A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment

Is it worth trying? A cross-sectional study on the implementation of point-of-care ultrasound in Hungarian primary care

BACKGROUND

Although the number of point-of-care ultrasound devices available in Hungarian primary care practices are increasing due to government funding, their use in day-to-day patient care is limited and unregulated. Our study aimed to evaluate the attitudes and needs of general practitioners (GPs) and patients in Hungary regarding the introduction of bedside ultrasonography in primary care practices.

METHODS

As a part of a cross-sectional study, an anonymous, self-administered questionnaire was distributed to GPs and patients on a social media platform. Data collection was carried out from August 2023 to October 2023. Chi-square test was used to determine the associations between categorical variables.

RESULTS

The survey was completed by 415 GPs (mean age 53.8 ± 11.1 years, 54.9% female, mean 19.5 ± 11.9 years of practice) and 693 patients (mean age 45.5 ± 12.3 years, 95.2% female). There was a statistically significant increase in interest in PoCUS among young and middle-aged GPs (age 28-59; p = 0.02). In addition, this population of GPs was also more likely to undertake training in PoCUS than their older colleagues (p < 0.0001). An inverse relationship was found between the duration of practice and training willingness (p = 0.0011). Even with the government's financial support, only 8.2% of GPs currently use PoCUS in a daily basis, and 59.5% of GPs are unfamiliar with the indications and the ways of using it. Patients would even pay to have the examination done in a primary care setting, even though only 45.9% of patients would pay a GP who is not certified in PoCUS, but the willingness to pay increased to 99.4% for those with formal training (p = 0.024).

CONCLUSION

Our findings indicate a significant interest in adapting PoCUS in primary care from both GPs and patients. Based on the fact that a significant proportion of Hungarian GPs are unaware of PoCUS and its indications, it is particularly important to develop educational frameworks, and practical guidelines for the effective incorporation of PoCUS in Hungary.

An extended focused assessment with sonography in trauma ultrasound tissue-mimicking phantom for developing automated diagnostic technologies

Introduction: Medical imaging-based triage is critical for ensuring medical treatment is timely and prioritized. However, without proper image collection and interpretation, triage decisions can be hard to make. While automation approaches can enhance these triage applications, tissue phantoms must be developed to train and mature these novel technologies. Here, we have developed a tissue phantom modeling the ultrasound views imaged during the enhanced focused assessment with sonography in trauma exam (eFAST). Methods: The tissue phantom utilized synthetic clear ballistic gel with carveouts in the abdomen and rib cage corresponding to the various eFAST scan points. Various approaches were taken to simulate proper physiology without injuries present or to mimic pneumothorax, hemothorax, or abdominal hemorrhage at multiple locations in the torso. Multiple ultrasound imaging systems were used to acquire ultrasound scans with or without injury present and were used to train deep learning image classification predictive models. Results: Performance of the artificial intelligent (AI) models trained in this study achieved over 97% accuracy for each eFAST scan site. We used a previously trained AI model for pneumothorax which achieved 74% accuracy in blind predictions for images collected with the novel eFAST tissue phantom. Grad-CAM heat map overlays for the predictions identified that the AI models were tracking the area of interest for each scan point in the tissue phantom. Discussion: Overall, the eFAST tissue phantom ultrasound scans resembled human images and were successful in training AI models. Tissue phantoms are critical first steps in troubleshooting and developing medical imaging automation technologies for this application that can accelerate the widespread use of ultrasound imaging for emergency triage.

Automated detection and localization of pericardial effusion from point-of-care cardiac ultrasound examination

Focused Assessment with Sonography in Trauma (FAST) exam is the standard of care for pericardial and abdominal free fluid detection in emergency medicine. Despite its life saving potential, FAST is underutilized due to requiring clinicians with appropriate training and practice. To aid ultrasound interpretation, the role of artificial intelligence has been studied, while leaving room for improvement in localization information and computation time. The purpose of this study was to develop and test a deep learning approach to rapidly and accurately identify both the presence and location of pericardial effusion on point-of-care ultrasound (POCUS) exams. Each cardiac POCUS exam is analyzed image-by-image via the state-of-the-art YoloV3 algorithm and pericardial effusion presence is determined from the most confident detection. We evaluate our approach over a dataset of POCUS exams (cardiac component of FAST and ultrasound), comprising 37 cases with pericardial effusion and 39 negative controls. Our algorithm attains 92% specificity and 89% sensitivity in pericardial effusion identification, outperforming existing deep learning approaches, and localizes pericardial effusion by 51% Intersection Over Union with ground-truth annotations. Moreover, image processing demonstrates only 57 ms latency. Experimental results demonstrate the feasibility of rapid and accurate pericardial effusion detection from POCUS exams for physician overread.

Advances in the Management of Coagulopathy in Trauma: The Role of Viscoelastic Hemostatic Assays across All Phases of Trauma Care

Uncontrolled bleeding is the leading cause of preventable death following injury. Trauma-induced coagulopathy can manifest as diverse phenotypes ranging from hypocoagulability to hypercoagulability, which can change quickly during the acute phase of trauma care. The major advances in understanding coagulation over the past 25 years have resulted from the cell-based concept, emphasizing the key role of platelets and their interaction with the damaged endothelium. Consequently, conventional plasma-based coagulation testing is not accurate in predicting bleeding and does not provide an assessment of which blood products are indicated. Viscoelastic hemostatic assays (VHA), conducted in whole blood, have emerged as a superior method to guide goal-directed transfusion. The major change in resuscitation has been the shift from unbridled crystalloid loading to judicious balanced blood product administration. Furthermore, the recognition of the rapid changes from hypocoagulability to hypercoagulability has underscored the importance of ongoing surveillance beyond emergent surgery. While the benefits of VHA testing are maximized when used as early as possible, current technology limits use in the pre-hospital setting and the time to results compromises its utility in the emergency department. Thus, most of the reported experience with VHA in trauma is in the operating room and intensive care unit, where there is compelling data to support its value. This overview will address the current and potential role of VHA in the seriously injured patient, throughout the continuum of trauma management.

Deep Learning Assisted Detection of Abdominal Free Fluid in Morison's Pouch During Focused Assessment With Sonography in Trauma

Background: The use of focused assessment with sonography in trauma (FAST) enables clinicians to rapidly screen for injury at the bedsides of patients. Pre-hospital FAST improves diagnostic accuracy and streamlines patient care, leading to dispositions to appropriate treatment centers. In this study, we determine the accuracy of artificial intelligence model-assisted free-fluid detection in FAST examinations, and subsequently establish an automated feedback system, which can help inexperienced sonographers improve their interpretation ability and image acquisition skills.

Methods: This is a single-center study of patients admitted to the emergency room from January 2020 to March 2021. We collected 324 patient records for the training model, 36 patient records for validation, and another 36 patient records for testing. We balanced positive and negative Morison's pouch free-fluid detection groups in a 1:1 ratio. The deep learning (DL) model Residual Networks 50-Version 2 (ResNet50-V2) was used for training and validation.

Results: The accuracy, sensitivity, and specificity of the model performance for ascites prediction were 0.961, 0.976, and 0.947, respectively, in the validation set and 0.967, 0.985, and 0.913, respectively, in the test set. Regarding feedback prediction, the model correctly classified qualified and non-qualified images with an accuracy of 0.941 in both the validation and test sets.

Conclusions: The DL algorithm in ResNet50-V2 is able to detect free fluid in Morison's pouch with high accuracy. The automated feedback and instruction system could help inexperienced sonographers improve their interpretation ability and image acquisition skills.

Abdominal ultrasound augments the medical students' ability to identify free intraabdominal fluid

OBJECTIVE

Free intra-abdominal fluid describes an accumulation of free fluid in the peritoneal cavity. It has different etiologies, but it frequently constitutes a meaningful clinical sign. In this study, the authors interrogate whether abdominal ultrasound augments the medical students' ability to identify free intra-abdominal fluid.

METHODS

Thirty-one medical students without any previous formal ultrasound training were subjected to cognitive assessment before and after four and a half-hour of theoretical lecture and hands-on course about the diagnosis of free intra-abdominal fluid by physical examination and abdominal ultrasound. The hands-on sessions were done in healthy volunteers with a simulated peritoneal catheter and in patients treated with peritoneal dialysis with different amounts of dialysate in their cavity.

RESULTS

The cognitive assessment before and after the course increased from 6.7±2.3 to 11.6±1.1 points (p<0.0001). The sensitivity, specificity, and accuracy in the diagnosis of free intra-abdominal fluid were higher when students used abdominal ultrasound. The students agree with the inclusion of abdominal ultrasound in the diagnose of free intra-abdominal fluid in the undergraduate curriculum.

CONCLUSIONS

This study demonstrates that incorporating abdominal ultrasound is feasible and improves medical students' short-time competency in performing and interpreting the findings diagnostic of free intra-abdominal fluid.

The expected frequency and amount of free peritoneal fluid estimated using the abdominal FAST-applied abdominal fluid scores in healthy adult and juvenile dogs

OBJECTIVE

To estimate the frequency and amount of free peritoneal fluid in juvenile and adult dogs using the abdominal focused assessment with sonography for trauma (AFAST) abdominal fluid scoring system.

DESIGN

Prospective case series.

ANIMALS

Healthy, privately owned juvenile and adult dogs.

PROCEDURES

Dogs undergoing routine surgical sterilization were evaluated at induction with AFAST and assigned measurements and fluid scores. A surgeon scored the degree of peritoneal fluid found during ovariohysterectomy.

RESULTS

Ninety-two dogs were enrolled (46 juveniles and 46 adults). Ninety-three percent and 52% were AFAST positive for peritoneal fluid, respectively. The AFAST-positive view frequency for right lateral recumbency in juveniles was diaphragmatico-hepatic (DH) 100%, spleno-renal (SR) 20%, cysto-colic (CC) 40%, and hepato-renal (HR) 20% versus adults, DH 60%, SR 20%, CC 0%, and HR 0%, respectively. The AFAST-positive view frequency for left lateral recumbency was DH 93%, SR 44%, CC 24%, and HR 12% in juveniles, and DH 50%, SR 3%, CC 3%, and HR 10% in adults. Overall abdominal fluid scores (AFS) in juvenilles were 0 (n = 3), 1 (n = 14), 2 (n = 22), 3 (n = 6), and 4 (n = 1); and in adults, scores were 0 (n = 22), 1 (n = 18), 2 (n = 6), and 3 and 4 (n = 0). The AFS differed between adults and juveniles (P < 0.001). Most dogs had maximum fluid dimensions ≤3 × 3 mm and width of fluid stripes ≤3 mm. The AFS was positively correlated to fluid amount observed during ovariohysterectomy with fair agreement (kappa = 0.233, P = 0.012).

CONCLUSIONS AND CLINICAL RELEVANCE

This study establishes the frequency and amount of free peritoneal fluid in healthy juvenile and adult dogs during AFAST. Maximum fluid pocket dimensions of ≤3 × 3 mm and fluid stripe widths of ≤3 mm in dogs with AFS 1 and 2 may be normal. The DH view was most frequently positive.

Flat Inferior Vena Cava: Indicator of Poor Prognosis in Trauma and Acute Care Surgery Patients

Flat inferior vena cava (IVC) on ultrasound examination has been shown to correlate with hypovolemic status. We hypothesize that a flat IVC on limited echocardiogram (LTTE) performed in the emergency room (ER) correlates with poor prognosis in acutely ill surgical patients. We conducted a retrospective review of all patients undergoing LTTE in the ER from September 2010 until June 2011. IVC diameter was estimated by subxiphoid window. Flat IVC was defined as diameter less than 2 cm. Fat IVC was defined as diameter greater than 2 cm. Need for intensive care unit admission, blood transfusion requirement, mortality, and need for emergent operation between patients with flat versus Fat IVC were compared. One hundred one hypotensive patients had LTTE performed in the ER. Average age was 38 years. Admission diagnosis was blunt trauma (n = 80), penetrating trauma (n = 13), acute care surgery pathology (n = 7), and burn (n = 1). Seventy-four patients had flat IVC on initial LTTE. Compared with those with fat IVC, flat patients were found have higher rates of intensive care unit admission (51.3 vs 14.8%; P = 0.001), blood transfusion requirement (12.2 vs 3.7%), and mortality (13.5 vs 3.7%). This population also underwent emergent surgery on hospital Day 1 more often (16.2 vs 0%; P = 0.033). Initial flat IVC on LTTE is an indicator of hypovolemia and a predictor of poor outcome.

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

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

The Use of Ultrasonography in the Emergency Department to Screen Patients After Blunt and Penetrating Trauma: A Clinical Update for the Advanced Practice Provider

Use of bedside ultrasonography to identify life-threatening injuries for patients with blunt and penetrating trauma is the standard of care in the emergency department. The "FAST" examination-focused assessment with sonography for trauma-ultrasound scan of the chest and abdomen allows clinicians to assess critical regions for free fluid without use of invasive procedures as quickly and as often as needed. In addition, ultrasonography has a high degree of sensitivity and specificity and is safe during pregnancy. For patients requiring evaluation of the pleura, the "eFAST" (or extended FAST) may be conducted, which may serve to locate pleural effusions, hemothorax, and pneumothorax. However, ultrasound quality is operator dependent and is recommended with other diagnostic measures to provide a complete clinical picture of trauma patients. Ongoing development of ultrasound competency among established clinicians and nurse practitioner students is vital to maintain diagnostic accuracy and ensure quality care for trauma patients in the emergency department.

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

BACKGROUND

Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children.

METHODS

Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document.

RESULTS

Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C).

CONCLUSIONS

Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

Modern Management of Bleeding, Clotting, and Coagulopathy in Trauma Patients: What Is the Role of Viscoelastic Assays?

Purpose of Review

The purpose of this review is to briefly outline the current state of hemorrhage control and resuscitation in trauma patients with a specific focus on the role viscoelastic assays have in this complex management, to include indications for use across all phases of care in the injured patient.

Recent Findings

Viscoelastic assay use to guide blood-product resuscitation in bleeding trauma patients can reduce mortality by up to 50%. Viscoelastic assays also reduce total blood products transfused, reduce ICU length of stay, and reduce costs. There are a large number of observational and retrospective studies evaluating viscoelastic assay use in the initial trauma resuscitation, but only one randomized control trial. There is a paucity of data evaluating use of viscoelastic assays in the operating room, post-operatively, and during ICU management in trauma patients, rendering their use in these settings extrapolative/speculative based on theory and data from other surgical disciplines and settings.

Summary

Both hypocoagulable and hypercoagulable states exist in trauma patients, and better indicate what therapy may be most appropriate. Further study is needed, particularly in the operating room and post-operative/ICU settings in trauma patients.

Emergency Focused Assessment with Sonography in Blunt Trauma Abdomen

Background:

Focused assessment with sonography in trauma (FAST) being a rapid noninvasive examination is used primarily to evaluate for the evidence of traumatic free fluid suggestive of injury in the peritoneal, pericardial, and pleural cavities. It is widely recognized as a mainstream emergency skill in the management of trauma.

Aim:

The aim of the study is to evaluate the accuracy of FAST in patients presenting with blunt abdominal trauma.

Methods:

Data were collected prospectively from FAST scans conducted in blunt trauma abdomen (BTA) patients. Positive and negative FAST scans were confirmed either with contrast-enhanced computed tomography (CECT) abdomen or with exploratory laparotomy, thus dividing it further into four groups, i.e., true-positive, false-positive, true-negative, and false-negative scans. After collecting the data, accuracy of FAST was calculated.

Results:

In this study, a total of 104 patients were included. The mean age was 38.17 years. Most common cause of BTA was road traffic accident. The overall sensitivity, specificity, and accuracy of FAST were 69.8%, 92.1%, and 80.8%, respectively.

Conclusion:

This study showed that FAST is of paramount importance in patients who are hemodynamically unstable as it has a high positive predictive value. However, a FAST-negative result should always be confirmed by other modalities.

Rapid Assessment of the Neonate With Sonography (RANS) Scan

The use of point-of-care sonography in clinical settings such as emergency medicine and intensive care units has increased, but adoption in neonatology has been slow. Unlike the focused assessment with sonography for trauma scan used in adults, a quick bedside scan to rapidly evaluate an acutely deteriorating neonate does not exist. The objective of our article is to introduce a focused bedside ultrasound scan that is easy to learn, rapidly performed, and relatively inexpensive.© 2018 by the American Institute of Ultrasound in Medicine.

Focused assessment with sonography in trauma (FAST) for the regional anesthesiologist and pain specialist

This article in our point-of-care ultrasound (PoCUS) series is dedicated to the role the focused assessment with sonography in trauma (FAST) exam plays for the regional anesthesiologist and pain specialists in the perioperative setting. The FAST exam is a well-established and extensively studied PoCUS exam in both surgical and emergency medicine literature with over 20 years demonstrating its benefit in identifying the presence of free fluid in the abdomen following trauma. However, only recently has the FAST exam been shown to be beneficial to the anesthesiologist in the perioperative setting as a means to identify the extravasation of free fluid into the abdomen from the hip joint following hip arthroscopy. In this article, we will describe how to obtain the basic FAST views (subcostal four-chamber view, perihepatic right upper quadrant view, perisplenic left upper quadrant view, and pelvic view in the longitudinal and short axis) as well as cover the relevant sonoanatomy. We will describe pathological findings seen with the FAST exam, primarily free fluid in the peritoneal space as well as in the pericardial sac. As is the case with any PoCUS skill, the application evolves with understanding and utilization by new clinical specialties. Although this article will provide clinical examples of where the FAST exam is beneficial to the regional anesthesiologist and pain specialist, it also serves as an introduction to this powerful PoCUS skill in order to encourage clinical practitioners to expand the application of the FAST exam within the scope of regional anesthesia and pain management practice.

The focused assessment with sonography in trauma (FAST) in hypotensive injured patients frequently fails to identify the need for laparotomy: a multi-institutional pragmatic study

Background

The ability of focused assessment with sonography for trauma (FAST) to detect clinically significant hemorrhage in hypotensive injured patients remains unclear. We sought to describe the sensitivity and specificity of FAST using findings at laparotomy as the confirmatory test.

Methods

Patients from the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study that had a systolic blood pressure < 90mm Hg and underwent FAST were analysed. Results were compared with findings at laparotomy. A therapeutic laparotomy (T-LAP) was defined as an abdominal operation within 6 hours in which a definitive procedure was performed. The sensitivity and specificity of FAST were calculated.

Results

The cohort included 317 patients that underwent FAST (108 positive, 209 negative). T-LAP was performed in 69% (n=75) of FAST(+) patients and 22% (n=48) of FAST(−) patients. FAST had a sensitivity of 62% and specificity of 83%.

Conclusions

In our multicenter cohort, 22% of FAST(−) patients underwent T-LAP within 6 hours of admission. In hypotensive patients with a negative FAST, clinicians should still maintain a high index of suspicion for significant abdominal hemorrhage.

Level of evidence

Level IV.

Veterinary-focused assessment with sonography for trauma-airway, breathing, circulation, disability and exposure: a prospective observational study in 64 canine trauma patients

OBJECTIVE

To describe the technique and findings of the 'veterinary focused assessment with sonography for trauma-airway, breathing, circulation, disability and exposure' protocol in dogs suffering from trauma.

MATERIALS AND METHODS

Prospective observational study on a new point-of-care ultrasound protocol on 64 dogs suffering from trauma and comparison of findings with radiology.

RESULTS

Comparison of the results of this new ultrasound protocol for trauma patients with radiography findings for pneumothorax, pleural effusion, alveolar-interstitial syndrome and abdominal effusion revealed positive agreement of 89, 83, 100 and 87% and negative agreement of 76, 83, 76 and 92%, respectively. Novel findings of the 'veterinary focused assessment with sonography for trauma-airway, breathing, circulation, disability and exposure' exam, which were not previously reported for dogs undergoing focused assessment with sonography for trauma, included alveolar-interstitial syndrome (suggestive of pulmonary contusions), diaphragmatic hernia, retroperitoneal effusion and tracheal injury. Our new technique may also help identify increased intracranial pressure via changes in optic nerve sheath diameter and haemodynamic instability through the evaluation of the caudal vena cava and cardiac function.

CLINICAL SIGNIFICANCE

The described ultrasound examination protocol can be rapidly performed on dogs suffering from trauma during resuscitation and it may detect injuries previously undetectable using other veterinary point-of-care ultrasound protocols.

The Benefit of Ultrasound in Deciding Between Tube Thoracostomy and Observative Management in Hemothorax Resulting from Blunt Chest Trauma

BACKGROUND

Hemothorax is most commonly resulted from a closed chest trauma, while a tube thoracostomy (TT) is usually the first procedure attempted to treat it. However, TT may lead to unexpected results and complications in some cases. The advantage of thoracic ultrasound (TUS) over a physical examination combined with chest radiograph (CXR) for diagnosing hemothorax¹ has been proposed previously. However, its benefits in terms of avoiding non-therapeutic TT have not yet been confirmed. Therefore, this study is aimed to evaluate the severity of hemothorax in blunt chest trauma patients by using TUS in order to avoid non-therapeutic TT in stable cases.

METHODS

The data from 46,036 consecutive patient visits to our trauma center over a four-year period were collected, and those with blunt chest trauma were identified. Patients who met any of the following criteria were excluded: transferred from another facility, with an abbreviated injury scale (AIS) score ≥ 2 for any region except the chest region, with a documented finding of tension pneumothorax or pneumothorax >10%, younger than 16 years old and with indications requiring any non-thoracic major operation. The decision to perform TT for those patients in the non-TUS group was made on the basis of CXR findings and clinical symptoms. The continuous data were analyzed by using the two-tailed Student's t test, and the discrete data were analyzed by Chi-square test.

RESULTS

A total of 84 patients met the criteria for inclusion in the final analysis, with TT having been performed on 42 (50%) of those patients. The mean volume of the drainage amount was 860 ml after TT. The TT drainage was less than 500 ml in 12 patients in the non-TUS group (40%), while none was less than 500 ml in the TUS group (p = 0.036, Fisher's exact test). In terms of the positive rate of subsequent effective TT, the sensitivity of TUS was 90% and the specificity was 100%. There were 3 patients with delayed hemothorax: 2 of the 58 (3.6%) in the non-TUS group and 1 of 26 (4.5%) in the TUS group (p > 0.05, Fisher's exact test). The hospital length of stay in the non-TUS group with non-therapeutic TT was significantly longer than in the TUS group without TT (8.2 vs. 5.4 days, p = 0.018). There were no other major complications or deaths in either group during the 90-day follow-up period.

CONCLUSION

In the case of blunt trauma, TUS can rapidly and accurately evaluate hemothorax to avoid TT in patients who may not benefit much from it. As a result, the rate of non-therapeutic TT can be decreased, and the influence on shortening hospital length of stay may be further evaluated with prospective controlled study.

Pre-hospital lung ultrasound for cardiac heart failure and COPD: is it worthwhile?

Background

Pre-hospital ultrasound is a new challenge and lung ultrasound could be an interesting opportunity in the pre-hospital medical service. The aim of our study was to evaluate the efficacy of lung ultrasound in out-of-hospital non-traumatic respiratory insufficiency.

Methods

We planned a case-controlled study in the ULSS 5 ovest vicentino area (Vicenza—Italy) enrolling subjects with severe dyspnea caused by cardiac heart failure or acute exacerbation of chronic obstructive pulmonary disease. We compared drugs administration, oxygen delivery, and laboratory tests between those patients with ultrasound integrated management and those without ultrasound.

Results

Pre-hospital lung ultrasound had a high specificity (94.4%) and sensitivity (100%) for the correct identification of alveolar interstitial syndrome using B lines, whereas the percentages obtained with pleural effusion were lower (83.3, 53.3%, respectively). The patients with ultrasound integrated management received a more appropriate pharmacological therapy (p 0.01), as well as non-invasive ventilation (CPAP) was used more frequently in those with an acute exacerbation of chronic obstructive pulmonary disease (p 0.011). Laboratory tests and blood gases analysis were not significant different between the two study groups. In a sub-analysis of the patients with an A profile, we observed a significant lower concentration of PCO₂ in those with an ultrasound integrated management (PCO₂: 42.62 vs 52.23 p 0.049). According with physicians’ opinion, pre-hospital lung ultrasound gave important information or changed the therapy in the 42.3% of cases, whereas it just confirmed physical examination in the 67.7% of cases.

Conclusions

Pre-hospital lung ultrasound is easy and feasible, and learning curve is rapid. Our study suggests that cardiac heart failure and acute exacerbation of chronic obstructive pulmonary disease can be considered two indications for pre-hospital ultrasound, and can improve the management of patient with acute respiratory insufficiency.

FAST in the deployed military setting

INTRODUCTION

Focused assessment with sonography in trauma (FAST) is historically an effective method of assessing the patient in the trauma bay in order to aid decision-making and optimise patient outcomes. However, in the UK civilian practice, the use of FAST may decline given a recent change in National Institute for Health and Care Excellence guidance as a result of improvement in CT availability and resuscitation techniques.

METHOD

In the Role 3 Medical Treatment Facility, Camp Bastion, 187 patients with trauma who received FAST in the trauma bay in 2014 were reviewed to determine the accuracy of FAST in the deployed environment.

RESULTS

The data demonstrates the sensitivity and specificity of FAST to be 75% and 99.3%, respectively.

CONCLUSIONS

This study demonstrates that FAST is accurate on operations. FAST is provided by the integrated radiologist as part of damage control radiology, which gives the team leader rapid diagnostic information to improve decision-making and ultimately patient outcomes. CT is heavily utilised in civilian practice; however, the military operates in a different environment often with multiple casualties and limited access to CT, as a result, portable ultrasound will continue to be a valuable tool on operations if used properly. The next challenge is to develop and maintain this high diagnostic accuracy in future deployments where the memories of our prior success may fade.

Use of Focused Assessment with Sonography in Trauma Examination Skills in the Evaluation of Non-trauma Patients

Study objectives

Although the focused assessment with sonography in trauma (FAST) examination was initially developed for rapid evaluation of trauma patients, the basic skillset required to perform a FAST examination provides valuable information that may alter a non-trauma patient’s clinical course. The objective of this study was to determine the utility of the FAST examination in the emergency department management of non-trauma patients.

Methods

Cases in which the FAST examination was used to direct care in non-trauma patients were retrospectively reviewed. Following the completion of the patient's care, emergency physicians were asked to complete a questionnaire indicating how information from the FAST examination was utilized to direct care of their non-trauma patients.

Results

A total of 63 non-trauma cases with average age of 48 years (range 16-94 years) were enrolled. The FAST examination positively impacted care in 57/63 (90.5%) cases. In 18/63 (28.6%) cases, the patient’s ultimate disposition changed because of FAST examination findings. In 9/63 (14.3%) cases, paracentesis was avoided by obtaining a FAST examination, and in 8/63 cases (12.7%) paracentesis was performed due to FAST examination results. In 16/63 (25.4%) cases, anticipated imaging changed due to FAST examination findings and 4/63 (6.3%) cases did not receive the anticipated computed tomography (CT) scan.

Conclusions

Although initially developed for evaluation of trauma patients, the FAST examination can provide valuable information that can positively impact care in non-trauma patients. The FAST examination can provide information to determine appropriate patient disposition, obtain appropriate additional imaging, ensure timely consultation, and eliminate risk from unnecessary procedures.

Focused assessment with sonography in trauma: a review of concepts and considerations for anesthesiology

The use of point-of-care ultrasound in trauma provides diagnostic clarity and routinely influences management. A scanning protocol known as the Focused Assessment with Sonography in Trauma (FAST) has been widely adopted by trauma providers of all specialties. The FAST exam addresses a broad array of pathologic conditions capable of causing instability, including hemoperitoneum, hemopericardium, hemothorax, and pneumothorax. The exam is an integral component to the primary assessment of injured patients and an iconic application of point-of-care ultrasound.This review article aims to summarize the application of the FAST exam with special consideration, where relevant, to anesthesiologists. The scope of the FAST exam, technical considerations, and clinical decision-making in trauma are explored.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Abdominal Trauma Revisited

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.

Splenic rupture following synchronised direct current cardioversion

Atraumatic rupture of the normal spleen is a rare entity. Often, a triggering factor or minor physical event can be ascribed as the aetiology for rupture, including coughing, vomiting or minor medical procedures not involving the spleen. A 65-year-old man who was hospitalised for eosinophilic pneumonia developed haemodynamically unstable atrial flutter that necessitated urgent synchronised direct current cardioversion (DCCV). Two hours after successful cardioversion, he developed signs of an acute abdomen with free intraperitoneal fluid identified on bedside ultrasonography. Exploratory laparotomy revealed gross haemoperitoneum and splenic rupture requiring splenectomy. With exception of capsular defects and haemorrhage suggestive of organ rupture, the gross and histological examination of the spleen was otherwise unremarkable. The patient denied recent trauma. The cause of his spleen rupture was attributed to cardioversion and subsequent abdominal muscle contraction. This represents the first known case of splenic rupture associated with DCCV.

FAST for blunt abdominal trauma: Correlation between positive findings and admission acid-base measurement

PURPOSE

This study aimed to determine any association between positive findings in ultrasonography examination and initial BD value with regard to diagnosis of intra-abdominal bleeding following blunt abdominal trauma.

METHODS

A prospective, multi-center study of consecutive adult patients was performed from April to September 2015. Demographics, initial vital signs and arterial BD were evaluated with respect to presence of any association with intra-abdominal bleeding and in-hospital mortality. FAST study was performed to find intra-abdominal bleeding. Receiver operating characteristic (ROC) curves tested the ability of BD to identify patients with intra-abdominal hemorrhage and probable mortality.

RESULTS

A total of 879 patients were included in final analysis. The mean (SD) age was 36.68 (15.7) years and 714 patients (81.2%) were male. According to multivariable analysis, statistically significant association was observed between negative admission BD and both intra-abdominal bleeding (OR 3.48, 95% CI 2.06-5.88, p<0.001) and in-hospital mortality (OR 1.55, 95% CI 1.49-1.63, p<0.001). ROC curve analysis demonstrated sensitivity of 92.7% and specificity of 22.1% for the best cut-off value of BD (-8mEq/L) to diagnose internal hemorrhage. Further, a cut-off value of -7mEq/L demonstrated significant predictive performance, 94.8% sensitivity and 53.6% specificity for in-hospital mortality.

CONCLUSION

This study revealed that arterial BD is an early accessible important marker to identify intra-abdominal bleeding, as well as to predict overall in-hospital mortality in patients with blunt abdominal trauma.

Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam

Introduction

The focused assessment with sonography in trauma (FAST) exam is a critical diagnostic test for intraperitoneal free fluid (FF). Current teaching is that fluid accumulates first in Morison’s pouch. The goal of this study was to evaluate the “sub-quadrants” of traditional FAST views to determine the most sensitive areas for FF accumulation.

Methods

We analyzed a retrospective cohort of all adult trauma patients who had a recorded FAST exam by emergency physicians at a Level I trauma center from January 2012 – June 2013. Ultrasound fellowship-trained faculty with three emergency medicine residents reviewed all FAST exams. We excluded studies if they were incomplete, of poor image quality, or with incorrect medical record information. Positive studies were assessed for FF localization, comparing the traditional abdominal views and on a sub-quadrant basis: right upper quadrant (RUQ)1 - hepato-diaphragmatic; RUQ2 - Morison’s pouch; RUQ3 - caudal liver edge and superior paracolic gutter; left upper quadrant (LUQ)1 - splenic-diaphragmatic; LUQ2 - spleno-renal; LUQ3 – around inferior pole of kidney; suprapubic area (SP)1 - bilateral to bladder; SP2 - posterior to bladder; SP3 – posterior to uterus (females). FAST results were confirmed by chart review of computed tomography results or operative findings.

Results

Of the included 1,008 scans, 48 (4.8%) were positive. The RUQ was the most positive view with 32/48 (66.7%) positive. In the RUQ sub-quadrant analysis, the most positive view was the RUQ3 with 30/32 (93.8%) positive.

Conclusion

The RUQ is most sensitive for FF assessment, with the superior paracolic gutter area around the caudal liver edge (RUQ3) being the most positive sub-quadrant within the RUQ.

The 100 most cited manuscripts in emergency abdominal surgery: A bibliometric analysis

BACKGROUND

The number of citations a scientific article receives provides a good indication of its impact within any given field. This bibliometric analysis aimed to identify the 100 most cited articles in Emergency Abdominal Surgery (EAS), to highlight key areas of interest and identify those that have most significantly shaped contemporary clinical practice in this newly evolving surgical specialty. This is of increasing relevance as concerns grow regarding the variable and suboptimal outcomes in Emergency General Surgery.

MATERIALS AND METHODS

The Thomson Reuters Web of Science database was used to search using the terms [Emergency AND Abdom* AND Surg*] to identify all English language, full manuscripts. Results were ranked according to citation number. The top 100 articles were further analysed by subject, author, journal, year of publication, institution, and country of origin.

RESULTS

The median (range) citation number of the top 100 out of 7433 eligible papers was 131 (1569-97). The most cited paper (by Goldman et al., Massachusetts General Hospital, New England Journal of Medicine; 1569 citations) focused on cardiac risk stratification in non-cardiac surgery. The Journal of Trauma, Injury, Infection and Critical Care published the most papers and received most citations (n = 19; 2954 citations. The majority of papers were published by centres in the USA (n = 52; 9422 citations), followed by the UK (n = 13; 1816 citations). The most common topics of publication concerned abdominal aneurysm management (n = 26) and emergency gastrointestinal surgery (n = 26).

CONCLUSION

Vascular surgery, risk assessment and gastrointestinal surgery were the areas of focus for 59% of the contemporary most cited emergency abdominal surgery manuscripts. By providing the most influential references this work serves as a guide to what makes a citable emergency surgery paper.

Ascites matters

The excess accumulation of intra-peritoneal fluid, referred to as ascites, is an important clue that points to a significant underlying illness. This may be due to a pathological event within the peritoneal cavity or secondary to an underlying systemic condition. Ascites is broadly classified into transudate and exudate, based on protein content, with a potential wide range of differential diagnoses. Traditionally, computed tomography has been regarded as the imaging modality of choice to demonstrate ascites and diagnose the underlying cause. However, ultrasound can reliably detect small volumes of fluid and is a useful first-line imaging modality for clinical triage. For instance, in the emergency setting, the detection of a trace of ascites may be the earliest indicator of an acute abdomen needing surgery. Ultrasound can quantify the volume of ascites and aid in the decision process for fluid drainage. Ultrasound is superior to computed tomography in the qualitative assessment of fluid. Broadly, simple fluid is anechoic, whereas complex fluid may appear particulate, layered or contain septations. On computed tomography, both have a uniform hypo-dense appearance and are often indistinguishable. Given ultrasound, in comparison to computed tomography, is safe, relatively inexpensive and readily available, it is a valuable tool in the assessment of ascites. Once ascites is detected on ultrasound, it is imperative for the operator to have a systematic approach to attempt to provide an underlying diagnosis. Through a series of cases, this article aims to increase awareness and reaffirm the role of ultrasound in the assessment of ascites.

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

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

Sports Ultrasound: Applications Beyond the Musculoskeletal System

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.

Screening Ultrasound in Blunt Abdominal Trauma

Ultrasound is used worldwide to evaluate patients with blunt abdominal trauma. Sometimes referred to as an extension of the physical exam, ultrasound can rapidly help distinguish patients with injury requiring computerized tomography (CT) or surgery (typically 5%-10%) from those with no abdominal injury (> 90%). Ultrasound has several advantages in the setting of trauma. It is portable, integrates easily into the resuscitation of trauma victims without causing delay in therapy, is noninvasive, and has no associated morbidity. Limitations of ultrasound include its dependence on operator skill and technique, poor image quality in patients with morbid obesity or extensive subcutaneous gas, limited visualization of the retroperitoneum, and less reliable localization of visceral injury compared to CT. Successful use of abdominal ultrasound in the setting of trauma can be maximized with adequate sonographer training, appreciation of technical limitations, and adherence to an appropriate trauma ultrasound protocol.

Surgical wound assessment by sonography in the prediction of surgical wound infections

BACKGROUND

Surgical site infections (SSIs) are important sources of morbidity, prolonged hospital stays, and readmissions, so they have become a major economic burden. We hypothesized that surgical wound assessment by sonography (SWATS) used at the bedside would detect wound fluid collections and that the presence of such collections would predict SSI better than standard clinical examination. If so, SWATS might be used to indicate early intervention that could prevent SSI morbidity.

METHODS

A prospective, single-institution observational study was conducted on adult inpatients following open abdominal surgery for trauma, gastrointestinal pathology, or biliary pathology at high risk (>5%) for SSI using traditional wound classifications. After informed consent was obtained, SWATS was performed using a smartphone-based ultrasound system on postoperative Day 2 to 4 and again before discharge or at postoperative Day 30, whichever came first. Primary treating physicians delivered standard wound care and were blinded to SWATS. SSI was diagnosed if treatment was implemented for suspected or documented wound infection by the treating physician. Results were analyzed by χ test and two-sample pooled variance t test where appropriate, with significance set at p < 0.05.

RESULTS

Forty-nine patients were studied. Nineteen patients had peri-incisional fluid collections found by SWATS. Eight of these patients went on to develop an SSI. SSI was significantly associated with the presence of fluid collections on SWATS (p = 0.009). SWATS had a sensitivity of 72.7% (0.43-0.92), a specificity of 71.1% (0.62-0.77), a positive predictive value of 42.1% (0.25-0.53), and a negative predictive value of 90.0% (0.79-0.97).

CONCLUSION

SWATS has a high negative predictive value that may allow it be an effective screening tool for developing SSI in high-risk surgical wounds. SWATS has the potential to be a useful and cost-effective adjunct to the clinician by objectively suggesting need for early therapy. Further study with larger sample sizes and randomized, SWATS-based interventions are required to validate this small study and determine its place in clinical care.

LEVEL OF EVIDENCE

Diagnostic study, level IV.

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

Background

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

Objectives

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

Patients and Methods

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

Results

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

Conclusions

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

Thinking outside the box: re-evaluating the approach to penetrating cardiac injuries

INTRODUCTION

Penetrating cardiac injuries are infrequent but highly lethal. To address these injuries, cardiopulmonary bypass and cardiothoracic surgery availability are required for Level I trauma center verification. However, acute care surgeons are more readily available for this time-sensitive injury. The purpose of this study was to review an acute care surgery-based experience with penetrating cardiac trauma at an urban Level 1 trauma center. Our hypothesis was that care provided solely by acute care surgeons was both safe and effective for this patient population.

METHODS

All patients with injuries to the 'cardiac box' following penetrating thoracic trauma were identified from 2005-2010. Demographic and injury related data were obtained. The types and location of cardiac injury, as well as patient outcomes, were determined from operative reports.

RESULTS

1701 patients with penetrating chest trauma were admitted during the study period. 260 patients were identified as having high-risk injuries and were included in the review. 37 patients underwent resuscitative thoracotomy, with a survival rate of 8 %. 76 patients (29 %) suffered a cardiac injury. 72 % of these patients had a preoperative FAST exam, which had a sensitivity and specificity of 56.5 and 82.5 % respectively. 82 % underwent a pericardial window, which had a positive predictive value of 81.4 %. 61 % (n = 46) of the patients with a cardiac injury survived, while the overall death rate in this cohort was 21 %. No patients in the cohort required cardiopulmonary bypass for emergent repair of cardiac injury and acute care surgeons performed all cases.

CONCLUSION

Penetrating injury to the heart is highly lethal and time-sensitive. Increasingly, FAST and subxyphoid pericardial window are relied upon to make the diagnosis in patients arriving in varying stages of shock to the resuscitation room. Acute care surgeons are the most appropriate surgeons to care for these injuries and provide safe and effective care.

Critical Care Basic Ultrasound Learning Goals for American Anesthesiology Critical Care Trainees: Recommendations from an Expert Group

OBJECTIVE

In this review, we define learning goals and recommend competencies concerning focused basic critical care ultrasound (CCUS) for critical care specialists in training.

DESIGN

The narrative review is, and the recommendations contained herein are, sponsored by the Society of Critical Care Anesthesiologists. Our recommendations are based on a structured literature review by an expert panel of anesthesiology intensivists and cardiologists with formal training in ultrasound. Published descriptions of learning and training routines from anesthesia-critical care and other specialties were identified and considered. Sections were written by groups with special expertise, with dissent included in the text.

RESULTS

Learning goals and objectives were identified for achieving competence in the use of CCUS at a specialist level (critical care fellowship training) for diagnosis and monitoring of vital organ dysfunction in the critical care environment. The ultrasound examination was divided into vascular, abdominal, thoracic, and cardiac components. For each component, learning goals and specific skills were presented. Suggestions for teaching and training methods were described.

DISCUSSION

Immediate bedside availability of ultrasound resources can dramatically improve the ability of critical care physicians to care for critically ill patients. Anesthesia--critical care medicine training should have definitive expectations and performance standards for basic CCUS interpretation by anesthesiology--critical care specialists. The learning goals in this review reflect current trends in the multispecialty critical care environment where ultrasound-based diagnostic strategies are already frequently applied. These competencies should be formally taught as part of an established anesthesiology-critical care medicine graduate medical education programs.

Prediction of critical haemorrhage following trauma: A narrative review

Introduction: Traumatic haemorrhagic shock can be difficult to diagnose. Models for predicting critical bleeding and massive transfusion have been developed to aid clinicians. The aim of this review is to outline the various available models and report on their performance and validation. Methods: A review of the English and non-English literature in Medline, PubMed and Google Scholar was conducted from 1990 to September 2015. We combined several terms for i) haemorrhage AND ii) prediction, in the setting of iii) trauma. We included models that had at least two data points. We extracted information about the models, their developments, performance and validation. Results: There were 36 different models identified that diagnose critical bleeding, which included a total of 36 unique variables. All models were developed retrospectively. The models performed with variable predictive abilities–the most superior with an area under the receiver operating characteristics curve of 0.985, but included detailed findings on imaging and was based on a small cohort. The most commonly included variable was systolic blood pressure, featuring in all but five models. Pattern or mechanism of injury were used by 16 models. Pathology results were used by 15 models, of which nine included base deficit and eight models included haemoglobin. Imaging was utilised in eight models. Thirteen models were known to be validated, with only one being prospectively validated. Conclusions: Several models for predicting critical bleeding exist, however none were deemed accurate enough to dictate treatment. Potential areas of improvement identified include measures of variability in vital signs and point of care imaging and pathology testing.

Chest Abdominal-Focused Assessment Sonography for Trauma during the primary survey in the Emergency Department: the CA-FAST protocol

PURPOSE

To evaluate the feasibility of a new protocol, Chest Abdominal-Focused Assessment Sonography for Trauma (CA-FAST), during the primary survey and to estimate its diagnostic accuracy when compared with thoracoabdominal computed tomography (CT) scan.

METHODS

A prospective accuracy study was performed from November 2012 to November 2013 at the Emergency Department. Only adult trauma patients who underwent a CA-FAST examination prior to a thoracoabdominal CT scan were enrolled. In addition to standard patterns detected by Extended-FAST (E-FAST) such as pneumothorax (PTX), hemothorax (HTX), pericardial and intraabdominal effusion, CA-FAST protocol also included the research of lung contusions (LCs).

RESULTS

Six hundred and one patients were enrolled. The mean time for protocol execution was 7 ± 3 min. Chest ultrasonography showed the following results (all p < 0.001): LCs sensitivity 59 %, specificity 98 %, positive predictive value (PPV) 92 %, negative predictive value (NPV) 86 %, accuracy 87 %; PTX sensitivity 84 %, specificity 98 %, PPV 93 %, NPV 95 %, accuracy 95 %; HTX sensitivity 82 %, specificity 97 %, PPV 87 %, NPV 95 %, accuracy 94 %. The standard 4-views FAST examination showed a diagnostic accuracy of 91 % with a sensitivity of 75 %, specificity of 96 %, PPV of 81 % and NPV of 94 %.

CONCLUSION

According to our results CA-FAST protocol proved to be a rapid bedside method, with good accuracy and high NPV in detection of ultrasonographic patterns suggestive of serious injury in trauma patients; moreover, the additional research of LCs did not cause a delay in the diagnosis. Ultrasonography should be used as initial investigation during the primary survey, sending to further diagnostic studies (CT scan) only those patients not clearly classified.

A Comparative Analysis of Diagnostic Accuracy of Focused Assessment With Sonography for Trauma Performed by Emergency Medicine and Radiology Residents

BACKGROUND

Focused assessment with sonography in trauma (FAST) is a method for prompt detection of the abdominal free fluid in patients with abdominal trauma.

OBJECTIVES

This study was conducted to compare the diagnostic accuracy of FAST performed by emergency medicine residents (EMR) and radiology residents (RRs) in detecting peritoneal free fluids.

PATIENTS AND METHODS

Patients triaged in the emergency department with blunt abdominal trauma, high energy trauma, and multiple traumas underwent a FAST examination by EMRs and RRs with the same techniques to obtain the standard views. Ultrasound findings for free fluid in peritoneal cavity for each patient (positive/negative) were compared with the results of computed tomography, operative exploration, or observation as the final outcome.

RESULTS

A total of 138 patients were included in the final analysis. Good diagnostic agreement was noted between the results of FAST scans performed by EMRs and RRs (κ = 0.701, P < 0.001), also between the results of EMRs-performed FAST and the final outcome (κ = 0.830, P < 0.0010), and finally between the results of RRs-performed FAST and final outcome (κ = 0.795, P < 0.001). No significant differences were noted between EMRs- and RRs-performed FASTs regarding sensitivity (84.6% vs 84.6%), specificity (98.4% vs 97.6%), positive predictive value (84.6% vs 84.6%), and negative predictive value (98.4% vs 98.4%).

CONCLUSIONS

Trained EMRs like their fellow RRs have the ability to perform FAST scan with high diagnostic value in patients with blunt abdominal trauma.

The Face, Content, and Construct Validity Assessment of a Focused Assessment in Sonography for Trauma Simulator

OBJECTIVE

Hemorrhage identification in trauma care is a major priority. Focused assessment in sonography for trauma (FAST) offers a rapid, reliable means of detecting torso bleeding. The aims of this study were to conduct a face, content, and construct validity assessment of a FAST simulator and establish a rigorous assessment tool.

DESIGN

Participants were requested to perform a FAST scan and state if any abnormality was found in each region. Metrics evaluated included time, errors, and missed targets. Accuracy of images obtained was assessed by 2 independent radiologists. Experts completed a face and content validity questionnaire at the end of the study.

SETTING

The study took place in the simulation suite within the Academic Surgical Unit of the Department of Surgery and Cancer.

PARTICIPANTS

Novices had no prior experience with ultrasound, intermediates had less than 6 months experience with fewer than 50 FAST scans performed, and experts had more than 1 year of experience with greater than 100 FAST scans performed. There were 31 participants: 11 experts, 10 intermediates, and 10 novices.

RESULTS

The face and content validity questionnaire scored high marks across all categories and achieved an overall median realism score of 8 ± 1.5 on a Likert scale. Experts performed the FAST scan faster with more accuracy and fewer errors than other cohorts (p < 0.001). Both the novices and intermediates were the slowest, least accurate, and either missed or made the most errors when scanning the lung bases and spleen.

CONCLUSIONS

This study has established the face, content, and construct validities of a FAST simulator, which could be used to accelerate training for novices. Additionally, it has demonstrated a rigorous method for FAST assessment, which has proven to be effective and in doing so addressed some of the criticisms leveled against it.