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FAST Exam in pediatric patients

FAST Exam in pediatric patients. Evidence in the ED March 5, 2014 Sarah Cavallaro PGY-3. Introduction. The role of the FAST exam in Pediatric Trauma is unclear Review 4 studies that set the stage for current thinking Share my thoughts on how I wish these were done

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FAST Exam in pediatric patients

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  1. FAST Exam in pediatric patients Evidence in the ED March 5, 2014 Sarah Cavallaro PGY-3

  2. Introduction • The role of the FAST exam in Pediatric Trauma is unclear • Review 4 studies that set the stage for current thinking • Share my thoughts on how I wish these were done • A HUPISM for future practice

  3. Paper #1 • Jateen C. Patel and J.J. Tepas III. The Efficacy of Focused Abdominal Sonography for Trauma (FAST) as a Screening Tool in Assessment of Injured Children. Journal of Pediatric Surgery, Vol34,No 1 (January), 1999: pp 44-47 • Study Type: Retrospective chart review • Subjects: Children (11.3yo mean) with Suspected Blunt Torso Trauma who received FAST exam • Hemodynamically unstable patients: Included (but limited n=2) • N: 94 • Ultrasonographer: Radiology • Gold Standard: None

  4. Results

  5. Author's Conclusion • Specificity 95%, Sensitivity 33% • This “excellent specificity” combined with clinical examination allowed avoidance of “additional abdominal imaging”

  6. Paper #2 • Coley et al. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. J Trauma. 2000 May;48(5):902-6. • Study Type: Prospective Study • Subjects: Children (7.9yo mean) with Suspected Blunt Torso Trauma who were to receive CT • Hemodynamically unstable patients: Excluded • N: 107 • Ultrasonographer: Radiology • Gold Standard:CT

  7. Results

  8. Author's Conclusions • Specificity 0.83, Sensitivity 0.55 • Not an “appropriate” imaging study for hemodynamically stable children with concern for blunt abdominal injury • Should not replace CT

  9. Paper #3 • Soudack et al. Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients. J Clin Ultrasound. 2004 Feb;32(2):53-61. • Study Type: Retrospective Chart Review • Subjects: Children (7.1yo mean) with Suspected Blunt Torso Trauma who had received FAST exam • Hemodynamically unstable patients: Included • N: 313 • Ultrasonographer: Radiology *also evaluated for parenchymal injury or retroperitoneal fluid • Gold Standard:None

  10. Results

  11. Results

  12. Author's Conclusions • Specificity 97.2% Sensitivity 92.5% • The clinical significance of blunt abdominal injuries with no FF must be established • FAST Exam can be useful in patients with a normal physical exam to eliminate the need for CT • A positive FAST exam should then go to CT if stable or the OR if unstable

  13. Paper #4 • Fox JC et al., Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. AcadEmerg Med. 2011 May;18(5):477-82. • Study Type: Prospective • Subjects: All blunt abdominal trauma patients aged 0-17yo (about ½ age 13-17) • Hemodynamically unstable patients: Included (n=1) • N: 357 • Ultrasonographer: EM Residents, EM attendings, EM Ultrasound Fellows, surgeons • Gold Standard:CT (with moderate or severe FF) or Laparotomy

  14. Results

  15. Results

  16. Author's Conclusion • Sensitivity 52%, Specificity 95% for clinically significant FF • Sensitivity 20%, Specificity 98% for any FF • A positive FAST exam suggests hemoperitoneum while a negative FAST exam is not useful in the setting of a pediatric patient with blunt abdominal injury

  17. My Thoughts • Studying a very different use of the FAST exam • Most studies do not examine our use of FAST in a pediatric population • Need better reporting on the clinical significance of injury that presents with a negative FAST • Use would require culture change • Okay Byron, let’s hear your thoughts

  18. HUPISM • If positive, a FAST exam may still be helpful to locate the source of bleeding in blunt traumatic pediatric patients presenting with hemorrhagic shock. It is not however a study that can replace CT scan for diagnosis of all intra-abdominal injury in hemodynamically stable pediatric patients.

  19. References • Jateen C. Patel and J.J. Tepas III. The Efficacy of Focused Abdominal Sonography for Trauma (FAST) as a Screening Tool in Assessment of Injured Children. Journal of Pediatric Surgery, Vol34,No 1 (January), 1999: pp 44-47 • Coley et al. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. J Trauma. 2000 May;48(5):902-6. • Soudack et al. Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients. J Clin Ultrasound. 2004 Feb;32(2):53-61. • Fox JC et al., Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. AcadEmerg Med. 2011 May;18(5):477-82.

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