indications for the FAST exam in the trauma patient?

[Painter1]

had a middle-aged guy brought in after he was struck by a car, he's talking, has lac to scalp. nurse had activated the trauma team.

i stand back and allow the surgery residents to perform the trauma survey. i'm kinda new at this hospital. anyway, so i get the US and start doing a FAST exam when the senior surgery resident becomes inapproriately loud asking why the FAST was being performed. he claimed it wasn't indicated because the patient had normal vitals and no abd tenderness.

where i trained, anyone with a significant mechanism got a FAST (e.g. getting struck by a car) as part of or right after the primary survey. this was independant of vitals.

i'm i missing something here?

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[turtle md]

No.

Don't let a surgeon tell you your job.

 

[Rendar5]

It's part of the secondary survey afaik. Where I'm at now, they teach us that abdominal pain is an indication for CT, not FAST, as FAST only looks for fluid pooling, not for organ damage, and is a screening tool, not a diagnostic tool.

 

[kungfufishing]

I've had a surgery resident loudly and vehemently suggest that a negative FAST ruled out intra-abdominal injury. Being condescending does not make them correct. I find the FAST to be relatively low yield in my practice, but it takes maybe a minute to do, so why not.

 

[iridesingltrack]

At my institution, everyone with blunt trauma and an abdomen gets a FAST by us or trauma as part of the secondary survey. However, it is my understanding that the "indications" are blunt abd trauma with hemodynamic instability (if positive: to the OR), and blunt abd trauma with distracting injury that makes abd exam unreliable (if positive: CT scan). Oddly, the majority of the latter get CTs regardless and therefore, the FAST doesn't change the medical decision making. It seems FAST only changes things if the patient is unstable.

Regardless, no one should become obnoxious just because a FAST is being done. People are strange.

Just my 0.02.

 

[southerndoc]

If it's important enough to involve the trauma team, it's important enough to do a FAST exam.

What's the downside? It's not like you're radiating the patient by doing a FAST. You can do one quickly, safety, and stay out of the other team member's way.

I've seen two cases where "isolated head injured" patients have had positive FAST's and turned out to have a liver lac and a ruptured spleen.

 

[Jeff698]

Now working in a non-trauma center community hospital, I've found a new indication for FAST scans...

Reassuring anxious non-ill patients that they don't need a CT scan. After all, the US is a "test" and "tests" clearly are better than physical exam.

Now I just wish I could find a way to do an US on a child's brain to "prove" they don't need a CT scan.

Take care,
Jeff

 

[deleted65604]

At academic institutions, FAST scans are usually done because you can. Residents need training in the modality and you have a trauma patient in front of you, so...why not?

I don't do ultrasound if the patient's mental status is normal and if they have no abdominal tenderness.

 

[jbar]

I'd argue that if the mechanism was large enough to "activate the trauma team" or call a trauma alert a FAST should be considered. Basically if you are calling the team you are saying "I think there is a strong indication that this patient has injured multiple things and/or may be seriously injured. Therefore wouldn't you want to do a FAST because if positive the patient may be skipping the CT and going directly for surgery (or chest tube or pericardiocentisis etc assuming unstable).

 

[Rendar5]

Has anyone had positive FASTs in trauma patients where there wasn't internal injury? Just wondering if there is reasonable chance of false positives and therefore some at least theoretical reason to not do them on a trauma pt without an "indication". I personally haven't heard of this in my very limited experience, just wondering if someone else has.

 

[Apollyon]

Has anyone had positive FASTs in trauma patients where there wasn't internal injury? Just wondering if there is reasonable chance of false positives and therefore some at least theoretical reason to not do them on a trauma pt without an "indication". I personally haven't heard of this in my very limited experience, just wondering if someone else has.

I never have. The FAST is for free fluid in the abdomen - it would take quite an alignment of stars to have 1. enough physiologic free fluid to be visible 2. no blood on ex lap and 3. trauma to the abdomen to get the FAST.

I mean, I guess it could happen...

 

[Haemr Head]

It never hurts to perform the FAST exam and it is standard to do so when activating the trauma team, even when the vital signs are stable.
As mentioned in an earlier post, a postive FAST implies a lot of fluid. Of course if the patient may ascites before the accident but this is usually easy to tell or very rare. In a healthy individual there is never enough physiologic fluid in the peritoneum to be seen on FAST.
There are plenty of reasons to do the FAST in a stable patient. If you are on the fence about the need for an abdominal CT, the FAST will provide a very strong indication for imaging.
If you are going to CT anyway, a positive FAST is useful because if the patient's vital signs take a nose dive before CT, you win the "Go straight to OR" card and shorten the time to the needed definitive intervention.
Doing a FAST in a stable trauma patient is standard in the 4 trauma centers I've worked at with ultrasound available, including Denver where we did a lot of the initial development of FAST.

The valuable lesson learned by this encounter should be that consultants, because of ignorance, personality disorder, work aversion, or stress, cannot be fully trusted as they can easily decompensate in the fast-paced enviroment of the ED. Unlike these visitors, emergency physicians do not loose their cool. You also (although you may not yet believe this) have more knowledge and skills in all types of resuscitation. As a good doctor, you should question yourself when challenged. Because of this, it is unsettling to be aggressed by an incompetent hysterical buffoon with a title. But one of the skills you need as an EM specialist is to manage unprofessional or incompetent consultants without losing your temper or allowing the patient to come to harm. Not being upset or angry is a trick that I still am trying to learn before I retire.

 

[WilcoWorld]

Has anyone had positive FASTs in trauma patients where there wasn't internal injury? Just wondering if there is reasonable chance of false positives and therefore some at least theoretical reason to not do them on a trauma pt without an "indication". I personally haven't heard of this in my very limited experience, just wondering if someone else has.

Yep - we have a lot of hepatopathic patients around here, and occasionally they get in car accidents. As far as I know ascites and blood can't be differentiated on FAST exam - both make it look positive. After scanning a guy with stable vitals, but a lot of free fluid, and finding no other evidence of injury we chalked it up to his liver disease.

That being said - if your liver's synthetic function is bad enough for you to have ascites I'm going to have a pretty low threshold for scanning you after an MVC.

 

[WilcoWorld]

But one of the skills you need as an EM specialist is to manage unprofessional or incompetent consultants without losing your temper or allowing the patient to come to harm.

I second and third this! The RRC should make this a core competency.

 

[Doctor Bob]

I second and third this! The RRC should make this a core competency.

Could we log it as a procedure?

 

[superpants]

A FAST exam is like any other test we do in the ED or anywhere else, you have to understand the characteristics and statistics of the study, otherwise the results can hurt you.

In teaching hospitals, the FAST exam is done more than indicated, mostly so that we get experience with the test.

In reality, the only utility in the FAST exam is in hypotensive, blunt trauma patients. The FAST truly only answers one question- does this hypotensive, blunt trauma patient need to go directly to the OR for laparotomy, or do they need a pericardiocentesis or something else to relieve tamponade.

If they are hemodynamically stable, then a FAST is not helpful, and may be hurtful. If someone has belly pain and they are stable, they get a CT. If somebody has AMS from a head injury with a significant, whole body mechanism (ie pedestrian vs auto, not baseball pitch to head), then you could argue that a FAST may be helpful there, but I still think a pan-scan is more useful if the patient is going to be intubated in an ICU for a while.

False positive FAST scans in hemodynamically stable people with normal mental status, and no abdominal pain or hematoma/seat belt sign, etc lead to to unneccesary CTs, and that means more $$, more radiation, and more contrast nephropathy.

This is how I use the FAST exam now as an attending. To be sure, I'm glad I did the exam hundreds of times as a resident when it was not truly indicated in order to develop my US skills. Just my 2 cents.

 

[EctopicFetus]

First post in 9 months.. Jeezz.. i used to be an all star on this site!

I would say this.. If the patient is stable (Vitals) and gonna get a CT there isnt much of a point in doing this since CT is superior. The real indication is your unstable trauma to guide the surgeon (open the belly or the chest)?

I would argue if you arent gonna CT the belly do the US on the belly.

But doing them on all patients is really just residency's way to get your practice.

I would be curious if anyone disagrees with the above.

 

[EctopicFetus]

A FAST exam is like any other test we do in the ED or anywhere else, you have to understand the characteristics and statistics of the study, otherwise the results can hurt you.

In teaching hospitals, the FAST exam is done more than indicated, mostly so that we get experience with the test.

In reality, the only utility in the FAST exam is in hypotensive, blunt trauma patients. The FAST truly only answers one question- does this hypotensive, blunt trauma patient need to go directly to the OR for laparotomy, or do they need a pericardiocentesis or something else to relieve tamponade.

If they are hemodynamically stable, then a FAST is not helpful, and may be hurtful. If someone has belly pain and they are stable, they get a CT. If somebody has AMS from a head injury with a significant, whole body mechanism (ie pedestrian vs auto, not baseball pitch to head), then you could argue that a FAST may be helpful there, but I still think a pan-scan is more useful if the patient is going to be intubated in an ICU for a while.

False positive FAST scans in hemodynamically stable people with normal mental status, and no abdominal pain or hematoma/seat belt sign, etc lead to to unneccesary CTs, and that means more $$, more radiation, and more contrast nephropathy.

This is how I use the FAST exam now as an attending. To be sure, I'm glad I did the exam hundreds of times as a resident when it was not truly indicated in order to develop my US skills. Just my 2 cents.

I should have read this prior to posting.. a more eloquent way of saying what I said!

 

[jbar]

I would say this.. If the patient is stable (Vitals) and gonna get a CT there isnt much of a point in doing this since CT is superior. The real indication is your unstable trauma to guide the surgeon (open the belly or the chest)?]

I mean you could argue that does it really make sense to CT the belly of someone who doesn't have any signs of of abdominal trauma? I guess many of our trauma patients are drunk/high/ have a distracting injury and you can't trust them. But as there is more and more data about the number of cancers we are causing with CTs, especially in younger patients, I think we're going to start seeing clinical rules of "what stable patients can you just do an FAST exam and defer the CT."

 

[EctopicFetus]

I would say this.. If the patient is stable (Vitals) and gonna get a CT there isnt much of a point in doing this since CT is superior. The real indication is your unstable trauma to guide the surgeon (open the belly or the chest)?]

I mean you could argue that does it really make sense to CT the belly of someone who doesn't have any signs of of abdominal trauma? I guess many of our trauma patients are drunk/high/ have a distracting injury and you can't trust them. But as there is more and more data about the number of cancers we are causing with CTs, especially in younger patients, I think we're going to start seeing clinical rules of "what stable patients can you just do an FAST exam and defer the CT."

JBar.. we already know the FAST isnt all that sensitive or specific so I dont see how this is true.

Additionally, there was a study that came out in November from UCLA that basically said.. you need to pan scan everyone with serious trauma cause we were missing too many problems. Now I doubt this study but I wouldnt get too excited about the use of US in trauma going much further than where we are now. I used it in every trauma patient I saw in residency but... that was for training.

I guess Ill just say I strongly doubt your idea comes to fruition anytime soon.

http://journals.lww.com/jtrauma/Abs..._of_Pan_Computed_Tomography_for_Blunt.18.aspx

Objective: Many trauma centers use the pan-computed tomography (CT) scan (head, neck, chest, and abdomen/pelvis) for the evaluation of blunt trauma. This prospective observational study was undertaken to determine whether a more selective approach could be justified.

Methods: We evaluated injuries in blunt trauma victims receiving a pan-CT scan at a level I trauma center. The primary outcome was injury needing immediate intervention. Secondary outcome was any injury. The perceived need for each scan was independently recorded by the emergency medicine and trauma surgery service before patients went to CT. A scan was unsupported if at least one of the physicians deemed it unnecessary.

Results: Between July, 1, 2007, and December, 28, 2007, 284 blunt trauma patients (average Injury Severity Score = 11) underwent a pan-CT after the survey form was completed. A total of 311 CT scans were judged to be unnecessary in 143 patients (27%), including scans of the head (62), neck (50), chest (116), and abdomen/pelvis (83). Of the 284 patients, 48 (17%) had injuries on 52 unsupported CT scans. An immediate intervention was required in 2 of the 48 patients (4%). Injuries that would have been missed included 5 of 62 unsupported head scans (8%), 2 of 50 neck scans (4%), 33 of 116 chest scans (28%), and 12 of 83 abdominal scans (14%). These missed injuries represent 5 of the 61 patients with closed head injuries (8%) in the series, 2 of the 23 with C-spine injuries (9%), 33 of the 112 with chest injuries (29%), and 12 of the 86 with abdominal injuries (14%). In 19 patients, none of the four CT scans was supported; nine of these had an injury identified, and six were admitted to the hospital (1 to the intensive care unit). Injuries that would have been missed included intraventricular and intracerebral hemorrhage (4), subarachnoid hemorrhage (2), cerebral contusion (1), C1 fracture (1), spinous and transverse process fractures (3), vertebral fracture (6), lung lacerations (1), lung contusions (14), small pneumothoraces (7), grade II-III liver and splenic lacerations (6), and perinephric or mesenteric hematomas (2).

Conclusions: In this small sample, physicians were willing to omit 27% of scans. If this was done, two injuries requiring immediate actions would have been missed initially, and other potentially important injuries would have been missed in 17% of patients.

I have the full article.. not perfect but quite compelling

 

[lucky_deadman]

I had Surgeons beat into my head during med school the following about digital rectal exams: The only two reasons to not do one is no finger or no rectum.

The only two reasons to not do a FAST in a trauma patient would be no U/S machine or no patient.

 

[roja]

The only two reasons to not do a FAST in a trauma patient would be no U/S machine or no patient.

I was going to say the same thing, although not as amusingly.


Remember: surgical residents are surgeons in training. They are prone to mistakes, to repeat something an attending told them or to have made their own false assumptions based on limited experience. although in a trauma, I am sure it is annoying, but if you are the attending, you are the one in charge. And you are in a position to educate. Of course, some are resistant to learning and I have found that sometimes a simple: could you show me the article/articles that show what you are saying, because this is what the literature I am familiar with shows..... or something along those lines.

Or if a resident is being disruptive in a trauma because they disagree, I politely tell them that I am the attending and x, y, and z will be done and once the patient has been evaluated, we can discuss it further. I have only had one resident continue to interfere. When the resident wasn't redirectable, I had the resident leave the resuscitation and call the surgical attending to come down.

 

[deleted89854]

I agree that a lot of FAST exams aren't indicated, but it's important to realize that the sensitivity of the test is directly proportional to the experience of the operator, with sensitivity approaching 90% in seasoned examiners. There's no real utility for the test in penetrating injury, since FAST cannot rule out hollow viscous injury. However, an example of when the test is essential is in the hemodynamically unstable blunt trauma patient. A positive test buys you an immediate trip to the OR, whereas a negative test increases suspicion of pelvic fracture (if cardiac/intrathoracic injury has been ruled out) and the IR team is activated for pelvic angioembolization. If there is any doubt, we perform DPL prior to heading to the angio suite.

 

[Apollyon]

I have only had one resident continue to interfere. When the resident wasn't redirectable, I had the resident leave the resuscitation and call the surgical attending to come down.

And then, post resuscitation, the resident had the attending driven right up the butt.

"In training" - that's the money right there.

 

[Haemr Head]

I had Surgeons beat into my head during med school the following about digital rectal exams: The only two reasons to not do one is no finger or no rectum.

The only two reasons to not do a FAST in a trauma patient would be no U/S machine or no patient.

There is a relative contraindication. No glove.

 

[Haemr Head]

From reading the exchanges on this topic, it seems that someone needs to formally study the effectiveness of FAST in the stable blunt trauma patient.
From experience (not evidence), I would argue for it, as "stability" ends up being a term used as clearly as the term "evidence". Appearance of stability is subjective (if I had a dollar for every patient the surgical resident thought was stable and I did not...). Stability can change within minutes and all it really tells you is that the patient does not need steel to the belly in the next 10 minutes. Knowing that there is a belly fully of blood in a patient with "stable" vital signs is information that I personally want as early as possible. Patients crash on the way to CT and in the CT scanner or while hanging out in a crowded ED. Knowing there is a significant bleed in the belly would ensure that everyone watches that patient a lot more closely. If you already have the info of the positive FAST and the vital signs turn south, the case becomes simple --> stop the radiation and start the cutting or the IR. I admit that in these settings a positive FAST will be rare but therefore I do not think that it will lead to obtaining lots of unecessary CT scans. Furthermore if you see a large amount of intraperitoneal fluid, you really do need to know why. Even if the patient is stable, the CT will tell you if there is a surgical indication (blush or normal spleen and liver hence high risk of bowel injury).

 

[EctopicFetus]

I am wondering if someone could tell me why someone with stable vitals who needs a belly CT would benefit from having a FAST done? Except for user training, it simply slows down the patient getting to the scanner which is a much better test.

I love the FAST but I def am not just USing every patient. Now I dont have residents to do my work, but outside of education I dont see the point.

 

[Doctor Bob]

I am wondering if someone could tell me why someone with stable vitals who needs a belly CT would benefit from having a FAST done? Except for user training, it simply slows down the patient getting to the scanner which is a much better test.

I love the FAST but I def am not just USing every patient. Now I dont have residents to do my work, but outside of education I dont see the point.

Well the FAST exam should be just that... fast. If it's slowing down your response time to the CT scanner then you're not doing it right.

But if it comes back positive then you can save the patient the radiation dose and just go directly to the OR.

Plus you might be some place where they don't have a CT scanner but you have a portable US machine (yes those places exist). It's good information to pass along to the surgeon at the facility you're sending the patient to.

 

[EctopicFetus]

Well the FAST exam should be just that... fast. If it's slowing down your response time to the CT scanner then you're not doing it right.

But if it comes back positive then you can save the patient the radiation dose and just go directly to the OR.

Plus you might be some place where they don't have a CT scanner but you have a portable US machine (yes those places exist). It's good information to pass along to the surgeon at the facility you're sending the patient to.

Again.. this depends on where u work. Where I am at after the initial assessment and an x ray the patient is off to the scanner ZERO delay.

If you have a +FAST it DOES NOT mean you need to go to the OR and if the patient is stable they will get a CT to assess other injuries.

As far as point 3.. i agree but my question was why do an US in a stable patient if you are gonna get a CT anyhow.

 

[Haemr Head]

I am wondering if someone could tell me why someone with stable vitals who needs a belly CT would benefit from having a FAST done? Except for user training, it simply slows down the patient getting to the scanner which is a much better test.

I love the FAST but I def am not just USing every patient. Now I dont have residents to do my work, but outside of education I dont see the point.

I work in EDs both with and without resident support and a FAST should be doable in less than a minute. There are many things that I agree are faciliated or done because of crowds of helpful residents but I disagree that this is one of them.

If I am getting a CT scan on a trauma patient then there usually is enough mechanism to worry about a spleen, liver, or rarely bowel injury. So at least for me, it is worthwhile. If I see fluid I know that the odds that the patient will get worse and need an intervention are considerably greater. I admit this is based on experience rather than evidence but so are parachutes. Seeing fluid might cause me to increase IV access, order type and crossed matched blood to be ready, give surgery an early warning about a potential case, etc... If the patient starts heading in the wrong direction things will be thus prepared to move the patient quickly to the definitive intervention rather than the mad scramble that occurs when a patient starts to box in the CT scanner. I admit that this will increase resource utilization and may not be cost effective hence the need for a study to really answer the question. If one is really confident that a patient does not have a life threatening injury and will remain stable in the ED then you might not even need the CT.

I admit that it is a practice style not a mandate or a standard of care. I wouldn't fault someone for not doing it but it does alter *my* management so, for me, it is worth doing. If you would not act differently based on the info then I agree, it does not make sense.

It's a very hard question to study as the number of patients with stable vital signs who are positive is small but these are the cases that either benefit from the test or generate the unnecessary cost. Until we have data, to each his own.

 

[EctopicFetus]

I guess no one is willing to answer the real question. In a level 1 trauma which is managed by the ED and trauma and the patient is about to go for a belly scan why wait and do the US?

Best answer above is I would get more IV access etc. I cant argue this point as it makes sense.

Also keep in mind we get CTs to evaluate injuries not just things that need to go to the OR etc.

IMO people are too confident in US, in as such as a negative scan is quite imperfect if we cant miss 5% of MIs what makes one think we could miss this many (Or more) trauma injuries?

That grade 2 splenic/liver lac might have a negative FAST but they need admission.

if you are talking about a 90% sensitivity thats 10% we are missing and just because there is fluid doesnt mean anyone knows where thats coming from?

 

[12R34Y]

I like the residents doing a FAST exam on every single trauma patient they see (as an attending at a teaching hospital). That's how you see positives. It takes literally 2 minutes at most.

We frequently use it on penetrating trauma as well. Shot in the belly, stable vitals..........positive fluid on FAST equals go to OR for ex lap.

Shot in belly, stable vitals, no fluid on FAST, CT scan..........nothing to do with evidence, but we sure see lots of people shot in the torso and the bullets never get inside to the good parts. They're always in abdominal wall, through and through big fat folks without ever penetrating the peritoneal cavity etc....

Usually, unless they're hypotensive and dying nobody is "running" to the OR. there is usually plenty of time for a FAST and its a great teacher/training tool.

That's how I do it anyway. I just like doing them.

later

 

[iridesingltrack]

I'm curious, several of you have suggested that positive FAST in the "stable" patient leads directly to the OR. Am I understanding your local situation correctly? I ask because at our shop, we definitely FAST every major trauma (for training), but it only alters the care of the patient if there is hemodynamic instability. These unstable, FAST +, patients go straight to the OR for Ex lap (no CT). From my read of the lit this process seems consistent with the data.

With that said, I don't see how performing a FAST on the stable trauma changes our medical decision making in the ED. I think that even the stable trauma patient with a positive FAST warrants a CT as it will provide the surgeon with infinitely more data than a positive FAST alone. In all honesty, our trauma team would not take a patient directly to the OR for an ex lap in the setting of a positive FAST and normal vitals. They would, I think rightly, require further imaging to help in their clinical and intraoperative decision making.

I'm not saying that one shouldn't do a FAST on the stable patient but more as to why, in a specialty where we are so concerned about efficiency, would we seemingly waste any steps on a process that will not change our actions.

Thoughts?

 

[deleted65604]

I'm curious, several of you have suggested that positive FAST in the "stable" patient leads directly to the OR. Am I understanding your local situation correctly? I ask because at our shop, we definitely FAST every major trauma (for training), but it only alters the care of the patient if there is hemodynamic instability. These unstable, FAST +, patients go straight to the OR for Ex lap (no CT). From my read of the lit this process seems consistent with the data.

With that said, I don't see how performing a FAST on the stable trauma changes our medical decision making in the ED. I think that even the stable trauma patient with a positive FAST warrants a CT as it will provide the surgeon with infinitely more data than a positive FAST alone. In all honesty, our trauma team would not take a patient directly to the OR for an ex lap in the setting of a positive FAST and normal vitals. They would, I think rightly, require further imaging to help in their clinical and intraoperative decision making.

I'm not saying that one shouldn't do a FAST on the stable patient but more as to why, in a specialty where we are so concerned about efficiency, would we seemingly waste any steps on a process that will not change our actions.

Thoughts?

I agree 100%.

FAST is a lot of hype with a very low yield.

 

[Haemr Head]

Does FAST alter management in the ED when performed in stable patients? Answer: Yes, at least in many systems.

Scenarios in the ones I have worked at (Denver Health, MGH, BWH, BIDMC)
A. FAST + AND Unstable VS ---> OR
B. FAST - AND Unstable VS ---> DPL (I'm sure this will draw some
reactions but is actually how the algorthim is written and what I
believe the evidence mandates)
C. FAST - AND Stable VS ---> Options: Serial ultrasound, observation,
CT scan (If we are seriously talking about reducing harm and cost for
patients not always doing a CT is the way to go)
D. FAST + and Stable VS ---> Ensure optimal access and volume
resuscitation and watch very closely as vital signs change and this
switches to scenario A. in the blink of an eye.

If your system has a CT with such a fast turn around time that the results are close to instantaneous and your ancillary support is so good that stable moderate mechanism trauma patients are truly watched carefully and optimally prepared for things to go sour , then I congratulate you and would like to know how I can move to your alternative universe).

 

[Haemr Head]

I agree 100%.

FAST is a lot of hype with a very low yield.

The yield is low for CTs for Aortic Dissection and cervical spine studies. But that does not mean the gain of doing this is not high or they are not warranted studies.

The same is true for the FAST. Time from injury to intervention in surgically correctable injuries resulting in intraperitoneal hemorrhage is the key variable in decreasing mortality, and reducing hospital costs. The problems created by delays in diagnosis are not often visible in the ED but the patient will pay from end organ damage and sepsis in the following days.

The FAST can be done in less than a minute (try timing yourself). It has revolutionized the initial management of the trauma patient. Most places are still not collecting revenue for this and do it because it is simply a safer way to manage these patients. Of course it will not provide unexpected informtaiotn on every case or even most cases. What does? But when this occurs, it can literally be a life saver.

 

[deleted65604]

The yield is low for CTs for Aortic Dissection and cervical spine studies. But that does not mean the gain of doing this is not high or they are not warranted studies.

REVOLUTIONIZED is a strong word.

The yield for most of the tests that we do in the ER is low. Most of them, however, are more definitive than a FAST exam. Why delay IV access, monitoring, unclothing, lab draw, and ultimately, CT scan of the abdomen, which will provide a much more definitive answer. How often do we do cross-table C-spine films anymore? I think a decent comparison is that FAST is to abd CT, as cross-table lateral c-spine is to C-spine CT.

The original question was, in an alert patient, with normal vitals, and no abdominal tenderness, does a FAST exam provide useful information?

Again, I don't think it does. Why is it done in residency? For training. Why is it done outside of a training situation? For money. ER docs at some places can bill for it, and it will increase their revenue. I'm not sure about the ethics of that practice.

The same is true for the FAST. Time from injury to intervention in surgically correctable injuries resulting in intraperitoneal hemorrhage is the key variable in decreasing mortality, and reducing hospital costs. The problems created by delays in diagnosis are not often visible in the ED but the patient will pay from end organ damage and sepsis in the following days.

In blunt trauma, patients who need surgical intervention is around 1 percent. The huge majority of patients are simply baby-sat by the surgeons for a night or two, while ortho takes care of their injuries.

FAST exam has little utility in stable patients (I can grant you more readily ordering blood in a patient with currently normal vitals). You are just delaying their transfer to CT scanning. It might have had more utility in past departments that were light years from the ER. The typical CT scanner is a few dozen feet from the department, and the patient is on a monitor, with time on the scanner now reduced to around 10 minutes out of the department.

Don't get me wrong, I still do FAST exams, but I've never had a FAST exam alter the management of a patient.

Why is there so much hype on the subject? In a lot of places, radiology doesn't like ER docs using ultrasound in the ER (they are losing revenue). The response is a plethora of biased research articles emphasizing its importance, written by authors who get paid to do ultrasound in their practice. There is also a subsequent taboo put on speaking the words UNNECESSARY and ULTRASOUND in the same sentence.

 

[deleted65604]

Does FAST alter management in the ED when performed in stable patients? Answer: Yes, at least in many systems.

A. FAST + AND Unstable VS ---> OR
B. FAST - AND Unstable VS ---> DPL (I'm sure this will draw some
reactions but is actually how the algorthim is written and what I
believe the evidence mandates)

I thought your examples would prove the utility in STABLE patients.

C. FAST - AND Stable VS ---> Options: Serial ultrasound, observation, CT scan (If we are seriously talking about reducing harm and cost for patients not always doing a CT is the way to go)

If a surgeon is at the bedside asking you not to do the CT, great! If they are asking you to admit the patient for observation without them laying hands on the patient, then you are putting the patient at risk by not ruling out all emergencies, and potentially delaying the definitive care (something that as you point out will increase mortality). If you have a really low suspicion for intra-abdominal injury, why are you going to admit them in the first place? In most ERs, you are not going to have the option of just letting the patient hang out in the ER for serial FAST exams and abdominal exams.

 

[Doctor Bob]

I wonder... if the wave of tumors secondary to CT scans comes to pass (as I keep reading about), if we'll get pushback on some of the kneejerk CT scans that we do on trauma patients.

Then the FAST will really move to the front of the trauma evaluation.

 

[Haemr Head]

REVOLUTIONIZED is a strong word.

Not when you compare it to how we practiced before FAST was used. FAST isn't competing with CT scans, it is competing with DPL and has reduced the indications for this procedure dramatically.

"The yield for most of the tests that we do in the ER is low. Most of them, however, are more definitive than a FAST exam. Why delay IV access, monitoring, unclothing, lab draw, and ultimately, CT scan of the abdomen, which will provide a much more definitive answer. "

I remain a little bewildered as to how much time it takes you and others to do a FAST at your sites. IV, monitoring, undress, and lab draw do occur before for the FAST so no delay there. The FAST takes less than a minute and can even be done while portabilizing the patient for CT. What are you doing in terms of FAST that creates a delay that anyone would even notice?

"How often do we do cross-table C-spine films anymore? I think a decent comparison is that FAST is to abd CT, as cross-table lateral c-spine is to C-spine CT."
Not even the same ballpark. The FAST is providing different information than at CT scan and it does so at the bedside immediately. It is simply a rapid triage tool both for bedside resuscitation and emergent indications for expl. lap.

"The original question was, in an alert patient, with normal vitals, and no abdominal tenderness, does a FAST exam provide useful information?
Again, I don't think it does."
Good for you. It is a dealer's choice as there isn't great evidence and it is a practice style. It is not standard of care and if it doesn't alter your practice, then don't do it. But I and many others I know have had a very different experience and find it useful. I agree anecdotal isn't evidence. The study to prove this would be a design nightmare to perform but is th e only way we can truly answer the question. This debate is futile because it is about opinion and experience, not hard data. I will happily acknowledge that the data might prove me wrong. I just would not bet on it.

"Why is it done in residency? For training. Why is it done outside of a training situation? For money. ER docs at some places can bill for it, and it will increase their revenue. I'm not sure about the ethics of that practice."

We don't bill for ultrasound but it is still done at our sites without residents as well as with residents. You certainly have a high respect for the ethics of your fellow specialists. In many states, billing for ultrasound is not feasible, yet somehow providers use it because it makes patients safer. Do you have a problem billing for the added income you get each time you do a full ROS that does not help you one iota? Or do you mark up for critical care on cases without major resuscitation or true critical care? The problem of reimbursement for emergency care is a whole thread onto itself. Before we start flagellating ourselves on reimbursement, please remember that radiology usually generate more income on an ED visit than the ED physician's professional fee. And don't worry about excessive charges, health care reform will soon fix that problem for all of us.


By the way, there is plenty of literature showing that a patient with a normal abdominal exam and normal vital signs can have a surgically life threatening injury. With normal mental status and low mechanism I might agree. I have had plenty of cases where the FAST has dramatically altered our management but then I've worked in busy trauma centers that concentrate the severity of the patients I see. The incidence of patients who require emergent surgery will vary based on the trauma systems in place in your area. I don't do a FAST on every low speed restrained alert MVA with a normal exam that I see. But I do perform it when there is mechanism and altered sensorium.

 

[Hamhock]

The original question was, in an alert patient, with normal vitals, and no abdominal tenderness, does a FAST exam provide useful information?

Again, I don't think it does.

Disclaimer: I am a resident. We FAST everybody for training purposes. (However, there is another reason)

FAST may not provide you (Jarabacoa) useful information in an alert patient with normal vitals an no abdominal tenderness, but it certainly provides me much info.

I am a resident at a major trauma center where often multiple trauma codes are being run at the same time. Patients are lined up to be scanned and must be prioritized.

If there are two trauma codes (both with normal vitals) and four other patients awaiting CT in the critical section of the ED (and who knows how many waiting in the rest of the ED; trust me, more than one), I am certainly going to rush the patient with free fluid to the scanner and let everyone else sit tight.

This may seem like a minor point, but with crazy amounts of trauma in a county hospital (therefore, slow/inefficient) with at most two CT scanners running (more than 80% of the time only one scanner), FAST is very useful in blunt abdominal trauma (and, I would argue penetrating too - but that would take another thread).

My point is: location, practice environment, and resources make the usefulness of the FAST increase in some cases. (and I bet there are many places with similar situations to mine)

HH

HH

 

[Seaglass]

A FAST exam is like any other test we do in the ED or anywhere else, you have to understand the characteristics and statistics of the study, otherwise the results can hurt you.

In teaching hospitals, the FAST exam is done more than indicated, mostly so that we get experience with the test.

In reality, the only utility in the FAST exam is in hypotensive, blunt trauma patients. The FAST truly only answers one question- does this hypotensive, blunt trauma patient need to go directly to the OR for laparotomy, or do they need a pericardiocentesis or something else to relieve tamponade.

If they are hemodynamically stable, then a FAST is not helpful, and may be hurtful. If someone has belly pain and they are stable, they get a CT. If somebody has AMS from a head injury with a significant, whole body mechanism (ie pedestrian vs auto, not baseball pitch to head), then you could argue that a FAST may be helpful there, but I still think a pan-scan is more useful if the patient is going to be intubated in an ICU for a while.

False positive FAST scans in hemodynamically stable people with normal mental status, and no abdominal pain or hematoma/seat belt sign, etc lead to to unneccesary CTs, and that means more $$, more radiation, and more contrast nephropathy.

This is how I use the FAST exam now as an attending. To be sure, I'm glad I did the exam hundreds of times as a resident when it was not truly indicated in order to develop my US skills. Just my 2 cents.

Superpants has it mostly right. The other indication for FAST is penetrating trauma to the thorax for which we really are only interested in the cardiac views to assess for hemopericardium (you want to know that's there BEFORE the patient crumps).

Bottom line - FAST only matters in the unstable trauma patient and should not delay the management of stable trauma patients. For teaching purposes I advocate doing the FAST after CT in stable trauma patients. There is an argument to be made that keeping it as part of the primary survey (to be performed either before or after CXR) helps keep the flow of trauma activations consistent but it does not affect the outcome of stable trauma and may indeed lead to unnecessary scanning (mostly in non-leveled trauma; as well all know leveled trauma must be obligitoraly pan-scanned).

 

[Haemr Head]

Bottom line - FAST only matters in the unstable trauma patient and should not delay the management of stable trauma patients. For teaching purposes I advocate doing the FAST after CT in stable trauma patients. There is an argument to be made that keeping it as part of the primary survey (to be performed either before or after CXR) helps keep the flow of trauma activations consistent but it does not affect the outcome of stable trauma and may indeed lead to unnecessary scanning (mostly in non-leveled trauma; as well all know leveled trauma must be obligitoraly pan-scanned).

Is that an opinion or do you have references supporting these statements? I'm mystified as to why an early FAST would increase the incidence of CT scans. I would predict the inverse. I also am unclear as to what you define as "leveled" trauma and disagree that there is any simplified indication for panscanning. Do you mean any level from 1 to 3? Do you panscan trauma arrests? Are you doing this on all unstable GSWs to the abdomen? Are you panscanning level 3 traumas in the 1st trimester of pregnancy?

 

[Seaglass]

Is that an opinion or do you have references supporting these statements? I'm mystified as to why an early FAST would increase the incidence of CT scans. I would predict the inverse. I also am unclear as to what you define as "leveled" trauma and disagree that there is any simplified indication for panscanning. Do you mean any level from 1 to 3? Do you panscan trauma arrests? Are you doing this on all unstable GSWs to the abdomen? Are you panscanning level 3 traumas in the 1st trimester of pregnancy?

OK, if you want a lit search I can get it for you but you'll have to give me a few days because I am working the next 4. As for leveled trauma, I mean that for which the trauma team is involved. At my institution and others I have been at (and judging from lectures at ACEP this seems to be a nearly universal approach) all blunt trauma is scanned from the head to the pelvis. I don't agree with it but that's the way the trauma surgeons want it. As for trauma arrests and penetrating trauma they of course are not pan scanned. Trauma for which the trauma team is not involved is actually examined and imaging is ordered appropriately.

As for the comment about unnecessary CTs you really have to think about what you are asking your test to do. FAST has published performance data indicating about 60-80 percent sensitivity for free fluid in the abdomen or pericardial space, and about a 95-99% specificity. In other words, if there is free fluid there then it's there (excluding operator error). If there isn't free fluid you have definitely not excluded any injury, so if imaging was initially indicated (as it apparently was since you did the FAST scan) then you probably should proceed to CT.

The cases I have seen where an unnecessary CT happened occurs where a FAST was done on a patient with no documented abdominal complaint or findings where an indeterminate or false positive result was noted and the patient got a CT that was normal. One could argue that an alternative management algorithm (serial exams) may have resulted one less CT had it not been for the FAST.

The bottom line is that a FAST scan result in the stable trauma patient doesn't MEAN anything except perhaps for triaging patients to the scanner (which is not something most places have to do). A negative FAST in a stable trauma patient does not prevent them from needing a CT. A positive FAST in a stable patient does not prevent them from needing a CT. So it doesn't mean anything. If the patient becomes unstable then it certainly would be indicated (even if they have had a CT!). A FAST scan is a very specific test that triages unstable trauma patients to the OR. And a good patient relations tool for the worried well.

 

[Seaglass]

Also regarding the "harm" of the FAST scan in the stable trauma patient. I have definitely seen it used as a "screening" test in trauma patients by attendings and residents who misuderstand the test. Something along the lines of "Her belly hurts but not that bad so I'll do a FAST and if it's negative she can go home." I honestly cannot tell you how many missed injuries this might represent but given the sensitivity of the FAST is 80% at best it is probably not zero.

As to the amount of time a FAST takes - if you are an experienced practitioner it might take a minute, if you are trying to teach a resident it takes considerably longer.

And I would say overall that it is not "useless" to do it in stable trauma for the reasons that our shark friend so eloquently states, but it is unlikely to change the patient's outcome and at least in systems I have participated in (including 2 level 1 trauma centers) it does delay to some extent CT scan which is otherwise generally available within minutes.

 

[EctopicFetus]

JBar.. we already know the FAST isnt all that sensitive or specific so I dont see how this is true.

Additionally, there was a study that came out in November from UCLA that basically said.. you need to pan scan everyone with serious trauma cause we were missing too many problems. Now I doubt this study but I wouldnt get too excited about the use of US in trauma going much further than where we are now. I used it in every trauma patient I saw in residency but... that was for training.

I guess Ill just say I strongly doubt your idea comes to fruition anytime soon.

http://journals.lww.com/jtrauma/Abs..._of_Pan_Computed_Tomography_for_Blunt.18.aspx



I have the full article.. not perfect but quite compelling

This article basically says.. pan scan all. Its recent but its out there.

 

[Haemr Head]

OK, if you want a lit search I can get it for you but you'll have to give me a few days because I am working the next 4. As for leveled trauma, I mean that for which the trauma team is involved. At my institution and others I have been at (and judging from lectures at ACEP this seems to be a nearly universal approach) ...QUOTE]

Just through with my own string of nights so here is a little lit search to wet your appetitie and at least challenge your conclusions:


Helling TS: The utility of focused abdominal ultrasound in blunt abdominal trauma: a reappraisal. Am J Surg (2007 Dec) 194(6):728-32: “FAST examinations can identify patients at risk for hemorrhage and in whom operation may be needed and, therefore, can guide mobilization of hospital resources. FAST-negative patients can be managed expectantly, using more specific imaging techniques.”
Kirkpatrick AW The hand-held ultrasound examination for penetrating abdominal trauma. Am J Surg (2004 May) 187(5):660-5 Hand-held sonography can quickly detect intraperitoneal fluid, which has good test performance in determining the presence of an intra- abdominal injury. Negative FAST examinations after penetrating trauma should be followed up with another diagnostic modality.
Rose JS Does the presence of ultrasound really affect computed tomographic scan use? A prospective randomized trial of ultrasound in trauma. J Trauma (2001 Sep) 51(3):545-50 “In this trial, the routine use of abdominal ultrasound in the evaluation of patients with multiple blunt injuries resulted in significantly fewer abdominal CT scans being obtained. A larger trial is needed to more clearly define the clinical and financial impact of ultrasound in the management of blunt abdominal trauma”.

As to the lectures at ACEP, I guess I have to point out that some of them do not support pan scanning (at least the ones I give like Abdominal Trauma: The Black Box). But as a veteran ACEP lecturer, I would be last to use that forum as the standard of care.

If you can turn around a scan in minutes and do not need to do any sorting, if you are not worried about the growing pressure about radiation exposure or cost containement, and if you wouldn't use the FAST to modulate your initial resuscitation, then I agree that it makes little sense. However, none of those statements are true in our practice so we continue to screen all trauma activation with a FAST exam. I completely agree that a negative scan does not rule out anything which is why I follow up a negative FAST in an unstable patient with a DPL. I do it in the stable patient to find the rare positive for the early warning, to check for a pericardial effusion, hemothorax and pneumothorax, as well as a quick hemodynamic assessment. Lots of potential information for a test that takes less than a minute. Somehow our residents who do the study with the attending looking over their shoulders can get it done in the same time frame. If I were making bets on the future, I would bet on less not more CTs. The study quoted earlier frm UCLA is small and has some pretty serious design flaws.

 

[Haemr Head]

In terms of increasing the use of CT, this article shows the opposite:

Rose JS Does the presence of ultrasound really affect computed tomographic scan use? A prospective randomized trial of ultrasound in trauma. J Trauma (2001 Sep) 51(3):545-50 “In this trial, the routine use of abdominal ultrasound in the evaluation of patients with multiple blunt injuries resulted in significantly fewer abdominal CT scans being obtained. A larger trial is needed to more clearly define the clinical and financial impact of ultrasound in the management of blunt abdominal trauma”.

 

[Seaglass]

I haven't forgotten you guys. I think I'll have time to post tomorrow. I have a couple of good articles for you, and some comments on those above.