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The Role of Focused Abdominal Ultrasound for Trauma (FAST) In Pediatric Trauma Evaluation

Saturday, October 20, 2012: 3:26 PM
Versailles Ballroom (Hilton Riverside)
Eric R. Scaife, MD1, Michael D. Rollins, MD2, Douglas C. Barnhart, MD, MPH2, Rebecka L. Meyers, MD2, Richard E. Black, MD2, Sasha Gordon, RDMS3, Mark H. Stevens, MD2, Jeffrey S. Prince, MD3, Deborah Battaglia, MD4, Stephen J. Fenton, MD2, Jennifer Plumb, MD, MPH5 and Ryan R. Metzger, PhD2, (1)Division of Pediatric Surgery, University of Utah, Primary Children's Medical Center, Salt Lake City, UT, (2)Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, (3)Department of Radiology, Primary Children's Medical Center, Salt Lake City, UT, (4)Division of Emergency Medicine, University of Utah, (5)Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT

Purpose: Due to limited sensitivity, FAST has not become popular in pediatric trauma. With increasing concerns about radiation exposure, we questioned whether a structured program of FAST might decrease CT use.

Methods: All pediatric trauma surgeons in our level 1 pediatric trauma center underwent formal training prior to the study and agreed to perform FAST in all children with potential abdominal trauma and no prior imaging.  Compliance with this protocol and results were collected prospectively from 10/2/09 to 7/31/11.  After physical exam and FAST, the surgeon declared whether the CT could be eliminated. Practitioners were surveyed about the utility of FAST at the completion of the study.  After the conclusion of the study we observed the surgeon's ongoing use of FAST to assess their inherent interest in the exam.

Results:  Of 536 children who arrived without imaging, 183 had potential abdominal trauma.  FAST was performed in 128 cases and recorded completely in 88.  In 47% (41/88) the surgeon would have elected to cancel the CT based on the FAST and physical exam. One of the 41 cases had a positive FAST and required emergent laparotomy while the others were negative. The sensitivity of FAST for injuries requiring operation or blood transfusion was 87.5%. The sensitivity, specificity, PPV, and NPV in detecting pathologic free fluid was 50%, 85%, 53.8%, and 87.9%.  Survey results (see table) suggest a more favorable view by pediatric emergency medicine physicians than surgeons for the implementation and routine use of FAST.  Without the supervision of the study the surgeon's FAST use decreased from 70% to 28% of potential cases.

FAST Exam Survey Responses (% of responders with positive response)

Question

Surgeon (n=7)

Pediatric emergency medicine physician (n=15)

Should FAST be routinely utilized for pediatric trauma?

43%

80%

Is FAST useful for a select subset of patients?

100%

80%

Compared to how you felt prior to the study, are you more impressed with the utility of FAST?

43%

47%

Do you recommend that pediatric level I centers have an ultrasound machine in the trauma bay?

72%

93%

Conclusions: Despite structured training and monitoring, surgeon compliance with the routine use of FAST was incomplete. True positive FAST exams are uncommon and would rarely direct management. While the negative FAST would have potentially reduced CT use due to practitioner reassurance, this reassurance may be unwarranted given the test's limited ability to reliably detect intra-abdominal fluid in our study. Lastly, interest in routine FAST faded after the conclusion of the study.