With advanced skill and technology, the use of emer- gency ultrasonography is extended from blunt abdominaltrauma to include chest trauma also. The term ‘Focused Assessment with Sonography for Trauma ’ (FAST) was coined by Rozycki et al. in 1996. In such FAST scans, in addition to detecting free intra-peritoneal fluid, they also attempted to detect any fluid collection in the pericardium and lung bases through the subxiphoid, right upper quadrant, and left upper quadrant views. FAST scan, therefore, also played a significant role in early detection of cardiac temponade and hemothorax in trauma patients . In 2002, Dulchavsky further extended the use of FAST scan to involve extremity and respiratory evaluation and named it the FASTER examination. Such FASTER examination may play an important role in remote locations, such as military and aerospace applications . There were several limitations to this study, including the small sample size. Also, it was a retrospective study and not randomized.
Although its location in the right upper quadrant and costal margin afford some protection, the position assumed at the time of injury may make it possible for injurious forces applied to the other quadrants of the abdomen to reach and produce deleterious effects on this organ. Death is usually due to haemorrhage. The mechanism of liver injuries are direct blows, which causes compression between lower ribs on the right and the spine, or shearing at fixed points, secondary to decelaration in blunt abdominaltrauma.
Fast is used to detect fluid in the Morison and splenore- nal pouch, pelvis and around the pericard, recently eFAST (Extended FAST) was introduced and included also the evaluation of both hemithoraxes. FAST has not gained popularity among pediatric trauma care pro- viders. A national survey published in 2009 revealed that only 15 % of pediatric trauma centers in the United States adopted FAST as part of a blunt abdominal injury assessment protocol, compared to 96 % of the adult centers . Therefore, the body of evidence for the use of FAST in the pediatric population is limited and mostly extrapolated from studies in adults. Furthermore, data on the sensitivity and specificity of FAST in toddlers
19-year-old man was brought to the emergency service after a high speed car crash. On arrival at the emergency department, the patient was monitorized and maintained a heart rate of 120 beats/minute (sinus tachycardia), with a blood pressure of 90/40 mmHg. Fluid resuscitation was initiated with normal saline. There was no obvious exsan- guination injury present. The Glascow Coma Scale score was 15. There was found no significant thoracic or cranial trauma. A FocusedAbdominalSonography for Trauma
symptoms and large differences in individual patient reactions to intra-abdominal injury . Thus, diagnostic tests must be selected, performed and interpreted to reliably discriminate between patients who require therapeutic intervention or further study from those who do not. Quick ultra sonographic screening to identify the presence of free intraperitoneal and intrapericardial fluid constitutes focusedabdominalsonography for trauma (FAST) examination, which is becoming the clinical standard . The most important benefits of this technique are an earlier and portable means of confirming the presence of intracavity hemorrhage or visceral leakage . Boulanger and associates reported in 2000 that FAST had replaced diagnostic peritoneal lavage as the initial screening test after blunt abdominaltrauma in the majority of North American trauma centers. The goal of FAST examination, as defined by a recent international consensus conference, is to detect free intraperitoneal fluid as a marker of injury. In current practice, FAST has taken on 2 congruous yet distinct roles. One is the early identification of unstable trauma victims requiring urgent surgical intervention, and the other newer, potentially controversial, role is that of excluding stable patients from further abdominal imaging . Institutional trauma protocols at many trauma centers have accepted FAST’s ability to do both; thus, unstable patients with positive FAST results are operated on, and stable patients with negative. FAST results tend to be observed, depending on the US findings and clinical examination. In one study, authors examined the validity of this practice and evaluated the role of HHFAST (Hand Held FAST).Portable hand-held (HH) ultrasonography (US) units have recently become available to clinicians. These units were developed through a joint civilian–military initiative to provide portable US capability suitable for the battlefield or a mass casualty situation .
diagnostics, hospital and ICU length of stay, and hospital charges. Regression models controlled for confounders and analyzed physician-to-physician variability. All analyses were conducted on an intention-to-treat basis. Results were presented as mean, first-quartile, median, and third-quartile with multiplicative change and 95% confidence intervals; or percentage with odds ratio and 95% confidence intervals. 444 patients with suspected torso trauma were eligible; 136 lacked consent and attendings refused enrollment of 46. 262 patients were enrolled: 135 PLUS and 127 controls; 45 patients were discharged from the ED or ‘‘Walked Out AMA’’, leaving 111 PLUS and 106 Control patients in the final analysis. There were no baseline differences between groups. Time to OR was 64% (48, 76) less for PLUS com- pared to control patients. PLUS patients underwent fewer CT, Odds Ratio = 0.16 (0.07, 0.32), spent 27% (1, 46) fewer days in hospital, suffered fewer complications, Odds Ratio = 0.16 (0.07, 0.32), and charges were 35% (19, 48) less compared to control. The authors concluded that a PLUS-inclusive protocol significantly decreased time to OR in patients with suspected torso trauma, with improved resource utilization and lower charges.
Their results are supported by a large retrospective cohort study that showed two independent factors – the presence of severe head injury and severe extremity injury – significantly associated with false-negative FAST examination with odds ratios of 4.90 and 1.86, respectively. Interestingly, abdominal organ injuries are not associated with false-negative FAST examination. There is no association between hospital length of stay, ICU length of stay, therapeutic laparotomy or mortal- ity and false-negative FAST examination. 61
In the first week of the term break, a five-day ultra- sound course for the new student tutors held by faculty members takes place. This course starts with an an- onymous written test of the students’ already existing anatomical / ultrasound knowledge. The actual content of the course is then delivered by alternating for each section between theoretical lectures and hands-on prac- ticals. In summary, day 1 covers the basic physics and the handling of the ultrasound device as well as image optimisation. The anatomical focus is then on the liver, gallbladder, and bile ducts. Day 2 deals with the retro- peritoneum, abdominal vessels, lymphnodes, pancreas, spleen, kidneys, bladder, uterus, and prostate covering their anatomy, scanning techniques as well as patholo- gies. Day 3 summarizes the above described skills to achieve a systematic examination of the abdomen. In a second section, focused echocardiography in emergency life support including thorax and heart (FEEL) is taught. Day 4 deals with the thyroid, jugular veins, carotid arter- ies, and lymph nodes - again including their anatomy, scanning technique, and pathologies. In the same way, duplex sonography and compression sonography of the deep veins are detailed. Day 5 deals specifically with thorax examination and an extended focus on ultra- sound in trauma assessement (eFAST). For the eFAST, students could practice on an ultrasound dummy. The course concludes with theoretical and practical post-test (including multiple choice tests and objective structured clinical examinations), the course evaluation, and a debriefing.
Focused abdominalsonographyin trauma (FAST) was familiarized in the United States by Rozycki in the early 1990s. starting and follow-up experience indicated that FAST was accurate, non-invasive, and expeditious inassessing the critically traumatised patient in the emergency room. As quality ultrasound machines have become portable there is an increasing trend of theirapplication in the initial assessment of blunt abdominal injury. The procedure can be done by surgeons as well as radiologists both of equal reliability and was particularly useful in detecting hemoperitoniumin the abdominal cavity.
Aim: To assess the sensitivity and specificity of FAST scans in pediatric trauma in a dedicated pe- diatric trauma centre. Method: A 3-year (2008-2011) analysis of prospectively collected data look- ing at the results of FAST scans compared to Computed Tomography (CT) or laparotomy findings. Results: There were 482 pediatric trauma calls of which 166 patients had suspected intra-abdo- minal injury. 163 patients underwent CT scans of which 89 (55%) had FAST scans prior to CT. 3 patients had FAST scans without CT; 1 patient went straight to theatre (positive FAST) and 2 pa- tients died in the department before any further imaging. The sensitivity of FAST scans to detect abdominal injury is 23% and the specificity is 97%. The injuries missed on FAST scan were: liver lacerations (n = 3), splenic lacerations (n = 5), 1 combined liver and kidney injury and 1 combined splenic injury and small bowel perforation. Conclusions: FAST scans in trauma have a low sensi- tivity in pediatric patients with the possibility of missing significant intra-abdominal injury. They do not obviate the need for CT scan when clinical suspicion is high.
It is obvious that in blunt abdominaltrauma, a rapid decision regarding the need for emergency laparotomy is crucial and lifesaving, especially for those with unstable hemodynamics. So, e-FAST done by EMPs, with good sensitivity and specificity and reasonable diagnostic accuracy, will save time, avoid patient transfer to the radiology department, and be a useful tool for early decision making in such cases. But, studies to assess the diagnostic accuracy of e-FAST done by EMPs are still limited in the Indian setting. Considering the importance of this topic, a comparative study was conducted to assess the accuracy and reproducibility of e-FAST performed by emergency medicine residents (EMRs) and radiology consultants (RCs) in multiple trauma patients.
Computed Tomography scan of the abdomen and pelvis is the procedure of choice to evaluate the hemodynamically stable patient who has sustained blunt or penetrating trauma. CT has replaced Diagnostic Peritoneal Lavage (DPL) as the first method of choice in many trauma centers worldwide [8,9]. However, it has several disadvantages as it is relatively expensive, involves the usage of ionizing radiation and requires the shifting of patient to the scanner which may interfere with ongoing resuscitation. Furthermore, it is not always available particularly in small peripheral centres. [5, 6, 10].
Method: In this prospective study, pediatric patients with BAT and high energy trauma who were referred to the emergency department (ED) at Al-Zahra and Kashani hospitals in Isfahan, Iran, were evaluated using FAST, first by EMRs and subsequently by RRs. The reports provided by the two resident groups were compared with the final outcome based on the results of the abdominal computed tomography (CT), operative exploration, and clinical observation.
Our center is a tertiary care hospital and one of the largest hospitals in central Gujarat, where many patients of Blunt AbdominalTrauma are referred from rural parts of central and south Gujarat region as well as from the border areas of nearby states like Madhya Pradesh, Maharashtra and Rajasthan also. Till date, no such study on FAST has been conducted at our center and perhaps in Gujarat. Therefore, this study was undertaken to assess the efficacy of FAST in patients with Blunt AbdominalTrauma and to define the utility of FAST as a screening test for detection of free fluid in abdomen .
or secretory) can lead to an increase in IAP. Resuscitation and edema formation after shock or relative ischemia may result in a cyclic process that perpetuates IAP elevation. Hence for aggressive resuscitation in the patients sustaining solid organ injuries the probability of hemodynamic de- rangement from IAP elevation is high. A further increase of the IAP will subsequently compromise the hemodynamics and result in non-operative failure. A negative abdominal exploration in these patients can be avoided if ACS due to excessive fluid can be recognized at an early stage by continuous monitoring of bladder pressures. Burch et al. developed a working grade system for ACS on the basis of urinary bladder pressure measurements. They recom- mended that in patients after celiotomy with bladder pres- sure of 26 to 35 cm H2O decompression is necessary and with bladder pressure exceeding 35 cm H2O reexploration is mandatory . These findings match with our study in which Bladder pressure more than 25 cm of H2O was sta- tistically significant when compared to time of intervention. In our study we found that more than 3 deranged clinical parameters (out of Bladder pressure, SC, RR, MAP and AG) was associated with 100 % intervention.
Contrary to popular belief that such injuries are usu- ally instantly fatal, accounts of coronary artery rupture report a time window ranging from 2 to 56 h [Table 1]. This time window could theoretically be sufficient to avoid mortality when timely management is provided. Patients with pericardial effusion or hemodynamic in- stability should undergo prompt exploratory surgery. As discussed above, pericardiocentesis might be of limited utility in these cases since it has been observed that blood can accumulate in the form of epicardial hematoma in- stead of collecting in the pericardial space. In addition, despite the presence of pericardial effusion, coronary in- jury was only identified intraoperatively or at autopsy and was not suspected preoperatively in most reported cases [Table 1]. Therefore, a low threshold for timely thoracot- omy and exploration should be kept in patients with blunt chest trauma and pericardial effusion or hemodynamic instability. More stable patients, in absence of pericar- dial effusion, who continue to complain of chest pain or other cardiac symptoms, and those who show evi- dence of myocardial ischemia on electrocardiogram or elevated cardiac enzymes, can undergo formal echocar- diogram followed by coronary angiogram to detect any coronary injury.
Clinicians and supervisors will need time and support to do this intensive work. Agencies must also be capable of delivering an intervention that may last 12-25 sessions. Although not all children need the full protocol, some components may require more time with some clients if they are to be effective. Teaching new skills or altering maladaptive cognitions often takes repeated sessions as well as practice between sessions. Also the trauma narrative component should not be delivered if the setting cannot offer regular sessions or if children remain in a dangerous environment because this component is based on the principle that repeated exposure to upsetting memories gradually decreases negative emotional responses or maladaptive avoidance coping.
The first aeromedical transport program was established in 1972 at St Anthony's Hospital in Denver, Colo. Since then, the number of aeromedical programs has grown steadily, reaching more than 160 today. Some services that began with single rotor-wing aircraft have added additional helicopters, fixed- wing aircraft, or ground critical care transport capability. Aeromedical transport services now provide much more than trauma scene response assistance. Air transport services also transfer patients from EDs or inpatient units of referring hospitals to receiving tertiary care centers. Fixed-wing transports (see Picture 2) are particularly useful for long-distance (ie, >150-200 miles) interfacility transports and can operate in weather conditions that may restrict rotor-wing aircraft.