Association Between a Positive ED FAST Examination and Therapeutic Laparotomy in Normotensive Blunt Trauma Patients
Moylan, Mark et al. Journal of Emergency Medicine, Volume 33, Issue 3, 265 – 271
- Introduction and background information
- Patients presenting to the ED with blunt trauma undergo FAST exams to determine presence of free fluid and therefore operative management
- Hemodynamically stable patients with positive FAST exam → CT scan
- Hemodynamically unstable patients with positive FAST exam → emergent exploratory laparotomy
- What was the primary objective of this study?
- To assess the association between positive ED FAST exam and therapeutic laparotomy in normotensive blunt trauma patients
- Methods and study design
- Retrospective cohort design of patients presenting to two level 1 trauma centers
- Inclusion criteria:
- Age > 16 years old
- Met trauma activation criteria
- ED SBP > 100 mmHg (even if patient was initially hypotensive in prehospital setting)
- ED FAST exam by senior resident or attending physician
- Imaging findings confirmed by either ED attending with ultrasound fellowship training, CT findings or intraoperative findings
- Exclusion criteria:
- Penetrating injuries
- What was the primary outcome?
- Therapeutic laparotomy within 2 days of presentation to the ED
- Results
- Total of 3,350 eligible trauma patients
- 1,636 included for analysis
- 4% of patients had a positive FAST exam
- 2% of patients underwent therapeutic laparotomy
- Odds ratio was 116 between positive FAST and therapeutic laparotomy (OR 44.6 after adjusting for confounding variables)
- Authors calculated a sensitivity of 75.8%, specificity of 97.4% for positive FAST exam and therapeutic laparotomy
- Discussion
- In patients with a low pretest probability for laparotomy, a negative FAST reduces the likelihood of requiring laparotomy in the setting of blunt abdominal trauma
- On the other hand, a positive FAST, even in normotensive blunt trauma patients, should be seen as a strong predictor for need of laparotomy
- This may be of particular significance to low resource settings or EDs without readily available CT imaging capability
- Were there any limitations?
- All FAST exams were performed by experienced operators which may limit generalizability
- Study did not perform serial FAST exams which may have changed sensitivity and specificity
- Take home points
- All blunt trauma patients should receive a FAST exam
- In patients with a low pretest probability for laparotomy, a negative FAST is reassuring
- A positive FAST, even with hemodynamic stability, predicts a high likelihood for emergent surgical management
