resource‐limited setting. The traditional focused assessment with sonography for trauma examination is a well‐established clinical tool in the initial evaluation of trauma victims. This article describes a novel technique of systematic sonography of the abdomen to look for occult wounds, which is used in conjunction with the focused assessment with sonography for trauma examination to evaluate occult intraperitoneal injury and improve patient treatment and use of resources. The technique is highlighted in a case of a child injured in a conflict zone in northern Iraq.     

Bedside Ultrasonography in the Management of Penetrating Cardiac Injury Caused by a Nail Gun

Background

Injuries from nail guns are a unique type of penetrating trauma seen in emergency departments (EDs), rising in prevalence in the United States. These devices can lead to life-threatening injuries that require rapid diagnosis to help guide management.

Prevalence,documentation, and communication of incidental findings in focused assessment with sonography for trauma (FAST) examinations

BackgroundAs the focused assessment with sonography for trauma (FAST) examination becomes increasingly ubiquitous in the emergency department (ED), a parallel increase in incidental findings can also be expected. The purpose of this study was to determine the prevalence, documentation, and communication of incidental findings on emergency physician-performed FAST examinations.MethodsRetrospective review at two academic EDs. Adult trauma patients undergoing FAST examinations used for clinical decision-making at the bedside were identified from an ED ultrasound image archival system. Expert sonologists reviewed ultrasound images for incidental findings, as well as electronic medical records for demographic information, mechanism of injury, type of incidental findings, documentation of incidental findings, and communication of incidental findings to the patient.ResultsA total of 1,452 FAST examinations were reviewed. One hundred and thirty-seven patients with incidental findings were identified (9.4%); 7 patients had an additional incidental finding. Renal cysts were most common (49/144, 34.0%), followed by pelvic cysts in women (32/144, 22.2%). While 31/144 (21.5%) incidental findings were identified and documented in the ultrasound reports or medical records by ED providers, only 6/137 (4.4%) patients were noted to be informed of their incidental findings.ConclusionIncidental findings were often encountered in FAST examinations, with cysts of the kidneys and pelvis being the most common findings. A vast majority of incidental findings were not documented or noted to be communicated to patients, which can be a barrier to follow-up care.     

Emergency physician credentialing for resuscitative thoracotomy for trauma

Objective: A low case incidence and variable skill level prompted the development of a credentialing programme and specific surgical training in resuscitative thoracotomy for emergency physicians at The Alfred, a Level 1 Adult Victorian Major Trauma Service. Methods: A review of the incidence of traumatic pericardial tamponade and the objectives of resuscitative thoracotomy were undertaken. Results: A training programme involving pre‐reading of a 17 page teaching manual, a 40 min didactic lecture and a 2 h surgical skills station using anaesthetized pigs were developed. The specific indication for resuscitative thoracotomy for this programme is ultrasound demonstrated cardiac tamponade secondary to blunt or penetrating truncal trauma in a haemodynamically unstable patient with a systolic blood pressure of less than 70 mmHg despite pleural decompression and intravenous volume replacement. Cardiac electrical activity must be present. The primary aims of resuscitative thoracotomy taught are release of cardiac tamponade, control of haemorrhage and access for internal cardiac massage. Conclusion: Emergency physicians working in high‐volume Trauma Centres are expected to diagnose cardiac tamponade and on occasion decompress the pericardium. Specific training in the procedure should be undertaken.     

Emergency ultrasound credentialling for focused assessment sonography in trauma and abdominal aortic aneurysm: A practical approach for Australasia

Objective: Focused assessment with sonography for trauma and emergency ultrasound for abdominal aortic aneurysm are now practiced widely by non‐radiologists in emergency departments worldwide. Various credentialling programs have been proposed for novice sonographers; however, their feasibility has been questioned. We adopted the Australasian College for Emergency Medicine (ACEM) credentialling process for emergency ultrasound to determine whether it is feasible for emergency physicians in the Australasian environment. Methods: Three full‐time emergency medicine specialists and a post‐Fellowship Examination trainee at Auckland Hospital undertook the credentialling process. Results: All four participants had sufficient scans to complete the process after 16 months. Accuracy for focused assessment with sonography for trauma, 90% (95% CI 83–95%), and abdominal aortic aneurysm, 99% (95% CI 90–100%), is similar to that previously reported. Conclusion: The ACEM credentialling process for focused assessment with sonography for trauma and abdominal aortic aneurysm is practical and achievable for emergency medicine specialists working in the Emergency Department at Auckland Hospital. Further studies are necessary to determine whether this holds true for other major trauma centres in Australasia.     

脑外伤动物模型认知障碍评价方法研究进展

认知障碍是脑外伤常见的后遗症之一。脑外伤动物模型目前广泛应用于基础和药物研究中,也出现了多种评价该模型的认知障碍评价的方法。本文综述近年来不同研究者对脑外伤动物模型认知障碍的行为学评价方法。     

Emergency and critical care applications for contrast-enhanced ultrasound

Introduction

Contrast-enhanced ultrasound (CEUS) using intravascular microbubbles has potential to revolutionize point-of-care ultrasonography by expanding the use of ultrasonography into clinical scenarios previously reserved for computed tomography (CT), magnetic resonance imaging, or angiography.

Predictability of successful trans-arterial embolization in pelvic fracture bleeding based on patient initial presentation

Background

Pelvic fracture bleeding generally leads to hemorrhagic shock. Trans-arterial embolization (TAE) is regarded as the most useful treatment; however, the initial presentation of the patient can impact the effectiveness of TAE for pelvic fracture bleeding. The aim of this retrospective study is to explore whether the patient data at the initial presentation can predict the success of TAE for pelvic fracture bleeding.

Conceptual Underpinnings of the Quality of Life in Neurological Disorders (Neuro-QoL): Comparisons of Core Sets for Stroke,Multiple Sclerosis,Spinal Cord Injury,and Traumatic Brain Injury

Objective

To determine the extent to which the content of the Quality of Life in Neurological Disorders (Neuro-QoL) covers the International Classification of Functioning, Disability and Health (ICF) Core Sets for multiple sclerosis (MS), stroke, spinal cord injury (SCI), and traumatic brain injury (TBI) using summary linkage indicators.