The Focused Assessment With Sonography For Trauma (FAST) Examination And Pelvic Trauma: Indications And Limitations (Trauma CME)

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Anatomy Of The Pelvis
6. Epidemiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Laboratory Studies
11. Treatment
    1. Pelvic Binding
    2. Surgical Consultation
    3. Tranexamic Acid
    4. Permissive Hypotension And Fluids
12. Special Populations
    1. Elderly Patients
13. Controversies And Cutting Edge
14. Disposition
15. Summary
16. Risk Management Pitfalls In Pelvic Trauma
17. Time- And Cost-Effective Strategies
18. Case Conclusions
19. Clinical Pathway For Using The FAST Examination In Acute Pelvic Injury
20. Figures
    1. Figure 1. Pelvic Vascular Anatomy
    2. Figure 2. Young-Burgess Classification Of Pelvic Fracture
    3. Figure 3. The 4 Views Of The FAST Examination
    4. Figure 4. Normal View Of Hepatorenal Recess (Morison Pouch)
    5. Figure 5. Normal View Of Perisplenic Area And Splenodiaphragmatic Recess
    6. Figure 6. Normal Rectovesicular Space (Suprapubic View)
    7. Figure 7. Normal Pericardial Window (Subxiphoid View)
    8. Figure 8. Probe Position On Pubic Symphysis And Subsequent Ultrasound Image Measuring Pubic Symphysis Distance
21. References

Abstract

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

1. “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.
2. “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.
3. “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.
4. “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.
5. “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.
6. “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.
7. “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.
8. “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.
9. “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.
10. “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.

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