FAST EXAM IN PEDIATRIC PATIENTSEvidence 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• A HUPISM for future practice

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

Results

Author's Conclusion• Specificity 95%, Sensitivity 33%• This “excellent specificity” combined with clinical

examination allowed avoidance of “additional abdominal imaging”

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

Results

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• 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

Results

Results

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• Fox JC et al., Test characteristics of focused assessment of sonography for trauma for

clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg 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

Results

Results

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 • 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 • 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 • 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. Acad Emerg Med. 2011 May;18(5):477-82.