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?
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.
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
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.
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 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
The clinician must consider additional clinical information including hemodynamic stability and clinical suspicion for injury.
Pericardial FAST (penetrating thoracic trauma)
Abdominal FAST (blunt abdominal trauma)
Abbreviations: CT, computed tomography; DPA, diagnostic peritoneal aspiration; TTE, transthoracic echocardiography.
Jennie Kim, MD
Morgan Schellenberg, MD, MPH
Kenji Inaba, MD, FRCSC, FACS
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.
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).
FAST results alone should not determine the decision to operate.
Grace Rozycki, MD, MBA
Copyright © MDCalc • Reprinted with permission.
Nadia Maria Shaukat, MD; Nilolai Copeli, MD; Poonam Desai, DO
March 1, 2016
April 1, 2019
Upon completion of this article, participants should be able to:
Date of Original Release: March 1, 2016. Date of most recent review: February 10, 2016. Termination date: March 1, 2019.
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