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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 400-404

Positivefocused assessment sonography as an indication for laparotomy in hemodynamically unstable blunt traumatized patient


1 Department of General Surgery, Faculty of Medicine, Menofiya University, Menofia Governorate, Egypt
2 Department of Radiology, Faculty of Medicine, Menofiya University, Menofia Governorate, Egypt
3 Department of Emergency and Accident Unite in General Surgery, Menofiya University, Menofia Governorate, Egypt

Date of Submission13-Aug-2016
Date of Acceptance06-Nov-2016
Date of Web Publication25-Sep-2017

Correspondence Address:
Noha A Elgndy
Elbr Elsharqy Shbine Elkom, Shbine Elkom, 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.215459

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  Abstract 

Objective
The aim of this studywasto evaluate the results of focused assessment with sonography for trauma (FAST) in hemodynamically unstable blunt traumatized patients and to determine its role in the diagnostic evaluation of these patients.
Background
The emergency physician faces significant clinical uncertainty when a multiple trauma patient arrives in the emergency department. Patients are assessed, and their treatment priorities are established in the primary survey. FAST is an important skill during trauma resuscitation. The use of point-of-care ultrasound among the trauma team working in the primary survey in emergency care settings is lacking in Menoufia university hospitals.
Patients and methods
This study was conducted on 50patients with blunt abdominal trauma, either a localized trauma to the abdomen or a polytrauma with a blunt mechanism. The patients were assessed in the primary survey using the FAST as a tool to determine the presence of intra-abdominal collection.
Results
There were a total of 50cases, and FAST scans were performed in all cases. The sensitivity and specificity were 92.6 and 100%, respectively. The negative predictive value was 92%, whereas the positive predictive value was 100%. The overall accuracy was 96%.
Conclusion
FAST with presence of free fluid intraperitoneal without reference to the amont is useful as the initial diagnostic tool for abdominal trauma to detect intra-abdominal fluid in hemodynamically unstable patients. FAST performed by clinicians detects intraperitoneal fluid with a high degree of accuracy. All FAST examinations are valuable tests when positive. However, ultrasound examination is operator dependent, and FAST scan has its own limitations. For negative FAST scan cases, we recommend a period of monitoring, serial FAST scans, or further investigations, such as computed tomography scan.

Keywords: blunt trauma, focused assessment with sonography for trauma, hemodynamically unstable


How to cite this article:
Zieneldin AA, Rageh TM, Azab SM, Elgndy NA. Positivefocused assessment sonography as an indication for laparotomy in hemodynamically unstable blunt traumatized patient. Menoufia Med J 2017;30:400-4

How to cite this URL:
Zieneldin AA, Rageh TM, Azab SM, Elgndy NA. Positivefocused assessment sonography as an indication for laparotomy in hemodynamically unstable blunt traumatized patient. Menoufia Med J [serial online] 2017 [cited 2019 Aug 24];30:400-4. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/400/215459


  Introduction Top


Blunt abdominal trauma(BAT) is a common reason for presentation to the emergency department. Unfortunately, patient history and physical examination often lack the necessary sensitivity and specificity to diagnose acute traumatic pathology accurately[1].

Diagnostic peritoneal lavage(DPL) was historically used to determine which patients needed exploratory laparotomy, but DPL is difficult to perform in pregnant patients, cannot be used for serial assessment, and is overly sensitive, which leads to a high negative laparotomy rate[2].

Abdominal computed tomography(CT) has better specificity compared with DPL for intra-abdominal injury in BAT. However, it can be difficult to perform in hemodynamically unstable patients, is expensive, requires removing patients from the clinical area, and may be relatively contraindicated in pregnant patients[3].

Focused assessment with sonography for trauma(FAST), however, is an important and valuable diagnostic alternative to DPL and CT that can often facilitate a timely diagnosis for patients with BAT[3],[4],[5].

The advantages of FAST are as follows: it is noninvasive[6]; it is safe in pregnant patients and children as it requires less radiation compared with CT[7]; it can be integrated into the primary or secondary survey and can be performed quickly without removing patients from the clinical area[8]; it helps to accurately diagnose hemoperitoneum[5]; it helps in assessing the degree of hemoperitoneum in BAT[6]; it can be repeated for serial examinations[8]; it decreases the time to diagnosis for acute abdominal injury in BAT[5]; and it leads to fewer DPLs. In the proper clinical setting, it can lead to fewer CT scans(patients admitted to the trauma service andto receive serial abdominal examinations)[7].


  Patients and Methods Top


This study was conducted on 50patients of both sexes and variable age groups with a history of blunt trauma to the abdomen either as a multiple trauma or a localized trauma with a presentation of hemodynamical unstability.

Primary survey was carried out for all patients by the emergency physician by maintaining a patent and the airway was secured with the application of high-flow oxygen, and then examination of breathing was carried out by means of inspection, palpation, percussion, and auscultation. Thereafter, pulse oximetry was applied for the assessment of circulatory blood pressure, heart rate, and capillary refilling, and urine output data were collected. Clinical examination of the abdomen was carried out by means of inspection, palpation, percussion, and auscultation of audible intestinal sounds and using FAST as an adjunct in the primary survey, followed by examination of the pelvis and long bone for unstability and fractures.

FAST examination was performed using a phased array or curvilinear 2.5–5 MHz probe. The FAST exam is performed using four views:

  1. Hepatorenal recess or Morison's pouch
  2. Splenorenal view
  3. Pelvic view
  4. Pericardial or subcostal view.


The starting probe position when looking for Morison's pouch should be the anterior axillary line in the seventh to ninth intercostal space. The probe marker should be pointing to the patient's head. To obtain a good view of the entire recess, the probe can be moved toward the head and then back toward the feet along this plane.

The starting probe position when looking for the splenorenal recess on the left should be in the posterior axillary line in the fifth to seventh intercostal space; the marker should be pointed toward the patient's head.

The starting position of the probe when examining the pelvic region is the transverse position(probe marker to the patient's right) on the symphysis pubis. The probe is angled toward the patient's feet. This part of the examination can be carried out before the bladder is emptied by means of catheterization, and if the patient was already catheterized, the accuracy of the study can be increased by instilling saline into the bladder until it is easily visualized using ultrasound. Examine for fluid posterior to the bladder, posterior to the uterus, and between loops of bowel. Once the bladder is identified transversely, rotate the probe ninety degrees for the longitudinal view by tilting the probe to the right and to the left to assess the sides of the bladder.

For the FAST subxiphoid view, position the probe almost flat on the abdomen with the marker to the patient's right and angle the probe to the patient's left shoulder.

The primary survey was completed with the assessment of disability using the glasgow coma score, pupil examination, and signs of lateralization. The survey was finished by detecting sites of external bleeding.

Data were collected and compared with the formal ultrasound results performed by the radiologist and with the results of exploratory laparotomy.

Statistical analysis

The data collected were tabulated and statistically analyzed using SPSS statistical package (SPSS, V17; SPSS Inc., IBM, Chicago, USA) on IBM compatible computer(IBM). In the following sections, continuous variables are expressed as mean and SD after checking for normality of distribution. Differences between baseline and follow-up findings were analyzed using the paired sample t-test. APvalue of 0.05 was considered statistically significant.


  Results Top


This study was conducted on 50patients of both sexes and variable age groups with a history of blunt trauma to the abdomen either as a multiple trauma or a localized trauma with a presentation of hemodynamical unstability.

  • The mean age for the study group was 27.98±20.39years; 28% of them were female and 72% were male. 78% of traumas were due to road traffic accident, 12% due to falling from height, 4% due to fall, 4% due to falling of a heavy object on the torso, and 2% due to train accident[Table1]
  • All patients fulfilled the criteria of hemodynamic unstability, with 52% of patients with unrecorded systolic blood pressure[Table2]
  • All patients were examined for sites of injury: 26% were chest injuries, 48% were injuries to the extremities, and 32% were abdominal injuries[Table3]
  • All patients were scanned with FAST in the circulatory assessment in the primary survey with 50% positive and 50% negative cases. All results were confirmed with the results of the radiologist at the time of presentation. All the negative cases were scanned after 2h by the radiologist, with 92% positive and 8% positive cases[Table4] and [Table5]
  • FAST scan was performed in the four cardinal views. 83.3% of the positive cases had a pelvic collection, 75% of them had a hepatorenal collection, 75% of them had lateral Peri-renalcollection, and 4.2% had a pericardial collection[Table6]
  • All cases underwent surgical intervention with laparotomy. As regards the organs affected, 24% were splenic injury, 4% were ruptured spleen, 6% were splenic injury with perforated hollow viscous, 2% were splenic injury with bladder injury, 2% were splenic injury with ruptured diaphragm, 8% were hepatic laceration, 2% were ruptured uterus, 4% were perinephric hematoma with kidney injury, and one case of thoracotomy[Table7]
  • A relation between the results of exploratory laparotomy and positive views of the FAST scan is shown in [Table8]
  • All positive cases of FAST scan underwent exploratory laparotomy. Two false-negative cases also underwent exploratory laparotomy, and 23 true-negative cases were managed with other maneuvers for other causes of hemorrhagic shock [Table9]
  • The validity of FAST results in comparison with formal ultrasound results performed by the radiologist revealed a sensitivity of 92.6%, specificity of 100%, positive predictive value of 100%, negative predictive value of 92%, 0.0% false-positive rate, 7.4% false-negative rate, and accuracy of 96% [Table10].
Table 1: Distribution of the studied cases according to demographic data

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Table 2: Distribution of the studied cases according to vital signs

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Table 3: Distribution of the studied cases according to site of trauma

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Table 4: Distribution of the studied cases according to focused assessment with sonography for trauma and follow-up formal ultrasound for negative focused assessment with sonography for trauma

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Table 5: Symmetry between focused assessment with sonography for trauma results and formal US results

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Table 6: Distribution of the studied cases according to ultrasound view

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Table 7: Distribution of the studied cases according to laparotomy

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Table 8: Relation between focused assessment with sonography for trauma views and affected organ seen on laparotomy

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Table 9: Relation between focused assessment with sonography for trauma and laparotomy

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Table 10: Validity of focused assessment with sonography for trauma results in comparison with formal ultrasound results

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  Discussion Top


BAT is regularly encountered in the emergency department. The lack of historical data and the presence of distracting injuries or altered mental status, from head injury or intoxication, can make these injuries difficult to diagnose and manage. Victims of blunt trauma often have both abdominal and extra-abdominal injuries, further complicating care[9].

FAST is a rapid, repeatable, noninvasive, bedside method that was designed to answer one single question: whether free fluid is present in the peritoneal and pericardial cavity. It has been a valuable investigation for the initial assessment of BAT[10],[11],[12].

Mishra etal. [12] fromIndia reported a sensitivity of 91% and a specificity of 100% in identifying fluid by radiologist in blunt trauma abdomen, whereas other studies reported a sensitivity of 100% and a specificity of 97.5% among nonradiologists and 95.8% sensitivity and 97.5% specificity among radiologists. Positive predictive value among normal range and relative risk were 88.8 and 88.46% and negative predictive values were 97.5 and 99.15%, respectively[13],[14],[15].

In our study, the sensitivity was 92.6%, specificity was 100%, positive predicted value was 100%, negative predictive value was 92%, false-positive rate was 0.0%, false-negative rate was 7.4%, and accuracy was 96%.

Limitations of a negative FAST examination have been recognized[16],[17] and a negative FAST should be repeated at an interval of 6h[18]. Patients with a negative scan were observed clinically and none of this group developed abdominal-related complications. In our study, negative FAST was repeated by a radiologist at an interval of 2h with two positive cases.

There are different causes of false-negative FAST. For example, acoustic shadows from ribs will obstruct a clear view of Morison's pouch and an empty bladder will limit the evaluation for free fluid in the pelvis. Patient habitus and subcutaneous air also degrade image quality[19]. Development of hemoperitoneum over time, can make it difficult to detect injuries with slower bleeding using the ultrasound. Hence timing may be more responsible for the discrepancy in this patient compared with imaging modality because of ongoing bleeding and active fluid resuscitation in the interval between FAST and follow-up ultrasound after 2 h [20].


  Conclusion Top


  • FAST is useful as the initial diagnostic tool for abdominal trauma to detect intra-abdominal fluid in hemodynamically unstable patients. FAST performed by clinicians detects intraperitoneal fluid with a high degree of accuracy
  • All FAST examinations are valuable tests when positive. However, ultrasound examination is operator dependent, and FAST scan has its own limitations
  • For negative FAST scan cases, we recommend a period of monitoring, serial FAST scans, or further investigations, such as CT scan.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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American College of Surgeons. Advanced TraumaLifeSupport. http://https://www.facs.org/quality-programs/trauma/atls. [Last accessed 2015 Apr 04].  Back to cited text no. 1
    
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Griffin XL, Pullinger R. Are diagnostic peritoneal lavage or focused abdominal sonography for trauma safe screening investigations for hemodynamically stable patients after blunt abdominal trauma? A review of the literature. JTrauma 2007; 62:779–784.  Back to cited text no. 3
    
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Helling TS, Wilson J, Augustosky K. The utility of focused abdominal ultrasound in blunt abdominal trauma: a reappraisal. Am J Surg 2007; 194:728–732; discussion 732–733.  Back to cited text no. 8
    
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Dossett LA, Riesel JN, Griffin MR, Cotton BA. Prevalence and implications of preinjury warfarin use: an analysis of the National Trauma Databank. Arch Surg 2011; 146:565–570.  Back to cited text no. 9
    
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Moshiro C, Heuch I, Astrøm AN, Setel P, Hemed Y, Kvåle G. Injury morbidity in an urban and a rural area in Tanzania: an epidemiological survey. BMC Public Health. 2005; 5:11.  Back to cited text no. 10
    
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Demircan A, Keles A, Gurbuz N, Bildik F, Aygencel SG, Dogan NO, etal. Forensic emergency medicine–six-year experience of 13823cases in a university emergency department. Turk J Med Sci 2008; 38:567–575.  Back to cited text no. 11
    
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Dolich MO, McKenney MG, Varela JE. 2576 ultrasounds for blunt abdominal trauma. JTrauma 2001; 50:108–112.  Back to cited text no. 13
    
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McKenney MG, Martin L, Lentz K, Lopez C, Sleeman D, Aristide G, etal. 1000 consecutive ultrasounds for blunt abdominal trauma. JTrauma 1996; 40:607–612.  Back to cited text no. 15
    
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McKenney M, Lentz K, Nunez D, Sosa JL, Sleeman D, Axelrad A, etal. Can ultrasound replace diagnostic peritoneal lavage in the assessment of blunt trauma. JTrauma 1994; 37:439–441.  Back to cited text no. 17
    
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Boulanger BR, McLellan BA, Brenneman FD, Ochoa J, Kirkpatrick AW. Prospective evidence of superiority of a sonography based algorithm in the assessment of blunt abdominal injury. JTrauma 1999; 47:632–637.  Back to cited text no. 18
    
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Maxwell-Armstrong C, Brooks A, Field M, Hammond J, Abercrombie J. Diagnostic peritoneal lavage. Should trauma guidelines be revised?. Emerg Med J 2002; 19:524–525.  Back to cited text no. 19
    
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Ballard RB, Rozycki GS, Newman PG, Cubillos JE, Salomone JP, Ingram WL, etal. An algorithm to reduce the incidence of false-negative FAST examinations in patients at high risk for occult injury. Focused assessment for the sonographic examination of the trauma patient. JAm Coll Surg 1999; 189:145–151.  Back to cited text no. 20
    



 
 
    Tables

  [Table1], [Table2], [Table3], [Table4], [Table5], [Table6], [Table7], [Table8], [Table9], [Table10]


This article has been cited by
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Adel Hamed Elbaih,Sameh T. Abu-Elela
Chinese Journal of Traumatology. 2017;
[Pubmed] | [DOI]



 

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