Double Jeopardy in Penetrating Trauma: Get FAST, Get It Right

Point of care ultrasound and sub-xiphoid window reduce uncertainty in the management of potential dual-cavity injuries in patients with torso stab wounds

INTRODUCTION

This paper reviews our experiences with the management of patients with torso stab wounds and potential injuries in both the chest and abdomen over the last decade. The aim of the project is to clarify our approach and provide an evidence base for clinical algorithms. We hypothesize that there is room for our clinical algorithms to be further refined in order to address the diverse, life threatening injuries that can result from stab wounds to the torso.

METHODS

Patients with one or more torso stab wounds, and a potential injury in both the chest and the abdomen were identified from a local database for the period December 2012 to December 2020.

RESULTS

A total of 899 patients were identified. The mean age was 29 years (SD = 9) and 93% of patients were male. Amongst all patients, 686 (76%) underwent plain radiography, 207 (23%) a point of care ultrasound assessment, and 171 (19%) a CT scan. Following initial resuscitation, assessment and investigation, a total of 527 (59%) patients proceeded to surgery. A total of 185 patients (35%) underwent a semi elective diagnostic laparoscopy to exclude an occult diaphragm injury. Of the 342 who underwent an emergency operation, 9 patients (1%) required thoracotomy or sternotomy exclusively, 299 patients (33%) required a laparotomy exclusively and 34 patients (4%) underwent some form of dual cavity exploration. In total, there were 16 deaths, a mortality rate of 2%. The use of laparoscopy, point of care ultrasound and subxiphoid pericardial window increased over the period of this study.

CONCLUSIONS

Patients with torso stab wounds and potential injuries above and below the diaphragm are challenging to manage. The highly structured clinical algorithm of the ATLS course should be complemented by the use of point of care ultrasound and sub-xiphoid window to assess the pericardium. These adjuncts reduce the likelihood of negative exploration and incorrect operative sequencing.

European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities

BACKGROUND

European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature.

METHODS

Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society.

RESULTS

Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training.

CONCLUSIONS

This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.

Diagnostic performance of sonography in penetrating torso trauma: a systematic review and meta-analysis

BACKGROUND

This systematic review investigates the diagnostic value of ultrasound in the evaluation of torso injuries following a penetrating trauma.

METHODS

We searched PubMed, Scopus, and WOS databases for related original articles until May 7, 2023, and extracted data related to diagnostic performance. The bivariate model and hierarchic summary receiver operating characteristic (HSROC) approach were used to calculate pooled diagnostic values. Cochrane Q test and I-squared were performed to evaluate heterogeneity. We assessed heterogeneity with meta-regression.

RESULTS

Seventeen studies were included, which involved a total number of 1866 patients. According to meta-analysis, sonography demonstrated a pooled sensitivity of 56% (45-67%) and specificity of 96% (94-97%), positive likelihood ratio (LR +) of 13.66 (8.03-23.23), and negative likelihood ratio (LR-) of 0.45 (0.35-0.59) for detecting abdominal injuries. In pericardial penetrating trauma, pooled sensitivity was 100% (45-100%), pooled specificity was 99% (96-100%), LR + was 136.7 (24.8-752.3), and LR- was 0.00 (0.00-1.22). For thoracic penetrating trauma, pooled sensitivity was 99% (93-100%) and specificity was 100% (98-100%).

CONCLUSIONS

Sonography demonstrated promising diagnostic value in the initial assessment of torso penetrating trauma, particularly in the thoracic and pericardial regions. However, the sensitivity of sonography is limited in abdominal penetrating trauma and a combination with other imaging modalities should be considered in these cases.

Management of thoracoabdominal gunshot wounds - Experience from a major trauma centre in South Africa

INTRODUCTION

The management of thoracoabdominal (TA) gunshot wounds (GSW) remains challenging. This study reviewed our experience with treating such injuries over a decade.

MATERIALS AND METHODS

A retrospective study was conducted at a major trauma centre in South Africa over a ten-year period from December 2012 to January 2022.

RESULTS

Two hundred sixteen cases were included (male: 85 %, mean age: 33 years). Median RTS: 8 and median ISS: 17 (IQR: 10-19). The mean value of physiological parameters: Heart Rate (HR): 98/min, Systolic Blood Pressure (SBP): 119 mmHg, Temperature (T): 36.2 °C, pH: 7.35, Lactate 3.7 mmol/l. Ninety-nine (46 %) underwent a CT scan of the torso. One hundred fifty-four cases (69 %) were managed operatively: thoracotomy only [5/154 (3 %)], laparotomy only [143/154 (93 %)], and combined thoracotomy and laparotomy [6/154 (4 %)]. Those who had surgery following preoperative CT had a lower rate of dual cavity exploration (2 % vs 4 %, p = 0.51), although it did not reach statistical significance. The overall morbidity was 30 % (69). 82 % required intensive care (ICU) admission. The mean length of hospital stay was 14 days. The overall mortality was 13 % (28). Over the 10-year study period, there was a steady increase in the number of cases of TA GSWs managed at our institution. Over the study period, an increasing use of CT was noted, along with a steady reduction in the proportion of operations performed.

CONCLUSIONS

Thoraco-abdominal GSWs remain challenging to manage and continue to be associated with significant morbidity and mortality. The increased use of CT scans has reduced the degree of clinical confusion around which body cavity to prioritize, leading to an apparent decrease in dual cavity exploration, and has allowed for the increased use of minimalistic and non-operative approaches.

Ultrasonography in thoracic and abdominal stab wound injury: results from the FETTHA study

BACKGROUND

While the role of Extended Focused Assessment with Sonography in Trauma (eFAST) is well defined in the management of severe blunt trauma, its performance in injuries caused by stab wounds has been poorly assessed.

METHODS

Prospective single centre study which included all patients with stab wounds to the thorax or abdomen between December 2016 and December 2018. All patients underwent initial investigation with both eFAST and CT scan, except in cases of haemodynamic or respiratory instability, and in cases with a positive diagnosis by eFAST in which case surgery without CT scan was performed.

RESULTS

Of the 200 consecutive patients included, 14 unstable patients underwent surgery immediately after eFAST. In these 14 patients, 9 had cardiac tamponade identified by eFAST and all were confirmed by surgery. In the remaining 186 patients, the median time between eFAST and CT scan was 30 min (IQR 20-49 min). Test characteristics (including 95% CI) for eFAST compared with reference standard of CT scan for detecting pneumothorax were as follows: sensitivity 77% (54%-92%), specificity 93% (90%-97%), positive predictive value (PPV) 60% (49%-83%), negative predictive value (NPV) 97% (93%-99%). Test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemothorax were as follows: sensitivity 97% (74%-99%), specificity 96% (92%-98%), PPV 83% (63%-93%) and NPV 99% (96%-100%). Finally, test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemoperitoneum were as follows: sensitivity 75% (35%-97%), specificity 97% (93%-99%), PPV 55% (23%-83%) and NPV 99% (96%-99%).

CONCLUSIONS

In patients admitted with stab wounds to the torso, eFAST was not sensitive enough to diagnose pneumothorax and haemoperitoneum, but performed better in the detection of cardiac tamponade and haemothorax than the other injuries. More robust multicentre studies are needed to better define the role of eFAST in this specific population.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

BACKGROUND

Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

RESULTS

This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

CONCLUSION

A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Military training-related abdominal injuries and diseases: Common types, prevention and treatment

Military training is intense, difficult and often dangerous, so all kinds of injuries or diseases frequently occur during training. Most of the previous studies and reviews on military training-related injuries focused on musculoskeletal system, whereas there are no reviews of abdominal injuries and diseases. Although the incidence of military training-related abdominal injuries and diseases is relatively low, the patients' condition is often critical especially in the presence of abdominal organ injury, leading to multi-organ dysfunction syndrome and even death. This paper elaborates on common types of military training-related abdominal injuries and diseases as well as the prevention and treatment measures, which provides some basis for scientific and reasonable training and improvement of medical security.

Double Jeopardy Injuries: Improved Clinical Outcomes With FAST Imaging and Subxiphoid Pericardial Window for Combined Cardiac and Abdominal Stab Wounds

BACKGROUND

This study reviews our experience with combined cardiac and abdominal stab wounds over 12 years and reviews how changes in technology and clinical approaches have impacted our management of these patients.

MATERIALS AND METHODS

A retrospective cohort study was conducted from January 2008 to January 2020 at a major trauma centre in South Africa. All patients with concurrent SWs to the chest and the abdomen and required both a thoracotomy for cardiac injury and a laparotomy for an intra-abdominal injury at the same setting were included.

RESULTS

Twenty-two cases were identified (100% male, mean age: 27 years). Mean values of admission physiology: systolic blood pressure (SBP): 85 mmHg, pH: 7.2, base excess: -10.2 mmol/L and serum lactate 6.7 mmol/L. Thirty-two percent (7/22) of cases underwent a Focused Assessment with Sonography in Trauma (FAST) scan (5 positive and 2 negative). All 7 cases had intraoperatively confirmed cardiac injuries. The thoracotomy first approach was used in 18 cases (82%), and the laparotomy first approach was used in the remaining 4 cases (18%). Nineteen (86%) of the 22 laparotomies were positive. A total of 6 patients (27%) experienced one or more complications. The mean length of hospital stay was 9 days. The overall mortality was 18% (4/22) and all mortality occurred prior to 2013.

DISCUSSION

Double jeopardy is still associated with an increased risk of mortality. The use of FAST and Subxiphoid Pericardial Windows (SPWs) have reduced clinical uncertainty, decreasing the need for concomitant thoracotomy and laparotomy to be performed.

Performance of Focused Assessment with Sonography for Trauma Following Resuscitative Thoracotomy for Traumatic Cardiac Arrest

BACKGROUND

In patients undergoing resuscitative thoracotomy (RT) for traumatic cardiac arrest, focused assessment with sonography for trauma (FAST) is often used to look for intraperitoneal fluid. These findings can help determine whether abdominal exploration is warranted once return of spontaneous circulation is achieved; however, the diagnostic accuracy of FAST in this clinical scenario has yet to be evaluated. The purpose of this study was to assess the performance of FAST in identifying intra-abdominal hemorrhage following RT.

METHODS

We performed a 3-year retrospective study at a high-volume level 1 trauma center from 2014 to 2016. We included patients who underwent RT in the Emergency Department. All FAST examinations were performed by non-radiologists. Operative findings, computed tomography reports, diagnostic peritoneal aspirate (DPA) results, and autopsy findings were used as reference standards to calculate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the FAST.

RESULTS

A total of 158 patients met our inclusion criteria. The median age was 35 years (interquartile range [IQR]: 23-53), 86.1% were male, and 60.1% sustained blunt trauma. Most patients suffered severe injuries with a median injury severity score of 27 (IQR: 18-38). The sensitivity, specificity, PPV, NPV, and accuracy of FAST for identifying intra-abdominal hemorrhage were 66.0%, 84.8%, 68.6%, 83.2%, and 78.5%, respectively. Among the 107 patients with a negative FAST, 22 (20.6%) underwent DPA, which was positive in 5 patients.

CONCLUSIONS

FAST can be utilized in the diagnostic workup of trauma patients after RT. In patients with a positive FAST, exploratory laparotomy is warranted, whereas other diagnostic adjuncts such as DPA or mandatory abdominal exploration may be considered in patients with a negative FAST.

Penetrating injury to the cardiac box

BACKGROUND

A penetrating injury to the "cardiac box" is thought to be predictive of an injury to the heart; however, there is very little evidence available to support this association. This study aims to evaluate the relationship between penetrating trauma to the cardiac box and a clinically significant injury.

METHODS

All patients presenting to a Level I trauma center from January 2009 to June 2015 who sustained a penetrating injury isolated to the thorax were retrospectively identified. Patients were categorized according to the location of injury: within or outside the historical cardiac box. Patients with concurrent injuries both inside and outside the cardiac box were excluded. Clinical demographics, injuries, procedures, and outcomes were compared.

RESULTS

During this 7-year period, 330 patients (92% male; median age, 28 years) sustained penetrating injuries isolated to the thorax: 138 (42%) within the cardiac box and 192 (58%) outside the cardiac box. By mechanism, 105 (76%) were stab wounds (SW) and 33 (24%) were gunshot wounds (GSW) inside the cardiac box, and 125 (65%) SW and 67 (35%) GSW outside the cardiac box. The overall rate of thoracotomy or sternotomy (35/138 [25.4%] vs. 15/192 [7.8%], p < 0.001) and the incidence of cardiac injury (18/138 [13%] vs. 5/192 [2.6%], p < 0.001) were significantly higher in patients with penetrating trauma within the cardiac box. This was, however, dependent on mechanism with SW demonstrating a higher incidence of cardiac injury (15/105 [14.3%] vs. 3/125 [2.4%], p = 0.001) and GSW showing no significant difference (3/33 [9.1%] vs. 2/67 [3%], p = 0.328]. There was no difference in overall mortality (9/138 [6.5%] vs. 6/192 [3.1%], p = 0.144).

CONCLUSION

The role of the cardiac box in the clinical evaluation of a patient with a penetrating injury to the thorax has remained unclear. In this analysis, mechanism is important. Stab wounds to the cardiac box were associated with a higher risk of cardiac injury. However, for GSW, injury to the cardiac box was not associated with a higher incidence of injury. The diagnostic interaction between clinical examination and ultrasound, for the diagnosis of clinically significant cardiac injuries, warrants further investigation.

LEVEL OF EVIDENCE

Prognostic study, Level IV, Therapeutic V.

Simulated Mass Casualty Incident Triage Exercise for Training Medical Personnel

Audience

The target audience is any medical professional who requires training in mass casualty incident (MCI) triage. This could apply to pre-hospital specialists, nurses, medical students, residents, and physicians.

Introduction

Emergency medicine specialists must be able to triage patients quickly, especially in an MCI scenario. The simple triage and rapid treatment (START) system allows providers to categorize patients according to the urgency with which patients must access limited resources. Providers should be comfortable utilizing the START triage system before an MCI or disaster so that they can be prepared to implement it if necessary. This exercise uses simulation and gamification as instructional strategies to encourage knowledge of and comfort with the START triage system for emergency providers.

Educational Objectives

By the end of this exercise, learners should be able to (1) recite the basic START patient categories (2) discuss the physical exam signs associated with each START category, (3) assign roles to medical providers in a mass casualty scenario, (4) accurately categorize patients into triage categories: green, yellow, red, and black, and (5) manage limited resources when demand exceeds availability.

Educational Methods

Gamification is the use of elements of game design in non-game contexts.1 Gamification was implemented in this scenario by assigning participants to roles and teams, while creating an engaging, fun, and competitive environment. The exercise also uses low fidelity simulation (without simulation equipment) to encourage learners to practice using the START triage system in a low stakes environment.2 It is possible for the learners to be divided into two groups that each have the same patients, resources, and objectives. The team that finishes triaging all patients first would be declared the winner. However, in our implementation, we completed the exercise as a single group of learners and patients.

Research Methods

Learners were given a survey at the end of implementation and also given the opportunity to discuss feedback with the instructors in a group discussion after completing the exercise. There was no formal assessment completed after the exercise.

Results

Informal feedback was collected at the end of the exercise. Residents and medical students all enjoyed the experience. The feedback was overwhelmingly positive. All participants providing feedback stated they would enjoy participating in the exercise again and suggested that it is implemented annually for review of triage topics. We also received informal feedback for suggested changes which we will discuss in this article. An optional, anonymous survey was given to participants at the end of the exercise. There were six responses. Of those surveyed, 100% of participants stated the effectiveness and value of the exercise was outstanding (a rating of five on a scale of one to five). Regarding the quality of the exercise, and whether the participants felt engaged, 100% of responses gave a rating of five. When asked to consider the relevance of the session, 100% of participants selected a score of five ("I loved this session"). Regarding whether the content was applicable to practice of emergency medicine, 80% of respondents stated the session was highly relevant and 20% of responses selected a score of mostly relevant. One question asked for points of improvement for the session to which there were no responses.

Discussion

Learners were assigned roles in the exercise by the incident commander, fulfilling objective three. The START categories were discussed at the beginning of the exercise by the lead proctor (using PowerPoint) and then utilized throughout the exercise, thus accomplishing objectives one and two. The residents/students filling the triage roles were primarily responsible for fulfilling objective four; however, all participants assisted in categorization of patients throughout the exercise. Finally, objective five was addressed through the various social situations and complications that can be implemented during the exercise. We chose not to implement the additional "radiation contamination" scenario (details available in the article text) due to time constraints; however, this is an additional option to address objective five. The implementation was effective based on informal feedback from participants and proctors as well as evidenced by the responses to the anonymous survey. Learners found the aspects of resource management, review of START triage, repetition of the START triage system, and medical management of various types of trauma informative and meaningful. We received valuable feedback from both learners and proctors, which we will discuss in this article.

Topics

Mass casualty incident, disaster, START, gamification, simulation, emergency medicine, triage, triage category, contamination, teamwork, trauma, projectile trauma, penetrating injury, blunt trauma, intracranial hemorrhage, fracture, trauma in pregnancy, active shooter, radiation, radio communication.

Decreasing Accuracy of the eFAST Examination—Another Challenge Due to Morbid Obesity

The extended focused assessment with sonography for trauma (eFAST) ultrasound examination is an essential step in the initial assessment of trauma patients. Its accuracy depends on the ability to acquire high-quality ultrasound images, and we hypothesized that increasing BMI was associated with increased odds for incorrect eFAST. All adult blunt trauma activations at a high-volume urban trauma center in 2016 that underwent eFAST and CT chest, abdomen, and pelvis were included (n = 446). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the eFAST were calculated with CT results as reference. The association of BMI and eFAST accuracy was determined using univariate analyses. Sensitivity and specificity of the eFASTexamination were 27.1 per cent and 91.7 per cent, respectively, with an overall 76.2 per cent accuracy. At BMI 36 kg/m2, the odds of having incorrect eFAST results increased to odds ratio (OR) = 1.85 (95% confidence interval, 1.03–3.32; P = 0.05). For those with BMI > 40 kg/m2, the OR increased to OR = 3.12 (95% confidence interval, 1.45–6.69; P = 0.01). One-third of patients in this study were obese or morbidly obese. The latter was associated with increased odds for incorrect eFAST results, particularly the abdominal examination component.

Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization

Background

Far reaching sub-specialization tends to become obligatory for surgeons in most Western countries. It is suggested that exposure of surgeons to emergency laparotomy after trauma is ever declining. Therefore, it can be questioned whether a generalist (i.e., general surgery) with additional differentiation such as the trauma surgeon, will still be needed and can remain sufficiently qualified. This study aimed to evaluate volume trends and outcomes of emergency laparotomies in trauma.

Methods

A retrospective cohort study was performed in the University Medical Center Utrecht between January 2008 and January 2018, in which all patients who underwent an emergency laparotomy for trauma were included. Collected data were demographics, trauma-related characteristics, and number of (planned and unplanned) laparotomies with their indications. Primary outcome was in-hospital mortality; secondary outcomes were complications, length of ICU, and overall hospital stay.

Results

A total of 268 index emergency laparotomies were evaluated. Total number of patients who presented with an abdominal AIS > 2 remained constant over the past 10 years, as did the percentage of patients that required an emergency laparotomy. Most were polytrauma patients with a mean ISS = 27.5 (SD ± 14.9). The most frequent indication for laparotomy was hemodynamic instability or ongoing blood loss (44%).Unplanned relaparotomies occurred in 21% of the patients, mostly due to relapse of bleeding. Other complications were anastomotic leakage (8.6%), intestinal leakage after bowel contusion (4%). In addition, an incisional hernia was found in 6.3%. Mortality rate was 16.7%, mostly due to neurologic origin (42%). Average length of stay was 16 days with an ICU stay of 5 days.

Conclusion

This study shows a persistent number of patients requiring emergency laparotomy after (blunt) abdominal trauma over 10 years in a European trauma center. When performed by a dedicated trauma team, this results in acceptable mortality and complication rates in this severely injured population.

Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis

Objectives

Performing an extended Focused Assessment with Sonography in Trauma (eFAST) exam is common practice in the initial assessment of trauma patients. The objective of this study was to systematically review the published literature on diagnostic accuracy of all components of the eFAST exam.

Methods

We searched Medline and Embase from inception through October 2018, for diagnostic studies examining the sensitivity and specificity of the eFAST exam. After removal of duplicates, 767 records remained for screening, of which 119 underwent full text review. Meta-DiSc™ software was used to create pooled sensitivities and specificities for included studies. Study quality was assessed using the Quality in Prognostic Studies (QUADAS-2) tool.

Results

Seventy-five studies representing 24,350 patients satisfied our selection criteria. Studies were published between 1989 and 2017. Pooled sensitivities and specificities were calculated for the detection of pneumothorax (69% and 99% respectively), pericardial effusion (91% and 94% respectively), and intra-abdominal free fluid (74% and 98% respectively). Sub-group analysis was completed for detection of intra-abdominal free fluid in hypotensive (sensitivity 74% and specificity 95%), adult normotensive (sensitivity 76% and specificity 98%) and pediatric patients (sensitivity 71% and specificity 95%).

Conclusions

Our systematic review and meta-analysis suggests that e-FAST is a useful bedside tool for ruling in pneumothorax, pericardial effusion, and intra-abdominal free fluid in the trauma setting. Its usefulness as a rule-out tool is not supported by these results.