Comparison of the accuracy and reproducibility of focused abdominal sonography for trauma performed by emergency medicine and radiology residents

Surgeon-performed point-of-care ultrasound for acute cholecystitis: indications and limitations: a European Society for Trauma and Emergency Surgery (ESTES) consensus statement

BACKGROUND

Acute cholecystitis (AC), frequently responsible for presentation to the emergency department, requires expedient diagnosis and definitive treatment by a general surgeon. Ultrasonography, usually performed by radiology technicians and reported by radiologists, is the first-line imaging study for the assessment of AC. Targeted point-of-care ultrasound (POCUS), particularly in the hands of the treating surgeon, may represent an evolution in surgical decision-making and may expedite care, reducing morbidity and cost.

METHODS

This consensus guideline was written under the auspices of the European Society of Trauma and Emergency Surgery (ESTES) by the POCUS working group. A systematic literature search identified relevant papers on the diagnosis and treatment of AC. Literature was critically-appraised according to the GRADE evidence-based guideline development method. Following a consensus conference at the European Congress of Trauma & Emergency Surgery (Valencia, Spain, May 2018), final recommendations were approved by the working group, using a modified e-Delphi process, and taking into account the level of evidence of the conclusion.

RECOMMENDATIONS

We strongly recommend the use of ultrasound as the first-line imaging investigation for the diagnosis of AC; specifically, we recommend that POCUS may be adopted as the primary imaging adjunct to surgeon-performed assessment of the patient with suspected AC. In line with the Tokyo guidelines, we strongly recommend Murphy's sign, in conjunction with the presence of gallstones and/or wall thickening as diagnostic of AC in the correct clinical context. We conditionally recommend US as a preoperative predictor of difficulty of cholecystectomy. There is insufficient evidence to recommend contrast-enhanced ultrasound or Doppler ultrasonography in the diagnosis of AC. We conditionally recommend the use of ultrasound to guide percutaneous cholecystostomy placement by appropriately-trained practitioners.

CONCLUSIONS

Surgeons have recently embraced POCUS to expedite diagnosis of AC and provide rapid decision-making and early treatment, streamlining the patient pathway and thereby reducing costs and morbidity.

Role of emergency physician–performed ultrasound in the differential diagnosis of abdominal pain

Objectives:

This prospective study was performed to evaluate the diagnostic accuracy of bedside point-of-care abdominal ultrasonography performed by emergency physician in patients with non-traumatic acute abdominal pain.

Methods:

The patients, who were admitted to emergency department due to abdominal pain, were included in this study. The emergency physician obtained a routine history, physical examination, blood draws, and ordered diagnostic imaging. After the initial clinical examinations, all the patients underwent ultrasonography for abdominal pathologies by emergency physician and radiologist, respectively. Point-of-care abdominal ultrasonography compared with abdominal ultrasonography performed by radiologist as the gold standard.

Results:

The study included 122 patients. Gallbladder and appendix pathologies were the most commonly detected in the abdominal ultrasonography. Compared with abdominal ultrasonography, point-of-care abdominal ultrasonography was found to have 89% sensitivity and 94% specificity in gallbladder pathologies; 91% sensitivity and 91% specificity in acute appendicitis; 79% sensitivity and 97% specificity in abdominal free fluid; 83% sensitivity and 96% specificity in ovarian pathologies. Compared to final diagnosis, preliminary diagnoses of emergency physicians were correct in 92 (75.4%) patients.

Conclusion:

This study showed that emergency physicians were successful in identifying abdominal organ pathologies with point-of-care abdominal ultrasonography after training.

Diagnostic Accuracy of Focused Assessment with Sonography for Blunt Abdominal Trauma in Pediatric Patients Performed by Emergency Medicine Residents versus Radiology Residents

INTRODUCTION

Focused assessment with sonography for trauma (FAST) has been shown to be useful to detect intraperitoneal free fluid in patients with blunt abdominal trauma (BAT).

OBJECTIVE

We compared the diagnostic accuracy of FAST performed by emergency medicine residents (EMRs) and radiology residents (RRs) in pediatric patients with BAT.

METHOD

In this prospective study, pediatric patients with BAT and high energy trauma who were referred to the emergency department (ED) at Al-Zahra and Kashani hospitals in Isfahan, Iran, were evaluated using FAST, first by EMRs and subsequently by RRs. The reports provided by the two resident groups were compared with the final outcome based on the results of the abdominal computed tomography (CT), operative exploration, and clinical observation.

RESULTS

A total of 101 patients with a median age of 6.75 ± 3.2 years were enrolled in the study between January 2013 and May 2014. These patients were evaluated using FAST, first by EMRs and subsequently by RRs. A good diagnostic agreement was noted between the results of the FAST scans performed by EMRs and RRs (κ = 0.865, P < 0.001). The sensitivity, specificity, positive and negative predictive values, and accuracy in evaluating the intraperitoneal free fluid were 72.2%, 85.5%, 52%, 93.3%, and 83.2%, respectively, when FAST was performed by EMRs and 72.2%, 86.7%, 54.2%, 93.5%, and 84.2%, respectively, when FAST was performed by RRs. No significant differences were seen between the EMR- and RR-performed FAST.

CONCLUSION

In this study, FAST performed by EMRs had acceptable diagnostic value, similar to that performed by RRs, in patients with BAT.

Diagnostic accuracy of the Extended Focused Abdominal Sonography for Trauma (E-FAST) performed by emergency physicians compared to CT

INTRODUCTION

The diagnostic accuracy of the FAST exam performed by EM residents were shown to be similar to radiology residents. However, in the last 2 decades, an extended-FAST (E-FAST) protocol including thoracic examination to exclude pneumo- and hemothorax was introduced. The accuracy of emergency physicians (EPs) while performing E-FAST is a less studied area, especially in Europe. The aim of this study was to compare the diagnostic accuracy of the E-FAST exam performed by EM residents with the results of CT scan as a gold standard.

METHODS

This was a prospective, observational, diagnostic accuracy study conducted at the ED of a Level 1 Trauma Center. All consecutive adult multiple trauma patients were eligible, and any patient in whom thoraco-abdominal CT was ordered were recruited. Unstable and unavailable patients were excluded. E-FAST examination was performed by EPs as the index test, and CT examinations reported by a blinded academic radiology faculty was the gold standard.

RESULTS

A total of 140 patients were recruited from eligible 144 patients. The final study population was 132 for abdominal and 130 for thorax examinations. In this study, AUC of E-FAST was 0.71 for abdominal free fluid, 0.87 for pneumothorax and 1.00 for pleural effusion. The sensitivity was 42.9% and specificity was 98.4%. The +LR for abdominal free fluid was 26.8 and -LR was 0.58.

CONCLUSION

E-FAST examination has an excellent specificity. However, the sensitivity of the test is not high enough to rule-out thoraco-abdominal injuries in trauma patients when performed by EPs.

Comparative Analysis of Simulated versus Live Patient-Based FAST (Focused Assessment With Sonography for Trauma) Training

OBJECTIVE

To investigate whether simulated patient (SP)-based training has comparable efficacy as live patient (LP)-based training in teaching Focused Abdominal Sonography for Trauma (FAST) knowledge and skill competencies to surgical residents.

DESIGN

A randomized pretest/intervention/posttest controlled study design was employed to compare the participants' performance in written and practical examinations regarding FAST examination after SP-based versus LP-based training.

SETTING

University-based general residency program at a single institution.

PARTICIPANTS

A total of 29 general surgery residents of various training levels and sonographic experience were recruited by convenience sampling.

RESULTS

There was no correlation between subjects' baseline training level or sonographic experience with either the posttest-pretest score difference or the percentage of subjects getting all 4 windows with adequate quality. There was no significant difference between the improvement in written posttest-pretest scores for SP and LP group, which were 33 ± 9.6 and 31 ± 6.8 (p = 0.40), respectively. With regard to performance-based learning efficacy, a statistically higher proportion of subjects were able to obtain all 4 windows with adequate quality among the LP than the SP group (6/8 vs 1/8, p = 0.01).

CONCLUSION

SP- and LP-based FAST training for surgical residents were associated with similar knowledge-based competency acquisition, but residents receiving LP-based training were better at acquiring adequate FAST windows on live patients. Simulation training appeared to be a valid adjunct to LP practice but cannot replace LP training. Future investigations on how to improve simulation fidelity and its training efficacy for skill-based competencies are warranted.

Should we perform a FAST exam in haemodynamically stable patients presenting after blunt abdominal injury: a retrospective cohort study

Background

Focussed Assessment with Sonography for Trauma (FAST) is a bedside ultrasonography technique used to detect free intraperitoneal fluid in patients presenting with blunt abdominal trauma (BAT) in the emergency department.

Methods

In this retrospective cohort study we investigated the potential of FAST as a risk stratification instrument in haemodynamically (HD) stable patients presenting after BAT by establishing the association between the FAST exam result and final outcome. An adverse outcome was defined in this context as the need for either a laparoscopy/laparotomy or an angiographic embolization or death due to abdominal injuries).

Results

A total of 421 patients with BAT were included, of which nine had an adverse outcome (2%). FAST was negative in 407 patients. Six of them turned out to have free intraperitoneal fluid (sensitivity 67 [41–86]%). FAST was positive in 14 patients, 12 of whom had free intraperitoneal fluid (specificity 99 [98–100]%). A positive FAST (positive likelihood ratio 34.3 [15.1–78.5]) was stronger associated with an adverse outcome than Injury Severity Score (ISS) or any individual clinical- or biochemical variables measured at presentation in the ED.

Discussion

The FAST exam can provide valuable prognostic information at minimal expenses during the early stages of resuscitation in haemodynamically stable patients presenting with BAT.

Conclusions

FAST exam should not be omitted in patients with BAT.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-016-0342-0) contains supplementary material, which is available to authorized users.

Diagnostic Accuracy of Focused Assessment With Sonography for Trauma in the Emergency Department

Background

Trauma is currently the fourth leading cause of death in developed countries. One of the main objectives in abdominal trauma patients is to develop a rapid and accurate diagnosis. There is a tendency to use emergency abdominal ultrasound with abdominal trauma, therefore, it is recommended in some centers as a diagnostic tool and as a primary choice in abdominal trauma.

Objectives

The aim of this study was to determine the diagnostic accuracy of sonography for trauma by emergency medicine residents and radiology residents

Patients and Methods

This was a descriptive and analytical study performed on patients with abdominal blunt trauma who referred to the emergency ward. The diagnostic accuracy of sonography for trauma by emergency medicine residents and radiology residents was evaluated.

Results

Of the 380 patients, 296 were males and 84 were females. The mean ages of male and female patients were 34.52 ± 16.38 years and 41.19 ± 21.38 years, respectively (P = 0.009). The sonographies performed by emergency residents were positive in 46 patients, with 22 of these confirmed by CT scans. The sensitivity and specificity of the sonography by emergency residents, as confirmed by CT scans, were 78.5% and 93.2%, respectively. The sonographies performed by radiology residents were positive in 38 patients, with 24 being confirmed by CT scans.

Conclusions

The sensitivity and specificity of the sonography by radiology residents, as confirmed by CT scans, were 85.7% and 96%, respectively. Sonographies performed by emergency residents were positive in 46 patients with 34 of these being confirmed by sonographies by radiology residents. The sensitivity and specificity of the sonographies by emergency residents, as confirmed by sonographies by radiology residents, were 89.5% and 96.5%, respectively