eFAST exam errors at a level 1 trauma center: A retrospective cohort study.

OBJECTIVES: Extended Focused Assessment with Sonography for Trauma (eFAST) ultrasound exams are central to the care of the unstable trauma patient. We examined six years of eFAST quality assurance data to identify the most common reasons for false positive and false negative eFAST exams. METHODS: This was an observational, retrospective cohort study of trauma activation patients evaluated in an urban, academic Level 1 trauma center. All eFAST exams that were identified as false positive or false negative exams compared with computed tomography (CT) imaging were included. RESULTS: 4860 eFAST exams were performed on trauma patients. 1450 (29.8%) were undocumented, technically limited, or incomplete (missing images). Of the 3410 remaining exams, 180 (5.27%) were true positive and 3128 (91.7%) were true negative. 27 (0.79%) exams were identified as false positive and 75 (2.19%) were identified as false negative. Of the false positive scans, 7 had no CT scan and 8 had correct real-time trauma paper documentation of eFAST exam results when compared to CT and were excluded, leaving 12 false positive scans. Of the false negative scans, 11 were excluded for concordant documentation in real-time trauma room paper documentation, 20 were excluded for no CT scan, and 2 were excluded as incomplete, leaving 42 false negative scans. Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam were the most common source of errors. CONCLUSION: The eFAST exams in trauma activation patients are highly accurate. Unfortunately poor documentation and technically limited/incomplete studies represent 29.8% of our eFAST exams. Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam are the most common source of errors.

Contemporary utility of diagnostic peritoneal aspiration in trauma.

BACKGROUND: Focused Assessment with Sonography for Trauma (FAST) has supplanted diagnostic peritoneal lavage (DPL) as the preferred bedside evaluation for traumatic hemoperitoneum. Diagnostic peritoneal aspiration (DPA) is a simpler, faster modification of DPL with an unclear role in contemporary practice. This study delineated modern roles for DPA and defined its diagnostic yield. METHODS: All trauma patients presenting to our Level I center who underwent DPA were included (May 2015 to May 2020). Demographics, comorbidities, clinical/injury data, and outcomes were collected. The diagnostic yield and accuracy of DPA were calculated against the criterion standard of hemoperitoneum at exploratory laparotomy or computed tomography scan. RESULTS: In total, 41 patients underwent DPA, typically after blunt trauma (n = 37, 90%). Patients were almost exclusively hypotensive (n = 20, 49%) or in arrest (n = 18, 44%). Most patients had an equivocal or negative FAST and hypotension or return of spontaneous circulation after resuscitative thoracotomy (n = 32, 78%); or had a positive FAST and known cirrhosis (n = 4, 10%). In two (5%) patients, one obese, the catheter failed to access the peritoneal cavity. Diagnostic peritoneal aspiration sensitivity, specificity, positive predictive value, and negative predictive value were 80%, 100%, 100%, and 90%, with an accuracy of 93%. One (2%) complication, a small bowel injury, occurred. CONCLUSION: Despite near ubiquitous FAST availability, DPA remains important in diagnosing or excluding hemoperitoneum with exceedingly low rates of failure and complications. Diagnostic peritoneal aspiration is most conclusive when positive, without false positives in this study. Diagnostic peritoneal aspiration was most used among blunt hypotensive or postarrest patients who had an equivocal or negative FAST, in whom the preliminary diagnosis of hemoperitoneum is a critically important decision making branch point. LEVEL OF EVIDENCE: Diagnostic, level III.

Point-of-care ultrasound for FAST and AAA in rural New Zealand: quality and impact on patient care.

INTRODUCTION: Point-of-care ultrasound (POCUS) has the potential to improve access to diagnostic imaging for rural communities. This article evaluates the sensitivity and specificity, impact on patient care, quality and safety of two common POCUS examinations - focused assessment with sonography in trauma (FAST) and aortic aneurysm (AAA) - in the rural context. METHODS: This study is a subgroup analysis of a larger study into POCUS in rural New Zealand. Twenty-eight physicians in six New Zealand rural hospitals, with limited access to formal diagnostic imaging, completed a questionnaire before and after POCUS scans to assess the extent to which it altered diagnostic certainty and patient disposition (discharge v admission to rural hospital v transfer to urban hospital). The investigators and a specialist panel reviewed images for technical quality and accuracy of interpretation, and patient clinical records, to determine accuracy of the POCUS findings and their impact on patient care. RESULTS: For FAST and AAA scans respectively, sensitivities were 75% and 100%, and specificities 100% and 93%; rural doctors correctly interpreted their POCUS images for 97% and 91% of scans. The proportions of scans that had either a 'significant' or 'major' impact on patient care were 17% and 31%. POCUS resulted in the disposition being de-escalated for 15% and 10% of patients and escalated for 5% and 3% of patients. CONCLUSIONS: In the rural context, POCUS AAA is a reliable 'rule out' test for ruptured abdominal aortic aneurysm and FAST scan has a role as a 'rule in' test for solid organ injury. These findings are consistent with larger studies in the emergency medicine literature.

Is E-FAST possible and useful on the battlefield? A feasibility study during medical courses in hostile environment (MEDICHOS): preliminary results.

INTRODUCTION: The extent of the French forces' territory in the Sahel band generates long medical evacuations. In case of many victims, to respect the golden hour rule, first-line sorting is essential. Through simulation situations, the aim of our study was to assess whether the use of ultrasound was useful to military doctors. METHODS: In combat-like exercise conditions, we provided trainees with a pocket-size ultrasound. Every patient for whom the trainees chose to perform ultrasound in role 1 was included. An extended focused assessment with sonography for trauma (E-FAST) was performed with six basic sonographic views. We evaluated whether these reference views were obtained or not. Once obtained by the trainees, pathological views corresponding to the scenario were shown to assess whether the trainees modified their therapeutic management strategy and their priorities. RESULTS: 168 patients were treated by 15 different trainee doctors. Of these 168 patients, ultrasound (E-FAST or point-of-care ultrasound) was performed on 44 (26%) of them. In 51% (n=20/39) of the situations, the practitioners considered that the realisation of ultrasound had a significant impact in terms of therapeutic and evacuation priorities. More specifically, it changed therapeutic decisions in 67% of time (n=26/39) and evacuation priorities in 72% of time (n=28/39). CONCLUSION: This original work showed that ultrasound on the battlefield was possible and useful. To confirm these results, ultrasound needs to be democratised and assessed in a real operational environment.

Variation in training and use of the focused assessment with sonography in trauma (FAST).

BACKGROUND: Training in ultrasound is variable among residents and practicing traumatologists. Focused Assessment with Sonography in Trauma (FAST) may be underused in non-urbanized areas, possibly due to lack of training. METHODS: State trauma registry data from January 2014-June 2016 were reviewed for FAST results. Trauma practitioners were surveyed querying training, confidence, and obstacles to performing FAST. RESULTS: 12,855 records revealed highest FAST use at the urban Level II center (39%, p < 0.0001). Despite similar injury patterns, non-urban/Level III centers' frequency of FAST was only 1-28%. 39 practitioners were surveyed, those with training (54%) were more likely to use FAST (p < 0.05). 61% of practitioners outside the Level II center cited lack of confidence in their ability to perform FAST as the primary reason for omitting the exam. CONCLUSIONS: FAST is relatively underused in non-urbanized areas of the state. Lack of confidence in ability to perform FAST was cited as the primary barrier.