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Bouzid D, Tran-Dinh A, Lortat-Jacob B, Atchade E, Jean-Baptiste S, Tashk P, Snauwaert A, Zappella N, Augustin P, Pellenc Q, Castier Y, Ribeiro L, Gaudemer A, Khalil A, Montravers P, Tanaka S. Ultrasonography in thoracic and abdominal stab wound injury: results from the FETTHA study. Emerg Med J 2023; 40:821-825. [PMID: 37673644 DOI: 10.1136/emermed-2023-213078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND While the role of Extended Focused Assessment with Sonography in Trauma (eFAST) is well defined in the management of severe blunt trauma, its performance in injuries caused by stab wounds has been poorly assessed. METHODS Prospective single centre study which included all patients with stab wounds to the thorax or abdomen between December 2016 and December 2018. All patients underwent initial investigation with both eFAST and CT scan, except in cases of haemodynamic or respiratory instability, and in cases with a positive diagnosis by eFAST in which case surgery without CT scan was performed. RESULTS Of the 200 consecutive patients included, 14 unstable patients underwent surgery immediately after eFAST. In these 14 patients, 9 had cardiac tamponade identified by eFAST and all were confirmed by surgery. In the remaining 186 patients, the median time between eFAST and CT scan was 30 min (IQR 20-49 min). Test characteristics (including 95% CI) for eFAST compared with reference standard of CT scan for detecting pneumothorax were as follows: sensitivity 77% (54%-92%), specificity 93% (90%-97%), positive predictive value (PPV) 60% (49%-83%), negative predictive value (NPV) 97% (93%-99%). Test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemothorax were as follows: sensitivity 97% (74%-99%), specificity 96% (92%-98%), PPV 83% (63%-93%) and NPV 99% (96%-100%). Finally, test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemoperitoneum were as follows: sensitivity 75% (35%-97%), specificity 97% (93%-99%), PPV 55% (23%-83%) and NPV 99% (96%-99%). CONCLUSIONS In patients admitted with stab wounds to the torso, eFAST was not sensitive enough to diagnose pneumothorax and haemoperitoneum, but performed better in the detection of cardiac tamponade and haemothorax than the other injuries. More robust multicentre studies are needed to better define the role of eFAST in this specific population.
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Affiliation(s)
- Donia Bouzid
- Université Paris Cité, Paris, France
- INSERM UMR1137, IAME, F-75006, Paris, France
- Université de Montpellier, VBMI, INSERM U1047, Nimes, France
- AP-HP Nord, Emergency Department, Bichat-Claude Bernard University Hospital, Paris, France
| | - Alexy Tran-Dinh
- Université Paris Cité, Paris, France
- AP-HP Nord, Anesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital, Paris, France
- INSERM UMR1148, Paris, France
| | - Brice Lortat-Jacob
- AP-HP Nord, Anesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital, Paris, France
| | - Enora Atchade
- AP-HP Nord, Anesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital, Paris, France
| | - Sylvain Jean-Baptiste
- AP-HP Nord, Anesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital, Paris, France
| | - Parvine Tashk
- AP-HP Nord, Anesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital, Paris, France
| | - Aurelie Snauwaert
- AP-HP Nord, Anesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital, Paris, France
| | - Nathalie Zappella
- AP-HP Nord, Anesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital, Paris, France
| | - Pascal Augustin
- AP-HP Nord, Anesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital, Paris, France
| | - Quentin Pellenc
- AP-HP Nord, Thoracic and Vascular Surgery Department, Bichat-Claude Bernard University Hospital, Paris, France
| | - Yves Castier
- Université Paris Cité, Paris, France
- INSERM UMR1148, Paris, France
- AP-HP Nord, Thoracic and Vascular Surgery Department, Bichat-Claude Bernard University Hospital, Paris, France
| | - Lara Ribeiro
- AP-HP Nord, Visceral Surgery Department, Bichat-Claude Bernard University Hospital, Paris, France
| | - Augustin Gaudemer
- AP-HP Nord, Radiology Department, Bichat-Claude Bernard University Hospital, Paris, France
| | - Antoine Khalil
- Université Paris Cité, Paris, France
- AP-HP Nord, Radiology Department, Bichat-Claude Bernard University Hospital, Paris, France
- PHERE, Physiopathology and Epidemiology of Respiratory Diseases, French Institute of Health and Medical Research (INSERM) U1152, Paris, France
| | - Philippe Montravers
- Université Paris Cité, Paris, France
- AP-HP Nord, Anesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital, Paris, France
- PHERE, Physiopathology and Epidemiology of Respiratory Diseases, French Institute of Health and Medical Research (INSERM) U1152, Paris, France
| | - Sebastien Tanaka
- AP-HP Nord, Anesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital, Paris, France
- INSERM UMR1188, Saint-Denis de la Réunion, France
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Yıldız Potter İ, Leo MM, Vaziri A, Feldman JA. Automated detection and localization of pericardial effusion from point-of-care cardiac ultrasound examination. Med Biol Eng Comput 2023; 61:1947-1959. [PMID: 37243852 PMCID: PMC11194944 DOI: 10.1007/s11517-023-02855-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Abstract
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.
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Affiliation(s)
| | - Megan M Leo
- School of Medicine, Boston University (BU), Chobanian & Avedisian, Boston, MA, USA
- Department of Emergency Medicine, Boston Medical Center (BMC), Boston, MA, USA
| | | | - James A Feldman
- School of Medicine, Boston University (BU), Chobanian & Avedisian, Boston, MA, USA
- Department of Emergency Medicine, Boston Medical Center (BMC), Boston, MA, USA
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Partyka C, Coggins A, Bliss J, Burns B, Fiorentino M, Goorkiz P, Miller M. A multicenter evaluation of the accuracy of prehospital eFAST by a physician-staffed helicopter emergency medical service. Emerg Radiol 2021; 29:299-306. [PMID: 34817706 DOI: 10.1007/s10140-021-02002-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/16/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study is to report the relative accuracy of prehospital extended focused assessment with sonography in trauma (eFAST) examinations performed by HEMS physicians. METHODS Trauma patients who received prehospital eFAST by HEMS clinicians between January 2013 and December 2017 were reviewed. The clinician's interpretations of these ultrasounds were compared to gold standard references of CT imaging or operating room findings. The outcomes measured include the calculated accuracy of eFAST for detecting intraperitoneal free fluid (IPFF), pneumothorax, hemothorax, and pericardial fluid compared to available gold standard results. RESULTS Of the 411 patients with adequate data for comparison, the median age was 39.5 years with 73% male and 98% sustaining blunt force trauma. For the detection of IPFF, eFAST had a sensitivity of 25% (95% CI 16-36%) and specificity of 96% (95% CI 93-98%). Sensitivities and specificities were calculated for pneumothorax (38% and 96% respectively), hemothorax (17% and 97% respectively), and pericardial effusion (17% and 100% respectively). These results did not change significantly when reassessed with several sensitivity analyses. CONCLUSION Prehospital eFAST is reliable for detecting the presence of intraperitoneal free fluid. This finding should inform receiving trauma teams to prepare for early definitive care in these patients. The low sensitivities across all components of the eFAST highlight the importance of cautiously interpreting negative studies while prompting the need for further studies. TRIAL REGISTRATION ACTRN12618001973202 (Registered on 06/12/2018).
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Affiliation(s)
- Christopher Partyka
- Aeromedical Operations, NSW Ambulance, 33 Nancy Ellis Leebold Drive, Bankstown Airport, Sydney, NSW, 2200, Australia. .,Emergency Department, Liverpool Hospital, Liverpool, NSW, Australia. .,South Western Sydney Clinical School, University of New South Wales, Kensington, Australia.
| | - Andrew Coggins
- Emergency Department, Westmead Hospital, Westmead, NSW, Australia.,Western Clinical School, University of Sydney, Sydney, Australia
| | - Jimmy Bliss
- Aeromedical Operations, NSW Ambulance, 33 Nancy Ellis Leebold Drive, Bankstown Airport, Sydney, NSW, 2200, Australia.,Emergency Department, Liverpool Hospital, Liverpool, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Brian Burns
- Sydney Medical School, University of Sydney, Sydney, Australia.,GSA-HEMS, NSW Ambulance, Blacktown, NSW, Australia
| | | | - Pierre Goorkiz
- Intensive Care Unit, Liverpool Hospital, Liverpool, NSW, Australia.,School of Medicine, Western Sydney University, Sydney, Australia
| | - Matthew Miller
- Aeromedical Operations, NSW Ambulance, 33 Nancy Ellis Leebold Drive, Bankstown Airport, Sydney, NSW, 2200, Australia.,UNSW St George and Sutherland Clinical Schools, Kogarah, Australia
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Cheng CY, Chiu IM, Hsu MY, Pan HY, Tsai CM, Lin CHR. Deep Learning Assisted Detection of Abdominal Free Fluid in Morison's Pouch During Focused Assessment With Sonography in Trauma. Front Med (Lausanne) 2021; 8:707437. [PMID: 34631730 PMCID: PMC8494971 DOI: 10.3389/fmed.2021.707437] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/25/2021] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Chi-Yung Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Ming-Ya Hsu
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Hsiu-Yung Pan
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Min Tsai
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chun-Hung Richard Lin
- Department of Computer Science and Engineering, National Sun Yat-sen University, Kaohsiung, Taiwan
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Warren J, Moazzez A, Chong V, Putnam B, Neville A, Singer G, Deane M, Kim DY. Narrowed pulse pressure predicts massive transfusion and emergent operative intervention following penetrating trauma. Am J Surg 2019; 218:1185-1188. [PMID: 31551145 DOI: 10.1016/j.amjsurg.2019.08.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 08/17/2019] [Accepted: 08/21/2019] [Indexed: 01/19/2023]
Abstract
INTRODUCTION The early identification of hemorrhagic shock may be challenging. The objective of this study was to examine the utility of a narrowed pulse pressure in identifying the need for emergent interventions following penetrating trauma. METHODS In this 2.5-year retrospective study of adult patients with a penetrating mechanism, patients with a narrowed pulse pressure (<30 mmHg) were compared to those without. Main outcomes measures were the need for a massive transfusion or emergent operation. RESULTS There were 957 patients, of which the majority were male (86%) and 55% presented with gunshot wounds. On multivariate analysis, a narrowed pulse pressure was associated with the need for massive transfusion (OR 3.74, 95% C.I. 1.8-7.7, p = 0.0003) and emergent surgery (OR 1.68, 95% C.I. 1.14-2.48, p = 0.009). CONCLUSIONS A narrowed pulse pressure is associated with the presence of hemorrhagic shock and need for emergent interventions among patients with penetrating torso trauma.
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Affiliation(s)
- Jonathan Warren
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, 90509, United States
| | - Ashkan Moazzez
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, 90509, United States; Los Angeles BioMedical Research Institute, 1124 W. Carson St, Torrance, CA, 90502, United States
| | - Vincent Chong
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, 90509, United States; Los Angeles BioMedical Research Institute, 1124 W. Carson St, Torrance, CA, 90502, United States
| | - Brant Putnam
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, 90509, United States; Los Angeles BioMedical Research Institute, 1124 W. Carson St, Torrance, CA, 90502, United States
| | - Angela Neville
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, 90509, United States; Los Angeles BioMedical Research Institute, 1124 W. Carson St, Torrance, CA, 90502, United States
| | - George Singer
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, 90509, United States; Los Angeles BioMedical Research Institute, 1124 W. Carson St, Torrance, CA, 90502, United States
| | - Molly Deane
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, 90509, United States; Los Angeles BioMedical Research Institute, 1124 W. Carson St, Torrance, CA, 90502, United States
| | - Dennis Y Kim
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, 90509, United States; Los Angeles BioMedical Research Institute, 1124 W. Carson St, Torrance, CA, 90502, United States.
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6
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de Moya M, Goldstein AL. Non-operative Management of Penetrating Abdominal Injuries: An Update on Patient Selection. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0234-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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8
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Sjogren AR, Leo MM, Feldman J, Gwin JT. Image Segmentation and Machine Learning for Detection of Abdominal Free Fluid in Focused Assessment With Sonography for Trauma Examinations: A Pilot Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:2501-2509. [PMID: 27738293 PMCID: PMC7929643 DOI: 10.7863/ultra.15.11017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/04/2016] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
| | - Megan M Leo
- Boston Medical Center, Boston, Massachusetts USA
- Boston University School of Medicine, Boston, Massachusetts USA
| | - James Feldman
- Boston Medical Center, Boston, Massachusetts USA
- Boston University School of Medicine, Boston, Massachusetts USA
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10
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Abstract
Over the history of surgery, the management of abdominal gunshot wounds in the stable evaluable patient without peritonitis has evolved. While non-operative management has been widely accepted and employed for the management of abdominal stab wounds, recently it has been deemed a safe option for abdominal gunshot wounds as well. Selective non-operative management of penetrating abdominal trauma in the appropriate setting has been shown to decrease the rate of nontherapeutic laparotomy as well as the cost and total length of hospital stay, and potentially decrease short- and long-term morbidity. This review examines the background support for non-operative management of abdominal gunshot wounds while discussing patient evaluation, selection, and clinical management.
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Affiliation(s)
- Stephen Varga
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Scott Zakaluzny
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
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11
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Smith ZA, Wood D. Emergency focussed assessment with sonography in trauma (FAST) and haemodynamic stability. Emerg Med J 2013; 31:273-7. [DOI: 10.1136/emermed-2012-202268] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundFocussed assessment with sonography in trauma (FAST) has assumed a key role in the rapid non-invasive assessment of thoracoabdominal trauma and assists in decreasing disposition time. This study evaluates FAST's efficacy with respect to haemodynamic stability in a South African emergency department (ED).MethodsData were collected prospectively by four emergency medicine doctors trained in emergency ultrasonography. FAST scans were performed by one ED doctor and timings, scan result and disposition were recorded. Patient haemodynamic stability was assessed by the emergency doctor performing the scan; subjectively at the time of scanning and objectively using calculation of the shock index. All scan results were subsequently verified by a second ED doctor in a blinded fashion and by CT scanning or operative intervention when clinically indicated.Results166 FAST scans were conducted of which 36 (21.7%) were positive. Mean age was 30.6 years (SD 12.8). 74.1% of patients sustained blunt traumatic injury. Doctors’ subjective haemodynamic stability assessments had higher specificity, sensitivity and predictive values than shock index alone. Haemodynamic instability and a positive FAST result were significantly related (p=0.004). Sensitivities and specificities of FAST scans for blunt and penetrating trauma were 93.1% and 100%, and 90.0% and 100%, respectively. Corresponding values for pneumothoraces were 84.6% and 100%.DiscussionThis study showed a valuable role for FAST in all traumas, particularly in haemodynamic compromise. As an addition to the physician's repertoire of bedside assessment tools, it improves diagnostic capabilities in comparison with simple haemodynamic assessments alone.
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Van Waes OJF, Van Riet PA, Van Lieshout EMM, Hartog DD. Immediate thoracotomy for penetrating injuries: ten years' experience at a Dutch level I trauma center. Eur J Trauma Emerg Surg 2012; 38:543-51. [PMID: 23162671 PMCID: PMC3495272 DOI: 10.1007/s00068-012-0198-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 05/18/2012] [Indexed: 10/31/2022]
Abstract
BACKGROUND An emergency department thoracotomy (EDT) or an emergency thoracotomy (ET) in the operating theater are both beneficial in selected patients following thoracic penetrating injuries. Since outcome-descriptive European studies are lacking, the aim of this retrospective study was to evaluate ten years of experience at a Dutch level I trauma center. METHOD Data on patients who underwent an immediate thoracotomy after sustaining a penetrating thoracic injury between October 2000 and January 2011 were collected from the trauma registry and hospital files. Descriptive and univariate analyses were performed. RESULTS Among 56 patients, 12 underwent an EDT and 44 an ET. Forty-six patients sustained one or multiple stab wounds, versus ten with one or multiple gunshot wounds. Patients who had undergone an EDT had a lower GCS (p < 0.001), lower pre-hospital RTS and hospital triage RTS (p < 0.001 and p = 0.009, respectively), and a lower SBP (p = 0.038). A witnessed loss of signs of life generally occurred in EDT patients and was accompanied by 100 % mortality. Survival following EDT was 25 %, which was significantly lower than in the ET group (75 %; p = 0.002). Survivors had lower ISS (p = 0.011), lower rates of pre-hospital (p = 0.031) and hospital (p = 0.003) hemodynamic instability, and a lower prevalence of concomitant abdominal injury (p = 0.002). CONCLUSION The overall survival rate in our study was 64 %. The outcome of immediate thoracotomy performed in this level I trauma center was similar to those obtained in high-incidence regions like the US and South Africa. This suggests that trauma units where immediate thoracotomies are not part of the daily routine can achieve similar results, if properly trained.
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Affiliation(s)
- O. J. F. Van Waes
- Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Room H-822k, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - P. A. Van Riet
- Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Room H-822k, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - E. M. M. Van Lieshout
- Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Room H-822k, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - D. D. Hartog
- Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Room H-822k, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
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Quinn AC, Sinert R. What is the utility of the Focused Assessment with Sonography in Trauma (FAST) exam in penetrating torso trauma? Injury 2011; 42:482-7. [PMID: 20701908 DOI: 10.1016/j.injury.2010.07.249] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 07/07/2010] [Accepted: 07/12/2010] [Indexed: 02/02/2023]
Abstract
STUDY OBJECTIVE A recent Cochrane Review has demonstrated that emergency ultrasonography decreases the amount of computerised tomographic scans in blunt abdominal trauma.13 However, there is no systematic review that has evaluated the utility of the Focused Assessment with Sonography for Trauma(FAST) exam in penetrating torso trauma. We systematically reviewed the medical literature for the utility of the FAST exam to detect free intraperitoneal blood after penetrating torso trauma. METHODS We searched PUBMED and EMBASE databases for randomised controlled trials from 1965 through December 2009 using a search strategy derived from the following PICO formulation of our clinical question: PATIENTS patients (12+ years) sustaining penetrating trauma to the torso. INTERVENTION FAST exam during their initial trauma workup. Comparator: either local wound exploration (LWE),computerised tomography (CT), diagnostic peritoneal lavage (DPL), or laparotomy. OUTCOME intraperitoneal and pericardial free fluid. The methodological quality of the studies was assessed.Qualitative methods were used to summarise the study results. ANALYSIS Sensitivities and specificities were compared using a Forest Plot (95% CI) calculated by Revman 5 (Review Manager Version 5.0. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration,2008) between the FAST exam and definitive diagnostic modalities such as LWE, CT, DPL, or laporotomy. RESULTS We identified eight observational studies (n=565 patients) that met our selection criteria. The prevalence of a positive FAST exam after penetrating trauma was fairly low ranging from 24.2% to 56.3%.The FAST exam for penetrating trauma is a highly specific (94.1–100.0%), but not very sensitive (28.1–100%) diagnostic modality. CONCLUSION From the review of the literature, a positive FAST exam has a high incidence of intraabdominal injury and should prompt an exploratory laparotomy. However, a negative initial FAST exam after penetrating trauma should prompt further diagnostic studies such as LWE, CT, DPL, or laparotomy.
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Affiliation(s)
- Antonia C Quinn
- Department of Emergency Medicine, SUNY-Downstate Medical Center, Brooklyn, NY 11203, United States.
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Lisciandro GR. Abdominal and thoracic focused assessment with sonography for trauma, triage, and monitoring in small animals. J Vet Emerg Crit Care (San Antonio) 2011; 21:104-22. [DOI: 10.1111/j.1476-4431.2011.00626.x] [Citation(s) in RCA: 134] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Long-Term Functional and Echocardiographic Assessment After Penetrating Cardiac Injury: 5-Year Follow-Up Results. ACTA ACUST UNITED AC 2011; 70:701-4. [DOI: 10.1097/ta.0b013e31820c405a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Accuracy of conventional imaging of penetrating torso injuries in the trauma resuscitation room. Eur J Emerg Med 2011; 16:305-11. [PMID: 19417677 DOI: 10.1097/mej.0b013e32832c3ab9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Chest X-ray (CXR), abdominal ultrasound, cardiac ultrasound, and abdominal X-ray are the most frequently used imaging modalities to radiologically evaluate patients with penetrating torso trauma. The aim of this study was to evaluate the accuracy of these imaging modalities. METHODS From January 2001 until January 2005, all consecutive patients with penetrating torso injuries presenting at the emergency department of a level 1 trauma center were included. Imaging modalities (chest/abdominal X-ray, abdominal/cardiac ultrasound), were compared retrospectively with a 'gold standard' (i.e. computed tomography or surgery within 2 h after arrival) or outcome of conservative treatment. The accuracy of the imaging modalities was calculated. RESULTS Three hundred and eighteen patients were included. On the basis of 299 CXRs, the sensitivity for diagnosing pneumothorax, hemothorax, and subcutaneous emphysema was 71, 63, and 61%, respectively. The sensitivity of abdominal ultrasound (N = 229) to detect free abdominal fluid and/or intra-abdominal injury was 65%. The specificity, positive predictive value, negative predictive value, and accuracy of the two imaging modalities to detect any of the diagnoses mentioned were >or=87%. Cardiac ultrasound (N = 31) did not show any false positive or negative results for detecting cardiac effusion. Pneumoperitoneum was not seen on abdominal X-ray in eight of 11 patients with perforation of a hollow organ. CONCLUSION Despite high specificity, positive predictive value, and negative predictive value, a considerable number of lesions remain undetected after CXR and abdominal ultrasound because of moderate-to-inadequate sensitivity. Abdominal X-ray hardly provides additional information. Careful clinical monitoring of patients is mandatory, particularly when computed tomography scan or operative treatment is not indicated.
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Morrison JJ, Clasper JC, Gibb I, Midwinter M. Management of Penetrating Abdominal Trauma in the Conflict Environment: The Role of Computed Tomography Scanning. World J Surg 2010; 35:27-33. [PMID: 20845038 DOI: 10.1007/s00268-010-0782-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jonathan J Morrison
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Edgbaston, Birmingham, B15 2SQ, UK.
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Hartert M, Dahm M, Neufang A, Vahl CF. Minimum cause--maximum effect: the travelogue of a bullet. Interact Cardiovasc Thorac Surg 2010; 11:698-700. [PMID: 20709697 DOI: 10.1510/icvts.2010.245100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This case report involves a 57-year-old male, accidentally shot in the chest with a small bore firearm. The bullet entered the left hemithorax, disrupting the left internal mammarian artery. It then penetrated the anterior wall of the right ventricle causing a pericardial tamponade. After leaving the base of the right heart it perforated the diaphragm, the liver, the spleen and the pancreas. Finally, it penetrated the abdominal aorta 3 cm proximally to the coeliac trunk and reached its final position paravertebrally. This case report illustrates that the management of even minimum gunshot wounds requires a maximum variety of surgical skills.
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Affiliation(s)
- Marc Hartert
- Department of Cardiothoracic and Vascular Surgery, University Medical Center, Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany.
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Clarke DL, Allorto NL, Thomson SR. An audit of failed non-operative management of abdominal stab wounds. Injury 2010; 41:488-91. [PMID: 19913226 DOI: 10.1016/j.injury.2009.10.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Revised: 10/13/2009] [Accepted: 10/13/2009] [Indexed: 02/02/2023]
Abstract
UNLABELLED Selective non-operative management based on clinical assessment has been shown to be a generally safe approach in the management of penetrating stab wounds of the torso. However there will be a subset of patients who fail selective non-operative management. This audit focuses on the failures. METHODS The metropolitan surgical service in Pietermaritzburg covers 3 hospitals. At the weekly metropolitan morbidity and mortality meeting all trauma patients are reviewed. All cases of failed selective non-operative management of penetrating abdominal stab wounds are discussed. Failed non-operative management is usually defined as any patient who ultimately requires surgical exploration. We do not subscribe to this as we feel as long as the need for surgical intervention is recognised within a short period of time (<12h) there is little additional morbidity. Recognition of the need for surgical intervention after 12h would be regarded by us as failed non-operative management as we feel the risk of delay associated morbidity begins to increase significantly after this time. RESULTS A total of 340 patients with a penetrating anterior abdominal stab wound were managed over the 2 year period under review. A total of 192 (56%) of these patients were subjected to mandatory laparotomy. Of these mandatory laparotomies 98% were positive. The remaining 148 (44%) patients were observed. Of the 148 observed patients a total of 30 (20%) subsequently underwent surgery. A total of 13 patients were only taken to surgery after 12h of observation. In this group of 13 patients the average delay between admission and recognition of injury was 40 h. There were six gastric injuries, one pyloric and pancreatic injury, two gallbladder injuries, one liver, one colon and two small bowel injuries. There were no deaths. 9 patients recovered with no additional morbidity. In the remainder, morbidity included, relaparotomy (1), open abdomen (1), renal failure (1) and prolonged stay in ICU (3). CONCLUSION Clinical assessment accurately predicts the need for mandatory laparotomy following a stab wound to the torso. In patients who do not meet the indications for mandatory laparotomy and who are subjected to non-operative management 20% will come to surgery. A subgroup may only be recognised as requiring surgery after more than 12h. These patients are at risk of delay associated morbidity. There are particular anatomical sites and structures which are prone to error.
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Affiliation(s)
- D L Clarke
- Pietermaritzburg Metropolitan Complex, Department of General Surgery, University of Kwa-Zulu Natal, Nelson R Mandela School of Medicine, South Africa.
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Stein DM, Scalea TM. Trauma to the Torso. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_27] [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]
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Pastore GE, Lamb CR, Lipscomb V. Comparison of the results of abdominal ultrasonography and exploratory laparotomy in the dog and cat. J Am Anim Hosp Assoc 2007; 43:264-9. [PMID: 17823475 DOI: 10.5326/0430264] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Results of preoperative ultrasonography and exploratory laparotomy were reviewed retrospectively in a series of 100 small animals to assess the agreement between ultrasonographic and surgical findings and to identify abdominal lesions likely to be missed by ultrasonography. Good agreement occurred between ultrasound reports and surgical reports in 64% of the animals, which supported the use of ultrasonography in potential surgical candidates. A major discrepancy was observed between the ultrasound report and surgical findings in 25% of the animals. Of the various types of pathology encountered in the study, gastrointestinal ulceration or perforation was the most likely lesion to be missed by ultrasonography.
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Affiliation(s)
- Gina E Pastore
- The Queen Mother Hospital for Animals, Royal Veterinary College, North Mymms, Hatfield, Hertfordshire, United Kingdom
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Abstract
The management of penetrating injuries to the abdomen has evolved back to a selective nonoperative approach. Using clinical examination for screening, evaluable patients without hemodynamic instability or peritonitis can safely undergo a trial of nonoperative management. For stab wounds, this involves serial clinical examination with delayed laparoscopic evaluation of the diaphragm for left thoracoabdominal injuries and CT scanning for suspected solid-organ injuries. The same contraindications to nonoperative management apply to gunshot injuries. Gunshot injuries undergoing nonoperative management require detailed trajectory imaging with CT. The presence of peritoneal violation without definite organ injury requires serial clinical examination. Isolated solid-organ injury is not an absolute contraindication to nonoperative management and may benefit from advanced endovascular and percutaneous interventions to facilitate management. Selective nonoperative management of both stab wounds and gunshot injuries is safe and has been shown to decrease the rate of unnecessary laparotomy, length of hospital stay, and management costs.
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Affiliation(s)
- Kenji Inaba
- Division of Trauma Surgery and Critical Care, Los Angeles County and University of Southern California Medical Center, 1200 North State Street, Rm 10-750, Los Angeles, CA 90033, USA.
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Menaker J, Cushman J, Vermillion JM, Rosenthal RE, Scalea TM. Ultrasound-diagnosed cardiac tamponade after blunt abdominal trauma—treated with emergent thoracotomy. J Emerg Med 2007; 32:99-103. [PMID: 17239739 DOI: 10.1016/j.jemermed.2006.05.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Revised: 10/07/2005] [Accepted: 05/22/2006] [Indexed: 11/29/2022]
Abstract
Ultrasound imaging enhances the physician's ability to evaluate, diagnose, and treat emergency department (ED) patients. Because ultrasound imaging is often time-dependent in the acutely ill or injured patient, the emergency physician is in an ideal position to use this technology. Focused ultrasound examinations provide immediate information and can answer specific questions about the patient's physical condition. We report a case in which blunt trauma to the abdomen and pre-existing pericardial fluid, due to human immunodeficiency virus (HIV), caused pericardial tamponade, diagnosed by bedside ultrasonography, and subsequent cardiac arrest. An ED thoracotomy released this tamponade, and spontaneous cardiac activity returned. The indications for and efficacy of ED thoracotomy have been debated for many years. Multiple studies have shown that patients with isolated penetrating chest trauma have the best outcome and that patients with blunt trauma without signs of life at the scene or in the ED have the poorest. We demonstrate the importance of ultrasound use by emergency physicians to assess trauma patients with pulseless electrical activity and suggest that in specific clinical situations after blunt trauma, an ED thoracotomy can be life saving.
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Affiliation(s)
- Jay Menaker
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Soffer D, Schulman CI, McKenney MG, Cohn S, Renaud NA, Namias N, Lynn M. What Does Ultrasonography Miss in Blunt Trauma Patients With A Low Glasgow Coma Score (GCS)? ACTA ACUST UNITED AC 2006; 60:1184-8. [PMID: 16766959 DOI: 10.1097/01.ta.0000196751.46589.0d] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The role of ultrasound (US) as a screening tool for the evaluation of blunt abdominal trauma is still controversial. Determining the types of missed injuries and the accuracy of US in patients with a low GCS will improve the evaluation of these blunt trauma patients. METHODS Prospectively collected data from the trauma registry of a Level I trauma center was reviewed. RESULTS 7,952 patients were included in the study. US examination had an accuracy of 89%, sensitivity of 77%, specificity of 97%, positive predictive value (PPV) of 78%, and negative predictive value (NPV) of 98%. GCS correlated with ISS and base deficit levels. US examination had a significantly lower accuracy in patients with a low GCS and in women. CONCLUSION The sensitivity and specificity of US examination is similar in those with normal and low GCS. Therefore ultrasonographic examination may be considered a good screening tool for the evaluation of patients with blunt abdominal trauma, but its accuracy is diminished in patients with a low GCS. Further imaging may be warranted in these patients.
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Affiliation(s)
- Dror Soffer
- Dewitt Daughtry Family Department of Surgery, Division of Trauma, University of Miami School of Medicine, Miami, Florida 33101, USA
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