Menoufia Medical Journal

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

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


Ashraf A Zieneldin1, Tarek M Rageh1, Sameh M Azab2, Noha A Elgndy3,  
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

Correspondence Address:
Noha A Elgndy
Elbr Elsharqy Shbine Elkom, Shbine Elkom, 32511
Egypt

Abstract

Objective The aim of this study was to 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 50 patients 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 50 cases, 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.



How to cite this article:
Zieneldin AA, Rageh TM, Azab SM, Elgndy NA. Positive focused assessment sonography as an indication for laparotomy in hemodynamically unstable blunt traumatized patient.Menoufia Med J 2017;30:400-404


How to cite this URL:
Zieneldin AA, Rageh TM, Azab SM, Elgndy NA. Positive focused assessment sonography as an indication for laparotomy in hemodynamically unstable blunt traumatized patient. Menoufia Med J [serial online] 2017 [cited 2020 Apr 6 ];30:400-404
Available from: http://www.mmj.eg.net/text.asp?2017/30/2/400/215459


Full Text

 Introduction



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 and to receive serial abdominal examinations) [7].

 Patients and Methods



This study was conducted on 50 patients 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:

Hepatorenal recess or Morison's pouchSplenorenal viewPelvic viewPericardial 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. A P value of 0.05 was considered statistically significant.

 Results



This study was conducted on 50 patients 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 ± 20.39 years; 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 [Table 1]All patients fulfilled the criteria of hemodynamic unstability, with 52% of patients with unrecorded systolic blood pressure [Table 2]All patients were examined for sites of injury: 26% were chest injuries, 48% were injuries to the extremities, and 32% were abdominal injuries [Table 3]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 2 h by the radiologist, with 92% positive and 8% positive cases [Table 4] and [Table 5]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-renal collection, and 4.2% had a pericardial collection [Table 6]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 [Table 7]A relation between the results of exploratory laparotomy and positive views of the FAST scan is shown in [Table 8]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 [Table 9]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% [Table 10].{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}{Table 7}{Table 8}{Table 9}{Table 10}

 Discussion



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 et al. [12] from India 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 6 h [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 2 h 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



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 accuracyAll FAST examinations are valuable tests when positive. However, ultrasound examination is operator dependent, and FAST scan has its own limitationsFor 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.

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