A Prospective evaluation of “focused assessment with sonography for trauma” done by Emergency Nurses and its comparative analysis with radiologists performance in identifying fluid during initial resuscitation of trauma

Bhoi S,SoniaChauhan, Geeta A,Shakuntla , Shoukkathali V,Sinha Tej P, RK. Ramchandani

Deptt. of Emergency Medicine,J P N Apex Trauma Center,AIIMS sonia_aiims@yahoo.co.in

Background Ultrasound has been used in the early

assessment of abdominal trauma. Emergency Ultrasound (EUS) helps the

treating clinician to identify emergent conditions thus facilitating the rapid diagnosis and treatment of critically ill patients

Point of care sonography training to Emergency Nurses in India would facilitate multiple skill hands especially in mass casualty incidents.

Objective To determine the accuracy of emergency

nurses in detecting free fluid in abdomen when compared to radiologist during primary survey of trauma victims by focused assessment with Sonography for trauma [FAST] scan in the Emergency Department [ED].

METHODOLOGY

• Study design- Qualitative prospective study

• Performance centre - ED of JPN Apex Trauma Centre, AIIMS.

• Study duration-January to September 2011

The study subjects included emergency Nurses

(EN) who underwent training at 3-day workshop on emergency sonography

They performed 10 supervised positive and negative scans for free fluid.

The FAST scans were first performed by the EN’s and then by radiology resident (RR).

Both were blinded to each other’s sonography findings.

CT scan and laparotomy findings were used as gold standard whichever was feasible.

Results were compared between both groups.

FAST

Focused Assessment by Sonography in Trauma

AUTLS

FAST scan

Minimal amount of fluid in abdomen detectable

by USG ~ 200 - 650ml

High sensitivity in detecting hemoperitoneum (63 -100% ) High specificity in detecting hemoperitoneum (96 - 99%)100%)

Low sensitivity in detecting specific organ lesions

(<50%)

FAST Exam- Primary Views or Windows

1. Subxiphoid2. Right upper

quadrant (RUQ) 3. Left upper

quadrant (LUQ) 4. Suprapubic

FAST Exam - RUQ

FAST Exam - LUQ

FAST Exam – Supra-pubic

Transverse view

Results 94 scans performed each by EN and RR were

analysed. Mean age of the patients was 29 [2 - 85] years. Out of 23 true positive patients 18 underwent CT

scan and exploratory laparotomy was done in 14 patients.

Sensitivity of FAST done by EN and RR was 90 %. Specificity of FAST done by EN was 94.6 %Vs RR. Positive predictive value and negative predictive

values were 81.8% and 97.2% respectively

Limitation: Inter-observer variability was not noted

FAST: Strengths and LimitationsStrengths Rapid (~2 mins) Portable Inexpensive Technically simple, easy

to train (studies show competence can be achieved after ~30 studies)

Can be performed serially

Useful for guiding triage decisions in trauma patients

Limitations Does not typically

identify source of bleeding, or detect injuries that do not cause hemoperitoneum

Requires extensive training to assess parenchyma reliably

Limited in detecting <250 cc intraperitoneal fluid

Particularly poor at detecting bowel and mesentery damage (44% sensitivity)

Difficult to assess retroperitoneum

Limited by habitus in obese patients

Conclusion FAST scan performed by EN who are

trained in short course of ultrasonography can be reliable and accurate when comparable to qualified radiologist.

It can be helpful during crisis scenarios e.g. Mass casualty incidents.