Post on 17-Sep-2018
TheRoleoftheFASTexamintheEDRU
A.RobbMcLean,MD,MHCMViceChairofClinicalOperations,
DepartmentofEmergencyMedicine
JointTraumaConferenceJune20,2017
Goals
• Describetheperformance,andperformancecharacteristics,oftheFAST/E-Fast• AnswercriticalquestionsabouttheuseofFASTexamsintrauma• FormallyintegrateFASTexamsintoTraumaResuscitationsintheEDRU
CriticalQuestions
• FASTvsE-FAST?• BluntvsPenetratingTrauma• Pediatrics– isitdifferent?• WhenisapositiveFASTanindicationfortheOR?
FASTExam– APanacea?
• Bedside• Rapid• Noradiation• Cheap• Repeatable• Nocomplications
• PotentialClinicalBenefitsReductionsin:- Timetosurgery- CTUse- ED/HospitalLOS- Complications- Cost- Radiation
FASTExam
• 4keylocations• FreeFluid• Sensitivityforintraperitonealhemorrhage• 43-100%
• Specificity• 90-100%
Radiology: Volume 283: Number 1—April 2017
FASTViews
• RUQviews• Sagittalprobeorientation• 7th-9th ICS,obliqueorientation• Morison’spouch• Sub-phrenic• Inferiorrenalpole• Diaphragm/lung
• Sub-xiphoidview• Transverseprobeorientation• Liver,rightheart,leftheart• Eval chambersandrelativesizeofventricles,squeeze,pericardialfluid
• LUQView• Sagittalprobeorientation• 5th-7th ICspace,obliqueposition• SweepfromAnttoPost• Spleno-renalandsub-phrenicrecesses,inferiorrenalpole
• Diaphragm/Pleuralinterface• PelvicView
• SagittalandTransverseprobeorientation
• Fullbladder• Fluidbehindbladder,behinduterus,behindloopsofbowel
E-Fast– ExtendedFAST
• Lungwindows• IncreasedsensitivityforPTXoverCXR
(43-91%vs11-50%)
• 2nd-3rd ICSpace(reduceDoF)- Slidinglung- Comettails- M-mode“seashore”sign
- “barcode”or“stratosphere”signinPTX
• Whatistheclinicalsignificance?Radiology: Volume 283: Number 1—April 2017
E-Fast(cont’d)
Radiology: Volume 283: Number 1—April 2017 http://emedicine.medscape.com/article/1883608-overview#a3
Comet-tailArtifactsM-mode:LungPoint,Seashore,Barcodesigns
LimitationsoftheFASTInjuries• LackofFFinpediatricSOI• Mesenteric,hollowviscous,diaphragmatic,andisolatedpenetratinginjuries• Retroperitonealbleeding/injuries• SuccessfullyidentifiesoccultPTXnotneedingintervention
PatientCharacteristics• Falsepositives(ascites,physiologicFFinfemales,PD,VPshunts,uroperitoneum inpelvictrauma)• Obesity,subcutaneousemphysema,bowelgas,adhesions,patientcooperationandpositioning• Pericardialfatpad,pre-existingeffusions• Mainstem intubation,pleurodesis,severeCOPD
AlternativestoFAST
• PhysicalExam!• CT• DiagnosticPeritonealLavage• LocalWoundExploration• Laparoscopy/Laparotomy
Emergencyultrasound-basedalgorithmsfordiagnosingbluntabdominalTrauma(update9/15)
4RCTsPoortomoderatemethodologicquality
PooledMortalityDataRR1.00(95%CI0.50to2.00)FAST-basedpathwaysreducedCTScans(randomeffectsmodelRD-0.52,95%CI-0.83to-0.21)
“Inahemodynamicallyunstablepatientwithbluntabdominaltraumaisbedsideultrasoundthediagnosticmodalityofchoice?...
LevelBrecommendation– Inhemodynamicallyunstablepatients(systolicbloodpressure<or=90mmHg)withbluntabdominaltrauma,bedsideultrasound,whenavailable,shouldbetheinitialdiagnosticmodalityperformedtoidentifythetheneedforemergentlaparotomy”
“SerialUltrasoundscanbehelpfulinpatientswithbluntabdominaltrauma.”
“Ultrasoundshouldnotbeconsideredthesoletest”
“Anegativeultrasoundresultinahemodynamicallyunstablepatientdoesnotprecludetheneedforfurtherdiagnostictesting.”
• FASTfallsunderprimarysurvey“C– Circulation”• AnegativeFASTdoesnotruleoutIAI• “AbsoluteindicationforlaparotomyisacontraindicationtoFAST”
• PediatricCaveats• largevolumebloodmoreassoc withsignificantinjurybutneedforoperativemanagementdeterminedbyhemodynamicinstabilityandresponsetoresuscitation.SmallamountsFFinstablechilddeservesCTscan
• Isolatedintraprenchymal injury(withoutFF)occursin1/3ofSOIinkids.
*RoleofFASTdependsonpatientstabilityandATLSprincipleofrapidresponders,transientrespondersandnon-responders
PenetratingTrauma
• EAST- PracticeManagementGuidelinesforSelectiveNonoperativeManagementofPenetratingAbdominalTrauma• JTrauma2010;68(3)721-733• AdditionalstudiesnecessaryifFASTnegative• “NotenoughdatatomakearecommendationabouttheuseofUSinthispatientpopulation”
• 2009Meta-analysis– 8studies• N=565• Sensitivity28-100%.Specificity94-100%.• Positivefastshouldpromptex-lap.Negativeshouldpromptadditionalstudies.
PediatricsandtheFASTExam• 2009Survey
• 15%dedicatedPeds EDsusedFASTvs96%AdultEDs• 2017study
• UseofFASTacross14centersrangedfrom1-94%(CTuse6-94%)• UniqueFeatures
• >1/3ofchildrenwithSOIwillhavenoFFonexam• OperativemanagementmoreoftendictatedbyVSinstabilityratherthanpresenceoffreefluid
• Moreoftenusedasanextensionofthephysicalexam- repeatable• Sensitivity(28-90%)
• 66%forhemoperitoneum (50%forIAI)in2007meta-analysis• 52%formoderateorgreaterHPinprospectivestudy
• Specificity(>90%)
FASTInPediatrics– Hotoffthepress!
FocusedAssessmentwithSonographyforTrauma(FAST)inChildrenFollowingBluntAbdominalTrauma:AMulti-InstitutionalAnalysis.JTraumaAcuteCareSurg.ePub 6/6/17
PediatricsandtheFAST(continued)
• PediatricTakeHomepoints• Moderatefreefluidsuggestshemoperitoneum fromIAIrequiringfurtherdiagnostics• NegativeFASTinstablepatientinadequateassolediagnostictest• PositiveFASTinunstablechildmaypromptearliertransfusionoremergentlaparotomywithoutfurtherimaging
DocRight• Completes“C”(circulation)oftheprimaryassessment(assessmentofBP,central&peripheralpulses,currentIVaccess)andannouncesittothetraumateamleader• Performsthesecondaryassessmentfromheadtotoeandreportsallpositiveandnegativefindings• Obtains“AMPLE”historyatthecompletionofthesecondaryassessmentofthepatient• MayperformothertasksasdelegatedbyTTL
PrinciplesofFASTexamsintheEDRU• AllTraumaAlertProtocolpatientsshouldgetaFASTexam(DocRight)• UnstablePatients– PartofC,Circulation• Stablepatients– aftersecondaryexamORuponreturnfromCT
• UnstablepatientswithpositiveFASTexamsgototheOR(Non-Responders)• USshouldnotbeusedassoleimagingforpatients“atrisk”• CT,serialexams,laparotomy,DPL,LWE
• FASTinPediatricpatientshaslowersensitivityforIAIandmaynotaltermanagement