FAST scan in STABLE BLUNT TRAUMA patients

Editor's Notes

• #4: FAST has been around for a while (1970’s) Screening test to identify “not readily apparent injuries” in patients with altered consciousness, distracting injury or intoxication. Does this unstable patient have an intraabdominal injury requiring urgent laparotomy ?? YES → proceed to OT NO → look for other causes...Sn 73-88%, Sp 98-100%
• #6: This is the first group of “stable patients” We’ve all had come into our Trauma bay… When we do see them, it is hard to believe that anything is wrong with them, but that is based on a PRE-TEST probability following a review of their mechanism of injury, prehospital clinical course and primary survey. They don’t require a FAST scan – because our clinical assessment tells us so!
• #7: But then is the next group of patients with stable vital signs but positive findings on physical examination. You already know their eFAST will be abnormal… So, you treat the patient clinically & arrange interventions or further imaging based on the pattern of injury.
• #8: For me stable is the combination of; haemodynamics/perfusion (absence of clinical shock) & not requiring immediate resuscitative interventions. Unfortunately, even in patients like these with normal vital signs & a high index of suspicious for injury the value of the FAST scan is often bought into question...
• #9: So, in pondering the usefulness of the FAST scan in STABLE BLUNT TRAUMA patients we must have a look at some evidence.
• #10: 7 year review of trauma database at a level 1 trauma centre in Nebraska
• #11: 7 year review of trauma database at a level 1 trauma centre in Nebraska Given the low sensitivity, a negative focused assessment with sonography for trauma without confirmation by computerized tomography may result in missed intra-abdominal injuries.
• #12: Given the low sensitivity, a negative focused assessment with sonography for trauma without confirmation by computerized tomography may result in missed intra-abdominal injuries…. The conclusion - leave the scan for the unstable patient & just get a CT if they are stable ...
• #13: The first question you must ask yourself is; “IS IT REALLY NEGATIVE”
• #14: The FAST scan has some notorious ‘gotchas’, especially the caudal tip of the liver & the diaphragmatic surface of the spleen. In patients with a high-index of suspicion for a significant injury, one must pay particular attention to these areas & interrogate them cautiously.
• #15: Retrospective cohort study from the Netherlands, reviewing the potential for risk stratification via use of FAST scan in haemodynamically stable blunt trauma patients.
• #16: The FAST exam can provide valuable prognostic information at minimal expenses during the early stages of resuscitation in haemodynamically stable patients presenting with BAT.
• #17: The FAST exam can provide valuable prognostic information at minimal expenses during the early stages of resuscitation in haemodynamically stable patients presenting with BAT.
• #18: Trauma registry database (over 6 years), US study (UC Davis) 4029 patients with blunt abdominal trauma who got a FAST. 3907 were normotensive.
• #19: Trauma registry database (over 6 years). 4029 patients with blunt abdominal trauma who got a FAST. 3907 were normotensive. For all normotensive patients with positive FAST, 59% (189/323) required therapeutic laparotomy.
• #20: Trauma registry database (over 6 years). 4029 patients with blunt abdominal trauma who got a FAST. 3907 were normotensive. For all normotensive patients with positive FAST, 59% (189/323) required therapeutic laparotomy. The greater amount of fluid, the more frequent the need for laparotomy !!
• #21: So, what does all this mean?
• #22: You can NOT exclude intraabdominal injury with a negative FAST scan in stable patients with blunt trauma. In trying to make a clinical judgment in this instance, you may as well flip a coin!! You CANNOT exclude a significant injury based on a negative scan & you are compelled to move onto more advanced diagnostic studies, ideally contrast CT.
• #23: You could say however, that the FAST SCAN in the STABLE BLUNT TRAUMA PATIENT is THE CANARY IN THE MINE. I can identify patients who are (1) likely to deteriorate & (2) likely to require more urgent surgical intervention ….
• #24: There is no doubt in my mind that ultrasound makes us better clinicians. Over the past 40 years, ultrasound itself however has also been in a state of evolution. Optic nerve sheath diameter as a predictor of raised intracranial press Pubic symphysis separation Lung ultrasound...
• #25: It has found its way OUTSIDE of the resus room, out onto the road side, in the vehicle with the trapped patient, in the helicopter prior to transportation... It has even found its way into the air & can be performed at 4000ft or 400kms away from the major trauma centres…
• #26: It is here that the prehospital FAST scan can be used for not only communication with the MTC, but also for patient triage…
• #27: At a scene like this, it helps us to decide WHO goes first ???
• #28: At a scene like this, it helps us to decide WHO goes first ???
• #29: To finish my talk, I want to share with you my own anecdote which I think highlights my stance on FAST…
• #30: It's late in the afternoon on a Public Holiday weekend & the batphone calls for attention... You are being tasked to Burcher in Central NSW *click* for a single vehicle, high-speed roll over. *click* Your pilot informs you that it is ~88mins flight time to scene.
• #31: It's late in the afternoon on a Public Holiday weekend & the batphone calls for attention... You are being tasked to Burcher in Central NSW *click* for a single vehicle, high-speed roll over. *click* Your pilot informs you that it is ~88mins flight time to scene.
• #32: (M) single car (ute), rollover at >100km/hr, 20-30m from roadside through barbed wire fence. Accident at 1750 3 cars on scene. R21 on scene ~20-30mins ahead of us. We arrived ~2hrs post accident. All patients still on scene. 4 patients (two orange, two green). - 8M (Orange); CHI, GCS 12-13. Treated by R21 crew to CHW - 17F (Green, also treated by us, & TF by road to Orange in Car 645): R82346 - 7F (Green): taken to CHW by R21.
• #33: Here’s your patient. 34M, restrained driver of this ute. Ejected during rollover and found ~10m from car. Likely transient LOC, but recalls most events. (I) CHI, left chest + hypoxia, lower back pain, right hip. (S) P120, SBP 150. GCS15. SaO2 82% (RA) --> 98% (10L). Left chest pain. Midline lower back pain. Right hip pain (RLL shortened & ext rotated). (T) IVC, C-collar, Morphine 20mg, Ketamine 20mg, Ondansetron 4mg. TPod placed but not tightened!! On HEMS assessment; A. Own. Slight blood in oropharynx (no loose teeth or obvious oral injury). ?haemoptysis. B. Left chest wall tenderness ++. No crepitus or SCE. SaO2 94% (on O2). RR 32. Minimal increased WOB. Left basal creps++. Right lung clear. C. Warm & well perfused. No external haemorrhage. P120-130, SBP140-150. Right leg shortening (thigh not tense). High concern for pelvic injury. D. GCS 15. PEARL. Moving all 4. E. Right facial abrasion. Left leg shortening + external rotation.
• #34: WHAT DO YOU DO ?? Treatment: 1. IVC 2. Titration analgesia (ketamine aliquots) 3. TPod repositioned & tightened. 4. EFAST: No PTX (L or R), but confluent B-lines at left base consistent with pulmonary contusion. No FF. Impression. 1. Chest trauma with left pulmonary contusion (reasonable oxygen requirement) 2. Likely pelvis # (+/- acetabulum or NOF#)
• #39: Ultrasound used as a reason NOT to treat, where remaining clinical signs may have pushed a clinician to place a drain...
• #40: Case summary. Avoid an unnecessary invasive procedure.