The Role of the FAST exam in the EDRU A. Robb McLean, MD, MHCM Vice Chair of Clinical Operations, Department of Emergency Medicine Joint Trauma Conference June 20, 2017
TheRoleoftheFASTexamintheEDRU
A.RobbMcLean,MD,MHCMViceChairofClinicalOperations,
DepartmentofEmergencyMedicine
JointTraumaConferenceJune20,2017
Goals
• Describetheperformance,andperformancecharacteristics,oftheFAST/E-Fast• AnswercriticalquestionsabouttheuseofFASTexamsintrauma• FormallyintegrateFASTexamsintoTraumaResuscitationsintheEDRU
CriticalQuestions
• FASTvsE-FAST?• BluntvsPenetratingTrauma• Pediatrics– isitdifferent?• WhenisapositiveFASTanindicationfortheOR?
FASTExam– APanacea?
• Bedside• Rapid• Noradiation• Cheap• Repeatable• Nocomplications
• PotentialClinicalBenefitsReductionsin:- Timetosurgery- CTUse- ED/HospitalLOS- Complications- Cost- Radiation
FASTExam
• 4keylocations• FreeFluid• Sensitivityforintraperitonealhemorrhage• 43-100%
• Specificity• 90-100%
Radiology: Volume 283: Number 1—April 2017
FASTViews
• RUQviews• Sagittalprobeorientation• 7th-9th ICS,obliqueorientation• Morison’spouch• Sub-phrenic• Inferiorrenalpole• Diaphragm/lung
• Sub-xiphoidview• Transverseprobeorientation• Liver,rightheart,leftheart• Eval chambersandrelativesizeofventricles,squeeze,pericardialfluid
• LUQView• Sagittalprobeorientation• 5th-7th ICspace,obliqueposition• SweepfromAnttoPost• Spleno-renalandsub-phrenicrecesses,inferiorrenalpole
• Diaphragm/Pleuralinterface• PelvicView
• SagittalandTransverseprobeorientation
• Fullbladder• Fluidbehindbladder,behinduterus,behindloopsofbowel
E-Fast– ExtendedFAST
• Lungwindows• IncreasedsensitivityforPTXoverCXR
(43-91%vs11-50%)
• 2nd-3rd ICSpace(reduceDoF)- Slidinglung- Comettails- M-mode“seashore”sign
- “barcode”or“stratosphere”signinPTX
• Whatistheclinicalsignificance?Radiology: Volume 283: Number 1—April 2017
E-Fast(cont’d)
Radiology: Volume 283: Number 1—April 2017 http://emedicine.medscape.com/article/1883608-overview#a3
Comet-tailArtifactsM-mode:LungPoint,Seashore,Barcodesigns
LimitationsoftheFASTInjuries• LackofFFinpediatricSOI• Mesenteric,hollowviscous,diaphragmatic,andisolatedpenetratinginjuries• Retroperitonealbleeding/injuries• SuccessfullyidentifiesoccultPTXnotneedingintervention
PatientCharacteristics• Falsepositives(ascites,physiologicFFinfemales,PD,VPshunts,uroperitoneum inpelvictrauma)• Obesity,subcutaneousemphysema,bowelgas,adhesions,patientcooperationandpositioning• Pericardialfatpad,pre-existingeffusions• Mainstem intubation,pleurodesis,severeCOPD
AlternativestoFAST
• PhysicalExam!• CT• DiagnosticPeritonealLavage• LocalWoundExploration• Laparoscopy/Laparotomy
Emergencyultrasound-basedalgorithmsfordiagnosingbluntabdominalTrauma(update9/15)
4RCTsPoortomoderatemethodologicquality
PooledMortalityDataRR1.00(95%CI0.50to2.00)FAST-basedpathwaysreducedCTScans(randomeffectsmodelRD-0.52,95%CI-0.83to-0.21)
“Inahemodynamicallyunstablepatientwithbluntabdominaltraumaisbedsideultrasoundthediagnosticmodalityofchoice?...
LevelBrecommendation– Inhemodynamicallyunstablepatients(systolicbloodpressure<or=90mmHg)withbluntabdominaltrauma,bedsideultrasound,whenavailable,shouldbetheinitialdiagnosticmodalityperformedtoidentifythetheneedforemergentlaparotomy”
“SerialUltrasoundscanbehelpfulinpatientswithbluntabdominaltrauma.”
“Ultrasoundshouldnotbeconsideredthesoletest”
“Anegativeultrasoundresultinahemodynamicallyunstablepatientdoesnotprecludetheneedforfurtherdiagnostictesting.”
• FASTfallsunderprimarysurvey“C– Circulation”• AnegativeFASTdoesnotruleoutIAI• “AbsoluteindicationforlaparotomyisacontraindicationtoFAST”
• PediatricCaveats• largevolumebloodmoreassoc withsignificantinjurybutneedforoperativemanagementdeterminedbyhemodynamicinstabilityandresponsetoresuscitation.SmallamountsFFinstablechilddeservesCTscan
• Isolatedintraprenchymal injury(withoutFF)occursin1/3ofSOIinkids.
*RoleofFASTdependsonpatientstabilityandATLSprincipleofrapidresponders,transientrespondersandnon-responders
PenetratingTrauma
• EAST- PracticeManagementGuidelinesforSelectiveNonoperativeManagementofPenetratingAbdominalTrauma• JTrauma2010;68(3)721-733• AdditionalstudiesnecessaryifFASTnegative• “NotenoughdatatomakearecommendationabouttheuseofUSinthispatientpopulation”
• 2009Meta-analysis– 8studies• N=565• Sensitivity28-100%.Specificity94-100%.• Positivefastshouldpromptex-lap.Negativeshouldpromptadditionalstudies.
PediatricsandtheFASTExam• 2009Survey
• 15%dedicatedPeds EDsusedFASTvs96%AdultEDs• 2017study
• UseofFASTacross14centersrangedfrom1-94%(CTuse6-94%)• UniqueFeatures
• >1/3ofchildrenwithSOIwillhavenoFFonexam• OperativemanagementmoreoftendictatedbyVSinstabilityratherthanpresenceoffreefluid
• Moreoftenusedasanextensionofthephysicalexam- repeatable• Sensitivity(28-90%)
• 66%forhemoperitoneum (50%forIAI)in2007meta-analysis• 52%formoderateorgreaterHPinprospectivestudy
• Specificity(>90%)
FASTInPediatrics– Hotoffthepress!
FocusedAssessmentwithSonographyforTrauma(FAST)inChildrenFollowingBluntAbdominalTrauma:AMulti-InstitutionalAnalysis.JTraumaAcuteCareSurg.ePub 6/6/17
PediatricsandtheFAST(continued)
• PediatricTakeHomepoints• Moderatefreefluidsuggestshemoperitoneum fromIAIrequiringfurtherdiagnostics• NegativeFASTinstablepatientinadequateassolediagnostictest• PositiveFASTinunstablechildmaypromptearliertransfusionoremergentlaparotomywithoutfurtherimaging
DocRight• Completes“C”(circulation)oftheprimaryassessment(assessmentofBP,central&peripheralpulses,currentIVaccess)andannouncesittothetraumateamleader• Performsthesecondaryassessmentfromheadtotoeandreportsallpositiveandnegativefindings• Obtains“AMPLE”historyatthecompletionofthesecondaryassessmentofthepatient• MayperformothertasksasdelegatedbyTTL
PrinciplesofFASTexamsintheEDRU• AllTraumaAlertProtocolpatientsshouldgetaFASTexam(DocRight)• UnstablePatients– PartofC,Circulation• Stablepatients– aftersecondaryexamORuponreturnfromCT
• UnstablepatientswithpositiveFASTexamsgototheOR(Non-Responders)• USshouldnotbeusedassoleimagingforpatients“atrisk”• CT,serialexams,laparotomy,DPL,LWE
• FASTinPediatricpatientshaslowersensitivityforIAIandmaynotaltermanagement