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Choi J, Carlos G, Nassar AK, Knowlton LM, Spain DA. The impact of trauma systems on patient outcomes. Curr Probl Surg 2021; 58:100849. [PMID: 33431134 PMCID: PMC7286246 DOI: 10.1016/j.cpsurg.2020.100849] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/27/2020] [Indexed: 01/21/2023]
Affiliation(s)
- Jeff Choi
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - Garrison Carlos
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - Aussama K Nassar
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - Lisa M Knowlton
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA.
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2
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Bahrami-Motlagh H, Hajijoo F, Mirghorbani M, SalevatiPour B, Haghighimorad M. Test characteristics of focused assessment with sonography for trauma (FAST), repeated FAST, and clinical exam in prediction of intra-abdominal injury in children with blunt trauma. Pediatr Surg Int 2020; 36:1227-1234. [PMID: 32844307 DOI: 10.1007/s00383-020-04733-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE In children with blunt abdominal trauma (BAT), focused assessment of sonography in trauma (FAST) has been reported with low sensitivity, on the whole, in the detection of intra-abdominal injuries (IAI). The aim of the present study was to assess test characteristics of FAST using different strategies including repeated FAST (reFAST), and physical exam findings. METHODS This retrospective study evaluated BAT pediatric patients with stable hemodynamics who underwent computed tomography (CT). Demographic data, initial physical examination, and results of FAST, reFAST (if done), and CT imaging were recorded. Different strategies of FAST were cross-tabulated with CT as the gold standard and test characteristics including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were interpreted. RESULTS 129 patients with a mean age of 8.6 ± 4.7 were studied and 74% were male. Comparing CT-positive and -negative groups, from the demographic and clinical findings, only positive physical exam (tenderness or ecchymosis) was significantly higher in the CT-positive group (59% vs. 17%; p < 0.01). In a multivariate analysis, positive FAST modality and clinical exam remained independent predictors for a positive CT result (likelihood ratios of 34.6 and 6.4, respectively). Out of the different diagnostic strategies for the prediction of IAI, the best overall performance resulted from the FAST-reFAST-tenderness protocol with sensitivity, specificity, PPV, NPV, and accuracy of 87%, 77%, 70%, 91%, and 81%. CONCLUSION For children with blunt abdominal trauma, physical examination plus FAST and reFAST as needed, seems to have reasonable sensitivity, specificity, and accuracy in detecting intra-abdominal injuries and may reduce the need for CT scans.
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Affiliation(s)
- Hooman Bahrami-Motlagh
- Department of Radiology, Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Clinical Research Development Unit (CRDU) of Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Hajijoo
- Department of Radiology, Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. .,Clinical Research Development Unit (CRDU) of Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Masoud Mirghorbani
- Department of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Babak SalevatiPour
- Department of Radiology, Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Clinical Research Development Unit (CRDU) of Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Haghighimorad
- Department of Radiology, Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Clinical Research Development Unit (CRDU) of Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Tarrazo Suárez JA, Morales Cano JM, Pujol Salud J, Sánchez Barrancos IM, Diaz Sánchez S, Conangla Ferrín L. [Usefulness and reliability of point of care ultrasound in Family Medicine: Focused ultrasound in neck and emergency]. Aten Primaria 2019; 51:367-379. [PMID: 31101376 PMCID: PMC6836943 DOI: 10.1016/j.aprim.2019.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 03/13/2019] [Indexed: 11/17/2022] Open
Abstract
La ecografía clínica es una herramienta que complementa a la anamnesis y a la exploración física, lo que facilita y agiliza la toma de decisiones en cualquier entorno de atención médica El médico de familia es el especialista que más se puede beneficiar del empleo de la ecografía porque debe ser competente en todos los terrenos de la enfermedad El estudio mediante ecografía, por su fiabilidad, seguridad, reproducibilidad y bajo coste debe estar accesible para su empleo en atención primaria, tanto en el ámbito de la atención normal como la urgente Esta técnica, aplicada en escenarios concretos y con una sistemática de estudio definida, confirma o descarta enfermedades, lo que orienta el diagnóstico con elevada fiabilidad, así como sustenta de modo eficaz la conducta del profesional Este artículo revisa la fiabilidad y la utilidad de la ecografía clínica en escenarios como la enfermedad cervical, y en diferentes situaciones de urgencia, como sospecha de trombosis venosa profunda en la extremidad inferior, traumatismo toracoabdominal, inestabilidad hemodinámica o parada cardiaca
La ecografía es una herramienta de gran valor para el diagnóstico y el manejo de una gran variedad de situaciones clínicas cotidianas. El médico de familia como especialista generalista debe ser competente para el abordaje de prácticamente cualquier problema de salud que afecte a su población, por lo que, en sus manos, esta herramienta puede proporcionar un elevado impacto sobre la calidad y la eficacia del proceso asistencial. Este es el último artículo de una serie dedicada a mostrar la aplicabilidad de la ecografía clínica en nuestras manos, en la que hemos revisado la mayoría de sus aplicaciones, como la ecografía clínica abdominal, la nefrourológica, la musculoesquelética, la cardiaca o la pulmonar. Queremos terminar con escenarios como la afección del cuello o su uso en situaciones de urgencia, en las que proporciona datos definitivos para la orientación diagnóstica, el manejo clínico e incluso la supervivencia del paciente, tales como el paciente con sospecha de trombosis venosa profunda en miembros inferiores, traumatismo toracoabdominal, compromiso hemodinámico o parada cardiaca.
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Affiliation(s)
- José Antonio Tarrazo Suárez
- Medicina Familiar y Comunitaria; Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Salud Siero-Sariego, Servicio Asturiano de Salud, Pola de Siero, Asturias, España
| | - José Manuel Morales Cano
- Medicina Familiar y Comunitaria; Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Salud Ciudad Real 2, Servicio de Salud de Castilla-La Mancha, Ciudad Real, España
| | - Jesús Pujol Salud
- Medicina Familiar y Comunitaria; Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Atención Primaria Balaguer, Instituto Catalán de Salud, Balaguer, Lleida, España
| | - Ignacio Manuel Sánchez Barrancos
- Medicina Familiar y Comunitaria; Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Consultorio de Membrilla, Centro de Salud Manzanares 2, Servicio de Salud de Castilla-La Mancha, Membrilla, Ciudad Real, España.
| | - Santiago Diaz Sánchez
- Medicina Familiar y Comunitaria; Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Salud Pintores de Parla, Servicio Madrileño de Salud, Parla, Madrid. España
| | - Laura Conangla Ferrín
- Medicina Familiar y Comunitaria; Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Atención Primaria Badalona-2, Centre Dalt la Vila, Instituto Catalán de Salud, Badalona, Barcelona, España
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4
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Chan CKM, Chiu HS, Chung CH. Delayed Rupture of Occult Splenic Injury: a Case Report. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790301000309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We report on a case of splenic rupture that presented eleven days after a trivial injury. Possible explanations of the delay in presentation and ways for early detection are discussed. Emergency physicians should always bear this entity in mind before discharging patients with left thoracoabdominal injury.
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Affiliation(s)
- CKM Chan
- North District Hospital, Accident and Emergency Department, 9 Po Kin Road, Sheung Shui, N.T., Hong Kong
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Finnoff JT, Ray J, Corrado G, Kerkhof D, Hill J. Sports Ultrasound: Applications Beyond the Musculoskeletal System. Sports Health 2016; 8:412-7. [PMID: 27519599 PMCID: PMC5010139 DOI: 10.1177/1941738116664041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Traditionally, ultrasound has been used to evaluate musculoskeletal injuries in athletes; however, ultrasound applications extend well beyond musculoskeletal conditions, many of which are pertinent to athletes. EVIDENCE ACQUISITION Articles were identified in PubMed using the search terms ultrasound, echocardiogram, preparticipation physical examination, glycogen, focused assessment with sonography of trauma, optic nerve, and vocal cord dysfunction. No date restrictions were placed on the literature search. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS Several potential applications of nonmusculoskeletal ultrasound in sports medicine are presented, including extended Focused Assessment with Sonography for Trauma (eFAST), limited echocardiographic screening during preparticipation physical examinations, assessment of muscle glycogen stores, optic nerve sheath diameter measurements in athletes with increased intracranial pressure, and assessment of vocal cord dysfunction in athletes. CONCLUSION Ultrasound can potentially be used to assist athletes with monitoring their muscle glycogen stores and the diagnosis of multiple nonmusculoskeletal conditions within sports medicine.
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Affiliation(s)
- Jonathan T Finnoff
- Department of Physical Medicine and Rehabilitation, Mayo Clinic School of Medicine, Rochester, Minnesota Mayo Clinic Sports Medicine Center, Minneapolis, Minnesota
| | - Jeremiah Ray
- Division of Emergency Medicine, University of Utah, Salt Lake City, Utah
| | - Gianmichael Corrado
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts
| | | | - John Hill
- Primary Care Sports Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Beyond focused assessment with sonography for trauma: ultrasound creep in the trauma resuscitation area and beyond. Curr Opin Crit Care 2012; 17:606-12. [PMID: 21934613 DOI: 10.1097/mcc.0b013e32834be582] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The use of ultrasound for the management of the injured patient has expanded dramatically in the last decade. The focused assessment with sonography for trauma (FAST) has become one of the fundamental skills incorporated into the initial evaluation of the trauma patient. However, there are significant limitations of this diagnostic modality as initially described. Novel ultrasound examinations of the injured patient, although useful, must also be considered carefully. RECENT FINDINGS Increasing evidence supports the high specificity of FAST for detecting a pericardial effusion and intra-abdominal free fluid (hemorrhage) in the patient with blunt injury. On the other hand, a so-called negative FAST result still requires further diagnostic work up given its low sensitivity. Similarly, the role of FAST in penetrating abdominal trauma appears to be limited because of lower sensitivity for visceral injury compared to other modalities. Extended FAST (EFAST), that adds a focused thoracic examination, has high accuracy for the detection of pneumothorax comparable to computed tomographic scan, the significance of which is not currently known. Finally, the utility of intensivist-performed ultrasound in the ICU is expanding to limited hemodynamic assessment and facilitation of central venous catheter placement. SUMMARY The indications for FAST and additional ultrasound studies in the injured patient continue to evolve. Application of sound clinical evidence will avoid unsubstantiated indications for ultrasound to creep into our clinical practice.
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Fox JC, Boysen M, Gharahbaghian L, Cusick S, Ahmed SS, Anderson CL, Lekawa M, Langdorf MI. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med 2011; 18:477-82. [PMID: 21569167 DOI: 10.1111/j.1553-2712.2011.01071.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Focused assessment of sonography in trauma (FAST) has been shown useful to detect clinically significant hemoperitoneum in adults, but not in children. The objectives were to determine test characteristics for clinically important intraperitoneal free fluid (FF) in pediatric blunt abdominal trauma (BAT) using computed tomography (CT) or surgery as criterion reference and, second, to determine the test characteristics of FAST to detect any amount of intraperitoneal FF as detected by CT. METHODS This was a prospective observational study of consecutive children (0-17 years) who required trauma team activation for BAT and received either CT or laparotomy between 2004 and 2007. Experienced physicians performed and interpreted FAST. Clinically important FF was defined as moderate or greater amount of intraperitoneal FF per the radiologist CT report or surgery. RESULTS The study enrolled 431 patients, excluded 74, and analyzed data on 357. For the first objective, 23 patients had significant hemoperitoneum (22 on CT and one at surgery). Twelve of the 23 had true-positive FAST (sensitivity = 52%; 95% confidence interval [CI] = 31% to 73%). FAST was true negative in 321 of 334 (specificity = 96%; 95% CI = 93% to 98%). Twelve of 25 patients with positive FAST had significant FF on CT (positive predictive value [PPV] = 48%; 95% CI = 28% to 69%). Of 332 patients with negative FAST, 321 had no significant fluid on CT (negative predictive value [NPV] = 97%; 95% CI = 94% to 98%). Positive likelihood ratio (LR) for FF was 13.4 (95% CI = 6.9 to 26.0) while the negative LR was 0.50 (95% CI = 0.32 to 0.76). Accuracy was 93% (333 of 357, 95% CI = 90% to 96%). For the second objective, test characteristics were as follows: sensitivity = 20% (95% CI = 13% to 30%), specificity = 98% (95% CI = 95% to 99%), PPV = 76% (95% CI = 54% to 90%), NPV = 78% (95% CI = 73% to 82%), positive LR = 9.0 (95% CI = 3.7 to 21.8), negative LR = 0.81 (95% CI = 0.7 to 0.9), and accuracy = 78% (277 of 357, 95% CI = 73% to 82%). CONCLUSION In this population of children with BAT, FAST has a low sensitivity for clinically important FF but has high specificity. A positive FAST suggests hemoperitoneum and abdominal injury, while a negative FAST aids little in decision-making.
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Affiliation(s)
- J Christian Fox
- Department of Emergency Medicine and Department of Surgery (JCF, MB, SSA, CLA, ML, MIL), University of California at Irvine, Orange, CA.
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8
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Melniker LA. The value of focused assessment with sonography in trauma examination for the need for operative intervention in blunt torso trauma: a rebuttal to “emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma (review)”, from the Cochrane Collaboration. Crit Ultrasound J 2009. [DOI: 10.1007/s13089-009-0014-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Abstract
Background and significance
The Cochrane Database of Systematic Reviews published a manuscript critical of the use of the FAST examination. The reference is Stengel D. Bauwens K. Sehouli J. Rademacher G. Mutze S. Ekkernkamp A. Porzsolt F. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database of Systematic Reviews. (2):CD004446, 2005. UI: 15846717. The stated objective was the assessment of the “efficiency and effectiveness” of ultrasound-inclusive evaluative algorithms in patients with suspected blunt abdominal trauma (BAT). The primary outcome measures explored were Mortality, CT and DPL use, and laparotomy rates. Little or no benefit was seen and the conclusion was that “there is insufficient evidence from randomized controlled trials to justify promotion” of FAST in patients with BAT. While the review used the same rigorous methods employed in all Cochrane Reviews, it appears that several serious flaws plagued the manuscript. The finest methodological rigor cannot yield usable results, if it is not applied to a clinically relevant question. In a world of increasingly conservative management of BAT, do we need FAST, a rapid, repeatable screening modality at the point-of-care to visualize any amount of free fluid or any degree of organ injury? The obvious answer is no. However, quantifying the value of FAST to predict the need for immediate operative intervention (OR) is essential.
Methods
To rebut this recurrent review, a systematic literature review was conducted using verbatim methodologies as described in the Cochrane Review with the exception of telephone contacts. Data were tabulated and presented descriptively.
Results
Out of 487 citations, 163 articles were fully screened, 11 contained prospectively derived data with FAST results, patient disposition and final diagnoses, and a description of cases considered false negatives or false positives. Of the 2,755 patients, 448 (16%) went to the OR. There were a total of 5 patients with legitimately false-negative diagnoses made based on the FAST: 3 involving inadequate scans and 2 of blunt trauma-induced small bowel perforations without hemoperitoneum.
Conclusion
The FAST examination, adequately completed, is a nearly perfect test for predicting a “Need for OR” in patients with blunt torso trauma.
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Gillman LM, Ball CG, Panebianco N, Al-Kadi A, Kirkpatrick AW. Clinician performed resuscitative ultrasonography for the initial evaluation and resuscitation of trauma. Scand J Trauma Resusc Emerg Med 2009; 17:34. [PMID: 19660123 PMCID: PMC2734531 DOI: 10.1186/1757-7241-17-34] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Accepted: 08/06/2009] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Traumatic injury is a leading cause of morbidity and mortality in developed countries worldwide. Recent studies suggest that many deaths are preventable if injuries are recognized and treated in an expeditious manner - the so called 'golden hour' of trauma. Ultrasound revolutionized the care of the trauma patient with the introduction of the FAST (Focused Assessment with Sonography for Trauma) examination; a rapid assessment of the hemodynamically unstable patient to identify the presence of peritoneal and/or pericardial fluid. Since that time the use of ultrasound has expanded to include a rapid assessment of almost every facet of the trauma patient. As a result, ultrasound is not only viewed as a diagnostic test, but actually as an extension of the physical exam. METHODS A review of the medical literature was performed and articles pertaining to ultrasound-assisted assessment of the trauma patient were obtained. The literature selected was based on the preference and clinical expertise of authors. DISCUSSION In this review we explore the benefits and pitfalls of applying resuscitative ultrasound to every aspect of the initial assessment of the critically injured trauma patient.
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Affiliation(s)
- Lawrence M Gillman
- Regional Trauma Services, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Surgery, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
| | - Chad G Ball
- Regional Trauma Services, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
| | - Nova Panebianco
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Azzam Al-Kadi
- Regional Trauma Services, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
| | - Andrew W Kirkpatrick
- Regional Trauma Services, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Surgery, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Critical Care Medicine, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada
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Abstract
Training medical providers to care for traumatically injured patients is a difficult undertaking and currently used training strategies are often suboptimal. The further strains placed on trauma care in the military environment only add to the challenge. Simulation applications ranging from simple physical models to complex, computer-based virtual reality systems have either been developed or are being developed to help support and improve trauma care training. Several of these applications have been shown to be as good as or better than the standard training methods they are designed to replace. Simulators are available for training in the treatment of disorders of the airway, difficulty with breathing, and problems dealing with circulation as well as various non-life-threatening but disabling injuries. Some of these simulators have already drastically changed how the standard Advanced Trauma Life Support course is taught. Advances in both technology and application of simulators will continue to affect trauma skills training for the foreseeable future.
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Affiliation(s)
- E Matt Ritter
- National Capitol Area Medical Simulation Center; Norman M. Rich Department of Surgery; Uniformed Services University, Bethesda, Maryland, USA
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Godambe SA, Boulden T. The use of an emergency physician-directed bedside ultrasound examination to clarify a diagnosis in an 8-year-old boy with chronic abdominal pain. Pediatr Emerg Care 2007; 23:560-2. [PMID: 17726416 DOI: 10.1097/pec.0b013e31812e578c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abdominal pain is a common presenting complaint to the emergency department. Often, patients with chronic, intermittent histories of abdominal pain with multiple visits to medical providers find it difficult to be taken seriously. We describe a patient with a history of episodic abdominal pain who was found to have intermittent ureteropelvic junction obstruction after a timely ultrasound examination by the treating emergency physician.
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Affiliation(s)
- Sandip A Godambe
- Division of Pediatric Emergency Medicine, Department of Pediatrics, LeBonheur Children's Medical Center, University of Tennessee, Memphis, TN 38103, USA.
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12
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Abstract
Traumatic death remains pandemic. The majority of preventable deaths occur early and are due to injuries or physiologic derangements in the airway, thoracoabdominal cavities, or brain. Ultrasound is a noninvasive and portable imaging modality that spans a spectrum between the physical examination and diagnostic imaging. It allows trained examiners to immediately confirm important syndromes and answer clinical questions. Newer technologies greatly increase the fidelity, accessibility, ease of use, and informatic manipulation of the results. The early bedside use of focused ultrasound as the initial imaging modality used to detect hemoperitoneum and hemopericardium in the resuscitation of the injured patient has become an accepted standard of care. Widespread dissemination of basic ultrasound skills and technology to facilitate this brings ultrasound to many resuscitative and critical care areas. Although not as widely appreciated, the focused use of ultrasound may also have a role in detecting hemothoraces and pneumothoraces, guiding airway management, and detecting increased intracranial pressure. Intensivists generally utilize a treating philosophy that requires the real-time integration of many divergent sources of information regarding their patients' anatomy and physiology. They are therefore positioned to take advantage of focused resuscitative ultrasound, which offers immediate diagnostic information in the early care of the critically injured.
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Affiliation(s)
- Andrew W Kirkpatrick
- Department of Critical Care Medicine, Foothills Medicine Centre, Calgary, Alberta, Canada.
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13
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Staren ED, Knudson MM, Rozycki GS, Harness JK, Wherry DC, Shackford SR. An evaluation of the American College of Surgeons’ ultrasound education program. Am J Surg 2006; 191:489-96. [PMID: 16531142 DOI: 10.1016/j.amjsurg.2005.10.023] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2005] [Revised: 10/26/2005] [Accepted: 10/26/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ultrasound has a wide variety of applications in surgery, but until recently few surgeons received any formal training in its use. To facilitate incorporation of ultrasound into surgical practice, the American College of Surgeons (ACoS) developed an ultrasound educational program. The purpose of this study was to evaluate the impact and effectiveness of the ACoS ultrasound education program. METHODS A survey was mailed to all surgeons who had completed at least one of several ultrasound courses offered by the ACoS from 1998 to 2002. RESULTS A total of 1,791 surveys were mailed out and 873 completed surveys were returned. Sixty-five percent (576) of respondents reported using ultrasound in their practices after these educational courses. Of those performing ultrasound examinations, 267 did so in one clinical area and 309 in more than one. The most common examination was breast (369 surgeons); vascular, acute/trauma, abdominal, intraoperative/laparoscopic, and head/neck were utilized fairly equally (100-200 surgeons). The number of examinations performed by surgeons before they felt competent was between 11 and 20 and did not vary by the type of ultrasound examination. Of the 267 surgeons performing ultrasound in one clinical area, 176 performed ultrasound-guided procedures. Most surgeons had access to 2 ultrasound machines, but 386 (67%) were restricted from performing ultrasound in certain locations. CONCLUSIONS The ACoS ultrasound courses are extremely popular and have contributed to the increasing use of ultrasound in surgical practice. Surgeons successfully use ultrasound in their practices including performance of ultrasound-guided procedures but are restricted from using ultrasound in certain patient care areas. Since many surgeons received prior and/or additional training outside of the ACoS, there is a need to facilitate export of ACoS courses to other venues and to focus on incorporating ultrasound training into surgical residency programs.
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Affiliation(s)
- Edgar D Staren
- Cancer Treatment Centers of America, 2520 Elisha Ave., Zion, IL 60099, USA.
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14
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Affiliation(s)
- Michael A. Frakes
- Michael Frakes is a senior flight nurse with LIFE STAR at Hartford Hospital in Hartford, Conn
| | - Tracy Evans
- Tracy Evans is the trauma program manager and director of emergency medical services at Norwalk Hospital in Norwalk, Conn
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15
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Chen CM, Liaw HC. Ultrasonography in Hemodynamically Unstable Abdominal Trauma Patients. J Med Ultrasound 2003. [DOI: 10.1016/s0929-6441(09)60044-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Miller MT, Pasquale MD, Bromberg WJ, Wasser TE, Cox J. Not so FAST. THE JOURNAL OF TRAUMA 2003; 54:52-9; discussion 59-60. [PMID: 12544899 DOI: 10.1097/00005373-200301000-00007] [Citation(s) in RCA: 224] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- M Todd Miller
- Division of Trauma/Surgical Critical Care, Lehigh Valley Hospital, Cedar Crest & I-78, P.O. Box 689, Allentown, PA 18105-1556, USA
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Abstract
Trauma is the leading cause of death and disability in children. More than 90% of pediatric trauma admissions are the result of a blunt mechanism. Although injury to the abdomen and pelvis account for only 10% of injuries sustained by victims of pediatric trauma, they can be potentially life threatening. Optimal evaluation of the injured child may require the use of multiple diagnostic modalities. The spleen is the most frequently injured intra-abdominal organ, followed by the liver, intestine, and pancreas. Fortunately, the majority of injuries to the spleen and liver can be treated nonoperatively. Conversely, injuries involving the intestine and pancreas often require operative intervention.
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Affiliation(s)
- Barbara A Gaines
- Division of Pediatric Surgery, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213, USA
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Baka AG, Delgado CA, Simon HK. Current use and perceived utility of ultrasound for evaluation of pediatric compared with adult trauma patients. Pediatr Emerg Care 2002; 18:163-7. [PMID: 12065999 DOI: 10.1097/00006565-200206000-00003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the current use and perceived utility of ultrasound in the assessment of pediatric compared with adult trauma patients. METHODS A questionnaire was developed and mailed to 72 pediatric emergency physicians, 120 general emergency physicians, and 117 trauma attendings at 240 institutions. RESULTS Of 309 surveys, 234 (75%) were completed. Ultrasound was available to 169 of 234 (72%) of the physicians, and 122 of 169 (72%) were performing the Focused Assessment by Sonography for Trauma examination to evaluate trauma patients. Seventy-three percent (110/150) of general emergency and trauma surgeons reported that ultrasound was available equally with or more readily than computed tomography (CT) scan. Only 26% (5/19) of pediatric emergency attendings considered ultrasound equally available with CT scan, and none considered it more readily available than CT scan. Ninety-two percent (137/149) of general emergency and trauma attendings responding to the question about utility considered ultrasound somewhat useful to extremely useful for assessing adult trauma patients, and 77% considered it useful for pediatric patients. Only 57% (12/21) of pediatric emergency attendings responding to the same question perceived ultrasound as useful for pediatric trauma evaluations. CONCLUSIONS We conclude that ultrasound for the assessment of trauma patients is widely used by general emergency physicians and trauma surgeons, whereas pediatric emergency physicians report less use and perceived utility.
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Affiliation(s)
- Agoritsa G Baka
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University, Atlanta, Georgia, USA.
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Yen K, Gorelick MH. Ultrasound applications for the pediatric emergency department: a review of the current literature. Pediatr Emerg Care 2002; 18:226-34. [PMID: 12066016 DOI: 10.1097/00006565-200206000-00020] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kenneth Yen
- Section of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA.
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20
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Rowland JL, Kuhn M, Bonnin RL, Davey MJ, Langlois SL. Accuracy of emergency department bedside ultrasonography. EMERGENCY MEDICINE (FREMANTLE, W.A.) 2001; 13:305-13. [PMID: 11554861 DOI: 10.1046/j.1035-6851.2001.00233.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To determine which focused ultrasound examinations can be interpreted accurately by emergency physicians who have limited training and experience. To determine whether image quality and/or the operator's level of confidence in the findings correlates with accurate scan interpretation. METHODS A prospective sample of consenting adult emergency department patients with the conditions was selected for study. Scans were performed by emergency physicians who had attended a 3-day focused ultrasound examinations instruction course. All scans were videotaped and subsequently reviewed by a radiologist. Accuracy was determined by comparing the emergency physicians scan interpretation with preselected gold standards. Chi-squared tests were employed to determine if the individual performing the scan, the type of scan, patient's body habitus, image quality and/or operator confidence were reliable predictors of accuracy. RESULTS Between September 1997 and January 1999, 221 scans were studied. Accuracy varied widely depending on the type of scan performed: aortic scans were 100% accurate whereas renal scans had 68% accuracy. On bivariate analyses, there was little variation in the various operators' levels of proficiency and accuracy of interpretation was not associated with patient body habitus, image quality or operator confidence. CONCLUSIONS Neophytes can accurately perform and interpret aortic scans; additional training and/or experience appear to be necessary to achieve proficiency in conducting most of the other scans studied. Inexperienced operators are unable to discern whether their scan interpretations will prove accurate.
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Affiliation(s)
- J L Rowland
- Department of Emergency Medicine, The Royal Adelaide Hospital, Adelaide, South Australia, Australia
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21
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Boulanger BR, Kearney PA, Tsuei B, Ochoa JB. The routine use of sonography in penetrating torso injury is beneficial. THE JOURNAL OF TRAUMA 2001; 51:320-5. [PMID: 11493792 DOI: 10.1097/00005373-200108000-00015] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Torso sonography (focused assessment with sonography for trauma [FAST]) has been added to our protocols for the evaluation of penetrating torso injury. The purpose of this study was to evaluate our recent experience and determine whether the use of FAST is beneficial. METHODS From January 1999 to January 2000, patients with penetrating torso injury and no clinical indication for surgery were evaluated by sonography with a selective use of other investigations. FAST consisted of sonographic views of the peritoneum and/or pericardium to determine the presence or absence of fluid. RESULTS During the study period, there were 238 victims of penetrating injury assessed by our trauma service, and sonography was performed in 72 (30%) patients as per our protocols. There were 31 stab, 37 gunshot/shotgun and, and 4 puncture wounds. Thirty-eight patients had peritoneal views, 6 patients had pericardial views, and 28 patients had both pericardial and peritoneal views obtained. Thirteen of 66 patients had free fluid in the peritoneal cavity and 12 of the 13 patients had a therapeutic laparotomy. No peritoneal fluid was seen in 53 of 66 patients, of whom 6 had abdominal injuries, 5 requiring surgery for diaphragm or bowel injuries. The sensitivity of FAST alone for abdominal injury was 67%, specificity was 98%, positive predictive value was 92%, and negative predictive value was 89%. Pericardial fluid was seen in 3 of 34 patients; one had a heart wound and two had negative pericardial windows. All 31 patients without pericardial fluid recovered without surgery. CONCLUSION The routine use of sonography in penetrating torso injury is beneficial. The detection of pericardial or peritoneal fluid is clinically useful. However, a negative FAST examination does not exclude abdominal injury, such as a diaphragm or hollow viscus wound, and further investigation or close follow-up is required.
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Affiliation(s)
- B R Boulanger
- Department of Surgery, University of Kentucky Medical Center, Lexington, USA.
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Boulanger BR, Kearney PA, Brenneman FD, Tsuei B, Ochoa J. Utilization of FAST (Focused Assessment with Sonography for Trauma) in 1999: Results of a Survey of North American Trauma Centers. Am Surg 2000. [DOI: 10.1177/000313480006601114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Although much has been written about FAST (Focused Assessment with Sonography for Trauma) in the last decade little is known about its present clinical utilization. The purpose of this study was to evaluate and characterize the contemporary utilization of FAST at trauma centers in the United States and Canada. In 1999 trauma directors or their delegates at Level I regional trauma centers in the United States and Canada were surveyed either by fax or phone regarding the present utilization and the future of FAST at their center. The overall survey response rate was 91 per cent with 96 of 105 centers completing the survey. Of the 96 centers surveyed 78 were in the United States and 18 were in Canada. Of the 78 U.S. centers surveyed 62 (79%) routinely use FAST, and it is done by surgeons in 39 per cent, surgeons and emergency departments in 21 per cent, emergency departments in 5 per cent, and radiologists in 35 per cent. Most centers (79%) thought that it sped up their workups, and 89 per cent said it was an advance in patient care. FAST is used in penetrating injury at 58 per cent of centers, and some centers use FAST to assess organ injury. The utilization of diagnostic peritoneal lavage and CT has markedly decreased at many centers. Almost all respondents thought that FAST should be a component of surgery resident training. The utilization of FAST is significantly less in Canada than in the United States ( P < 0.05). Our conclusions are the following. FAST has become routinely used at the majority of the U.S. centers surveyed. FAST is performed by clinicians at 65 per cent of the trauma centers surveyed. The utilization of CT and diagnostic peritoneal lavage has changed. Many centers have broadened the scope of FAST to include the assessment of organ, pediatric, and penetrating injury.
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Affiliation(s)
| | - Paul A. Kearney
- Departments of Surgery, University of Kentucky, Lexington, Kentucky
| | | | - B. Tsuei
- Departments of Surgery, University of Kentucky, Lexington, Kentucky
| | - Juan Ochoa
- Departments of Surgery, University of Kentucky, Lexington, Kentucky
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23
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Coley BD, Mutabagani KH, Martin LC, Zumberge N, Cooney DR, Caniano DA, Besner GE, Groner JI, Shiels WE. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. THE JOURNAL OF TRAUMA 2000; 48:902-6. [PMID: 10823534 DOI: 10.1097/00005373-200005000-00014] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Focused abdominal sonography for trauma (FAST) has been well reported in adults, but its applicability in children is less well established. We decided to test the hypothesis that FAST and computed tomography (CT) are equivalent imaging studies in the setting of pediatric blunt abdominal trauma. METHODS One hundred seven hemodynamically stable children undergoing CT for blunt abdominal trauma were prospectively investigated using FAST. The ability of FAST to predict injury by detecting free intraperitoneal fluid was compared with CT as the imaging standard. RESULTS Thirty-two patients had CT documented injuries. There were no late injuries missed by CT. FAST detected free fluid in 12 patients. Ten patients had solid organ injury but no free fluid and, thus, were not detected by FAST. The sensitivity of FAST relative to CT was only 0.55 and the negative predictive value was only 0.50. CONCLUSION FAST has insufficient sensitivity and negative predictive value to be used as a screening imaging test in hemodynamically stable children with blunt abdominal trauma.
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Affiliation(s)
- B D Coley
- Children's Radiological Institute, Columbus Children's Hospital, OH 43205, USA.
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24
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Avolio AW, Agnes S, Chirico AS, Cillo U, Frongillo F, Castagneto M. Successful transplantation of an injured liver. Transplant Proc 2000; 32:131-3. [PMID: 10700996 DOI: 10.1016/s0041-1345(99)00910-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A W Avolio
- Division of Organ Transplantation, A. Gemelli Catholic University of Rome, Italy
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25
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Polk JD, Fallon WF. The use of focused assessment with sonography for trauma (FAST) by a prehospital air medical team in the trauma arrest patient. PREHOSP EMERG CARE 2000; 4:82-4. [PMID: 10634291 DOI: 10.1080/10903120090941722] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- J D Polk
- Division of Trauma, Critical Care, Burns, and Life Flight, MetroHealth Medical Center, Cleveland, Ohio 44109, USA.
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26
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Boulanger BR, McLellan BA, Brenneman FD, Ochoa J, Kirkpatrick AW. Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. THE JOURNAL OF TRAUMA 1999; 47:632-7. [PMID: 10528595 DOI: 10.1097/00005373-199910000-00005] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although the routine use of FAST (focused assessment with sonography for trauma) in the evaluation of trauma victims is increasing, to our knowledge, a prospective comparison of contemporary adult trauma victims managed with and without FAST has not been reported in North America. METHODS Adult victims of blunt trauma for whom there was a suspicion of abdominal injury were managed with one of two diagnostic algorithms, FAST or no-FAST. The two algorithms were compared for diagnostic accuracy, cost, time, and delayed diagnoses. RESULTS Among 706 patients (mean Injury Severity Score, 23), 460 were managed with FAST and 246 with no-FAST. The two groups were similar with respect to age, Injury Severity Score, prehospital time, and mortality (p = not significant). There were 3 of 460 (0.7%) delayed diagnoses in the FAST group and 4 of 246 (1.6%) in the no-FAST group (p = not significant). The diagnostic accuracy for the FAST and no-FAST algorithms was 99% and 98%, respectfully. The FAST and no-FAST algorithms led to similar rates of laparotomy, 13% and 14%, respectfully, but nonoperative management was more common in the no-FAST group (p < 0.01). The mean diagnostic cost for the FAST algorithm was $156, compared with $540 with the no-FAST algorithm (p < 0.0001) and the mean time required for diagnostic work-up was 53 minutes with the FAST algorithm, compared with 151 minutes with the no-FAST algorithm (p < 0.0001). CONCLUSION This study has provided prospective evidence that a FAST-based algorithm for blunt abdominal injury was more rapid, less expensive, and as accurate as an algorithm that used computed tomography or diagnostic peritoneal lavage only. Trauma centers are encouraged to incorporate a FAST-based algorithm into their initial management of blunt trauma victims.
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Affiliation(s)
- B R Boulanger
- Department of Surgery, University of Kentucky Medical Center, Lexington 40536-0084, USA
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27
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Thourani VH, Feliciano DV, Cooper WA, Brady KM, Adams AB, Rozycki GS, Symbas PN. Penetrating Cardiac Trauma at an Urban Trauma Center: A 22-Year Perspective. Am Surg 1999. [DOI: 10.1177/000313489906500903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
This is a report of a 22-year experience with penetrating cardiac trauma at a single urban Level I trauma center. We conducted a retrospective chart review supplemented by computerized patient log. Comparisons of mortality between Period 1 (1975–1985; 113 patients) and Period 2 (1986–1996; 79 patients) were by χ2 or Fisher's exact tests. Statistical significance was defined as P ≤ 0.05. From 1975 to 1996, 192 patients (mean age, 32 years; 88% male) with penetrating cardiac stab wounds (68%) or gunshot wounds (32%) were treated. The most common initial clinical presentation was cardiac tamponade, and most patients (54%) were hypotensive (systolic blood pressure 30–90 mm Hg). The most common initial intervention in the emergency center was tube thoracostomy. The use of pericardiocentesis as a diagnostic and therapeutic modality in the emergency center virtually disappeared in Period 2, as compared with Period 1. Since 1994, surgeon-performed cardiac ultrasound has been performed and has correctly diagnosed hemopericardium in 12 patients (100% survival). The overall mortality for all patients during the 22-year study interval was 25 per cent and was not significantly different between Period 1 (27%) and Period 2 (22%). The mortality associated with gunshot wounds was increased compared with that of stab wounds. Similarly, mortality for patients who arrested in the emergency center was increased compared with those patients who did not arrest. We conclude: 1) cardiac tamponade is the most common presentation in patients with cardiac wounds; 2) pericardiocentesis in the emergency center has essentially disappeared; 3) surgeon-performed ultrasound of the pericardium should improve survival of future patients who are normotensive or mildly hypotensive; 4) over the last 11 years, there has been a substantial decrease in mortality in patients with stab wounds and a statistically significant decrease in arrested patients; and 5) overall mortality for penetrating cardiac trauma has not changed during the 22-year interval.
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Affiliation(s)
- Vinod H. Thourani
- Divisions of Trauma/Surgical Critical Care, Emory University School of Medicine, Atlanta, Georgia
| | - David V. Feliciano
- Divisions of Trauma/Surgical Critical Care, Emory University School of Medicine, Atlanta, Georgia
| | - William A. Cooper
- Divisions of Trauma/Surgical Critical Care, Emory University School of Medicine, Atlanta, Georgia
| | - Kevin M. Brady
- Divisions of Trauma/Surgical Critical Care, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew B. Adams
- The Carlyle Fraser Heart Center of Crawford Long Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Grace S. Rozycki
- Divisions of Trauma/Surgical Critical Care, Emory University School of Medicine, Atlanta, Georgia
| | - Panagiotis N. Symbas
- Cardiothoracic Surgery, Department of Surgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
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28
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Shanmuganathan K, Mirvis SE, Sherbourne CD, Chiu WC, Rodriguez A. Hemoperitoneum as the sole indicator of abdominal visceral injuries: a potential limitation of screening abdominal US for trauma. Radiology 1999; 212:423-30. [PMID: 10429699 DOI: 10.1148/radiology.212.2.r99au18423] [Citation(s) in RCA: 135] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine, at screening ultrasonography, the prevalence, severity, and clinical outcome of clinically important abdominal visceral injuries, without associated hemoperitoneum, that result from blunt abdominal trauma. MATERIALS AND METHODS Computed tomography (CT) was performed at admission in 466 patients with visceral injury. A retrospective review was performed of findings from surgery and contrast material-enhanced spiral and conventional CT performed to verify abdominal visceral injuries in 467 (4%) of 11,188 patients with blunt trauma. These patients were admitted to a level 1 trauma center over 33 months to determine the presence of hemoperitoneum and to identify the grade of injury. Medical records of patients with abdominal visceral injury without hemoperitoneum were reviewed for the management required and for results of focused abdominal sonography for trauma (FAST). RESULTS A total of 575 abdominal visceral injuries were identified at CT and/or surgery. Findings of CT at admission (n = 156) and of surgery (n = 1) revealed no evidence of hemoperitoneum in 157 (34%) patients with abdominal visceral injury; 26 (17%) of whom also had negative FAST studies. Abdominal visceral injuries diagnosed in patients without hemoperitoneum included 57 (27%) of 210 splenic injuries, 71 (34%) of 206 hepatic injuries, 30 (48%) of 63 renal injuries, four (11%) of 35 mesenteric injuries, and two (29%) of seven pancreatic injuries. Surgical and/or angiographic intervention was required in 26 (17%) patients without hemoperitoneum. CONCLUSION Reliance on the presence of hemoperitoneum as the sole indicator of abdominal visceral injury limits the value of FAST as a screening diagnostic modality for patients who sustain blunt abdominal trauma.
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Affiliation(s)
- K Shanmuganathan
- Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore 21201, USA.
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29
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Burnett HC, Nicholson DA. Current and future role of ultrasound in the emergency department. J Accid Emerg Med 1999; 16:250-4. [PMID: 10417929 PMCID: PMC1343362 DOI: 10.1136/emj.16.4.250] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- H C Burnett
- Department of Radiology, Hope Hospital, Manchester
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30
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Sankoff J, Keyes LE. Emergency medicine resident education: making a case for training residents to perform and interpret bedside sonographic examinations. Ann Emerg Med 1999; 34:105-8. [PMID: 10382004 DOI: 10.1016/s0196-0644(99)70281-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- J Sankoff
- McGill University Emergency Medicine, Residency Training Program, SMBD Jewish General Hospital/, Royal Victoria Hospital, Montreal, Quebec, Canada
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31
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Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon WF, Kato K, McKenney MG, Nerlich ML, Ochsner MG, Yoshii H. Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. THE JOURNAL OF TRAUMA 1999; 46:466-72. [PMID: 10088853 DOI: 10.1097/00005373-199903000-00022] [Citation(s) in RCA: 380] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assemble an international panel of experts to develop consensus recommendations on selected important issues on the use of ultrasonography (US) in trauma care. SETTING R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Md. The conference was held on December 4, 1997. PARTICIPANTS A committee of two co-directors and eight faculty members, in the disciplines of surgery and emergency medicine, representing four nations. Each faculty member had made significant contributions to the current understanding of US in trauma. RESULTS Six broad topics felt to be controversial or to have wide variation in practice were discussed using the ad hoc process: (1) US nomenclature and technique; (2) US for organ-specific injury; (3) US scoring systems; (4) the meaning of positive and negative US studies; (5) US credentialing issues; and (6) future applications of US. Consensus recommendations were made when unanimous agreement was reached. Majority viewpoints and minority opinions are presented for unresolved issues. CONCLUSION The consensus conference process fostered an international sharing of ideas. Continued communication is needed to advance the science and technology of US in trauma care.
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Affiliation(s)
- T M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore 21201-1595, USA
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32
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Newman PG, Rozycki GS. Diagnosis of visceral organ injury. Eur Surg 1999. [DOI: 10.1007/bf02619789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Mutabagani KH, Coley BD, Zumberge N, McCarthy DW, Besner GE, Caniano DA, Cooney DR. Preliminary experience with focused abdominal sonography for trauma (FAST) in children: is it useful? J Pediatr Surg 1999; 34:48-52; discussion 52-4. [PMID: 10022142 DOI: 10.1016/s0022-3468(99)90227-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND/PURPOSE Most pediatric surgeons and pediatric radiologists consider computed tomography (CT) the best radiological test for the evaluation of children with suspected intraabdominal injury. The majority of injured children evaluated with CT will be found to have a normal scan. Focused abdominal sonography for trauma (FAST) has been shown to be a useful screening test in the evaluation of adult patients with suspected intraabdominal injury. Limited data exist regarding the use of FAST in children. Our aim was to evaluate the usefulness of FAST as a screening test in the evaluation of children with suspected intraabdominal injury in an attempt to minimize the number of normal CT scans performed. METHODS Hemodynamically stable children evaluated for suspected intraabdominal injury were prospectively screened with FAST. FAST, real-time sonography at four sites, was performed by staff pediatric radiologists. The average duration of the examination was 2 minutes. Positive and negative FAST scan findings were defined prospectively. The result of each FAST was recorded (positive or negative) and then all patients underwent CT as a control. All management decisions were based on CT results. RESULTS Forty-six patients were included in the study. FAST identified four children with positive findings (free intraperitoneal fluid), whereas CT showed 13 children with injuries (nine with associated free intraperitoneal fluid and four with only solid organ injury and no associated intraperitoneal fluid). There were nine false-negative and no false-positive FAST scans. The sensitivity of FAST was 0.3 and the specificity was 1.0. Injuries missed by FAST included liver laceration, adrenal hematoma, renal laceration, small bowel injury and splenic laceration. CONCLUSION Preliminary results suggest that FAST alone is not a useful screening test in the evaluation of children with suspected intraabdominal injury.
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Affiliation(s)
- K H Mutabagani
- Department of Pediatric Surgery, The Ohio State University College of Medicine and Public Health and Children's Hospital, Columbus, USA
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34
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Rozycki GS, Ochsner MG, Feliciano DV, Thomas B, Boulanger BR, Davis FE, Falcone RE, Schmidt JA. Early detection of hemoperitoneum by ultrasound examination of the right upper quadrant: a multicenter study. THE JOURNAL OF TRAUMA 1998; 45:878-83. [PMID: 9820696 DOI: 10.1097/00005373-199811000-00006] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The focused assessment for the sonographic examination of the trauma patient (FAST) is a rapid diagnostic test that sequentially surveys for hemopericardium and then the right upper quadrant (RUQ), left upper quadrant (LUQ), and pelvis for hemoperitoneum in patients with potential truncal injuries. The sequence of the abdominal part of the examination, however, has yet to be validated. The objectives of this multicenter study were as follows: (1) to determine where hemoperitoneum is most frequently identified on positive FAST examinations; and (2) to determine if a relationship exists between that areas and the organs injured. METHODS Ultrasound registries from four Level I trauma centers identified patients who had true-positive FAST examinations. Demographic data, areas positive on the FAST, and organs injured were recorded; injuries were classified as multiple, single solid organ (liver or spleen), isolated hollow viscus, or retroperitoneal. Relationships between positive locations on the FAST examinations and the associations of organs injured to areas positive were assessed using McNamara's chi2 test; a p value < 0.05 was considered statistically significant. RESULTS The RUQ was the most common site where hemoperitoneum was detected, and this was statistically significant compared with either the LUQ or the pelvis. Also, statistically significant correlations (p < 0.001) were observed between positive RUQ areas on the FAST and multiple injuries, single solid organ (liver or spleen) injury, and retroperitoneal injuries. CONCLUSION Blood is most often found on the FAST in the RUQ area in patients with multiple intraperitoneal injuries or isolated injury to the liver, spleen, or retroperitoneum, but not when there is injury to a hollow viscus.
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Affiliation(s)
- G S Rozycki
- Department of Trauma/Surgical Critical Care, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia 30303, USA
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Fernandez L, McKenney MG, McKenney KL, Cohn SM, Feinstein A, Senkowski C, Compton RP, Nunez D. Ultrasound in blunt abdominal trauma. THE JOURNAL OF TRAUMA 1998; 45:841-8. [PMID: 9783637 DOI: 10.1097/00005373-199810000-00047] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- L Fernandez
- Department of Surgery, University of Miami School of Medicine, Veterans Administration Medical Centers, Florida, USA
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36
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Boulanger BR, Brenneman FD, Kirkpatrick AW, McLellan BA, Nathens AB. The indeterminate abdominal sonogram in multisystem blunt trauma. THE JOURNAL OF TRAUMA 1998; 45:52-6. [PMID: 9680012 DOI: 10.1097/00005373-199807000-00011] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND North American trauma centers are beginning to note the limitations of emergent torso sonography. The purpose of this prospective study was to evaluate the frequency, causes, associations, and sequelae of indeterminate (IND) sonograms in blunt trauma. METHODS Among adult blunt trauma patients assessed with screening torso sonography, clinician sonographers recorded the abdominal sonogram as positive, negative, or IND for free fluid. Patients with IND sonograms were further investigated with repeat sonography, computed tomography, or diagnostic peritoneal lavage. RESULTS Among 417 patients with blunt trauma (mean Injury Severity Score = 21) managed with sonography, there were 28 (6.7%) IND and 389 (93.3%) non-IND sonograms. Sonograms were IND because of patient factors in 71% (20 of 28) and because of operator factors in 29% (8 of 28). None of the 28 patients were managed with repeat sonography alone. All 4 diagnostic peritoneal lavage examinations gave negative results, whereas 8 of 23 computed tomographic scans were abnormal (6 of 8 patients underwent laparotomy). The mean time required for diagnostic workup was 117 minutes in the IND group and 48 minutes in the non-IND group (p < 0.001 in both cases). CONCLUSION This prospective study has demonstrated that IND sonograms are not common at our center (6.7%), are usually attributable to patient factors, and are associated with greater diagnostic time. Patients with IND sonograms require further investigation because they often have injuries requiring laparotomy.
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Affiliation(s)
- B R Boulanger
- Department of Surgery, Sunnybrook Health Science Centre, University of Toronto, Ontario, Canada
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37
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Partrick DA, Bensard DD, Moore EE, Terry SJ, Karrer FM. Ultrasound is an effective triage tool to evaluate blunt abdominal trauma in the pediatric population. THE JOURNAL OF TRAUMA 1998; 45:57-63. [PMID: 9680013 DOI: 10.1097/00005373-199807000-00012] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although computed tomography has been considered the diagnostic modality of choice for pediatric patients with blunt abdominal trauma (BAT), it is costly, time-consuming, requires sedation, and may be associated with complications in young children. Abdominal ultrasonography (US) is a promising modality in the evaluation of BAT that is quick, noninvasive, repeatable, and cost-effective. We hypothesized that emergency department US, performed by trauma surgeons, is a useful triage tool for pediatric BAT that reduces the need for computed tomography. METHODS The 230 children (<18 years old) with suspected BAT were initially evaluated with US in the emergency department by surgeons. Subsequent computed tomographic scan or exploratory laparotomy was performed as indicated by the key clinical pathway. RESULTS Twelve children (5.2%) had documented intra-abdominal injuries. All five injured children with significant intraperitoneal fluid were identified by US. Of the seven patients who had intra-abdominal injury not detected by US, six sustained solid organ injuries that were managed nonoperatively. Extrapolated reductions in hospital charges due to the decreased number of computed tomographic scans total $130,000. CONCLUSIONS Using US as a triage tool may dramatically reduce the cost of pediatric BAT evaluation while being able to quickly identify significant intraperitoneal fluid that requires further evaluation and possible laparotomy.
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Affiliation(s)
- D A Partrick
- Department of Surgery, Denver Health Medical Center, University of Colorado Health Sciences Center, 80204, USA
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38
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Abstract
Diagnostic medical ultrasound may have a brief history, but its roots date back to the early nineteenth century. From its modest beginnings in military institutions where ultrasound was used to examine pathologic specimens, to the routine evaluation of the fetus, injured patients, and those with cerebrovascular disease, ultrasound has secured a position as a key diagnostic test both currently and in the future. Its ability to diagnose valvular and congenital heart disease has reduced the need for invasive cardiac angiography with its attendant risks. Furthermore, endoluminal, transvaginal, transrectal, and transesophageal ultrasound have expanded physicians' diagnostic armamentarium and ability to "look inside" their patients. Notwithstanding all these advancements, ultrasound research and development continue to be fostered, and the ideas of today will be the technology of tomorrow (Fig. 5).
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Affiliation(s)
- P G Newman
- Department of Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
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39
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Thourani VH, Pettitt BJ, Schmidt JA, Cooper WA, Rozycki GS. Validation of surgeon-performed emergency abdominal ultrasonography in pediatric trauma patients. J Pediatr Surg 1998; 33:322-8. [PMID: 9498410 DOI: 10.1016/s0022-3468(98)90455-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND/PURPOSE The focused assessment for the sonographic evaluation of trauma patients (FAST) in adults is effective in detecting intraperitoneal and intrapericardial fluid and can be performed quickly by surgeons in the emergency department (ED). The authors sought to validate the accuracy of FAST performed by surgeons during ED resuscitation of pediatric trauma patients. METHODS Patients were assigned to one of three groups based on standard clinical criteria: immediate surgery, abdominal computed tomography (CT), or observation alone. FAST was then performed in the ED by a surgery resident (postgraduate year 3 or higher) or an attending trauma surgeon. Four views were used to assess the possible presence of fluid in the pericardial, subphrenic, subhepatic, and pelvic spaces. Time needed to conduct FAST was noted. Presence of peritoneal or pericardial fluid by FAST was compared with that determined by CT or surgery. Sensitivity, specificity, and predictive values were calculated. For those who did not undergo CT or surgery, FAST findings were compared with the clinical course. RESULTS Technically adequate studies could be performed on 192 of 196 eligible children. Their ages ranged from 3 months to 14 years (mean, 6.9 years); 119 were boys (62%), and 188 (98%) had sustained a blunt injury. FAST was performed in a mean time of 3.9 minutes (range, 1-17 minutes). All FAST examinations were reviewed by our senior surgeon-sonographer (GSR). Interrater agreement between the performing and reviewing surgeon-sonographer was 100%. Sixty (31%) patients underwent either abdominal CT (n = 56; mean Injury Severity Score (ISS), 9.6) or immediate operation (n = 4; mean ISS, 18.8). Of the 10 patients with verified presence of intraperitoneal fluid, eight had positive and two had false-negative FAST examination results. Of the 50 patients with verified absence of intraperitoneal fluid, none had a positive FAST (ie, no false-positives); sensitivity was 80%; specificity, 100%; predictive value positive, 100%; predictive value negative, 96%. None of the 132 patients followed up clinically without CT or surgery (mean ISS, 4.5) had fluid documented by FAST, and all did well. CONCLUSIONS The focused assessment for the sonographic evaluation of pediatric blunt trauma patients performed by surgical residents and attendings in the ED rapidly and accurately predicted the presence or absence of intraperitoneal fluid. The FAST is a potentially valuable tool to rapidly prioritize the need for laparotomy in the child with multiple injuries and extraabdominal sources of bleeding.
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Affiliation(s)
- V H Thourani
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30303, USA
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40
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Vincent EC, Scott RH. Surgical Problems of the Digestive System. Fam Med 1998. [DOI: 10.1007/978-1-4757-2947-4_93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sherbourne CD, Shanmuganathan K, Mirvis SE, Chiu WC, Rodriguez A. Visceral injury without hemoperitoneum: A limitation of screening abdominal sonography for trauma. Emerg Radiol 1997. [DOI: 10.1007/bf01451070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
This article focuses on some general principles of care and then discusses devastating pelvic injury secondary to both blunt and penetrating trauma. The authors describe the current approach to the mangled extremity and discuss indications for primary amputation.
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Affiliation(s)
- S M Henry
- Department of Emergency Medicine, SUNY, Health Science Center at Brooklyn, USA
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43
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Abstract
Some of the earliest damage control techniques were applied to the chest during emergency center thoracotomy. It provided a paradigm that was adapted to other areas. Damage control of chest injuries has a different philosophy than that of abdominal injuries. Damage control in the abdomen primarily consists of multiple staged operations with abbreviated closures. Damage control in the chest consists of different technical maneuvers to use quicker and technically less demanding operations to accomplish the same goal. The philosophy of doing only enough to restore a survivable physiology is still a common theme. The following are the major principles of damage control for thoracic injuries: 1. Emergency center thoracotomy is a damage control prototype. 2. Anterolateral thoracotomy is the empiric incision of choice in the patient in extremis. 3. Nonanatomically stapled lung resections, pulmonary tractotomy, and en masse lobectomy/pneumonectomy are pulmonary damage control procedures. 4. The unique physiology of the chest may require en masse closure of muscles or patch closure of the wound. 5. Cardiopulmonary physiology can be affected by packing. Packing thus has a limited role in thoracic damage control. 6. Prosthetic grafts, intravascular shunts, and ligation are common thoracic vascular damage control techniques. 7. With new technology, an increased role for cardiopulmonary bypass and cardiac assistance may develop. 8. New technology must not overly complicate a procedure if it is to be a valuable damage control adjunct.
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Affiliation(s)
- M J Wall
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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Kraut EJ, Owings JT, Anderson JT, Hanowell L, Moore P. Right ventricular volumes overestimate left ventricular preload in critically ill patients. THE JOURNAL OF TRAUMA 1997; 42:839-45; discussion 845-6. [PMID: 9191665 DOI: 10.1097/00005373-199705000-00014] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Studies have shown right ventricular end-diastolic volume (RVEDV) to be a more accurate estimate of left ventricular preload than pulmonary artery wedge pressure. We prospectively evaluated the ability of RVEDV to predict left ventricular end-diastolic volume (LVEDV) in critically ill patients. METHODS Thirty critically ill patients in the surgical intensive care unit underwent concurrent measurement of RVEDV and LVEDV. RVEDV was measured using a residual fraction Swan-Ganz catheter (RF Swan). LVEDV was measured using transesophageal echocardiography with acoustic quantification. Intracardiac, intra-abdominal, and ventilatory pressures were also measured. RESULTS RVEDV as measured by the RF Swan was significantly larger (by a factor of 2) than LVEDV (p < 0.0001 analysis of variance). However, the RVEDV and LVEDV were strongly correlated (r = 0.71, p < 0.0001, Pearson's correlation). CONCLUSIONS RVEDV from the RF Swan markedly overestimated left ventricular preload. If RVEDV is used as an absolute value for determining preload, patients may be underresuscitated. Transesophageal echocardiography in conjunction with RF Swan can be used to more accurately determine preload and cardiac performance than RF Swan alone in critically ill patients.
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Affiliation(s)
- E J Kraut
- Department of Surgery, University of California, Davis Medical Center, Sacramento 95817-2214, USA
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45
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Akgür FM, Aktuğ T, Olguner M, Kovanlikaya A, Hakgüder G. Prospective study investigating routine usage of ultrasonography as the initial diagnostic modality for the evaluation of children sustaining blunt abdominal trauma. THE JOURNAL OF TRAUMA 1997; 42:626-8. [PMID: 9137248 DOI: 10.1097/00005373-199704000-00007] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In this prospective study, 217 children sustaining blunt abdominal trauma were initially evaluated with ultrasonography (US) and those with any abnormal ultrasonographic findings were further evaluated with computed tomography. Results of ultrasonographic examination were normal in 157 children and showed abnormalities such as free intraperitoneal fluid (FIF), intra-abdominal organ injury, and intrapleural fluid in 60 children. Computed tomographic examination of the 42 children with organ injury, the seven children with minimal FIF of no definite source, and the three children with intrapleural fluid revealed findings consistent with ultrasonographic findings. Computed tomographic examination of the eight children with more than minimal FIF of no definite source detected by US showed the source as liver injury in one and spleen injuries in two patients. The source of FIF could not be identified with computed tomography in five patients. After clinic follow-up examination, one of these five patients was operated on for abdominal tenderness, fever, and air-fluid levels detected on plain abdominal radiographs, and duodenal perforation was encountered. Clinical courses of the patients with normal ultrasonographic findings were uneventful. We conclude that US, aside from being a screening tool, is alone sufficient in the evaluation of the majority of the children sustaining blunt abdominal trauma. Although this is a preliminary study with further work needed to be done, we propose that further evaluation with computed tomography should be performed on those children in whom more than minimal FIF of no definite source is detected with US.
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Affiliation(s)
- F M Akgür
- Department of Pediatric Surgery, Dokuz Eylül University, Medical Faculty, Izmir, Turkey.
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46
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Nordenholz KE, Rubin MA, Gularte GG, Liang HK. Ultrasound in the evaluation and management of blunt abdominal trauma. Ann Emerg Med 1997; 29:357-66. [PMID: 9055775 DOI: 10.1016/s0196-0644(97)70348-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Failure to detect intraabdominal injury in the patient with blunt trauma may result in significant morbidity and mortality. The diagnosis of abdominal injury remains a clinical challenge. Presented here is a review of recent literature comparing ultrasound with diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma.
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Affiliation(s)
- K E Nordenholz
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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47
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Tandy TK, Hoffenberg S. Emergency department ultrasound services by emergency physicians: model for gaining hospital approval. Ann Emerg Med 1997; 29:367-74. [PMID: 9055776 DOI: 10.1016/s0196-0644(97)70349-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We anticipate that over the next few years, emergency physician use of emergency department ultrasound will become the standard of care. However, many EDs are hampered in their efforts to gain hospital approval for emergency physician use of ultrasound because of the lack of publicized information regarding the goals of such use, the scope of emergency physician ultrasound privileges, emergency physician ultrasound credentialing criteria, and ED ultrasound quality-improvement plans. In this article we address these issues and provide an example of a proposal used successfully to gain hospital approval for ED use of ultrasound by emergency physicians.
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Affiliation(s)
- T K Tandy
- Department of Emergency Medicine, Naval Medical Center, Portsmouth, Virginia, USA
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48
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Wherrett LJ, Boulanger BR, McLellan BA, Brenneman FD, Rizoli SB, Culhane J, Hamilton P. Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage. THE JOURNAL OF TRAUMA 1996; 41:815-820. [PMID: 8913209 DOI: 10.1097/00005373-199611000-00008] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Trauma victims with hypotension require a rapid and reliable localization of bleeding and expedient surgical triage. Our hypothesis is that emergent abdominal sonography (EAS) is a rapid and accurate test of the need for urgent laparotomy in blunt trauma victims with hypotension. METHODS Among 400 blunt trauma victims entered in a prospective blind study of EAS, a subgroup of 69 (17%) patients had a systolic blood pressure < or = 90 mm Hg during their initial assessment. Although the EAS results [(+) = fluid, (-) = no fluid] were not used in clinical decision making, the potential contribution of EAS to patient care was examined. RESULTS The mean Injury Severity Score was 32. Twenty-two (32%) patients were EAS (+), of which 19 required an acute laparotomy. No laparotomies were performed in the 47 EAS (-) patients. The EASs required 19 +/- 5 seconds in the EAS (+) group and 154 +/- 13 seconds in the EAS (-) group. Twenty of the 22 positive EASs had free fluid in Morison's pouch. All 13 patients with an ultrasound score > or = 3 had a laparotomy. The primary etiology of hypotension was blood loss in 42 patients, hemoperitoneum in 18, and retroperitoneal hemorrhage in 12. CONCLUSION EAS is a rapid and accurate indicator of the need for urgent laparotomy in the hypotensive blunt trauma victim. Further, a negative EAS can hasten the search for other causes of hypotension. Diagnostic peritoneal lavage may become obsolete in centers with EAS capabilities.
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Affiliation(s)
- L J Wherrett
- Department of Surgery, Sunnybrook Health Science Centre, University of Toronto, Ontario, Canada
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Boulanger BR, McLellan BA, Brenneman FD, Wherrett L, Rizoli SB, Culhane J, Hamilton P. Emergent abdominal sonography as a screening test in a new diagnostic algorithm for blunt trauma. THE JOURNAL OF TRAUMA 1996; 40:867-74. [PMID: 8656471 DOI: 10.1097/00005373-199606000-00003] [Citation(s) in RCA: 126] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Although there is an interest in emergent abdominal sonography (EAS), the clinical utilization of EAS in North America is minimal. The purpose of this study was to develop a new diagnostic algorithm for blunt abdominal injury based on a prospective blinded comparison of EAS, diagnostic peritoneal lavage (DPL), and computed tomography (CT). EAS (+ = fluid, - = no fluid) was performed before the DPL or CT, in 400 patients with a mean Injury Severity Score of 26; 293 had a CT and 107 had a DPL. The EASs required 2.6 +/- 1.2 minutes with 82% < or = 3 minutes. The accuracy of EAS for free fluid was 94% with a positive and negative predictive value of 82 and 96%, respectively. Only 1 of 338 patients with EAS- had an acute therapeutic laparotomy. Three patients with EAS- had a delayed laparotomy based on evolving clinical findings. The radiologists interpretation of the EAS video disagreed with the clinician sonographer in only 3% of cases. Based on these results, a diagnostic algorithm was developed using EAS as a screening test with selective use of DPL and CT. Emergent abdominal sonography performed by clinician sonographers is a rapid and accurate test for peritoneal fluid in blunt trauma victims, and the need for laparotomy in patients with a negative EAS is rare. Our study supports the routine use of EAS as a screening test in a diagnostic algorithm for the evaluation of blunt abdominal trauma.
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Affiliation(s)
- B R Boulanger
- Department of Surgery, University of Toronto, Canada
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Rozycki GS, Feliciano DV, Schmidt JA, Cushman JG, Sisley AC, Ingram W, Ansley JD. The role of surgeon-performed ultrasound in patients with possible cardiac wounds. Ann Surg 1996; 223:737-44; discussion 744-6. [PMID: 8645047 PMCID: PMC1235223 DOI: 10.1097/00000658-199606000-00012] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The authors evaluate surgeon-performed ultrasound in determining the need for operation in patients with possible cardiac wounds. BACKGROUND DATA Ultrasound quickly is becoming part of the surgeon's diagnostic armamentarium; however, its role for the patient with penetrating injury is less well-defined. Although accurate for the detection of hemopericardium, the lack of immediate availability of the cardiologist to perform the test may delay the diagnosis, adversely affecting patient outcome. To be an effective diagnostic test in trauma centers, ultrasound must be immediately available in the resuscitation area and performed and interpreted by surgeons. METHODS Surgeons performed pericardial ultrasound examinations on patients with penetrating truncal wounds but no immediate indication for operation. The subcostal view detected hemopericardium, and patients with positive examinations underwent immediate operation by the same surgeon. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded. RESULTS During 13 months, 247 patients had surgeon-performed ultrasound. There were 236 true-negative and 10 true-positive results, and no false-negative or false-positive results; however, the pericardial region could not be visualized in one patient. Sensitivity, specificity, and accuracy were 100%; mean examination time was 0.8 minute (246 patients). Of the ten true-positive examinations, three were hypotensive. The mean time (8 patients) from ultrasound to operation was 12.1 minutes; all survived. Operative findings (site of cardiac wounds) were: left ventricle (4), right ventricle (3), right atrium (2), right atrium/superior vena cava (1), and right atrium/inferior vena cava (1). CONCLUSIONS Surgeon-performed ultrasound is a rapid and accurate technique for diagnosing hemopericardium. Delay times from admission to operating room are minimized when the surgeon performs the ultrasound examination.
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Affiliation(s)
- G S Rozycki
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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