TheRoleoftheFASTexamintheEDRU

A.RobbMcLean,MD,MHCMViceChairofClinicalOperations,

DepartmentofEmergencyMedicine

JointTraumaConferenceJune20,2017

Disclosures

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

• https://youtu.be/26RQyxk5vGc?t=34s

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.

2017WesternTraumaStabWoundAbdomenAlg.*PresentedatMarchmeeting

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

Discussion