Pelvic trauma accounts for only 3% of all skeletal injuries but may have mortality as high as 45% in cases of severe trauma. Significant high-grade-mechanism trauma to the pelvis must always take the abdomen into consideration for evaluation. The focused assessment with sonography for trauma (FAST) examination has been shown to be a valuable tool in assessing the unstable trauma patient with blunt abdominal injury, though its diagnostic utility is much less well-defined than in primary pelvic trauma. This systematic review explores the utility and limitations of the FAST examination in patients with blunt pelvic trauma and discusses the timing for the examination during the trauma survey. Newer techniques for emergency department management of the unstable trauma patient are also addressed.
Case Presentations
You arrive at the trauma bay in the evening just as a 24-year-old man is brought in by ambulance following a scooter accident against a moving car. He arrives with spinal precautions, and EMS reports transient hypotension en route that resolved with a 500-cc bolus of normal saline. The paramedics add that he is complaining about severe pelvic and diffuse abdominal pain, and they noted tenderness on palpation, with deformity and ecchymosis of his entire right pelvis. EMS has bound his pelvis with a sheet. His blood pressure on arrival is 86 mm Hg and he is tachycardic, but IV fluids are running in. You wonder if a FAST would be helpful in this case, but do you have enough have time to perform one? Should you even consider a CT? How do you determine whether the hemodynamic instability is due to hemorrhage from a primary abdominal or pelvic source? Will he need to go to the operating room or interventional radiology?
Just as you’re ready to perform a FAST on the young man, in rolls a 74-year-old gentleman who had a mechanical slip and fall from a standing position onto his left hip. He has severe pain with walking. He denies hitting his head and admits to taking his metoprolol for his high blood pressure with his morning medications. His blood pressure is 94/70 mm Hg. You note that he remains alert and responds to your questions appropriately, but you wonder why his blood pressure is relatively low. He denies feeling dizzy, and states he did not lose consciousness at any time, but complains only of left hip pain. Should you give him some fluids and assume his low blood pressure is medication-related? Should you perform a FAST exam and/or an x-ray? Should you consider a CT instead?
As you start walking back to begin the ultrasound for these patients, there is an EMS notification for a helmeted 41-year-old man catapulted from his motorcycle after losing control while going 75 mph on the expressway. EMS reports he flew off, feet first, skidding across the road, destroying his thick leather jacket and leather pants. He is complaining about right-sided abdominal pain. His pelvis is wrapped up in a sheet, and he seems to be in significant pain, with a very apparent deformity to the pelvis. He is only intermittently responsive to questions. He is tachycardic, with a blood pressure of 86/58 mm Hg and a GCS score wavering between 11 and 14. You are almost certain he has severe pelvic and/or abdominal trauma, but you wonder: Is there a way to distinguish which of the two may be the cause of the patient’s hemodynamic instability? Should you prepare the operating room for exploratory laparotomy and/or pelvic packing or call in an interventional radiologist for angiography? Since it is the middle of the night, interventional radiology is not immediately available, but you have to do something now! Do you perform the FAST and x-ray first, or take the patient to the operating room immediately?
Introduction
In assessing patients with thoracic and abdominal trauma, the focused assessment with sonography for trauma (FAST) examination remains part of the initial clinical survey in Advanced Trauma Life Support (ATLS). While the order and timing of when the FAST examination is performed differs from one institution to another, there is little doubt about the importance of employing it early in clinical decision-making, particularly in the unstable patient. One area of controversy surrounding the use of FAST in the trauma survey is its role when simultaneous pelvic injuries are suspected in the patient with abdominal trauma. While trauma sustained to the pelvis can precipitate intraperitoneal bleeding detectable on FAST, many known high-energy-mechanism in-juries to the pelvis can cause life-threatening bleeding into areas not normally viewed by the FAST examination, such as the retroperitoneum. This issue of Emergency Medicine Practice discusses the application and limitations of the FAST examination, the nature and clinical considerations of pelvic injuries, and how FAST may be incorporated in the setting of abdominal trauma with concomitant pelvic injuries or in isolated blunt pelvic trauma.
Critical Appraisal Of The Literature
A review of the literature was conducted through article databases using PubMed, Ovid MEDLINE®, EMBASE, and the Cochrane Database of Systematic Reviews. The National Guideline Clearinghouse was reviewed for the use of FAST in different clinical settings. The policies of multiple organizations were reviewed, including the American College of Emergency Physicians (ACEP), the American College of Radiology, the American Association of Orthopedic Surgery, the Western Trauma Association, the Eastern Association for the Surgery of Trauma (EAST), and the American Institute of Ultrasound in Medicine (AIUM). Keyword searches included: US FAST, focused assessment in ultrasonography, abdominal ultrasound, pelvic ultrasound, pelvic fracture, pelvic injury, and pelvic trauma.
Although an abundance of literature on the usefulness of the FAST examination in blunt abdominal trauma exists, there are only a few studies, mostly retrospective, that attempt to address whether FAST has any utility in the assessment and management of primary pelvic injuries. While the data are somewhat limited, many institutions continue to incorporate FAST into their clinical algorithms when evaluating patients with primary or concomitant pelvic trauma. To the authors’ best knowledge, no study has investigated the use of FAST in isolated pelvic trauma alone. Given the high rate of association of abdominal hemorrhage in high-energy pelvic trauma, this separation is likely impossible and not clinically relevant. A distinction, however, is made between pelvic hemorrhage and intraperitoneal hemorrhage as a cause for hemodynamic instability, as management considerations differ for these entities.
Current ACEP and AIUM guidelines fully support the use of FAST in blunt abdominal trauma, but they do not clearly specify its utility in concomitant or isolated pelvic trauma, other than to acknowledge the limitations of FAST in detecting retroperitoneal hemorrhage.1,2 The most recent EAST guidelines for pelvic trauma management acknowledge the specificity of the FAST examination in unstable patients with pelvic fractures, enough to recommend laparotomy to control hemorrhage. A Level I recommendation, however, was also made to emphasize that FAST was not sensitive enough to exclude an intraperitoneal source of bleeding in the presence of a pelvic fracture.3
Risk Management Pitfalls In Pelvic Trauma
“I know he’s older, but I’m not seeing a pelvic or hip fracture on this x-ray.”
With older patients, a higher index of suspicion needs to be maintained. The elderly will require a less-traumatic mechanism, have more-benign-appearing x-rays, will need more blood transfusions, and have an overall worse prognosis than a younger patient with a similar mechanism. Most commonly, an intertrochanteric or femoral neck fracture may be more likely to be missed on an x-ray. A CT may be warranted and should be considered if a more significant mechanism or pain is noted.
“I know EMS said that he flew off his motorcycle, but he’s stable and his FAST is negative, so I think I can rule out all intra-abdominal injury.”
The sensitivity of FAST in detecting intra-abdominal fluid in the hemodynamically stable patient is 42%. If the mechanism warrants it and the suspicion remains high, FAST cannot be used to rule out intra-abdominal injury, and a CT is warranted.
“The CT of my stable patient with a pelvic fracture shows a very large pelvic hematoma, but no active extravasation of contrast, so the patient will likely remain stable.”
While arterial intravascular contrast extravasation is a large risk factor for the need for emergent angioembolization, a pelvic hematoma > 500 cc is also highly predictive. In this scenario, the patient will need close monitoring and possible early involvement of interventional radiology for emergent angioembolization.
“This patient is hypotensive, and he is classified as an APC3 (rupture of the anterior and posterior sacroiliac ligaments) by Young-Burgess on his pelvic x-ray. I guess he’s got a pelvic bleed and needs angioembolization.”
Multiple studies have indicated that patients with serious pelvic fractures also have a high rate of concomitant intra-abdominal injuries. A FAST exam, with or without DPA, should be used to help guide whether hemodynamic instability may be related to a primary pelvic or intra-abdominal bleeding source, potentially directing disposition towards exploratory laparotomy instead of immediate IR angioembolization.
“I have an unstable patient with primary pelvic trauma with a positive FAST exam. That must mean he has an abdominal source of bleeding. I guess he needs an exploratory laparotomy.”
While a positive FAST is often related to an intra-abdominal source of bleeding, particularly in patients with primary pelvic trauma, a positive FAST may be related to a uroperitoneum from a bladder rupture or a large retroperitoneal bleed that has spilled into the abdominal cavity from a pelvic source of hemorrhage. A DPA may be helpful in this setting to evaluate for gross blood. If negative for blood or if urine is aspirated, a pelvic cause of hemodynamic instability is suggested. If positive, the bleeding may be secondary to either, but assumed likely abdominal, and an exploratory laparotomy with or without pelvic packing is likely indicated.
“This patient has a bad pelvic fracture and is hypotensive and probably bleeding from it. This pelvic sheet should stop the bleed.”
According to EAST 2011 Level III recommendations, a pelvic binder or sheet, while reducing fractures and pelvic volume, has not been shown to reduce risk of hemorrhage and further blood loss.
“The FAST is positive in the Morison pouch, so that means there’s a liver laceration.” While the right upper quadrant (the Morison pouch view) is the most sensitive location to detect free fluid in the abdomen, the FAST examination does not determine location and source of free fluid. In addition, it does not detect the type of fluid, so that a positive FAST in the setting of serious pelvic injury can represent hemoperitoneum from a pelvic or abdominal source, uroperitoneum, or even pre-existing ascites that are incidentally noted.
“I know he’s older, his hip really hurts, and says he ‘fell down a flight of stairs,' but he doesn’t look too bad and he’s probably just a little hypotensive from his metoprolol. I’ll just watch him and give him some fluids.”
While beta blockers may further exacerbate hypotension, a dangerous mechanism should be taken seriously, particularly in the elderly, and hypotension should always be potentially attributable to a possible pelvic or intra-abdominal source of bleeding in this scenario. A FAST and x-ray should be performed, and the patient may need to be placed in a pelvic binder. If the patient remains relatively stable, a CT can then be performed to rule out intra-abdominal or pelvic hemorrhage as a cause of hypotension.
“I have a CT nearby in the ED, and while the patient is mildly hypotensive, he’s mentating well. I’ve placed a pelvic binder, and I am actively resuscitating him. His pelvic x-ray shows a lateral compression fracture and his FAST is negative. He’s somewhat stable, but I guess he’s going to need angiography anyway, so I can skip the CT.”
n a small cohort of patients who remain somewhat stable, despite hypotension, a short transport to CT, particularly if in the ED, may be extremely helpful in further delineating the source and extent of pelvic and abdominal injuries. There is high incidence of simultaneous intra-abdominal injury associated with serious pelvic injuries so that, if feasible, a rapid CT may help to guide management in a different direction in the semistable patient.
“The DPA is useless now that we have the FAST. The FAST is positive in this pelvic fracture patient, so the patient should go to the operating room.”
While the FAST examination has overwhelmingly replaced DPA for assessing hemoperitoneum in the trauma patient and remains the standard of care in the hypotensive trauma patient, recent evidence supports that the DPA may have a new and evolving role in guiding management strategies in the setting of a positive FAST in pelvic trauma. A positive aspirate for blood may indicate the need for exploratory laparotomy and an abdominal etiology of bleed, while a negative aspirate can indicate a pelvic hemorrhage and the need for angioembolization instead.
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study are included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
American Institute of Ultrasound in Medicine, American College of Emergency Physicians. AIUM practice guideline for the performance of the focused assessment with sonography for trauma (FAST) examination. J Ultrasound Med. 2014;33(11):2047-2056. (Guidelines)
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* Eastridge BJ, Starr A, Minei JP, et al. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma. 2002;53(3):446-450. (Retrospective review; 231 patients)
* Manson T, O’Toole RV, Whitney A, et al. Young-Burgess classification of pelvic ring fractures: does it predict mortality, transfusion requirements, and non-orthopaedic injuries? J Orthop Trauma. 2010;24(10):603-609. (Retrospective review; 1248 patients)
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Starr AJ, Griffin DR, Reinert CM, et al. Pelvic ring disruptions: prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. J Orthop Trauma. 2002;16(8):553-561. (Retrospective review; 325 patients)
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Ismail N, Bellemare JF, Mollitt DL, et al. Death from pelvic fracture: children are different. J Pediatr Surg. 1996;31(1):82- 85. (Trauma registry review; 23,700 patients)
Beydoun H, Teel A, Crowder C, et al. Past blood alcohol concentration and injury in trauma center: propensity scoring. J Emerg Med. 2014;47(4):387-394. (Retrospective chart review; 1057 patients)
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Shlamovitz GZ, Mower WR, Bergman J, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med. 2007;50(1):25-33. (Retrospective review, 1401 patients)
Obaid AK, Barleben A, Porral D, et al. Utility of plain film pelvic radiographs in blunt trauma patients in the emergency department. Am Surg. 2006;72(10):951-954. (Case series; 174 patients)
Kessel B, Sevi R, Jeroukhimov I, et al. Is routine portable pelvic x-ray in stable multiple trauma patients always justified in a high technology era? Injury. 2007;38(5):559-563. (Case series; 129 patients)
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Guillamondegui OD, Pryor JP, Gracias VH, et al. Pelvic radiography in blunt trauma resuscitation: a diminishing role. J Trauma. 2002;53(6):1043-1047. (Retrospective review; 130 patients)
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* Duane TM, Tan BB, Golay D, et al. Blunt trauma and the role of routine pelvic radiographs: a prospective analysis. J Trauma. 2002;53(3):463-468. (Prospective series; 520 patients)
Blackmore CC, Cummings P, Jurkovich GJ, et al. Predicting major hemorrhage in patients with pelvic fracture. J Trauma. 2006;61(2):346-352. (Retrospective cohort review; 627 patients)
Stephen DJG, Kreder HJ, Day AC, et al. Early detection of arterial bleeding in acute pelvic trauma. J Trauma. 1999;47(4):638-642. (Retrospective review; 192 patients)
Nüchtern J, Hartel M, Henes F, et al. Significance of clinical examination. CT and MRI scan in the diagnosis of posterior pelvic ring fractures. Injury. 2015;46(2):315-319. (Prospective study; 60 patients)
* Natarajan B, Gupta PK, Cemaj S et al. FAST scan: is it worth doing in hemodynamically stable blunt trauma patients? Surgery. 2010;148(4):695-700. (Prospective study; 2105 pa-tients)
Miller MT, Pasquale MD, Bromberg WJ et. al. Not so FAST. J Trauma. 2003; 54(1):52-59. (Retrospective cohort study; 1169 patients)
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Rhea JT, Garza DH, Novelline RA. Controversies in emergency radiology. CT versus ultrasound in the evaluation of blunt abdominal trauma. Emerg Radiol. 2004;10(6):289-295. (Review article)
Stengel D, Bauwens K, Sehouli J, et al. Systematic review and meta-analysis of emergency ultrasonography for blunt abdominal trauma. Br J Surg. 2001;88(7):901-912. (Systematic review of prospective clinical trials; 9047 patients)
Nunes LW, Simmons S, Hallowell MJ, et al. Diagnostic performance of trauma US in identifying abdominal or pelvic free fluid and serious abdominal or pelvic injury. Acad Radiol. 2001;8(2):128-136. (Prospective study; 156 patients)
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* Hoffman L, Pierce D, Puumala S. Clinical predictors of injuries not identified by focused abdominal sonogram for trauma (FAST) examinations. J Emerg Med. 2009;36(3):271- 279. (Retrospective chart review; 1453 patients)
Baylis TB, Norris BL. Pelvic fractures and the general surgeon. Curr Surg. 2004;61(1): 30-35. (Review article)
Branney SW, Wolfe RE, Moore EE, et al. Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J Trauma. 1995;39(2):375-380. (Prospective study; 100 patients)
Carter JW, Falco MH, Chopko MS, et al. Do we really rely on FAST for decision-making in the management of blunt abdominal trauma? Injury. 2014;46(5):817-821. (Retrospec-tive chart review; 1671 patients)
Sheng AY, Daltziel P, Liteplo AS, et al. Focused assessment with sonography in trauma and abdominal computed tomography utilization in adult trauma patients: trends over the last decade. Emerg Med Int. 2013:678380. (Retrospective study; 19,940 patients)
Ollerton JE, Sugrue M, Balogh Z, et al. Prospective study to evaluate the influence of FAST on trauma patient manage ment. J Trauma. 2006;60(4):785-791. (Prospective study; 419 patients)
Barbosa RR, Rowell SE, Fox EE, et al. Increasing time to operation is associated with decreased survival in patients with a positive FAST examination requiring emergent laparotomy. J Trauma Acute Care Surg. 2013;75(1 Suppl 1):S48-S52. (Retrospective review; 115 patients)
Laselle BT, Byyny RL, Haukoos JS, et al. False-negative FAST examination: associations with injury characteristics and patient outcomes. Ann Emerg Med. 2012;60(3):326-334. (Retrospective cohort study; 332 patients)
Ruchholtz S, Waydhas C, Lewan U, et al. Free abdominal fluid on ultrasound in unstable pelvic ring fracture: is laparotomy always necessary? J Trauma. 2004;57(2):278-285. (Prospective study; 1472 patients)
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Focused Assessment with Sonography for Trauma (FAST) assesses for fluid in the pericardium or abdomen (hemopericardium or hemoperitoneum, respectively).
The traditional 4 views consist of a subxiphoid view of the heart and pericardium, right and left upper quadrant windows, and the pelvis.
More recently, the extended FAST (eFAST) has entered into clinical practice with the addition of bilateral thoracic views to assess for pneumothoraces and hemothoraces.
Negative FAST does not exclude injury. Ultrasound is user dependent; therefore, clinicians should be cautious in the interpretation of negative FAST. Sensitivities of abdominal and suprapubic views in FAST vary widely, with ranges of 22% to 98% reported in the recent literature (Richards 2017, Carter 2015).
In penetrating thoracic trauma, pericardial view sensitivity approaches 100% (Matsushima 2017, Ball 2009, Rozycki 1999), but cardiac injury can be missed if there is concomitant pericardial laceration allowing decompression into the left chest (Ball 2009).
If clinical suspicion for injury persists despite negative FAST, FAST should be repeated, additional investigations should be performed, or intervention should be pursued, depending on the patient’s clinical condition.
Advice
Most clinicians use the low-frequency phased array ultrasound probe (cardiac probe) to obtain all windows in FAST.
Pericardial: Place the probe in the subxiphoid area and orient toward the patient's left shoulder. Apply downward pressure to look under the costal margin and toward the heart. The heart and pericardium will come into view, allowing inspection for hemopericardium and ultrasound findings of cardiac tamponade.
Right upper quadrant: Place the probe in the right anterior to the midaxillary line (between the eleventh and twelfth ribs). Visualization of the hepatorenal recess (Morison's pouch) allows the assessment for hemoperitoneum in the right upper quadrant. Blood most likely accumulates here if hemoperitoneum is present.
Left upper quadrant: Apply the transducer firmly onto the skin in the left posterior axillary line (between the ninth and tenth ribs) to visualize the splenorenal and subphrenic spaces.
In practice, it is important to remember that the right and left upper quadrant views are often more posterior than anticipated. It can be helpful to bring the probe all the way down to the stretcher in order to best visualize these windows.
Suprapubic: Place the transducer superior to the pubic symphysis and fan the probe inferiorly to visualize the bladder.
Why and When to Use, Next Steps and Suggested Management
Why to Use
FAST is a rapid, noninvasive, and repeatable imaging modality that can guide the surgeon in the decision to operate. It is performed in the trauma bay, and does not require patient transport out of the emergency department, which is risky for unstable patients.
When to Use
FAST should be used liberally in the evaluation of trauma patients.
It is especially useful in patients with penetrating thoracic trauma and in unstable patients after blunt abdominal trauma.
Next Steps
FAST results alone should not determine the decision to operate. However, FAST can be a helpful adjunct in clinical decision-making, particularly in an unstable blunt trauma patient, in order to rapidly assess the chest and abdomen for potential causes of hypotension
Suggested Management
The clinician must consider additional clinical information including hemodynamic stability and clinical suspicion for injury.
Pericardial FAST (penetrating thoracic trauma)
Positive: Emergent surgical intervention is recommended. Median sternotomy is preferred if the patient is stable; otherwise, use left anterolateral thoracotomy.
Equivocal: Pericardial window or formal TTE is recommended.
Negative: Close clinical monitoring or discharge are recommended, according to clinical suspicion for injury.
Abdominal FAST (blunt abdominal trauma)
Positive: In the unstable patient, emergent exploratory laparotomy is recommended. In the stable patient, cross-sectional imaging (CT scan) is recommended.
Equivocal: In the unstable patient, DPA is recommended. In the stable patient, cross-sectional imaging (CT scan) is recommended.
Negative: In the unstable patient, DPA is recommended if clinical suspicion for intra-abdominal bleeding exists. In the stable patient, CT scan, close clinical monitoring, or discharge are recommended, according to clinical suspicion for injury.
Repeating FAST while preparing to perform diagnostic peritoneal aspiration is useful to quickly reassess unstable patients with blunt abdominal trauma who have an initially negative FAST. Intra-abdominal hemorrhage may not be significant enough on presentation to be FAST-positive initially.
Be cautious if pericardial FAST is negative in patients with penetrating thoracic trauma, especially if unstable. Cardiac injuries can decompress through the injured pericardium, most commonly into the left hemithorax, resulting in negative pericardial FAST (Ball 2009). Therefore, unstable patients with this mechanism of injury and FAST finding should undergo a chest x-ray. If the x-ray reveals a hemothorax, a chest tube must be placed. Ongoing or high-volume chest tube output in this clinical context may be from cardiac injury.
Evidence Appraisal
The original study conducted by Rozycki et al in 1993 utilized FAST in patients aged ≥ 16 years, after blunt or penetrating trauma (n = 476). When compared to gold standards of computed tomography scan, diagnostic peritoneal lavage, and/or operative findings, FAST had a sensitivity of 79% and a specificity of 96%. FAST was further validated in 1998 in a much larger study (n = 1540) by the same group. This showed that FAST is most sensitive and specific in patients with penetrating precordial wounds (sensitivity 100%, specificity 99%) and in hypotensive patients after blunt abdominal trauma (sensitivity 100%, specificity 100%). Rozycki et al (1998) concluded that the accuracy of FAST in these clinical scenarios justified surgical intervention on the basis of the FAST findings in these trauma patients. With the application of FAST outside of study protocols by nonexperts and nonradiologists, the contemporary diagnostic yield of FAST ranges more broadly. Recent studies quote a sensitivity of 22% to 98% for FAST in the detection of hemoperitoneum (Richards 2017, Carter 2015).
More recently, thoracic views have been added to the FAST exam and termed eFAST. These windows assess the chest bilaterally for pneumothoraces and hemothoraces. In some series, the reported sensitivities of eFAST (86%-100%) are superior to that of chest x-ray (27%-83%) in the detection of pneumothoraces (Governatori 2015, Nandipati 2011, Wilkerson 2010).
Important
FAST results alone should not determine the decision to operate.
Upon completion of this article, participants should be able to:
Recognize the utility and limitations of the FAST examination in the trauma survey of patients with suspected pelvic fracture
Describe different management modalities available for pelvic hemorrhages.
Stratify management decisions of stable and unstable patients with known pelvic fracture.
Physician CME Information
Date of Original Release: March 1, 2016. Date of most recent review: February 10, 2016. Termination date: March 1, 2019.
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Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice, has been reviewed and is acceptable for up to 48 Prescribed credits by the American Academy of Family Physicians per year. AAFP accreditation begins July 31, 2014. Term of approval is for one year from this date. Each issue is approved for 4 Prescribed credits. Credit may be claimed for one year from the date of each issue. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA Accreditation:Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2A or 2B credit hours per year.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.
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Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common mediocolegal pitfalls for each topic covered.
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