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FAST Exam in pediatric patients. Evidence in the ED March 5, 2014 Sarah Cavallaro PGY-3. Introduction. The role of the FAST exam in Pediatric Trauma is unclear Review 4 studies that set the stage for current thinking Share my thoughts on how I wish these were done

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fast exam in pediatric patients

FAST Exam in pediatric patients

Evidence in the ED

March 5, 2014

Sarah Cavallaro PGY-3

introduction
Introduction
  • The role of the FAST exam in Pediatric Trauma is unclear
  • Review 4 studies that set the stage for current thinking
  • Share my thoughts on how I wish these were done
  • A HUPISM for future practice
paper 1
Paper #1
  • Jateen C. Patel and J.J. Tepas III. The Efficacy of Focused Abdominal Sonography for Trauma (FAST) as a Screening Tool in Assessment of Injured Children. Journal of Pediatric Surgery, Vol34,No 1 (January), 1999: pp 44-47
  • Study Type: Retrospective chart review
  • Subjects: Children (11.3yo mean) with Suspected Blunt Torso Trauma who received FAST exam
  • Hemodynamically unstable patients: Included (but limited n=2)
  • N: 94
  • Ultrasonographer: Radiology
  • Gold Standard: None
author s conclusion
Author\'s Conclusion
  • Specificity 95%, Sensitivity 33%
  • This “excellent specificity” combined with clinical examination allowed avoidance of “additional abdominal imaging”
paper 2
Paper #2
  • Coley et al. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. J Trauma. 2000 May;48(5):902-6.
  • Study Type: Prospective Study
  • Subjects: Children (7.9yo mean) with Suspected Blunt Torso Trauma who were to receive CT
  • Hemodynamically unstable patients: Excluded
  • N: 107
  • Ultrasonographer: Radiology
  • Gold Standard:CT
author s conclusions
Author\'s Conclusions
  • Specificity 0.83, Sensitivity 0.55
  • Not an “appropriate” imaging study for hemodynamically stable children with concern for blunt abdominal injury
  • Should not replace CT
paper 3
Paper #3
  • Soudack et al. Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients. J Clin Ultrasound. 2004 Feb;32(2):53-61.
  • Study Type: Retrospective Chart Review
  • Subjects: Children (7.1yo mean) with Suspected Blunt Torso Trauma who had received FAST exam
  • Hemodynamically unstable patients: Included
  • N: 313
  • Ultrasonographer: Radiology *also evaluated for parenchymal injury or retroperitoneal fluid
  • Gold Standard:None
author s conclusions1
Author\'s Conclusions
  • Specificity 97.2% Sensitivity 92.5%
  • The clinical significance of blunt abdominal injuries with no FF must be established
  • FAST Exam can be useful in patients with a normal physical exam to eliminate the need for CT
  • A positive FAST exam should then go to CT if stable or the OR if unstable
paper 4
Paper #4
  • Fox JC et al., Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. AcadEmerg Med. 2011 May;18(5):477-82.
  • Study Type: Prospective
  • Subjects: All blunt abdominal trauma patients aged 0-17yo (about ½ age 13-17)
  • Hemodynamically unstable patients: Included (n=1)
  • N: 357
  • Ultrasonographer: EM Residents, EM attendings, EM Ultrasound Fellows, surgeons
  • Gold Standard:CT (with moderate or severe FF) or Laparotomy
author s conclusion1
Author\'s Conclusion
  • Sensitivity 52%, Specificity 95% for clinically significant FF
  • Sensitivity 20%, Specificity 98% for any FF
  • A positive FAST exam suggests hemoperitoneum while a negative FAST exam is not useful in the setting of a pediatric patient with blunt abdominal injury
my thoughts
My Thoughts
  • Studying a very different use of the FAST exam
  • Most studies do not examine our use of FAST in a pediatric population
  • Need better reporting on the clinical significance of injury that presents with a negative FAST
  • Use would require culture change
  • Okay Byron, let’s hear your thoughts
hupism
HUPISM
  • If positive, a FAST exam may still be helpful to locate the source of bleeding in blunt traumatic pediatric patients presenting with hemorrhagic shock. It is not however a study that can replace CT scan for diagnosis of all intra-abdominal injury in hemodynamically stable pediatric patients.
references
References
  • Jateen C. Patel and J.J. Tepas III. The Efficacy of Focused Abdominal Sonography for Trauma (FAST) as a Screening Tool in Assessment of Injured Children. Journal of Pediatric Surgery, Vol34,No 1 (January), 1999: pp 44-47
  • Coley et al. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. J Trauma. 2000 May;48(5):902-6.
  • Soudack et al. Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients. J Clin Ultrasound. 2004 Feb;32(2):53-61.
  • Fox JC et al., Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. AcadEmerg Med. 2011 May;18(5):477-82.
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