Contrast-enhanced point of care ultrasound for the evaluation of stable blunt abdominal trauma by the emergency physician: A prospective diagnostic study.

ABSTRACT

Objectives: Clinical examination alone cannot reliably rule out significant traumatic abdominal injury. Computed tomography (CT) has become the primary method for evaluating blunt abdominal trauma and clinicians rely heavily on it to rule out abdominal injury. Ultrasound examination may miss significant abdominal injury particularly in stable patients. The use of a contrast agent improves ultrasound sensitivity to visceral abdominal injuries. The objective of this diagnostic study is to compare bedside contrast enhanced ultrasound (CEUS) performed by emergency physicians to CT in hemodynamically stable adults for the assessment of blunt abdominal trauma and evaluate CEUS accuracy outcomes. Methods: Hemodynamically stable patients with blunt trauma were prospectively enrolled in the trauma bay. After initial evaluation, we included patients at risk of abdominal injury and for whom an abdominal CT was planned by the trauma leader. Ultrasonography was performed prospectively and at the bedside by the emergency physician followed by abdominal CT used as a reference standard. Results: Thirty-three patients were enrolled in the study; among them, 52% showed positive traumatic findings in abdominal CT scans, and 42% were diagnosed with solid organ lesions. Compared to CT, a focused abdominal sonography (FOCUS) examination, looking for free fluid or perirenal hematoma, showed limited performance for traumatic findings with a sensitivity of 65% (95% confidence interval [CI] 38%-86%), a specificity of 75% (95% CI 48%-93%), a negative likelihood ratio (NLR) of 0.47 (95% CI 0.23-0.95), and a positive likelihood ratio (PLR) of 2.59 (95% CI 1.03-6.48). When combining FOCUS with CEUS, the sensitivity of the sonography increased to 94% (95% CI 71%-100%) with a specificity of 75% (95% CI 48%-93%). The PLR was 3.76 (95% CI 1.6-8.87) and the NLR was 0.08 (95% CI 0.01-0.54). In our population, abdominal sonography with contrast failed to identify a single positive abdominal CT with a grade 1 kidney injury. Conclusions: A FOCUS examination shows limited sensitivity and specificity to detect positive abdominal CT in stable adults with abdominal trauma. With the addition of contrast and careful inspection of solid organs, abdominal sonography with contrast performed by the emergency physician improves the ability to rule out traumatic findings on abdominal CT. CEUS performed by emergency physicians may miss injuries, especially in the absence of free fluid, in cases of low-grade injuries, simultaneous injuries, or poor-quality examinations.